ON THE TREATMENT OP CONICAL CERVIX UTERI.
Surgeon
By
J. Ewabt,
M.D.,
to the
Presidency
General
I.?Mes. G??, aged 28 years,
Hospital,
on
the 6th
May 1872,
was
Hospital.
admitted into the General
for barrenness.
She has been
upwards of twelve years. She believes (doubtless erroneously) that up to the 7th year of her marriage she had had three miscarriages. During the last five years she hag
married
certainly never conceived. She complains of much pain in the loins, and suffers from bearing down pains. Sexual congress lias always been accompanied by much pain. On examination I discovered a highly sensitive conical cervix, fully an inch in length. The canal of the cervix admitted the uterine sound without any difficulty. The upper part of the vagina was much dilated. She was somewhat anajtnic and hysterical. Tonics, good nourishing food, and wine, were given. Peeling convinced that, in all probability, the hypersensitive
>
and conical cervix
was
at
the foundation of her barrenness and
distress, I determined, in company with Dr. Barnett, Surgeon to the Viceroy, to excise about three quarters of an inch of it on the 20th of May, or the second day after the menstrual epoch. The operation was performed whilst the patient was under the influence of chloroform. There was very little bleeding. A tent of cotton well soaked in a saturated solution of glycerine of tannin was placed over the wound, and retained there by plugs of cotton. An opium suppository was placed in the rectum. The nourishing food and wine were continued. On the 24th, the plugs wero removed under a cloud of carbolic spray. As there seemed to be some tendency to bleeding, the dressings were repeated a3 before. These were again removed on the 26th, after which the vagina was woll washed out with weak carbolic acid lotion morning and evening. The water was drawn off regularly, as it appeared that she had not the power, after the operation, to empty the bladder completely. She menstruated on the 18tlx of June. During the initiation of this physiological process, she became very hysterical, but the excitement was perfectly amenable to moderate doses of hydrate of chloral. The menstrual flow ceased on the 28th. The wound was now carefully examined, and found to be almost covered throughout by cicatricial strucAt the margins of the os uteri there was a small circle ture. of granulations, which bled on being slightly touched. The uterine sound passed into the uterus with the greatest facility. I examined her again on the 8th of July, and then found that the wound had quito healed up. After this, when about to discharge the patient, she was attacked with a low form of fever, and this, with its consequences, caused her detention in hospital till the 6th of August, when she was discharged. At that time the hypersensitiveness of the parts around the os had quite disappeared. Menstruation had again occurred without pain. The sound passed along the canal with ease.
II.?Mrs. L
aged 42, an Eurasian, was admitted into Hospital, on the 29th January 1873, with a greaty liypertrophied and elongated condition of the cervix. The posterior lip, with a lateral portion of each end of the anterior lip, was uniformly enlarged and elongated. The exaggerated portion of the cervix was so largo that it protruded ,
the Generul
the vulva. It had caused much discomfort. On admission she was suffering from fever and monorrhagia. For these conditions appropriate remedies wero prescribed, and the geuorul health improved. It was necessary, moreover, to wait
through
August 1,
1873.]
TREATMENT OF CONICAL CERVIX UTERI.?BY J. EWART.
until ii menstrual epocli had been completed before undertaking the removal of the hypertrophied cervix. It was, therefore, removed under chloroform on the 3rd of March 1873. There any haemorrhage. A piece of cotton soaked in a saturated solution of glycerine of tannin was carefully and uniformly applied to the raw surface, and maintained in position
scarcely
was
by plugs
terminated
portion charged around
required
An opium suppository was placed in On the 29th of March menstruation began. It on the 6th of April. Then there was otdy a small
of cotton wool.
the rectum.
of the wound uncovered by cicatrix. Siie was disa small patch of raw surface on the 9th of April, with the margin of the os, as her services were urgently elsewhere, with instructions to show herself once a
only returned once, when it was found that the completely healed. The os was well defined, nnd admitted a No. 8 catheter, which passed up into the cavity of the uterus without the slightest resistance being opposed
tarily. were
administered. 7th.?She passed
III.?Mrs. W cal cervix.
on
1st
aged 24, was admitted into the General May, suffering from a hypersensitive and coni,
She has been married three
times.
