ment. I have been in the habit of removing the sutures about the tenth day, but in the majority of cases they might be taken out on the seventh or eighth day.

FIG. 212.

The Mode of Passing the Sutures.

FIG. 213.

H WW

The Sutures Properly Placed and Twisted.

CHAPTER XXIV.

OCCASIONAL UNTOWARD EFFECTS OF UTERINE MANIPULATIONS AND OPERATIONS.

FOR the purpose of making the student understand the necessity of great caution and gentleness in examinations and operations upon the uterus, I subjoin a summary of the researches of Dr. George J. Engleman, of St. Louis, on the subject.*

Many of the cases mentioned by Dr. Engleman occurred in the hands of the most accomplished practitioners in different parts of the world.

A simple digital examination of the unimpregnated uterus, in the hands of Nelaton, was followed by fatal peritonitis.

Several cases of death from peritonitis were the result of the use of the uterine sound; some because the sound perforated the uterine tissues on account of fatty degeneration rendering them soft and permeable; others without any apparent reason.

There are also cases in which untoward results followed the use of vaginal injections of warm water.

A number of deaths are recorded in which peritonitis was caused by the use of sponge tents. One case is mentioned of severe peritonitis from replacing the uterus by means of the sound. There is always more or less risk in this operation. Dr. J. M. Allen gives a case in which death was caused by the application of tincture of iodine to the cervix.

Cellulitis has followed the application of various substances to the cervical and uterine canal.

The danger of injections into the uterine cavity is shown by allusion to several cases of death in the hands of skilful gynecologists. The most trivial operations on the uterus or other organs in the pelvic cavity are sometimes followed by fatal results. Even scarification of the cervix has been the cause of fatal peritonitis.

I have known of two cases of death follow incision of the cervical canal, and several others are mentioned in Dr. Engleman's paper. Operations for lacerations of the cervix have been followed by death in several instances. The most careful removal of small polypi may be the cause of fatal peritonitis.

Perineorrhaphy has, in a number of instances, been followed by

* Paper read before the Missouri Medical Society, and published in September No., 1880, American Practitioner.

similar consequences. Stem pessaries, when incautiously used, are very dangerous instruments.

It therefore appears that any kind of manipulation of the uterus or its lining membrane is, under certain inscrutable circumstances, liable to start an acute peritonitis. One of these circumstances, and perhaps the most frequent one, is the existence of an inappreciable grade of inflammation in the cellular or peritoneal structures immediately surrounding the uterus.

Dr. Noeggerath* believes that latent gonorrhoea is very often the character of this lurking inflammation.

It would seem that the use of sponge tents, intrauterine stem pessaries, intrauterine injections, intrauterine applications, and cutting operations on the cervix uteri, were especially dangerous.

We should exercise great care in all our manipulations of the pelvic organs, and leave no precautions known to gynecology unemployed to avoid the dangers that occasionally present themselves when we venture upon the use of sponge tents, intrauterine injections, stem pessaries, or operate upon the cervix. Antiseptic precautions are always advisable.

* Gynecological Transactions, 1876.

CHAPTER XXV.

HYPERTROPHY OF THE CERVIX.

HYPERTROPHY of the cervix is different from enlargement caused by fibrinous accumulation, and consists of an increase in the proper tissues of the organ. It is a real hypertrophy. Although not nearly so frequent as the enlargement from chronic inflammation, it is not of very rare occurrence. The symptoms do not differ from prolapse of the uterus sufficiently to characterize it. The patient generally experiences a sense of bearing-down or weight on the perineum, pain in the sacral region, leucorrhoea, sometimes menorrhagia, and the various sympathetic symptoms already sufficiently dwelt upon of uterine irri

tation.

Diagnosis.

Upon examination the cervix is found hypertrophied and enlarged. There are two general forms observed so well marked as to entitle them to special mention. The first is such as we usually find in the nulliparous, an elongation of the whole cervix, and, some but not generally very great circumferential increase of size, and without much deviation from shape. This form is seen in Fig. 214. The next variety is an elongation and enlargement of the anterior or posterior labium, as represented in Fig. 215. I am not certain, from my own observation, whether this is always a pure hypertrophy or a mixture of this process with fibrinous infiltration; probably the latter.

The only appropriate treatment is amputation, and it is generally sufficient to remove all the disagreeable symptoms resulting from it. The plan I have usually pursued in removing this growth is by écrasement. The chain of the écraseur is passed around, at the place where the point marked out by the dotted line is seen in the figures, and the ratchet slowly worked until the division is complete. This operation is easily performed, and is perfectly safe when carefully done, and the parts cicatrize in a few days. An inconvenience mentioned by Dr. J. Marion Sims is encountered, in some instances, in amputating the first variety, viz., the contraction of the opening of the cervical cavity. It is an inconvenience, however, that is of no great importance generally, and may be remedied by making a small incision with a blunt-pointed bistoury immediately after the operation of amputation. Dr. Sims

amputates the cervix with scissors. He exposes the organ with his speculum, cuts the parts squarely through at the dotted lines, and then

FIG. 214.

FIG. 215.

Figures showing two Varieties of Hypertrophic Elongation and Enlargement of the Cervix Uteri. The Dotted Lines show the Proper Place for Amputation.

draws the mucous membrane together over the cut surfaces with silver sutures. (Figs. 217 and 218). This lessens the size of the cut surfaces, and the parts heal more readily.

Elongation of the Supravaginal Cervix.

This condition of the cervix so completely simulates procidentia of the uterus that upon a superficial examination it may be mistaken for that condition. The elongated vaginal cervix with the vagina are protruded from the external parts. The vaginal walls are everted anteriorly and posteriorly, forming in most instances cystocele and rectocele. Sometimes the protrusion is less extensive, and the cervix alone protrudes from the external parts.

The diagnosis is made by introducing the sound. That instrument will enter to a much greater depth than when the uterus is prolapsed, sometimes five or six inches.

2d. By placing the patient in the knee-chest position. In this posture the cervix very readily enters the pelvis and rises up to its normal position. If the sound is now introduced it will not enter the uterus to so great a depth.

3d. By introducing the finger into the rectum while the patient is standing, we can feel that the length and shape of the uterus are greatly changed from the normal. The fundus and body will be