LACERATIONS OF THE CERVIX UTERI AS A 
CAUSE OF UTERINE DISEASE. 
BY 
W. H. BAKED, M.P., 
INSTRUCTOR JN GYNECOLOGY. MEDICAL DEPARTMENT, HARVARD UNIVERSITY. 
[Reprinted from The Boston Medical and Surgical Journal, September 20, 1877.] 
CAMBRIDGE : 
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1877. LACERATIONS OF THE CERVIX UTERI AS A CAUSE OF 
UTERINE DISEASE.1 
W. H. BAKER, M. D. 
We are indebted to Dr. T. Addis Emmet for first recognizing this 
lesion as a cause of uterine disease, and for first demonstrating to the 
profession a ready and efficient means of cure by his operation of No- 
vember 27, 1862. This operation as performed fourteen years ago is 
practically the same as that performed by him to-day, and by those 
who from him have learned to relieve so many women suffering from 
the effects of this injury. 
That the above accident is a very frequent cause of uterine disease 
is indicated by the figures produced by Dr. H. T. Hanks at a meet- 
ing of the Medical Society of the County of New York, September 28, 
1874, when he was able to show that of all the uterine cases treated 
by him at the Demilt Dispensary in five months of service, number- 
ing two hundred and twenty-nine, in nineteen, or over eight and four 
tenths per cent., he recognized the above lesion. 
During a residence of eighteen months in the Woman’s Hospital of 
New York, of the four hundred and thirty-five uterine cases received 
for treatment, thirty-nine, or nearly nine per cent., were of the above 
class. Since then, of the one hundred and eighty-one cases which I 
had treated up to September, 1876, in private and hospital practice, 
eighteen, or nearly ten per cent., belonged to the same class. 
That this injury is not only of very frequent occurrence, but that it 
takes place to such an extent that it is followed in time by serious 
changes, all of which are directly dependent upon it, is still farther 
shown by the fact that at the time Dr. Emmet read his valuable paper 
upon this subject, some two years ago, he had already operated for the 
remedy of this difficulty nearly two hundred times. 
Where so large a percentage of uterine cases can be traced to one 
exciting cause, as we have here pointed out to be the fact with regard 
to the subject of our paper, it will certainly be well for us to make the 
matter one for careful study, for close clinical observation, and for the 
minute record of cases, from which, taken collectively, we may be able 
to deduce laws which may aid us not only in the more satisfactory treat- 
ment of the patient after the injury is done, but which may also assist 
1 Head before the Boston Society for Medical Observation, May, 1877. 2 
Lacerations of the Cervix Uteri, 
the accoucheur in his attempt to prevent the accident, or in the early 
restoration of the part to its normal condition. 
It is with a view of aiding the above purpose that I present the fol- 
lowing cases which have been operated upon by me during the past 
three years:— 
Case I. A. T. entered the Woman’s Hospital of New York Feb- 
ruary 24, 1874. She was a native of Ireland, thirty-five years of 
age. Married at nineteen, she gave birth to her first child one year 
afterwards, and a year following the second and last child was born, 
although she aborted twice subsequently. Both labors were quite rapid, 
and she dated her illness from the birth of her last child. She entered 
the hospital complaining of more or less bearing-down pain, and pain in 
the left groin extending down the thigh. Leucorrhoeal discharge had been 
abundant for years. On examination the cervix was found low in 
the pelvis, and lacerated bilaterally to such an extent that the inner sur- 
faces had rolled out and had become so hypertrophied that it was impos- 
sible with tenacula to restore them to their natural position. March 2d, 
the patient being etherized, I operated for Dr. Sims by cutting away the 
hypertrophied tissue to that amount that the everted lips could be rolled 
back into their original position, where they were secured by five silver 
sutures. Ten days after the operation two of the sutures were found 
to have cut out, having been twisted too tightly; the remaining ones 
were removed. In a month from the time of her entrance to the hos- 
pital she was discharged cured, the slight gaping following the cutting 
out of the two sutures having healed by granulation. Unfortunately 
this case could not be followed farther. 
Case II. S. W. was admitted to the Woman’s Hospital Decem- 
ber 8, 1873, suffering from sharp pains in the back and through the 
lower part of the abdomen, which were greatly increased by walking. 
