QpMl'ftMENTS OF THE AlITHOE, 
SVest 4.'>th Street, New York. 
THE INDICATIONS 
FOR 
HYSTERO-TRACHELORRHAPHY, 
OR THE 
Operation for Laceration of the Cervix Uteri. 
BY (JME01CUS 
PAUL F. MUNDK. 
Fellow of the Obstetrical Society op New York, and of the American 
Gynecological Society ; Corresponding Fellow op the Obstetrical 
Societies op Edinburgh and Philadelphia, and of the Gyne- 
cological Society of Boston. 
WITH TWO CH ROMO-LITHOGRAPHIC PLATES. 
Reprinted from the. American Journal op Obstetrics and Diseases op 
Women and Childben, Vol. XII., No. January, 1879. 
NEW YORK: li /, 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1879. THE INDICATIONS 
FOR 
HYSTERO-TRACHELORRHAPHY, 
OR THE 
Operation for Laceration of the Cervix Uteri. 
BY 
PAUL F. MUNDE. 
Fellow of the Obstetrical Society of New York, and of the American 
Gynecological Society ; Corresponding Fellow of the Obstetrical 
Societies of Edinburgh and Philadelphia, and of the Gyne- 
cological Society of Boston. 
WITH TWO CH ROMO-LITHOGRAPH IC PLATES. 
Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XII., No. /., January, 1879. 
NEW YORK: x/r i 
WILLIAM WOOD & CO., 27 GREAT JONES STREET1, 
1879. THE 
INDICATIONS FOR HYSTERO-TRACHELORRHAPHY, 
OE THE 
OPERATION FOR LACERATION OF THE CERVIX UTERI. 
BY 
PAUL F. MUNDE 
(With two Chromo-lithographic Plates.) 
The first to devise and carry out the proper operative pro- 
cedure for the relief of the lesion now familiarly known as 
“ laceration and eversion of the cervix uteri,’’ was Dr. Thomas 
Addis Emmet. His claim to the priority of this operation is 
so well established as to be universally acknowledged. I had 
been under the impression that he was also the first to recog- 
nize the injury as a distinct lesion, and to appreciate its etio- 
logical importance as a prime factor in the production of 
uterine disease, as he certainly was the first to do away with 
at least four-fifths of that time-honored and favorite affection, 
“ ulceration of the womb,” by showing how the ulcerated 
surface can be rolled in and made to disappear by approximating 
the edges of the “ ulcer ’’ with tenacula.2 But on looking over 
Gardner’s work on Sterility,3 published in 1856,1 find that this 
author repeatedly speaks of “ laceration of the os and cervix ” 
as productive of ulceration, hypertrophy of the cervix, endo- 
cervicitis, and sterility. He also gives two colored plates (I. 
1 This term was first employed (to my knowledge) by Dr. E. C. Dudley, now 
of Chicago, in a paper published in the N. Y. Vied. Journal for January, 1878, 
and is derived from neck, and pacpr/, a seam. I have adopted it, 
because I think so important an operation should have a distinctive name of 
its own, and for convenience’ sake. 
2 See Remarks by Peaslae, after the reading of a supplementary paper on 
“ The Proper Treatment of Lacerations of the Cervix Uteri,” by Dr. Emmet, 
before the N. Y. County Med. Society, December 1876 (N. Y. Med. Jour., Jan., 
1877). “When at Demilt Dispensary, a large number of cases of the class 
referred to by Dr. Emmet presented themselves, but were not recognized, 
for none of us knew anything about them till Dr. Emmet told us. It was he, 
who, in a happy moment, brought the anterior and posterior surfaces together 
with two tenacula, and instantly demonstrated that what we all thought was 
an ulceration of the cervix was nothing more or less than a laceration.” 
3 The Causes and Curative Treatment of Sterility, etc., by A. K. Gardner, 
A.M., M.D., New York, 1856. 4 
Munde : Indications for Hystei'o- Trachelorrhaphy, 
and Y.) of the cervix seen through a four-bladed speculum, one 
of which is intended to represent “ fissure of the os,” a frequent 
cause of abortion; and the other two, the inflamed and ulcer- 
ated endocervical mucosa exposed by the expansion of the 
blades of the speculum. The first figure mentioned (Plate V., 
Fig. 1), clearly shows multiple superficial fissures of the os, 
with eversion and ulceration ; Plate I. is a partial, and Plate 
V., Fig. 2, a complete laceration and eversion. Of an operative 
procedure for the cure of this affection not a word is said. 
Professor Poser, of Marburg, Germany, also lays claim, I 
believe, to having recognized what he calls “ cicatricial ectro- 
pium of the cervix” long before it was referred to by others, 
but although the exact reference to Poser’s paper has escaped 
my memory, I am certain that he never recommended its cure 
by a plastic operation. 
Emmet’s first operation was performed Nov. 27th, 1862, in 
the presence of his assistant Dr. G. S. Winston, and of Dr. T. 
G. Thomas. Although during the next seven years he repeated 
the procedure many times, in the presence of numerous profes- 
sional gentlemen from all parts of the Union, his first pub- 
lished account of the operation and its technique did not 
appear until February, 1869, in a paper on the Surgery of the 
Cervix, read before the Medical Society of the County of New 
York, February 8th, 1869, and printed in the Amer. Jour, of 
Obstetrics for the same month. 
