Compliments of tnK^uthor. 
LACERATIONS OF THE NECK OF 
THE UTERUS. 
BY A. REEVES TACKSffl, A.M., M.D., 
Formerly Surgeon-in-Chief of the Woman's Hospital of the State of Illinois, late Lecturer on 
the Surgical Diseases of Women at Rush Medical College, Fellow 
of the American Gynecological Society, etc. 
READ BEFORE THE TIPPECANOE COUNTY MEDICAL SOCIETY AT LAFAYETTE, IND., 
MAY 6, 1880. 
REPRINTED FROM THE AMERICAN PRACTITIONER. 
LOUISVILLE, KY. : 
John P. Morton & Co., Printers, 156 and 158 West Main Street. 
1880. LACERATIONS OF. THE NECK OF 
THE UTERUS. 
BY A. REEVES JACKSON, A.M., M.D., 
Formerly Surgeon-in-Chif of the Woman’s Hospital of the State of Illinois, late Lecturer on 
the Surgical Diseases of Women at Rush Medical College, Fellow 
of the American Gynecological Society, etc. 
READ BEFORE THE TIPPECANOE COUNTY MEDICAL SOCIETY AT LAFAYETTE, IND., 
MAY 6, l88o. 
REPRINTED FROM THE AMERICAN PRACTITIONER. 
LOUISVILLE, KY.: 
John P. Morton & Co., Printers, 156 and 158 West Main Street. 
1880. LACERATIONS OF THE NECK OF THE UTERUS. 
Mr. President: In response to an invitation to address your 
society I have selected a topic which is at the present time 
exciting a good deal of attention among gynecologists and 
obstetricians, ‘but which there is reason to believe has not yet 
received such degree of consideration from general practitioners 
as it deserves. I allude to lacerations of the neck of the uteru-s. 
On July 7, 1879, I read before the Chicago Medical Society 
a paper upon this subject, which was subsequently published.* 
I have embodied here some portions of the matter contained in 
that paper, and have added thereto some thoughts and sugges- 
tions which have been prompted by an increased experience. I 
intend to speak only of the practical phases of the subject, and 
in doing so will endeavor to be as brief as is consistent with 
clearness. The points to which I desire specially to call your 
attention are those which relate to the frequency of the lesion, 
its symptoms, diagnosis, and treatment. 
History. The history of laceration of the cervix uteri is 
a short one, and its literature has been, until quite recently, 
meager. In 1856 Dr. A. K. Gardnerf spoke of “laceration of 
the os and cervix” as among the causes of ulceration, enlarge- 
ment of the cervix, sterility, etc., and, so far as I am aware, this 
was the first mention made of the lesion as a distinct patho- 
logical condition by any author. Thirteen years later (in 1869) 
• Chicago Medical Journal and Examiner, August, 1879. 
f The Causes and Curative Treatment of Sterility, etc., by A. K. Gardner, A. M 
M. D., New York, 1856. 4 
Lacerations of the Neck of the Uterus. 
Dr. Emmet, of New York, published a paper in which he stated 
that seven years before—to wit, in 1862—he had accidentally 
discovered the existence and importance of the lesion in a par- 
ticular case and devised an operation for its cure. This was 
followed in five years by another paper from the same author, in 
which prominence was given to the frequency of the accident 
and the relation it bore to the etiology of pelvic diseases. It 
was not until then that the attention of the medical profession 
began to be directed to the subject; but since that time several 
other papers more or less full and valuable, by various writers, 
have appeared in the medical journals in relation to it, and in 
the recent work of Dr. Emmet on the Principles and Practice of 
Gynecology the subject is fully and systematically treated. 
Frequency. Is laceration of the cervix uteri of frequent occur- 
rence? Many excellent persons of extensive medical experience 
deny that it is. They say it is inconceivable that a lesion which 
from the easy accessibility of the parts involved should be 
readily detected could escape the investigations of so many 
careful persons as have been engaged in treating the diseases 
of women all the years that have elapsed since the introduction 
of the speculum and other modern gynecological appliances. 
We might urge as a reply to such argument as this that the 
history of all art and science is full of examples in which the 
plainest facts and simplest devices have escaped discovery for 
centuries; that it is but a repetition of the old story of Columbus 
and the egg. But we can do better than this. We can advance 
a stronger argument—one based upon facts. The experience 
of Dr. Emmet, embracing observation of five hundred cases 
occurring in private practice, leads him to affirm that 30.80 per 
cent—that is, nearly one third—of “ all women who had been 
impregnated and had suffered from some uterine disease were 
found to have laceration of the cervix;” and he concludes his 
consideration of the subject by stating that “at least one half of 
the ailments among those who have borne children are to be 
attributed to laceration of the cervix.” * 
* Loc. Cit. p. 480. Lacerations of the Neck of the Uterus. 
