WITH THE COMPLIMENTS OF THE AUTHOR. 
LACERATION 
OF THE 
CERVIX UTERI. 
33 
A. Reeves Jackson, a.M., M.D. 
Formerly Surgeon-in-Chief of the Woman’s Hospital of the State of Illinois; late Lecturer 
on the Surgical Diseases of Women in Rush Medical College, Chicago; Fellow 
of the American Gynecological Society, etc., etc. 
READ BEFORE THE CHICAGO MEDICAL SOCIETY, 
JULY 7th, 1879. 
REPRINTED FROM THE CHICAGO MEDICAL JOURNAL AND EXAMINER, 
For August, 1879. 
Chicago : 
Bulletin Printing Co., 113 Madison Street. 
1879. LACERATION 
OF THE 
CERVIX UTERI. 
B ~5T 
A. Reeves Jackson, a.M„ M.D 
Formerly Surgeon-in-Chief of the Woman’s Hospital of the State of Illinois; late Lecturer 
on the Surgical Diseases of Women in Rush Medical College, Chicago; Fellow 
of the American Gynaecological Society, etc., etc. 
READ BEFORE THE CHICAGO MEDICAL SOCIETY, 
JULY 7th, 1879. 
REPRINTED FROM THE CHICAGO MEDICAL JOURNAL AND EXAMINER, 
For August, 1879. 
Chicago : 
Bulletin Peinting Co., 113 Madison Street. 
1879. LACERATION OF THE CERVIX UTERI. 
BY 
A. Reeves Jackson, A.M., M.D. 
If Dr. Thomas Addis Emmet had done nothing more for the 
medical profession than tell its members what he has told them 
in reference to the subject of laceration of the cervix uteri, he 
would be entitled to their warmest gratitude. Not that he was 
the first to recognize the lesion as a distinct factor in the causa- 
tion of uterine disease, for this had already been done, as early 
as 1856, by Dr. A. K. Gardner,* who speaks of “ laceration of 
the os and cervix ” as causes of ulceration, enlargement of the 
cervix, sterility, etc. : but to Dr. Emmet is due the credit of 
effectively calling attention to the frequency and pathological 
importance of the injury, and, above all, of showing how to 
recognize and cure it. Indeed, he has written so much about it, 
and so identified himself with its history, that other observers 
have been able to do but little more than add to the number of 
his facts, corroborate his views and commend his methods. 
7 % 
* The Causes and Curative Treatment of Sterility, etc., by A. K. Gardner, a m., m.d., New 
York, 1856. 4 
Though it is not the lot of all to be discoverers of important 
truths, all may aid in their dissemination; and I hold it to be 
the duty of those who have found themselves benefited and their 
hands strengthened by the observations and experience of others 
to assist, so far as it may be in their power, in extending these 
benefits to their fellows. Herein lies the reason why, although 
I have no new facts to offer — nothing, indeed, but the meagre 
results of my own experience — I yet feel warranted in asking 
your attention to this subject; one whose interest and import are 
not, I am sure, duly appreciated by the profession at large. 
If it were in my power to do so, I would like to make every 
member of this society, and every member of the medical profes- 
sion, understand and realize that injuries to the uterine cervix 
during the process of parturition are not of rare and occasional 
happening, but that they are, on the contrary, of extremely fre- 
quent occurrence; that these lesions are not trivial in their 
nature and consequences, but that they are often of great and 
enduring pathological moment; that they are frequently the 
undiscovered cause of many of the derangements of health in 
women which have been and still are habitually attributed to 
other sources and conditions ; that the venerable myth “ ulcera- 
tion,” and its Fidus Achates, enlargement of the cervix, are so rare 
(except when the seat of malignant disease) that one may reach a 
ripe old age without seeing either of them ; and that these terms, 
in such common use, may and should be in almost every instance 
rendered “ laceration of the cervix.” When these truths — for 
such I hold them to be — are known and accepted, there will not, 
I trust, be so many nervous, weak-backed, tired-out women as 
now crowd our waiting-rooms; we shall hear less of the use- 
lessness of pessaries for “ falling ” wombs, less of amputation for 
enlarged ones; know less of failures to cure “the whites; ” see 
less of pallid patients who wander — hopelessly at last—from 
one doctor to another, only to have repeated, by each one in 
turn, the “burning off” of the ulcers! This was the ordeal 
through which all womb-ailing women formerly passed, and 
through which thousands are passing now. 
Until within the past two or three years the literature of cervical laceration was very scanty. In the autumn of 1862 
Emmet* accidentally discovered the existence and importance of 
the injury, and devised an operation for its cure. Seven years 
later he published a paper,f in which the details of the operation 
were fully described. In November, 1874, he published another 
paper,J giving prominence to the frequency of the lesion, and 
the relation it bore to the etiology of pelvic disease; and in 
December, 1876, he read still another paper before the New 
York County Medical Society, on “ The Proper Treatment for 
Laceration of the Cervix,” which was subsequently published.§ 
A few additional papers by Wing,|| Baker,f Breisky,** Dudleyft 
(two), Goodell I! and Mundd,§§ constituted about all the published 
writings upon the subject until the appearance of the recent work 
of Dr. Emmet (op. cit.), in which it is treated systematically and 
with great fullness. 
Dr Emmet gives a graphic description of the manner in which 
he detected the presence of the laceration in the first case upon 
which he operated. The patient had been an invalid for several 
years, and had been treated for menorrhagia and hypertrophy of 
the uterus with an extensive erosion. The latter had, with great 
care, been healed several times, but a relapse always occurred. 
Attributing his want of success to the condition of his patient’s 
general health, which was very much impaired, he had almost 
despaired of affording her any permanent relief. He says : 
While making a digital examination one day, I was puzzled to account 
for the greater width of the cervix in comparison to that of the body 
beyond, a condition I had for the first time appreciated. I placed her on 
the left side, and with Sim’s speculum brought the cervix into view. I 
* Principles and Practice of Gynaecology, p. 445. 
f Amer. Jour. Obstetrics, Feb.. 1S69. 