In this publication Dr. Emmet was preceded by a few months 
by Dr. M. A. Pallen, then of St. Louis, who independently, he 
informs me, described substantially the same operation for 
the same purpose.1 In spite of these two papers and the con- 
stantly increasing number of operations performed by Dr. 
Emmet, amounting up to 1874 to nearly 200, it was not until 
the reading of a second and more lengthy paper by Dr. 
1 St. Louis Med. and Surg. Jour., May 10th, 1868. 
The diagrams in this article represent a lesion slightly different from that 
now commonly considered as requiring operation; for while we at present gener- 
ally look upon the eversion of the lacerated lips as the condition chiefly call- 
ing for operative interference, in this diagram merely a fissure, with no ever- 
sion whatever, only a slight gaping of the lower edges of the wound, is 
depicted. In fact, Dr. Pallen calls the lesion “uterine harelip.” The oper- 
ation itself and the after-treatment are described precisely as by Dr. Emmet, to 
whom Dr. Pallen (in a letter to me) unqualifiedly accords the priority in 
devising the operation and recognizing its indications. or the Operation for Laceration of the Cervix. 
5 
Emmet before the same Society on Sept. 28th, 1874, and its 
publication in the Jour. Oust. for November following, that 
the profession became fully aroused to the immense value of 
the discovery of the lesion, its consequences, and its cure. 
From that time on, probably few of the rising gynecologists of 
our larger cities, particularly those coming from that fountain- 
head of uterine surgery, the New York Woman’s Hospital, 
have neglected the opportunity to perform this operation ; and 
papers descriptive of the lesion and its operative cure have 
been written by Wing,1 Baker,'2 Breisky,3 Dudley,4 Emmet him- 
self,6 and others, those by Wing and Dudley being illustrated by 
diagrammatic sketches, which were omitted in all the previous 
descriptions. A careful perusal of these papers shows me, and 
the diagrams referred to confirm this impression, that all the 
authors who have hitherto written on this subject, speak only 
of complete laceration or fissure of the cervix, either uni- or 
bilateral, with a rolling out of the lips of the cervix up to the 
vaginal reflection, the cervix presenting the appearance of an 
eroded surface two inches or more in diameter. These are the 
typical cases of the lesion, as to the deleterious effects of which, 
both locally and on the general system, their incurability by 
other means, and their rapid, sure, and safe cure by Emmet’s 
operation, with the usual entire relief of all symptoms, no 
unprejudiced and experienced observer can at the present day 
entertain a particle of doubt. These very common injuries, 
and the technics of the operation by which they are cured 
have now become so familiar to the majority of the profession, 
by means of the papers above referred to, that it would be 
tedious and waste of time to describe them again. But, so 
uniform as is the acceptance by all the initiated of Emmet’s 
operation for these the gravest forms of the lesion, so greatly 
divided does the profession still seem to stand as regards the 
exact point when a laceration and eversion of the cervix requires 
operation, and when it is still curable by topical applications 
—astringents, caustics, or cautery. 
Not only is this uncertainty not confined to medical gyne- 
cologists proper, but even some of the leading uterine surgeons 
1 Boston Med. and Surg. Jour., March, 1876. 2 Ibid., Sept. 27th, 1877. 
3 Wiener Med. Wochenschrift, 1876. 
4 N. Y. Med. Jour., January, 1878. 5 L. c. 6 
Munde: Indications for Uystei'O-Trachelorrhaphy, 
have expressed the opinion that the minor degrees of laceration 
and eversion do not require operation, as they are too insigni- 
ficant to be productive of evil, or can be cured by mild astrin- 
gents. 
Thus, at a meeting of the Boston Obstetrical Society, held 
Oct. 11th, 1876, Dr. James R. Chadwick takes occasion to 
protest against the impression unintentionally conveyed by Dr. 
Wing (1. c.) that these lesions are curable only by operation, 
“having found that, in the vast majority of cases, the tender 
mucous membrane of the cervix may be toughened by the 
application of mild astringents so as to bear exposure to fric- 
tion with impunity.” “The treatment,” Dr. C. adds, “may, 
however, have to be continued for many months. In extreme 
cases an operation is certainly advisable.” 
More recently, Dr. Thomas, in a lecture delivered in his 
regular course at the College of Physicians and Surgeons, 
October 10th, 1877,1 exhibited a patient with slight laceration 
of the cervix uteri (“the two lips of the wound were separated to 
a very small extent, but cicatrization had taken place, and they 
were everywhere covered with mucous membrane”), the remain- 
der of the genitalia being apparently normal, for the avowed pur- 
pose of cautioning the class against attaching too much import- 
ance to such “ trivial particulars ” as this slight laceration of the 
cervix. He therefore referred her “ pain in head, back, side 
and down the leg,” and too frequent menstruation, all dating 
from last confinement, to some obscure intestinal trouble, and 
decidedly discountenanced the operation of her laceration, as 
entirely devoid of importance. 