5 
This is a startling statement, and one which I am inclined to 
believe is an exaggeration of fact. I believe that a much larger 
number of observations than have been made are necessary to 
establish the point in question. Still, the malady is undoubtedly 
very frequent. Dr. P. F. Munde* found one hundred and nine- 
teen lacerations in seven hundred wojuen examined, and Dr. 
Goodellf says that his experience would lead him “to infer that 
about one out of every six women suffering from uterine trouble 
has an ununited laceration of the cervix.” 
As I have already said, there are many who absolutely reject 
this evidence and deny the facts. But it will occur to you at 
once that persons who have not looked for the lesion, who have 
not considered it as one of the conditions likely to give rise to 
the symptoms usually recognized as indicative of uterine dis- 
ease, can hardly be in a position to form an intelligent opinion 
upon this subject. But more than this, as we shall see pres- 
ently, those who would discover it must not only look for it; 
they must look for it in a proper manner, or it may elude their 
search. 
You can form for yourselves some estimate of the frequency 
of the injury by recalling the number of cases in .which you 
have discovered, when making a specular examination of women 
who have borne children, a soft, gaping os uteri surrounded by 
a red patch of irregular granular surface, sometimes readily 
bleeding under slight pressure, and in which, issuing from the 
central opening, you have observed a glairy, yellowish-white 
discharge—cases which, twenty-five years ago, were almost uni- 
versally and by many still are called “ulceration,” and by more 
modern pathologists are denominated erosion, granular erosion, 
granular degeneration, etc. These are generally cases of lacera- 
tion of the cervix uteri. While these erosions unquestionably 
may and do exist independently of laceration, the instances in 
which they do so are quite rare. 
* American Journal of Obstetrics, etc., January, 1879. 
t “Laceration of the Cervix Uteri”—the address in Obstetrics delivered before 
the Medical Society of the State of Pennsylvania by Wm. Goodell, A.M., M.D., 
May, 1879. 6 
Lacerations of the Neck of the Uterus. 
Symptoms and progress. The fact that a laceration has taken 
place is rarely known at the time of the occurrence. When a 
digital examination of the pelvic organs is made immediately 
after delivery it is usually for some purpose connected with the 
removal of the placenta or blood coagula, and the attention is 
not directed to any thing else; but even were a possible injury 
to the cervix the object of search it would be difficult of detec- 
tion, owing to the soft, yielding, -and enlarged condition of the 
parts at the time. A short time after the woman has left her 
bed and resumes her ordinary duties she becomes conscious of 
an unusual amount of leucorrheal discharge, possibly tinged at 
times with blood. This discharge is commonly thick, yellow, 
and viscid in character. But I must caution you that the ab- 
sence of discharge is not to be accepted as proof that there is no 
laceration present, for I have seen several cases of long standing 
and with extensive injury in which there was no discharge what- 
ever, or at least none which appeared externally. The catamenia 
are likely to appear after two or three months, sometimes sooner, 
usually more profusely than before, and at shortened intervals. 
Metrorrhagia is likewise not infrequent. Sometimes, on the 
contrary, the menstrual discharge is diminished in quantity, 
while in still others it is not disturbed in any way. Sexual 
appetite is frequently impaired and sometimes abolished. Dys- 
pareunia is an occasional, and sterility a frequent result. 
Pains, varying in degree and character, are felt about the 
hypogastrium, hips, back, and thighs, together with a sense of 
weight and dragging in the pelvis, increased in severity when 
the patient is in the standing position or has- undergone unusual 
fatigue. In some cases severe neuralgic pains referred to the 
region of the cervix are present, and in several the patients have 
complained of a peculiar pain described as “pulling” or “draw- 
ing” about the umbilicus. 
In the worst class of cases no long time elapses before the 
lack of exercise and the persistence of pain and exhausting- dis- 
charges produce their legitimate results upon the general health. 
Digestion is impaired, the appetite fails, the bowels become con- Lacerations of the Neck of the Uterus. 
stipated, assimilation is interfered with. A lessened supply of 
impoverished blood produces pallor and sallowness of com- 
plexion, debility, disturbed and insufficient sleep. The stomach, 
liver, bowels, kidneys, and especially the bladder and rectum, all 
contribute their quota of sympathetic manifestations, and com- 
bine to render the woman’s life utterly wretched. 
