CLINICAL REPORT ON CASES OF LACERATED CERVIX, AND OVARIOTOMY. FROM PRIVATE PRACTICE. BT JOSEPH H. WARREN, A. M., M. D., BOSTON, MASS., PHYSICIAN IN THE MASSACHUSETTS HOME INTEMPERATE WOMEN. A' Reprinted from the Boston Medical and Surgical Journal of August 30 and September 6, 1883. Printeb at the fttomibe press. CAMBRIDGE; 1883. CLINICAL REPORT ON CASES OF LACERATED CERVIX, AND OVARIOTOMY, FROM PRIVATE PRACTICE. BT JOSEPH H. WARREN, A. M., M. D., BOSTON, MASS., PHYSICIAN IN THE MASSACHUSETTS HOME FOR INTEMPERATE WOMEN. Reprinted from the Boston Medical and Surgical Journal of August 30 and September 6, 1883. CAMBRIDGE: srintes at tlje Hiocrsifo Stress. 1883. CLINICAL REPORT ON CASES OF LACER- ATED CERVIX, FROM PRIVATE PRACTICE.1 BY JOSEPH H. WARREN, A. M., M. D., BOSTON, MASS., PHYSICIAN IN THE MASSACHUSETTS HOME FOR INTEMPERATE WOMEN. From observations of over twenty-five years I have learned that lacerations of the cervix uteri occur much more frequently and extensively on the right side than on the left, but that when both sides are lacerated the left is usually torn more than the right. The most natural question is, Why should this laceration occur so much more frequently and extensively on the right than on the left side ? and to this question I can give no other answer than that, in many cases at least, the laceration is due to had and meddlesome midwifery. I do not mean that the obstetrician should never inter- fere with the progress of a labor when by such inter- ference he may render the necessary assistance that is all-important to the successful termination of a labor that is already unduly protracted; nor do I mean that the accoucheur should be blamed if in rendering such necessary assistance he consciously or unconsciously lacerates either the cervix or the perinteura. A lacera- tion in some cases is probably inevitable, and the fault is no more with the physician than with nature. But there are certain ways of conducting a labor that must be censured by every conscientious practitioner, and it is to these gross mismanagements that I apply the term bad and meddlesome midwifery. The cause of lacerations in general is a weakened 1 Eead before the Suffolk District Medical Society, February 24, 1883. 4 Cases of Lacerated Cervix. state of the woman’s constitution, a child abnormally large for the woman’s pelvis, which is often narrow and contracted, the correction of some malposition or malpresentation, or the use of instruments, or in some cases a natural but a too rapid labor. I recall a case which is interesting and instructive in many ways. Mrs. O. 8., of Dorchester, became pregnant with her first child when she was forty-seven years of age. I was called to her June 1, 1857, and found that she had considered herself pregnant for about six weeks. Her history was that on the very next day after connec- tion with her husband she began to complain of nausea and vomiting, so that she could retain nothing either solid or fluid upon her stomach. I attended her almost daily during the whole of her pregnancy, and can rely upon her statement that she was able to retain noth- ing upon her stomach during all this time, unless, pos- sibly, it might be a little beef or lamb scraped fine and mixed with sugar and champagne. Although she was nourished by injections of beef tea and milk she be- came much emaciated by the time of her confinement. Her labor was protracted for three days, but at last I succeeded in dilating the os sufficiently to introduce the blades of the forceps and deliver a large and healthy female child. In doing this I lacerated the cer- vix upon both sides, slightly on the right but pretty extensively on the left, but not extensively enough to require an operation for lacerated cervix. I consider the reason why in these double lacerations the left side is torn more than the right to be that with the woman lying upon her back or left side we are inclined to pull up in making traction upon the forceps, and thereby cause a corresponding depression of the ends of the blades, which cuts and tears the left side more than it does the right. Another feature of this case which I will mention is that the patient’s nausea and vomiting could be con- trolled for the space of three or four days by the ap- plication of tincture benzoin comp, to the cervix. This Cases of Lacerated Cervix. 