of mucous membrane is left on the anterior and posterior lips of the cervix (Fig. 232).

The second step is to introduce the sutures. The first needle is pushed in a quarter of an inch outside of one of the denuded surfaces

Diagram Illustrating Trachelorrhaphy in a case of Bilateral Laceration: 4, posterior lip; B anterior lip; C, cervical canal (apparent os surrounded by red and swollen mucous membrane, which used to be regarded as an ulcer). The numbers mark the order in which the sutures are inserted. When they are tied 4 comes in contact with B and forms the real os (e, f, g, h). The reader can easily realize the whole effect of the operation by copying this figure on a piece of paper and folding it at a line uniting D and D, which represents the angle between the lips.

of the posterior lip near the angle. It is pushed transversely under the denuded surface and made to emerge just on the line of demarkation between this and the undenuded central portion. Next, it is inserted on the corresponding point of the anterior lip, and carried under the denuded surface and made to emerge a quarter of an inch outside of it, on a point corresponding to the first in which the needle was pushed in. When the point of the needle emerges anywhere the assistant holds the counter-pressure hook (p. 219) in under it, and presses against the tissues in order to facilitate the passage of the needle. The needle carries a loop of linen thread (p. 218) into which is hooked a silver wire 10 inches long. This is closed temporarily as explained on p. 219, and held aside so as to be out of the way. As a rule, three such sutures are inserted on either side, and when they all are in place they are twisted and cut off, beginning nearest the angle. The ends ought to be left at least half an inch long, as they are apt to become imbedded and are hard to find when you want to remove them. It takes more time to use silver wire than other material, but in this particular operation I have sometimes found decided advantages in using silver wire. Later I have abandoned silver wire for silkworm-gut or chromicized catgut, which does away with the suture-carrier and the twisting.

Before and after closing the sutures I thoroughly irrigate with some antiseptic fluid.

Originally, the operation was performed in Sims's position, but the insertion of the needles and disinfection are much facilitated by the dorsal position.

After having described the most common form of trachelorrhaphy we must mention some of the many conditions that call for a modification of the operation.

Modifications. If it has been necessary to cut very deep into the angle between the lips, the wound cannot be closed in a reliable way by inserting the sutures from the vagina as described above. Then the uppermost should go much deeper in than it is possible to get it when starting from the vagina. This is obtained by using two needles, each with a loop of thread. One of them is introduced from the cervical canal and pushed out through the posterior lip, the other is in the same way carried from within outward, through the anterior lip. Next the posterior loop is passed through the other, and the latter pulled out through the anterior lip, carrying the posterior loop with it. Finally, the suture is hooked into this loop and carried back through both lips.

In the unilateral tear only one side is operated on.

In the stellate tear it is sometimes necessary to cut off a whole lobe between two fissures on one or even both sides.

If there is much glandular hypertrophy and cystic degeneration, it may be necessary to remove the whole mucous membrane from one or both lips. This may be done before the operation by means of Simon's spoon, and hemorrhage staunched with liquor ferri or tamponade. The operation is then postponed until the parts are healed over. It may also be done at the time of the operation by omitting to leave an undenuded strip in the center for the canal or by curetting it. If this is done on both sides, some provision must be made for preventing the cervical canal from growing together. I have used an intra-uterine glass stem for the purpose or introduced a probe repeatedly during the healing process. Others leave a silk thread or reopen the canal by electrolysis.'

When there is much hyperplasia, so that the lips stand far apart, and when brought together offer two convex surfaces, it is necessary to hollow the denuded surfaces well out in order to approximate them.

If one lip is longer than the other, the position of the angle must be changed by cutting the tissues in such a way as to get the angle over on the longer lip, and thus obtain two lips of the same length that will form a regular os.

If besides the cervix the perineum is torn, we are in general compelled to do both operations at one sitting; but if there came second

1 Geo. Engelmann of St. Louis, Gyn. Trans., 1885, vol. x. p. 202, and 1886, vol. xi.

P. 90.

ary hemorrhage necessitating tamponade the perineal work would be destroyed, and if menstruation came on unexpectedly, which sometimes happens, it might be hard to diagnosticate (p. 223).

As a rule, there is no more hemorrhage than that the operator can go on as described above. If, in very exceptional cases, the circular artery bleeds considerably, the deepest suture should be inserted immediately on the bleeding side. As soon as the two lips are in apposition all bleeding stops. In rare cases it may be necessary to cut out a cicatrice from the fornix of the vagina. Here, also, an artery may spurt that should be seized with pressure-forceps. It will hardly be necessary to tie any artery.

If the operator has denuded a larger surface than he can cover there may come serious hemorrhage, which, however, can be controlled with styptic cotton and a tampon of common cotton, and need not interfere with a perfect result.

Great care should be taken to have a perfect line of union, the vaginal mucous membrane on one lip coming in contact with that of the other. If necessary one or two superficial catgut sutures may be inserted besides the deeper sutures.

If the lips of the torn cervix are adherent to the vaginal wall, the adhesions should be separated sufficiently to allow the lips to be brought together. The gap made by the incision in the vagina should be packed with iodoform gauze.

