A CONTRIBUTION TO THE TREATMENT OF UTERINE LESIONS, BY IODOFORM, COTTON AND MECHANICS. EPHRAIM CUTTER, M. D., NEW YORK. Reprint from the Therapeutic Gazette, January, 1882. A Contribution to the Treatment of Uterine Lesions, by Iodo- form, Cotton and Mechanics.* PRELUDE. leg, just above the ankle. It was as large as a silver half dollar. Edges perpendicular. Bottom of excavation, raw and purulent. The leg was laid horizontally, and the cavity filled with pow- dered iodoform. A piece of lead adhesive plaster, large enough to go half around the leg, and three inches wide, was warmed and applied over the ulcer and iodoform. Orders were left to leave it undisturbed till the writer’s next visit, which was in four days. The pain ceased soon after the ap- plication. The ulcer had not discharged any, and had given no trouble whatever. On removing the plaster most of the iodoform had been absorbed, and—it can hardly be believed, it is so incredible— two-thirds of the excavation was filled up, healed over even, and covered with sound skin! Dr. Charles Haddock, of Beverly, informs the writer that he has had exactly the same experience. Dr. James II. Salisbury, Prof. Nunn, of Savannah, Ga., and some French physicians, confirm this history, so that it is no exceptional experience, but must be regarded as a legitimate and natural therapeusis. So that iodoform must rank with the very foremost of remedies, as a healer of ulcers, a quieter of pain, and a restorer of organic lesions. Before this the writer used it in ulcerations of the uterus, as others did, mixed with cocoa-butter as a suppository; but, after the experience given, the vehicle was dispensed with. The accompany- ing instrument was devised with a spring catch, which, when released, threw the powder out. But the powder would engage between the cylinder and the piston, and stick, causing the piston to work too slowly, and not project the iodoform with force enough. Second device.—Suggested by Dr. C. W. Stevens, 54 Elm street, Boston, Charlestown district. He used copper tubes, one half inch or more in diam- eter, curved (in a quarter circle), ten to twelve inches long, really a vaginal insufflator; the end of the tube, charged by pushing into the collection of iodoform, was introduced through to the os, then withdrawn one-half inch, and the current of air forced in by the mouth of the patient, de- positing the iodoform against the uterus. There is, however, a nickel-plated tube made for this same purpose, and fitted with an india- rubber tube, twenty-four inches long, terminating with a glass tube; calibre inside of all tubes, one- half inch. This device works well, but the iodo- form revealed its presence unpleasantly by often getting outside the vagina. After, however, absorbent cotton came out, an elegant preparation of it by Denni- son & Co., 19 Milk street, Boston, was brought before this society. This preparation, sub- TO attempt a monograph on iodoform, and its therapeutic applications, would be a task of such magnitude as to be out of place here. The writer’s acquaintance with iodoform was made in Paris in 1862, and he has used it more or less ever since. It is very popular among continental physicians, and if the reputation of iodoform here were equal to its character, it would outrank ether and opium, if it were possible. But its literally bad odor, among gynecists, like Sims, has thrown it out of the use it ought to have. Not that a bad odor debars anything from employ- ment, for we have a plant that is loathsome to some, yet millions of our race use it daily, and spend money for it more than for flour. They delight, enjoy and revel in its peculiar odor and taste, and often prefer it to aliment. Tobacco is referred to. Now, to the writer, iodoform is cleanly, pleasant and agreeable. Its beautiful golden color glistens in the sun. Under the micro- scope it is made up of crystalline, hexagonal plates, hastate Greek-cross shaped, and sometimes pecu- liarly digitate, with re-entrant angles. The barbs of the hastate crystals explain why they are so diffi- cult to detach when caught on the clothing, and, consequently, why their odor is so persistent, simply because the crystals stick by their barbed points. Taste peculiar, sweet, dry, sulphurous. In the South dentists use it to set loosened teeth (Nunn). To the touch it feels unctuous, ta’c-like. It makes no impression on the sense of sound. Its peculiar, pervading smell makes it a subject of query. Since most gynecological cases dislike inquiries as to themselves, or to have anything about them that may raise suspicion as to the nature of their complaint; and, on the other hand, those like Dr. Sims say the objection is because of its making the physician malodorous: hence iodoform has been tabooed. Nothing opposes its laryngological use, as it is quite in order to have diseases of the throat sub- jects of society discourse. Hence such men as Elsberg apply the ethereal and chloroformic tinc- ture, combined with ol. menth. pip., freely to the air passages, with the best effect. There is no more soothing, quieting and anodyne throat appli- cation, for topical pain and soreness, than that of the ethereal tincture of iodoform, applied with an Elsberg holder. Again, it is one of the best applications to irri- table dermal ulcers. About the year 1865 a man had an exceedingly painful, irritable ulcer of the •Read before the Gynecological Society of Boston, November y I88«. A COFTRIBUTION TO THE TREATMENT OF UTERINE LESIONS. 