Still more recently, at the meeting of the State Medical 
Society in Albany, in January last, on occasion of the reading 
of a paper on this topic by Dr. Walter B. Chase, of Windham, 
N. Y., remarks favoring the medical treatment of some of these 
lesions were made by Drs. Fordyce Barker and A. Jacobi, which, 
coming from so high authority, have attracted considerable 
attention and are, in my opinion, calculated to depreciate both 
the significance of the lesion in question and the restorative 
operation.2 
Dr. Barker, after admitting the existence of large laceration 
1 Bost. Med. and Surg. Journal, Nov. 8th, 1877. 
2 Med. Record, March 9th, 1878. or the Operation for Laceration of the Cervix. 
7 
and eversion ot* the cervix uteri, and the efficacy of the plastic; 
operation, both having been demonstrated to him by Dr. Em- 
met, asserts that some of these cases will get well without sur- 
gical treatment. He says that formerly, before Dr. Emmet’s 
first publication on the subject, he succeeded by local treat- 
ment in removing the ulcerated appearance, diminishing the 
size of the uterus, and relieving the symptoms in the cases then 
“supposed to be granular inflammation, ulceration or abrasion 
of the cervix, with enlargement of the uterus ; the patient, for a 
time at least, was cured. But, in a few weeks, some of these 
patients would return, and, upon examination, they would be 
found to be just as bad as ever”' In some cases, however, he 
did succeed in effecting a cure—a complete involution of the 
organ and restoration of the ulcerated tissue by placing the 
woman in a recumbent posture for two or three weeks' and 
making occasional applications of the actual cautery. Then 
he goes on to say that “ the fact that some such cases as these 
can be cured without a surgical operation is important, because 
the operation always requires confinement of the patient, and 
some of them will not consent at all to it.” He then describes 
his method of treatment briefly, as follows: Recumbent pos- 
ture, hot vaginal injections, tr. chlor. of iron, ergot, and mix 
vomica. After three or four weeks the uterus is reduced in 
size, and the patient is then allowed to be up, wearing a cotton 
tampon dipped in a saturated solution of tannin in water, to be 
renewed daily. “ After a time,” this could be dispensed with, 
and the patient was cured. 
Dr. Jacobi claimed that, if the puerperal uterus and vagina 
be kept clean by repeated warm-water injections until the 
lochial discharge ceases, in all probability every laceration, 
unless it enters the peritoneum, will heal. And if it does not 
heal, the operation will do no more than close the laceration 
and remove the ulcerated surface ; the uterine catarrh and 
chronic enlargement usually accompanying the lesion will, he 
asserts, get well only under separate treatment. The treat- 
ment covering all these indications at once, in Dr. Jacobi’s 
experience, is the actual cautery applied to the cervix and 
endometrium, which destroys the cicatricial surface, and 
enlivens the adjoining circulation. 
1 Italics are mine. 8 
Mitnde: Indications for Hystero- Trachelorrhaphy, 
In Europe, with the exception of Germany, the existence of 
laceration or fissure of the cervix as a distinct lesion requiring 
recognition and treatment, appears scarcely to have dawned 
upon the profession. With, it would seem, almost wilful neg- 
lect, all mention of the affection is omitted in the two latest 
books on gynecology, Barnes1 and Leblond f and authors so 
well acquainted with American medical literature as Hegar 
and Kaltenbach3 and Schroeder,4 in Germany, do not refer 
either to the lesion or its treatment. Beigel, in his first work,4 
omits all mention of it; but in his recent treatise on Sterility6 
he describes and recommends the operation. A translation of 
Emmet’s second (1874) paper, by Yogel, of Berlin, appeared 
early in 1878, and has now doubtless familiarized the pro- 
fession in Germany with the subject. The only authors 
speaking of it arc Breisky,7 who operated on five cases under 
the guidance of a former house-surgeon at the New York 
Woman’s Hospital, and was enthusiastic for the operation, and 
Huge and Veit,8 who, in an article on “ The Pathology of the 
Cervix,” give a chromo-lithograph of a lacerated cervix. Bar- 
nes, to be sure, gives one woodcut of “eversion or rolling out 
of the lining membrane of the cervical canal ” (Fig. 117), and 
two of “ eversion of the lips ” of the cervix, one in the early, 
the other in the advanced stage of hypertrophic elongation of 
cervix uteri (Figs. 120 and 121), which eversion he explains as 
caused by “ growth or extension of the cervix from within out- 
wards,” but which, to my mind, evidently represent the famil- 
iar laceration and eversion by traction of the hyperplastic lips. 
I think his diagrams plainly show this, as well as two previous 
ones (Figs. 101 and 103) of “ epithelial abrasion ” around the 
os, several weeks after delivery, which also plainly show the 
first degree of ectropium of a multi-fissured os. Of course, the 
epithelium is abraded, but it is the epithelium of the everted 
endocervical mucosa, just within the oral border, not of the 
'Diseases of Women, June, 1878. 
2Traite glementaire de Ghirurgie Gynecologique, Paris, 1878. 
3 Operative Gynakologie, 1874. 
4Dis. of the Female Sexyal Organs, Ziemssen, 1875. 
5 Krankheiten des weibl. Geschlechtes, Stuttgart, 1874. 
8 Pathologische Anatomie der weibl. Unfruchtbarkeit. Braunschweig, June, 
1878. 
1 Wiener Med. Wochenschr., 1876. 
8Zeitschrift f. Geburtsh. u. Gyniikologie, ii., 1878. or the Operation for Laceration of the Cervix. 
9 
vaginal mucous covering of the cervix, just without the border. 
I have seen many such cases, the recognition of which, though 
easy with a Sims’ speculum, is difficult or impossible through 
the cylindrical or bivalve specula ordinarily in use. 
