INFLAMMATION OF THE CERVICAL MUCOUS MEMBRANE (CERVICAL CATARRH).
The mucous membrane of the cervical canal may be the seat of acute or
chronic inflammation. Acute inflammation usually occurs as part of
a general acute process affecting the whole of the endometrium, and
is commonly the result of gonorrheal or septic infection. It will be
considered under General Endometritis.
Chronic inflammation of the mucous membrane of the cervical canal
(cervical catarrh or cervical endometritis) is an exceedingly common
affection. Unless caused by gonorrhea, it is nearly always secondary to
some local or general condition.
The pathological changes that take place in the mucous membrane
resemble those found in a similar process in other parts of the body.
There is a very marked congestion and hypersecretion of the racemose
glands of the cervical canal, so that the most prominent symptom of
cervical catarrh, a profuse cervical leucorrhea, is produced. This
discharge resembles the normal secretion of the cervical glands. In
its physical properties it is characteristic. It is a thick, tenacious
mucus, and differs decidedly from the thin, more serous discharge from
the vagina or from the body of the uterus. The discharge is often
opaque; it is rarely purulent, and is very rarely streaked with blood.
The mucous membrane of the cervical canal becomes swollen, and may
project or prolapse beyond the limits of the external os, so that the
external os has around it a ring of red congested mucous membrane. A
similar condition is observed on the eyelids in conjunctivitis. Such a
prolapse of the mucous membrane would bring the orifices of some of the
racemose glands upon the vaginal aspect of the cervix, where it will
be remembered they are not normally present. The inflammatory action
extends beyond the limits of the external os on to the vaginal aspect
of the cervix. The squamous epithelium exfoliates over a limited area
around the external os, and there is produced an erosion resembling
that already described under Laceration of the Cervix. Consequently,
the red eroded area surrounding the external os that appears in
many cases of chronic inflammation of the cervical mucous membrane
is due to extension of the inflammatory process on to the vaginal
aspect (with desquamation of the superficial squamous cells) and to
prolapse of the mucous membrane of the cervical canal. The racemose
glands may become obstructed, either as a result of thickening in the
character of the secretion or of occlusion of the orifices, and small
retention-cysts are formed, which often fill the body of the cervix,
and, extending peripherally, appear beneath the mucous membrane of
the vaginal aspect. The cervix is then said to have undergone cystic
degeneration. Deep-seated inflammatory changes may also take place as a
result of cervical catarrh, so that at first a slight hypertrophy from
inflammatory exudate results, and later the formation of connective
tissue produces a sclerotic condition of the cervix.
As has been said, chronic cervical catarrh, unless of gonorrheal
origin, is nearly always secondary to some local or general condition.
The most usual cause of the disease is laceration of the cervix,
which causes inflammation of the mucous membrane by direct injury and
exposure.
The various flexions and displacements of the uterus are often
accompanied by cervical catarrh, which probably is caused by the
chronic congestion brought about by interference with the circulation
of the body and cervix. The use of frequent douches of cold water to
prevent conception is said to result in chronic inflammation of the
cervical mucous membrane.
Imperfect involution after labor, miscarriage, or menstruation may
cause cervical catarrh from the chronic congestion that results.
Gonorrhea seems in many cases to be communicated directly and primarily
to the cervical mucous membrane, and results in a most obstinate form
of chronic inflammation.
The scrofulous and tubercular diatheses seem undoubtedly to predispose
a woman to chronic inflammation of the mucous membrane of the cervix,
as of other mucous membranes of the body. Cervical catarrh often
appears in such women without any local lesion to account for it. The
severity of the local trouble depends upon the general condition,
diminishing when the general health improves.
In all cases of cervical catarrh, even though dependent upon a distinct
local lesion like a laceration of the cervix or a flexion of the
uterus, the severity of the catarrh, as measured by the quantity of the
discharge, is very much dependent upon the general health. The woman is
often troubled by leucorrhea only at those times at which her general
health is impaired by overwork, anxiety, or from some other cause;
and even though the disease may be apparently cured by appropriate
treatment, the symptom, leucorrhea, is very apt to reappear whenever
the woman is subjected to such depressing influences.
