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the actual extent of injury done to the cervix, is a fact well known to every observing Gynæcologist; for instance, one patient may have a complete laceration (or in the 3d degree) reaching to the vaginal reflexion, with the torn cervix presenting the appearance of an eroded surface two inches or more in diameter, while this again under the deleterious influence of friction against the posterior vaginal wall, is secreting profusely a constant stream of muco-purulent discharge, denuding and eroding the organic structures it comes in contact with, and to all appearances, making life a source of discomfort, misery and wretchedness; and yet with all of this no evidence of unusual disturbance of the system and calling forth no proportionate complaints from the victim, while another which may have a slight fissure with a moderate degree of abraded epithelium, which ordinarily give no trouble whatever, but under the same baneful in fluence of friction against the posterior vaginal wall, produce torments that cannot be assuaged by anything short of an operation. Why this is so, it is difficult at present to explain; but that surgical interference is justifiable in either case, no sane Gynæcologist can well afford to dispute.
Case I.—Mrs. B., aged 28 years, of American nativity, and of fair physique, when she first visited my office in the spring of 1880, claimed to have been perfectly healthy before the birth of her second child; but that after that puerperium-the first and second stages of labor being unusually prolonged and the child finally delivered with the forceps—to use her own language she became a “total wreck," incapable of performing the most trivial work about the house and never free from pain. Her group of symptoms were characteristic of her condition-pain in the head (reaching from top of head to nape or back of neck) pain in the back and loins, a sense of dragging-aching pain in or about the pelvis, and a feeling of soreness in the thighs, with a too frequent as well as a too profuse menstruation. On examination per vaginam, the following discovery was made:-A retroverted uterus, much enlarged, the probe entering to the depth of 3 1-2 inches, a bilateral laceration of the cervix with complete eversion, and a profuse muco-purulent discharge filling the posterior cul-de-sac. Like many of the unfortunate patients of this class, previous to the advent of Emmet's plastic operation, she had submitted herself to the care and treatment of various physicians, who resorted to as many and different modes of treatment, including the use of various pessaries and every known escharotic, with but little it any benefit. After a preparatory treatment of a few weeks, trachelorraphy was performed on the 7th of November 1881, assisted by Dr. Sluigsby, of Rio, the husband and a neighboring mid-wife. The patient was placed on a table and anæsthetized with a. C. e., or 1, 2, 3 mixture, after which she was placed in the lithotomy position, and the limbs held by the husband and mid-wife, one on each side, while the doctor attended to the anæsthetic. The uterus was brought down with a tenaculum and secured by a thick silk suture passed through the middle of the anterior lip, which, after tieing the ends together, was handed to one of the assistants, while a similar string was passed through the middle of the posterior lip, tied and handed to the other assistant. Everything being in readiness, the operation of paring was commenced and carried on until every vestige of the cicatricial tissue and hyperplastic growth was removed -complete denudation of the diseased part being always essential to success—when the edges were brought together and united with silver wire sutures. Ten days subsequent to the operation, the sutures were removed, when it was found complete union had taken place, and evident reduction in the size of the uterus, (cavity only measuring 2 3-4 inches,) with the os externus so small as to resemble that of a virgin. The patient refused to remain in bed but for a few days after the operation although requested so to do, especially until the removal of the sutures, and was able to do the housework without evident discomfort from the bunch of collected wires in the vagina. After the removal of the sutures and washing of the vagina, the patient remarked as she stepped off the table, that she felt as well as she ever did in her life. In three months subsequent to the operation, the womb cavity was reduced in size to 2 1-4 inches, with complete disappearance of all the pains, aches and discomforts.
