*L**¿T
MEDICAL
LIBRARY
H618.2
F97
B 477036
LACERATION
OF
CERVIX UTERI.
F. S. FULTON, M.D.

ARTES
LIBRARY
1837
VERITAS
E PLURIBUS UNUM
SCIENTIA
UNIVERSITY OF MICHIGAN
TUBBOR
OF THE
SI QUAERIS PENINSULAM AMOENAME
CIRCUMSPICE
VJU!
HOMOEOPATHIC
LIBRARY
Archiz Fraser M.D
LACERATION Nov 2-1893.
Ipsilanti

OF
CERVIX UTERI
BY
F. S. FULTON, M.D.
ILLUSTRATED
NEW YORK
A. L. CHATTERTON & CO.
INTRODUCTORY.
WHEN I was preparing the fifth edition of my work on Surgery,
the late Dr. F. S. Fulton was House Surgeon to the Hahnemann
Hospital. Being daily in attendance in that institution, Dr.
Fulton and myself were brought into close relationship, and ob-
serving his surgical ability and the direction of his tastes toward
gynæcology, I requested that he would prepare for me a chapter
on "Lacerations of the Cervix." To this he immediately con-
sented and very soon set about the work. After a time he
brought me the complete manuscript; it was too voluminous for
a work on general surgery, but an excellent and exhaustive
monograph. I curtailed it to the proper dimensions for a work
on general surgery, but strongly advised its publication entire.
Since his death Dr. Fulton's widow has carried out the desire
of her late husband, and now presents his complete work to the
profession. No one can read over the following pages, without
being struck with the conscientious work that has been bestowed
upon them.
I can recommend this monograph as one of the best that has
been published on the subject, and trust that it will be in the
hands of many physicians, especially of those who expect to per-
form operations for the restoration of the cervix.
WM. TOD HELMUTH, M.D.
THE MADRID,
No. 180 West Fifty-ninth Street,
December 3, 1890.
155048
LACERATION OF CERVIX UTERI.
The first mention which we have regarding this most im-
portant lesion was made by Dr. James Henry Bennett, of
London, about forty-five years ago.
Previous to that time mothers had conceived and borne
children, been torn and lacerated by at times competent,
often by incompetent, midwives, tormented afterward by
outraged nature and well-intentioned but ignorant physi-
cians, been seared with the cautery, burnt with pastes and
escharotics, suffered many things of many physicians, and
gradually weakened, and at last fell victims to exhaustion,
epithelioma, or too quickly developed phthisis. While
Dr. Bennett recognized the fact that a cervical lesion existed,
he did not fully appreciate its true nature, or the necessary
treatment. He says: "Sometimes the cervix is not so much
dilated as burst open, and then the lacerations, radiating
from the center, divide it into segments, which can be traced
both with the finger and the eye at a subsequent period.
Thus it is that the foundation is laid for still more serious
diseases. Instrumental and difficult labor is very frequently
accompanied by laceration of the uterus in the absence of
any morbid state. In such cases the cervix generally pre-
sents deep fissures caused by the lacerations. The lacera-
tion or abrasions may heal in the course of a short period,
under the reparative process set up in the uterus after labor.
Reprinted from the Homœopathic Journal of Obstetrics.
Uorm
IO
LACERATION OF CERVIX UTERI.
!
On the other hand, under the influence of a general febrile
condition, or of local inflammation, and often from the
operation of causes which it is impossible to appreciate,
these lesions, whether slight or severe, do not heal, and
thus a confirmed inflammatory ulceration of the cervix uteri
becomes established."
While recognizing the lesion and its cause, he suggested
no treatment other than local applications. He also made
the mistake of confounding the raw, eroded mucous surfaces,
attended, as they uniformly are, with cervical and gener-
ally uterine hyperplasia, with ulcerations, which are of ex-
ceedingly rare occurrence.
In 1862 Dr. J. Addis Emmet accidentally recognized the
importance of this lesion, and originated the operation for
its relief which has since been styled by different authors,
"Emmet's operation," "Hystero-trachelorraphy,” “Trache-
lorraphy," and "Tracheloplasty?
Tracheloplasty. In 1869 Dr. Emmet
described the operation in a paper on "Lacerations of the
Cervix Uteri," read before the Medical Society of the
County of New York. In 1871 he read a second paper
before the same society upon the subject. This paper re-
ceived a very wide circulation, being translated by Dr. M.
Vogel and published in Berlin in 1875.
As even yet Dr. Emmet's views were not fully under-
stood, he prepared and read a third paper in 1876 upon
"The Proper Treatment of Lacerations of the Cervix."
This paper, together with the preceding, was translated and
published in Berlin. Following this were several articles in
the medical journals upon what was then a new operation.
To Dr. Emmet belongs the honor of introducing to the
profession an operation which has probably done more to
relieve the sufferings of women than any other surgical pro-
cedure known to gynæcology.
Since its first introduction very little modification has
been made in the original operation. As in all operations.
or new methods of treatment of real merit, it was at fir
LACERATION OF CERVIX UTERI.
I I
decried as irrational and lacking the virtues attributed to it.
Later, as some of the more venturesome surgeons adopted
it and met with, sometimes, startling success, it became the
fashion, and was lauded to the skies. Every woman in
whose cervix the slightest nick could be detected was in-
duced to submit to the operation, with little regard to any
possible connection between her sufferings and the cervical
lesion. No doubt, that in this stage of the operation, many
were performed of which there was no need. But every
operation of real value goes through the three stages of de-
preciation, over-valuation, and later, as time and experience
determine, takes its true place among the remedial pro-
cedures of surgery. While trachelorraphy is not done now
as often as formerly, no doubt from greater knowledge of
its pathology, consequence, both nervous and textural,
and indications calling for its performance, much better
results are obtained. Of these we will have occasion to
speak later.
Etiology. The lesion is most apt to occur in primiparæ,
whose cervical tissues yield with difficulty to the dilating
force of the head and amniotic fluid. In multiparæ the os
naturally is patulous, while in those who have not borne
children the inelasticity of the tissues resists the dilating
force of the uterine contents, and remains tightly drawn
together until just preceding delivery, greatly favoring
laceration.
At such times the tissues will be torn, even in what
would otherwise be a natural delivery. Of the different
causes which operate to produce this lesion, rapid and
difficult deliveries rank among the foremost. The cervix
cannot relax and mold itself with sufficient speed to meet
the necessities of the tremendous expulsive action of the
uterine and abdominal muscles. The amniotic sac is rup-
tured spontaneously or by the accoucheur in an early stage,
the uterine contents are forced rapidly down through the
parturient canal without time being given for the parts to
12
LACERATION OF CERVIX UTERI.
1
adjust themselves to the passage of the child, and laceration
occurs.
Dr. Emmet's statistics show that in his cases slow and
tedious labor has been more frequently the cause, 30 per
cent. of his cases being due to this. But, although contrary
to their present evidence, he says he fully believes that more
extended investigation will prove that rapid and difficult
delivery is more often responsible. Careless, and often-
times needless, instrumentation is another most productive
cause. Application of the obstetric forceps within or above
the superior straits is an operation attended with danger,
even in the hands of experienced obstetricians.
Oftentimes, by the power which one gains over the move-
ments of the head, and his greater ability to guide it and
to favor by slight rotation, flexion, or extension, the
stretched and rigid tissues of the cervix and perineum,
lacerations can be prevented; but many physicians, and we
fear the practice is growing, after having become accustomed
to the use of instruments, apply them quickly, as soon as
there is any delay in the pains or progress of labor, often
from merely selfish motives, preferring to subject their
patient to the risks of laceration, with its subsequent evils,
to spending a few hours in the lying-in room or depriving
themselves of a night's sleep. Such instrumentation is
criminal in the extreme. When the forceps are properly
applied in cases which demand instrumental interference,
we believe that the cases when lacerations occur in excess
of what would have resulted without their use, are very
few indeed. But statistics make evident that to hurried
and careless instrumentation are due many serious cases of
laceration of both the cervix and perineum.
In the country, where these lesions are little thought of,
and very frequently not recognized, or, if diagnosed, not
considered of sufficient importance to warrant operative
interference, it is a matter of not so much importance to
the accoucheur if he lacerates his patient by needless vio-
LACERATION OF CERVIX UTERI.
13
lence, as it is not apt, afterwards, to redound to his dis-
credit.
In the city, among the wealthy, it is quite different, though
this accident is common among them; but among the poor
who are compelled to accept the city charities, the frequent
lacerations, which are generally bilateral, and, when forceps
are known to have been used, of an extended character,
coupled with the history these poor unfortunates present,
make it evident that to instrumental interference during
parturition must be attributed many needless and serious
lacerations. Another cause to be found in the lying-in
room is the persistency and haste which some physicians
insist upon displaying in forcibly dilating with the finger
the cervical tissues during the presence of the pains. No
doubt, in certain cases of rigid os, or labor delayed for some
cause in the first stage, this is necessary; but it is not
imperative that the moment the mother feels the onset of
the true labor pains, the attendant should inaugurate a
ceaseless attack upon the relaxing tissues of the cervix;
nor is it in the least essential for the physician to administer
heavy doses of ergot to stimulate a uterus which is laboring
as hard as possible, until it suddenly expels its contents at
the expense of a serious tear which might have been
avoided had time been given for the yielding cervix and
perineum to have accommodated themselves to the enlarged
diameters of the cranial vault.
Dr. J. A. Reamy, of Cincinnati, considers the use of the
fingers and ergot as of greater injury in the production of
lacerations than are the forceps; while Dr. A. McDonald,
in the New York Obstetrical Journal, says "that meddle-
some application of obstetrical fingers in hurrying dilatation
of a slow cervix, or in forcibly pushing the neck over the
occiput during a pain, is the most frequent cause of cervical
lacerations." It is a fact which is not always recognized
that abortion, even at an early period, is capable of pro-
ducing a serious lesion of this character. Dr. Emmet says
14
LACERATION OF CERVIX UTERI.
that in every case where criminal abortion is acknowledged
or can be proven, laceration has resulted.
In severe cases of anteflexion, where the flexure occurs
at the os internum or below, and persists during the period
of gestation, a laceration of one of the lips is apt to occur
from unequal pressure being exerted upon one lip by the
dilating head and amniotic sac. In these cases the poste-
rior lip is most apt to suffer, as it affords the greatest ob-
struction to the passage of the cranial vault and enclosing
membranes, by lying directly across what must be their
channel of exit. Cases also of long-standing cellulitis,
which have resulted in binding the cervix firmly to the
pelvic walls, thereby materially interfering with its descent
and movability, particularly if it be found necessary to
resort to the application of forceps, offer conditions which
strongly predispose to oftentimes extensive lacerations.
G
Frequency.-As we have indicated, this lesion is of very
frequent occurrence in first labors. It is scarcely possible
for delivery to occur without some, great or small, nick in
the cervix resulting. Very many, by cleanliness and quiet,
heal spontaneously, showing afterwards no trace of any
previously existing lesion, or if the cleft be extensive and
in proper location to favor spontaneous union, the healing
may leave behind it a band of connective tissue, cicatricial
in nature, which not infrequently contracts, causing more
or less cervical deformity. This condition is most apt to be
found either when the laceration occurs in the anterior or
posterior lip. Emmet says that at least one-half of the
women who have borne children have cervical tears of
greater or less degree. Dr. Pallen makes the statement
that 40 per cent. of the women who suffer from uterine dis-
ease have laceration. Goodell asserts that about one woman
in six, who suffer from uterine disease, has an ununited
laceration of the cervix. Mundé says that out of 2500
parous women he found that 25 per cent. suffered from this
lesion, and that 50 per cent. of these were of a nature
1
LACERATION OF CERVIX UTERI.
15
serious enough to demand operative treatment, making,
according to his statistics, only about 12 per cent. of all
I have
parous women who would require this operation.
but little doubt that, as the operation assumes more and
more its rightful place in surgery, and the detection of the
lesion becomes more frequent, through greater knowledge,
and its evil results better known, this estimate will not be
found too large.
Pathology. The proper pathology of laceration of the
cervix cannot be understood unless the normal process by
which the enlarged uterus, after parturition, returns to its
wonted size be kept constantly in mind.
The cervical rent exerts a very great influence against the
proper involution of the organ. The uterus and appen-
dages become lessened in size immediately after delivery,
but instead of involution being carried on until the uterus
again possesses a length of from two and a half to three
inches, with a proportionate diameter, the process is slow,
and at a certain point ceases entirely, leaving an enlarged,
boggy uterus, which possesses no inherent power, unaided
by art, to ever again assume its rightful proportions. After
this the probe will discover that the length of the uterine
canal is from two and a half to three and a half inches,
according to the amount of laceration and consequent
hypertrophy. No doubt that this is due to a certain extent
to the reflex nervous irritation brought about by the un-
healthy condition of the cervix reacting upon the highly
sensitive nerves imbedded in the tissue; but probably the
greater reason is the obstruction to the blood current, both
in the arterial and venous system, offered by the eversion
of the lips. The uterine artery, which furnishes almost the
entire blood supply in the neck and body of the uterus, is
a branch from the anterior branch of the internal iliac.
runs obliquely downward from outside the ovary between
the two folds of the broad ligament, in close connection
with the ureters, to the junction of the peritoneum and
A
It
16
LACERATION OF CERVIX UTERI.
cervix, from which point it turns upward, and with numer-
ous windings and doublings runs upward along the uterine
body to the fundus, where it enters the muscular structure
of the organ and is lost in minute ramifications.
The circular artery of the cervix is given off at the lowest
point of the uterine vessel, and runs at right angles to the
main trunk around the cervix on either side, anastomosing
in front and behind with its fellow of the opposite side.
It is this artery which offers the only danger of hemorrhage,
and which is the one not infrequently severed in the repair
of deep lacerations extending to or beyond the cervico-
vaginal junction. The other branch of the uterine artery
of importance is the ovarian, which proceeds outward near
the fallopian tube and anastomoses with the ovarian, or
spermatic, which is a branch from the abdominal aorta,.
and furnishes the blood-supply to the ovary through a
system of numberless reduplications and offshoots upon the
posterior aspect of that gland.
The venous supply consists in two large plexuses, which
follow the course of the arteries and are termed, respect-
ively, the "Plexus uterinus" and "Plexus pampiniformus."
The former accompanies the uterine artery, and carries the
return current of blood from the uterus and broad ligament
downward, and empties ultimately into the internal iliac
vein. The plexus pampiniformis accompanies the ovarian
arteries and empties, as does the spermatic in the male, on
the left side in the vena renalis, and on the right in the vena
While the veins are in the substance of uterus and
broad ligament, they are very poorly supplied with valves,.
allowing very easily of a damming back of the blood from
mechanical obstruction. When the laceration occurs, and
by the force of the surrounding structures and the increased.
weight of the uterus the lips of the cervix are everted, it
produces a natural constriction of the venous channels, par-
ticularly those which return the blood from the body of the
uterus, and which emerge from the uterine body and con-
cava.
LACERATION OF CERVIX UTERI.
17
junction of the broad ligament just at the point where the
stretching process produced by the eversion of the lips is
most markedly felt. By this natural means the blood is
forced back into the uterine body and appendages, produc-
ing a condition of plethora and consequent hypertrophy.
When the patient begins to again assume her household
work after delivery, this enlarged uterus drags on the pelvic
structures; the ligaments, not yet hardened after their
great distension, cannot resist the strain. Sooner or later
the organ will prolapse to a greater or less extent, the liga-
ments become weakened, flabby, and no longer give the
needed support. Cellulitis is generally established. It may
occur immediately, before the patient has left her bed; not
infrequently it manifests itself so quickly as to seriously
interfere with the proper performance of nursing, as the
presence of cellulitis consequent upon a cervical laceration
has a direct tendency to suppress the secretion of milk.
It is claimed by Emmet that you can, not infrequently,
ascertain at which delivery the laceration occurred, by find-
ing out after which delivery the mother had been unable
to nurse her child.
As a consequence of the cellulitis and the phlegmonous
deposit usually occurring in one of the broad ligaments,
bands of adhesions are formed, which, by ultimately con-
tracting, draw the uterus over to one side or the other, or
backward. When these occur it is very difficult, often im-
possible, to restore the uterus to its normal position. When
this does not happen, the increased weight of the uterus
not only presses it down, but, as the cervix is the fixed
point and the fundus movable, retroverts it. Anteversion
and anteflexion also occur, but more rarely. In the Amer-
ican Journal of Obstetrics and Gynecology, for July, 1883,
Dr. Van de Warker reports thirty-one cases, in which the
uterus was retroverted in twenty-two, prolapsed in seven,
anteverted in one, and normal in one.
When the laceration occurs anteriorly or posteriorly, it is
18
LACERATION OF CERVIX UTERI.
not infrequent for it to heal spontaneously; but when the
laceration is lateral, particularly if bilateral, the lips have a
natural tendency to eversion. The main ligamentous at-
tachments are the vesico-uterine, extending forward to the
bladder, the recto-uterine, passing between the uterus and
rectum, and the broad ligaments, extending laterally to the
bony walls of the pelvis. If one will closely consider the
manner in which these ligaments are attached to the uterus,
and their modus operandi, it will become at once obvious
why eversion of the lips must almost necessarily follow