3 jected to a careful morphological examination by a skilled botanist, revealed no difference of form from that of ordinary cotton. The absorbent prop- erty was found to be due to the removal of the minute film of cotton seed oil from the fibre by ammonia, soda, potash, ether, chloroform, etc. At once this seemed the right agent to stop the smell of iodoform—that if applied to the os, in quantities of a half-drachm, or more, through a speculum, and a pledget of this absorbent cotton crowded down through the speculum, and held there when the speculum was withdrawn, the pledget would remain, and act like a dry sponge to absorb the secretions and iodoform; and that if the cotton was removed when it was saturated, or just before saturation, and fresh cotton substituted, there would be no odor of the iodoform to exhale. These suppositions were realized, and there has been no trouble since, save when the patients were spares the sensitiveness of subjective feelings in vaginal exploration. The capsules may be filled as follows: A toy pewter spoon or a common steel pen put point into a holder serves to shovel the iodoform into the larger division of the capsule. When filled the cap is fitted on, and thus the iodoform can be handled and introduced into the vagina by the patient. She then takes a pledget of absorbent cotton and plugs the vagina. To facilitate the removal of the pledget when saturated, a thread may be attached beforehand. The writer has thought that the capsules might be filled by the apothecary in quantities of 3 j. 3 ss, 15 grains and 7Yz grains. Also, that cotton and iodoform might be em- braced in one capsule. This idea is already in the market. Also, in connection with divided capsules, to FIG. I. IODOFORM CRYSTAL^,X 8oO. careless and allowed the cotton to be saturated without removal. This mode of application is the common one, and requires the attention of the physician in per- son, usually twice a week. But there is a great improvement (not patented) on this method, on which special stress is here laid. It was first sug- gested to the writer by an advertising doctor, whose wife was in my care for a uterine cancer, originally a fibroid. He asked if the gelatine capsules of Planten & Son could not be filled with iodoform, applied to the os, and the gelatine dissolved in the vaginal secretions, thus making a topical application. The idea was taken in at once and proved admirable in practice. Thanks are here given for the suggestion. The points are that the patient can fill the capsules herself, and make an a; plication without assistance. It enables those in Un ited cir- cumstances to avail themselves of the ren edy. It relieves the attendant and saves his tijoe. It have undivided capsules complete in one cell. Then the most sensitive patient could not complain of the trouble in preparation. In order to have all preliminaries satisfactory, the wtiter applied to the enterprising and reliable firm of manufacturing chemists, Parke, Davis & Co., of Detroit and New York, and they have consented to furnish the iodoform in capsules, ready for use in the quantities suggested, to wit: 1. 7Yi. grains; 2. 15 grains, 3. 30 grains; 4. 60 grains—samples of which are shown here, held at the following prices: In boxes of 100 capsules— 1. $2.50; 2. $4.50; 3. $8.50; 4. $16.00. They also furnish pellets of cotton, salicylated, ready for use, in loose, textile cloth, samples of which are shown. They also will furnish 20 grains iedoform, with absorbent cotton, in one capsule, at $12 00 per 100; 5 grains eaeh, at $2.25 per 100; 30 grains each, at $15.00 per 100. In this iodoform cartridge are all the requisites for one application, 4 A CONTRIBUTION TO THE TREATMENT OF UTERINE LESIONS, Hyperesthesia — supersensitiveness — the irri- tation of Hodge—must be regarded as a disease by itself, and associated with inflammation, ulcera- tion (ectropium, eversion, solution of continuity, sub-involution), with metritis and hyperplasia, and SUBJECT PROPER. drove her distracted. Immediately she was treated with iodoform and cotton, applied to patient while reclining in a Cutter’s invalid chair, in a posi- tion where the diseased cervix was exposed to direct sunlight through a Neugerbaum speculum. The iodoform was literally shoveled in by a vaginal sound, and the whole cervix buried in the powder. A large pledget of the cotton was introduced, and the speculum withdrawn, the cotton held in place at the same time with sound. The effect of this was like magic. The pains, the bloody flow, and the discharges, ceased at once. The surface looked less red