%Amer. Jour. Obstetrics, Nov., 1874. 
$ American Practitioner, Indianapolis, Ind., Jan., 1877. 
|] Bost. Med. and Surg. Jour., March, 1876. 
f Ibid, Sept. 27, 1877. 
** Wiener Med. Wochenschrift, 1876. 
ft New Yorlc Med, Jour., Jan., 1878. Chicago Med. Jour, and Exam., Mar., 1878. 
+J “ Laceration of the Cervix Uteri.” The address in Obstetrics delivered before the Medical 
Society of the State of Pennsylvania, by Wm. Goodell, a.m., m.d., May, 1879. 
Am. Jour. Obstetrics, etc., Jan., 1879. 6 
drew the posterior lip forward toward me with a tenaculum, but with no 
special purpose, wdien I was surprised to observe that it had decreased to 
nearly half its previous size. On lifting up the anterior lip with a tenacu- 
lum in the other hand, so as to bring the two portions in approximation, 
the outline of a cervix presented, of nearly a normal size. The difficulty 
was at once apparent, for the parts had rolled back within the uterine canal, 
and a deep lateral fissure became evideut, which extended on each side 
entirely through the cervix and beyond the vaginal junction. On separa- 
ting the flaps and forcing them back to their former position, I saw the 
tissues gradually roll out and the cervix again present its previous appear- 
ance. There could then be detected no appearance of laceration, and with 
the reduplication ot the vaginal tissue over the sides of the uterus, as I 
have already described, the cervix presented a normal length above its 
apparent junction with the vagina. The remedy at once suggested itself; 
the operation was performed. * * * On completing the operation, the 
uterus was five inches in depth; it rapidly reduced in size, and in time all 
evidence of local disease subsided. 
My own attention was called to this subject more than four 
years ago, in connection with a case which was almost the coun- 
terpart of the one just related. 
Mrs M., thirty-two years of age, the mother of three children, the youngest 
of whom was five years old, had been under my care about two years, with 
occasional intermissions. She had become as tired of me as I was of her, 
when one day she asked me whether I thought she could be cured if she 
went to New York. I felt piqued by the question, which aroused in me a 
fresh interest in her condition. I had a short time before been reading Dr. 
Emmet’s paper, already referred to, on the subject of laceration of the 
cervix, and it occurred to me to ascertain whether my patient might possibly 
be suffering from such an injury. Accordingly I placed her in the knee- 
chest position, and introduced a perineal elevator into the vagina. The 
latter became widely distended, and I was afforded a full view of its ante- 
rior and lateral walls, and the vaginal portion of the cervix. But the parts 
appeared so differently from what I had been accustomed to see, that I 
almost doubted their identity. Prior to this time I had always examined 
her in the dorsal position, the head and shoulders being raised. In that 
posture, and also when the patient was on her feet, the lower part of the 
uterus was found just within the vulva, and a finger could be passed into 
the vagina to the depth of two and a half inches before it reached the 
apparent utero-vaginal junction. Now, however, as the weight of the 
uterus carried it from the vulva and drew out the vaginal walls to their 
full length, I saw that the erosion, instead of appearing, as formerly, to 
involve a flattish surface nearly two inches in diameter at the end of an 
elongated cervix, was depressed in the middle, and reached not only to but 
beyond the vaginal junction; while the vaginal portion of the cervix was 
actually but little longer than it should be. Subsequently, aided by an assistant, I brought the anterior and posterior flaps together with tenacula, 
and the red eroded tissues were rolled in out of sight, and the mushroom- 
shaped thickening of the cervix at once disappeared. In short, it was 
evident that I had before me a typical case of bilateral laceration of the 
cervix uteri, which I had been typically maltreating for something else. I 
had been trying, secundum artem, to cure this patient of a granular erosion 
of the os uteri, with enlargement and elongation of the cervix uteri, when 
properly speaking, neither of these conditions were present, or at least, only 
as symptoms. 
Although this was the first case in which I discovered the 
lesion, it was not the first in which I operated; for, before I 
could obtain the consent of Mrs. M.—or rather that of her 
friends—to have an operation performed, I had succesfully 
operated upon another lady in whom, guided by my experience 
in the former case, I diagnosticated a laceration at the first 
examination. 
Down to the present time I have operated twenty-three times 
for this malady. In one case the operation was followed by a 
rather severe attack of pelvic cellulitis, from which, however, the 
patient recovered, and the operation succeeded. In another 
case, there was secondary haemorrhage, requiring the vaginal 
tampon. In three cases the parts failed to unite — in two com- 
pletely, in one partly, results due, I believe, to the lack of suffi- 
cient and proper preparatory treatment. In two of these, a 
second operation was successful ; the third declined further 
treatment. 
Frequency. — The experience of Dr. Emmet, based upon 500 
cases observed in private practice, leads him to affirm that 32.80 
per cent. — that is, nearly one-third — of “ all women who had been 
impregnated, and had suffered from some form of uterine disease, 
were found to have laceration of the cervix ; ” and he concludes 
his consideration of the subject by stating that “at least one-half 
of the ailments among those who have borne children are to be 
attributed to laceration of the cervix.”* 
While I believe that there are few who would go so far as 
to endorse this statement unconditionally, I am of the opinion 
that, if all cases of laceration, slight and severe, be included, he 
* Loc. Cit., p. 480. 8 
is not wide of the mark; certainly, he is more nearly correct 
than are those who regard the injury as of rare occurrence. The 
conclusions of other observers whose attention has been directed 
to this point, do not greatly differ from those of Emmet. Thus, 
Dr. P. F. Mundd* found 119 lacerations in 700 women examined ; 
and Dr. Goodell f says, “ My own experience at the Dispensary 
for Diseases of Women at the University of Pennsylvania, would 
lead me to infer that about one out of every six women suffering 
from uterine trouble has an ununited laceration of the cervix.” 