Fig. 1.*
bilateral laceration. As a result, the delicate, sensitive.
membrane of the cervical canal is exposed to constant fric-
tion against the vaginal walls, an inflammation of the endo-
trachelian membrane is established, the Nabothean glands.
become congested and pour out a profuse, sticky, often.
acrid leucorrhoea, which irritates the parts and produces a
condition of profound anæmia. The entire cervix impli-
cated in the laceration undergoes septic hyperplasia, by
which the parts are rendered prominent, boggy, and soft,
as is indicated in Fig. 1.
Figures Nos. I to 6 and Nos. 30 and 31 are from Helmuth's Surgery and
appear through the courtesy of Mr. F. E. Boericke, Philadelphia.
LACERATION OF CERVIX UTERI.
19
Nature endeavors to repair the damage and to again
restore the normal outline of the cervix by filling in the
bottom of the cleft with a large amount of cicatricial tissue,
which is hard, and at times almost horny in consistency.
For this reason, unless careful examination be made, an
extensive laceration may be overlooked. It is this cicatrix
which, by pressure upon the nerve of the cervix, causes so
much reflex nervous disturbance. The cervical glands be-
come stopped up and cystic, presenting those small cysts,
containing a thick, jelly-like secretion which is so often
present in an everted surface.
At times this cystic degeneration and hyperplasia result
to such an extent that it has been mistaken by some most
eminent gynecologists for malignant neoplasms. Fig. 2
well represents this simulation of carcinoma.
Regarding the tendency of these new formations to
appear at the site of old lacerations, there can be but little
question.
As is well known, epithelioma is apt to develop wherever
there is any constant irritation perpetuated for considerable
time. A sharp tooth will cause epithelioma of the tongue;
the constant smoking of an old clay pipe will develop one
on the lip; epithelioma of the scrotum in chimney-sweeps,
from the irritation caused by the accumulated soot, is not
uncommon; an obstinate eczema or psoriasis of the breast
will not infrequently terminate in carcinoma; the same
holds true regarding the cervix. The constant friction of
the everted and eroded surfaces, which naturally tend to
cystic proliferation, against the vaginal walls; the irritation,
and often bleeding, occasioned during coition, together
with the other sources of local disturbance to which the
part is subject, are quite sufficient to account for its not
infrequent development in cases of severe laceration, and
go far toward proving that they stand to each other in the
relation of cause and effect. Sterile women, or those who
have born no children, rarely suffer from cancer of the
20
LACERATION OF CERVIX UTERI.
uterus, while in those poor unfortunates whom this terrible
malady attacks, it is exceedingly rare not to find, on re-
moval of or in the diseased tissues, the nick of an old
laceration. Dr. Beale reported in the New York Medical
Journal of July, 1883, that he had had seven cases of
uterine carcinoma, in all of which there was a pre-
existing laceration. Dr. Goodell, of Philadelphia, says
he believes that the operation for laceration prevents the
development of cancer, as the more children a woman has,
the more liable was she to carcinoma of the uterus, and that

Fig. 2.
when they did develop it was not infrequent to be able to
see within them the notch of an old laceration. The dan-
ger of the occurrence of this most lamentable complication
is greatly increased in those women whose family history
present cases of cancer in any of its developments. In
these women a bad laceration, or even a slight one, ought
never to be allowed to go unrepaired, for fear that at any
time a benign erosion may assume a malignant type, and
by rapid proliferation, hæmorrhages, and gradual exhaustion
terminate a life which might, by timely surgical interference,
have been spared.
LACERATION OF CERVIX UTERI.
21
Varieties and Degrees.-Any portion of the cervix is
liable to rupture during delivery. The laceration may be
unilateral, bilateral, anterior, posterior, stellate, or internal.
When unilateral, it involves only one side of the cervical tis-
sue, leaving the opposite side intact. The side most usually
implicated is the left. Emmet's statistics for the cases in
which it is recorded as to what form of laceration existed,
show the following results: Right side, 15.7 per cent.; Left
side, 40.7 per cent.; Bilateral, 39.5 per cent.; Posterior, 4.0
per cent. From the large number of cases, however, in
which it is not stated as to the variety of laceration, we
cannot regard these results as correct, as in other statistics,
as well as in my hospital experience, I found a very much
greater proportion of bilateral lacerations than are reported
here.
Dr. T. A. Reamy, of Cincinnati, Ohio, in an article which
appeared in the New York Medical Record of May 10, 1884,
reported 223 cases of laceration, with the following results:
Bilateral, 170; unilateral, 30; stellate, 16; posterior, 5;
anterior, 20.
Extending into cervico-vaginal junction, 15.
With perineal laceration also, 167.
Small sphincter damaged, 15.
Recto-vaginal septum opened, 7.
Perineorraphy subsequently in, 50.
I believe that these statistics would much more nearly
represent the proportion of the different forms of lacera-
tion.
Fig. 3 represents a right unilateral laceration (all the cer-
vix cuts represent the appearance with the patient in Sims's
position upon the left side). When the cleft involves only
one side of the cervix the erosion of the lips is confined to
the side on which the lesion exists. A superficial erosion
usually develops upon the everted surfaces without involv
ing the remaining portions of the cervix. If bilateral, the
laceration extends across the entire width of the cervix,
22
LACERATION OF CERVIX UTERI.
and may involve merely the endo-trachelian and cervical
mucous membrane, together with the superficial fibers of
the muscular tissue beneath, constituting what is arbitrarily
classified as the first degree of laceration; or the tear may-
penetrate deeper and involve about half of the substance
of the cervix from the os to the vaginal reflection, consti-
tuting the second degree; or it may extend still deeper
through the entire tissue to the cervico-vaginal junction or
even beyond, constituting the third, or worst, degree.
Figs. 4 and 5 show the second and third degrees of bilat-
eral laceration.
In certain very difficult obstetrical cases, this lateral lacer-

Fig. 3.
ation may be so great as to extend entirely through the
neck and body of the uterus into the cellular tissue between
the folds of the broad ligament. This exceedingly danger
ous accident may exist when the mere superficial fibers of
the cervix do not disclose more than an ordinary laceration.
Violent hemorrhage is apt to follow this extensive tear.
After the uterus has contracted and checked the external
flow of blood, it may still continue to discharge into the
cellular tissue of the broad ligaments, forming a hæmatoma
of no mean proportions, which not only causes exhaustion
and nervous shock, and establishes a violent peritonitis or
cellulitis, but, by subsequent breaking-down and formation
LACERATION OF CERVIX UTERI..
23
of an abscess, opens the way for pyæmic infection and death
by septic peritonitis.
In the American Journal of Obstetrics, April, 1884, Dr.
W. W. Seymore reports two cases of septicæmia following
parturition, in both of which laceration into the broad liga-
ments, with the formation of a hæmatoma, was discovered
by the passage inward of the sound into the substance of
the ligament a distance of between two and three inches,
followed subsequently by the partial rushing out of
clotted blood, and later by septic infection. An autopsy
revealed the nature of the accident as stated above. No
doubt that many cases of septic peritonitis following partu-

Fig. 4.
rition have as their origin an undiagnosed internal lacera-
tion of the uterine tissue, extending more or less deeply
into the surrounding structures. When the tear extends
forward through the anterior lip, as is not usually the case,
it is generally healed spontaneously, if cleanliness is ob-
served. It may extend but a short distance, or it may be
so extensive as to open a passage into the cavity of the
bladder. This will heal to a certain extent, sometimes en-
tirely with the exception of leaving a small vesico-uterine
or vesico-vaginal fistula, for which the appropriate operation
must be performed. In rare cases the cervix will heal after
24
LACERATION OF CERVIX UTERI.
such an accident, leaving a small fistula which opens into
the cavity of the uterus, and through which the urine is
continually finding its way.
If the rent occurs posteriorly only, it is usually healed
spontaneously; sometimes, however, with the formation of
a dense mass of cicatricial tissue. It may extend into the
rectum or into the cul-de-sac of Douglass, in either of which
cases it makes a very formidable complication.
The stellate laceration, as shown in Fig. 6, is one in which
the rents extend into the cervical tissue, from the os uteri

