ticed: The general health to be improved by rest, ferruginous tonics, and a liberal diet; the uterus to be held in position by mechanical support; the hot-water vaginal douche, temperature 105° Fahr., to be applied for twenty minutes twice daily, the patient being in the recumbent posture, and the hips elevated; to open from day to day, by piercing with a fine-pointed lance, the cysts of the cervix, which were present in large numbers; the everted and eroded membrane to be treated by daily applications of a pledget of cotton saturated with tannin and glycerine.

After four weeks of treatment the cysts had been emptied, the erosion had healed, the diameter of the cervix had been reduced one-fourth, and the depth of the canal from five to four inches.

November 1st.-The operation of trachelorrhaphy' was performed by Dr. Emmet.

In Fig. 1, suppose the plane on one side of the line x x' to represent the inner surface of the anterior lip of the lacerated cervix, and that on the other side, the inner surface of the posterior lip: suppose these planes to intersect at an obtuse angle, and a ' to be their line of intersection, then will the figure represent the lacerated cervix, as viewed through Sims's speculum, and the circle in the middle of the line a ' will be a section-view of the uterine canal at the angle of laceration. In Fig. 2 is shown a lateral view of the laceration, and the bell-shaped cervix, larger even than the fundus.

x

With the curved scissors and a tenaculum, the surfaces A', x', A, and 6"", x, 6", Fig. 1, were carefully denuded; while the surface A', A, 6", 6"", was left intact for the membrane of the cervical canal about to be restored. Observe that the lines A, A', and 6", 6", diverge toward their extremities, so that, when restored, the lower part of the cervical canal will be considerably larger than normal, and the os externum nearly double its natural size. This result is only temporary; for subinvolution and hypertrophy, dependent upon laceration of the cervix, always pertain more especially to the outer

1

1 This word, from тpáxn2oç, a neck, and papń, a suture, is here proposed as the name of the operation for repair of the lacerated cervix uteri—an operation hitherto nameless.

edges of the lacerated lips, and atrophy and involution following repair of the laceration must also pertain equally to the same parts, and the restored cervical canal must soon become

The lines on the right side indicate the position of the sutures, as always passed by Dr. Emmet; those on the left, as ordinarily passed.

symmetrical throughout. It is therefore evident that, if the lines A', A, and 6"", 6", had been made parallel, involution would have resulted in stenosis of the os externum.

A hard, dense, wedge-shaped piece of cicatricial tissue, which, in the attempt of Nature to repair the laceration, had formed in the angle and extended from point to point a' (Fig. 1), was removed. Great care always should be taken thoroughly to remove all such tissue, because, if not removed, it generally renders difficult the approximation of the lips, and exerts an amount of tension on the sutures which may cause them to cut out, thereby preventing union; or if, unfortunately, there be union over such a mass of cicatricial tissue, it would certainly act as a foreign body, and, by obstructing the circulation, would cause pressure upon the fine network of sympathetic nerves with which the submucous tissues of the cervix

are so richly endowed, and thus constitute a focus of irritation capable of producing a large amount both of direct and reflex neuralgia, the hidden cause of which might remain undiscovered.

The denuded surfaces were now brought into apposition and held by six silver-wire sutures on each side. All the sutures represented on the right side (Fig. 1) were then tightened and twisted; also those on the left, which had been passed, not as represented on that side of the figure, but exactly as those on the right. The denuded surfaces were thus so held in contact that the points 1, 2, 3, 4, 5, 6, A, coincided respectively with the points 1', 2', 3', 4', 5', 6', A', and the points a, b, c, d, e, f, with the points a', b', c', d', e', f'. The corresponding points on the left side, in like manner, also coincided with each other.

The preference for passing the sutures as shown on the right side of Fig. 1 depends upon the following considerations: The surfaces can be more readily and accurately brought in contact with each other; the sutures include a much smaller amount of tissue, and are less liable to strangulate or cut the included tissue.

Observe that the os externum, point 6, Fig. 3, corresponds in position with the angle of laceration, point o, Fig. 2, and that the lips of the lacerated cervix, represented by the doubledotted lines, have taken the position indicated by the line of twisted sutures, 1, 2, 3, 4, 5, 6, and not, as is sometimes supposed, that indicated by the single-dotted lines. In proof of the accuracy of this drawing, and of the inaccuracy of one in which the single-dotted lines are made to represent the repaired cervix, the following measurements are given: Before operation, the distance from the angle of laceration, point o, Fig. 2, to the plane of the vaginal junction, was seven-eighths of an inch. After operation, the distance from the os externum, point 6, Fig. 3, to the same plane, was not more than seven-eighths of an inch, as it evidently would have been if the single-dotted lines truely represented the repaired cervix.

Before operation, the depth of the uterus from the angle of laceration, point o, Fig. 2, to the fundus was four inches. After operation, the depth from the os externum, point 6, Fig.

3, was three and one-half inches. This decrease in the size of the cervix and depth of the uterus is doubtless due partly

A lateral view of the sutures on one side, as they appeared before twisting.

FIG. 3.

3 4

A lateral view of the twisted sutures on one side of the repaired cervix.

to the stimulus of the operation, which tends to produce uterine contractions, partly to hæmorrhage and removal of

tissue in denuding, but more especially is it explained by the fact that the operation causes the everted (not hypertrophied) tissue to be rolled back into the uterus whence it came. With this restoration, the tension and dragging on the uterine vessels, due to the eversion, are relieved, and the congested uterus is at once disgorged of much of its superfluous blood.

December 10th.-The uterus is now in a perfectly healthy condition; is only two and one-half inches deep, and so much reduced in weight that its natural supports are capable of holding it inside of the body. It is expected that an operation on the anterior vaginal wall, and another on the perinæum, will complete the cure.

Correction. The three cuts have the common fault of not locating the first suture low enough down in the angle; i. e., in Fig. 3, for example, the first suture should be between points 1 and o; for experience has shown that, unless a suture be placed there, blood and uterine discharges may find their way between the flaps at that point, and, by preventing union, cause a utero-vaginal fistula.

IV.-Remarkable Cases of Fracture. By W. T. BULL, M.D., Surgeon to the House of Relief of the New York Hospital.

I. Multiple Fracture of the Pelvis.-V. S., aged seventy, a native of Germany, fell through a hatchway, a distance of about fifteen feet, December 22, 1876, striking on the right side of the body. When seen at the hospital a few minutes later, he was found to have received severe injuries to the pelvis and right shoulder. The humerus was dislocated forward and inward, so as to be situated just within the coracoid process; and on replacing the head of the bone, which was done at once by gentle manipulation, a movable fragment of the coracoid process was plainly felt below and to the inside of its normal situation.

The right lower extremity was completely helpless, but lay in a natural position. On careful measurement, a shortening of half an inch was made out. On rotation, abundant crepitus was felt in the region of the trochanter; the crest of the ileum