You will observe that the symptoms here given are not at all 
distinctive, and no more indicate the existence of a laceration of 
the cervix than they do of half a score of other abnormal con- 
ditions of the pelvic viscera. Hence they are insufficient for the 
purposes of diagnosis. 
The symptoms produced by laceration of the cervix are not 
always in direct proportion to the extent of the injury—a 
fact frequently observed in connection with pelvic disorders in 
women. Usually the amount of suffering depends upon the 
Fig. 1. 
Figure i.—V and V' represent the position of the 
uterine lips in the normal state of the parts. 
degree of eversion of the lining membrane of the cervix which 
has taken place. This occurs in most cases where the injury 
has extended beyond the crown of the cervix, and reaches its 8 
Lacerations of the Neck of the Uterus. 
maximum where the rent is bilateral and has passed to or 
beyond the vaginal junction. Glance for a moment at this 
diagram (Fig. i), which represents the normal shape of the 
parts. Here the uterine labia, V V', are kept in apposition by 
the perfectly-adjusted counteraction of the circular and longi- 
Fig. 2. 
Figure 2 represents a lacerated cervix with eversion. 
V, the posterior lip, is crowding backward into the pos- 
terior cul-de-sac; V',the anterior lip,forward in the axis 
of the vagina; 1, the upper angle of the laceration. (Af- 
ter Dudley.) 
tudinal fibers of the organ. It is seen in strong contrast with 
Fig. 2, in which is shown the appearance of the parts after a 
severe laceration has occurred. In such a case as this, the cir- 
cular fibers being unable to act, there is no power to oppose the 
action of the longitudinal ones, which tend therefore to drag 
the lips apart. The delicate epithelium covering the mucous 
membrane, accustomed to contact only with its own alkaline 
secretion, is now constantly bathed in the acid secretion of the 
vagina, which, acting as an irritant, soon causes its removal. 
This unnatural state of the parts prevents or retards the proper 
involution of the uterus, which consequently remains enlarged Lacerations of the Neck of the Uterus. 
and soft. So soon as the woman quits her bed and gets upon 
her feet all these unfavorable conditions are increased. The 
heavy uterus, inadequately sustained by its supports, presses to- 
ward and finally upon the floor of the pelvis, dragging with it 
Fig. 3. 
Figure 3.—This represents the state of the parts when 
eversion is complete. The curved lines forming the angles 
1, 2, 3, 4, and 5 indicate the gradual process of eversion. 
The point 1 has been rolled out to point 5, where it appears 
to be the external os. The utero-vaginal junction at X 
and Z now appears by the reduplication of the vagina to 
be at X'and Z', thus making the cervix appear longer and 
broader than it really is. (After Dudley.) 
the upper part of the vagina, whose walls lie in folds about it 
like the sides of a closed accordion, giving to the cervix an ap- 
pearance of elongation. The everted and eroded surface now 
suffers additional irritation from the pressure and chafing to 
which it is subjected. The flaps are forced farther and farther 
apart; th*e extruded lining membrane, by reason of its inter- 
rupted circulation, becomes thickened and congested, and thus 
assists in its own outrolling. The uterus being in a state of 
fatty degeneration — the first stage of involution only having 10 
Lacerations of the Neck of the Uterus. 
been accomplished — the flaps are soft and yielding. Their 
inner surfaces are readily flattened out against the vaginal 
walls, and the entire cervical lining in some instances is finally 
extruded, the internal os uteri becoming the lowest portion of 
the organ, and appearing at the end of what seems, owing to 
the reflection of vaginal tissue drawn downward, to be a very 
long and very broad cervix. 
The full extent of the eversion is rarely seen in recent cases, 
the process of extrusion being a gradual one. The angle formed 
at the upper portion of the flaps (i, Fig. 3) gradually descends 
as the lower ends of these latter diverge, so that it successively 
reaches the points 2, 3, 4, and 5, and in this way the internal 
os uteri comes to occupy the position of the external; and this 
explains why it is that a deeply-lacerated cervix, when viewed 
through an ordinary speculum, presents a red, flat surface. In- 
deed the slighter cases of laceration, which permit no eversion 
at all, are more readily detected in this manner than are the 
more extensive ones in which the eversion is complete. 