A letter published in the Chicago Med. Journal and Exam- 
iner for April, 1878, from a physician travelling abroad, would 
seem to indicate that the eminent gynecologist of Dublin, 
Lombe Atthill, for whose writings and practice I have the 
highest regard, either does not or will not recognize the impor- 
tance of the lesion in question and its operative cure. A 
typical case of laceration being presented to the writer, Att- 
hill, on being asked what he thought of Emmet’s operation, is 
reported as saying that “ just now following in the wake of 
Dr. Sims, we (American physicians) were a little crazy on the 
subject of uterine surgery, and when a case presented itself, we 
lost sight of every therapeutical appliance except the knife.” 
In vivid contrast are the views of the eminent Danish gyne- 
cologist Howitz, of Copenhagen, who recently1 published his 
experience on seventy-six cases of “ Emmet’s rupture of the 
cervix uteri.’’ He found ectropium and erosion of the everted 
cervical mucosa to be almost constant results of the lesion, and 
cystic degeneration of the lips frequently present. The neces- 
sity for operation he regards as unquestionable, the condition 
being remediable in no other way. 
The impression obviously conveyed by the remarks of Drs. 
Barker, Jacobi, and Atthill is, that the operation for lacerated 
cervix has been and is far too frequently performed; that, in 
the vast majority of instances, the lesion is curable by local 
applications, rest, and general treatment; that the operation is 
to be restricted only to the gravest forms of the accident; 
and, finally, that the minor varieties are, as a rule, too trivial 
to be either productive of evil or in need of an operation. 
How, while I certainly admit that slight lacerations or nicks 
of the cervix, without ectropium and with normal mucous sur- 
faces, yes, even deep fissures without eversion, or rolling out 
of the flaps (Fig. 3), further, deep lacerations with eversion, 
but with the whole everted cervical mucosa cicatrized and 
smooth (Fig. 11)—while I admit that all these in no wise 
call for operative interference or any interference whatever 
1 Gyniikologiske og Obstetriciske Meddelelser, vol. i., No. 3, 1878.  Munde: Indications Jor Hystero- Trachelorrhaphy7 
10 
(except there be cervical neuralgia from inclusion of nerve-til- 
aments in the cicatrix, a symptom pointed out by Emmet as an 
indication for the operation), my experience decidedly warrants 
me in claiming that there are numerous cases of the minor 
degrees of cervical laceration and eversion in which the plas- 
tic operation is the most safe, sure, and rapid therapeutic 
measure for the relief of the local disease with which the 
patient is afflicted. Such cases are : 
1. Slight lacerations (as shown in Fig. 8), which ordinarily 
give no trouble whatever, but in which, under the influence 
of friction against the posterior vaginal wall (the uterus 
often being subinvoluted and depressed), the trivial ectropium 
becomes a profusely secreting ulcer, gradually spreading into 
the cervical canal, and producing the familiar mucopurulent 
tenacious plug projecting from the fissured os. 
Here, strong caustics, chiefly solid nitrate of silver, nitric 
and chromic acids, or perhaps, in due time, milder astringents, 
such as tannin and iodoform, etc., may finally glaze over the 
ulcerated surface and cure the endocervicitis; but, as Hr. 
Barker himself admits, the cure would be merely temporary, 
lasting only a few weeks, “the ulceration” would then be 
found “ as bad as ever,” and in any case, as Dr. Chadwick 
says, the treatment may last for many months. 
In these cases, the excision or curetting of the diseased endo- 
cervical mucosa (if much hypertrophied) may be necessary, 
before closing the laceration ; but, as a rule, I have found the 
removal of the ulcerated surface from irritation by means of the 
operation to be sufficient, and hut little, if any, after-treatment 
required to cure the former endocervicitis. 
2. Slight lacerations, perhaps not ulcerated and non-produc- 
tive in themselves of local disturbance, but still acting through 
the gaping and everted os, as chronic feeders of the subinvolu- 
tion and hyperplasia, against which we all acknowledge our 
boasted therapeutics, local and constitutional, to be ordinarily 
of little avail. Here, where a stimulus to circulation and 
absorptive nutrition is needed, is not the irritation of the opera- 
tion, the loss of blood attending it, and the persistence of the 
sutures for one to two weeks, a far better, and surely no more 
cruel agent than the actual cautery, which, besides, puts a 
cicatrix where the operation places normal mucous membrane? or the Operation for Laceration of the Cervix. 
11 
The operation in this class of cases (and they constitute the 
majority of those met with by the gynecologist), affords a 
mild and equally efficient substitute for amputation of the cer- 
vix, recommended as a stimulus to involution in “ chronic metri- 
tis” or “areolar hyperplasia” by numerous writers (Mayer, 
Simon, Sims, Spiegelberg, Hegar, Carl Braun, and others). 
That it is not necessary to remove the whole or a large por- 
tion of the cervix in order to insure this involution appears 
from the statement made by Thomas1 in referring to this ope- 
ration of amputation in areolar hyperplasia. He says that 
“when a superficial layer of an organ which is affected by 
hypertrophy is cut off, a marked tendency to diminution in the 
bulk of the remaining tissue shows itself. . . . No great amount 
of tissue need be removed.” 