I am aware that this great frequency of the lesion has been 
denied, but it is evident from what has already been advanced, 
that any one who has not given special attention to it — who has 
not looked for it—and who, above all, has not adopted the proper 
means for detecting it, can hardly be in a position to form a just 
opinion upon the question. 
Causes.—Previous organic disease of the cervical uterine tis- 
sues doubtless predisposes to the accident. Cervical metritis, for 
example, whether in its soft or indurated stage would interfere 
during parturition more or less effectually with the gradual and 
uniform dilatation of the parts upon which the integrity of these 
latter depend. So, likewise, would the rigid cicatricial condition 
of the os and cervix, which is so frequently found as the result 
of the long continued application of nitrate of silver, caustics, 
etc., for real or fancied disease. 
Among the exciting causes may be ranked obstetric operations, 
as turning, the use of forceps, etc., not necessarily from careless- 
ness or lack of skill on the part of the obstetrician, but because 
these manoeuvres require a certain amount of manual force, and 
also because of the state of the parts which frequently makes 
their employment necessary. Of course, such an untoward result 
is more likely to follow these procedures if they be attempted 
before the os uteri is in a suitable condition of dilatation or dila- 
tability. A laceration may likewise occur in consequence of 
an undue violence in delivering the placenta. Other causes of 
this character are, the administration of ergot in unsuitable cases, 
especially before dilatation has been accomplished ; the premature 
* Loc. Cit. 
t Loc. Cit. 9 
rupture of the foetal membranes, whereby their soft and insinu- 
ating pressure is replaced by the more unyielding head. 
I have had the impression that rapid labors, by not affording 
sufficient time for normal dilatation, would be found to be a cause 
of laceration, but an examination of the tables furnished by Dr. 
Emmet seems to show that such is not the case. In 164 cases 
in which the character of the labor was ascertained, it was rapid 
in 30, tedious in 50 and natural in 21. 
Varieties.—The injury varies both in direction and extent. 
It may involve only the anterior or posterior lip or both; it may 
be transverse or oblique. The rent is not always in a straight 
line, but is sometimes curvilinear, or at least it assumes this direc- 
tion during the healing process. 
In extent, too, it varies greatly; in some cases involving only 
the edge of the os uteri to the depth of a quarter or third of 
an inch, but in others passing quite across the crown of the cer- 
vix, and in still others extending to and beyond the vaginal junc- 
tion. Dr. Emmet * mentions several instances in which the rent, 
passing the cervical limits invaded the bladder and posterior cul- 
de-sac respectively, leaving as a consequence, in the former case,, 
either an extensive fistula involving all the injured parts, or, 
where partial spontaneous union subsequently occurred, either a 
small vesico-vaginal fistula just in front of the cervix, or a vesico- 
utero fistula, through which urine might escape from the bladder 
into the uterine canal at a point as high as the internal os uteri 
or even above. 
Lacerations which do not extend to the vaginal junction are 
called incomplete, while those which reach to or above that point 
are said to be complete. 
There is another variety of the injury besides those mentioned 
which may also be termed incomplete. It is that in which the 
rent does not involve the entire thickness of the cervical wall. 
Emmet describes these cases as follows : “ It would seem as if 
partial laceration took place from the internal os downward on 
different sides through the mucous membrane and deeper tissues, 
without extending to the vaginal surface of the cervix, making 
* Yesico-Vaginal Fistula, etc. By Thos. Addis Emmet, m.d. Wm. Wood & Co., New York. 10 
folds not unlike those between the ribs of a partially opened 
umbrella, which disappear when it is fully opened out. Through 
the patulous os and canal the mucous membrane is seen pro- 
lapsed, and its appearance is like that presented after dilating 
with a sponge tent a partial contraction of the canal which had 
taken place above, but had not yet extended to the external os. 
The cervix is frequently but little enlarged in diameter, but its 
walls are seen to be thinner than natural.” 
Yet other varieties than those enumerated result from the 
number of fissures. If there be but one, to the right or left, it 
is said to be unilateral; while, if there be one on each side it is 
bilateral; should there be still more, trilateral, stellate, etc. 
Of all the varieties of laceration, Dr. Emmet believes that 
those in the antero-posterior direction are the most frequent, but 
that, owing to the fact that the patient is enforced to maintain 
the recumbent position for some time after labor, the pressure of 
the lateral walls of the vagina maintains the torn edges in con- 
tact until union occurs, leaving only a cicatricial line to mark the 
site of the injury. My own experience — much more limited, cer- 
tainly— does not, however, coincide with that opinion. Although 
since my attention was first called to this subject, I have care- 
fully looked for the evidences of previous laceration, I have not 
found them nearly so often in the anterior and posterior 
lips as in a transverse direction ; and I think we might in 
advance suppose that this should be the case, from the fact that 
the cervical walls are thinner in this direction than in the other. 
However this may be, it is quite certain that lacerations through 
the anterior or posterior lip are much more apt to heal sponta- 
neously than are those in other directions, because of the lateral 
pressure of the vaginal walls ; and, also, that even where sponta- 
neous union does not take place, the same force tends to prevent 
the serious consequences which result from the eversion of the 
cervical lining which so much more commonly occurs in the other 
varieties of cervical laceration, especially the bilateral, provided 
they be of sufficient extent. 
Progress, Symptoms, etc. — Lacerations which involve only 
the edges of the os uteri frequently, perhaps generally, heal 
spontaneously before the woman leaves her bed. Those which 11 
occur in a forward or backward direction, even when com- 
plete, may likewise unite and leave little or no trace, the 
raw surfaces being kept in contact in the manner already indi- 
cated. 