The Nabothian glands, thus exposed, are at first stimulated to 
undue activity, as evinced by the greatly-increased quantity of 
secretion poured out by them, and which constitutes the glairy, 
tenacious discharge which is so characteristic of endo-cervical 
inflammation. By-and-by they become diseased. Their excre- 
tory ducts close, and their contents being thus retained they 
enlarge and form protruding roundish masses varying in size 
from that of a millet seed to that of a grain of barley. Some 
of these rupture, and their open mouths add an appearance of 
increased roughness and rawness to the already eroded surface. 
Before bursting they may frequently be felt as small shot-like 
bodies in the tissues. 
When the injury is confined to one side the eversion of the 
cervical lining is not so marked, and occasionally does not occur 
at all, even when the rent has extended to the vaginal junction. 
In these cases there has usually taken place some degree of 
union at the bottom of the fissure, and the cicatrix thus formed 
restrains, partially or wholly, the tendency to protrusion. Lacerations of the Neck of the Uterus. 
11 
Diagnosis. As already stated, the subjective symptoms are 
never sufficient to enable us to do more than suspect the exist- 
ence of a laceration of the cervix. But they are of such a 
character as should alzvays impel us to make a physical exam- 
ination; and if we do this, and do it properly, we need never 
remain in doubt; for the diagnosis may be made in the most 
definite manner. 
In many cases this can be done by the touch alone. The 
patient should lie upon the back, with the knees drawn up and 
separated. A finger introduced into the vagina may detect the 
uterus in its normal situation, although usually it i§ depressed 
and more or less retroverted. The os is patulous, and its bor- 
ders and the entire vaginal portion of the cervix are of softened 
texture and commonly unduly tender to pressure. If there be 
laceration present, and if it be of such extent and nature as to 
permit eversion, as shown in Fig. 2, the cervix will be felt appa- 
rently enlarged, and the distance from the os to the vaginal 
junction much greater than usual, as though the cervix were 
elongated. If the finger be now carried up to the vaginal junc- 
tion and made to sweep around the cervix at that point it will 
be found notably smaller than the portion below. When these 
conditions can be clearly made out they may be considered as 
very strong evidence of the existence of laceration with eversion. 
But there is a test which I regard as infallible. Let the pa- 
tient be placed in the knee-chest position, and then introduce 
a Sims speculum or other form of perineal retractor, and if the 
parts have been seen before through a tubular or bivalve spec- 
ulum with the patient on the back, an astonishing change will be 
found to have taken place in their relation to each other as they 
now are brought into view. The uterus, falling away from the 
vulva by its own gravity, carries with it the upper portion of the 
vagina, thus causing the unfolding, as it were, of the latter organ 
and its restoration to its full length. Not only is the apparent 
elongation of the cervix thus reduced, sometimes to the extent 
of one or two inches, but the size of the eroded surface is like- 
wise diminished from the partial inrolling of the cervical lining 12 
Lacerations of the Neck of the Uterus. 
membrane. If, now, while an assistant holds the speculum, the 
anterior and posterior flaps be seized with tenaculae at the points 
V V' (Fig. 2), and drawn toward the vulva and toward each 
other, the eroded surface will be found to disappear; that is, the 
intra-cervical mucous membrane will be restored to its proper 
place, and the vaginal portion of the cervix will resume its 
natural form and almost its natural size. If this can be done it 
amounts to a demonstration. There is no other condition or 
combination of conditions in which this maneuver can be ac- 
complished with these results. 
But to obtain this certain evidence the necessary means- must 
be used and the conditions complied with. In such a case as 
that described, when the parts are observed through an ordinary 
cylindrical or valvular speculum, it is frequently impossible to 
command a view of the entire cervix, so widely are the lips 
spread apart. The ends of these latter, which the observer 
thinks he is looking at, are not visible at all. The red, 
raw-looking mass appears to the unpracticed eye as though 
hypertrophied and ulcerated. Indeed these constitute the so- 
called severe cases of ulceration for which powerful and pro- 
tracted cauterizations were formerly the approved and usual 
remedies. 
Diagnosis. The maladies with which laceration of the cervix 
may be confounded are thickening and elongation of the cervix, 
simple granular erosion of the os and cervix, true ulceration, and 
epithelioma. 
When there is actual enlargement of the cervix from other 
causes than laceration—for of course the two conditions may 
coexist—the part is gradually increased in diameter from below 
upward toward the body of the organ, but in laceration with 
eversion the lower portion is the largest; and as the body of the 
organ is approached there is a more or less distinctly-marked 
narrowing, so that the shape of the vaginal portion has been 
compared to that of an inverted mushroom. 