With precisely this object in view, August Martin, of Ber- 
lin, recently reported 2 having amputated the cervix uteri sev- 
enty-two times, with the invarying result of seeing the hyper- 
plastic uterus decrease in length by 2 to 3 cm. beyond the 
dimensions of the part removed (2 to 4 cm.). The operation, 
as performed by him, he states to be quite a small matter, 
occupying often not more than ten to twelve minutes. As one 
of the advantages of the operation is stated the removal of the 
usually diseased cervical mucous membrane—an advantage 
equally well attained by trachelorrhaphy. Of Martin’s cases, 
only seven experienced inflammatory after-effects. In the dis- 
cussion which followed, Kehrer, Schroeder, and Olshausen 
agreed substantially with Martin, that removal of a portion of 
the cervix is greatly preferable to cauterization in stimulating 
the uterus to involution, and described their own operations 
for the attainment of the same object. To the objection of 
Kugelmann, of Hanover, that these cases are curable “in time 
and with patience ” by less severe measures, Schroeder replied 
that the time and patience of the patient should also be con- 
sidered, and that it “ certainly was preferable to obtain a cer- 
tain result in a fortnight by a safe method, than an uncertain 
result after months of other treatment.” 
It will be seen that these opinions coincide precisely with those 
expressed in this paper, which, I may add, was substantially 
1 Dis. of Women, 1874, p. 307. 
2 Trans. German Gynecological Society, Sept. 12th and 13th, 1878. See 
this number. 12 
Munde: Indications for Trachelorrhaphy, 
written and read to some friends in June, 1878, three months 
before the meeting just quoted from. In order to be sure of 
sufficiently stimulating the uterus to involution, I should say 
that the flaps removed in hyperplasia should be larger and 
the incisions deeper, extending into the tissue of the uterus 
itself, than in the ordinary cases where there is but slight 
enlargement of the cervix or whole uterus. The usual large 
size of the cervix in hyperplasia eo ipso calls for larger denu- 
dation, and perhaps excision of a portion of one or the other 
lip. The subsequent approximation of the lips and mucous 
covering is also practised by Martin, who always draws the 
mucous membrane over the stump by sutures. 
3. Cases of hyperplastic or cystic ectropium of one lip 
(Fig. 5), in which a raw, ulcerated surface, often one-half 
to one inch in diameter, takes the place of the lip. To excise 
this redundant and useless piece of tissue, slightly pare the 
edges of the broad cervix, and restore the normal transverse 
os, is certainly a much neater way of curing this difficulty 
than by the tedious cautery or often repeated scarification. 
Such cases, and those shown in Fig. 4, where the hyperplasia 
extends to both lips, generally complicated with fissure, form 
a large contingent for and are particularly benefited by the 
operation. 
4. Cases of laceration of the endocervical mucous membrane, 
with comparatively slight injury to the border of the os, which, 
however, is patulous and funnel-shaped, often admitting the 
point of the index finger (Fig. 6), and frequently everted and 
eroded (Barnes, Fig. 117). The gaping os is usually filled with 
a muco-purulent, tenacious plug, the result of endocervicitis 
from exposure, and the patient complains of the symptoms 
peculiar to this condition. Here also the strong caustics fail, 
or are tedious. What is better, then, than to slit the cervix 
bilaterally, denude, and stitch it up like an ordinary laceration ? 
I performed this operation in precisely such a case as the figure 
shows, during the past winter, in which nitric acid had been 
previously tried in vain for several weeks. I neglected, how- 
ever, to slit the cervix on either side, and, therefore, failed 
partly in securing perfect union; sufficient contraction was, 
however, obtained to permit of subsequent rapid cure by nitric 
acid. or the Operation for Laceration of the Cervix. 
13 
For this species of lesion, my friend Dr. M. D. Mann pro- 
poses passing a long, slender, curved bistoury (tenotomy 
knife) into the normal margin of the cervix, carrying it down 
as far as the gaping extends, and then sliding it around to 
the point on the opposite side, and cutting out into the canal; 
this procedure is to be repeated on the opposite side. Two 
crescentic shavings of tissue are thus removed, and the oppo- 
site edges united by sutures. 
5. We are all familiar with the difficulty experienced in 
curing large granular and follicular erosions of the cervix by 
caustics. Why not, then, hasten the cure by removing the 
diseased mucous membrane and uniting the healthy edges by 
sutures, as is done in Emmet’s operation ? I am confident 
much time could thus be saved. 
Tf such slight cases of cystic or follicular erosion as seen in 
Fig. 2 would not necessarily require trachelorrhaphy, that 
depicted in Fig. 12, and taken from a case seen in my service 
at Mt. Sinai Hospital, certainly would. It was my intention 
in this case to excise completely the large cystic degeneration 
(which with its fissures closely resembled epithelioma, the 
differential diagnosis being made by the microscope as hyper- 
plasia cystica), and then to create two lateral fresh surfaces 
and unite them in the ordinary manner, but the patient unfor- 
tunately declined the operation, and I lost sight of her. 
If there ever was a case ripe for malignant degeneration this 
was the one. Who will deny that the plastic operation pro- 
posed by me was an infinitely more rational and radically resto- 
rative procedure than the puncture of the enlarged follicles and 
cautery usually recommended? 
Another reason why even otherwise trifling ectropia should 
not be allowed to go on for years unheeded and untreated was 
recently1 advanced by Prof. Breisky, of Prague, who has ob- 
served and operated upon four cases of laceration in which one 
everted lip had become carcinomatous in consequence of the 
irritation to which the exposed cervical mucosa was subjected. 
These observations are confirmed bjr Veit,2 who out of 9 cases 
of carcinoma cervicis found 3 in which the disease originated 
in the enlarged glandular elements. 