She
has not
She has always had considerable pain had any children. during sexual intercourse. There has been much leucorrhcea.
Bysmenorrhoea has been frequently complained of. On the 24th, or on the second day after the cessation of the menses, the enlarged cervix, to the extent of three quarters of an inch, a blunt was carefully excised with pointed bistoury, without much haemorrhage. A layer of cotton wool soaked in glycerine of tannin was applied to the exposed surface, and this was fixed in position by means of cotton plugging. An opium suppository was inserted into the vagina, and a grain of opium ordered every four hours, if necessary, to relieve pain and produce sleep. 2C,th ?The cotton plugs were removed to-day. The wound looked healthy. No haemorrhage. No constitutional disturbance. A piece of cotton saturated with the glycerine of tannin was again uniformly applied to the raw surface, and fixed there by plugging the vagina. 27th.?Going on well. June 3rd.?Slightly feverish. Complains of pain in the lower part of the abdomen, and a certain amount of tenderness all over the stomach. Suffering from retention of urine ; water to be regularly drawn off every four or six hours. The pain remained after the urine had been drawn off. Ordered blue pill .3 grains and 1 grain of opium every four hours. G p.m?The pain over the hypogastrium somewhat lessened. The excitement of the pulse and febrile re-action augmented. There is no appetite, and much uneasiness and restlessness. Large linseed meal poultice to be applied every three hours to the abdomen. A watery discharge, tinged with blood, continues to flow from the wound.
4lh.?During last night there was some secondary haemorrhage, which was easily commanded by the tannin solution and plugging. It is still needful to draw off the water. The pain There is a distinct over the hypogastrium is still acute. swelling corresponding to the position of the uterus. Both by vaginal examination and careful palpation, separately and combined, it is now certain that the patient is suffering from acute metritis. to
in
The abdomen is
tympanitic.
Eructations and
nausea
complained of. Tills to be continued. Tepid enema be given to clear out the large intestine. Eggs beaten up port wine to be given frequently. Beef-tea and Liebig's
are
much
extract ad libitum.
olh.?The uterus can now be determined to reach half way up to the umbilicus. It is very tender to the touch. The pain on pressure is now limited to this region. She lias regained control over the bladder and passes her urine volun-
water
again voluntarily; bowels
well
of the uterus is diminished. Discharge bloody; vagina to be washed out morning and evening with tepid carbolic acid water. In the morning the temperature
opened: swelling
the
Hospital
abdo-
tympanitic ; bowels confined. Tepid enema. 6 p.m.?Temperature 102?. To have a grain of opium every four hours to relieve pain, and diaphoretic mixture to mitigate the fever. Good liquid nourishing food and port wine to be freely
was
its entrance.
again
a m.
plugs
men
She
to
the wound pinkish. All the Omit the pills. been drawn off again. Fever
6th.?The urine had increased. The temperature in the rectum 103?: at 8
?wound had
-week.
Discharge from yesterday.
removed
209
102?; in the evening 103?. The pain is much less. Omit opium. Continue the fever mixture, and good nourishing
food.
8th.?Temperature evening. Ten grains
103? in the of
quinine
morning, and 104? in the given during the acme
were
of the fever. 9th?Better. Temperature 100 5?. Ordered five grains of disulphate of quinine three times a day. In the evening the temperature was 102?. Fifteen grains of hydrate of chloral to be given at bed-time. 10th.?Decided improvement. Temperature 100? in the morning. In the evening it became reduced to 99 5?. The volume of the uterus is clearly diminishing. The discharge is profuse, and much resembles the menstrual flow. The pain It has been necessary, over the organ is greatly decreased.
however,
to
draw off the water from time to time. improvement has been steady and
From this date
progressive.
On the 19tli the wound was examined by means of the speculum. It was found to be almost completely cicatrized. A small portion around the os was covered with granulations. On digital examination, it fell exactly like the natural os ; the tip of the finger sinking slightly into the same. The sound without difficulty into the canal, which, with the cavity
passed up
of the uterus, did not measure more than two inches and a half. The painful condition previously experienced, when the speculum or finger impinged upon the apex of the conical cervix, has entirely disappeared. Her aspect of countenance has also much improved for the better; instead of depression and des-
pondency, there
is
now
evidence of brightness and cheerfulness. quite well, and authorized to rejoin
2Uh.?Patient is now
her husband.