From elongation of the uterine neck—the so-called hyper- 
trophic elongation—laceration may be distinguished, as already Lacerations of the Neck of the Uterus. 
13 
stated, by placing the patient in the knee-chest position. Here 
the apparent elongation which is present in some cases of lacera- 
tion entirely disappears, by discovering the true vaginal junction, 
whereas if the elongation were real the part would project as far 
into the vagina as before. 
Granular erosion of the os and cervix sometimes occurs from 
irritating contact of catarrhal discharges, but uncomplicated with 
laceration it is a comparatively rare affection. 
It should not be a matter of surprise that the red, roughened, 
eroded cervical lining seen in cases of laceration should have 
been so frequently and for so long a time mistaken for ulcera- 
tion. But if by the term ulcer we mean to designate a condition 
in which there is loss of substance beyond the epithelium it is 
comparatively rare in this locality. The only true ulcers of the 
cervix are those produced by friction and exposure when the 
uterus is procident, or which are the result of chancroid or 
carcinomatous disease. 
It is likewise not wonderful that the extruded lining mem- 
brane, studded with enlarged follicles, elevated and swollen, 
bleeding readily, and bathed with muco - purulent secretion, 
should have been frequently mistaken for malignant disease. 
But from all these conditions — simple erosion, ulceration, 
whether benign or malignant — presenting a reddened, rough- 
ened, raw surface, laceration with eversion may be certainly 
distinguished in the manner already indicated. 
Let every one bear in mind that laceration is frequent and 
that hypertrophy is rare; that eversion is frequent and ulcera- 
tion rare; and it will lead to the adoption of this practical and 
only safe rule, namely, Whenever the cervix uteri appears en- 
larged and denuded of tissue, make the trial test which I have 
described, and all doubt will be cleared away. 
Treatment. If the foregoing views as to the nature and path- 
ology of laceration be concurred in, the indications for treatment 
become as clear as that for harelip. While it is possible in many 
cases, especially of the milder forms of the injury attended by 
slight eversion, to effect a cure of the erosion by means of as- Lacerations of the Neck of the Uterus. 
tringents and stimulating applications, the improvement is only 
temporary usually, and in most cases does not take place at all. 
Having realized the inefficiency of these “applications” and 
“treatments,” Dr. Emmet devised and practiced an operation to 
take their place—an operation so simple that any one who has 
ordinary dexterity may perform it; so safe that it has never 
caused a fatal result; and so effectual that it accomplishes in a 
fortnight what alteratives and caustics can not effect in years, 
namely, an abiding cure; an operation which, instead of destroy- 
ing the normal structure of the part, restores both its shape and 
almost its natural size. Having had occasion to perform this 
operation quite frequently, I have from time to time modified its 
various details, with the view chiefly of shortening the time of 
its performance, so that it has now come to differ from that 
of Dr. Emmet in almost every particular. 
The instruments I employ are few and simple. They con- 
sist of a perineal retractor, a small double vulsellum forceps, 
a tissue-holder, a needle of peculiar construction, two pairs of 
scissors, and, where silver wire is used, an adjuster and twister. 
The use and application of each of these I will endeavor to 
exemplify. 
The patient having been etherized, is placed upon a table 
properly prepared with bedding, sheet, pillows, etc. The table 
need not be more than four feet long. While the semi-prone or 
knee-chest position is the best for the diagnosis of laceration, I 
very much prefer the dorsal for this and all other operations 
upon the cervix. The patient is drawn forward so that the 
coccyx projects four or five inches beyond the end of the table, 
the head and shoulders being well raised. Each lower limb is 
placed in charge of an assistant, by whom the thighs are ab- 
ducted and moderately flexed on the abdomen. These two 
assistants should face the operator, and each should command 
the thigh of the patient with the arm nearest the latter. In this 
way each of them will have a hand at liberty for' any other pur- 
pose that may arise. Two other assistants are necessary—one 
for the administration of the anesthetic; the other to hand in- 
struments, use sponges, etc. Lacerations of the Neck of the Uterus. 
15 
The operator, seated in front, now passes one or two fingers 
of the left hand into the vagina, and, having ascertained the 
position of the cervix, with the right introduces the retractor. 
The blade of this instrument is much broader, flatter, and shorter 
than that of Sims’s speculum, and is, I think, much more con- 
venient than the latter for all uterine operations done in the 
dorsal position. This is guided to its place in the posterior 
cul-de-sac by the fingers in the vagina, and the perineum being 
pressed backward while the vaginal walls are separated laterally 
the cervix is readily brought into view. The retractor is now 
given in charge of one of the assistants, who takes it with his 
disengaged hand. The anterior flap of the laceration is next 
seized-with the vulsellum forceps and drawn down to the vulva. 