Most of the cases met wTith in practice are those in which the 
laceration is in a transverse direction, and in which it has passed 
beyond the crown of the cervix. In nearly all of these, espe- 
cially where the rent has extended to or beyond the vaginal 
juncture, the intra-cervical membrane becomes everted. Its 
delicate covering accustomed to contact with only its own alkaline 
secretion is now constantly bathed with the acid secretion of the 
vagina, which, acting as an irritant, soon causes removal of the 
epithelium. This abnormal state of the parts prevents or retards 
the proper involution of the uterus, which, consequently, remains 
enlarged and soft. All these unfavorable conditions are increased 
so soon as the woman quits the bed and gets upon her feet. Then 
the heavy uterus, inadequately sustained by its supports, presses 
upon the floor of the pelvis. The intra-cervical surface of the pos- 
terior flap of the laceration impinges upon the corresponding vagi- 
nal wall, while the anterior flap is pushed toward the vulva. The 
everted and eroded surface now suffers additional irritation from 
the pressure and chafing to which it is subjected. Under these 
circumstances the flaps are forced farther and farther apart; the 
extruded lining membrane, by reason of its interrupted circula- 
tion, becomes thickened and congested, and thus assists in its 
own out-rolling. The uterus being in a state of fatty degenera- 
tion (the first stage of involution only having been accomplished), 
the flaps are soft and yielding. Their inner surfaces are hence 
readily flattened out against the vaginal walls, and the entire 
cervix finally is everted, the internal os uteri becoming the lowest 
portion of the organ, and appearing at what seems, owing to the 
reflection of the vaginal tissue, a very long and very broad 
cervix. 
The Nabothian glands, thus exposed, are at first stimulated to 
undue activity, as evinced by the greatly increased quantity of 
secretion poured out by them, and which constitutes the glairy, 
tenacious discharge which is so characteristic of endo-cervical in- 
flammation. By and by, they become diseased. Their excretory 12 
ducts close, and their contents being thus retained, they enlarge 
and form protruding roundish masses, varying in size from that 
of a millet-seed to that of a grain of barley. Some of these 
rupture, and their open mouths add an appearance of in- 
creased roughness and rawness to the already eroded surface. 
Before bursting they may frequently be felt as small shot-like 
bodies in the tissues. 
When the injury is confined to one side, the eversion of the 
cervical lining is not so marked, and occasionally does not occur 
at all, even when the rent has extended to the vaginal junction. 
In these cases there has usually taken place some degree of union 
at the bottom of the fissure, and the cicatrix thus formed restrains, 
partially or wholly, the tendency to protrusion. 
Symptoms.—The symptoms produced by laceration of the 
cervix consist of various pains in the back, hips and thighs; a 
sense of weight and “ dragging ” in the pelvis, increased in se- 
verity when the patient is in the standing posture, or has under- 
gone any unusual amount of fatigue. Leucorrhoea is nearly 
always present, and the discharge is sometimes tinged with blood. 
Menstruation is frequently though not always disturbed. Usually 
the flow is increased in quantity, and appears after shortened in- 
tervals ; metrorrhagia is also not infrequent. On the contrary, in 
a smaller number of cases the menstrual discharge is diminished 
in quantity. Sexual appetite is frequently impaired, and some- 
times abolished entirely. Neuralgic pains referred to the region 
of the cervix, sometimes of great intensity, are present in some 
instances. 
In the worst class of cases no long time elapses before the lack 
of exercise and the persistence of pain and exhausting discharges 
produce their legitimate results upon the general health. Diges- 
tion is impaired, the appetite fails, the bowels become constipated, 
assimilation is interfered with. A lessened supply of impover- 
ished blood produces pallor and sallowness of complexion, debil- 
ity, disturbed and insufficient sleep. The stomach, liver, bowels, 
kidneys, and especially the bladder and rectum, all contribute their 
quota of sympathetic manifestions, and combine to render the 
woman’s life utterly wretched. 
One of the notable effects of the injury, as pointed out by Dr. 13 
Goodell,* is that of sterility. He says, “ This lesion is so 
common a cause of sterility that I always suspect its existence 
whenever a guileless woman stops bearing after her first labor.” 
As a rule, the severity of the symptoms, local and general, 
resulting from laceration of the cervix, are in direct proportion 
to the extent of the injury, and especially to the amount of ectro- 
pium present. But this is by no means always the case. I have 
known some instances in which the laceration was of very mod- 
erate extent, and in which only a small portion of the cervical 
lining membrane was extruded, and yet the patients were obliged 
to be in bed the greater part of the time on account of uterine 
and ovarian neuralgia, dysmenorrhoea, pains in the back and 
pelvis, general ansemia, etc. ; while, on the other hand, I have in 
mind one case in which, with a transverse laceration extending on 
both sides from the os uteri quite to the vaginal junction, with 
accompanying extensive eversion, the woman was able to perform 
her usual household duties. These anomalies of the relation be- 
tween cause and effect are not, however, as is well known, con- 
fined to the injury under consideration. The history of disease 
— of pelvic disease, particularly — is full of them. The extent 
to which women suffer from a given amount of disease or injury 
of the reproductive organs is greatly influenced by the social 
condition and surroundings of the patient. Those in the higher 
ranks of life, who live luxuriously, whose nervous systems have 
been unduly and unsystematically developed at the expense of the 
osseous and muscular suffer most, for in them is engendered an 
unnatural tendency to irritability and emotional and sensational 
disorders. 
Diagnosis.—It would seem that, from the accessibility of the 
parts both to touch and sight, nothing could be easier than the 
recognition of a laceration of the cervix uteri; but the fact that 
it eluded discovery by so many expert and earnest workers for so 
many years, shows that what appears to be so simple a matter is 
really not so. And, if any one should still entertain a doubt 
upon this point, Dr. Emmet’s testimony is surely sufficient to 
remove it. He says,f “ It was fully six years after my first 
* Loc. Cit. 
f Principles and Practice of Gynaecology, p. 447 14 
operation before I had gained experience enough to detect this 
lesion under its varied forms.” 