and angry. Applications were made twice and thrice a week through the summer, with the result that the ulceration was healed, or nearly healed. All the while she was partially on the Salisbury plan for cancer. The result was that she thought herself cured enough to go home. Certainly, as far as signs, symptoms and feelings were concerned, her situation coincided with her opinion, but not with the writer’s. Reluctantly she was dismissed, with strictest in- junctions to have the iodoform reapplied, if there were any signs of the reappearance of the disease, and also was instructed to keep continually on the plan. But these instructions were disregarded, and, soon after her arrival home, she relapsed, grew worse, and died of cancer of the womb in about nine months after she left the north. Remarks. At this time the capsular mode of self administration was not known to the writer. From what has happened in other cases since, in the writer’s opinion, the continued use of the iodo- form would have insured a longer lease of life, FIG. «. (CATCH PISTON. with displacements—versions, flexions, prolapsus. Sometimes uterine disease is associated with fig. .3. ''vaginal insufflator." hypoaesthesia (sub-sensitivsness) and anaesthesia (loss of sensitiveness). Again, byperaesthesia, ectropium, hyperplasia and displacements are associated, so that if in- stances of the treatment of the hyperesthesias, of ulceration, and of hyperplasia, precede the instances of treatment by odorless iodoformiza- tion, it is hoped that the apparent digression will not appear out of taste. Case 1. Hyperaesthesia and ulceration of the cervix, that was improved under iodoform, but finally proved to be fatal as a cancerous lesion. “Mrs. “One,” married, over 50 years of age, residing in Louisiana. Summer of 1867 applied to the writer for treatment for what was called cancer of the womb by her local physician; and one in New Orleans. She presented a good physique, but had copious bloody vaginal dis- charges; sometimes, not always, with severe pains, with the cervix enlarged laterally, ragged, rough and bleeding, but not dense or stony; rather soft and punky to the touch. Uterine cavity normal depth. Appetite unimpaired, etc., etc. Before her trouble came on, a year previous, she was a subject of intense grief on account of a relative, which shattered her nervous system. #nd almost and a longer immunity from suffering. At any rate, the history, as given, taught the writer that iodoform, for such cases, has advantages over galvano-caustic, actual cautery, scraping with the curette, and operative interference, especially since it can be applied by the patient herself, under medical advice. Had this patient remained longer and been cured, of course it would have passed for anything but cancer, from the very fact of the cure, but, as the history shows, it was cancer, fa- vorably modified, and relieved for a time by the use of iodoform. Of one thing the writer is sure: That any remedy that will do as iodoform did here is entitled to consideration from gynecologists. Case 2. Mrs. “Two,” 45 years old, married, mother of nine children; severe, stinging pains about the vulva, associated with copious leucorr- hoea; laceration of cervix; redness, infilrated and dense nodular enlargement of posterior lip of uterus. Behind the uterus were three or four well-marked, dense, mobile, marble-like tumors, beneath the mucous membrane, the touch of which suggested cancer. Cancer being hereditary, the patient’s father having died of cancer of the stom- ach, and her maternal great-grandmother of cancer of the breast, fears of malignancy were expressed, BY IODOFORM, COTTON AND MECHANICS. 5 especially as the pain was severely lancinating at times. She was treated much as case I, and recov- ered, and is living now at the expiration of four years. The tumors soon disappeared, the uterus returned to normality, as far as was possible, with out an operation for the ectropium, to which the patient would not consent. Had death ensued, this case would have been called cancerous, but, as it recovered, of course it was not. (?) Case 3. Hyperaesthesia ; foetid intra-uterine ulce- ration; latero-flexion to the left, mistaken for a fibroid. Treatment with iodoform. Miss “Three,” 24 years of age; syphilitic, both from confession and blood-examination; general malaise; complexion, ash color, formerly ruddy; vaginismus; uterus, too sore to examine with sound; iodoformization; Salisbury plan for fibroid; foetid discharge checked; uterus mobile and sin- istro-latero flexed, angle \'/£ inches from os; com- plexion restored; great gain in flesh; amenorrhoea supposed to be caused by the iodoform; tannin substituted for iodoform; return of menses. This was actually a “stinking” case. Odor per- vaded the house and office: Still it was subdued by the faithful use of iodoform. (A gentleman present, when this paper was read, said he knew of a case where iodoform was used extensively for eczema of the limbs. The amenorrhoea was attributed to the iodoform.) Case 