The most conspicuous =symptom= of cervical catarrh is the
leucorrhea--the discharge from the cervical glands. As has already
been said, in its physical properties it is characteristic. It is a
thick, opaque, tenacious mucus. The quantity is often so great that the
clothes of the woman are soiled and she is obliged to wear a napkin.
There may be present slight backache and a feeling of vague discomfort
or pain in the pelvis as a result of the inflammation of the cervix.
It is difficult, however, to separate symptoms referable distinctly to
the cervical inflammation from those due to the primary trouble, to
which the cervical inflammation is also to be attributed. The only one
distinct symptom of cervical inflammation is the leucorrhea.
Digital examination in a case of cervical catarrh usually reveals an
altered condition of the cervix. The vaginal cervix may be somewhat
enlarged and soft in the early stages of the disease, or cystic and
sclerotic in the later stages. The external os is usually enlarged,
often admitting the tip of the index finger even in those who have not
suffered with laceration of the cervix. The prolapsed mucous membrane
is present, and the erosion may be readily felt around the external
os, being easily distinguished from the smooth, less velvety squamous
mucous membrane of the vaginal aspect.
Speculum examination shows a congested vaginal cervix and a patulous
external os around which is the red erosion already described. Escaping
from the external os is seen the thick cervical mucus, which is often
so tenacious that it may be lifted from the cervical canal with forceps.
The diagnosis of cervical catarrh is usually very easily made from a
consideration of the signs described. The important thing in any case
is to determine the cause of the inflammation of the cervical mucous
membrane, in order that the proper treatment may be directed to it.
=Treatment.=--As has been said, cervical catarrh is always secondary
to some local or general condition, except in the case of direct
gonorrheal infection. The gonorrheal cases must be determined by the
history of the disease and by the distinctive signs of gonorrheal
infection which will be described later.
In every case of cervical catarrh a thorough examination to determine
the local cause of the disorder must be made. If, as will usually be
the case, such a local cause is discovered, the treatment should be
applied to it, and the inflammation of the mucous membrane may be
disregarded, with confidence that it will disappear when the exciting
cause is removed. Many cases are treated by local applications,
the whole attention of the physician being wrongly directed to the
secondary condition, while the exciting lesion, such as laceration of
the cervix, subinvolution, or a flexion or version, is neglected. Such
treatment, of course, results in but temporary benefit.
Besides such cases of chronic local inflammation dependent upon a
distinct local lesion, there are many others in which the catarrh is
but a local manifestation of a general state of depressed or poor
health, or of a distinct dyscrasia like tuberculosis, syphilis, or
scrofula. Local treatment in such cases, to the neglect of the general
health, is wrong.
If the advice here given--to seek for the primary cause of the cervical
catarrh and to cure it--is followed, it will be found that there are
but very few cases that depend for cure upon local applications. Simple
local treatment by douches, etc. may, however, be valuable aids in
hastening the cure of the disease after the exciting cause has been
removed.
The treatment may be considered under two heads, the general and the
local treatment.
General tonic treatment is required in most cases of protracted
cervical catarrh. The preparations of iron are the most valuable in
this condition.
The contraindication to the use of iron in uterine disease is
menorrhagia or metrorrhagia--profuse bleeding from the uterus. If in
any case this symptom is present, and it is found that the bleeding is
increased after the administration of iron, then this drug should be
discontinued.
The following are useful prescriptions in those cases in which iron is
indicated:
Bland’s pill, the prescription for which may be written:
℞. Pulv. ferri sulph. exsic.,
Potass, carb. puræ, _āā._ ʒij.
Ut fiat, massa dividenda in pilulas No. xlviii.
Sig. One pill three or four times a day.
Basham’s mixture, the formula for which is--
℞. Tinct. ferri chloridi, fʒiss;
Acidi acetici diluti, fʒij;
Liquor, ammoniæ acetat., fʒxiv;
Elix. aurantii, fʒvj;
Glycerin., f℥j;
Aquæ, f℥iv.