5 can readily be applied by adding it to elastic collodion. The late Dr. Miller, of Dorchester, in his practice used the tincture of iodine for the same purpose, and both his article and my own upon this subject can be found in the Boston Medical and Surgical Journal. The next case of a laceration of the cervix that I remember was in a labor where the cord had pro- lapsed. While I was vainly attempting to hang the cord upon some prominent point of the child that I might hope to find, and when I had just succeeded in pushing back the loop within the os, a sharp pain came on, caught my finger in the os, and ruptured the cervix upon the right side. Another laceration took place upon the right side while I was attempting to change an arm and shoulder presentation into a footling, and still an- other while I was assisting a physician to deliver a dead child with the blunt hook. The hook was intro- duced on the left side of the cervix, and had caught the left side of the lower maxilla, but the traction was toward the right side of the os, and hence the lacera- tion was upon that same side. There are, however, two classes of lacerations that are needless, and are due to improper interference, meddlesome if not directly criminal. Some practi- tioners will try to assist the progress of the labor by helping nature to dilate the os, even when the labor is progressing as rapidly as it ought. By fingering the os they make both it and the vagina hot, dry, and irri- table, and if the patient continues to bear down con- stantly, as they wish her to do, the time will speedily come when the os will tear. If this was caused by ig- norance we might hope to root out the evil, but 1 am afraid it arises in many cases from impatience and will- ful carelessness. But the most criminal lacerations are those produced by those vipers in the community, the miserable and soulless abortionists. To produce a miscarriage, and to free a woman of the inconvenience of carrying her child, these wretches cut her, and almost always upon the right side of the cervix. In- 6 Cases of Lacerated Cervix. deed, I believe this injury to be one of the prime causes of death after an attempted abortion, by causing an acute septicaemia, and I think it would be an inter- esting study for the medical examiners to ascertain what proportion of those dying from abortion have a lacer- ated cervix. I have sometimes thought it a fit punish- ment designed by Providence for those who yield to this great sin, and I feel confident that many more lacer- ations than we now suspect have been caused in this way, even among our American women, for within a short time 1 have operated on no less than three such lacerated cervices due to this cause alone. It often happens that a laceration exists when we little think it, and to show how easily one may fall into this mistake I will relate a case. I saw a lady three times, but could find nothing more abnormal in her as seen through a bivalve speculum than possibly a slight fissure which I should not think of repairing. She went to another medical gentleman, who was so positive of his position that he was willing to take oath that she had no laceration. Finally she went to a dis- tinguished practitioner, who said she had a terrible laceration, and who operated upon her for it. I am willing to confess that my diagnosis may have been a mistake, and for the following reason : the last gentle- man used a Sims’s speculum probably in his examina- tion, which I think was the proper instrument to use. Recently I have made an operation for a lacerated cervix uteri which to the touch would seem to be only slightly if at all fissured, but which on examination with a Sims’s speculum, by which the uterus was drawn down, revealed an extensive laceration winding obliquely around the cervix, the edges of the tear being kept in perfect coaptation. Moreover, this is the second case of the same peculiar kind that I have seen and treated within a year, so that I must ask pardon of my good friend for ever doubting his diagnosis in the case I have mentioned. These lacerations are by no means always the fault Cases of Lacerated Cervix. 7 of the physician attending the labor, for similar acci- dents happen with the best of practitioners abroad, both in private and in hospital practice, and will con- tinue to happen so long as women bear children, un- less, indeed, future generations develop more physical perfection that is at present known. But it is to Amer- ican gynaecologists that modern surgery has had to look for the diagnosis and treatment of these cases, and this is only a single instance of the homage Eu- rope has had to pay to us. Indeed, I feel proud to say that I believe that medicine and surgery in all their branches, except possibly pathological anatomy (and this through no lack of ability in our professors'), are taught as well, if not better, in Boston and Philadel- phia, and I might add the schools at Portland and Bowdoin College and some few others, as in any Eu- ropean schools, those of Vienna and Berlin not ex- cepted. - My usual plan in treating lacerations, particularly those of the cervix, is to take stitches pretty closely together in the lips after they have been thoroughly pared and freshened, and to use the animal ligatures for the upper stitches. The last stitches I usually make with fine silk, either black or white. In addition, in all of my late operations, I pass a very fine animal lig- ature through the edges of the laceration after draw- ing