4. Mrs. “Four”—over 50 years of age, multiparous, subject of retroversion—complains of pain in abdomen every time she takes a step. Hyperaesthesia of abdominal skin; numbness in both legs and feet ; menstruates. yEsthesiometry: Could distinguish two points, one-half inch apart, over both legs and feet, showing the subjective and functional character of the numbness. Palpi- tation of the heart. Great agitation of manner, and signs of insanity from talk, and other actions. The uterus was enlarged, thickened, exquisitely sore to touch, and too sore to be explored by sound. Vagina hot. In former times the writer would have used leeches ; still, by the capsular use of iodoform and cotton combined, with confine- ment to bed, she was relieved of the symptoms in a few weeks. 3. The use of iodoform in uterine hyperaesthesia —the “irritation” of Hodge—associated or not with lesions of organic structure—the esses that seem to the writer to make up the largest class of uterine disease. Generally found associated with versions, flexions and prolapsus of the uterus, with tumors, and organic disease, etc. Perhaps, in this connection, the writer may be pardoned for an allusion to his “Contribution to the Treatment of the Versions and Flexions of the Unimpregnated Uterus,”* intended for those who use the writer’s pessaries. In this work great stress is laid on the necessity of preparing the patient for the pessary. Mention is made of the iodoformization, but the great reliance is laid on the use of depletion, by leeches, or scarification. Since then the writer has, to use a good Methodist word, “realized” the supreme value of iodoform over all other agents, in the reduction of the hyperaesthetic vagina, uterus and appendages, to a state of normal feeling (agathaesia—ayado£? good, cncrSr/criZ, feeling), so that the uterus can be handled with a sound, and sus- tained by a pessary, selected by measurement. It seemed to the writer that the neglect of the preliminary treatment, before the introduction of a pessary, has brought, undeservedly, a disrepute upon the use of pessaries. The unimpregnated uterus and vagina, if normal, should have no more sensitiveness than the tip of the healthy nose. For these reasons, and in order to bring the sub- ject fairly up to date, the writer would beg leave to make an especial point of the use of iodoform and absorbent cotton, to prepare the patient for the wearing of pessaries. Case 5. Miss “Five” will illustrate this better in the concrete than in the abstract. Unmarried, virgin, 34 years old. Is consumptive, as evidenced by the physical signs furnished by macroscopical and microscopical inspection, auscultation and per- cussion. Pretubercular stage. Complains of gen- eral weakness and prostration; inability to walk or exert herself, beyond a certain limited degree; no pain, no anaesthesia, or hyperaesthesia; on par- ticular disturbance at the menstrual epoch. So that neither she nor any of her medical attendants could account for the great nervous prostration, and, curiously, no one had suspected the uterus. Certainly, the systemic and local diseases were in- sufficient to account for the prostration. Acting on the dogma of the late Prof. Hugh L. Hodge, my instructor in gynaecology, in 1854, that “no woman complains unless she is sick, and has reasons;” and “ that if we (his pupils) were unable to find out the cause of sickness—to confess our inability, and not treat the patient as malingerer. Rather,” Prof. Hodge said, “lament your igno- rance and spur yourself to find out the trouble, and never cease until you have thoroughly explored the case.” So, on exploration, vaginismus, with a retroverted and hyperaesthetic uterus, were found. Now, before the uterus could be replaced, or even touched with a sound, it was necessary to relieve the vaginismus, and restore the uterus to as insensitive a condition as the tip of the nose, when it could be handled. With difficulty iodo- form capsules, with cotton were applied by the writer, and the necessary physical contact caused severe pain. These were applied once in three days, so that in about two weeks the writer was enabled to introduce the uterine sound, and restore the retroverted uterus, and obtain the measure for a Cutter retioversion loop pessary, which was soon procured, applied, and continuously worn ever since, without any trouble, up to the present time, a period of five months. The feeling of prostra- tion has almost ceased, and the patient is making a good recovery on the Salisbury plans. Remarks. The writer knows no other agent by which this could have been accomplished so speed- ily and satisfactorily. He thinks enthusiasm js not out of place when connected with iodoform. If it were in order here to show the importance, in cases of consumption, to look to the uterine com- plications, space for this paper would be insufficient; perhaps it may make the subject of future communication. It is enough to say that it will not do to overlook uterine complications in •Boston: J. Campbell & Co., 1877. 