Fig. 5.
as a center, it being not infrequent to find as many as four
or five different tears. These clefts can be discovered radi-
ating in all directions from the os, some filled entirely with
cicatricial tissue, others gaping; with exuberant granula-
tions covering some of the everted surfaces, and hard no-
dosities disfiguring others, and all to a greater or less
extent covered with erosions, from which is constantly
poured a thick, yellow, or pearly leucorrhoea, which in time
produces a profound conditon of anæmia. The os is patu-
lous, the lips everted, and the whole cervix and uterine
body hyperplastic and low down upon the floor of the
pelvis.
LACERATION OF CERVIX UTERI.
25
The only other form of laceration which is of significance
is that in which the fibers of the internal os and cervix are
torn internally, without any outward evidence of existing
lesion except a patulous os and prolapsed endo-trachelian
membrane. The diagnosis can only be determined by
examination of the cervical cavity with the sound and
finger. This seems to afford all the evil consequences of
other lacerations.
At other times severe cervical tears will be filled up with
such a large amount of cicatricial tissue, causing such
extensive subsequent contraction as to nearly obliterate

Fig. 6.
the healthy cervical tissue, leaving these hard nodular
masses of scar tissue projecting from the surface, closely
resembling a small fibroid in the substance of the cervix.
Symptoms and Effects.-The average length of time in
which symptoms become so distressing as to drive the
sufferer to the physician for relief is about five years. It
is not infrequent, however, for the patient to feel the bad
effects of the laceration from the time she leaves her bed
until she submits to the operation. At others, aside from
a malaise from which they suffer, they may notice no incon-
venience for several years, except the tendency to abort,
which was not their habit previously. After a time symp-
toms begin to manifest themselves. The patient will be
26
LACERATION OF CERVIX UTERI.
unable to undertake her usual amount of exercise or work.
Slight exertion brings with it an unwarrantable amount of
fatigue. She will shake and tremble for hours after walking
a comparatively short distance. There is a dragging weight
in the pelvis, oftentimes a severe bearing-down drives the
patient nearly frantic. As the uterus becomes heavy from
its condition of hyperplasia and subinvolution, the natural
tendency is for it to become retroverted; in which case the
heavy and enlarged fundus is thrown over against the
sacrum and rectum, causing the dull, dragging backache,
with not infrequently tenderness of the sacral or lumbar
portion of the spine.
It also produces a condition of partial stenosis of the
rectum, obstructing the passage of the excrements and
inducing an obstinate form of constipation. Both from the
mechanical pressure upon the sacral nerves and nervous
disturbance produced by the laceration itself, there is de-
veloped all forms of sacralgia, and neuralgic pains in the
limbs, more generally extending from the small of the back
through the pelvic structures, and downwards over the
anterior surface of the thighs, sometimes reaching to the
calf of the leg, but more usually stopping at the knee.
The spine is the seat of a dull, dragging pain, or at times
sharp neuralgic darts. It gives out easily on effort, seems
to have scarcely strength to sustain the weight of the body,
and if required to do so for any length of time fails utterly,
not infrequently prostrating the patient for days. The
ovarian and hypogastric regions are usually more or less
sensitive to pressure, and the seat either of sharp, darting
pains, usually extending across the abdomen; or of a dull,
aching distress, which is just as annoying. At other times
a persistent form of sciatica is developed, which of course
resists all forms of medicinal treatment. As a consequent
of the laceration, cellulitis is usually developed, which is
evidenced, if it occurs early, by stoppage of the milk
secretion, great pain and tenderness, fever and strong dis-
LACERATION OF CERVIX UTERI.
27
inclination to move on account of the pain occasioned.
When the cellulitis results in bands of adhesions being
formed, binding the uterus backward, as is most common,
or laterally, it produces a displacement, with its entire
coterie of symptoms, which is most intractable.
Every variety of menstrual disturbance known to woman
is produced by this lesion. In 17.80 per cent. of the cases
recorded by Emmet, menstruation remained unchanged as
at puberty; 44.74 per cent. had the flow either lessened,
increased, or made irregular as to quantity, without altera-
tion in the length of time of menstruation. In 62.55 per
cent. the time remained unchanged as at puberty. In 82.17
per cent. the menstruation was altered as to quantity, the
flow being either increased, diminished, or irregular, and of
these 62.8 per cent. had their menstruation increased. In
the great majority of cases pain attends the monthly flow;
most frequently it is felt with greatest intensity at the
beginning, lasting for the first day or two, and then
gradually subsiding. All the symptoms, distressing at all
times, are aggravated at this time. The ovaralgia, sacralgia,
sciatica, abdominal pain and tenderness, backache, distress
in the limbs, become intensified to a great discomfort or to
an almost unbearable distress.
As a result of the condition of the lips, their consequent
erosion, the hypersecretion of the endotrachelian mucous
membrane and the cervical follicles, a profuse leucorrhoeal
discharge generally results. This may be either profuse
or scanty, bland or excoriating, of any describable color or
consistency. But it is generally depleting, and aggravated
before and after menstruation. The cervix generally un-
dergoes to a greater or less extent septic degeneration from
stopping up of the mouths of the Nabothian glands, which
can be detected as small, hard, distended follicles projecting
from the surface of the cervix, and which, when punctured,
are found to contain a quantity of clear, transparent, gluey,
gelatinous mucus. These small follicles, by enlarging
28
LACERATION OF CERVIX UTERI.
and pressing upon the cervical nerves, will not infrequently
cause great reflex nervous trouble, as sickness at the
stomach, loss of appetite, sadness, lachrymose condition,
great nervousness, neuralgic headache; all of which will
generally be relieved by puncturing, evacuating the cysts,
and obliterating them with iodine. As stated before an
erosion generally forms, which looks dingy and red, and
may extend as far as the cervico-vaginal junction. This
must be healed before any operative measures are resorted
to. There is a condition, evidenced by the sound and ex.
amining finger, of hyperplasia and subinvolution of the
entire uterus. Coition is painful and not infrequently at-
tended with hemorrhage.
When the laceration first occurs, before the plugs of cica-
tricial tissue are deposited in the angles of the cleft, the
woman is apt to be unusually productive; one impregnation
succeeds another with great rapidity, only to be aborted
about the second or third months. This condition of affairs
is especially apt to supervene after a large stellate lacera-
tion. The reason of this is plain, when the large patulous
os, the softness of the cervical tissues, and the great facility
which is offered the spermatozoa to enter the uterine cavity
are considered.
This habit of aborting generally persists until the cleft is
filled with hardened tissue and a heavy thick leucorrhoea is
developed, which occludes the passage, when impregnations
usually cease and absolute sterility follows.
71.34 per cent. of the women suffering from laceration of
the cervix, examined by Emmet, were sterile, and there is
no proof that a single one became pregnant after a bilateral
laceration; and, as stated above, if they do become impreg-
nated, it is only a pseudo-fertility, as the uterus possesses no
power to carry its contents to full term.
If the laceration be anterior or posterior and severe enough
to enter the bladder or rectum, in addition to the cellulitis
or peritonitis established, the excrements from one viscus
•
LACERATION OF CERVIX UTERI.
29
or the other will find their way into the vagina. As a re-
sult of all these depleting conditions a profound condition.
of anæmia is at length developed; the patient becomes
thin, weak, sallow, cachectic, and almost resembles one
affected with chlorosis. The climax is generally postponed;
in cases where the menstruation is persistently lessened, it
may be hastened. In either case from the depleted con-
dition and profound anæmia of the patient, her system does
not seem to be able to withstand this great revolution in
her physical organism, and she easily falls a victim to early
developed phthisis or epithelioma. In women of a spare,
rather fragile build, the danger of phthisis is always to be
remembered in advising the patient regarding treatment.
On the contrary, those patients not unusually suffer from
epithelioma of the cervix, who have had the least impair-
ment of their general health previously. Aside from these
conditions, which are largely local, many reflex nervous.
troubles are developed, which are more distressing than all
the others. In almost every case there is a most persistent
cephalalgia; its usual seat is in the occiput, where it exists
as a dull, heavy ache, as if the person had been struck with
a club in that locality. It may occupy the vertex or forehead.
It is usually a sort of a crazy ache, or of such intense character
as to entirely prostrate the woman. She thinks she is going
crazy, and, in fact, her mental strength is somewhat im-
paired. Her memory is weaker, and she can use her facul-
ties for only a short time without great exhaustion.
The following case is important, as illustrating several
important features of symptomatology and effect:
CASE-Mrs. A., aged forty-three, stout, though well pro-
portioned, came first under my care October 10, 1886. At
that time she was complaining of what had been diagnosed
and treated as malaria. She was chilly, with shivers creep-
ing up the spine; occipital headache of a dull, heavy,
distracting character, extending down the back towards the
shoulders; the eyes were scre and heavy; she was restless,
30
LACERATION OF CERVIX UTERI.
and, to a great extent, sleepless at night, lying awake not
from any distress, excepting very frequently her headache,
which at times became very intense and occupied the entire
head, preventing her sleeping. Quite contrary to the usual
custom her back and limbs troubled her but very slightly.
She was excessively nervous and despondent, the slightest
disturbance or extra demand upon her time or nervous force
proving quite sufficient to almost prostrate her. The re-
ception of a few friends would completely unnerve her.
Although she had a beautiful home, a most devoted
husband and family, and everything to make life happy
and enjoyable, she was continually despondent and fre-
quently gave way to violent fits of crying, which greatly
distressed herself and family. She was aware that there
was no reason for it, but said that it was entirely beyond
her control. She complained also of dizziness, which was
markedly worse in the morning, as indeed were nearly all
the symptoms. The periodicity was so marked that, taken
in connection with the chilliness, which almost always pre-
ceded or attended the exacerbations, it was not to be
wondered that a diagnosis of malaria was rendered.
An examination was not at once made, but on Novem-
ber 1, becoming convinced that her sufferings were due to
a more definite cause than the hydra-headed malaria, I
made a careful examination with the patient in Sims's posi
tion. The uterus was high up, with the fundus tipped for-
ward; pressing the cervix well back into the posterior cul-
de-sac. The entire uterus was hyperplastic and boggy.
No sound was used at the examination, as the more I be-
come acquainted with that instrument, even in the hands
of skillful manipulators, the more I distrust it. I do not re-
gard it as a safe instrument, as I am confident that in my
hands it has several times been the cause of acute attacks
of pelvic inflammation, though the greatest care was used in
its manipulation. So many women present themselves to
the gynecologist with the history of acute inflammations
LACERATION OF CERVIX UTERI.
31
excited by the passage of an instrument into the uterine
cavity, that its use should receive a well-deserved condem-
nation. Besides, I believe, as Dr. Tait says, that "the phy-
sician who can not ascertain the position of the uterus and
its relative size without the use of the sound is either a nov-
ice or one unfit to practice gynæcology." It was very diffi-
cult to bring the cervix into view, as it appeared bound back
by strong bands of adhesion, which could be felt by the
finger in the posterior cul-de-sac, and also seen when the cer-
vix was forcibly drawn downwards and forwards with the ten-
aculum. The anterior lip was almost black from venous con-
gestion, very greatly hypertrophied, and so soft and pulpy
that it was difficult to distinguish the exact line of junction.
between the cervix and the anterior vaginal wails. It was
precisely the condition which would naturally precede the
development of a malignant neoplasm. It bled profusely
upon being punctured with the scarificator. The mucous
membrane and the entire cervix was intact, no eversions.
being present. Numerous cysts filled with the characteris-
tic gelatinous, sticky secretions, dotted the cervix. There
was comparatively little eversion of the lips, and excepting
the hypertrophied anterior lip, were in very nearly normal
relation to each other.
The entire cervix was greatly enlarged and hyperplastic.
Upon drawing the uterus down and forcibly separating the
lips, two dense hard bands, of white and glistening appear-
ance, could be plainly seen connecting the lips and thus pre-
venting the characteristic eversion.
There was comparatively little tenderness, and no evi-
dences of cellulitis, although the cervix itself was more sen-
sitive than normal.
When the examination was completed the cervix was
freely punctured, relieving it of its engorged condition and
emptying the cysts, the whole painted with Churchill's io-
dine, and a cotton tampon soaked in glycerine applied to
the cervix. She was directed to take a hot water douche
32
LACERATION OF CERVIX UTERI.
of about a gallon, night and morning. It was to be used
with the patient in the dorsal decubitus, with her hips ele-
vated upon a large bed-pan.
Local treatment was given over a week, and internally
she was given cimicifuga tincture, to be taken every two
hours. This plan of treatment was persisted in till February,
at which time the cervix was reduced greatly in size, the
hypertrophied and engorged anterior lip was greatly re-
duced in size and of normal color and consistency. The
cysts had disappeared from the cervix, and the hard bands
which bound the cervix backward, or which at least gave
tactile and ocular evidence of having once done so, had to
a great extent disappeared and allowed the cervix to be
dislocated downwards with comparatively little effort. Her
symptoms were greatly ameliorated, though at every men-
strual period she had her old trouble.
I expected to operate after her February menstruation,
but sickness in the family and her own illness from fol
licular tonsillitis postponed the operation till a month
later. Treatment was continued. Four days after dis-
appearance of her menstruation, assisted by Dr. H. M.
Banks, of Englewood, Dr. Jno. B. Garrison, of New York,
Dr. Cox, and the nurse, I operated after the manner de-
scribed under the head of operating, cutting up upon
the somewhat everted lips, and dissecting very deeply into
the uterine body to remove the hardened tissue which filled
the gap and which was densest and most abundant upon
the side which formed the uterine canal. The circular
artery on both sides was cut, and the hemorrhage was, of
course, proper for a cervix operation. The cicatricial
tissue was all removed, though it was necessary to cut over
an inch directly into the uterine body. The lips were
approximated and held together by six silver-wire sutures,
three on a side, the ends cut short and bended over towards
the os along the line of incision, the uterus replaced, irri-
gated with the bichloride solution, I to 2000, which had
ID
LACERATION OF CERVIX UTERI.
33
been used freely both as a douche and as a fluid in which
to wash the sponges, and the patient put to bed. All
hemorrhage stopped by the approximation of the lips. The
sutures were placed as near the angle of the wound as
possible. The stitches were removed the tenth day; there
never having been any fever or pain, except a slight sense
of strain in the inguinal and hypogastric regions, and the
lips found to be perfectly united. After the first night, she
slept every night, sleeping nearly all the time for the first
twenty-four hours after the first night. Her headache had
left her, she felt no nervousness or inclination to weep, and
said on the fourth day that she thought she might get up
as she felt perfectly well.
This case was illustrative in many ways. She had borne
three children since the one, judging from the puerperal
fever, stoppage of milk, milk legs, etc., which followed that
delivery' which must have occasioned the laceration. Of