M. Sig. Tablespoonful after each meal.
The prescription which Professor Goodell called the “mixture of the
four chlorides” is--
℞. Hydrarg. chloridi corrosivi, gr. j-ij;
Liq. arsenici chloridi, gtt. xlviij;
Tinct. ferri chloridi,
Acidi hydrochlorici dil. _āā._ fʒiv;
Syrupi, f℥iij;
Aquæ, ad f℥vj.
M. Sig. One dessertspoonful in a wineglassful of
water after meals.
This prescription should not be given for more than two weeks at a time.
Careful attention should always be paid to the regularity of the
bowels, in order to prevent pelvic congestion, which may result from
constipation.
Two or three drams of Rochelle salts may be administered in a
tumblerful of water every morning, one hour before breakfast.
A useful prescription, combining the saline purgative and the iron, is--
℞. Ferri sulph., gr. xij;
Magnes. sulph., ℥iss;
Sodii chloridi, gr. xij;
Acid. sulph. dil., ʒiss;
Infus. quassiæ, ad ℥vj.
M. Sig. One tablespoonful one hour before meals.
An excellent laxative pill is--
℞. Extract. colocynthidis,
Extract. hyoscyami, _āā._ gr. x;
Massæ hydrargyri, gr. xx.
M. Fiat massa dividenda in pilulas No. xx.
Sig. One pill three times a day.
Strychnine in addition to the iron is often a most useful medicine in
cervical catarrh.
Various medicines have been administered internally to control the
hypersecretion from the cervical glands. Such therapeutics, however, is
not to be relied upon.
Any distinct pathological condition, like tuberculosis or syphilis,
should, of course, receive the appropriate treatment.
Local treatment may be directed to the vaginal aspect of the cervix
or directly to the cervical canal. The former treatment should always
be tried first, and it will usually be found sufficient. It consists
of the administration of hot vaginal douches, the application of
Churchill’s tincture of iodine to the vaginal vault, and the use of the
glycerin tampon as described under the treatment of laceration of the
cervix. Puncture of the cervix in order to produce local depletion, as
already mentioned in the preparatory treatment of laceration of the
cervix, may also be tried.
If any case of cervical catarrh persists after the cure of the primary
local or general lesion, in case such a lesion is present, and after
the additional local treatment by douches and applications to the
vaginal vault, then we may be obliged to make applications directly to
the mucous membrane of the cervical canal.
These applications should be made as follows, any time in the menstrual
interval being appropriate: The cervix should be exposed through the
Sims or the bivalve speculum, and should be steadied by seizing it with
a tenaculum. The cervical canal should then be wiped out with cotton
either in the grasp of long thin forceps or upon an applicator. The
cervical mucus should be removed in this way, in order to permit the
direct application of the desired solution to the mucous membrane. The
applicator or forceps, armed with cotton saturated with the solution,
should be introduced in the cervical canal and applied to all portions
of the mucous membrane.
In place of the applicator we may use the glass pipette or
instillation-tube (Fig. 110), as recommended by Skene. This instrument,
charged with a few drops of the solution, should be introduced as far
as the internal os, and the solution should be expressed as the pipette
is slowly withdrawn.
[Illustration: FIG. 110.--Instillation-tube.]
In most cases of cervical catarrh the external os is sufficiently large
and the canal sufficiently patulous to permit the applications already
described. Sometimes, however, when the external os and the canal are
contracted, it is desirable to dilate slightly with the small uterine
dilators before making the application. Such dilatation to one-quarter
or one-half an inch may be performed without an anesthetic, and may be
repeated as often as necessary.
Various solutions are used for application to the cervical canal.
Violent caustics should be avoided. The solutions of mild strength
are preferable. A solution of 1 or 2 grains to the ounce of chloride
of zinc, sulphate of zinc, tannic acid, nitrate of silver (5 to 10
per cent.), or bichloride of mercury (1:1000) is often useful. An
application of pure carbolic acid is sometimes followed by good
results. Perhaps the most generally useful application is Churchill’s
tincture of iodine or a solution of 2 parts of tincture of iodine and 1
part of carbolic acid.