She also complained of a leucorrlimal discharge of a thick and tough 
consistence. The patient was thirty-five years of age, had been mar- 
ried twelve years, had had one miscarriage at six months, and subse- 
quently a child after a rapid labor, ten years before her admission to 
the hospital. For this latter period she had suffered from the above 
symptoms, and although not entirely incapacitated for work, yet her 
usefulness was greatly impaired by constant suffering. She had during 
this time been treated for “ ulceration of the womb ” by several physicians, 
who, mistaking the effect for the cause, had failed to benefit her. On 
examination the uterus was found retroverted, its cervix lacerated on 
the left side down to the vaginal junction, and very much hypertro- 
phied, the surface being covered with the discharge already described. 
One week after the patient's admission to the hospital I operated upon 
the case for Dr. Emmet, for the closure of the lacerated cervix. The 
patient being etherized this was successfully done, the haemorrhage, Lacerations of the Cervix Uteri. 
3 
which was considerable, being entirely controlled as soon as the sutures 
were introduced. She made a good recovery from the operation, and 
then, the uterus being replaced and some intra-uterine applications of 
impure carbolic acid being made, the womb gradually regained its 
proper position, and the patient, feeling entirely relieved of her suffer- 
ing, was discharged from the hospital, cured, January 17, 1874. She 
was seen four months afterwards, and had continued well. The uterus 
was then in a normal position, and the cervix looked perfectly natural, 
no evidence of the operation being visible. 
Case III. M. B. was sent me from the western part of the State, 
May 20, 1874. She was an American, thirty-eight years of age. 
Married at eighteen, she had given birth to seven children, and had 
had four abortions, all of which had occurred since the birth of her 
third child, twelve years before. This third labor was unlike all the 
others in that it was very rapid, the pains being severe and forcible, 
with almost no intermission. She recovered very slowly, and then 
began to complain of sharp shooting pains through the lower part of the 
abdomen, dragging and bearing-down pains, and burning sensations in 
the uterine region. There was also present an excessive leucorrhoeal 
discharge. All these symptoms gradually but constantly increased. 
The nervous state, too, was most deplorable. She was unable to sleep 
at night or to keep quiet by day, crying at the least opposing circum- 
stance. I can truly say that I have seldom seen a patient whose nerv- 
ous system was in such a shattered condition. The patient had been 
under almost constant treatment for so-called ulceration of the womb 
for four years before coming under my care, and had been confined to 
the bed for the greater part of that time. In examining the case I 
found the laceration of the cervix to be confined to the left side, but 
had extended through the vaginal junction, having gone into the cel- 
lular tissue beyond ; the everted surfaces were greatly hypertrophied, 
and had undergone cystic degeneration. The cervix was presenting at 
the vulva, the whole organ being retroverted. The perinaeum had 
been torn down to the sphincter muscle, and a large cystocele had 
formed. It was found necessary to give the patient some prepar- 
atory treatment on account of the cystic degeneration of the cervix, be- 
fore performing the operation, which was done June 16th, or in about 
a month from the time when she was first seen by me. The lacera- 
tion was the most extensive one that I had ever operated upon, re- 
quiring seven sutures to close it, the line of union being fully one and 
a half inches long. The result was highly satisfactory. When the 
sutures were removed perfect union was found, and within a month 
from the time of the operation the patient could walk one and a half 
miles comfortably. Subsequently operations were done for the cys- 
tocele and ruptured perinaeum, after which, the uterus having regained 4 
Lacerations of the Cervix Uteri. 
its natural position, the patient was sent home, cured. She has been 
heard from from time to time since, and lias continued to do well, be- 
ing able to keep a house full of boarders, doing all the work herself, 
including the washing and ironing. She has been once pregnant since, 
but fearing a return of all her troubles with the birth of another child, 
without any advice she caused an abortion at the third month. 