its occurrence at that time I have no doubt. If it be correct,
it shows that the most violent laceration need not entail
sterility. It also shows with what rapidity the relief of the
symptoms at times follows the operation. It also makes
apparent, I believe, the necessity of removing the entire
cicatricial mass, even if the dissection has to be very deep
into the uterine tissue. The depth of the dissection is of
little importance, nor is the severing of the circular artery
to be feared. The one thing to be apprehended is that
the diseased tissue, whether it consist of hardened cicatrice
or tissue which has undergone cystic degeneration, shall
not be entirely removed and the coaptation of the lips
rendered easy and natural.
In addition to the characteristic symptoms as presented
in the above case, certain unusual, indirect, reflex troubles
at times owe their origin to severe lacerations, as for ex-
ample: Dr. Mann, of Buffalo, reports a case of anuria of
five years standing which was entirely relieved by an opera-
tion upon the cervix. Dr. H. W. Songyear, of Detroit, re-
$
34
LACERATION OF CERVIX UTERI.
ports a case of persistent salivation which was relieved in a
similar manner; the salivation disappearing five days after
the operation. Dr. R. S. Sutton, of Pittsburg, Pa., has
recorded a case of cataleptic convulsions cured by trachelor-
raphy. In this case the convulsion cured could be induced
at will by pressure of the finger against the angle of the lacer-
ation. The convulsions did not recur after the operation.
Dr. Emmet records three cases where persistent sub-orbital
pain of long standing has been removed by trachelorraphy.
In two of these the pain was induced by pressing on cer-
tain portions of the cervix, making evident the cause of
the pain. Dr. Paul F. Munde reports a violent case of
hemicrania, and also one in which the patient would fall
into a profound sleep on every act of coition, which were
cured by a repair of the cervix. In the latter case the patient
fell into this deep sleep during the progress of the exami-
nation upon exploring the deep bilateral laceration. The
excision of the cicatricial plug and the uniting of the lips
entirely relieved the patient. Beyond a doubt a large num-
ber of neuroses are attributable to the existence of a severe.
laceration, but the surgeon who operates upon all cervixes
which are cleft with the expectation of relieving some re-
flex neuroses which may be coexistent, will meet with many
and bitter disappointments.
Diagnosis.-This must be reached by means of both the
finger and eye. Neither alone is quite sufficient. Where
the finger is introduced, it will generally find the uterus pro-
lapsed, retroverted, and in a condition of subinvolution;
the finger will detect the patulous os, the cleft angles of the
laceration, and usually the cervix studded with little cysts
presenting as hard, nodular bodies above the cervical mu-
cous membrane. The finger will also usually be able to
detect the abrasion of the mucous membrane by the absence
of the soft, smooth feel of the healthy cervix. There will
usually be more or less tenderness from existing cellulitis.
The variety of the laceration can usually be detected by
LACERATION OF CERVIX UTERI.
35
feeling the different clefts, or the hard, stringy bands of
cicatricial tissue which have filled them.
In the use of the speculum there is a great deal of choice.
If the tubular one is used, the vaginal tissues are generally
pushed forcibly back, not infrequently carrying with them
the posterior lip of the cervix, so that the appearance
through the speculum is of a raw ulcerating surface. The
natural ectropion is greatly increased, and no true idea can
be gained of the proportionate amount of laceration and
healthy tissue. The bivalve speculum is very much better,
and affords a much truer view, but even here the natural
erosion of the lips is greatly increased, and it is usually very
difficult, if not impossible, to successfully approximate the
lips in order to accurately determine the amount of lacera-
tion. The Sims's removes this difficulty. With the patient
in Sims's position, the vagina ballooned out and the peri-
neum retracted, there is nothing which offers any traction
upon the cervical flaps. It presents itself to the eye exactly
as it is.
The relative tear, ectropion, and erosion can be accurately
estimated. Then, by hooking one tenaculum into the
anterior flap and a second one into the posterior, by care-
fully approximating them and turning in the eroded sur-
faces, it is possible to estimate the exact extent of the lacer-
ation. By the traction of the tenacula the normal conicity
of the cervix is restored. If the lips cannot be turned in or
approximated, there is no laceration; if they can be, the
amount shows both the degree of the erosion and the ex-
tent to which the flaps will have to be denuded and stitched
together in the reparative operation.
Having completed the diagnosis, the next question is
when to operate, as statistics show that only about 50 per
cent. of the cases of laceration require surgical treatment.
If there is simply a slight laceration, without marked erosion
of the lips, a slight amount of cicatricial tissue in the angles
of the cleft, with a healthy mucous membrane, even if there
36
LACERATION OF CERVIX UTERI.
be nervous symptoms and a certain degree of anæmia, there
is 'no indication for operating; and, if it were performed,
would probably be only disappointing in its results. When,
however, there is marked ectropion, more or less exten-
sive soreness, deposit of cicatricial tissue in the cleft, cysts.
of the cervix, leucorrhoea, with menstrual disturbances,
anæmia, and reflex nervous troubles, as mentioned above,
appearing as sciatica, ovaralgia, cephalalgia, neuralgia of
various forms in different portions of the body, or, as in
some of the cases cited, anuria, catalepsy, chorea, subor-
bital pain, etc., to which no assignable cause can be given
aside from that afforded by the existence of a well-marked
laceration with the above distinctive marks, the probability
is that an operation will be followed by most brilliant re-
sults. There is no doubt of its being indicated in those
cases.
In women with a phthisical or cancerous history, an opera-
tion is not infrequently demanded as a prophylaxis against
the subsequent invasion of either of these terrible maladies.
Even when symptoms do not demand it, an operation should
be performed in every case of extensive laceration with
more or less nodular hyperplasia, particularly if the woman
has been unusually prolific and has behind her a history of
carcinoma or phthisis.
A marked degree of cellulitis is a contra-indication to an
operation, unless the surgeon is well satisfied that it is
originated and perpetuated by the laceration.
Emmet says that, as long as any tenderness can be
detected by digital examination, it is unsafe to operate,
but I cannot accept this statement, as to relieve the cellu-
litis would require a much longer time than most women
can wait, and, besides, of very many operations performed
in cases in which more or less tenderness was easily dis-
cernible, we have never yet seen a patient have more
than a slight exacerbation of the trouble, from which she
recovered speedily and was free from any additional evi-
LACERATION OF CERVIX UTERI.
37
dences of cellulitis by the time it was proper for her to
sit up.
An operation immediately after delivery will be found
usually impracticable, and even if it could be done, I do not
believe it would be advisable.
The parts are swollen, oedematous, so soft as to be
almost indistinguishable from the vaginal walls, and all the
parts are so distorted as to make it exceedingly difficult to
properly approximate and suture. Added to this is the
danger of subjecting a patient already exhausted by parturi-
tion to the depressing effect of the ether and its subsequent
vomiting, and also of seriously disturbing the child's stomach
by forcing it to take the mother's milk saturated with ether,
or else to resort for the time to cow's milk or artificial feed-
ing, which is not what the child needs. The better time
to operate we believe is after the uterus has become reduced
in size and the cervical mucous membrane has regained its
normal pink appearance. The flaps will then be clean
and hard and capable of yielding satisfactory results. In
ordinary cases the most favorable time to operate is the
third day after menstruation. The operation at this
time is less apt to induce menstruation, which is of very
common occurrence if it is postponed. As is true in all
surgical proceedings, February and March are not as favor-
able for operation as other seasons of the year, owing to
the poisons which accumulate in the atmosphere at that
time, and also to the system being generally somewhat
exhausted by the winter's work or dissipation, and feeling
the ennervating effect of approaching spring.
In hospitals this is particularly true. The many opera-
tions, the large number of suppurating wounds, the presence
in crowded wards of a large number of patients with all
sorts of diseases, contaminate the air, so that it is not only
unfavorable to speedy union but strongly predisposes to
all forms of low suppuration and sloughing. A chronic
condition of "hospitalism" arises, which militates strongly
38
LACERATION OF CERVIX UTERI.
against both the success of surgical procedures and the
rapid recovery of the patient.
Preparatory Treatment.-All gynæcologists with scarcely
any exception consider that this is essential in order to ob-
tain a satisfactory result. Where there is the usual con-
dition of subinvolution, hyperplasia, ectropion, cystic degen-
eration, erosion, leucorrhoea, and cellulitis with its attend-
ant pain and soreness on manipulation, the patient
should have hot water douches night and morning, giving
at one time about one gallon of water as hot as the patient
can endure. There is probably no agent which is of greater
therapeutic value in treatment of uterine and pelvic inflam-
mations than hot water used in large quantities. Its astrin-
gent action on the blood-vessels and tissues of the pelvis is
very great; so much so that where a douche has been proper-
ly given, the vaginal walls will be found thrown into many
additional rugæ, narrowing the canal very perceptibly and
greatly reducing the enlarged congested cervix. The proper
method of giving a douche is to place the patient in bed,
or on a douche board, with her hips elevated sufficientlyto
retain a large amount of the water in the vagina. The
Davidson syringe should be used in place of the customary
fountain bag, as there is a certain mechanical effect to be
derived from the interrupted current of the former. Some
patients are not able to tolerate the Davidson on account
of the pain which the more forcible jets of water occasion.
In these cases of course the fountain syringe must be used.
Having gotten the patient on the board and the bulb of
the Davidson in the right hand, the nozzle, which to avoid
burning the patient should be of hard rubber or glass, is in-
serted in the lowest angle of the vulval cleft. With the
left hand the lips of the vulva should be held tightly to-
gether except at the upper angle, at which point they
should gap to allow the exit of the water, thus forcing the
hot water to travel over the entire vagina and subjecting
every portion of the canal and cervix to its astringent
LACERATION OF CERVIX UTERI.
39
action. The nozzle of the syringe should be bulbous at its
extremity, with perforations on the side, but none in the
center, in order to avoid the possible danger of throwing a
stream into the uterine canal, which might, from the force
given it, find its way into the Fallopian tubes, and through
them into the abdominal cavity, exciting peritonitis, which
might prove fatal.
If there should be any cysts upon the cervix, they should
be punctured and their contents evacuated. It is not
necessary to carefully select each cyst, but with a scarifica-
tor, of which perhaps the most convenient is figured below.
The cervix may be punctured on its entire surface. This
will empty the cysts and at the same time relieve the con-
gestion by allowing some of the additional blood to escape.
After this the entire cervix, and, if there is much tender-
or
Fig. 7.
ness or congestion of the vaginal walls, they also should be
painted with Churchill's tincture of iodine. Care should be
exercised to introduce the iodine into the sack of any large
cyst which may be punctured in order to obliterate it. The
iodine will stop the bleeding and also reduce the con-
gestion. If, is as usually the case, extensive erosions are
present, iodine can be used, or a solution of hydrastis in
the proportion of:
or
or
or
R. Glycerine.
4.TIKNABI-GU.
Hydrastis (A.1. ext.).
R. Glycerine....
Churchill's Iodine
Water....
Nitric acid(c. p.)..
· ·
·
R. Glycerine...
Alum (pulverized).
R. Glycerine...
Tannic acid..
or a creamy mixture of iodoform powder and carbolic acid.
of peroxide of hydrogen.
• ·
• •
·
·
•
•
•
•
3 ss
·
WUN VIUN
3 j
SS
9 parts
(6
..I
ss
3 j
. I
8 parts
•
(C
.4 parts
...I
(
Or an application
One of the most satisfactory medicaments for local ap.
plication I have ever used is ominico, diluted about one.
40
LACERATION OF CERVIX UTERI.
half, and applied as a douche night and morning. It is not
necessary to use a large quantity, but merely enough to
thoroughly wash the cervix.
A convenient method of application is by Dr. J. A. Haw-
ley's double-bulbed syringe, by which the cervix can be
thoroughly washed without splashing or -waste.
Also a
favorite application of mine, particularly with raw, sore,
eroded surfaces, is:
R. Glycerine.
•
R. Arg. nit. (cryst)...
Aquæ dist....
Calendula tincture...
I
•
Tannic acid, q. s. to make dark solution and give it some
consistency.
This will be found particularly useful for soaking the
tampons to be applied after treatment. Also chromic acid,
in 16 or 20 gr. to the ounce, nitric acid, carbolic acid in full
strength, are at times required and will yield excellent re-
sults. Argentum nitricum is best used in graded solutions,
and if used properly will afford excellent results. Their
strength must vary all the way from ten grains to ninety
grains to the ounce. The latter will not be often required.
In the New York Medical Journal of October 10, 1885,
Dr. B. Brown, of Alexandria, Ga., states that by the use
of these graded solutions many cases even of severe lacera-
tions can be cured. His method is as follows:
•
.4 parts
CC
··
R. Arg. nit. (cryst.)...
Aquæ dist....
•
3 ss
..f 3 j
Which he applies to the cervix and canal as far as the os
internum. This solution he uses only in simple fissures of
the cervix, without deep laceration or ectropion.
In deeper laceration he uses a solution.
•
Dijss
..fzj
With this he washes the entire surface until a uniform
white coating, which consists of the albuminate of silver,
is formed over the entire abraded surface of the cervix.
This answers the double purpose of preventing irritation and
septic infarction, and also of stimulating the formation of
healthy tissue.
He uses a third solution to be applied to the cervix after
LACERATION OF CERVIX UTERI.
4I
the parts have healed, to reduce hypertrophy and indura-
tion, which consists of:
·
R. Arg. nit. (cryst.). .
Aquæ dist..
•
3 jss
..fzj
He claims that by this method of treatment the great
majority of patients will afterwards recover from their
sterility and bear children.
However this may be, there is no doubt but by the use of
arg. nit. solutions, commencing with a solution containing
60 or 40 grains to the f3j, and gradually reducing the
strength, as the abrasion heals and the white coating be-
comes less, that a cervix can be properly prepared for an
operation in a comparatively short time.
After all of these applications it is advisable to insert a
tampon soaked in glycerine, or the glycerine and alum, or
the glycerine, tannic acid, and calendula solutions. This
tampon should remain in situ about twenty-four hours.
By its use and proper placing any displacement or eversion
may be either greatly benefited or entirely relieved. The
benefit of these medicated glycerine tampons lie in the
watery, profuse discharge which they occasion from the
parts, thereby greatly reducing the congestion and hyper-
trophy. It is a peculiar action which glycerine has upon
parts covered with mucous membrane. If tannic acid or
alum is also used, the astringent action is also obtained,
which greatly increases the tonicity of the relaxed structures.
If there is a very marked degree of eversion of the lips
with corresponding hyperplasia, the lips can be brought
together by two silver wires introduced one on either side
of the cervical canal and allowed to remain there for over
two weeks previous to the operation. They should be only
loosely drawn, as otherwise they will cut through. This
naturally assists in reducing the hypertrophy. At the time
of the operation they can be cut and removed. Dr. Good-
ell, of Philadelphia, says when the anterior lip is very
largely increased in size over the posterior one, that it is
his practice to excise a V-shaped portion from the anterior
-
42
LACERATION OF CERVIX UTERI.
lip about three or four weeks previous to the plastic
operation.
Instruments and Room.-The room in which the opera-
tion is done should be scrupulously neat and clean, and
should every little while be thoroughly disinfected by the
use of carbolic acid, sulphur, thymol, listerine, or some of the
J
Fig. 8.-Bozeman's Duck Bill Speculum.

