XTLU SERIES VOL. VIII, No. z Gibson-CervicaI Lacerations American Journal of Surgery 3o9

of 3 to 4 mm. thickness and, therefore, in this type immobihzation for a tota of fourteen days is advised.

This pressure necrosis method is possibIe since the digita arteries, veins and nerves lie close to the phaIanges.

FoIIowing the usua1 teaching, the correc- tion of a web on one side of a finger is compIeted before the web on the opposite

side attacked. The method wouId seem equaIIy as appIicabIe to webbed toes although, as yet, it has not been attempted. The method has been used up to the age of ten years, but it is best empIoyed .rn infancy.

The resuIts have been most satisfactory both from a cosmetic as we11 as a functional standpoint.

CERVICAL LACERATIONS AND INFECTIONS* GORDON GIBSON, M.D., F.A.C.S.

BROOKLYN, N. Y.

B EFORE taking up the offIce treat- uterus, whereas in reality the condition is ment of these conditions, Iet us one of subinvoIution of the entire pelvic have a cIear idea of the pathologica contents, and the underIying Iesion a

processes to which the cervix is prone and subinvoIution of the uterine supports. try to evaluate the measures necessary If one wiI1 carefuIIy determine in such a for their correction. The most important case the excursion of the uterus, one is are congestion, infection, Iaceration and often surprised to find that he can push the malignant change. uterus up into the pIane of the brim or

It is of the first three that we are con- down into the introitus; that he may hoId cerned as far as the possibiIity of offIce it tight against the pubis or push it back treatment having any heIpfu1 effect. Many into the hoIIow of the sacrum. a case of simpIe chronic passive congestion The question naturaIIy arises, where is has been caIIed chronic endocervicitis. this uterus when the woman is on her The dictum that every Iacerated cervix feet? The old examination of a woman in a is infected does not stand the test of carefu1 standing position had much merit and cIinica1 investigation. True, a great many often wouId revea1 conditions unthought are, and in many cases it is at times of if the examination was carried out in extremely diffIcuIt to differentiate between the usua1 manner. Before such a woman infection and congestion and as congestion in the chiId-bearing period is subjected renders any structure more susceptibIe to any operative procedure on the cervix, to Infection, the picture is more complicated. even though there may be some degree of

i\ carefu1 history and thorough physica Iaceration, she should be treated with examination wiI1 often revea1 that aIthough the idea of stimuIating invoIution of the there is IeucorrheaI discharge and the uterine supports and of the uterus as a cervix is Iacerated, enIarged, everted and whole. eroded, the cervix is more sinned against Again, carefui examination will revea1 than sinning, the condition in the cervix the fact that many of these women are being the effect of other Iesions as we11 as of the ptotic type with poor genera1 of the Iacerations. The commonest condi- muscular tone, fauIty posture, flat feet, tion is subinvoIution. For many years varicose veins, etc. \\.e have used the term SubinvoIution of the Before such a woman’s cervix is con- * Front The Department of Obstetrics and Gynecofogy, Long Island Cokge HospitaI. Submitted for pubIication

December 18, 1929.

3’0 American JournaI of Surgery Gibson-CervicaI Lacerations FEBRUARY, rgjo

demned to surgery, much can be accom- phshed to improve her genera1 condition and to stimuIate invomtion. Tonics, proper

FIG. I. Section through portio of cervix.

A, Squamous epithelium of cervix. B, Healing foIlicuIar erosion being lined by columnar

epithelium. c, Hypertrophy and hyperplasia of cervica1 gIands. D, Druse exudate in stroma and about the gIands,

consisting of smaI1 lymphocytes and pIasma ceI1.s.

food, proper rest, attention to the boweIs and bIadder, tampons, douches, knee- chest posture, and that most vaIuable instrument, the pessary, wiI1 aII have a definite pIace. If there be much erosion, painting with 20 per cent siIver nitrate or brushing with the eIectric cautery wiI1 invariabIy cause compIete heaIing, and if there be extension Iaceration with con- siderahIe eversion, a very deep Iinear cauterization with a thin bIade wiI1 often give astonishing resuIts. AI1 of this, of course, takes time and the condition shouId be carefuIIy expIained to the patient lest she become impatient and FaiI to cooperate.