Case IV. B. T. was sent me for treatment May 14,-1875. She 
was an American lady, twenty-eight years of age, and had suffered 
since the birth of her first child, which was delivered with instruments 
after a labor of ten hours; four years previous to the above date her 
second and last child was born naturally, one year after the first. The 
complaints made by this patient were not unlike those in the preceding 
cases, except that there was a much greater inability to regain strength 
after her first labor, and a tendency to the most violent attacks of 
headache on the slightest exertion or even after being present where 
there was any confusion or noise. The physician who kindly referred 
the patient to me told me that for some time he had attempted to heal 
an eroded condition of the os uteri by various applications, and that 
although she seemed better generally for the time being, yet the ero- 
sion had not healed. As the cervix was brought into view by the aid of 
a Sims speculum, the eroded condition already referred to presented 
itself, which, bv rolling into the canal with a tenaculum in each hand, 
showed itself to be the lining membrane of the canal, everted after the 
slight bilateral laceration of the cervix which had undoubtedly taken 
place at the birth of her first child. There was also a laceration of the 
perinasum and the remains of an old attack of cellular inflammation of 
the left broad ligament, which held the uterus somewhat firmly to that 
side. The operation had to be delayed for more than four months, or 
until the adhesion on the left side of the uterus had disappeared. The 
operation itself did not differ from those already described, except that 
on account of the very anaemic condition of the patient the precaution 
was taken to use a uterine tourniquet. She recovered without a bad 
symptom, and has since enjoyed good health. When I met her some 
months afterwards she told me that she was making up for lost time, 
saying that she had gone to six entertainments in as many consecutive 
evenings without feeling any ill effects therefrom. 
Case V. M. S. came to me November 15, 1875, complaining 
of great leucorrhceal discharge, which had annoyed her since the birth 
of her first and only child, two years before. She was a native of 
this country, and was twenty-three years old. Her labor occurred at 
seven months. She remembered none of the details, as she was uncon- 
scious for four days. The child was born without forceps being applied, 
notwithstanding that the patient had repeated convulsions for forty-eight 
hours previous to the delivery. In twelve days after her labor she at- Lacerations of the Cervix Uteri. 
5 
tempted to get up ; but, as she expressed it, the “ blood flowed so freely 
that she was obliged to keep her bed for some time longer.” Her 
strength returned gradually, and since getting up from her labor she 
had suffered no pain of any kind, and would not have presented herself 
for treatment except for the annoyance of the discharge referred to 
above. On examination, the cervix was found to be torn very irregu- 
larly on the left side, quite through the vaginal junction. The surfaces 
of the laceration had rolled out, and looked highly injected. There 
was very little hypertrophy and no cystic degeneration. It was difficult 
in this case to make the patient understand the importance of an imme- 
diate operation. It was, however, soon consented to and performed, 
being similar in its details to those already described. Since then she 
has been free from the previous annoyance, and we feel sure saved 
herself a great deal of suffering which must have followed had not the 
operation been done. 
As the remaining six cases do not present features unlike those 
already given, we will not lengthen this paper by a prolonged recital of 
them here, but taking them together with those which are now under 
treatment awaiting an operation, and those in which it has thus far been 
found impracticable to perform the operation, we will state some points 
in their history which are of special interest. 
We have, then, the histories of eighteen cases where this lesion has 
occurred. These include all the cases of this class which have been 
treated by me in private or hospital practice up to September, 1876. 
To these we may add the two cases upon which I operated in the New 
York Woman’s Hospital, the full histories of which I retained, giving 
us twenty cases in all, from which we derive the following facts. 
In ten cases the injury occurred with the first labor, and in an equal 
number at some other than the first confinement. 
In ten cases the labor was rapid and the pains usually very severe. 
In six others the labor was more or less delayed, and finally accom- 
plished by the aid of instruments ; in one, the waters having been 
evacuated two weeks before, the labor was much prolonged ; in one 
the labor occurred at seven months, and after two days of convulsions 
the child was born naturally; in another the labor was normal; and in 
the remaining one the character of the labor was not specified. 
In all instances we have reason to believe the presenting part to have 
been the head. In fourteen the laceration was of the left side of the 
cervix alone. In the remaining six it was bilateral. In sixteen the 
injury had been followed by some structural change or malposition, 
directly or indirectly dependent upon this accident, and in the remain- 
ing four time enough had not elapsed since the injury for such change 
to have taken place, and the operation was performed to restore the 
cervix to its natural condition before such changes should be inaugu- 
rated. 6 
Lacerations of the Cervix Uteri. 
In all the cases except one thei'e was an abundant leucorrhoeal dis- 
charge, which was characterized as thick and tough, and was compared 
to the white of an egg. In thirteen there were irregularities in men- 
struation, and an equal number had been treated previously for so- 
called “ ulceration of the womb ” or erosions. 
Eleven of the cases were operated upon with the most satisfactory 
results. 
