[From Proceedings of the Connecticut Medical Society, May, 1887.] 
ON EROSIONS OF THE CERVIX UTERI; THEIR PA- 
THOLOGY AND TREATMENT. 
By E. W. Cushing, M.D., of Boston.* 
[Read by invitation before the Connecticut State Medical Society, 
May 25, 1887.] 
Of all morbid conditions of the uterus none is more frequently 
met in practice than what is spoken of as erosion, or ulceration of 
the os; and I take it for granted that most physicians are only too 
familiar with the gross appearances of such cases. 
It may be well, however, briefly to recall the classifications of 
Tyler Smith in England, and of Mayer in Germany, as showing 
how much can be learned by ocular inspection through the specu- 
lum, and post-mortem, without the assistance of careful microscop- 
ical work. 
Tyler Smith's division is as follows: 
a. Simple red ring. 
/]. Erosion and partial exposure of the papillae, leaving them 
bare of epithelium, the secretion being mucous, not purulent. 
y. Superficial ulcerations with destruction of papillae, which he 
called granular condition of os uteri. 
He also described under the head of cockscomb granulation, 
what is now called ectropium. 
Carl Mayer distinguishes 
a. Erosions and thickening of the lining of the cervical canal, 
which sometimes though seldom pass on to the outer surface of 
the vaginal portion, although by the thickening the lips are often 
everted, especially in women who have had children. 
/3. Follicular excoriations and ulcerations of the cervical canal 
* The plates illustrating this paper are from advance sheets of the Annals of Gynaecology, 
-kindly furnished by Dr, Cushing. 2 
EROSIONS OE THE CERVIX UTERI. 
with formation of cysts which may ulcerate. With this form 
occur the mucous polyps. 
y. Papillary erosions, where the papillae, lying just under the 
epithelium are denuded, and are often stripped of the outer layers 
of their substance. 
Emmet in 1874, and afterwards, insisted on the importance of 
ectropium, or eversion of the swollen mucous membrane of the 
cervix, with rolling asunder of the lips, showing what might 
readily be taken for an erosion, but is not necessarily such; 
although, particularly when there is a laceration of the cervix, 
secondary alterations of the mucous membrane do occur. 
Other writers have in general followed the above classifications, 
differing on some points, but in the main, agreeing on what seems 
the most natural explanation of the appearances, viz.: That there 
is first a loss of epithelium, laying bare the papillae, that then the 
latter are destroyed, forming an ulcer; the condition when occur- 
ing on the outside of the vaginal portion was supposed to com- 
mence in the follicles. 
There was great difference of opinion as the nature of ectropium, 
while the ovula nabothi were considered as retention cysts of the 
pre-existing mucous glands. 
the photograph, Fig. 1, from *Ruge and Veit's work is seen: 
Fig. 1. A simple erosion (Mayer). 
Fig. 2. The minute anatomy of the same. 
Fig. 3. A follicular erosion (Mayer). 
Fig. 4. An ectropium of the mucous membrane of the 
cervix (Emmet). 
Fig. 5. A portion of the cervix amputated. 
I will not stop to describe more minutely the gross appearances. 
The microscopic figures, however, are very characteristic, and ex- 
plain the position taken by Ruge and Veit that what are called 
erosions, ulcerations, etc., are various degrees of one process, 
which consists essentially in a new formation of glandular tissue, 
on the surface of the vaginal portion, or in the cervical canal. 
The glands are formed by a reduplication, or sinking inwards, of 
the lowest layer of the cells of the rete malpighi, which are devel- 
oped into a delicate cylindrical epithelium, which every where lines 
the glands as well as the parts between them. The latter forming 
*Zeitsch. fur Geburtsh u. Gynaek., Band II, 1878. Martin's Atlas. Hart & Barbour's 
Hand book of Gynaecology. EROSIONS OF THE CERVIX UTERI. 
3 
partitions grow upward, while the glands grow downward; but 
still the projections thus formed are everywhere covered with a 
continuous layer of cylinder epithelium. The process goes on 
under the layer of flat epithelium which naturally covers the cer- 
vix, outside of the cervical canal; this layer is then lost, under- 
mined as it w'ere, but no proper erosion occurs. What was for- 
merly considered as an erosion is a patch where the flat epithelium 
has been replaced by glandular formation; the so-called papillary 
form is where the partitions between the glands have grown up- 
wards (not bare of all epithelium, however). 
The follicles and cysts are not usually enlargements of pre-exist- 
ing ducts, which have been occluded, but are new-formed glands 
without ducts. In ectropium there is essentially the same process 
going on in the cervical canal, and everting the lips. 
The above described active formation of glandular tissue may 
spread over the outer surface of the vaginal portion, where few, if 
any, glands normally exist. It may even extend to the vagina. 