CHRONIC ENDOCERVICITIS

As said before, at times it may be exceedingIy diffrcuIt to differentiate be- tween the cervix which is simpIy congested and the one which is infected. Where

there is infection, examination wiI1 often reveal a sIight amount of tenderness in the peIvis, generaIIy in the parametrium

FIG. 2. Section through center of same excised cervica1 cone.

A, No exudate about gIands or in fibromuscular coat of cervix.

R, Absence of hyperpIasia and hypertrophy of muscIe WIIS.

c, GIand spaces are normaI.

and utera1 sacra1 Iigaments caused by a peIvic Iymphangitis anaIogous to the Iym- phangitis which accompanies infection elsewhere. The cervix may be enIarged, eroded and infected and bathed with a mucopuruIent discharge. In long-standing cases, the cervix is cystic and hard with hyperplasia.

HistoIogic examination of the cervices which have been removed wil1 show the marked, round-ceI1 infiItration character- istic of subacute inflammation and aIso show in the majority of cases that the infection onIy extends from I to 2 cm. up the cervica1 cana1. (Figs. I and 2.)

Novak pointed out in a recent paper that in the first stage of endocervicitis there is a hypersecretion of the cyIindricaI epithelium and an extension outward on the pars vaginaIis with production of an erosion. In this stage, the erosion is covered with cylindrical epithelium. The Iatter

NI \I SERIFS Vol. VIII, No. ez Gibson-CervicaI Lacerations American Journnl 01 Surprrv 3’1

still retains its gIand-forming tendency so that many gIand invaginations may be formed far out on the pars vaginalis. As the inflammation recedes, the squamous epithehum asserts itseIf again, pushing back the cyIindrica1 epithehum to the region of the externa1 OS.

The treatment is obviously the destruc- tion or remova of this infected cvIindrica1 epitheIium. This can be accomplished by three methods: operation, caustics or the cautery. The disadvantage of the operation is we11 known. AI1 surgeons can recaI1 patients who are steriIe, who have had abortions or who have had cervica1 dystocia foIlowing operation in the child-bearing period. With this in mind, we beIieve that other methods shouId be faithfuIIy tried before operation is advised.

That these cases can be cured by means of the cautery is born out by numerous articles in the Iiterature reporting Iarge series of cases by many observers. It is not our purpose to discuss any series of cases, but rather to describe the method.

We have found that the best results are obtained by using the nasa1 cautery Ioop and bIade. The transformer shouId be a noiseIess one which can be obtained from any instrument house. The handIe shouId have a finger switch which gives perfect contro1 of the current. OnIy enough current shouId be used to give a bright, cherry-red gIow to the bIade or Ioop.

The most important factor in the pro- cedure is the management of the patient. She shouId be toId just exactIy what one expects to do, that she wil1 experience a fleeting sense of heat and that as soon as she feeIs it, she is to say so and the current wiI1 be turned off. She shouId be told that this treatment cannot be carried out in one sitting, but that severa wiI1 be neces- sary. The necessity for patience and cooperation must be expIained.

The cervix is then exposed, anv dis- charge removed and the coId bIade Ibid on the area in the periphery of the erosion one wishes to cauterize first. The current is then turned on and as soon as the patient

feeIs it the current is turned off. She is then asked, “How much did that reaIIy hurt?” and she will generaIIy repIy, “liTby, not much.” “ Could you stand another applica- tion Iike that now, or would you rather wait until the next treatment?” Most women wiI1 stand from three to six applica- tions the first visit. Others who are high strung and nervous had better be .gi\ren only one so that their confidence can be obtained. The patient is toId that she wiI1 have an increased discharge for a few days and that there may be a IittIe bleeding which is unimportant; that she should take a daily aIkaIine douche and return in one week.