No doubt the tardy recognition of the injury, and the diffi- 
culties attending its diagnosis may be partly explained by the fact 
that ocular examination of the parts is usually made with tubular 
or valvular specula, as these instruments, especially the former, 
by their peculiar action prevent rather than facilitate the revela- 
tion of the condition. Another circumstance which leads to 
error is that women are commonly examined while lying on the 
back, with the head and shoulders elevated. In this position the 
heavy uterus is found low down in the pelvis, and, carrying with 
it a reflection of the vagina, the vaginal portion of the cervix 
acquires a fictitious elongation, to the extent, sometimes, of more 
than two inches. At the same time, the forces which separate the 
flaps of the laceration also cause these latter to present a flat- 
tened surface of eroded tissue from one to two inches across, with 
the apparent os uteri externum in the center. Looked at in this 
state, all appearance of laceration is lost. 
The conditions with which laceration is liable to be confounded 
are, simple granular erosion, thickening and elongation of the 
cervix, ulceration and epithelioma. 
Erosion of the os and cervix, uncomplicated wTith laceration, is 
usually caused by the irritating contact of uterine catarrhal dis- 
charges ; and to show how comparatively rare this condition is, I 
may mention that, among the 700 women examined by Mundd, 
and who furnished 119 cases of erosion with laceration, there 
were but eleven cases without that complication. 
Where there is actual enlargement of the cervix, the part is 
gradually increased in diameter from below upwards towards the 
body of the organ ; whereas, when a laceration with eversion is 
present the lowest portion is the largest; and between it and the 
part above there is formed a more or less distinct neck or nar- 
rowed portion, so that its shape has been compared to that of an 
inverted mushroom. Hence, when by the touch this constricted 
portion can be felt, a laceration may be suspected. 
I do not wish to be understood as implying that there may not 
be actual enlargement of the cervix when the latter has been 
lacerated. In point of fact, the irritation to which, in cases of 15 
marked eversion, the cervical lining is subjected, the cystic de- 
generation of its glands, and the continually increasing obstruc- 
tion to its circulation combine to produce what Klob denominates- 
a “ formative irritation,” which results in increased growth. 
But the touch is not sufficient to enable us to distinguish a 
laceration from true elongation of the cervix, a condition, by the 
way, which Emmet affirms has no existence. Whether in this he 
be correct or not, the apparent elongation of the cervix which is 
present in some cases of laceration may always be made to disap- 
pear by placing the patient in the knee-chest position. The 
superincumbent pressure of the intestines being thus removed, 
and the uterus permitted to fall away from the pelvic floor 
rather than toward it, the vagina is pulled out to its full length, 
including the reflected portion which has been carried down 
by the cervix, and the true cervico-vaginal junction is at once 
seen. 
Any one who has observed the appearance presented by the 
red, roughened, eroded cervical lining in a case of laceration of 
the cervix, need not be told how easy it is to mistake it for a true 
ulceration of the part. But, if by the term ulceration of the 
cervix we mean to imply a loss of substance other than epithelial, 
it is a comparatively rare condition. The only true ulcers of 
this part are those produced by friction when the uterus is proci- 
dent, or which are the result of chancroid or carcinomatous 
disease. 
The extruded lining membrane studded with enlarged follicles, 
elevated and swollen, bleeding readily, and bathed with muco- 
purulent secretion has not infrequently been mistaken for malig- 
nant disease, and, it is reasonable to suppose that some of the 
cases of reported permanent cure by amputation, cautery, etc., of 
supposed carcinomatous enlargement of the cervix have really 
been cases of laceration with extensive eversion. 
From all other conditions presenting a red, eroded or ulcer- 
ated surface, and from all those which are accompanied by 
enlargement, laceration may be distinguished with the utmost 
certainty and precision. It is done as follows : Place the patient 
in the semi-prone position, or, still better, the knee-chest position. 
Introduce Sim’s duck-bill speculum or other form of perineal re- 16 
tractor, and when the vagina is sufficiently distended insert small 
tenacula into the sound mucous membrane in front and behind, 
just beyond the edge of the eroded surface. If, now, by approxi- 
mating the points of the tenacula the erosion can be rolled into the 
cervical canal, and the vaginal portion be made at the same time 
to present a comparatively normal shape and size, it is a lacera- 
tion. With no other condition can this manoeuvre be made with 
these results. 
If the laceration has healed without union, and there be left 
a fissure to mark its site, there' can be no difficulty in recognizing 
it. But this result does not commonly occur unless the laceration 
has been unilateral; and these cases, so easily detected, are not 
of great pathological importance, for they are not attended by 
the out-rolling of the cervical lining which is generally the essen- 
tial cause of the symptoms resulting from the injury. In by far 
the greater number of bad cases no cleft or fissure whatever is 
apparent either to sight or touch. 
Treatment. — Many of the distressing symptoms — backache, 
pelvic pains, leucorrhoea — may be greatly benefited by rest in the 
recumbent position, vaginal injections of hot water, glycerine 
tampons, astringent and caustic applications, etc. By persistence 
in the use of these means in conjunction with the internal ad- 
ministration of ergot, strychnia, iron, etc., and such other con- 
stitutional remedies as may be indicated, patients afflicted with 
laceration, even in some of its severer forms, may be kept in a 
fairly comfortable condition ; and where the injury is slight and 
unaccompanied with marked eversion, a permanent cure may some- 
times be effected. Usually, however, soon after their use is discon- 
tinued, and the patient resumes her ordinary duties, the former 
symptoms manifest themselves anew, and she becomes as misera- 
ble as before. This result is quite certain to occur if the injury 
has been so extensive as to permit much eversion. 