If necessary, this should be aided by supra-pubic pressure. 
Both flaps are now brought together, with the view of de- 
termining accurately the extent of the laceration, the proper 
position of the external os uteri, the amount of tissue to be re- 
moved, the number of stitches necessary for closure, etc. This 
having been done, a needle, such as I here show you, is passed 
through the anterior flap, which is steadied by the grasp of the 
vulsellum. The needle is rectangular in shape, with a very 
strong, short shank affixed to a handle. The needle proper has 
no eye, but on one edge of its flattened blade, near the point, 
has a notch for the purpose of catching and carrying a wire or 
silk suture. This device is a modification of Skene’s perineal 
needle. The requirement here is for a needle which shall be 
sufficiently strong to be pushed through the tissues (which are 
sometimes extremely dense), and which at the same time can 
be quickly threaded. . 
The needle is passed through as stated, unarmed, and so 
soon as its point appears the loop of a strong silk cord is caught 
in the notch of the needle by the assistant. The needle is then 
withdrawn, leaving the silk in the flap. The vulsellum is now 
transferred to the posterior flap and the same process repeated. 
By means of these threads, which should be sufficiently long to 
enable the assistant who has charge of them to draw them in 16 
Lacerations of the Neck of the Uterus. 
any needed direction without incommoding the operator, com- 
plete control of the cervix is had throughout all the subsequent 
steps of the operation. 
I formerly used a single thread 
which passed through both lips, but 
this prevented the easy separation of 
the latter, and I find the mode I now 
adopt much more convenient. 
The next step consists in making 
raw the surfaces which are to be joined 
together. This is better and quicker 
done by scissors, and the cut surface 
bleeds less than when the knife is used. 
The shape and size of the flaps de- 
termine the amount of tissue to be re- 
moved. Sometimes when the lips are 
not much thickened and present a flat 
surface it is only necessary to take off 
a thin layer; but where they are hy- 
pertrophied and have a rounded, bulg- 
ing surface, the entire convexity should 
be cut away. A practical and safe rule 
is to remove enough tissue to permit 
the opposing surfaces to be brought 
easily into contact. Care should be 
taken not to freshen the edges too near 
the center of the flaps, lest their sub- 
sequent union result in obliteration or 
narrowing of the external os. A space 
at least half an inch long should be 
left for this opening, for the subsequent 
shrinkage of the part will reduce this 
to the proper size. The denuded portions of the opposing sur- 
faces should be equal in length and width, so that when brought 
together they may be accurately coaptated. (Fig. 4.) 
The passing of the sutures is sometimes very difficult, owing 
Fig. 4. 
s 
Figure 4.—A A represent the 
guiding threads in the labia, mark- 
ing the center of the restored os 
uteri; B B, strips of undenuded tis- 
sue to form the continuation of the 
cervical canal; C, the apparent os 
uteri externum. The dotted lines 
indicate the direction in which the 
freshening of the surfaces is made. Lacerations of the Neck of the Uterus. 
to the thickness and density of the tissues. When ordinary 
needles are used it is necessary to have a strong needle-holder— 
one which permits the needle to be placed at any angle. The 
needles should have a cutting-edge near the point, and should 
vary in length from three fourths of an inch to an inch and a 
quarter. They should be thick enough to allow of a large eye 
through which the loop of a doubled silk thread may pass. The 
eyes of most needles are too small. I formerly met with many 
cases in which there was difficulty in this step of the operation. 
I then used Emmet’s needle-holder and vesico-vaginal fistula 
needles, but since I have made use of the needle just shown 
you I have found little or no trouble in this way. The first 
suture is passed at or near the inner angle of the fissure. The 
part being steadied by means of the vulsellum, the point of the 
needle is entered about a quarter of an inch from the edge of 
the freshened surface, and is made to emerge just at the edge 
of the undenuded strip which has been left for the continuation 
of the cervical canal. It is then reentered at the correspond- 
ing point opposite, and, passing through the other flap, 
finally issues at a point opposite that of its first entrance. 