In exaggerated cases it resembles cancer so closely that the best 
experts cannot make a diagnosis without the aid of the microscope. 
In a comparatively large number of cases, cancers of the cervix 
are preceded by this condition of gland formation, or, to state it 
otherwise, these so-called erosions when inveterate not infre- 
quently become cancerous. A pathological condition of this kind, 
where normal tissues are wholly supplanted by new-formed glands 
is at best suspicious, and considered pathologically it is no wonder 
that it often serves as the starting point of cancer. 
The importance of these researches of Ruge and Veit, of which 
I have given a hasty summary, is so great, and their bearing on 
practical gynaecology is so obvious, that it is very strange that they 
have met with so little attention in America, although figured in 
the English edition of Martin's Atlas, and in the work of Hart and 
Barbour. There is hardly an allusion to them in the text-books in 
the hands of the profession here, and until recently they were 
ignored by most of our leading gynaecologists in their writings. 
The original articles being thus inaccessible and neglected, I trust 
it may be interesting to consider some preparations which I have 
made while studying the diseased conditions of the cervix. 
Before considering the latter, however, I will call attention to 
some pictures which I took from the living subject, as, although 
2 4 
EROSIONS OF THE CERVIX UTERI. 
wanting in the diagrammatic instructiveness of the plate of Ruge 
and Veit, they show about what one can see in the speculum. 
The first, Fig. 2, is a case of simple erosion of the cervix (after 
Mayer) in a virgin, who has for years been a sufferer from dysmen- 
orrhcea, having an anteflexion. It is important as showing that 
these glandular hypertrophies, being encountered in virgins, and 
being of the same nature, as we shall presently see, with the mor- 
bid conditions occurring in laceration of the cervix, with ectro- 
pium, it follows that the latter condition is to be regarded not sim- 
ply as a rolling asunder of the lips of a fissured cervix, as Emmet 
describes it, but as an eversion of the lips pushed apart by a gland- 
ular growth, which is the essential disease. 
The next picture, Fig. 3, is from the cervix of a sterile married 
woman with chronic endometritis. A follicular ulceration accord- 
ing to Mayer. Here the glandular cysts can be seen as bright 
spots, reflecting the light from their convex surfaces. 
The next picture, Fig. 4, is from a woman who had borne a 
child, then had a miscarriage, with subinvolution, metritis, and 
finally a high grade of induration of the cervix, requiring excision 
of the glandular mass, which in hardness and general appearance 
closely resembled an incipient cancer, but was not of that nature. 
The tissues were crowded with cysts, extending on to the vaginal 
poition, and as there was no fissure, it was impossible to suppose 
that this new formation of glands was in any sense an eversion of 
the cervical mucous membrane. 
The next case, Fig. 5, shows a badly ruptured perineum, with 
a fissure of the cervix on one side. The lips, as drawn down, do 
not show the eversion which they naturally had, but do show the 
edge of the red thickened mucous membrane, a mass of glandular 
new-growths extending up into the cervical canal. 
Fig. 6 shows an extreme condition where, after a double rent in 
the cervix, with complete rupture of the perineum, the glandular 
hypertrophy was so excessive as to cause a great ectropium, a red, 
secreting, fungous mass. The whole cervix was enlarged, and 
could easily be drawn down by forceps, as seen in the cut, so that 
the os uteri presented externally. 
There is, however, another form which the glandular hyper- 
trophy may take. Instead of growing in the tissue of the cervix, 
the glands, in combination with connective tissue, abundant small EROSIONS OF THE CERVIX UTERI. 
5 
cells and blood vessels may form polyps, or semi-detached masses, 
which bleed easily, secrete abundantly, and thus exhaust the 
patient. 
Fig. 7 shows a lacerated os, containing two such polyps, which 
by continuous hemorrhseges had nearly exsanguinated the patient 
before she applied for relief. 
In calling attention to the next figure, a micro-photograph, I 
desire to acknowledge my great obligation to Dr. M. Greely 
Parker of Lowell, forf his aid and instruction in the making of 
micro-photographs. 
Figs. 8, 11, and 13, were taken by the light of a common 
petroleum lamp, and, as in this manner, without expensive appa- 
ratus it is possible for physicians to record the results of their 
microscopic work, I hope that great benefit will result from a 
general use of this fascinating branch of pathological study. 
I am also under obligations to Dr. W. W. Gannett, of Harvard 
University, for the facilities courteously afforded me in the 
laboratory of that institution when I made the sections from 
which the photographs were taken. 
Fig. 8 represents one of my sections as photographed by 
Dr. Parker with Hartnack 7. The amplification on the plate is 
about 300. It shows the normal mucous membrane of the vaginal 
portion at the edge of the cervical canal. It resembles a section 
of skin, that is, there is a well-defined layer of flat epithelium, a 
lower layer of rounder cells reaching down between the small 
papillae, which come up at intervals, carrying the blood vessels. 