the pared lips together by silk sutures. I find this materially assists in obtaining perfect union at the ex- treme end of the laceration. Then I return the parts into their normal position in the vagina, and leave the silk ligatures in their places for ten or twelve days. The animal ligatures will in time become absorbed, but I consider it a great mistake to remove the silk or silver stitches after they have been in place only six or eight days, as recommended by most authors. The tissues of these parts do not heal so rapidly as in other portions of the body, and I have found by experience that better results are obtained if we allow the stitches to remain for twelve or fourteen days. They cause no 8 Cases of Lacerated Cervix. trouble by remaining this length of time. After forty- eight hours have passed since the operation I have the vagina well washed out night and morning with a solu- tion of carbolic acid or a solution of thymol in glycer- ine. In twelve or fifteen days the parts will usually be found to be well healed ; but if the first operation should not be successful another should be performed after a few weeks or months, or as soon as the consti- tution of the patient will allow without producing too much depression or shock, for it will be found that very many of our failures in this operation are due to a want of a proper standard of good health at the time of operating. To illustrate my position more plainly, I will select out of a large number of cases that I have operated and treated for this quite com- mon affection the few following somewhat interesting ones:— My first case of lacerated cervix uteri was that of a Mrs. T., of Newton, late in the fall of 1853. Mrs. T. had been bedridden for nearly twenty years from what was supposed to be extensive ulceration of the os and cervix. I operated by applying strong nitric acid and packing the parts well around with fine linen tow. We used tow at that time more frequently than cotton in surgical dressing. She made a fine recovery, the lacerated cervix united perfectly. She regained her health so fully that she was enabled to perform all the duties of a housewife, and she remained in good health for years afterwards. This laceration occurred in a rapid childbirth twenty years before, and took place on the right side, which peculiarity will also be noticed in a majority of the cases that follow. They also il- lustrate the constitutional severity of these lacera- tions.1 Mrs. S., of South Boston, aged thirty-two, was con- fined with a second child six years previous to the time of the operation. The labor was only of four 1 To fully appreciate this affection, see Savage’s Anatomy of the Female Organs. Cases of Lacerated Cervix. 9 hours’ duration, very rapid, it will be seen. She felt a certain giving away and shock about fifteen minutes before the birth of her child. She said the man called in was so fearful that he would not get through before my arrival that he pulled and hurt her very much, tell- ing her to bear and force down with all her might, and he would help her by dilating the os, which it would seem was most fearfully and rapidly dilated without any such urging or assistance on his part. I arrived just as the child was born. This man in attendance, not a regular physician, skulked away seemingly with great haste. I found the woman bleeding very pro- fusely, so that I was obliged to plug hex-, and it re- quix-ed no little effort besides on my part to arrest the hsemori’hage. Her recovery was necessarily very slow, and upon examining her 1 found that a terrible laceration of the parts had taken place. I told her that this tissue we would repair as soon as she was in suitable health to undergo the operation. I lost sight of her until Octo- ber, 1881, when, with the assistance of Dr. W. E. Smith and my son, C. E. Warren, I denuded the lacer- ated parts and secured them together with carbol- ized animal ligatures for the upper stitches, the two lower being silver. 1 found it necessary to take eight stitches. The sutures of silver were removed on the twelfth day, when perfect union of the parts had taken place. For the first few days after the operation she had increased temperature, running up as high as 101° F., and on the fourth day the menses made their ap- pearance. The operation was done under antiseptic precautions. I should remark that both lacerated lips were covered with a soft, velvety growth, and the in- terstices loaded with pus. This was very friable, and easily broken down under the slightest pressure, so that I was obliged, fearing a malignant tendency of the disease, to remove the tissue for some distance till I arrived to where it seemed healthy and sound before I brought the parts together and closed them with six- 10 Cases of Lacerated Cervix. tures. The patient is now in good health, and the ap- pearance of the uterus is like that of a virgin. The removal of this softened tissue