The wound has
quite cicatrized. abnormality which, in these cases, severe operation for its remedy, was
Kemakks.?I believe the demanded
a
radical and
and that the married state was calculated rather to aggravate than to mitigate it. That it is a very frequent cause of barrenness there can be no doubt whatever. With the consent of the patient, this is, I take it, a sufficient justification for undertaking the excision of the elongated and conical cervix. Nothing short of this extreme measure will accomplish the object in view, viz., the placing of the of
congenital origin,
effectually patient under
the most favorable circumstances for conception. The amount of the cervix to be removed will vary in different In all, sufficient must be excised, so that only about a cases. of an inch is left. The level of the incision must be
quarter
uniform.
The
simple enough.
procedure Care
rectum have been viscera, the kidneys,
to be observed for the excision is been taken that the bladder and
having
duly evacuated, and that the chylopoietic lungs, and heart, are in a healthy condition, the cervix is hooked down by the vulsellum forceps and firmly held by an assistant (the patient being under the influence of chloroform). The redundant portion of the cervix is cut off by one or more sweeps of a probe-pointed bistoury. Pressure is at the same time made over that part of the liypogastrium covering the uterus. The bleeding is effectually controlled by the direct application of the glycerine of tannin, and substantial
THE INDIAN MEDICAL GAZETTE.
210
vagina. These dressings are left in from 48 to Complications and sequelae are to be treated as they arise. Another cardinal point to be observed is to undertake the operation a day or two after the completion of the menstrual epoch. Full doses of opium, both by the rectum and the mouth, must be used to relieve pain and produce sleep ; whilst wine and good nourishment must be given to aid in effecting the repair of the wound that has been inflicted, and to protect the system against the supervention of the chief dangers, viz., pyaemia, metritis, or pelvic cellulitis, or, it may be, peritonitis. By the observance of these precautions, many married women, who are inevitably barren, from the existence of a conical and elongated cervix, may be restored to a condition admitting of conception, and the bearing of children to the full term of utero-gestation.
plugging
72 hours.
\
of the
[August 1,
1873.
Surgeon
By
J. Ewabt,
M.D.,
to the
Presidency
General
I.?Mes. G??, aged 28 years,
Hospital,
on
the 6th
May 1872,
was
Hospital.
admitted into the General
for barrenness.
She has been
upwards of twelve years. She believes (doubtless erroneously) that up to the 7th year of her marriage she had had three miscarriages. During the last five years she hag
married
certainly never conceived. She complains of much pain in the loins, and suffers from bearing down pains. Sexual congress lias always been accompanied by much pain. On examination I discovered a highly sensitive conical cervix, fully an inch in length. The canal of the cervix admitted the uterine sound without any difficulty. The upper part of the vagina was much dilated. She was somewhat anajtnic and hysterical. Tonics, good nourishing food, and wine, were given. Peeling convinced that, in all probability, the hypersensitive
>
and conical cervix
was
at
the foundation of her barrenness and
distress, I determined, in company with Dr. Barnett, Surgeon to the Viceroy, to excise about three quarters of an inch of it on the 20th of May, or the second day after the menstrual epoch. The operation was performed whilst the patient was under the influence of chloroform. There was very little bleeding. A tent of cotton well soaked in a saturated solution of glycerine of tannin was placed over the wound, and retained there by plugs of cotton. An opium suppository was placed in the rectum. The nourishing food and wine were continued. On the 24th, the plugs wero removed under a cloud of carbolic spray. As there seemed to be some tendency to bleeding, the dressings were repeated a3 before. These were again removed on the 26th, after which the vagina was woll washed out with weak carbolic acid lotion morning and evening. The water was drawn off regularly, as it appeared that she had not the power, after the operation, to empty the bladder completely. She menstruated on the 18tlx of June. During the initiation of this physiological process, she became very hysterical, but the excitement was perfectly amenable to moderate doses of hydrate of chloral. The menstrual flow ceased on the 28th. The wound was now carefully examined, and found to be almost covered throughout by cicatricial strucAt the margins of the os uteri there was a small circle ture. of granulations, which bled on being slightly touched. The uterine sound passed into the uterus with the greatest facility. I examined her again on the 8th of July, and then found that the wound had quito healed up. After this, when about to discharge the patient, she was attacked with a low form of fever, and this, with its consequences, caused her detention in hospital till the 6th of August, when she was discharged. At that time the hypersensitiveness of the parts around the os had quite disappeared. Menstruation had again occurred without pain. The sound passed along the canal with ease.