Between the tissue of the papillae and the cells of the rete 
malpighi you see a single layer of cylindrical cells, forming a con- 
tinuous row like the lining of a gland. I would call attention 
particularly to this, because it is from this layer, as Ruge and 
Veit discovered, that the glandular formation proceeds in cases of 
so called erosion. I cannot help thinking, however, that these 
authors overstate the case in considering all erosions as of glandu- 
lar origin. 
The next plate, Fig. 9, is an enlarged photograph of a section 
from a cervix which, microscopically, certainly appeared to be 
eroded, and yet there are no glands to be seen Nevertheless, an 
inspection of the specimen shows that the principle is the same, 
for you see that the cells of the rete malpighi are in very active 6 
EROSIONS OF THE CERVIX UTERI. 
proliferation, and form processes which are growing downward, 
while, at the same time, the papillae lying between them are 
longer, so that the surface is actually raised. Between the patches, 
rapidly enlarging pouches of epithelium are places where the sur- 
face is depressed and flat, and there are no signs of papillae nor 
any distinct layer of flat epithelium. 
The contrast between the patches, where thickening has occurred 
as above described, and the intervening depressed flat places, is so 
great that the surface would readily be classed as eroded, and yet 
in no place is the epithelial covering wholly lost, although the flat 
epithelium has disappeared in many places. 
The next plate, Fig. 10, is from a micro photograph (of 50 
diameters) of the pouches of proliferating epithelium surrounding 
the long and slender papillae, which here reach nearly or quite to 
the surface. The thickness of the epithelial layer is at least six 
times that of the normal layer (vide Fig. 8). Each papilla is 
clothed with a layer of cylindrical cells, more or less distinct, and, 
of course, thus the lining of the glandular pouches is the same 
layer as the investment of the papillary septa. This continuous 
layer is preserved in all cases of " erosion," and it is precisely the 
breaking through of this layer of cylindrical epithelium by the 
cells contained in the pouches which, in constituting a real ulcer, 
also implies a cancerous invasion. 
Fig. 11 is a photograph (100 x) of the depressed flat part, 
which shows, in the submucous portion, a great abundance of 
round cells sprinkled through the stroma, no papillae, and a total 
loss of the layer of flat epithelium, which can be seen at one end 
tapering away. The layer which represents the mucous membrane 
is a mass of rapidly proliferating cells of the rete malpighi, which 
take the color readily, and evidently clothe the subjacent stroma, 
in lieu of a better mucous membrane. I see no reason why this is 
not a fair example of a simple erosion, although Ruge and Veit 
apparently do not admit the existence of such a condition. There 
is no sign of new formation of glands, such as I will show you 
presently. 
Possibly in these cases medical treatment had brought about a 
cessation of the morbid process and an attempt at healing with 
hypertrophy of the connective tissue. Yet the fact remains that, 
in what, after death, on examination, by the naked eye, by myself, 
and by others well qualified to judge, were considered as specimens EROSIONS OF THE CERVIX UTERI. 
7 
of slight erosions of the cervix there was no such grandular for- 
mation as Ruge and Veit describe, but only what seemed to be a 
subsequent stage. I mention this because our ideas on the 
pathology of the condition of erosion are bound to have an impor- 
tant influence on our treatment, as I shall hereafter show. 
The next plate, Fig. 12, shows two sections from an eroded 
cervix. In the first the cervical canal is included, and the other 
section is slightly more lateral You observe the epithelium of the 
lips very much thickened, with long thin papillae, as in the other 
specimens already shown; but nearer the os the flat epithelium is 
lost, and there is an evident erosion. You also see between the 
lips a section of a small polyp, or mass of mucous membrane, 
which, in the original specimen, was pear-shaped and rather loosely 
attached. On the left is a large gland in process of development 
to form a cyst or ovulum nabothi. In some places the whole 
epithelial layer seems ready to separate, and at one side it is lost, 
leaving the papillae bare, as described by the early authors. This, 
however, is a post-mortem change due to maceration, while the 
manner in which the epithelium is lost during life is by an under- 
mining of its attachment by a growth of glands, such as can readily 
be detected here in many places with a microscope. 
The next plate, Fig. 13, shows such a spot in one of the pre- 
ceding sections, magnified three hundred times, as photographed 
by Dr. Parker. The enlarged papillae are seen at one side, rising 
up through masses of swollen flat epithelium;-everywhere, 
however, clothing the papillae, and separating them from their 
covering, can be traced the layer of cylinder epithelium to which I 
particularly called your attention in showing the first micro-photo- 
graph. Gradually, however, this layer becomes flat, and then dips 
down and is reduplicated, forming a grandular space, and it is 
easy to see that the masses of flat epithelium above are thus 
sundered from their resting-place, and ready to fall away, leaving, 
as the process spreads, a red, raw-looking secreting surface 
depressed below the immediate border of thickened papillae, in 
fact a so-called erosion. 