I speak of was extremely necessary, as I once before operated on a case where there was a union which lasted for one or two years, but finally all sloughed out, so that the hiatus was even larger than it was previous to my op- eration, and the parts were greatly degenerated. Fi- nally cancerous affection took place along the track of our former operation, and nothing more of course could be done, but I felt that had I pared deeper and got more sound tissue there would have been less like- lihood of this malignant growth appearing. Mrs. E., aged twenty-five, had her third pregnancy. She applied to a professional abortionist, and he per- formed an abortion on her by cutting the right side of the uterus from the external os very deep through the neck and into the body of the organ. She suffered two years from ill health, when she consulted me for uterine trouble. She said she had been to the City Hospital, and the physicians there said it was the most extensive laceration they had ever seen. With the assistance of Dr. C. P. Bancroft I operated after denud- ing the lacerated parts, and secured them together with six silver wire sutures. On the tenth day I removed them, and found perfect union. No great rise of tem- perature took place, only a slight feverish condition. Injections of carbolized water were used frequently, and administrations were made of ten grains of quinine sulphate per day. She has enjoyed most perfect health since. Miss L., of Maine, aged twenty-two, became en- ceinte, and sought relief at the hands of a notorious abortionist in that State. He operated in a similar manner, cutting very extensively the os and cervix, and into the body of the uterus far beyond the junc- tion of the vagina. This was also on the right side, and a fearful laceration. She suffered, too, from pains of a neuralgic character in both ovaries and uterus, Cases of Lacerated Cervix. 11 extending down the limbs, with bloating of abdomen and legs. Another serious symptom was irritability of the bladder. Her appetite was poor, and she was sleepless at night. Upon examination all the lacerated parts were found covered with a thick, creamy secre- tion or mucus, and under the slightest touch the little papillae underneath bled very freely. After proper constitutional treatment with triple phosphates and bromides, she being apparently in a sufficiently healthy condition to warrant an operation, I operated January 5, 1882, with the assistance of Dr. W. E. Smith and C. E. Warren. After thoroughly denuding, the parts were brought together, and silver sutures used for the first two lower stitches and for the four upper ones silk. For the lower edge of the os a transverse suture was applied, which greatly strengthens those higher up, and also helps to maintain the position of the de- nuded parts in a far better manner than when this stitch is not applied. In this case menstruation re- turned on the eighth day, and the removal of the stitches was deferred until the fifteenth, when the parts were found perfectly united. The next interesting case was that of Mrs. J., aged twenty-seven, her first confinement having been some six years before. She had a very painful, long, and tedious labor. The attending physician perceived an audible fracture of the os pubis. This was owing to a greatly contracted pelvis. She being threatened with great collapse, the instruments were applied, and in delivering her the cervix was lacerated on both sides, the left very extensively, whilst the right was not torn through the crown of the os. In November, 1880, I operated with the above-named assistants, and after paring and making coaptation of the parts, silver and silk ligatures were used, as in many of my former cases. The patient was slightly feverish the first few days, the temperature rising to 101° F. on one day. On the sixteenth day the sutures were removed, and I found perfect union had taken place. She made a 12 Cases of Lacerated Cervix. rapid and good recovery, whereas she had been almost bedridden, and was unable to take any exercise for six years previous to the operation. She has ever since been enabled to go where she pleased, and perform all the duties of the head of a family. This is the only case of fracture of the os pubis I ever saw that took place at the time of labor, and we can imagine with what force must have been the contraction of the uterus upon the child that pressed against the os pubis suffi- ciently to cause that bone to give way. I might mention other cases. One I recall where the laceration, commencing at the anterior portion of the cervix, passed obliquely around nearly to where it began in front, really a spiral laceration. This case I treated for some time before discovering that the laceration extended above the crown of the os, but upon a thorough examination of the patient on her side with a Sims’s speculum I discovered the extent of this rupture. Whilst seeing