A silver wire eighteen inches long, bent at a sharp angle 
an inch from one end, is then hooked into the notch of 
the needle, and on the withdrawal of the latter is left in 
place. Unless the flaps are of unusual thickness the needle 
may be thus passed through both of them before attaching the 
suture; and in that event it is unimportant through which flap it 
is passed first, although I usually prefer the posterior as being 
more convenient. But where they exceed a thickness of half an 
inch each it is better to transfix one at a time, and then it will 
be found easier to pass the needle first into the denuded surface 
of the anterior lip, and after placing the suture to detach the 
latter and reintroduce the needle from the vaginal side of the 
posterior flap, and then finish as just stated. The number of 
sutures required will vary according to the extent of the fissure. 
Usually from two to four are needed on each side. They should 
be placed about one third of an inch apart. 18 
Lacerations of the Neck of the Uterus. 
Either silk or silver wire may be used for the sutures. I 
have nearly always used wire, and know it to be reliable. Oth- 
ers prefer silk, and consider it equally good. 
The sutures having all been inserted, the patient should be 
placed in bed, where ordinarily she ought to remain until the 
stitches are removed. This may be done as early as the eighth 
day; but I prefer, unless the prolonged confinement is especially 
irksome or contra-indicated, to allow her to remain until the 
ninth or tenth. In one case, in which they were removed on the 
eighth day, the adhesion of the flaps was so feeble that they sub- 
sequently separated, and a repetition of the operation became 
necessary. 
The operation is not a very painful one, and an anesthetic is 
not always necessary, although usually desirable. I have oper- 
ated on several occasions without using any, and the only 
complaint made generally had reference rather to the irksome- 
ness of the position than to the other procedures. 
Neither is there much pain or discomfort felt after the opera- 
tion. Indeed patients usually suffer so little from it that it is 
difficult to make them appreciate the necessity for lying in bed 
afterward. And it is possible that this necessity has been over- 
rated. Several times patients have, contrary to my directions, 
resumed many of their ordinary duties after the third day. In 
one case, on the second morning after the operation, I found the 
patient dressed and sitting up, and she informed me that she felt 
less discomfort in the parts than she habitually did before the 
operation. In none of these cases did the seeming imprudence 
produce any bad result or prevent a successful issue. Dr. Skene 
states that he has operated eight times at his office and sent the 
patients home on the street-cars. 
After-treatment. At the close of the operation I am in the 
habit of placing in the vagina the ordinary cotton tampon 
saturated with glycerin, with a string attached to facilitate its 
removal, and in the rectum a suppository of cocoa butter con- 
taining two grains of opium and one sixth of a grain of extract 
of belladonna. The tampon should be removed on the day Lacerations of the Neck of the Uterus. 
19 
following the operation, and the vagina should be carefully 
washed once or twice daily with warm water slightly carbolized. 
It is not necessary to prohibit the patient from leaving the bed 
to urinate or for other necessary purposes. Rarely I have had to 
use the catheter once or twice. The bowels, if not open spon- 
taneously, may be acted upon by a mild laxative, followed by an 
enema on the fourth or fifth day. 
Reasons why the Medical Profession does not accept the 
facts of Laceration of the Cervix Uteri. 
As I stated in the outset, a comparatively small number of 
the members of the medical profession have given any attention 
to the subject of laceration. Many to whom the facts have been 
presented have contented themselves with denying their exist- 
ence without making any effort either to prove or disprove them. 
Some who can not be supposed to be unfamiliar with what has 
been written upon the subject seem to ignore it altogether. As 
an ekample of the latter class, I may mention the name of so 
great and prominent a teacher and author as J. Matthews Dun- 
can, who, in his recent work on the Diseases of Women, refer- 
ring to a case of chronic catarrh of the uterus, thus describes 
the state of the parts as revealed by physical exploration: “Per 
vaginam— cervix uteri is in normal situation, considerably en- 
larged by expansion so that two fingers can easily be introduced; 
quite soft, and partially denuded of epithelium, and secreting a 
yellow muco-pus.” A patient in such physical condition would 
have a uterine catarrh certainly, but what would be its cause ? 
Can any one doubt from the description that this was a case of 
laceration with eversion? 