Fig. H shows such a gland which has pushed its way deep into 
the muscular tissue of the cervix, where, normally, no such gland 
should occur. This plate shows that, in speaking of glands, one 
does not refer to any mere folds of mucous membrane, but to 
a typical acinous structure. 8 
EROSIONS OE THE CERVIX UTERI. 
Fig. 15 shows the arrangement of the glandular spaces in a 
mucous or glandular polyp. Here, however, the process is some- 
what different, for instead of a loss of the fiat epithelium of the 
cervix and a substitution for it of the glandular hypertrophy, in 
the mucous polyp there is an exaggeration of the conditions obtain- 
ing in the mucous membrane of the cervix. The small points in 
Fig 15 dotting everywhere the inter-glandular spaces are the 
nuclei of rapidly proliferating small cells, which fill the tissue of 
the polyp and contribute to its rapid growth, while the large 
capillaries account for the tendency to hemorrhage. 
The specimen from which this section was made was plucked 
with forceps from the patulous cervix of a young lady of sixteen 
years, who had had a considerable haemorrhage, and had passed a 
mass from the vagina, probably a blood-clot. A consulting physi- 
cian suspected an abortion, and brought me the specimen for 
examination, thinking it was part of a placenta. The result of my 
examination, which showed that it was simply a thickened bit of 
mucous membrane, with hypertrophy of the glands, restored 
tranquillity to a distinguished family. 
In bad cases the process represented by Fig. 13 does not stop at 
the surface, but goes on, as previously described, until the whole 
mucous membrane is a thickened mass of glands, filled with cysts. 
In cases where there is any rent in the cervix the swollen mucous 
membrane pushes the lips apart, forming, secondarily, the.ectro- 
pium described by Emmet. 
I think, however, if I understand Emmet aright, that he errs in 
considering the eversion as directly a consequence of the laceration 
of the cervix; in fact, as only an exposure to sight of a not very 
abnormal cervical mucous membrane. As I understand it the 
process is just the opposite, i.e., the mucous membrane becomes 
diseased from some cause not at present fully understood. Person- 
ally, I believe that the "irritation" is due to some form of 
bacterial growth. 
Where there is a laceration, of course the cervical canal is more 
accessible, and more ready to take on disease; but without 
lacerations, and even in virgins, as previously shown, the same 
glandular endometritis goes on. Where there is no laceration the 
growth is more compressed, and spreads more or less evenly in a 
ring round the os uteri, actually supplanting the flat epithelium 
normally clothing the vaginal portion. The existence of a lacera- EROSIONS OF THE CERVIX UTERI. 
9 
tion permits of an eversion of the swollen lips, and thus secondarily 
adds to the irritation. 
But, even in these cases, the whole surface of the erosion is 
usually not everted cervical mucous membranes, as it is frequently 
represented to be, and as I understand Emmet to regard it. On 
the contrary, the process of glandular growth, and cystic degen- 
eration, spreads beyond the boundary where flat epithelium should 
commence The everted lip of the lacerated os is thickened, and 
elongated, by being actually stuffed with the degenerate glands 
(vide Fig. 6), and these may really spread to the vaginal surface of 
the cervix and even to the vagina. 
It becomes a very nice question to determine whether such a 
cervix is cancerous or not, for the simple reason that in some 
cases the diagnosis cannot be made without the microscope, and it 
has frequently happened that cervices have been amputated as 
cancerous which were only in glandular degeneration; and, on the 
other hand, that after a laborious treatment of an eversion or 
ulceration, it has been found to be malignant. 
This fact has an important bearing on treatment, for, if it is a 
fact that an everted and glandular cervix is more liable than a 
healthy one to become cancerous, it is plain that it must be radi- 
cally healed as soon as possible, even at the trouble and inconven- 
ience of surgical measures. If, on the other hand, it is a pure 
coincidence that some eroded and ectropic cervices become cancer- 
ous, and if we should believe that they would have become so even 
if not previously diseased, the indications for heroic or surgical 
treatment are not nearly so strong. The question is a very diffi- 
cult one, and there is a great difference of opinion on it among 
physicians. I think that I am safe in saying that where there are 
the greatest opportunities for observation, and where the habit of 
early removal of portions of suspected tissue, and of careful micro- 
scopic study of such specimens prevails, there is a consensus of 
opinion that a condition of laceration, eversion, and glandular or 
cystic degeneration of the cervix, predisposes very decidedly to 
cancer, under which name I mean to include epithelioma. 