At the next visit it wiI1 be found that there is a sIough at the site of the cauteri- zation. This may be wiped off and the raw surface touched with an applicator dipped in IO per cent silver nitrate solution. At this time, several other areas may be cauterized, depending on the tolerance of the patient. After two or three treatments, it wiIl be found that a11 exposed cervical mucosa and erosion have been destroyed and that squamous epitheIium of the portio is covering the area. When this has been done, the Iower part of the cana may be cauterized. This should be done with the greatest care for if the cauteriza- tion is too deep, distressing stenosis or atresia may occur. GeneraIIy four applica- tions at one sitting will be all that is necessary. Douches- are continued anc1 the patient returns once a week for cieans- ing of the sIough and stimulation of the squamous epithelium with weak siIvel nitrate soIution. In from two to three weeks foIIowing the Iast cauterization, the cervix wiI1 be heaIed. The time varies, however, a great deal depending on the severity of the Iesion and the ability of the patient to toIerate the treatment.

If cysts are present near the surface, they may be punctured with the ca.uterJ 100~. When there is much elrersion, a few deeper linear cauterizations may be made, care being taken not to invade the canal Iest one cause stenosis or atresia.

3’2 American JournaI of Surgery ThurIow-Toe

LACERATIONS OF THE CERVIX

We are perhaps too prone to think of Iacerations of the cervix as just Iacerations, forgetting that the troubIe does not Iie in the Iaceration per se, but in the changes which may take pIace because of the Iaceration. Many a woman has a Iacerated cervix, at times quite extensive, who compIains of no symptoms and it is onIy when some subinvoIution or infection superimposes that she compIains. That a Iaceration tends to cause sterihty is not true. It is onIy when there is subinvoIution with marked passive congestion and in- creased hypersecretion or infection with again hypersecretion, the Iatter of the mucopuruIent discharge, that spermatozoa cannot pass. Measures to remove conges- tion and to stimuIate invohrtion with cauterization of the infected mucosa in infected cases wiI1 be aI1 that is necessary.

The onIy Iacerations which require operation in the chiId-bearing period are the very extensive ones and here tracheIor- raphy shouId be the operation of choice.

Nail Defects FEBRUARY, ,930

When the Iips of the Iacerated cervix are everted with exposure of the cyIindrica1 epitheIium, remova of this exposed epithe- Iium and its repIacement by squamous epithelium Ieaves simpIy a misshapen Portia with a shortened cana Iined by heaIthy cyIindrica1 epitheIium. Such a cervix does not predispose to steriIity nor wiI1 it cause dystocia as there is no scar tissue in the body of the cervix.

Emmett, many years ago, pointed out the danger of scar tissue and so was carefu1 to remove it, and did his carefu1 tracheIorraphy hoping for and obtaining primary union without scar tissue formation.

WhiIe this paper was being prepared, I saw a young gynecoIogist do a tracheIo- pIasty on a perfectIy good inoffensive cervix with a very miId degree of infection with moderate erosion; one in which a very short period of cautery treatment properly carried out wouId have been a11 that was necessary.

So perhaps after a11 the topic is not untimeIy.

DEFECTS OF THE TOE NAILS (INGROWN AND VERTICAL) *

ALFRED AMOS THURLOW, M.D.

SANTA ROSA, CALIF.

T HE Iiterature on this subject seems short, are aIso bIamed in most articIes rather meager when we consider on the subject. The nai1, however, is the frequency with which we see onIy a passive offender, and when properIy

both ingrown toe naiIs and the vertica1 trimmed straight across, Ieaving the cor- naiIs. ners square, and not too short, it is prac-

“ Ingrown” toe naiIs is a misnomer, ticaIIy impossibIe for the condition to since the nai1 is reaIIy overgrown by the occur. soft parts. FaiIure to trim the toe naiIs VerticaI toe naiIs are usuaIIy a resuIt of squareIy across the end, which wouId incorrect fit of shoes (too short), in which aIIow the dista1 corners of the naiIs to the crowding of the soft parts of the toe over-ride the soft parts, is responsibIe for into the end of the shoe resuIts in pushing much of this condition. Narrow toed shoes, up the ffexibIe nai1. The matrix becomes Iow hard toe caps, socks too Iong or too hypertrophied, and a thicker nai1 is formed.

* Submitted for pubIication December 7, 1929.