6 A CONTRIBUTION TO THE TREATMENT OF UTERINE LESIONS, consumption, as the combination is very formi- dable. In the present case the writer has no doubt that the uterine complaint accelerated the pul- monal. Iodoform and the Cutter stem pessary. The state- ment that no stem pessary can be worn is not in harmony with the fact that the writer has seen a case where the above instrument has been worn for five years successively successfully, and with relief from prolapse of the ovaries, and also for a year to four years’ wearing in other cases of flex- ions and versions. But, if it were generally known that iodoform paves the way for the use of the above stem pessary, perhaps there might be less confidence in the idea of the absolute impossibility of wearing said pessary. As the writer’s relations are close to the instru- ment in question, it may be proper to give in de- tail the use of said pessary, and to state how the barriers are overcome that appear so insurmount- able. We testify, as Stanley witnesses to his disco- veries in Africa. Ate not stem pessaries to gynae- cologists a “dark continent?” Case 6. Anteversion, complete, chronic, and uterus sensitive—Iodoformization—Restoration of normal sensibility to vagina and uterus—Applica- tion of a Cutter stem pessary—Continuous use for twelve months—Restoration of embonpoint, vivac- ity, ambulation, travel to Duluth, and good health. Miss “Six,” 24 years old, virgin; was drooping, pale, feeble; fond of dancing, but unequal to the labor involved. Suffered much during menstru- ation. Nervous. Appetite poor. Father died of consumption. Local trouble: anteversion, with hyperaesthesia of the uterus and vagina. After, iodoformization, it was replaced and measured with vaginal sound for a anteversion Cutter loop pes- sary. This kept the uterus in position for a time. There was some discomfort, occasioned by the uterus forming an anteflexion over the pessary. In such cases the Cutter stem pessary is advised: 1st, as it keeps the uterus from flexing, on true mechanical principles; 2d, holds the organ in per- fect position, easily and readily ; 3d, is not apt to get out of order; 4th, is under the control of pa- tient, as she can withdraw it by simply extracting it; 5th, it, when borne, requires less attention than any other pessary; 6th, when worn, the uterus is mobile, but within normal limits. Iodoformization was kept up and a stem pessary applied, the patient lying in bed, as a precaution, undressed, as if sick. The instrument was well borne. This was verified by occasional digital examinations, and the vagina found to be cool and the uterus in place. The sensitiveness of the uterus was tested by pressing in the pessary out- side, and also the abdomen. The iodoformization was kept up by the capsules passed up by the side of the body of the stem. There was some flowing beyond the menstrual period (the instru- ment is not removed during menses); but, as there was no pain or soreness of the womb, no tender- ness of the abdomen, no fever, nor anything but the hemorrhage, which was slight, no change w’as made in the instrument, so that Miss “Six” has worn it up to the present time without trouble. She lives on a very high hill, nearly a mile in ascent in one direction. This she climbs and de- scends at will. Also goes into society, and the way she came beaming into the writer’s office, to have her face beautified by the removal of a small mole on her chin, would startle one who insists that stem pessaries cannot be worn. Besides, her breasts have filled out, and her form has rounded out, as it would have done, in all probability, had not her development been stunted by the strain upon her system, “to run,” so to speak, her womb in its anteverted and irritable condition. The writer confesses that the general opposition to the use of any stem pessaries has deterred him from always employing them when indicated; but the present cases, with others, makes him think he ought to respect his own opinion and expe- rience more than that of those who, more eminent in all respects than himself, yet condemn the stems in toto. But now tbat iodoformization is available, it is to be hoped that the bl'ank opposi- tion may be revised, for the pleasure that is real- ized in the restoration to health and active life, in the present case for example was one of the sweeten t that has fallen to the writer’s lot as a physician. It should be stated that the stem used had a moveable disc, which is regarded and found to be a great improvement on the fixed disc, though Dr. Sanford Hanscom, of East Somerville, Mass., says his sister, who has the prolapsed ova- ries referred to above, removes and applies the stem herself, and likes the fixed disc much better than the stem with the movable disc. Case 7. Showing that iodoform does not regu- late every case. Mrs. “Seven.” After this patient had got well- nigh relieved of her uterine enlargement and in- flammation, a change came over her in relation to the iodoform, which should be related in this con- nection. She found herself