II.?Mrs. L
aged 42, an Eurasian, was admitted into Hospital, on the 29th January 1873, with a greaty liypertrophied and elongated condition of the cervix. The posterior lip, with a lateral portion of each end of the anterior lip, was uniformly enlarged and elongated. The exaggerated portion of the cervix was so largo that it protruded ,
the Generul
the vulva. It had caused much discomfort. On admission she was suffering from fever and monorrhagia. For these conditions appropriate remedies wero prescribed, and the geuorul health improved. It was necessary, moreover, to wait
through
August 1,
1873.]
TREATMENT OF CONICAL CERVIX UTERI.?BY J. EWART.
until ii menstrual epocli had been completed before undertaking the removal of the hypertrophied cervix. It was, therefore, removed under chloroform on the 3rd of March 1873. There any haemorrhage. A piece of cotton soaked in a saturated solution of glycerine of tannin was carefully and uniformly applied to the raw surface, and maintained in position
scarcely
was
by plugs
terminated
portion charged around
required
An opium suppository was placed in On the 29th of March menstruation began. It on the 6th of April. Then there was otdy a small
of cotton wool.
the rectum.
of the wound uncovered by cicatrix. Siie was disa small patch of raw surface on the 9th of April, with the margin of the os, as her services were urgently elsewhere, with instructions to show herself once a
only returned once, when it was found that the completely healed. The os was well defined, nnd admitted a No. 8 catheter, which passed up into the cavity of the uterus without the slightest resistance being opposed
tarily. were
administered. 7th.?She passed
III.?Mrs. W cal cervix.
on
1st
aged 24, was admitted into the General May, suffering from a hypersensitive and coni,
She has been married three
times.
She
has not
She has always had considerable pain had any children. during sexual intercourse. There has been much leucorrhcea.
Bysmenorrhoea has been frequently complained of. On the 24th, or on the second day after the cessation of the menses, the enlarged cervix, to the extent of three quarters of an inch, a blunt was carefully excised with pointed bistoury, without much haemorrhage. A layer of cotton wool soaked in glycerine of tannin was applied to the exposed surface, and this was fixed in position by means of cotton plugging. An opium suppository was inserted into the vagina, and a grain of opium ordered every four hours, if necessary, to relieve pain and produce sleep. 2C,th ?The cotton plugs were removed to-day. The wound looked healthy. No haemorrhage. No constitutional disturbance. A piece of cotton saturated with the glycerine of tannin was again uniformly applied to the raw surface, and fixed there by plugging the vagina. 27th.?Going on well. June 3rd.?Slightly feverish. Complains of pain in the lower part of the abdomen, and a certain amount of tenderness all over the stomach. Suffering from retention of urine ; water to be regularly drawn off every four or six hours. The pain remained after the urine had been drawn off. Ordered blue pill .3 grains and 1 grain of opium every four hours. G p.m?The pain over the hypogastrium somewhat lessened. The excitement of the pulse and febrile re-action augmented. There is no appetite, and much uneasiness and restlessness. Large linseed meal poultice to be applied every three hours to the abdomen. A watery discharge, tinged with blood, continues to flow from the wound.
4lh.?During last night there was some secondary haemorrhage, which was easily commanded by the tannin solution and plugging. It is still needful to draw off the water. The pain There is a distinct over the hypogastrium is still acute. swelling corresponding to the position of the uterus. Both by vaginal examination and careful palpation, separately and combined, it is now certain that the patient is suffering from acute metritis. to
in
The abdomen is
tympanitic.