GTIEMANN & CO.
many disinfectants. It is not necessary for the operation
to adopt all the antiseptic precautions which are essential
in an abdominal section. The various modifications of
Sims's speculum offer a choice of shape and size. Some
form of Sims's will, however, be required. The requirements
&
A
G-FILMAKNA CO

lah agar to an
hiện nội y hà nội t
Fig. 9.-Dawson's Sims's Speculum.
of this speculum are that it shall be broad and shallow, not
exceeding 3 or 3½ inches in length. The most of those
offered for sale are either too long or the blade is too hol-
low, and so occupies too much space in the vagina.
LACERATION OF CERVIX UTERI.
43
Dr. McDonald's modification of Sims's is one of the best.
Bozeman's as figured is good, but does not possess all the
advantages spoken of above.

C.TIEMANN & CO
Fig. 10.-Emmet's Needle Forceps.
Dr. Dawson has modified Sims's by placing the blades on
hinges for ease in transportation.

G. TIEMANN & CO.
Fig. 11.-Russian Needle-holder.
Various needle-holders are used, such as Emmet's, Rus-
sian, Sims's, Skene's.
+

GTIEMANN & CO
FRAUTO
Fig. 12.-Sims's Needle-holder.
A modification of Sims's has been made by putting a
catch on the handle, which greatly improves it. Skene has

GTIEMANN-CO
Fig. 13.-Skene's Needle-holder.
devised a new holder for which he claims the special advan-
tage of being able to better grasp and draw the needle
through the cervical tissue.
44
LACERATION OF CERVIX UTERI.
·
For all purposes our preference is for the Russian forceps,
as they grasp the needle firmly and are simple in construc-
tion.
For the operation three pairs of scissors are necessary,
G.TIEMANN&CO
Fig. 14.-Emmet's Curved Scissors.
unless some of the more modern revolving scissors are used.
Those needed are Emmet's scissors, straight, curved to the
right, curved to the left, and curved on the flat as figured
8
G.TIEMANN-CO.
Fig. 15.-Sims's Curved Scissors.
below. They should have strong, rather heavy blades, not
the fine, delicate ones as are sold to the inexperienced. The
Q
O
Fig. 16.-Sims's Straight Scissors.
tough cervical tissue, and particularly the cicatricial plug,
will turn the blades if they are not pretty heavy.
G TIEMANN & CO
There are scissors set in handles, as these devised by Mr.
Stohlman, in which the blades can be made to occupy any
1



LACERATION OF CERVIX UTERI.
45
angle by means of a steel rod. They have been used with
success in deep cavities where the application of others
would have been impossible. The blades are firm and
strong, and do good service.
If knives are to be used, and many operators are very
응
​
STIEMANN &.CO
Fig. 17.
partial to them on the ground that the deeper angles can
be more easily reached and tissue can be divided more
accurately, three attached to long handles will be neces-
APANES

G.TIEMANN & CO.
GTILMANN G

G-EEMANN ca
and kit ja arendte at sa a
Fig. 18.-Bozeman's Scalpels.
sary, one straight, and two curved at the junction of the
placed so as to allow of
Dr. Helmuth clings to
blade and shaft, and with the edge
cutting either to the right or left.

C
Fig. 19.-Skene's Hawk Bill Scissors.
the use of the knife with great fondness, claiming much
greater rapidity and nicety of operation.
A double scissors has been recently devised by Dr. Skene
46
LACERATION OF CERVIX UTERI.
for the purpose of removing by one stroke and with greater
certainty the tissue in the angle of the laceration.
Fig. 20.-Emmet's Tenaculum.
Two small Emmet's tenacula will be needed to raise the
tissue as it is dissected away.
********
WHOL
Fig. 21.-Skene's Double Tenaculum.
A double tenaculum is often found exceedingly service-
able for drawing down the cervix toward the vulval orifice.
Fig. 21 is one devised by Dr. Skene for that purpose.
Generally no artery forceps are necessary. If the circu-
lar artery be cut it can be best secured by passing a thread
of catgut or whale tendon beneath it and ligating it
through the tissue. If a tenaculum is not desired, the tis
sues as they are dissected up must be caught by a pair of
tissue forceps, which should be toothed and possess a slide
ANM COMM JOULES
KTYABRINDAfri
SKAAKITABUSARA AQUATH{{{{T}}L___"MAGOLIRUAUND
&TIEMANN-ÇO,

G.TIEMANN

DUTY
ARGOHER NAMSTUREPARATIEVENTEE
amanāmo comfairON FI KEMUD
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b
Fig. 22.-Tissue Forceps.
that the grasp may be firm. Many forceps have been de-
vised for this purpose, and every operator has his own par-
ticular favorite. One of the latest of these has been devised
by Dr. Geo. Cowan of Danville, Ky., and is designed to first
a
LACERATION OF CERVIX UTERI.
47
transfix the part to be seized and then to clamp it, in this
way preventing the constant slipping which is the trouble
with most others. As we have never tried it we cannot
speak of its value from experience.
The needles to be used will vary with the operator. The
G.TIEMANN &CO.
ETIEMANN &C.
G.TIEMANN co.
Fig. 23.-Emmet's Needles.
Fig. 24.-Sims's Needles.
majority of surgeons use either Emmet's or Sims's. For
practical use we prefer Emmet's latest needles, which are
slightly curved at the point, and instead of being round
pointed as were his first ones, have three rather dull cutting
edges which greatly facilitate their passage through the
dense cervical tissue.
Dr. Helmuth prefers and usually uses the large heavy

G.TIEMANN&CO.
GTIEMANN &CO.
Fig. 25.-Van de Warker's Needles for Lacerated Cervix.
Helmuth needle, for the sake of greater rapidity and ease
of placing the sutures. Dr. Van de Warker of Syracuse has
devised a needle especially designed to overcome the diffi-
culty of passing small or large needles through a very tough
cervix retracted, as it sometimes is, high up in the pelvis.
These will be found useful at times, but under most cir-
48
LACERATION OF CERVIX UTERI.
*
cumstances no device will be found equal to the ordinary
needle placed at any angle desired in a serviceable pair of
needle-holders. With these either a counterpressure hook,
as figured below, or Emmet's blunt hook must be used to

exert pressure against the cervix while the needle is being
forced through.
If in the operation wire is to be used, a shield or wire
C
Fig. 26. Counter-pressure Hook.
P
DUFFIE
Fig. 27.-Emmet's Counter-pressure Hook,
adjuster and wire twister will be needed. Emmet's instru-
ments are most excellent for this purpose.
GETIEMANNEL-GO==

Any heavy pair of scissors will answer as wire scissors.
A uterine sound will also be needed, and half a dozen sponge.
G.TIEMANN&CO.
(G.TIEMANN & CO

|!!?!!!!!!
Fig. 28.-Emmet's Wire Twisting Forceps.
holders and small sponges. These will comprise the neces-
sary instruments. According to the preference of the oper-
ator, will be needed silver wire, silk, whale tendon or cat-
gut. Each of these materials have their special advocates.