But this need not surprise any one. All new truths in medi- 
cine, or rather those which seemed new, have been met in a 
similar manner. There are, however, some especial reasons 
why laceration of the cervix and its pathological importance 
have not been recognized, and upon these I desire to comment 
briefly. They are as follows: 
I. The frequent neglect of physical examination.—It is too much 20 
Lacerations of the Neck of the Uterus. 
the custom among physicians to base their treatment upon the 
subjective symptoms alone. In the disorders of women such a 
course can rarely be successful. It is simply guess-work—guess- 
ing at the diagnosis and guessing at the treatment. During the 
child-bearing period of life especially there are comparatively 
few of these disorders that do not originate in, or extend their 
influence, to the reproductive organs, and if these latter be not 
interrogated very important elements of diagnosis are likely to 
be omitted. A faulty or imperfect diagnosis results in erroneous 
if not injurious treatment. The debility, nervousness, anemia, 
and other results of organic pelvic disease are treated by so- 
called tonics, nervines, and blood-restorers, while the underlying 
cause of all the mischief is allowed to continue its destructive 
work. It is as though the pumps of a sinking vessel were 
worked and no effort made to stop the leak. Where there are 
present in any given case such symptoms as deranged menstrua- 
tion, more or less constant leucorrheal discharge, headache, pel- 
vic, vesical, or rectal pains or discomfort, the indications for a 
physical examination of all the pelvic organs should be consid- 
ered imperative and an essential prerequisite to treatment. Yet I 
know that patients suffering from such manifestations of disease 
are frequently treated, sometimes for many months, without any 
adequate means having been taken to ascertain the condition of 
the parts in question. Such negligence as this would result not 
only in the failure to detect a laceration, but any other morbid 
condition of the pelvic organs. 
2. Faulty methods of examination. — Among those who are 
diligent enough to make physical exploration when it seems 
demanded, there is much room for criticism as to the manner in 
which it is done. The most common fault is perhaps a want of 
due care. Many facts which might readily be ascertained are 
not even sought for. This need not be for want of proper in- 
struments. The very best of these—the index finger—is always 
at hand. It is the most valuable of all gynecological investi- 
gators, and when properly educated and used to the full extent 
of its capability there is scarcely any of the pathological con- Lacerations of the Neck of the Uterus. 
21 
ditions of the pelvic organs in women which can escape its 
detective powers. The tubular speculum, which is exclusively 
used by many, is not only incapable of aiding in the discovery 
of laceration of the cervix, but actually prevents such discovery. 
The various valvular specula, while not quite so useless for this 
purpose, are nearly so. Neither of these forms of the instru- 
ment are valuable for diagnostic purposes. None of them 
permit, except in a limited degree, the sort of exploration which 
is necessary. The duck-bill speculum has never become pop- 
ular in private practice, and it is doubtful if it ever will. It can 
only be used with the aid of an assistant—an objectionable fea- 
ture to many women — and some degree of exposure almost 
necessarily attends its employment. Its efficient use is likewise 
frequently productive of pain. For these reasons it is compara- 
tively seldom used. And yet, as we have seen, without it a 
laceration of the cervix is almost certain to escape detection. 
3. Reluctance to abandon old doctrines for new ones.—Physi- 
cians, as a class, are conservative, and this is well. When they 
« 
are asked to give their assent to new facts and new doctrines 
they do rightly to ask for proof of the correctness and genuine 
character of the new things. When, however, they not only do 
not ask for such proof, but deliberately refuse to receive it when 
offered, they cease to be conservative; they are bigoted. Are 
any of us free from this fault? We all know that it is not pleas- 
ant to give up old beliefs, old modes of thought, and adapt 
ourselves to new ones. Humiliating though it be, it is a fact 
that truth is not welcome to us unless it come quietly and take 
its place side by side with that which has come before. If it 
approach as a displacer or usurper we do not bid it enter, but 
guard our portals against it. 
Applying these remarks to our present subject, we can at 
once appreciate the dilemma in which many physicians find 
themselves. If they admit the frequency and importance of 
laceration of the cervix they must abandon the long-cherished 
phantom of ulceration; they must acknowledge a long persist- 
ence in erroneous opinion and practice: if they abolish the 22 
Lacerations of the Neck of the Uterus. 
theory of “womb-ulcers” they must cease “burning them off”— 
a fee-getting, if not a health-giving practice. When a man’s 
knowledge of womb-diseases is limited to “displacement” and 
“ulceration” he can not afford to relinquish much, or he will 
have no uterine pathology left! The establishment of the facts 
of laceration implies the abandonment of the ulceration theory 
and the speculum-and-caustic treatment which was its legitimate 
offspring—a mode of treatment which embodied more profes- 
sional malpractice than it is possible to estimate; that has pro- 
duced in untold hundreds of women deformed, maimed, and 
sterile wombs; and that has resulted, both by what it did and 
what it prevented from being done, in more injury to the health 
and happiness of the women of this land than a generation of 
enlightened physicians can atone for. 
Chicago, III.