MIDWIFERY. ON HYPERTROPHIC ELONGATION OF THE NECK OF TIIE UTERUS IN PROLAPSUS

UTERI, IMPROPERLY SO CALLED, AND ON ITS TREATMENT BY AMPUTATION OF THE NECK OF THE UTERUS. BY M. HUGUIER, SURGEON TO THE HOPITAL

BEAUJON, PARIS. In this remarkable mSmoire M. Huguier maintains that the ordinarily re-

ceived opinion is erroneous, viz., that the appearance of the os uteri at the

vulva, or of a greater or less portion of the uterus itself beyond the external organs of generation, is the result of a displacement of the organ, of a general lowering, or of a true prolapsus en totalite ; and he holds that this opinion can be shown to depend on inaccurate observation. When the uterus appears externally, and even when the vagina is completely inverted, and the uterus, from the size of the tumour in the centre of which it lies, appears to be en- tirely prolapsed between the thighs, it is not because it has become generally lower in level, and completely left the pelvic cavity, but simply because it has undergone a partial or general (as the case may be) hypertrophic elongation. The best proof that can be given of this is, that in almost all the cases, the body of the uterus remains nearly in its usual situation; and that, if we examine the tumour with care, and measure the uterine cavity by means of the uterine sound, or any other appropriate instrument, the elongation is easily detected. And we can equally assure ourselves of the presence of the body of the organ in the pelvis by careful palpation of the tumour, and by the introduction of one or two fingers into the rectum. M. Huguier does not treat of all the various kinds of uterine hypertrophy ; but confines himself to the consideration of the longitudinal hypertrophy which simulates, accompanies, or determines the descent of the uterus. The two principal varieties of the longitudinal hypertrophy?viz., as it affects the uterine neck above, or below the insertion of the vagina?constitute two different diseases, although their nature is the same. Their causes, their mechanism, their symptoms, the accidents they may de- termine, and even the treatment they demand, are, however, quite different. Hence these two conditions demand separate consideration. And 1st, with regard to the hypertrophic elongation of that portion of the uterine neck below the insertion of the vagina. This is not of so much importance as the other form of hypertrophy; and we give merely the conclusions with which M. Huguier terminates this, the first part of his paper. 1. In this variety, the body of the uterus forms in the cavity of the vagina a cylindrical swelling, either resembling a more or less elongated cone, the free extremity of which approaches the vulva, or even passes between its labia without any shortening ?r inversion of the vulvo-uterine canal. 2. This elongation, which has been noticed by Morgagni, Saviard, Bichat, Lallemand, Desormeaux, Lisfranc, and Boivin, was considered by them as a simple anatomical variety. 3. Even until lately, it has been commonly confounded with the sinking and descent ?f the uterus, when it has been mistaken and treated for a polypus, a chronic retroversion, a follicular cyst, a cancerous or a dropsical enlargement of the neck. 4. No anatomical and nosological description has yet been given of it, although it possesses sufficiently precise characters as regards its causes, de- velopment, symptoms, and treatment. 5. The medical appliances, and the

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different kinds of cauterisation, are only applicable to cases of slight hyper- trophic elongation, and particularly to those which are of little extent, and are complicated with inflammation and engorgement. G. When a hypertrophic elongation of the vaginal portion of the os uteri causes serious symptoms, and has attained a length of from five to seven centimetres, there is only one truly efficacious means of cure, viz., the resection of the uterine neck to half a centimetre below the insertion of the vagina.?The second part of the paper is taken up with the consideration of the hypertrophic elongation of that portion of the uterine neck situated above the reflexion of the vagina and its escape outside the vulva. M. Huguier affirms that the affection designated by authors and practitioners under the names of prolapsus and complete descent of the uterus is nothing else, in the very great majority of cases, than a longitudinal hypertrophy of the uterus, the body of which remains in the pelvic cavity, even although the vagina be entirely inverted, and the tumour hanging between the thighs be equal or even superior in length to the uterus in its normal condition. This proposition, startling though it appears, is the result of fifteen years' labour and conscientious inquiry. He denies the frequency of the

complete prolapsus, holds that it is rarely seen, and that it has been generally confounded with the hypertrophic elongation of the upper portion of the uterine neck. Indeed, the swelling, which up to the present time has been described as complete descent or prolapsus, may depend on two different conditions,?the one quite exceptional, viz., the true descent of the uterus with or without longitudinal hypertrophy ; the other much more frequently met with, and forming the subject of the present paper. In establishing his proposition, M. Huguier relies on three kinds of proofs: viz., on cases scattered through the records of science, on pathological anatomy, and on clinical observation. Under the first head, reference is made to cases related by Saviard, Morgagni, Dance, and Cloquet. Under the second, the magnificent work of Cruveilhier is appealed to; and M. Iluguier asks, if cases of the complete descent of the uterus were as frequent as authors pretend they are, how comes it that Cruveilhier has only been able to give a single representation of the affection in a work on which he has been occupied twelve years, and which he closed with the description of the diseases of the uterus and ovaries ? With the exception of two cases, observed by MM. Morel-Lavallee and Blandin, M. Huguier knows of no others where the characters of the affection have been described in such a manner as to leave no doubt as to its exact nature. Of course, in this review, cases accompanied by considerable peritoneal effusion, or with very voluminous ovarian cysts, where all the pelvic organs are apt to be pushed downwards, are excluded. Since the year 1843, when M. Huguier began to use the uterine sound, he has care- fully examined sixty-four cases of pretended complete prolapsus ; and of this number only two were instances of true and complete prolapsus, unaccompanied by hypertrophic elongation. In a third case, there were at once complete prolapsus, retroflexion, and considerable hypertrophic elongation of that portion of the uterine neck above the^ insertion of the vagina. In this series of sixty- four cases, M. Iluguier has included only those which would be considered, according to the descriptions of authors, as instances of complete prolapsus, in which the length of the tumour was at least equal to that of the uterus in its normal condition (though in most cases it exceeded this), and where the vagina was completely inverted. All cases of slight descent of the uterus, described by authors under the name of semi-prolapsus or incomplete descent, and even those where the neck and vulvo-utenne canal, partly inverted, projected from two to three centimetres from the vulva, were excluded. After mentioning that for some time past he has been in the practice of expounding these facts at his hospital visit, and that M. Robert, at the Hopital Beaujon, has verified them in his own practice, M. Huguier concludes by stating that a careful

examination of the various preparations in the Musee Dupuytren, along with the conservator, M. Houel, only confirms the truth of his observations.? L' Union Medicate, 10th March 1859.