When, in consequence of its increased size and weight the 
uterus has become retroverted and prolapsed, much relief may 
sometimes be obtained by raising the organ to its proper position 
and supporting it with a suitable pessary. This not only serves 
to lessen the uterine congestion by promoting the emptying of 
the uterine veins and sinuses, but it also prevents the extruded 17 
and eroded mucous membrane from pressing and rubbing against 
the vaginal walls. However, the use of pessaries is not always 
feasible. In some cases there is present so great a degree of ten- 
derness in and about the uterus as to preclude the slightest pres- 
sure from an instrument, while in others the cul-de-sac is so 
effaced by the contraction of cicatricial bands and post-uterine 
inflammatory deposits as to leave no resting place for the upper 
end of the pessary, which, consequently, has a constant tendency 
to slip forward over the cervix and take a position between it and 
the bladder. In this position it not only ceases to be of benefit 
but is positively hurtful. When the use of a pessary is indicated 
I prefer a Hodge closed lever, or some one of its modifications, 
especially that of Dr. Albert Smith. 
I may say, in passing, that I regard those cases of retro- 
flexion and retroversion of the womb as practically incurable in 
which the body or fundus is bound down by adhesions, or where, 
without adhesions, the displacement is accompanied either by a 
very shallow cul-de-sac or a very short vaginal portion. 
For the relief of the tender and painful condition of the parts 
just referred to, I have found the following plan satisfactory : 
Once a week I abstract from the cervix a half ounce to two ounces 
of blood, by numerous punctures with Buttle’s lance. The 
punctures are made directly into the eroded mucous tissue and 
into any cystic glands that may be apparent. When these latter 
are small and very abundant short incisions are preferable to 
punctures, as they are less likely to close subsequently. The 
operation is followed by the application to the cervix of a glycer- 
ine tampon on which has been sprinkled two or three grains of 
iodoform. When the odor of this agent is objected to I replace 
it with one grain of sulphate of morphia. In addition, I direct 
a hot water vaginal injection to be used every night at bedtime— 
except on the day of scarification — and a glycerine tampon, un- 
medicated, to be placed every morning. All this local treatment 
is suspended during the menstrual period. I need hardly say 
that the blood-letting, even to the slight extent advised, is contra- 
indicated in the case of patients who are anaemic and in whom 
the blood-making power is impaired. 
By the judicious use of these means for a few weeks we may 18 
frequently be enabled to use a small pessary (the instrument 
should never be large) where at first it would have been impossible 
to do so. 
But, as already intimated, all the foregoing means are at best 
uncertain, always tedious, and generally ineffectual. It is fortun- 
ate, therefore, that we have a remedy which is both safe and 
certain ; one which not only removes the symptoms of the dis- 
order but which restores the parts to their normal condition. 
I refer to the plastic operation devised by Emmet, and to which 
my friend, Dr. E. C. Dudley, has given the distinctive name 
trachelorrhaphy. 
This operation is one of the most successful with which I am 
acquainted, and when its simplicity and freedom from danger are 
considered in relation to the amount of benefit which it is capable 
■of conferring, one of the most useful in uterine surgery. 
Treatment Preparatory to the Operation.—In most cases where 
the operation is decided upon, some amount of preparatory treat- 
ment is beneficial and in some it is absolutely necessary. 
It should be an inflexible rule in plastic surgery to have the 
parts in a healthy condition, if possible, before any operation be 
attempted, otherwise full success cannot reasonably be expected. 
To lack of attention to this rule I think may be fairly attributed 
many of the failures of operations undertaken for the cure of 
vesico-vaginal fistula, ruptured perineum, vesicocele, etc. In 
lacerations of the cervix it is not always possible to bring the 
parts into this desirable state of local health, because their dis- 
placement is incompatible with it; still it may always be approx- 
imated. 
The proper preparatory measures should be such as tend to 
remove or lessen uterine congestion ; as the daily hot vaginal 
douche, the evacuation of the cervical cysts, the local abstraction 
of blood, the glycerine tampon, etc.; in short, just such means 
as have been detailed under the head of palliative treatment. No 
attempt should be made to glaze over the eroded surface with the 
solid nitrate of silver, formerly, and, I fear still, the common 
practice. The improvement produced in the appearance of the 
part by this measure is fallacious. The dense cicatrical tissue 
thus formed, by enclosing and compressing the peripheral nerve 19 
filaments almost invariably causes uterine and ovarian neuralgias, 
diminishes or destroys sexual appetite, and leads to various other 
nervous and psychological disturbances.—(Goodell). 
The existence of marked tenderness as a result of inflamma- 
tion in the neighborhood of the uterus or broad ligaments, is a 
contra-indication to an operation ; but the presence of old 
inflammatory exudations which are not the seat of tenderness or 
pain, I do not consider so, provided there be no present uterine 
congestion. For the operation, if carefully performed, without 
dragging the uterus from its position, is less likely to re-establish 
fresh inflammation than is the continuance of the laceration. I 
have operated two or three times under these circumstances with- 
out any untoward result. 
The best time for the operation is between the third and seventh 
day after a menstrual period; as the pelvic organs are then 
physiologically more quiescent than at any other time, and 
besides, sufficient time is afforded them to recover entirely before 
the onset of the next period. 
The patient should take a laxative dose of medicine in the 
afternoon of the day preceding that of the operation; and I find 
it well also to have an enema of warm water given on the follow- 
ing morning an hour before the operation. 
Operation. — x\ll being in readiness, the operation may be 
performed as follows : The patient, being etherized, is placed on 
her back on a firm table, which need not be more than four feet 
long. She is drawn forward so that the hips project three or 
four inches beyond the edge, and each lower limb is given in 
charge of an assistant, by whom the thighs are flexed upon the 
abdomen. The operator then passes one or two fingers of the 
left hand into the vagina, and with the right introduces the blade 
of a perineal retractor. (I prefer one of this sort for the pur- 
pose : it is a modification of that of Simon, and has a much 
shorter and much flatter blade than Sim’s duck-bill.) This is 
guided to its position in the posterior cul-de-sac by the fingers in 
the vagina, and the perineum being pressed downwards while the 
vaginal walls are separated by the fingers, the cervix is readily 
brought into view. 