In reviewing the foregoing facts it is interesting in the first place to 
notice the character of the labor in which this accident occurred. In 
half of the cases this was denominated as rapid and the pains usually 
very severe ; or in other words we understand the force of the uterine 
contractions to have been so great, even from the commencement of the 
labor, that time enough was not given for the full dilation of the os, 
and the rent was made at the point where the greatest amount of force 
was brought to bear. In three fifths of the remaining cases the labor 
was prolonged, and finally accomplished by instruments. If, then, 
there existed any rigidity about the os at the time the forceps were ap- 
plied, these may have been the immediate cause of the laceration. 
It would seem, then, from our cases, that we are not to look for this 
accident most frequently among the tedious, difficult, or instrumental 
cases, but rather among those where from the rapidity of the labor we 
have been led to congratulate ourselves that the patient has passed 
favorably through her trial. 
It is interesting, again, to see the frequency with which the lacer- 
ation took place on the left side of the cervix. This same fact was ob- 
served and most satisfactorily explained by Dr. George T. Harrison in 
the December number of the Virginia Medical Monthly of 1874, where, 
referring to the mechanism of labor, he shows that with the most fre- 
quent form of labor, occurring with the occiput directed to the left, 
more or less anteriorly, we may look to the above point for the most 
frequent place of injury. Again, Dr. Emmet, in his most valuable arti- 
cle on this subject, published in the November number of the American 
Journal of Obstetrics for 1874, shows that although lacerations of the 
cervix most often occur in the median line anteriorly, yet on account 
of the raw surfaces being kept in contact by the lateral pressure of the 
vagina these lacerations heal, and that “ in practice we have chiefly to 
deal with the consequences of lateral lacerations,” because of the great 
tendency of the tissues to roll out. 
It is still farther interesting to see from our summary of cases that 
in every instance where sufficient time had elapsed from the occurrence 
of the injury some structural change or misplacement had followed. 
When we consider that the connective tissue of the cervix uteri is in 
excess of the muscular tissue, we can understand at once why its 
proper involution should be so readily interfered with ; for, as shown Lacerations of the Cervix Uteri. 
7 
by Dr. Lott,1 and referred to in the article by Dr. Harrison, already 
noticed, the very condition of tetanic contraction of the body of the 
uterus, where the muscular tissue predominates, which so influences 
its further nutrition and consequently its involution, would have little 
effect upon the cervix. We can easily see how materially affected the 
proper involution of this lower segment of the uterus would be by the 
occurrence of a lateral laceration of its tissues, and in fact where this 
injury has extended through or even to the vaginal junction the cervix 
is very apt to remain in a state of subinvolution. The process of ever- 
sion or rolling out of the cervical canal, which soon follows the puer- 
peral state where this accident has happened, and which is so fully de- 
scribed by Dr. Emmet in the article to which we have already alluded, 
brings the lining membrane of the canal in contact with the posterior 
wall of the vagina, the friction against which soon occasions an abrasion 
of this tender membrane. The constant irritation keeps up as constant 
a hyperaemia of the part, which in its turn favors the hyperplasia that 
is almost sure to follow. 
There is still another condition which follow's upon this state of ever- 
sion of the cervical canal, namely, that of cystic degeneration of the 
cervix. By these terms are meant the formation of numerous cysts 
from the muciparous glands of the canal, the mouths of which have 
become occluded by their exposed and unnatural position. It must be 
evident to all that the combined influences of the above conditions, in- 
creasing the size and weight of the cervix, tend to produce some mis- 
placement of the uterus. 
We regret to observe that in more than one half of our cases the pa- 
tient had been treated more or less persistently for so-called “ ulceration 
of the womb,” and had derived not only no permanent benefit from the 
treatment, but had been made worse, as the increased suffering proved. 
In these cases when a mass of cicatricial tissue is formed over the 
cervix as a result of the frequent applications of caustic, which is very 
likely to be the solid nitrate of silver, the nerve filaments becoming 
compressed, the patient is kept in a state of almost constant suffering. 
Dr. Emmet, in his pamphlet on the Surgery of the Cervix in Connection 
with the Treatment of Certain Uterine Diseases, compares this condition 
to an irritable stump where some nerve filament has been involved in 
the cicatricial line after an amputation. 
Dr. Clifton E. Wing has well pointed out the frequency with which 
this lesion of the cervix is mistaken for ulceration, in an article in the 
Journal of March 16, 1876. 
