relief and enable us to go on in their use. Generally, however, we will have to do with the substitutes when the hemorrhage is considerable.

Remedies for the Pain.-When the pain is great, emollient injections of linseed infusion, infusion of slippery elm bark, with laudanum, in large quantities, thrown into the vagina, or half a teaspoonful of laudanum in a little starch-water or linseed tea, per rectum, will also aid very much in quieting. It is better in all cases for the patient to remain still in the recumbent position, for some hours after an application; when there is much pain, it is indispensable. The patient should be quiet until the pain is over.

Remedies for Nervousness.-When the nervous symptoms are excessive, we should be cautious about repeating the applications. If opium does not disagree with patients, its anodyne influence may enable us to continue the treatment. Tinct. hyoscyamus and camphor may also be tried, or valerian, brandy, &c. But some of these, particularly the last, must be used sparingly. If the nervousness subsides in a few hours, either with or without the aid of the anodynes, we can still resort to the nitrate applications. But if it continue at all obstinate, we must use some of the substitutes. I can but remark again, that it is singular that the caustic potash, and all the stronger caustics, produce less pain, less hemorrhage, and less nervous excitement, than the nitrate of silver.

Is its Application allowable in Pregnancy?—Is it ever allowable to apply the nitrate to the cervix uteri, inside or out, after the commencement of pregnancy? I confess that I am afraid to do so, and if a patient becomes pregnant during treatment, I advise a discontinuance until after confinement, and complete involution has taken place; say three months after accouchement. I know that Drs. Bennett and Whitehead both advise the use of the nitrate during the first three months, for the purpose of avoiding abortion, but the great irritation it sometimes causes intimidates. me from using it, or recommending others to do so. I think I have seen abortion caused by it, in cases where pregnancy was not suspected. On the other hand, I have seen cases where pregnancy was not thought to exist, treated for some time without any bad effects. Upon the whole, I think it is much the best practice to desist after conception, or not to begin if we know it has taken place.

Loss of a Piece in the Cervix.-Some object to the introduction of the nitrate of silver, in the solid form, into the cervix uteri, lest a piece of it accidentally be left in that cavity, and very bad results follow. I have had this accident to occur to me repeatedly, and as yet I have not seen any bad results from it. It is true, the pain is sometimes a little more severe and protracted in duration, but it dissolves and runs out, or is expelled into the vagina, which is the more probable course, and there is dissolved and neutralized by the mucus of that cavity. I have been so strongly impressed with the harmlessness of the presence of a small piece of the nitrate there, that I have, in certain cases, intentionally passed some up the cervix, and allowed it to dissolve in the fluid and distribute itself over the surface of that cavity.

Pressure by Bougies in Endocervicitis.-Before leaving this part of the subject, I will mention another substitute for the nitrate, which, in certain cases, I have seen do a great deal of good; that is, pressure upon the mucous membrane of the cavity of the cervix, by means of bougies, prepared sponge, &c. In some cases, with all the facilities afforded by flexible caustic-holders, our applications are imperfect, and the cure is unreasonably protracted. This may be the case when the cavity of the cervix is small, or tortuous from flexion or inflammatory adhesions. A bougie of slippery elm, large enough to fill the cervical cavity, introduced as high as the inflammation extends, and allowed to remain for twenty-four or thirty-six hours, not only prepares the way for other applications, but favorably modifies the disease by its pressure upon the capillaries. In order to use this bougie handily, we may cut it about two inches long and about the right size, and then tie a piece of thread around one end, so that it can be removed at will. After exposing the cervix with the speculum, we may, with the dressing forceps, introduce it as high as possible, leaving the end with the ligature extending out of the os uteri. If not supported it may slip out, and not remain long enough to do any good; hence it is a good plan to place a sponge or piece of cotton against it, to prevent it from being discharged. This should be repeated every four or five days. The use of the stem pessary proves beneficial, too, I think, in some instances, on account of the stem pressing upon the inflamed part inside the cavity of the cervix, and thus changing the character of capillary

action. If used intermittingly, it will act better in this respect than if allowed to remain constantly in place. We may use flexible gum bougies, wax or metallic. The object to be gained, it should be borne in mind, is pressure, intermitted and sufficiently strong to produce a decided impression. I think I have, on several occasions, verified the excellent effect of pressure applied in this way, when it was difficult to make perfect applications of the nitrate; the main point of the disease being so high up, and the canal at a pretty sharp angle with the axis of the vagina.