CASE II.—Mrs. R., aged 32 years, of German nationality, and mother of one child of some 12 years of age, called on me on Feb. 7, 1782, and gave the following history of her case: -Some twelve years previous she was in her first and only labor, which lasted three days and during which time she suffered on account of some malposition of the child, an untold account of misery, that she was finally delivered with the forceps by an experienced accoucheur, she having been anæsthetized before their application and that since her
puerperium, to use her own phraseology, she had “not since seen a well day," and that she was good for nothing." Her symptoms were so like those of case 1, that it would be difficult to find two cases possessing so close an analogy--the peculiar and characteristic headache, running from the top of the head to the nape of the neck, pain in the back and loins, dragging-aching discomfort in or about the pelvis, and a feeling of soreness in the thighs, accompanied with a frequent and too profuse menstruation that indicated the necessity for an examination of the uterus and appendages. The examination disclosed the following facts: An enlarged and subinvoluted uterus, with a probe length of 3 3-4 inches, a bilateral laceration of the cervix reaching almost to the junction, and complete eversion, mostly cicatrized but not ulcerated,and an excessive mucopurulent discharge, which often ran down the thighs in a stream when in the erect posture. Trachelorraphy was performed on Feb. 21, 1882, at my office, and the patient rode home the same day, in lumber wagon, a distance of five miles; and, although requested to assume the recumbent posture on her arrival home, she attended to her household duties the very next day after the operation, and continued so to do, until the removal of the sutures on the tenth day. Union was complete, and all symptoms ameliorated. Six weeks subsequent to the operation, I again examined her, when the uterus was found to have become normal in size and appearance, with but slight discharge, which clearly resembled that of a mild endocervical catarrh. Her menses appeared prematurely on the third day after the operation, and continued for the usual time. She informed me at this examination, that she felt perfectly well with the exception of a peculiar gastric trouble, which no doubt, was of a reflex nature, and similar to what she used to experience at the age of puberty. Four months subsequent to the operation she suddenly ceased to menstruate, and fearing something was wrong, she consulted me in regard to her condition, when, after a careful examination, I informed her that I believed her to be pregnant. This she could not believe possible at the time, but the course of events verified my suspicions; and, in due time, after twelve years of procreative respite, she was delivered of a fine healthy girl, weighing some seven pounds without any injury whatever to the organ that had remained so long a source of such misery.
The third case, was a left unilateral laceration with eversion
the fourth and fifth, a right unilateral laceration with eversion—and the sixth, a stellate laceration with eversion and cystic hyperplasia -all of which were more or less benefitted by the surgical interference; but since no one of the cases contains anything new or original, to give a summary of even the principal points would be too monotonous. No operation had to be repeated, and I attribute my good success to the care and thoroughness with which the paring was done. If the diseased surface be properly prepared, and the parts be brought together and held in perfect co-aptation, there is no necessity of a failure. Of course, should some unforeseen occurrence, or some influence beyond the control of the surgeon, interfere with a successful termination, a second operation can readily rectify the over-sight or mistake of the first one.
In conclusion, I will add that it is true that the benefit derived from an operation for the recovery of the integrity of the cervix is not always in proportion to the extent of the laceration, any more than are symptoms of its existence an index to the true physical extent of the injury done; for instance, No. 1 and 3, of the cases above mentioned will readily illustrate the point in question to-wit: the former or the bilateral laceration, which was to all appearances a source of constant and intense irritation, while the latter, or the unilateral, was not in any sense of the nature and severity of the other, yet No. 3 complained of the most acute and intense pain, while No. I complained of the same symptoms but much less severe and aggravating; and, although both Nos. I and 3 were not only benefitted but cured by the operation, yet the latter was far more emphatic in her praise and gratitude for the relief she had experienced, as she was, prior to the operation, the more earnest and solicitous in her complaints of her condition and appeals for relief,and this fact I believe was not due to difference in temperament, or idiosyncrasy, or hysteria, or any other characteristic, inherent or acquired, but due solely to the true and unavoidable exigency of the case itself.
FUNGOUS AND POLYPOID ENDOMETRITIS WITH CASES.
BY DR. A. H. LEVINGS, OF APPLETON.
Mrs. G., American, age 32, admitted to Prescott Hospital, Appleton, December 3d 1885. She became my patient on Dec. 8th and gave the following history: Not very strong as a child, menstruation at 14, regular, duration 3 to 4 days, not profuse, nor painful. Some pain and irregularity after first year, which continued until marriage at 24.
Confined fifteen months after. She now thought herself perfectly well and again became pregnant in seven months. She miscarried however at the end of the fifth month, from over-work, caring for her house and her husband, who had been seriously ill. During her miscarriage her physician informed her that the child lay crosswise; he introduced his hand, turned and delivered causing her great pain. She left her bed on the fifth day, though suffering from great pelvic discomfort. This occurred in 1881 and she expressed herself as having never been well since, never free from pelvic soreness and distress. She remained however pretty regular until the spring of 1885 when her menstruation became irregular and excessive. For three months menstruation occurred every two weeks, lasting three days, and for the three subsequent months every week, lasting from two to three days. The flow during that tin.e was very profuse. At the time of her admitance to hospital she was flowing almost constantly. Her condition was one of extreme anæmia and exhaustion. On examination the perineum was found somewhat lacerated, but still giving good support, vagina healthy, uterus low down, much enlarged, and somewhat fixed; cervix not lacerated; on passing sound, which entered 3 1-4 inches, blood gushed out in a stream, and was only checked by tamponing. On Dec. 12th the uterus was dilated with sea tangle tents, and on the following morning was thoroughly curetted.