GTIEMANN & CO.
Fig. 29.-Sims's Wire Adjuster.
The greater number of operators prefer wire. Dr. Skene
uses silk and claims excellent results. Dr. Helmuth and
some other surgeons use almost exclusively whale tendon,
which is a Japanese article and manufactured by teasing
out into small threads the actual tendon of the whale.
These threads are then twisted and spun together as ordi-
nary silk. It was discovered by Dr. T. Ichiguro, chief sur-
LACERATION OF CERVIX UTERI.
49
geon of the Imperial Japanese army, who first introduced
it in 1877. The advantages of it are: first, that it does not
have to be removed, as being an animal substance it be-
comes absorbed in between four and seven days according
to the strain and location; the sixth or seventh day will
find nearly all those portions which are subjected to any
strain softened and absorbed. Second, that it allows of a
certain amount of giving as the tissues swell, and thus pre-
vents cutting through. It apparently does not absorb quite
so quickly as catgut. I believe from my experience and
that of others that silver wire possesses great advantages
over any of the others. Properly prepared silk would prob-
ably do well also. Dr. Sims, I believe, first introduced
silver wire to the notice of the profession. Since then it
has rapidly grown in favor, and is now used almost exclu-
sively by the most prominent gynecologists of the country,
among whom Emmet, Mundé, Hunter, Pallen stand fore-
most. The advantages which it possesses over all others are,
that it is clean and entirely aseptic; that, if necessary it can
be left in situ for two months or more; that the rigidity of the
wire gives proper support to the tissues while uniting, and
that, being approximated by twisting, the tension of the
suture can be accurately adapted to the needs of the coapted
parts. Further, a great advantage which I believe it pos-
sesses over whale tendon or catgut lies in the fact that
both of the latter are absorbed in from four to seven days
which does not allow time enough for the parts to unite
except under the most favorable circumstances. I have
never seen a cervix in which catgut or whale tendon were
used in which in some place the stitches had not given way
and allowed the parts to gape to a greater or less extent.
In some cases, despite every effort, or from some fault of
the operator, sloughing will ensue. If that occurs with the
whale tendon or catgut, it makes the operation necessarily
a total failure, as the suture will have absorbed and can
give no support to the part; or in certain cases healing is
50
LACERATION OF CERVIX UTERI.
delayed, until several days after the absorption of the
sutures, in which case also, for the above reason, failure
must result. But if wire is used in either case, by tighten-
ing the sutures and irritating the surface in the first place, or
by allowing the sutures to remain for a week longer, most
frequently union will occur.
Numerous cases are recorded where this has been illus-
trated. I have had a similar experience in the case of a
lady who had previously been operated upon, whale tendon
being used, with a result of union on one side and total
failure on the other. In the second operation silver wire
was used but still one lip sloughed. In a state of despera-
tion I irritated the surfaces, and allowed the wires to remain.
An examination a week later showed union along the bor-
der of the cervical canal and in a great degree of the cleft.
The result after a few months was entirely satisfactory as
regards both the cervical lesion and reflex neuroses. I
examined the patient about eighteen months after the oper-
ation, and found that the mucous membrane over the cervix.
was perfectly normal; there was a slight nick in the side
which had sloughed, but the tissues had adhered along the
line which was to and did for the cervical canal, preventing
any erosion and restoring the cervix to the normal size and
contour, excepting the slight nick. It should be stated also
that to a subsequent operation for urethrocele which I per-
formed must be attributed considerable credit for her im-
proved condition. The only objection to wire is the neces-
sity for its subsequent removal. But this is neither diffi-
cult nor painful in ordinary cases, and the slight inconve-
nience should not deter the practitioner from giving the
patient the benefit of the best means at his disposal.
Dr. Skene uses braided silk, prepared by soaking it for five
or six hours in melted wax, to which has been added car-
bolic and salicylic acid. The thread is then taken and
drawn through a piece of cardboard to remove all the super-
abundant wax. Dr. Skene prefers this to silver wire.
LACERATION OF CERVIX UTERI.
51
METHOD OF PERFORMING THE OPERATION.-On the
night preceding the day of operating, the patient is given
a mild cathartic, compound liquorice powder from one to
four teaspoonfuls, or Hunyadi water one-third of an ordi-
nary tumblerful, or citrate of magnesia one-half to one
bottleful; or, in some badly constipated individuals, a
compound cathartic pill may be needed.
Having insured a free movement of the bowels in the
morning, an enema is also to be given about three or four
hours previous to the operation, in order to free the rectum
and colon from any remaining fecal matter. About one-
half hour before the operation a heavy vaginal douche is to
be given as hot as can be borne by the patient, both for its
cleansing effect and its astringent action on the cervical
blood-vessels. Hæmorrhage at the operation can be reduced
to a minimum by means of the abundant use of hot water
previously. As in all operations where ether is to be given,
only a very light breakfast should be taken. If the after-
noon is the time selected a cup of broth, or beef-tea, or
milk, can be taken at eleven o'clock. The instruments
should be in carbolized water, I to 40; the hands of the
operator and attendants should be carefully washed with
soap in a carbolized solution. No one should be allowed
to touch the parts whose hands are not thoroughly aseptic,
as serious failures have resulted in which no reason could
be assigned other than meddlesome interference on the part
of those who failed to appreciate the importance of anti-
septic precautions.
Some system of irrigation should be at hand by which a
douche of hydrarg. bich., I to 2000, can be thrown into the
vagina just before and also at the completion of the opera-
tion. The most convenient method is the use of large two-
gallon irrigation bottles to which is attached rubber tubing
with glass nozzles and a spring catch. A short gynæcolo-
gical table, four feet by two and a half, and two and a half
52
LACERATION OF CERVIX UTERI.
high, is the most convenient. The table should be upon
heavy casters to allow of its free movements.
The instruments are placed at the left of the operator
near the lower end of the operating table; the table for
sponges at the right, a chair for the operator at the foot of
the operating table.
When everything is in readiness the patient is introduced,
placed upon her back on the table, and anæsthetized.
When this is accomplished she is turned over on her left
side in Sims's position, well on her chest, the pillow at her
head removed to facilitate respiration, and her limbs well
drawn up, the right knee being higher than the left, and
towels placed around her buttocks and a rubber elastic
under them. An assistant attends to the ether and nothing
else, another stands at the back of the patient to hold the
speculum and retract the labia or buttock, another at the
operator's right to manipulate the sponges and keep the
parts free from blood. If assistants are plentiful it is well
to have one, a nurse, keep the sponges clean and hand them
to a physician who will keep the parts free from 'blood.
The speculum, warmed and well oiled with vaseline, is
introduced and given to the nurse or assistant to hold.
The douche of merc. bich. is then given, and cervix seized
and drawn carefully downward toward the vulval orifice,
great care being exercised not to exert traction where there
is any resistance arising from old bands which have been
deposited by some preceding cellulitis. The cervix in ordi-
nary cases can be drawn to within an inch of, and sometimes
entirely outside, the vulva without danger. It is not safe,
however, to practice the latter usually, as there is great
danger of exciting peritonitis or cellulitis, and ordinarily an
operation can be performed with but little discomfort with
the cervix from an inch to two and a half within the vagina.
It should always be the rule to avoid all unnecessary trac-
tion. The cervix can either be held steadily in situ by a
double tenaculum or by passing a double thread through
LACERATION OF CERVIX UTERI.
53
the anterior lip and tying it, by which means the cervix
can be manipulated to suit the convenience of the operator.
The most convenient method, and the one which I employ,
is to seize the posterior lip with Skene's double tenaculum,
Fig. 21.
The catch prevents it unhooking, while the small peg in
one blade and the construction of the instrument prevents
any compression of the tissues. The bend in the instru-
ment is also of advantage, as are its strength and firmness.
The insertion of a thread in this lip is sometimes a matter
of some difficulty, as the uterus is sometimes high up and
unmanageable. The tenaculum saves time and patience.
Whether the laceration be anterior, posterior, unilateral,
or bilateral the operation is practically the same, excepting
that in the bilateral the denudation must be double what is
necessary in the others. For the stellate and internal lacer-
ation a different proceeding must be adopted; of that we
will speak later. Of the others a description of the bilateral
will suffice, as it includes the remaining. Having the cervix
within easy adjusting distances, the everted lips of the
cervix are brought together by means of tenacula, placed in
either lip, in order to determine the amount of tissue to be
removed and to mark out the area of denudation. Having
determined this and also where the cervical canal must be
located, the mucous membrane is hooked up upon a tenacu-
lum or grasped with forceps, and the work of cutting com-
menced. In a bilateral laceration it is well to operate the
lower cleft first, in order to avoid the constant running of
blood over the surface upon which you are cutting, which
will result if the upper surface is denuded first. The mucous
membrane to be left for the cervical canal is mapped out
with the eye, and with the curved scissors the mucous mem-
brane to the left of that is then cut away until the entire
cleft is bare, care being taken to make a clean and complete
removal in the angle of the laceration. The denudation
must be carried well out toward the vaginal junction to
54
LACERATION OF CERVIX UTERI.
prevent any puckering of the tissue. The amount to be
removed must be governed by the extent of the laceration
and the consequent size of the flaps to be coapted. Fig. 30
represents the area of denudation and the strip left for the
cervical canal.
If the cervix and denuded area could be transformed into
a flat surface it would be seen that a triangular piece with
its base impinging upon the cervical canal had been
removed. Fig. 31 well represents this. If there is no cica-
tricial tissue in the angle of the cleft this is a comparatively
easy matter, but if as is usually the case a large plug of

401
holl
ilia
Jul
./">
Fig. 30.
scar tissue has been deposited at the angle of laceration, its
removal is attended with considerable difficulty. The
impression and sound arising from the cutting of this har-
dened tissue is quite distinct from that caused by the divi-
sion of healthy cervical tissue. An impression of additional
resistance is conveyed to the operator's fingers; while the
sound is harsh and grating like that produced when tough-
ened tendon is divided by scissors. Oftentimes the eye
can detect the shiny, gristly appearance and the absence of
hæmorrhage from the incised surface. The best guide to
its presence is, however, found in the tactus eruditus. With
the finger and nail the dissimilarity between the tissues can
be easily detected. The healthy is soft and yielding, not
nodular and projecting, while the cicatrix is hard, lumpy,
conveying to the finger a sense of resistance not found in
LACERATION OF CERVIX UTERI.
55
the normal cervical tissue; this entire amount must be
removed. The depth of the incision is not a matter of
great moment unless, as is very unusual, it extends beyond
the os internum. If any portion of it is left the easy and
natural coaptation of the lips is hindered; the probability of
union by first intention is seriously diminished, as cicatricial
tissue has but little tendency to unite; and what is of the
greatest importance, in the majority of cases the reflex
menses, such as headache, backache, vesical trouble, neu-
ralgia, etc., will probably not be materially benefited, as