One of the assistants now takes charge of the retractor with 20 
his disengaged hand. The anterior flap of the laceration is 
seized with a small double-hooked vulsellum, and, aided if neces- 
sary by supra-pubic pressure, the lower portion of the uterus is 
brought quite to the vulva. Both flaps are now approximated, 
with the view of determining accurately the proper position of 
the external os uteri, the extent of the laceration, the quantity 
of tissue to be removed, the number of stitches requisite, etc. 
These points having been settled, a curved or rectangular needle, 
fixed in a handle, and having its eye near the point, is passed 
through the posterior flap at a point which is to mark the middle 
of the os uteri: it carries a strong silk suture, the loop of which 
is seized when it appears, and the suture is left in the flap on the 
withdrawal of the needle. The same process is repeated with the 
anterior flap. By means of these sutures, complete control of 
the cervix is had throughout all the subsequent steps of the 
operation. They should be sufficiently long to enable the 
assistant who has them in charge to draw them in any needed 
direction, without at all incommoding the operator.* I formerly 
used a single thread, which passed through both lips, but this 
prevented the separation of the latter when they were drawn 
upon, and I find it much more convenient to transfix each 
separately, so that either lip can be acted upon independently of 
the other. 
The surfaces of the parts to be joined together are next made 
raw. I prefer doing this with scissors, as being a more expedi- 
tious and less bloody mode than that by the knife. The thick- 
ness of tissue to be removed depends somewhat upon the shape of 
the flaps. If their inner surface be full and rounded, the con- 
vexity should be wholly ablated. A safe rule is to remove enough 
to permit the opposing sides to be brought easily into contact, so 
that there may be no undue strain upon the stitches. Emmet 
lays much stress upon the necessity of removing all cicatricial 
tissue, regarding its presence as a frequent cause of neuralgia. 
Care should be taken to not freshen the surfaces too near the 
central portion of the flaps, lest their subsequent adhesion should 
* I find that Dr. Goodell makes use of a similar device. He “ passes on each side of it ” (the 
os externum), “ through both lips of the cervix, a long iron-wire suture.” 21 
result in obliteration or narrowing of the external os. A space 
ut least one-half inch long should be left for this opening ; for 
the subsequent shrinking of the part will reduce this to about the 
proper size. Indeed, a still more liberal provision for the outlet 
ought to be made if there be present very great hypertrophy of 
the uterus. The opposing denuded surfaces should be equal in 
length and width, so that when brought together coaptation may 
be accurately made. 
Usually but little haemorrhage attends the freshening of the 
tissues, although in some cases it is sufficiently profuse to delay 
the operation somewhat. The only artery likely to be injured is 
the circular, which passes near the vaginal junction, sometimes 
just within the outer angle of the fissure, and great care should 
therefore be taken to not cut deeply when paring the edges at 
this point. The capillary bleeding commonly ceases directly the 
sutures are tightened. 
The passing of the sutures is sometimes very difficult, owing to 
the thickness and density of the tissues. It is necessary to have 
a strong needle holder, one which permits the needle to be placed 
at any angle. The needles should have a cutting edge near the 
point, and should vary in length from three-fourths of an inch to 
an inch and a quarter ; they should be thick enough to allow of 
a large eye through which the loop of a doubled silk thread may 
pass. The eyes of most needles are too small. 
The first suture is passed at or near the inner angle of the 
fissure. The part being steadied by means of a firm tissue- 
holder, the needle is entered about a quarter of an inch from the 
edge of the freshened surface, and made to emerge just at the 
edge of the undenuded strip which has been left to form the con- 
tinuation of the uterine canal; it is then re-entered at the cor- 
responding point opposite, and, passing through the other flap, 
finally issues at a point which corresponds with that of its first 
entrance. A silver wire of suitable length is then connected with 
the loop, and is left in place on withdrawal of the needle, in the 
usual manner. It is immaterial through which flap the needle is 
passed first. The number of sutures required will vary according 
to the length of the fissure. Usually, from two to four are 22 
needed on each side. They should be placed about one-third of 
an inch apart. 
In my more recent operations I have adopted a different plan 
from that just described for passing the sutures in all cases in 
which the cervix could be brought sufficiently within reach ; that 
is, I have used a small perineal needle in a fixed handle, with the 
eye near the point. With this I transfix both flaps, and when 
the eye of the needle emerges from the second one, it is directly 
threaded with the silver suture. The needle is then withdrawn, 
leaving the wire in place. In this way the sutures are inserted 
with great accuracy and rapidity. 
Either silk or silver wire may be used for the sutures. I 
prefer the wire, because, perhaps, I am accustomed to it, and 
know it to be reliable. Dr. A. J. Skene,* of Brooklyn, reports 
that he successfully uses silk, in every case obtaining a satisfac- 
tory result. If, upon further trial, silk be found equally trust- 
worthy with the wire, the operation can be more quickly and 
easily done. 
The sutures having all been inserted, the patient should be 
placed in bed, where, ordinarily, she ought to remain until the 
stitches are removed. This may be done as early as the eighth 
day, but I prefer, unless the prolonged confinement be especially 
irksome, or contra-indicated, to allow them to remain until the 
ninth or tenth. In one case, in which they were removed on the 
eighth day, the adhesion of the flaps was so feeble that they sub- 
sequently separated, and a repetition of the operation became 
necessary. 
The operation is not a very painful one, and an anaesthetic,, 
although desirable, is not always necessary. I operated on one 
patient without using any, and she subsequently stated that she 
suffered less from the pain of the procedures than she had on a 
former occasion from the nausea and vomiting following the inha- 
lation of chloroform for the extraction of a tooth. And, in an- 
other case, in which Dr. Dudley kindly operated at my request, 
to exemplify the manner of Emmet, no anaesthetic was given, and 
although the operation lasted a full hour, the patient only coin- 
* Proceedings of the Medical Society of the County of Kings, June, 1878. 23 
plained of the constrained position and the action of the Sims’ 
speculum. 