Having reviewed some of the most interesting points brought out by 
our summary of cases, let us inquire a little more fully into the rational 
and physical signs present in these cases as a means of diagnosis. At the 
1 Anatoraie und Physiologic des Cervix Uteri. Von Dr. G. Lott, 341. 8 
Lacerations of the Cervix Uteri. 
time of labor neither of these classes of signs is at all well marked, for 
it is the secondary effects of the laceration which make the rational 
signs the most noticeable, and when the accident occurs the tissues are so 
soft that it would not be readily recognized even by the touch ; therefore 
the injury is likely to pass unobserved at this time, unless, as Dr. Emmet 
has shown, the tear has extended beyond the cervix into the vaginal 
and cellular tissues, and has occasioned an unusual haemorrhage. 
The first thing which attracts our attention in the list of symptoms 
is the tardy recovery of the patient, a “ bad getting up,” as she ex- 
presses it, and when more than the usual time has elapsed, and she 
thinks she should be able to be about, she feels somewhat discouraged 
on account of her inability to stand ; or it may be that with the attempt 
to walk more or less haemorrhage is noticed. As time goes on, in- 
tercourse may be complained of as being painful, or perhaps followed 
by a slight show ; there is ever present backache, a sense of weight in 
the pelvis, pains extending down the thighs, a sensation of heat or burn- 
ing in the hypogastrium, irregularities in menstruation, and throughout 
the whole there persists a more or less abundant leucorrhoeal discharge. 
As the nervous system is continually taxed by the foregoing symptoms, 
it finally claims its full share in the trials to which the patient is sub- 
jected, and she is probably by this time a confirmed invalid, and may 
indeed think herself fortunate if she is not confined to her bed, a truly 
deplorable wreck. 
The physical signs change very much, of course, as the case pro- 
gresses. At an early stage we are struck by the size and softness of 
the cervix, and by the aid of the speculum we see at once the everted 
membrane of the canal, the epithelial layer of which is often abraded ; 
later we have the large flattened, appropriately termed mushroom 
cervix, with its firmer tissue and shot-like feel ; and still later we find 
the cervix hypertrophied, the tissue firm and indurated, and if it has 
been treated with caustics the surface covered over with cicatricial tis- 
sue and the substance as hard as a piece of granite. Or the case hav- 
ing been left to itself the epithelium becomes abraded, and the constant 
friction to which the part is exposed keeps it constantly irritated, so 
that the appearance might readily be mistaken for that of malignant 
disease. To all these appearances in this latter stage we might have 
added the various malpositions which have been occasioned by the 
change which has taken place in the cervix. 
Obviously a case of this class must go on indefinitely unless measures 
are taken to repair the injury. Nor does the long-looked-for meno- 
pause prove that haven of rest anticipated ; for the misplacements 
which have been induced by this accident may remain and still exert the 
most deleterious influence on the health of the patient. It is sometimes 
necessary to advise some preparatory treatment before resorting to the Lacerations of the Cervex Uteri. 
9 
operation, as in Case IV., where the evidence of an attack of cellular 
inflammation remained, which was removed by the use of the hot vagi- 
nal douche and the local application of the tincture of iodine. Or if 
the case has been one of long standing and the cervix is in a condition 
of cystic degeneration this will require attention, in order that when 
the everted surfaces of the canal are rolled back into position again at 
the time of the operation, none of these little cysts may be included in 
the wound. 
Dr. Emmet’s operation, which he so fully describes in his paper, is 
certainly one of the most practicable and highly satisfactory known in 
the department of uterine surgery. It consists simply in denuding the 
surfaces of the laceration and in bringing them together with silver 
sutures, which are to be left in place for eight days or more, as the case 
may be. 
The dangers of the operation are primarily haemorrhage, which can 
be usually controlled by the use of the uterine tourniquet, or subse- 
quently by the twisting of the sutures ; and secondarily from peri-uterine 
inflammation, which, if proper care is used, will very rarely happen. 
From the fact that this injury has been shown to be of such frequent 
occurrence, practitioners cannot be too strongly impressed with the im- 
portance of examining all patients who have been confined before they 
are discharged from their care with the assurance that they are perfectly 
well again, and by thus doing they may sometimes save their patients 
years of suffering by rectifying the damage before the long train of 
diseases consequent upon this lesion shall have shown themselves.