7/11
11. THERE ARE O
|
||
||
Fig 31.
these disturbances depend very largely upon the pressure
exerted upon the sensitive cervical nerves by this cicatricial
plug. Piece after piece must be caught up by the tenacu-
lum or forceps and cut away until the finger fails to detect
any remaining. In this, sometimes, deep dissection there
is danger of incising the circular artery of the cervix.
Unless this accident occurs the resulting hæmorrhage is of
little moment. If the circular is cut the bleeding can easily
be controlled by the artery forceps and ligature, which is a
rather difficult process owing to the difficulty of properly
securing the knot at that depth without including the blade
of the forceps, or by passing a small needle threaded with a
56
LACERATION OF CERVIX UTERI.
piece of fine catgut through the flap just below the artery.
This can be easily tied and cut off short, stopping the hæm-
orrhage and not in the least interfering with subsequent
union.
The flaps having thus been symmetrically denuded and
found to coapt easily, the operator can pass to the other
side. If the flaps do not approximate readily it is evidence
of still more cicatricial tissue at the angle, which must be
removed. In going to the opposite side and commencing
the denudation, the operator must very carefully mark out
the portion which is ultimately to form the cervical canal.
Over this portion on both sides of the os the mucous mem-
brane must not be removed except in certain cases which
are mentioned below. Symmetrical strips of mucous mem-
brane should be left on either side of the cervical canal
between the triangular surfaces which are denuded. These
strips should be wider at their outer extremity, which is to
form the os externum, than at the inner, in order to give
sufficient size to the uterine canal and to prevent either
dysmenorrhoea or sterility resulting from partial stenosis of
the canal. Having been careful to leave sufficient mucous
membrane, the second triangle is to be denuded, care being
taken, as before, to remove the cicatricial tissue and to
make the flaps symmetrical.
At times the anterior lip will be found greatly hyper-
trophied, so as to render it difficult to make symmetrical
flaps. It was for this condition that Goodall was accus-
tomed to remove a V-shaped piece from the lip as a meas-
ure preparatory to trachelorraphy.
For this same condition Dr. Emmet has employed a dif-
ferent device. He denudes the posterior lip upon the vagi-
nal junction down as much as there is hypertrophy of the
anterior lip. He then adjusts the flaps, thus reducing the
hypertrophy by drawing the anterior lip down and uniting
it to the lengthened denudation on the posterior lip.
Another method of reducing this hypertrophy is by denud-
Ba
LACERATION OF CERVIX UTERI.
57
ing the entire anterior lip, and cutting away all the excess
of tissue until it is of the same size as the posterior and the
denuded surfaces are symmetrical. The mucous membrane
which is left upon the posterior lip insures the potency of
the canal. By this method there would be greater dan-
ger from contraction of the granulating surface on the an-
terior lip.
Ad
Of these different methods the preferable one is no doubt
Emmet's, as we believe that in most cases this hypertrophy
is more apparent than real.
The plan of trimming away the anterior lip, however, has
been employed frequently at the Hahnemann Hospital
with good results.
If there should have been any cysts left in the cervix at
the time of operating, these should be trimmed away, as
they will cause reflex disturbances and prevent satisfactory
union.
If the laceration be stellate or bifid without to any great
extent involving the outer cervical structures, nature will
usually unite the parts, as they will be kept in apposition.
If, however, the cleft involves to a greater extent the tissue
of the cervix, and consequently does not heal, or if, from
the profuse discharge, the woman is greatly weakened and
is not relieved by local treatment, an operation must be
performed. It is not sufficient simply to denude and unite
the vaginal surfaces, leaving the canal as patulous as ever.
No benefit will result from this, as the unhealthy secretion
will continue to be poured out and, meeting the obstruction
of the vaginal membrane, will dilate the canal still more
and cause still greater reflex disturbances. In these cases,
when the lacerations are close together and, as is usually
the case, the tissue is greatly hypertrophied, a V-shaped
piece, including the laceration and cicatricial tissue, can be
removed. This can be done on both sides and the lacera-
tion then treated as a double laceration. If this is not
practicable the cervix must be laid open by a free incision
58
LACERATION OF CERVIX UTERI.
on either side, in the track of the old laceration. This
incision must extend until the cervical canal is found to be
of normal size. The point may not be gained until the
internal os is reached. The diseased tissue, including the
cystic mucous membrane, and the cicatricial tissue, must
then be removed, the flaps brought together, and the incis-
ion treated as a double laceration. A less radical treat-
ment will be of no benefit. The laceration in which the
internal fibres of the cervix are badly rent must be treated
in a similar manner, by freely laying open the cervix, remov-
ing the diseased tissue, reducing the canal to its normal
size, and treating the whole as a double laceration.
Mrs. B
presented herself at the Deaconess Institute
for confinement. She was delivered of a dead child by the
use of forceps, suffering a very severe laceration of the peri-
neum, the rent extending through the anal sphincter, and
also a peculiar laceration. Several months after delivery
she was placed under my care for operative treatment.
The cervix was enlarged, boggy, with erosions on the
slightly everted lips. The cervical canal was plugged with
characteristic thick pearl-like secretion. The lips were
scarcely everted, but the canal was exceedingly enlarged
and the uterus had not undergone proper involution. A
sound introduced in the canal showed that it was very
greatly increased in size behind the thin stretch of mucous
membrane, which covered the external portion and con-
cealed the laceration. After the parts had been rendered
healthy through the action of hot water douches and bell.
tinct. internally, I operated. The cervix was first laid
directly open down to the vaginal junction on both sides,
disclosing a greatly enlarged canal covered with unhealthy
mucous membrane studded with dark granulations. The
canal of proper size was marked out by the knife and the
diseased tissue cut away from both lips until it was all
removed. A slight amount of mucous membrane was also
removed from the lips in order to roll in their surfaces.
LACERATION OF CERVIX UTERI.
59
The stitches were then inserted as usual, bent over toward
the canal, and the patient put to bed. When the sutures
were removed on the tenth day union was found perfect.
A week later I operated upon the perineum with entire suc-
cess. When the two operations of trachelorraphy and per-
inorraphy have to be performed upon the same patient, it is
better to first perform the former, and the latter at a sub-
sequent time. The reaction is better, the shock and pain
much less. They can be done together, and I have per-
formed both operations at once in several instances, but it
greatly inconveniences the patient, and the result is not
so satisfactory. If wire is used, which I think is preferable
at all times, it is necessary to leave the sutures in the
cervix too long before removal on account of the sensitive-
ness and weakness of the newly united perineum, which
would only with danger of rupture and severe pain endure
the stretching of the speculum necessary for the removal of
the wire from the cervix. Everything is now ready for the
sutures. The needles and material to be used have already
been described. If whale tendon, catgut, or silk is used,
they can be threaded directly into the needle and drawn.
through. If silver wire is used, for which I have a very
great preference, the needle must be threaded with a
double thread of silk. The thread will need to be thirty
inches long. It is doubled and the two ends drawn through
the eye of the needle about three or four inches.
Six or
eight needles will need to be threaded in this manner.
Some operators prefer to use but one needle and thread,
adjusting the wire as they proceed. It makes but little
difference which way is accepted. The former offers the
advantage of being able to hold the cervical flaps more in
apposition, thus favoring the insertion of the sutures and
their more perfect coaptation. The needle is placed in the
forceps at a convenient angle, and steadying the cervix by
the counter-pressure hook or tenaculum the first suture
is inserted at the outer angle of the laceration. The
60
LACERATION OF CERVIX UTERI.
needle is entered about one quarter of an inch from
the denuded border and
border and passes from
from the
the cervical
mucous membrane downward to the bottom or angle
of the denudation. Where the cervix is not greatly
hypertrophied the needle can frequently be passed.
through both lips at once. It should emerge at a point
opposite the entrance. The thread is then pulled through
until the disconnected ends are free upon the further side
of the cervix and the loop still on the other. These are
drawn easily, making a double thread on each side of about
six inches, the needle removed, and the thread handed to
an assistant who holds them against the corresponding
buttock out of the way of the operator. Three or four
such sutures are usually needed on each side. In the inser-
tion of the sutures near the central portion of the cervix
where it is thick and unyielding, it will be necessary
usually to bring the needle out at bottom of the cleft and
to reinsert it at the same point, carrying it from within
outward though the second flap, as the cervix at this point is
too thick and dense to allow of a needle penetrating both lips.
at once. As fast as the threads are adjusted as described
they are handed to the assistant. The silver sutures are not
introduced until all the silk threads are in position on both
sides. Great care must be taken to have the mucous strips
designed for the lining of the new cervical canal in exact
apposition. The wire is then taken, turned over at its end
and hooked into the loop of the thread first introduced.
The loop in the wire must be as small as possible to facilitate
its being drawn through the tissue. It is best to squeeze
it down to a point by use of the needle-holder or artery
forceps before drawing it through. It is drawn through by
a slight, quick movement from the wrist. It is then cut off,
leaving about three inches on either side of the cervix.
The ends are merely looped together and given to an assist-
ant to hold. If twisted at this time it draws the flaps
too tightly together and interferes with the drawing through
of the remaining sutures. Each wire is introduced as above.
LACERATION OF CERVIX UTERI.
61
When all are in, those nearest the new cervical canal are
drawn down, unlooped at their extremities, first straightened
out, and then carefully drawn over the cervix and line of
incision, and given a twist to hold them until they can be
seized with the wire-twister. The edges must be seen to be
well coapted, or else it must be done with tenacula. This
shield or wire adjuster is then placed over the line of incision
and around the wire, which is twisted by the wire-twister
until sufficient traction is exerted to hold the lips in good
apposition.
It is to assist in obtaining the proper degree of tension
of sutures that the shield is useful. After the wires are
properly drawn together by the fingers with sufficient force
to hold the lips in easy coaptation, and given a half turn to
hold them at that point, the shield is pushed down upon
the cervix and the wire bent over that at a rather sharp
angle. If the wire is good there will be no twisting beyond
the angle formed by its bending over the shield, even though
it be twisted very tightly up to the instrument. In fact it
will break before tightening beyond this point. It is safer
to leave them apparently too loose than too tight, because
there will always be more or less inflammatory swelling,
which will easily fill out any gap but which will cause
sloughing if the sutures be tight. The sloughing will not
be serious, merely the tissue around the stitches will be
eaten into. Usually it will not seriously affect the ultimate
result of the operation, but even this amount of sloughing
is unnecessary if sufficient care is exercised in not drawing
them too tight. After being twisted, the wire should be
bent over a tenaculum toward the cervical canal and cut
off, leaving about half or three-quarters of an inch which can
be grasped when the sutures are removed. Many operators
prefer to bend the wire directly backward over the pos-
terior lip and then cut them away; but I prefer to place.
them parallel to the line of position of the two lips, for the
reasons that not the slightest inconvenience has ever been
experienced from the wires which have been so treated;
62
LACERATION OF CERVIX UTERI.
and as the uterus should be well anteverted after the opera-
tion, if the sutures are turned back over the posterior lip,
the ends are brought more directly in contact with the pos-
terior vaginal wall, and when they are removed they are
exactly where you don't want them, and if, as is usually the
case, the uterus is high up, it affords additional difficulty in
their removal. Besides, if the sutures are turned in toward
the center from both sides it is more easy to find the wires
leading to the outside sutures, which, unless this expedient
is employed, at times become buried in the folds of mem-
brane and greatly delay the removal.
Another point about the insertion of stitches, which will
apply as well to other parts of the body as to the cervix,
is, do not insert too many.
The fewer inserted which will
hold the tissue in good apposition, the better. I believe
that three on a side is all that is needed for the most exten-
sive laceration of the cervix, and for moderate ones two is
better. The most perfect union I ever had or saw was in a
case in which three sutures were used on one side and two
on the other; and twisted much looser than it is usually
the custom. When the stitches were removed entire union
had resulted, and there was not à break in the continuity of
the mucous membrane covering the cervix, except where
the sutures entered and found exit. The teaching of many
operators is to insert all the sutures possible, and the more
that can be introduced the better will be the union. The
results of a large number of operations in which this method
has been followed has led me to an exactly opposite conclu-
sion. More stitches than are absolutely needed to hold
the parts in apposition, and that is comparatively few, tend
to strangulate the tissue, especially in weak, anæmic indi-
viduals, and to prevent union by sloughing under the
sutures. Not only that, but it unnecessarily prolongs the
operation, which is a very grave error. One great factor
in the success of Dr. Tait's ovariotomies is the rapidity with
which he operates, and the very short time in which his
patients are kept under the influence of an anesthetic. In
LACERATION OF CERVIX UTERI.
63
a lesser degree, the same principle holds true in operations
on the cervix or elsewhere. Cæteris paribus, the less the
shock and the more rapid and easy the convalescence of the
patient.
All the sutures are treated in the same manner. In the
introduction of the needles, when the cleft is very deep
there is sometimes great difficulty experienced in bring-
ing the needle out in the desired point in the angle of the
cleft, it being difficult to reach the exact bottom without
going deeper than necessary. To overcome this difficulty,
the needle can be inserted in the inmost portion of the
cleft, which has been previously hooked up with a tenacu-