suffering more after the use of iodoform, and finally, by a crucial test, she decided that it made her bowels hard and pe- culiar in feeling, and rather distressing, so that she would no longer use it. Now, the writer found it difficult to believe that the iodoform, from being benign, could become nocent; still, having confidence in the patient, he feels forced to admit the truth of the change of character from good to bad. Remarks. This is seen in the case of parasitic cryptogamic vegetations. Innocous fungi may become animalized and then also be nocent, and cause diseased conditions, as the botyritis of the potato rot may become animalized, nocent, and cause diphtheria. Also alcohol changes its char- acter in sickness and disease. The writer had once a case of chronic erysipelas of the right leg, which spread beyond the knee joint, and involved an amputation at the middle part of the thigh. Pulse, 140. The only food this patient took dur- ing this time—a period of three months—was one and one-half pints of whisky daily. Vouchers for this can be furnished. Still, when convalescence was established, and, even after recovery (the man is now alive, and several years have elapsed since his sickness), he could not take a teaspoonful of whisky without its going to his head. Besides this, it was very repugnant to his taste.* *Note.—Another case has occurred to the writer since this was written, when iodoform, that agreed well with others, burned and scalded badly the vagina. This is inexplicable, but it is clinical history, and should not be suppressed. BV IODOFORM, COTTON AND MECHANICS. 7 At any rate, as the patient was very much bet- ter, and called herself well, the writer was very willing to discontinue the iodoform, and to record, that iodoform, after being used with success, be- came an agent of distress, as the alcohol did in the remarkable case alluded to. Still, should the same lady have a similar experience, iodoform would be indicated, as before, under the guidance of a physician. Case 8. Mrs. “ Eight," 42 years old; multi- parous; flooding; pale; confined to bed; hyperes- thesia of abdomen, vagina and uterus; pelvis packed firmly. Supposed fibroid proved to be retroflexion and version. After iodoformization, in- troduction and use of stem pessary. This case was very sensitive, else a sound introduced would have corrected the diagnosis at first. She is now wear- ing the stem well. Without iodoform this would have been impossible. The capsular method was employed, with no trouble to those in the house. Case 9. Mrs. “Nine,” 34 years of age. Ab- dominal. pelvic, interstitial fibroid. This patient complained of being hurt on walking, so that loco- motion was quite abandoned. It seemed as if the whole uterine growth was sensitive to the motion of ambulation, though not so on digital explora- tion. Capsular iodoformization relieved the symp- toms. The following extract, from a late letter of this patient, gives her version of her history: “ I have had the iodoform applied all of the time. I do not think it possible for any one to have less trouble from wearing it than I have had. I wear the capsule and cotton a week without removal, not experiencing any unpleasant odor, only as it is inserted and removed. Had I better try to do without it, if I don’t realize sensitiveness there? I do not think I could walk as much as I do, if it was not for iodoform.” The question was answered: “Yes.” More cases could be adduced, but the above seem enough to illustrate the positions taken. Is iodoform absorbed? When applied en masse to the uterus, so much remains undissolved that it is pertinent to ask if it acts by absorption, or sim- ply by contact, as we used to think the subnitrate of bismuth acted on the stomach, but in which the mistake is shown by the relief following the use of liquid bismuth. Patients have spoken of tasting the iodoform in their mouths, after its de- position in the vagina—which is good evdence of absorption. The following case, in the opposite sex, shows it can be absorbed from the rectum: Mr. “Ten”—30 years old, 10 years sick, pseudo- seminal emission, enlargement of liver, atrophy of both testicles, neurasthenia, sweating almost with- out provocation, headache, general malaise, loss of flesh, hyperesthesia of integument, etc.