Neither is there much pain or discomfort felt after the opera- 
tion. Indeed, patients usually suffer so little from it that it is 
difficult to make them appreciate the necessity for lying in bed 
afterwards. And it is possible that this necessity has been over- 
rated. Several times patients have, contrary to my directions, 
resumed many of their ordinary duties after the third day; in 
one case, on the second morning after the operation, I found the 
patient dressed and sitting up, and she informed me that she felt 
less discomfort in the parts than she habitually did before the 
operation. In none of these cases did the seeming imprudence 
produce any bad result or prevent a successful issue. Dr. Skene 
states that he has operated eight times at his office and sent the 
patients home in the street cars. 
After Treatment.—At the close of the operation I am in the 
habit of placing in the vagina the ordinary cotton tampon satu- 
rated with glycerine, with a string attached to facilitate removal; 
and in the rectum a suppository of cocoa-butter, containing two 
grains of opium and one-sixth of a grain of extract belladonna. 
The tampon should be removed on the day following the opera- 
tion, and the vagina should be carefully washed once or twice 
daily with warm water slightly carbolized. It is not necessary 
to prohibit the patient from leaving the bed to urinate, or for 
other necessary purpose. Rarely, I have had to use the catheter 
once or twice. The bowels, if not open spontaneously, may be 
acted upon by a mild laxative, followed by an enema on the 
fourth or fifth day. 
Among those who have investigated this subject and who have 
learned to recognize and treat the lesion — with few exceptions — 
there is no longer any doubt as to the safety, the efficiency, and 
in cases of complete laceration, of the necessity of hystero-trache- 
lorraphy as a means of cure. But there are a vast number of 
cases in which the laceration has been slight, in which the rent 
has not extended beyond the vaginal junction, perhaps only in- 
volving the crown of the cervix. In many of these cases the 
mucosa is only slightly everted, and there is no such apparent 
elongation or enlargement of the cervix as is seen in the more 24 
typical cases. But the patient suffers from leucorrhoea, back- 
ache, possibly menorrhagia, and may present marked nervous 
disturbance. What should be done for these cases ? These are 
the milder forms of “ ulceration,” and it is the experience of all 
gynaecologists that they may be cured by topical applications of 
an astringent and caustic nature. But the treatment by these 
means is tedious, usually covering several months and sometimes 
is not successful. Iodine, carbolic acid, nitrate of silver, iron 
and similar applications fail very often to do anything more than 
temporarily ameliorate the patient’s condition. After each men- 
strual period she is usually found to have relapsed more or less, 
and after exhausting her patience — perhaps her purse, also — 
and the ingenuity of one doctor after another, she finally ceases 
her efforts and accepts a life of invalidism as best she may. Even 
in the most successful of these cases, several weeks of uninter- 
rupted treatment are necessary to the cure. Cannot and should 
not these cases, like the more severe forms of laceration, be 
treated by the operation ? 
Dr. P .F. Mund£, in an admirable paper, already alluded to * 
advocates the practice on the ground that by, means of the opera- 
tion such cases can be more quickly and more certainly cured 
than by the methods in common use, and he adds by way of 
final argument: “ Another reason why trifling ectropia should 
not be allowed to go on for years unheeded and untreated, was 
recently advanced by Prof. Breisky,f of Prague, "who has ob- 
served and operated upon four cases of laceration, in which one 
of the everted lips had become carcinomatous in consequence of 
the irritation to which the exposed cervical mucosa was subjected.” 
These observations are confirmed by Veit,! who, out of nine cases 
of carcinomatous cervices found three in which the disease origi- 
nated in the enlarged glandular elements. 
At a meeting of the German Gynaecological Society, held at 
Cassel, Sep. 12th and 13th, 1878, § Kugelman, of Hanover, ex- 
pressed his disapproval of operative measures for the cure of such 
* Indications for Hystero-Trachelorrhaphy. Amer. Jour. Obs., June, 1879. 
f Wiener Med-Chirurg. Rundschau, Aug. 1877. 
$ Gyn. Sec. German Congress of Phys., 1877. 
§ See Amer. Jour. Obs., Jan., 1879. uterine ailments as were amenable to other less severe means of 
treatment, although the latter might require “ much time and 
patience.” In reply to this, Prof. Schroder said that “ the pa- 
tient, as well as the physician, needed time and patience,” and 
that it was surely better for her to be freed from the trouble in a 
fortnight, by a safe and certain method, than to pass through 
months of treatment for an uncertain result. Private Hospital for Women 
348 W, Washington Street, 
CHICAGO, ILL. 
This institution has been established for the treatment of the 
Medical and Surgical diseases peculiar to Women, and is under 
the personal and exclusive management of the undersigned, found- 
er, and for eight years surgeon-in-chief of the Woman’s Hospital 
of the State of Illinois. 
It is designed to meet the needs of medical practitioners who, 
from lack of opportunity, may not have been able to perfect them- 
selves in the diagnosis and treatment of this special class of ailments 
or who, in the absence of such skilled assistants and nurses as can 
usually only be found in large cities, do not deem it expedient to 
resort to the surgical procedures which frequently are essential to 
the cure of their patients; or who, for these or any other reasons 
may desire to place their patients where the latter can receive ad- 
vantages not obtainable at their homes, 
The cases which are especially suitable for such an infirmary 
are those of ovarian and uterine tumors, uterine polypus, vesico- 
vaginal and recto-vaginal fistulas, lacerations of the cervix utiri and 
perineum, displacements of the uterus, vesicocele, rectocele, ob- 
structive dysmenorrhcea sterility, etc., Facilites will also be pro- 
vided for the class of anasmic nervous patients who need rest, 
seclusion, massage, and electricity. 
The Hospital for women is not a charity. Patients are re- 
quired to pay for boarding, nursing, professional services etc. as 
they would elsewhere, but they have the assurance that they will 
not be subjected to the neglect and numerous annoyances insep- 
arable from a sojourn in boarding houses and hotels. 
For terms and any other particulars, address 
A REEVES JACKSON, M- D. 
785 Michigan Avenue: 
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