lum, and passed through the lips from within outward and
the needle unthreaded. The loop is carried out with the
needle, leaving the detached ends in the angle of the cleft.
A second needle is inserted at the same point as the former
and carried from within outward through the opposite flap.
In this case the detached ends are carried with the needle,
leaving the loop in the angle. Through this loop the
detached ends of the first thread are passed and drawn
through the second flap, thus drawing the first thread
through both lips and insuring its reaching easily the deep-
est angles of the laceration. The wire or whale tendon is
then to be hooked into this and drawn through. The
wires being all in position, a sound is introduced into the
cavity of the uterus to ascertain if the canal is pervious,
the uterus replaced in position and rather strongly anti-
verted, a final douche of merc. bich. given, or, if any oozing
is observed, of very hot water, which will usually contract it
without trouble, the patient cleaned up by the nurse and
removed to her room and bed.
After Treatment.-In ordinary cases this is exceedingly
simple. No medicines are necessary unless fever or sore-
ness from the stretching of the ligaments in drawing down.
the uterus manifest themselves. If fever appears, aconite
tinct. will usually control it, while rhus.³ acts best in reliev-
ing the hypogastric soreness and tenderness. Cloths wrung
64
LACERATION OF CERVIX UTERI.
out in hot water and applied after the manner given below
will add materially in relieving the discomfort. Probably
for the first day or two, especially if the bichloride solution
has been used, there will be a slightly bloody, serous dis-
charge. This is of no consequence, even if it should con-
tinue for some time, and needs no especial attention.
Douches need not be given unless the discharge becomes
purulent and offensive. In fact, it is better here, as in all
surgical procedures, to allow nature to be her own nurse as
far as possible, and not to needlessly interfere with her
processes of repair, for which she is usually amply sufficient,
by unnecessary douching and assistance. If, however, the
discharge becomes purulent and offensive, douches of warm
water, to which may be added a little carbolic acid, about
I-100, or boracic acid, are to be given as soon as the
vaginal discharge appears. These may be given two or
three times a day. If the patient can pass her urine she
may be allowed to do so, receiving a slight douche of warm
water immediately after each urination to avoid any urine.
getting upon the parts. If, as is sometimes the case, she is
unable to void the urine herself, the catheter must be used
every six or eight hours according to her individual
requirements.
The patient should be kept in bed until after the stitches
are removed. She need not be limited as to position, but can
occupy any which is most comfortable. It is best for the
patient to avoid any great restlessness, as it may irritate the
parts. It is rare for any secondary hæmorrhage which will
need attention to occur, though Dr. Mundé in the Ameri-
can Journal of Obstetrics for October, 1883, reports three
cases in which quite violent hæmorrrhage occurred on the
fifth and sixth days respectively. Dr. Emmet also, I be-
lieve, records a similar case. If such occurs the hæmor-
rhage can be controlled by ample douches of hot water, or
rather strong alum water; or a little water to which has
been added enough iodine to rather strongly color it can be
thrown into the vagina and retained for a time, or by paint-
LACERATION OF CERVIX UTERI.
65
ing the cervix with Churchill's iodine, and if these fail, a
tampon moistened with glycerine and covered, on the part
which will lie against the cervix, with powdered alum, or a
vaginal suppository containing twenty grains of powdered
alum and enough cocoa butter to hold it well and make a
good sized suppository, can be inserted.
If the hæmorrhage is not checked by any of these means,
the patient may be placed as Dr. Donaldson has suggested,
upon the table, or bed, if necessary, the speculum in-
serted, the cervix drawn down, steadied with the counter
pressure hook, and a large needle, threaded with heavy silk,
driven through the center of the cervical canal; the thread.
is then caught on a tenaculum in the canal, drawn out and
cut, leaving a thread passed through either lip, deep in its
substance. By tightening these threads alternately it can
easily be seen which one controls the hæmorrhage, as one
will probably do. A perforated shot is then slipped down
close to the cervix, traction made upon the silk, the shot
clamped down upon it, and the whole allowed to remain.
The thread in the opposite lip is then removed. The shot
ligature is allowed to remain in for twenty-four or forty-
eight hours, when it can be removed with little danger of a
recurrence of the hæmorrhage. Some of these methods
will no doubt control the bleeding. It is not usual for the
patient to experience much pain after trachelorraphy unless
great traction has been exerted in drawing the uterus down
at the time of the operation, or unless there exists severe
pelvic inflammation which has not been removed by treat-
ment, thus inciting a fresh attack of cellulitis or peritonitis.
If these unfortunate complications arise, they must be
treated according to their special indications. In addition
to such remedies as ac., bell., bry., as., carb. veg., kali chlor.,
kreos., arn., apis, and others, which find their legitimate
sphere of action in this morbid condition, great relief and
benefit will be derived from the abundant use of hot water
applied as a vaginal douche and also as hot fomentations.
The douches, to be effective, must be given early, and in
66
LACERATION OF CERVIX UTERI.
quantities of not less than a gallon, three or four times a
day, while the fomentations must be applied by soaking
four thicknesses of flannel in as hot water as can be borne
and applying them to the abdomen. Over this is placed a
piece of oiled silk or rubber tissue and the whole covered.
with four thicknesses of dry, hot flannel. This must be
changed as often as it becomes cold-every two or three
hours will generally suffice. If a rubber coil can be had,
and be made to work so as not to suddenly burst and scald
the patient, it will do excellent service.
On the seventh or eight day, if the patient has progressed
favorably, the stitches are to be removed. If perineorrhaphy
has been performed at the same time as the trachelorraphy,
the stitches in the perineum had best be left till about the
tenth day, while those in the cervix should remain a month.
longer. No harm will accrue from the presence of the
stitches in the cervix. Dr. Hunter, of New York, reports
that in frequent cases he has allowed them to remain for
from one to two months with no harm arising. If whale
tendon or cat-gut has been used, of course it obviates the
necessity of removal.
Ordinarily the removal of the stitches is not painful.
The twisted end of wire is grasped by long dressing forceps,
and cut by a wire cutter, or wire scissors which have a short
arm on the end of the blade, at right angles to the long
diameter, to hook up the wire. The cervix is then steadied
and the wire drawn out over the line of union, not away
from it. This prevents any traction being made upon the
newly united surfaces. Each wire is then removed. Care
must be taken not to cut the twisted portion of the wire
close to the suture. If this accident happens, and it is not
difficult to make this mistake, it is very hard to find the
suture, as it will be imbedded somewhat in the tissue. It
is better not to irritate the parts too much by searching for
it, but allow it to remain till the cervix has somewhat re-
duced in size, when it can be detected more easily. After
the removal of the stitches the patient should be confined
LACERATION OF CERVIX UTERI.
67
to her bed for two or three days, commencing to sit up and
walk on the eleventh or twelfth day.
If, on attempting to remove the wire, the operator finds,
much to his chagrin and disappointment, that the surfaces
have not united, or, still worse, have sloughed, he must.
irritate the surfaces with scalpel, probe, scissors, or anything
which will freshen the indolent parts, tighten the wires a
little, if need be, and leave it alone for another week. Not
infrequently a second examination will show very fair
union. If, after all, union fails to result, the wires must be
removed and the parts healed by the argentum nitricum
solution. For this purpose a solution containing from
twenty to forty grains to the ounce will be needed, accord-
ing to the depth of the slough and the sluggishness of the
parts. Dr. Emmet reports a case in which sloughing and
consequent non-union followed two successive operations,
upon the same individual, which was subsequently healed
by arg. nit. The benefit to be derived from the operation
is not always to be measured by the perfection of the
union following. If the cicatricial plug has been removed.
from the angles of the laceration the same good results will
generally accrue, even if union does not follow. By clean-
liness and stimulating applications, as arg. nit. or iodine,
the gap will usually fill up, the irregularities resulting from
the projecting lips be smoothed down by absorption, and
the cervix ultimately present a very creditable appearance.
If it is healed without the development of cicatricial tissue,
the same good results will accrue.
If erosions spring up,
and the lips evert, the condition of hyperplasia with atten-
dant neuroses will return and greatly impair the result of
the operation. In this case a second operation is all that
promises any favorable result.
The benefits of trachelorraphy do not always immediately
follow the operation. In certain cases, even of long stand-
ing, the tormenting headache or backache will disappear as
by magic as soon as the patient recovers from the influence
of the anesthetic, and she will obtain the most refreshing
68
LACERATION OF CERVIX UTERI.
and enjoyable night's sleep which has visited her for years.
As a rule, however, there is a very gradual improvement
which must be measured by months. And it is not unu-
sual for a year and a half or two years to elapse before the
patient realizes the full benefit of her operation. She
should be acquainted with this fact in order to guard her
from yielding to disappointment when the expected bene-
ficial results do not at once appear, and also to prevent her
attaching blame to the surgeon for subjecting her to an
operation from which she sees no present benefits. Not
infrequently, as a result of the mental excitement of the
operation and the mechanical irritation of the parts, men-
struation will appear. This ordinarily causes no disturb-
ance, nor does it appear to retard the healing process. If
the discharge from the wound is slight the douches can be
omitted during the catamenial flow.
The mortality after trachelorraphy is very low. Dr.
Mundé reports one case in which the patient died of septic
peritonitis, though the wound healed perfectly. A few
other cases are also recorded. Ordinarily, however, it is an
operation remarkably exempt from surgical dangers. Sta-
tistics show that failure of the denuded surfaces to unite
occurs in about eight per cent. of cases. This lack of suc-
cess may be occasioned by sloughing, appearance and long
continuance of the menstrual flow, the too speedy getting
up of the patient, or by lack of proper preparatory treat-
ment, thus operating before the congestion, subinvolution,
cystic degeneration, erosions have been removed.
After Results.-The length of this chapter will allow of
but a word regarding the effects of trachelorraphy upon
sterility, subjective and objective symptoms, the pathologi-
cal condition attributable to the lesion, and the tendency
to laceration in subsequent deliveries. The uterus gradu-
ally returns to its normal size, the subinvolution and hyper-
plasia disappear, the cervix assumes its natural conicity, and
becomes covered with a healthy, pink mucous membrane.
The endometritis and consequent leucorrhoea usually subside
LACERATION OF CERVIX UTERI.
69
in from a few weeks to several months, and the menstrual
flow becomes more free from pain and again approaches
the normal standard.
Dr. Van de Warker in the American Journal of Obstetrics
and Gynecology for July, 1883, gives the results of thirty-one
cases of trachelorraphy as follows:
Uterine displacement unchanged in.
C
CC
removed in..
"C
CL
catarrh unchanged in. . . .
removed in...
"C
Subjective neurosis unchanged in...
"C
Co
IO
II
3
.16
.18
5
Many cases, of course, cannot be subsequently followed,
and statistics from them cannot be gathered. When the
wound is properly healed without sloughing there is usually
no scar left either to mar the normal appearance of the
cervix, to obstruct delivery, or to render the patient liable
to a subsequent laceration. Even where a cicatrix forms it
is longitudinal, and at subsequent deliveries does not in the
least interfere with dilatation nor offer any additional pre-
disposition to laceration.
Drs. Goodale, Hunter, Skene, Lee, Emmet, besides many
others, have reported, through the medical journals, numer-
ous cases of pregnancy following trachelorraphy, with no
impairment of the natural continuity of the cervix.
The subsequent history of the operation shows that
laceration is no more apt to occur than in one whose cervix
has never been torn.
·
improved or removed in.
Nutrition improved in..
"C
unchanged in.
•
•
*
··
•
O
+
• • ·
16
II
In viewing the effect of the operation on sterility, it must
be remembered that many women, from the long continu-
ance of the inflammation consequent upon the lesion, have
no doubt been thrown beyond the medical action of any
procedure, surgical or medical. The constriction of the tube
by bands of tissue left by a former cellulitis; the establish-
ment of salpingitis or ovaritis of some form; the fixation
of the pelvic roof and binding down of the uterus, all tend
70
LACERATION OF CERVIX UTERI.
greatly to diminish the possibility of a future pregnancy.
Taking this into consideration, the statistics referring to the
removal of sterility are very fair.
In the New York Medical Journal for July, 1883, Dr. B.
F. Baer reports the results, as regards sterility, of twenty-
seven cases operated upon by him. Of this number six had
reached the menopause or were widows; thirteen had been
sterile for from five to sixteen years previous to the opera-
tion, and from reasons as stated above probably could not
become pregnant. Of the remaining eight, six afterward
became pregnant. Dr. Baer thus estimates that in seventy-
five per cent. of those in whom there was a possibility of a
subsequent impregnation the sterility was cured. I should
regard this percentage as too high, for the reason that
probably a fair proportion of the thirteen who were ex-
cluded from the estimate had not suffered severely enough
from the results of inflammatory action to render them ne-
cessarily sterile.
In the following number of the same journal, Drs. Githens,
Lee, Montgomery, and Goodell reported numerous cases of
pregnancy following the operation.
Dr. Emmet remarks that the effect of trachelorraphy
upon sterility is good providing the pelvic organs have
not been too greatly injured by inflammation; that, after
preparatory treatment, pregnancies were of very common
occurrence without subsequent laceration.
As the majority of patients operated upon have passed
the period in which impregnation is most apt to occur, the
actual benefit of the operation upon sterility is not to be
measured entirely by statistics, which necessarily include a
very large number of cases in which no possible benefit could
be anticipated. But, under favorable circumstances there
can be no doubt but that trachelorraphy, properly per-
formed, exercises a very beneficent local and reflex action
upon the sterility as well as upon other symptoms dependent.
upon a severe laceration of the cervix.
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