Medicated Bougies.-These slippery elm bougies may be made to carry medicated applications, and retain them in contact with the inflamed spot, when situated high up in the cervix. Calomel may be placed, as I have done, upon the end of the bougie, or ointment of creasote, calamine ointment, ointment of lead, or any other that is likely to produce a proper stimulus. The tincture of iodine, the iodine ointment, and also the iodide of potassium, in pieces, pushed before the bougie, to be dissolved and diffused over the mucous membrane, are good substitutes for the nitrate, that may be used with the bougie. The use of bougies in this way is like the treatment sometimes instituted for inflammation. in other mucous canals, as the urethra, for instance, with salutary effect. The danger from the bougie is less, perhaps, than any irritating application to the part, producing its effect, not by causing acute inflammation, as does the nitrate and other strong stimulants, but by pressing upon the part, and thus diminishing the capillary circulation in it, reducing the inflammation.

I subjoin a summary of the treatment of Robert Ellis, Esq., Obstetric Surgeon to the Chelsea and Belgrave Dispensary, London Lancet for July, 1862, reprint. It is a choice tabular view of the kinds of ulceration we meet with, and the very best mode of treating them, and I think will be useful to the inexperienced:

VARIETY.

1. Indolent Ulcer.-Cervix hypertrophied, of a pale pink color, and hard. Os patulous to a small extent. Ulcer of a rose red. Granulations large, flat, insensitive, and edge of the ulcer sharply defined. Discharge: mucus, with a little pus, and occasionally a drop of blood.

.

TREATMENT.

For a few times the caustic pencil,— solid nitrate silver. Afterwards, the solution of nitrate of silver in strong nitric acid.

CHAPTER XX.

TREATMENT OF SUBMUCOUS INFLAMMATION.

TREATMENT OF SUBMUCOUS INFLAMMATION, COMPLICATED WITH ULCERATION-SCARIFICATION-MODE OF DOING-LEECHING-SETON OR ISSUETREATMENT OF INDURATION AND ENLARGEMENT-CAUSTIC POTASSAOBJECTS IN USING CAUSTIC POTASSA-MODE OF APPLYING IT.

SUBMUCOUS inflammation, as has been seen, is observed under a variety of accompanying circumstances; with mucous inflammation, without mucous inflammation, and without change of size or consistency, and with fibrinous deposit, enlargement, and induration of the cervix. Of course, all these circumstances will more or less modify the treatment of the different cases in which they are observed to occur.

Submucous Inflammation, with Ulceration and Mucous Inflammation.-There is often evidence of submucous inflammation when ulceration affects the mucous surface of the cervix. When the tenderness is not considerable, nor the part enlarged and tumefied, the cure of the mucous disease by the means heretofore indicated, will suffice to cure the submucous also, and hence the case will need no further treatment whatever. But if the cervix is quite tender to the touch, somewhat swollen and hot, and the ulcerated surface red and excavated, and giving out pus copiously, other remedies than those adapted for the cure of the mucous inflammation ought to be used. Leeches, in numbers to suit the intensity of the inflammation and the general condition of the patient, should be applied, and repeated every week, until the tenderness and heat have subsided to a great extent. But as local depletion will not always produce the effect, it will almost always be better to resort to internal alteratives and sedatives. Very many of these cases yield promptly to the alterative influence of mercury, gradually induced, with an occasional active cathartic of salines. Probably the best general plan is to leech the cervix, give a cathartic of calomel, to be rendered a little more active by sulph. magnesia, citrate of mag