Not to go further into this question here, I will refer to the 
decided statements in support of this view made by Dr. Beamy, 
the President of the .American Gynaecological Association at the 
meeting of that body in 1886. 1 believe that the members present 10 
EROSIONS OF THE CERVIX UTERI. 
did not dissent from nor oppose Dr. Reamy's statement of opinion 
on this subject. 
The results of American clinical observation thus appear to sup- 
port the doctrines taught in Germany, which are the result not 
only of the study of a vast number of cases, but of careful patho- 
logical investigations, all emphasizing the fact that diseased cer- 
vices are more liable to cancer than sound ones. 
A little reflection will show how natural this is, when we realize 
how narrow is the line which separates the heterologous glandular 
development invading new tissues, with its immense reduplication 
and proliferation of epithelium external to the continuous base- 
ment membrane of the glands, from a cancerous degeneration, 
where the cells, breaking through into the lumen of the glands, 
grow inward, forming solid plugs or processes instead of hollow 
tubes or acini. The subject is of great interest, and I hope at 
some future time to speak further on it, showing preparations and 
photographs of the transition of glandular ''erosions" into cancer, 
which will, 1 am sure, impress others as they have impressed me 
with the importance of curing the preliminary disease as thor- 
oughly, and radically, and quickly as possible. 
TREATMENT. 
In the matter of treatment of erosions, everything depends on 
the condition of the uterus; for the erosions are merely to be con- 
sidered as a symptom of a glandular endometritis, which has 
become visible, .either by spreading beyond the normal limit of the 
cervical columnar epithelium on to the portio vaginalis, or by 
everting a more or less patulous or lacerated os; thus, in either 
case coming into the field of view, particularly when a bivalve 
speculum is used. 
For convenience it is well to divide the cases into - 
(a.) Those of so-called simple erosions in virgins or nulliparae, 
associated with anteflexion of the uterus, or with stenosis of the 
os, or with elongation of the cervix, or with various combinations 
of these conditions, in most cases causing dysmenorrhcea. 
(6.) Erosions and endometritis of moderate degree, with subin- 
volution, following parturition. 
(c.) Erosions with ectropium, as complications of a laceiated 
cervix. In either of the last two classes there may be a more or EROSIONS OF THE CERVIX UTERI. 
11 
less complete rupture of the perineum; in any case there may be 
parametritis, pelvic peritonitis, salpingitis, adhesions, etc. 
(</.) Inveterate cases with induration of cervix, and suspicion 
of commencing malignant degeneration. 
I believe that nearly all cases will fall into one or the other of 
the above categories, and I believe that, except in the second class, 
and provided there is no inflammatory trouble in the parametrium, 
by far the most satisfactory results are to be obtained by surgical 
measures. 
For the first class of cases, those of erosions in cases of ante- 
flexion, the last being usually congenital, or a survival of the 
infantile form, aggravated by repeated menstrual congestions, 
there are three modes of treatment, viz.: First - The medical, 
comprising douches, dilatations, tampons with medicated glycerine, 
or boro-glyceride, intra-uterine applications, etc. This has been 
admirably elaborated and described by my friend, Prof. Wylie, 
and in many cases with care and persistence, it is effectual. 
However, it is a rather serious matter to condemn a virgin to a 
long course of local treatment, and with the best of care it often 
fails to give satisfactory results, even in sterile married women, 
where ethical objections have less weight. This treatment, how- 
ever, skillfully applied, is, I believe, usually inferior to surgical 
interference. 
Second.- Slitting the cervix, at one time in vogue, and lately 
recommended, may have its place in certain intractable cases, 
where the cervix is extremely hard, but such cervices must be very 
rare, except as complicated with a state of hypertrophy, better 
cured by partial amputation, i.e., of the excesses of tissue. 
Third.- For the vast majority of such cases, in fact for all but 
exceptional ones, and particularly where there is endometritis and 
stenosis of the os, it is much better to advise an operation at once; 
for, if properly done, with complete antiseptic precautions, there is 
no danger, there is little subsequent discomfort, and a speedy and 
satisfactory cure. 
The patient is etherized, the vagina well washed with sublimate 
solution 1: 2000, the cervical canal well disinfected with a stronger 
solution of the same on an applicator, the os dilated with Goodell's 
strong dilator, or Wylie's modified Sims' dilator, the diseased 
mucous membrane scraped opt with a Sims or a Martin-Recamier 
3 12 
EROSIONS OF THE CERVIX UTERI. 
curette or a sharp spoon, removing thoroughly the glandular 
hypertrophy. 
Injection of iron solution is not necessary, although advised by 
many. 