Upon the whole, small as the field is, and free from danger as the operation is, if performed aseptically, trachelorrhaphy requires, in my opinion, as much judgment and skill as any other gynecological operation I know of.

At the end of the operation I cover the cervix with a long strip of iodoform gauze, packed loosely into the fornix of the vagina. The patient may urinate herself. The bowels are kept open if necessary. On the fourth and the seventh day the tampon is changed and the vagina swabbed with antiseptic solution. On the tenth day the sutures and the tampon are removed, and some vaginal injection administered morning and evening. The patient stays nine more days in bed.

The effect of the operation both locally and as to general health is wonderful. The womb diminishes in size, the nervous phenomena disappear, the patients grow fat, a new period full of comfort and blooming health follows in the course of a few months, and very often conception puts an end to sterility.

The stitched surface may, of course, be ruptured in a new labor, just as the intact cervix was, but very often it goes uninjured through subsequent childbirths.

CHAPTER III.

FOREIGN BODIES.

FOREIGN bodies are by far not so common in the uterus as in the vagina. Still, occasionally an intra-uterine instrument, especially a glass tube, may break and the end remain inside, or absorbent cotton used for applying drugs to the interior may come off. Sometimes a leech applied through Fergusson's speculum to the vaginal portion has slipped into the interior of the womb. A hairpin used to produce abortion has also been found there. A Hodge pessary slipped from the vagina into the cervix while the patient lifted another person.1

Treatment. If any object is in the womb which cannot be withdrawn, the patient should be anesthetized, the cervix dilated, and the foreign body removed with finger, curette, or forceps. If it is a living leech, a strong solution of table-salt injected into the womb will make it loosen its grip. If there is any hemorrhage the uterus should be tamponed with iodoform gauze.

CHAPTER IV.

METRITIS.

METRITIS is inflammation of the uterus.

As in vaginitis a large number of different forms of metritis are described according to the special part affected, the cause, the course, and certain peculiarities. As this is not a treatise on morbid anatomy, but above all a guide to the recognition of the diseases of the female genitals and their treatment, it would not only lead us too far, but cause unnecessary repetition and confusion, if we were to admit all these distinctions as special diseases. We will only mention such varieties as are clinically distinct or call for different treatment. In regard to time and severity of symptoms we distinguish between acute and chronic metritis.

Acute Metritis.-In the acute inflammation the whole organ-body, cervix, mucous membrane, muscular layer, and peritoneal covering-is more or less implicated. The peritoneal inflammation-so-called perimetritis-is, however, not always found, and if found extends generally to neighboring parts of the peritoneum, and will, therefore, be treated of under Pelvic Peritonitis.

The inflammation of the mucous membrane is called endometritis, that of the muscular layer parenchymatous metritis, that of the cervix

1 Henry Heiman, Med. Record, March 17, 1894, p. 347.

has been designated as cervicitis, and that of the mucous membrane of the cervix as endocervicitis.

Pathological Anatomy.-The whole uterus is enlarged and softened, the cut surface is red with yellow points. The mucous membrane is swollen and red. Microscopical examination shows both in the mucous membrane and between the muscle-fibers an abundant infiltration with small round cells, dilated blood-vessels, and masses of extravasated blood. The inflammation extends sometimes to the peritoneum and the pelvic connective tissue, either through the tubes or through the lympathics (p. 60). Sometimes it is combined with vaginitis.

It is doubtful if ever an abscess is formed in the uterine tissue, except in puerperal cases where the metritis appears as part of a more comprehensive infection.

Etiology.--Menstruation being accompanied by a development that has much in common with that of inflammation, predisposes to the latter. Thus exposure to wet or cold is more liable to end in acute metritis during the menstrual period than at other times. Coition during menstruation may have a similar effect. Parturition and miscarriage are the most common causes, either through direct puerperal infection or as a predisposing element: if a woman who has recently given birth to a child or aborted, fatigues herself, catches cold, or has sexual intercourse, she is more liable to have an acute inflammation of the womb than otherwise. Coition ought not to take place before involution is completed-say, two months after childbirth and one month after early abortion.

Acute metritis may be brought on by any gynecological operation, even the mere introduction of a sound, and still more easily by curetting, or by the irritation caused by an intrauterine stem or even a badlyfitted vaginal pessary. Trachelorrhaphy or incision of the cervix has often led to endometritis extending through the tubes to the peritoneal cavity, and ending fatally. Retained blood may become decomposed and cause acute metritis. The true agent in all these cases is doubtless the introduction of pathogenic microbes, for by proper antiseptic precautions the evil may be avoided.

Acute metritis appears sometimes in the exanthematous fevers, typhoid fever, cholera, acute yellow atrophy of the liver, phosphoruspoisoning, and in persons affected with syphilis.

As we have seen above (pp. 131 and 291), gonorrheal infection invades sometimes the uterus.

Symptoms.-Acute metritis is accompanied by fever, a sensation of heat in the pelvis, bearing-down pain, a painful sensation of contractions called cramps, or pain extending up to the lumbar region. Sometimes the patient complains of vomiting, diarrhea, dyschezia, and dysuria. Often she suffers from suppressio mensium or menorrhagia, or has a purulent discharge from the uterus. In gonorrheal