1 Wiener Med.-chir. Rundschau, Aug., 1877. 
2 Gynecol. Sec. German Congress of Pliys., 1877. 14 
Munde: Indications for /lystero- trachelorrhaphy, 
I do not deny the statement that the majority of fresh cer- 
vical lacerations will get well merely with cleanliness and the 
recumbent posture, nor that many cases can be cured by the 
treatment advocated by Drs. Barker and Jacobi; but I would 
ask, What is the advantage of subjecting patients to a treatment 
extending over weeks and months, and confinement to a recum- 
bent posture for two or three weeks, enlivening the monotony 
of this course by the occasional application of the actual 
cautery, when all this can be obtained (the wound closed, the 
cervix restored to its normal shape, and the uterus certainly 
diminished somewhat in size) after less than two weeks’ con- 
finement in bed by an almost entirely safe, simple, and compar- 
atively painless operation ? Should the uterus be depressed in 
the pelvis or its involution retarded, daily tannin tampons and 
hot injections for some time will certainly aid the complete cure, 
but by these the patient is in no wise incommoded, as she can 
apply them herself. That the operation is comparatively pain- 
less I have witnessed myself, since I have three times performed 
it without anesthesia, the patients telling me afterwards that 
they much preferred the only severe pain felt, that of the intro- 
duction of the sutures, to the nausea following etherization. 
That the operation is comparatively devoid of danger is shown 
by the statistics of the New York Woman’s Hospital:1 In 84 
operations, but one death occurred (from peritonitis); and Dr. 
Emmet2 states that, in nearly 200 operations of the kind per- 
formed by him, only one case of cellulitis occurred, due, he 
believes, to inflammatory tendency in the hospital; and even 
in this case the operation was successful. So we have (consid- 
ering that Dr. Emmet performed two-thirds of these operations 
in the Woman’s Hospital down to 1875) at least 250 operations 
for trachelorrhaphy, with a mortality of two-fifths of one per 
cent, and a similar ratio of inflammatory trouble following it. 
Surely, but few operations involving equal skill and followed 
by equally beneficial results can boast of such security! 
It is true that the operation occasionally fails (in 10 cases out 
of the 84 above quoted), but this is chiefly due to lack of pro- 
per preparatory treatment, to insufficient paring and careless 
adaptation of the wounded surfaces, and to influences not under 
1 Annual Keport for 1877. 
2 L. c., Amer. Jour. Obst., vol. vii., p. 449. or the Operation for Laceration of the Cervix. 
15 
the control of the surgeon. A second operation usually cures 
the case. 
At a meeting of the New York Obstetrical Society, held No- 
vember 20th, 1877, Dr. Alex. J. C. Skene, the President, 
expressed the opinion that there were many abnormal conditions 
of the cervix uteri, other than lacerations, which could he cured 
better by the plastic operation than by any otiier means. While 
he did not explain himself more precisely, I drew the inference 
that he alluded to conditions very similar to those which I 
have been here describing and which I have looked upon as, 
under proper conditions, calling for the operation. 
During the past year I twice performed the operation for 
lacerations smaller than that shown in Fig. 9, in both of which 
cases the indication was not the extent of the injury, but the 
irritation exerted on the hyperplastic uterus by the friction of 
the everted surfaces, and the beneficial influence to be expected 
for the reduction of the enlargement. These indications were 
confirmed by Dr. Thomas, who saw the ladies with me in 
consultation. 
In the first case, the patient had suffered from hyperplasia and 
endocervical leucorrhea since the birth of her first and only child 
20 years previously. The uterus was anteflexed, much enlarged, 
the probe entered to the depth of 3 inches, aud a profuse, glairy, 
muco-purulent plug constantly protruded from the gaping os, the 
laceration and eversion of which held about the medium between 
the appearances depicted in Figs. 8 and 9. The left ovary was 
enlarged and tender, the uterus low in the pelvis. The patient had 
worn various pessaries, of which only the last, Hitchcock’s, gave 
her some relief, without, however, removing the constant dragging 
and aching pelvic pains, for which principally she sought advice. 
Two months of local treatment bringing but temporary lelief, the 
operation of paring and uniting the edges of the greatly enlarged 
cervix was performed April 18th, 1877, for the indications above 
stated. Complete union took place, leaving an almost virginal os. 
Within one month after the operation the uterus was reduced to 
inches in length, the pelvic and ovarian pains disappeared, the 
patient, wearing a block-tin anteversion pessary covered with soft 
rubber, was able to spend the whole summer in the Adirondacks 
walking and riding, restored to complete health. 
The second case was a still more striking illustration of the 
benefit to be derived from the operation, other than the mere 
closure of a small laceration. 