If there is hypertrophy of the cervix it is to be removed, or if 
there is anteflexion, a stem pessary, well disinfected and rubbed 
with iodoform, is to be introduced into the uterus, after the latter 
has been carefully washed out with the sublimate solution. 
Some iodoform-wool is placed against the end of the stem to 
retain it, and remains there for two or three days. 
The patient keeps the bed for a week, and then the stem is 
removed with antiseptic precautions. In a few days more she may 
get up, and the suffering and trouble are usually found to be 
cured; the eiosions, naturally, are gone. Seldom is after-treatment 
necessary. 
Such a case with such a result is represented by the first photo- 
graph, Fig. 2, and I could report a series of similar cases with 
equally satisfactory results, operated on by Dr. Marcy and myself. 
I suppose that it is hardly necessary to insist here on the fact 
that neither this nor any other operation on the cervix is to be 
undertaken while there are acute inflammatory processes going on 
in the uterus or the parametrium. Emmet has sufficiently pointed 
out the necessity of removing all inflammation by rest, hot douches, 
tampons, etc. 
With our present knowledge of the frequency of salpingitis, 
and of the bacterial exciters of inflammation, we can understand 
better than formerly the reasons why the precautions are neces- 
sary, and how often the whole focus of inflammation can be 
removed in the form of a diseased fallopian tube. For cases of 
stenosis with elongation of the cervix, erosions, and endometritis, 
mere dilation is often not sufficient, and it is desirable to remove 
a portion of the hypertrophic tissue, and at the same time to 
restore the proper shape to the cervical canal and os externum. 
It is not my present purpose to enter into the question of the 
choice of operations; the habit and skill of each surgeon may ac- 
complish a good result in various ways. 
The next class of cases is where, after parturition, although 
there is little laceration of the cervix, the uterus remains subinvo- 
luted. with endometritis and erosions. 
I believe that in these cases the subinvolution is caused by the EROSIONS OF THE CERVIX UTERI. 
13 
endometritis and not vice versa, i. e., they are the results of a mild 
sepsis, or bacterial infection; and precisely these cases, when not 
too inveterate, are susceptible of cure by antiseptics, such as nitrate 
of silver, tincture of iodine, or strong carbolic acid; of these the 
latter applied thoroughly, on a cotton holder, is the most effective. 
Of course, hot douches, and ergot, strychnia, etc., are also indicated, 
with vaginal tampons of glycerine 14, alum 1, boroglyceride 1, 
as recommended by Wylie. 
Even in old cases, where the uterus is enlarged and hardened, 
much good can be accomplished by this sort of treatment, but the 
results are not usually very satisfactory; and in the next class of 
cases, where there is cervical laceration, the indications for surgical 
interference are even more imperative. 
Nevertheless, where want of courage, or opportunity, on the 
part of the patient, or a want of faith in surgical measures on the 
part of the physican. exclude operative interference, the patient 
can be made comfortable, and with patience sometimes apparently 
cured without operation. Some women have such a horror of a 
knife that they will go about all their lives with a lacerated cervix 
and ruptured perineum, never being quite well, and requiring 
more or less perpetual treatment, rather than undergo an operation. 
This state of mind is not confined to women; in fact I think they 
are braver than men, who when they have hemorrhoids, or her- 
nia, hydrocele, or spermatocele, are notoriously unwilling to undergo 
any radical operation, but find that their u business " requires it to 
be perpetually postponed to a more convenient season. 
For such women much can be accomplished, even in cases of 
ectropium, by puncturing the cysts, scraping off as much of the 
glandular structure as is possible under the influence of cocaine, 
and applying at intervals strong carbolic acid to the diseased mu- 
cous membrane. 
The dry treatment as used by Dr. Engleman is very effective in 
healing the erosions, and promoting involution of the everted lips. 
He dusts the parts with iodoform, and packs against the ero- 
sions balls of iodoform-cotton wool, about an inch in diameter, each 
of which balls is enclosed in a thin layer of styptic iron-cotton. 
This remains in place for two or three days, when it is removed 
and a new dressing applied. 
Under this treatment, without douches or glycerine tampons, 
the erosions heal, the glands diminish, and the everted lips come 14 
EROSIONS OF THE CERVIX UTERI. 
together. Dr. Engleman was kind enough to show me several 
such cases in St. Louis, and it struck me as a very nice, clean, and 
effective treatment. 
Apostoli, of Paris, who has been kind enough to send me his 
pamphlet, uses a constant current of electricity., with one pole in 
the uterus, and with a large pad of fuller's earth for the other pole 
on the abdomen; by this means a current of high tensile strength can 
be used without much pain, which effectually arrests the glandular 
development in the endometrium, causing an eschar, and thus in 
Apostoli's opinion, answers the purpose of a curetting. 