somewhere in the neighborhood of 450 cases of laceration, besides the number that I have already reported, it is astonishing how many of these ruptures require little if any treatment, as the rup- ture does not extend through the tissue to the crown of the cervix, and will generally heal and the parts become as sound and healthy as any other portion of the tissue comprising the os ; but when this laceration extends above the circular muscular band of the os into the cervix of the uterus then it is that it gives rise to this fearful constitutional and nervous trouble and exhaustion, which is often supposed to be due to simple ulceration or some other morbid disease of the neck of this organ, not until within the last few years having been recognized by a very large number of our profession who have undertaken to treat these dis- eases. There are some lacerations which are external and very apparent; others may require our most thought- ful and rigid investigation, because the laceration, tak- ing place internally, does not show upon the external Cases of Lacerated Cervix. 13 parts. Many, I might say the large majority, of lacer- ations that I have seen have been what we may term internal lacerations. They may extend from the up- per portion of the uterine neck down through nearly to the os, and are recognized by dilating the organ by the tupelo tent, or. as may be done oftentimes in very large uterine canals, with the dressing forceps, when we shall see the fissure on one side extending down through the mucous membranes and extending for some distance into the interior of the uterus. This gives rise to very large and swollen lips and os, with a very great increase of bulk of the uterine neck, so that this portion of the lips and cervix uteri are often much larger than the body of the womb. These cases will go from one practitioner to another and be treated with slight apparent benefit to their irritable uterus and the leucorrhceal discharge which generally accompa- nies this extensive inflammation, but they soon relapse to be as bad as before, and seek some other practi- tioner who will relieve them. When such cases come to me I usually dilate and examine them thoroughly, and after I am convinced that there is an internal lac- eration I apply strong nitric acid or the acid nitrate of mercury, or the actual cautery in some cases (and of late I think much of the galvano-cautery), and it is surprising how soon the patients regain their health, and the enlargement of the lips and the whole organ returns to its normal condition. Many of these cases that I have treated have given me no little reputation in the curing of patients who had sometimes been at- tended by some of our best authors and practitioners in New York and other cities. Some of these cases are supposed to have been subinvolutions, when in reality they are fissures of the mucous membranes, caused by the birth of a child at full term, or, more likely, a miscarriage at three or four months. Out of a record of eighty-three operations on lacer- ated cervices by denuding the parts and using sutures I have in some ten failed, they requiring a renewal 14 Cases of Lacerated Cervix. of the operation. Three of these cases I re-operated on with success. The others disappeared, so that I know not what became of them. I have seen 250 lacerations that did not extend above the crown, and required no operative interference. I have seen over 450 cases of internal laceration, and of over 100 that I have now operated on seventy were on the right side and thirty on the left, and uniting, that is, double lacerations. Many of these superficial lacerations may be ben- efited by the application of the actual cautery and packing the parts around with carbolized or iodinized cotton. I have seen very good results in quite a large number of such cases. A CASE OF UTERINE AND OVARIAN TUMOR. OVA- RIOTOMY. Late in the autumn of 1880 I was called to see a refined and accomplished American lady, Miss F., a native and resident of Maine, twenty-seven years of age. Her history was as follows: About two years previous to this time she had fallen from a hammock to the ground, and soon began to complain of pains in the head and spine, especially in the lumbar region. There was great tenderness over the upper lumbar and lower dorsal vertebras. Menstruation became very irregular and painful, being sometimes profuse and at other times scanty. She was troubled with leucorrhcea and constipation, except that during her monthly periods she often had a diarrhoea for a few days. Mic- turition was frequent, and was attended with more or less pain and smarting of the bladder. Her sleep was disturbed by erotic dreams and frequent emissions. It should be said that in early life she had acquired the habit of masturbation, but had abandoned it as soon as she became old enough to realize its baneful in- fluences. Her general appearance was good and actions sprightly. Ordinarily she was fond of company and Oases of Lacerated Cervix. 