The lady, aet. 32, mother of one child years old. had had seve- 
ral miscarriages aud had suffered for over 3 years from almost regu- 16 
Munde: Indications for Hystero-Trachelorrhaphy, 
lar discharges of shreds, occasionally complete membranes, during 
menstruation. The pain and prostration attending these exfoliations 
were excessive. Uterus retroverted in the second degree, very much 
enlarged, cavity 3 inches long; os slightly lacerated and everted, 
scarcely as much as shown in Fig. 9 ; constant glairy, discolored 
cervical discharge. After 4 months’ steady treatment by means of 
intrauterine application of nitric acid (once only), tr. iodine and 
iodized phenol (once weekly, preceded by sponge-tents for 2 months), 
and local galvanization of endometrium (3 months), the patient was 
very much improved and the membranes had not appeared for 2 
periods. But still the endocervical catarrh continued and bade fair 
to keep up sufficient irritation to prevent the permanent cure of the 
membranous dysmenorrhea, the tendency to which was undoubtedly 
also aggravated by the chronic engorgement of the uterus. To 
relieve these two conditions and reduce the size and congestion of 
the uterus, with Dr. Thomas’ approval, the operation of trachelor- 
rhaphy was performed May 12th, 1877. Complete union was 
obtained. The further treatment consisted in intrauterine and 
chiefly vaginal galvanization, the latter applied for the most part by 
the patient herself, a very intelligent lady, her home being out of 
the city. In consequence of this treatment and the operation, the 
endocervical catarrh vanished entirely and the uterus was much 
reduced in size, being found to be normal before the lady left for a 
trip to Western New York in the following August. On this trip 
(wearing a retroversion pessary specially constructed for her) she 
was able to undergo fatigue and exertions to which she had been 
unequal since her illness. In spite of the unfavorable prognosis, 
her membranous dysmenorrhea seems cured, for it is now more 
than a year and a half since she passed the last shreds. 
In this case, I will not attribute more to the operation than is 
its due, but I am confident that no local treatment directed 
solely against the desquamative action of the uterine mucosa 
would have been productive of permanent benefit, had the focus 
of irritation—the gaping, although hut slightly lacerated cervix 
—been allowed to remain unrestored. 
I trust that I have made sufficiently clear and explicit the 
object of this paper, viz.: to demonstrate, not that every lacera- 
tion of the cervix should he operated upon as a duty, for I 
believe that a certain proportion of these lesions either do not 
require any treatment because they produce no symptoms, or, 
in a lesser proportion, are amenable to caustic and astringent 
applications—but that there is a very large class of cases in 
which the operation is called for, not by the extent of the 
injury, but by the symptoms which it produces and the patho- 
logical conditions which it aggravates or maintains. These 
cases I have stated above. or the Operation for Laceration of the Cervix. 
17 
My position is very materially strengthened by a short paper 
recently published by Dr. Skene in the June, 1878, number of 
the Proceedings of the Medical Society of the County of Kings, 
on the “ Treatment of Lacerations of the Cervix Uteri,” in which 
he strongly recommends the operation, and describes his sub- 
stitution of silk in place of the ordinary wire sutures. These 
he used in eight cases with perfect success. In one case, the 
operation was performed at his office without ether (as indeed 
were the others), the vagina tamponed, and the patient sent to 
her home by the street cars; and still union took place. In 
another case, the patient began to menstruate on the third day 
after the operation, left her bed, went to the adjoining room and 
voided a large clot from her vagina; and here also union 
occurred. Dr. Skene does not confine the bowels or particu- 
larly restrict the diet. Now, in view of these successes, I doubt 
not that we shall soon be able to operate on these slighter cases 
of laceration and eversion at our office or the Dispensary, send 
them home by the cars and let them go about their ordinary 
avocations (avoiding unusual exposure, of course), to return 
for the removal of the stitches at the end of a week. The 
absence of etherization, and the use of silk instead of wire, 
materially simplify and shorten the operation. When it has 
once been demonstrated that this plan is followed by success as 
regards union, then the great objection to the operation among 
the poorer classes, the confinement to bed, will be removed, 
and old cases of cervical ectropium should disappear from our 
clinics. Still, I consider the recumbent position during con- 
valescence as a most important factor for the ultimate results of 
the operation and one always to be insisted upon when feasible. 
It need scarcely be stated that the usual subjective indica- 
tions for the operation first specified by Dr. Emmet (dragging 
and weight in pelvis, loss of sexual appetite, cervical and ovarian 
neuralgia, hysteria, general anemia, etc.) apply to the slighter 
lacerations exactly in proportion to the extent of the injury. 
In conclusion, permit me briefly to refer to the experience 
on which these remarks and conclusions are based. 
Out of 700 parous women (meaning such as had been 
delivered of one or more children at or near term) treated by 
me at the Out-Door Department of Mt. Sinai Hospital during 
the past two years, there were 119 with lacerations of the cervix 18 
Munde: Indications for Hystero- Trachelorrhaphy, 
uteri of one or the other of the three degrees assumed by me. 
Of these, 92 were bilateral, 24 unilateral (17 right, 7 left; this 
latter result is contrary to the experience of others, who found 
the sinistral lacerations the more frequent, in accordance with 
the greater frequency of the left occipital presentations, and is 
probably accidental), two through the posterior and one through 
the anterior lip. Of these 119 cases, 20 were of the first, 45 of 
the second, and 54 of the third, or most severe degree. In only 
16 cases was there no eversion and an absence of local and gen- 
eral symptoms attributable to the lacerations. In 3 cases the 
everted surface was cicatrized and innocuous. To show the 
rarity of simple uncomplicated erosion of the cervix, in com- 
parison to the erosion and ulceration1 of the everted cervical 
mucosa, I will merely mention that only 11 instances of this 
formerly so commonly diagnosed affection were observed among 
these 700 cases. 
Of all the lacerations of the cervix which have been under 
my observation, the number of which is probably double that 
mentioned here (I have not thought it necessary to this paper 
to look over the records of former years and of private prac- 
tice, deeming the figures here presented sufficiently large), 16 
were operated upon by me, with 12 perfect successes and 4 
failures as to union; in two of these latter, the operation 
was repeated, and complete union and restoration to health 
obtained. Two of these patients conceived soon after the 
operation and, as I am informed by the attending physicians, 
were confined at term without any difficulty being noticeable 
in the dilatation of the cervix and without a recurrence of the 
laceration. 
