these cases. The cervix is drawn down with two volsellas, the lips are drawn apart, and the laceration denuded. The denudation must be -1 cm. (0.2-0.4 inch) broad, and partly encroach on the cervical mucous membrane. Below, at the seat of the new formed external os, the denudation must be narrower. The removal of tissue is often troublesome at the angles of the lacerations. The upper half of the denudation is united to the lower half by four sutures. The first suture lies at the angle of the laceration, and passes under the whole wound surface. This is not tied, but in case the laceration is left-sided, it is pulled upon by the assistant on the left towards his side. The next three sutures are passed above through the portial mucous membrane, and carried under the wound and out through the margin of the cervical mucous membrane, then they are passed in a reverse direction in the lower half of the denudation. The sutures are not tied until all have been passed (Fig. 68). In double-sided laceration both sides are denuded. The denudation surfaces are not in this case cut under such acute angles, but the lower surface forms a simple continuation of the upper. The denudation is therefore easier, but the suturing is somewhat more difficult in double lacerations. The suturing can be made easier by drawing the volsella, fixed in the cervix, to the right in left-sided tears, and vice versa. FIG. 68.-Emmet's operation (after Hofmeier). For accuracy, it is better to freshen both sides, and put in the sutures of both sides before any of these are tied. Severe bleeding may hinder this. Then the sutures at the angles of the tears should be tied at once. Latterly the author has frequently used the method of suturing given in Fig. 69. This has the advantage of preventing infection of the suture holes from the cervical canal by avoiding the cervical mucous membrane altogether. The after-treatment is the same as in removal of cervical mucous membrane. If severe follicular cervical endometritis coexist with cervical lacerations, and excision of the cervical mucous membrane is indicated, this may be combined with Emmet's operation. The angle of the laceration is incised slightly with the scissors, and the circumferential and transverse cuts are run into the FIG. 69. laceration angle. A cervical laceration may be closed without denudation by cutting into the laceration at the line of junction of the cervical and portial mucous membrane to the depth of cm. (for the length and the course of incision, see Fig. 69, line cd). By the separation or drawing apart of the edges of the wound a surface is formed whose upper half is united to the lower, as in Emmet's operation, and by his method of suturing. Yet simpler is the method of suturing with a single suture running the whole length of the wound, which I have used with success. The suture is carried under the whole length of the upper half of the wound, then emerges at the angle of the laceration, and is at once sunk again and carried under the lower half of the wound (Fig. 69). The passing of the suture is made easier by drawing the points c and d as high and as low, respectively, as possible with volsella. This "flap splitting" has an additional advantage over Emmet's operation, in that the fibrous bands running from the angle of the tear into the parametrium are easily and safely divided. The cervical flaps H FIG. 70. must not be made too thin. The incision must also run in the middle between the portial and cervical mucous membrane (Fig. 70, i, h, e, f). Ulcerations of the Cervix. Superficial ulcerations, which are true erosions of the cervix, arise in senile kolpitis quite independently of the cervical mucous membrane. They form a secondary condition. Similar erosions are described in syphilis as lentilshaped destructions of epithelium, which are at times arranged together in rings and have a copper-red tint. Soft chancre of the cervix causes a loss of tissue, its cavity is deep with undermined corroded edges, which are surrounded by a zone of reactionary inflammation. Its base is eaten out. Hard chancre of syphilis, on the other hand, is indurated with a livid margin, it has a diphtheritic surface, and, as opposed to soft chancre, is isolated and single. The adjacent lymph glands are indolently enlarged, and can be felt per rectum. Syphilitic ulcers (ulcerating syphilides) of the cervix have mostly a smooth spotted surface and a light opal colour. When we remember the existence of tubercular and cancerous ulceration of the cervix, it is evident that difficulties in differential diagnosis often arise which can only be settled by considering the patient's general condition and by microscopical examination. The treatment in tubercular and syphilitic ulcerations is directed against the disease itself. DISPLACEMENTS OF THE UTERUS. The Normal Position of the Uterus. THE position of the uterus is a changing one, which is due, on the one hand, to the mobility of the uterus, and, on the other hand, to the varying condition of distension of the bladder and rectum. 1. When the bladder and rectum are empty the uterus FIG. 71.-Schema of the displacements of the e-elevatio uteri, d=descencus et retroversio, lies normally in a position of anteversio flexio that is, the fundus is directed forwards and upwards towards the superior border of the symphysis pubis, the cervix is pointed backwards and downwards (anteversion), the uterus is slightly bent on its anterior surface (anteflexion), the fundus does not quite reach up to the level of the pelvic brim, and the tip of the cervix lies in the spinal line. This is the line joining the spina ischii p=prolapsus cum retroflexione, r-retro- (compare Figs. 5 and 6). positio, a antepositio. When the woman stands upright the posterior surface of the uterus looks somewhat upwards (B. S. Schultze). 2. With a full bladder the uterus lies normally somewhat retroplaced and retroverted-that is, the uterus is almost erect, the cervix pointing downwards and the fundus upwards. 3. With a very distended rectum the anteflexed uterus is pushed forwards (anteplaced) and dislocated upwards (elevated).1 The opposite condition of retroposition may be caused by peri-metritic adhesion. of the lower segment of the posterior uterine wall with the rectum (Fig. 72), or from shortening of the posterior parts of both broad ligaments. These displacements are of very little intrinsic importance. From what has been said it follows that the conditions found on examination with an empty bladder are of most value. For if one find a retroversion of the uterus with the bladder empty, it is evident that this is a pathological conretroversion of the uterus FIG. 72.-After B. S. Schultze. dition; but if one find a with a full bladder, there is a doubt as to whether the condition is a permanent one or merely temporary, and caused by the over-distension of the bladder. A constant and unalterable position of the uterus does not normally exist. Its attachments permit a certain mobility in all directions, and in addition the body of the uterus is 1 This dislocation is also caused by the growth of tumours in the pouch of Douglas. |