Where there is not much laceration of the cervix, nor rupture 
of the perineum, these various measures answer very well for pa- 
tients who have a fear of operative measures, and have a skillful 
and persevering physician. 
Nevertheless, it seems to me more scientific and satisfactory to 
give the patient ether, scrape out the uterus after thorough disin- 
fection, remove the. glandular hypertrophy at once, repair the 
lacerations, make a good os, covered with flat epithelium, and thus 
cure the patient. 
At the same time, if, as is very frequently the case, there is a 
rupture of the perineum, possibly complicated with cystocele or 
rectocele, the perineum can be repaired, and the appropriate col- 
porraphy performed, to remedy the other lesion. 
With little pain, and no fever, the patient thus gets in an hour 
a, benefit which she can seldom receive in years of local medical 
treatment. 
How much more, then, in cases where there is any symptom of 
malignant degeneration of the erosions, is it the plain duty of the 
attendant physician to recommend thorough removal of the sus- 
pected tissues? 
The consensus of authority all over the world asserts that in- 
veterate cervical erosions are peculiarly liable to cancerous degen- 
eration. 
I hope that the foregoing figures have made it clear that these 
so-called erosions are not in any sense losses of substance, caused 
by mechanical irritation, etc., but that they are an active new for- 
mation of glands, prone to recur, even when removed, readily in- 
vading the portio vaginalis, where it should be covered by flat 
•epithelium, and thus, by all analogy of pathology, they are to be 
viewed with suspicion, and removed with thoroughness. EROSIONS OF THE CERVIX UTERI. 
15 
Every one who is in a position to see many cases of cancer of 
the cervix knows that it is the saddest part of his mournful duty 
to tell the patient that it is " too late to remove it all," and in no 
one thing is a greater advance in practice to be hoped for than in 
the early recognition and removal of whatever seems either malig- 
nant, or doubtful, or so inveterate as to be likely to be an early 
stage of that most dreaded of all the ills to which the sex is sub- 
ject, viz., a cancer of the womb. 
Dr. Carrnalt expressed his gratification at Dr. Cushing's very 
beautiful illustrations as being an exceedingly clear demonstration 
of the transition of adenoma (as the glandular hypertrophy that 
Dr. Cushing demonstrated histologically is) into carcinoma, and as 
thereby confirming the views he had held and taught for many 
years. It is a further demonstration, if any were needed, of the 
correctness of the Thiersch and Waldeyer theory of the epithelial 
origin of carcinoma, a theory now very generally, though not 
universally accepted, but which is, as in this case, constantly 
receiving confirmation by investigations in the various fields of 
surgery and pathology. Dr. Carmalt had not had the opportunity 
to study the development of carcinoma from an adenoma in this 
particular locality, but he had studied it so frequently in the 
external skin, had seen it developing from sweat glands and hair 
bulbs and sebaceous follicles, as well as from the rete Malpighii, 
that the demonstrations of the evening, by reason of the similarity 
of structure and arrangement, seemed almost familiar. Dr. Car- 
malt desired to refer to the illustrations as also indicative of the 
local origin of cancer, and the text of Dr. Cushing's paper, while 
not directly stating so, was capable of this interpretation, inasmuch 
as he referred to the well-known clinical fact of the liability of 
cancer to attack persons who have had old "unhealed erosions" or 
glandular hypertrophy, as Dr. Cushing designates it, -the illustra- 
tions showing just how this took place by the invasion of the 
deeper layers of epithelium under the influence of a long-con- 
tinued irritation (" unhealed erosion ") into the connective tissue 
substratum. Our honored colleague, Dr. Emmett, has insisted 
upon the necessity in practice of making the incisions deep 
enough to get healthy tissues in apposition, so that union may 
take place; that means, as we see by Dr. Cushing's demonstration, 16 
EROSIONS OF THE CERVIX UTERI. 
that the deeper layers of the glandular hypertrophy, the adenoma- 
tons new growth, must be entirely eradicated, or it will continue 
to grow, and, ultimately penetrating the deeper strata of connective 
tissue, take on the uncontrolled, unformed, immature growth char- 
acteristic of carcinoma. 
The necessity of the careful removal of all tissues which may 
by any possibility contain the elements of a cancerous growth, 
that is. epithelial processes growing irregularly in the midst of 
connective tissue, extends, however, beyond the immediate locality. 