The percentage of lacerations observed by me (17 per cent) 
is decidedly higher than that reported by Dr. Hanks (8T4ff per 
cent) from a similar public institution, the Demilt Dispensary, 
and serves to illustrate very aptly a remark made by Dr. 
Barker on the occasion above mentioned, that this lesion 
1 The term “ ulceration ” of the everted cervical mucosa is not intended to 
imply a loss of substance. With the exception of the chancroid, carcinoma, 
and the excavated ulcer produced by direct friction on a prolapsed cervix, 
there is, “correctly speaking, no such disease as ulceration of the cervix 
uteri ” (Craig, Am. Practitioner, July, 1878). The familiar ulcer of the cervix 
and the raw, bleeding, profusely secreting surface of the everted mucous 
membrane of the cervix, presents a red, granular, frequently elevated and fis- 
sured appearance, similar to the granular degeneration of the conjunctiva. or the Operation for Laceration of the Cervix. 
19 
occurs with vastly greater frequency in persons who have had 
neither skilled obstetrical attendants nor the care and rest 
required after confinement, since in his own practice, con- 
fined to the more wealthy classes, he had met with this 
accident in but two well-marked cases. Now, the patients of 
the Demilt Dispensary are mostly of Irish and American 
nationality, among whom it is customary to employ a physician 
at their confinements, and observe the usual week or nine days 
of the recumbent posture afterwards, whenever their circum- 
stances permit; but among the Jewesses, who constitute by 
far the majority of patients of the Mt. Sinai Hospital Out- 
Door Department, I hear that it is the rare exception for them 
to be delivered by a physician, and that the lying-in period is 
but poorly observed. 
That this higher percentage (three times as high, indeed, as 
that stated by me in remarks made after the reading of Dr. 
Emmet’s last paper, two years ago, when I was less familiar 
with and had seen a much smaller number of cases of the 
lesion) is not accidental or confined to patients of the class 
named, is confirmed by the experience of Dr. Wm. Goodell, 
who, in “ The Address on Obstetrics” read before the State 
Medical Society of Pennsylvania in May, 1878, and received 
by me in reprint only a few days ago, says: “ My own experi- 
ence at the Dispensary for Diseases of Women at the Univer- 
sity 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.”1 He also states that he lias 
operated for this lesion eighteen times during the past twelve 
months. This paper of Dr. Goodell’s contains, by the way, the 
most forcible and graphic picture I have yet seen of the pecu- 
liar appearance and the consequences of tins lesion, drawn with 
all the eloquence for which the author is so justly celebrated. 
Finding that correct and intelligent representations of the 
lesion now known as Laceration, Fissure, or Ectropium of the 
Cervix Uteri are exceedingly rare, there being only one such 
diagram in colors, to my knowledge, in existence, made with the 
purpose of demonstrating its appearance—that of Ruge and 
Veit, above referred to—I had a series of colored plates of the 
1 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., etc., May, 1878. Phila. ; Collins, Printer, 705 Jayne St. 20 
Munde : Indications for Hystero- Trachelorrapliy. 
various forms and degrees of laceration and ectropiimi of the 
cervix uteri prepared from nature, for the faithful execution 
of which I am indebted to the kindness and skill of Dr. A. H. 
Fridenberg, house physician at Mt. Sinai Hospital, whose resi- 
dence in the hospital enabled me to secure his immediate 
attendance whenever a. case favorable for illustration presented 
itself. The cases of laceration were chosen to show, as nearly 
as practicable, without exaggeration, the typical varieties of the 
lesion designed to be discussed in this paper; and one diagram 
of simple erosion of the cervix was added to illustrate the 
difference in appearance between the two affections. I think 
they clearly and truthfully represent what they claim to do, 
and trust they may prove of practical value to the uninitiated. 
EXPLANATION OF PLATES. 
(All figures taken in the left semi-prone position through Sims’ speculum.) 
Fig. 1. Large catarrhal erosion of nulliparous cervix. 
Fig. 2. Follicular erosion of parous cervix with slight fissure. 
Fig. 3. Large stellate laceration without eversion. 
Fig. 4. Stellate laceration with eversion and cystic hyperplasia. 
Fig. 5. Cystic hyperplasia and eversion of anterior lip. 
Fig. 6. Patulous os, without distinct external fissure. 
Fig. 7. Unilateral laceration (right) with eversion. 
Fig. 8. Bilateral laceration with eversion, first degree. 
Fig. 9. Bilateral laceration with eversion, second degree. 
Fig. 10. Bilateral laceration with eversion, third degree, showing 
tenacula inserted to approximate the everted lips. 
Fig. 11. Bilateral laceration with eversion, third degree, mostly 
cicatrized and not ulcerated. Both upper corners show fresh 
breaking down of cicatrix. 
Fig. 12. Enormous cystic hyperplasia of anterior lip, simulating 
epithelioma. AM. JOURNAL OF OBSTETRICS 
AND 
DISEASES OF WOMEN AND CHILDREN 
JANUARY 1879. 
plate j. 
. 1 [wide on Late rations of the feme Uteri. AM. JOURNAL of obstetrics 
AND 
DISEASES OF WOMEN AND CHILDREN. 
JANUARY ;8?9. 
. I fnnde on Lace rations of the (dm Hen.