—was re- quested to use 15 grains of iodoform in a gelatine capsule, deposited in the rectum at night, on going to bed. The report was that the iodoform irritated the rectum, and that, while he could perceive no smell, he could taste it all night. Less quantity was substituted, the pain was relieved, but not the taste. This case was so sensitive that he could not bear the open air in June without a profuse sweat- ing. Now it is impossible to resist the conclusion that the iodoform was actually absorbed, and en- tered the circulation, as he was not warned before- hand. All cases do not have this experience, pos- sibly because their nervous systems are not sensi- tive enough to observe it4 Oftentimes the acrid burning of iodoform is due to some physical difference in the preparation, for the preparations vary in this respect. How does the iodoform act? By its effect on the nervous system evidently. This is the system, par excellence, to be acted on in gynecological cases. It controls irritation, the rapid waste and repro- duction of tissue elements in the body. It is a difficult phase of the subject, but it forms a part of the clinical history of iodoform, as it quiets irritated nerve fiber, ganglia, vaso motor nerves, plex- uses, and, removing the irritation, they recover their tone and then do their work. Or, to put it differently, the u«e of iodoform saves the nerve force by removing the hyperesthesia, and then the saved nerve force is applied to its legitimate work- ing duty of promoting organization, nutrition, secretion, tone, etc., etc. Our bodies are colonies of organs, managed, controlled, and “run,” so to speak, by the normal nervous energies. Use up this force, by having a uterus out of place and diseased, for example, and the nerve force for wok is by so much lessened. Save or increase that nerve force by local applications, mechanical procedure, proper feeding, and putting the whole body in prime working condition, then attention is paid by the composite organism to the repairs needed. Why iodoform acts as a nerve sedative, is as difficult to explain as why the protoplasm of the epithelia of the mammary gland secrete milk, and the epithelia of the liver secrete bile. As, however, the epithelia of the mammary gland secrete milk, and the epithelia of the liver secrete bile, and our lives go on without our knowing or caring how these functions are performed, so it seems needless to occupy ourselves with the ptactical results of iodoform, while we may be lost in wonder at the almost exceptionless benign- ancy of such a powerful neurotic. It is not cumu- lative like digitalis, nor poisonous and intoxica- ting, like opium and chloral, in over doses. It is not even ordinarily escharotic and irritating, as common salt in excess. It agrees with mucous membranes, the most irritable solutions of con- tinuity—the most hyperesthetic surfaces—and they agree with iodoform. It seems almost impossible that so mild and negative a chemical substance should have such a therapeutic power, though its penetrating smell is so pervading as to impress an observer with a sense of its aerial dispersion, and of the wonderful divisibility of matter. But, as was said at the outset, if the nauseous odor of tobacco is no barrier to its universal use in mod- ern life, it seems to the writer that the unpleasant odor of iodoform should be no bar to its use in gynecology—especially when, with a careful co- employment of absorbent cotton, and capsules of gelatine, the patient may move around in social and domestic life, without evincing the slightest token of its presence in the vagina. Other forms of application. It may be that iodo- form, dissolved in collodion, may prove a less odorous agent, but evidently such an application to the os uteri would need the services of a phy- sician, whereas the capsular method is in the control of the patient. Dr. Stevens (quoted above) states that he uses 8 A CONTRIBUTION TO THE TREATMENT OF UTERINE LESIONS. crayons of iodoform, made with gum tragacanth. These he introduces into the uterus, through a spe- culum. Dr. Mund6 has kindly criticised this paper, as follows: “ I have been very well pleased with iodoform in cervical ‘ ulceration ’ (ectropium), and, in these respects, quite agree with your expe- rience. Also in chancroids, and, further, have had excellent results with it as a local anaesthetic in utero-pelvic troubles.” It is possible others have had the same expe- rience. If so, it is pleasant to have it confirmed. But if, as the president of this society asserts, this relation is new to most practitioners, then the writer is justified in this presentation. What are societies for but to give opportunities to present one’s own practical experience? May we not express the hope that the near future will see a wider extension of wise mechani- cal treatment of uterine flexions—to say no more? Note.—At the time when this paper was read, Dr. C. W. Stevens, of Charlestown, Mass., was present and alluded to some crayons of iodoform he used in his practice. His formula was as fol- ows: B Iodoform, Bviij. Pulv. gum tragacanth, grs. 16. Glycerine. Muc. acacia, S3 q. s. M. Sig.—Roll into pencils one and one-fourth inches long and one-eighth in diameter. Dry. But the trouble with the pencils was the smell; so Parke, Davis & Co., at my suggestion, have covered them with gelatine, which isolates the odor, and makes a perfectly elegant crayon for intra-uterine use. Of course the cotton must tampon as before. no. 4. IODOFORM CRAYON. Finally, T. Metcalf & Co., of Boston, have sent me iodoform gelatine uterine bougies made like the urethral. They are nice, and covered in the gelatine. It would now seem as if perfect odor less iodoform intra-uttrine crayons and bougies were presunted by pharmacy to medicine.