Billroth first formulated the important difference between carci- 
nomas and sarcomas with regard to their generalization, that is, 
that, in the great majority of cases, the former generalized by 
means of the lymphatic system, and the latter by the blood ves- 
sels. Now we know that practically every secondary deposit is a 
focus for the further spread of the disease; and in this we see the 
necessity of enlarging the field of the operation beyond the part 
first affected, in order to search most thoroughly for any involve- 
ment of the neighboring lymphatic glands. In cancers of the 
breast this is so emphatically the case that all surgeons who are 
abreast of the times include a cleaning out of the axilla in their 
operations. It is not enough to say that we cannot detect any 
enlarged glands by palpation through the external skin; the skin 
must be cut through and the dissection carried down to glands 
themselves before one can assure himself or his patient that " all 
disease has been removed." This is so emphatically the case that 
Dr. S. W. Gross of Philadelphia, with whose work on "Tumors of 
the Mammary Gland" you are all doubtless familiar, told me that 
it was his general custom to make his first incision in the axilla 
and clear that out before the removal of the breast. If the axilla 
could not be satisfactorily cleared out, he preferred to desist from 
the operation, to close up the axillary wound, and leave the breast 
untouched. 
I beg the society to excuse this digression from the subject 
immediately under discussion. I only refer to it to emphasize the 
point Dr. Cushing has made, of the necessity of a thorough 
removal of all the diseased (hypertrophied) glandular tissues. 
Dr. Storrs seconded the motion and remarked: " I would like to 
ask Dr. Cushing a single question, suggested in part by the 
remarks made by Dr. Carmait. I believe with Dr. Carmalt that in 
excision of the breast for carcinoma, good surgery demands that EROSIONS OF THE CERVIX UTERI. 
17 
the glands and the lymphatics should be thoroughly removed, even 
if the dissection had to be carried to the clavicle. But I think that 
it would be easier to do this after the breast was removed. We 
can not in carcinoma of the womb liken the operation to that of 
amputation of the breast, since we are unable to remove the 
affected vessels and glands beyond the disease. The question I 
would ask Dr. Cushing is, if he would attempt the removal of 
uterine cancers for advanced cases?" 
Dr. Storrs mentioned having recently seen a case - seen for the 
first time where the vagina was infiltrated so that a digital 
examination could hardly be made. Could such a case, he asked, 
be one where an operation would be justifiable ? He said that in 
his experience he had seen no benefit in the operation for the 
advanced cases. 
Dr. Ingalls added: " I most cordially agree with Dr. Cushing in 
the importance of early operation in these cases of malignant dis- 
ease of the uterus, and believe that when uterine tissue only is 
involved, the early removal of the diseased structure affords the 
patient great relief, as well as prolongs her life, but I must take 
issue with him when he says that he advises operating where the 
cancer has invaded the cellular tissue adjacent to the cervix. It 
has been my experience in such cases, that the very fact of operat- 
ing seems to add a stimulus to the growth, which rapidly passes on 
to a fatal termination, and I believe that it is almost useless to 
attempt an operation unless you can get beyond the diseased struc- 
ture into sound tissue. In these cases such a procedure is well 
nigh impossible, for the cancer has generally so far infiltrated the 
vesico-vaginal and the recto-vaginal septa, that to get anything 
like the whole of it away would involve the creation of fistulae; 
and so firmly do I believe this, that my advice to all patients who 
come to me afflicted with cancer which has involved the cellular 
tissue about the uterus is not to have any operation, and 1 believe 
they live just as long and in the end are better off " 
Dr. Nelson remarked: " Dr Cushing was speaking of mitigat- 
ing symptoms by excision of the cancerous cervix. In Jan., 1883, 
a woman, multipara, 39, had had repeated monthly hemorrhages, 
very alarming, from some growth upon the anterior cervix. The 
entire anterior cervix was easily removed, there being a body, in 
in some degree encysted, as large as a small egg, easily detached, 
but the whole anterior cervix was excised. The only fault was, 18 
EROSIONS OF THE CERVIX UTERI. 
that we did not excise the posterior also, but it did not seem at all 
involved. The growth we found could be grossly classed as 
sarcoma, and the microscope revealed spindle-shaped and caudate 
cells with nuclei. In April she had two hemorrhages, a fortnight 
apart, not very troublesome, and no more. She had two years of 
comparative comfort, but in the year 1885 the rest of the neck 
and the fundus became involved, and she died Feb., 1886, more 
than three years after the operation. The neck was readily brought 
to the external vaginal os. so that a complete amputation could 
easily have been done. There was never after the operation any 
really troublesome hemorrhage." 
Dr Avery stated the history of a case of his, where the womb 
and the vagina and labia were involved in a hard cancerous 
mass. A speculum could not be passed into the vagina, and the 
finger could barely be introduced; the diseased mass felt exceed- 
ingly hard, and blood readily flowed upon manipulation. Exami- 
nation per rectum revealed implication to the vaginal septum. Now 
the question Dr. A. desired to present was: If with these condi- 
tions Dr. Cushing would advise extirpation by surgical operation. 
Dr. Cushing replied that cases of this kind should not be ex- 
cluded from possible surgical amelioration.