A Text-book of Diseases of Women

by Charles B. Penrose

Every five or six days the woman should be placed in the knee-chest position and the cervix should be exposed with the Sims speculum. The Nabothian cysts, which appear as translucent vesicles beneath the mucous membrane, should each be punctured with a sharp knife-point. If the cervix is much enlarged and congested, it should be freely punctured over the whole vaginal aspect to produce local depletion. Half an ounce or an ounce of blood may be removed in this way. The cervix should then be thoroughly dried, and an application of Churchill’s tincture of iodine should be made over the whole of the cervix and the vaginal vault. The excess of iodine should be removed with a little cotton, and a cotton tampon (to which is attached a string) saturated with glycerin should be placed against the cervix ([Fig. 105]). The hygroscopic action of the glycerin is most useful in depleting the cervix. The woman should be told to remove the tampon by traction on the string at the end of twelve hours, and to follow the removal with a vaginal douche of hot water.

Such local treatment should be instituted immediately after a menstrual period and should be repeated every five or six days, and continued until the erosion and the cysts have disappeared and the induration has diminished. Three weeks of such treatment usually produce a very marked change. The cervix not only becomes much more healthy in appearance, but most of the symptoms of which the woman complained vanish. The leucorrhea diminishes or ceases; the backache and headache disappear. The relief is often so marked that the patient suggests the advisability of deferring operation. This, however, should never be countenanced, as all the symptoms will return with cessation of treatment.

If, after the careful administration of the treatment here prescribed for five or six weeks, the induration and cystic degeneration do not disappear, then the case is not one that will be benefited by trachelorrhaphy. The mere closure or union of the indurated and cystic lips of the cervix will not cure the woman if these conditions persist.

If the inflammatory changes secondary to the laceration have become so deeply seated that they are not relieved by the preparatory treatment, amputation of the cervix is necessary. In any doubtful case, therefore, this preparatory treatment is to a certain extent indicative of the character of the ultimate operation to be performed.

The description of the operation already given is applicable to the most usual form of laceration—a bilateral laceration. If the injury be unilateral, it may be necessary to split the cervix on the sound side in order to denude, and to introduce sutures, on the injured side. The case may then be repaired as in the bilateral form of injury. In the case of the unusual stellate laceration the lacerations must be separately repaired, or two lacerations may be converted into one by excision of the intervening tissue.

The incomplete laceration may be recognized in the manner already described, by introducing a sound into the cervical canal and a finger in the vaginal fornix. Such an injury should be treated by splitting up the cervix and converting the incomplete into a complete tear, and then denuding where necessary and closing as in the case of an open laceration.

If, in an old laceration, the sclerotic and cystic condition of the cervix does not yield to the preparatory treatment advised, amputation of the cervix is necessary.

Fig. 106.—An old incomplete laceration of the cervix with hypertrophy and cystic degeneration. Amputation is necessary.

Amputation of the Cervix.—This operation is performed as follows: The cervix is split bilaterally to the vaginal junction with knife or scissors. Two flaps are formed in this way, and each flap is then amputated separately, the posterior one first (Figs. 107-109). An incision is made on the vaginal aspect of the posterior flap, extending from the angle of the split on one side to the angle of that on the other. The knife is thrust deeply into the cervical tissue and is directed toward the cervical canal. An incision is then made across the mucous membrane of the cervical canal, on the anterior aspect of this flap. The posterior lip is thus removed. The anterior lip is removed in a similar manner. The stump of the cervix is then closed by sutures. Two or three sutures are introduced on each side of the cervix to close the angles, just as in the operation of trachelorrhaphy for a bilateral tear, and two sutures are introduced on each flap to attach the mucous membrane of the cervical canal to the mucous membrane of the vaginal aspect, to form the new external os. The first sutures should be passed well up in the angles at the lateral vaginal fornices, to control bleeding. Bleeding is more likely to be free in this operation than in a simple trachelorrhaphy, but it may always be controlled by the proper application of the first sutures placed in the angles.