15 conversation, but at times, and especially if alone, she would be low spirited, morose, and disposed to sigh and cry. These periods of depression increased in frequency and intensity as time went on, and as there was a history of insanity in the family it was feared that she too was losing her mental vigor. During this time she bad been treated by her family physician for a uterine tumor with anteversion, and by a physician in Augusta for misplacement, retroversion with ante- flexion, and a tumor of the fundus of the uterus. She had also complained of flatulence and dyspepsia, al- though for a few months, by strict attention to diet, these symptoms had abated. She had no great thirst, and her only abnormal appetite had been for chalk and slate pencils in her school days. But she now complained of a choking sensation, and of pain in the left side over the slightly enlarged spleen, and of a pain over the left ovary which was constant, but aggravated so decidedly at her menstrual periods as to amount to an ovaritis. She had taken no exercise for some time either within doors or in the open air except now and then a short ride in a carriage, because walking in- duced more pain in the pelvic region and more frequent micturition. On January 1, 1881, with the assistance of Dr. W. Everett Smith, of Framingham, I made an examina- tion of the patient under ether. Through the abdom- inal walls it was easy to feel distinctly the outlines of a uterus enlarged to the size of a four or five months’ pregnancy. The os and cervical canal were so con- tracted that the smallest uterine probe was at first introduced with difficulty, but after some perseverance it was passed, and a larger one easily followed. The uterus was in a position of retroversion; the probe passed in about five inches and was easily moved around. By bimanual and rectal examination we found an ab- sence of adhesions as well as of ovarian disease. There had been, it will be remembered, no history of any excessive uterine hmmorrhage, and nothing to 16 Cases of Lacerated Cervix. indicate a uterine fibroid except a gradual increase of size for about two years. But the last twelve months had been marked by a more perceptible increase, to- gether with a greater amount of pain and suffering, so that at the time of examination the general appear- ance of the uterus was, to use a homely comparison, not unlike a large crook-necked squash with a very long neck. By passing the large uterine probe within the uterus the posterior wall could be felt of normal thick- ness by the finger in the rectum ; while by pressing the hand upon the abdomen the anterior wall of the uterus seemed greatly thickened. No enlargement of either ovary could be detected. The abdomen at the umbili- cus measured thirty-eight inches; but whether this in- crease was due to a fibroid tumor or to a simple hyper- trophy of the uterus, I was not sure then and am not now. The following day I examined the urine. The sj)ecific gravity was 1023, it later became 1026. There was an abundance of urates, earthy phosphates, and bladder epithelium, but no pus or blood corpuscles. There was no swelling of the feet or ankles. I pre- scribed for her sulphate of quinine four to five grains, with a half teaspoonful of compound licorice powder night and morning, and ten grains of bromide of sodium after dinner and supper. For the uterine tumor I be- gan to use clay from New Jersey, similar to the kind that Dr. Hewson mentioned in the Transactions of the American Medical Association for 1880. I mixed it into a soft mass with warm water and spread it on strips of muslin about 2.5 inches wide, with which I thoroughly covered the abdominal walls. These dress- ings were removed every five or eight days, when by molding a thin strip of sheet lead over the abdomen from the symphysis pubis to the ensiform cartilage the contour of the abdomen could be watched. At the same time the size of the abdomen could be determined by measuring the waist and abdomen at the umbilicus and crest of the ilium. Cases of Lacerated Cervix. 17 In May, when this treatment had been continued about four months, the patient measured twenty-two inches at the waist and twenty-six at the umbilicus ; the probe could be passed into the uterus only the normal 2.5 inches; the flexion and elongated cervix had disappeared, and the uterus seemed soft and virgin like. The bladder trouble had all subsided, tbe patient had gained in weight; her buoyancy of spirits return- ing, she had been able for two months to take exercise in the open air without difficulty, and in this happy state returned to her home. But this was far from being the end of this most interesting case, for soon after her return home she be- gan again to complain. We, however, who had seen her in apparently such good health, were inclined to think that her new complaints