Eructations and
nausea
complained of. Tills to be continued. Tepid enema be given to clear out the large intestine. Eggs beaten up port wine to be given frequently. Beef-tea and Liebig's
are
much
extract ad libitum.
olh.?The uterus can now be determined to reach half way up to the umbilicus. It is very tender to the touch. The pain on pressure is now limited to this region. She lias regained control over the bladder and passes her urine volun-
water
again voluntarily; bowels
well
of the uterus is diminished. Discharge bloody; vagina to be washed out morning and evening with tepid carbolic acid water. In the morning the temperature
opened: swelling
the
Hospital
abdo-
tympanitic ; bowels confined. Tepid enema. 6 p.m.?Temperature 102?. To have a grain of opium every four hours to relieve pain, and diaphoretic mixture to mitigate the fever. Good liquid nourishing food and port wine to be freely
was
its entrance.
again
a m.
plugs
men
She
to
the wound pinkish. All the Omit the pills. been drawn off again. Fever
6th.?The urine had increased. The temperature in the rectum 103?: at 8
?wound had
-week.
Discharge from yesterday.
removed
209
102?; in the evening 103?. The pain is much less. Omit opium. Continue the fever mixture, and good nourishing
food.
8th.?Temperature evening. Ten grains
103? in the of
quinine
morning, and 104? in the given during the acme
were
of the fever. 9th?Better. Temperature 100 5?. Ordered five grains of disulphate of quinine three times a day. In the evening the temperature was 102?. Fifteen grains of hydrate of chloral to be given at bed-time. 10th.?Decided improvement. Temperature 100? in the morning. In the evening it became reduced to 99 5?. The volume of the uterus is clearly diminishing. The discharge is profuse, and much resembles the menstrual flow. The pain It has been necessary, over the organ is greatly decreased.
however,
to
draw off the water from time to time. improvement has been steady and
From this date
progressive.
On the 19tli the wound was examined by means of the speculum. It was found to be almost completely cicatrized. A small portion around the os was covered with granulations. On digital examination, it fell exactly like the natural os ; the tip of the finger sinking slightly into the same. The sound without difficulty into the canal, which, with the cavity
passed up
of the uterus, did not measure more than two inches and a half. The painful condition previously experienced, when the speculum or finger impinged upon the apex of the conical cervix, has entirely disappeared. Her aspect of countenance has also much improved for the better; instead of depression and des-
pondency, there
is
now
evidence of brightness and cheerfulness. quite well, and authorized to rejoin
2Uh.?Patient is now
her husband.
The wound has
quite cicatrized. abnormality which, in these cases, severe operation for its remedy, was
Kemakks.?I believe the demanded
a
radical and
and that the married state was calculated rather to aggravate than to mitigate it. That it is a very frequent cause of barrenness there can be no doubt whatever. With the consent of the patient, this is, I take it, a sufficient justification for undertaking the excision of the elongated and conical cervix. Nothing short of this extreme measure will accomplish the object in view, viz., the placing of the of
congenital origin,
effectually patient under
the most favorable circumstances for conception. The amount of the cervix to be removed will vary in different In all, sufficient must be excised, so that only about a cases. of an inch is left. The level of the incision must be
quarter
uniform.
The
simple enough.
procedure Care
rectum have been viscera, the kidneys,
to be observed for the excision is been taken that the bladder and
having
duly evacuated, and that the chylopoietic lungs, and heart, are in a healthy condition, the cervix is hooked down by the vulsellum forceps and firmly held by an assistant (the patient being under the influence of chloroform). The redundant portion of the cervix is cut off by one or more sweeps of a probe-pointed bistoury. Pressure is at the same time made over that part of the liypogastrium covering the uterus. The bleeding is effectually controlled by the direct application of the glycerine of tannin, and substantial
THE INDIAN MEDICAL GAZETTE.
210
vagina. These dressings are left in from 48 to Complications and sequelae are to be treated as they arise. Another cardinal point to be observed is to undertake the operation a day or two after the completion of the menstrual epoch. Full doses of opium, both by the rectum and the mouth, must be used to relieve pain and produce sleep ; whilst wine and good nourishment must be given to aid in effecting the repair of the wound that has been inflicted, and to protect the system against the supervention of the chief dangers, viz., pyaemia, metritis, or pelvic cellulitis, or, it may be, peritonitis. By the observance of these precautions, many married women, who are inevitably barren, from the existence of a conical and elongated cervix, may be restored to a condition admitting of conception, and the bearing of children to the full term of utero-gestation.
plugging
72 hours.
\
of the
[August 1,
1873.
![[Papillomatous changes in the cervix uteri].](/assets/img/hold.png)