arose from the discontent and loneliness she naturally felt after a winter in the city, and for some time could not believe that she was really so sick as her family represented her to be. It seems by her account, when she presented herself again for treatment late in the fall of 1881, that at the time of her return home she thought she strained her- self while riding in the cars, as she felt sore around the hips and could not walk without pain there. Also in about six weeks after her return she noticed that she began to enlarge over the right side of the abdo- men, until in eight months she was as large as when she first came under treatment. She had the same old symptoms, headache, backache, melancholy, dyspep- sia, frequent micturition, and pain over left ovary, but menstruation nearly normal. Otherwise than this she seemed physically stronger than she had been in Jan- uary. On December 22d, with Drs. H. O. Marcy, Nelson, and C. E. Warren, we again etherized her, and found the uterus normal, but upon the right side we found an ovarian tumor of large size. The left ovary was also thought to be enlarged. We recommended the removal of the tumor, and the patient seemed very impatient for the operation. 18 Cases of Lacerated Cervix. Accordingly, after a tonic treatment to remove the dyspepsia, I performed the operation of ovariotomy on January 18, 1883, assisted by Drs. H. O. Marcy, Nel- son, Bancroft, Smith, and C. E. Warren. Antiseptic precautions were taken. I made my incision about five inches long in the median line, and found the tumor to be multilocular and pretty free from adhe- sions. The largest cysts were filled with a very dark fluid, of the color and consistency of malt. I tapped them with Fitch’s trocar. The smaller cysts were filled with a pearly white fluid resembling boiled starch. Since they extended high up in the abdomen, even to the ensiform cartilage, there was great danger of puncturing the stomach and intestines by the trocar, as Thomas points out in his treatise. I feel confident that with Wells’ or Fitch’s trocars I should have been in great danger both of puncturing the intestines and of tearing the thin walls of the cysts and allowing the fluid to escape into the abdominal cavity. But I had with me a small trocar, No. 36, of my own device, with a revolving point, and all present were highly pleased with its use. It passed readily into the cysts without jerking or jumping, and when in one cyst could be passed directly into an adjoining one with per- fect safety and great ease. The tumor and its contents weighed 13.5 pounds, a fair sized tumor for a girl whose entire weight was less than one hundred pounds. The pedicle was ligatured with carbolized animal ligatures obtained from the ten- dons of the moose, and kindly furnished me by Dr. Marcy ; but before returning the stump into the cavity I stitched the end with fine carbolized catgut of Lis- ters preparation. Being careful that all blood and fluid were sponged from the abdominal opening, I brought the integument together with seven stitches and applied a thick dressing of thymolized cotton. Her temperature immediately after the operation was 97.4° F., and pulse 60, but by nine o’clock in the evening the temperature was 100.4° F., and pulse 108. Cases of Lacerated Cervix. 19 She complained of great abdominal pain in the right iliac fossa, for which small subcutaneous injections of morphia were repeatedly given. On the third day her menses returned, and the temperature and pulse ac- cordingly rose to 101.6° F. and 112 respectively. But they speedily subsided to the normal point, and so con- tinued until the fourteenth day, when the patient be- came hysterical and almost unmanageable. By her violent motions she thus succeeded in superficially opening the abdominal incision from which on the twelfth day ftmr stitches had been removed. I soon called in consultation Dr. C. P. Bancroft, Superintend- ent of the New Hampshire State Insane Asylum, and tried in succession the bromides, hyoscyamus, and mor- phine with only partial success. I then called Dr. Jelly, late Superintendent of the McLean Insane Asy- lum, and returned to the trial of hyoscyamus. The patient gradually became more quiet in her manner, and seemed to justify our opinion that she would ultimately regain her mental condition. Men- struation returned at the proper time without any in- crease of temperature or disturbance of the system, so that in about six weeks after the operation it was thought best to take her to the Insane Asylum in Augusta, Me., near her home. She endured the jour- ney well, but the asylum was full, and she was there- fore attended at her home by Dr. Harlow, the Superin- tendent. She gradually recognized her surroundings, and for a brief space became mentally clear. All abdominal symptoms had disappeared, but in May, four months after her operation, she suddenly and unex- pectedly died from pneumonia.