except at the top, about half an inch. Then the remainder of the cervix is cut off transversely at the base of the flaps. These flaps

FIG. 241.

Kaltenbach's Supravaginal Amputation of the Cervix.

are stitched to the vaginal wall with three or four deep sutures, comprising some of the muscular part of the stump. If we go too near up to the constrictor, the stumps of the cervix are apt to retract beyond it.

Next, a triangular piece is cut out on both sides of the collar formed by the receding vagina, and a couple of deep sutures are passed through the edges and around the vessels running on the side of the cervix, the base of the triangle being about a quarter of an inch from the outermost suture on either side and the top at the constrictor. This excision allows us to exercise tighter pressure on the ligated bloodvessels, and affords an excellent adaptation of the fornix to the stump. Finally, the contact between the edges of the two mucous membranes is perfected with a running suture of catgut. Then the constrictor is removed, and if there is any bleeding, one or more deep sutures are inserted on the sides of the stump.

This is the best of all the operations, in so far as it exposes less to hemorrhage and leaves a fine stump.

The amputation of a conical piece of the cervix, as in Hegar's operation, may also be accomplished by means of the galvano-caustic knife. or wire (p. 235). But even this does not prevent secondary hemorrhage, and is liable to cause stenosis of the cervical canal (p. 421). The patient should, therefore, be carefully watched during the healing process.

Besides primary and secondary hemorrhage, those methods of the

supravaginal amputation which leave a large deep-seated, more or less anfractuous wound predispose to sepsis.

4. Vaginal Hysterectomy.-These drawbacks are avoided by removing the whole uterus, which may be done from the vagina or from the abdomen. The vaginal operation will be described below under Prolapse of the Uterus.

5. Abdominal Hysterectomy.-If the supravaginal hypertrophy of the cervix is combined with such an hypertrophy of the body that the removal of the uterus through the vagina would be difficult, it may be undertaken through the abdominal wall, exactly as for a myomatous uterus. (See below, under Fibroid.)

CHAPTER IX.

ACQUIRED ATROPHY; SUPERINVOLUTION.

ATROPHY of the uterus may be congenital or acquired. We have described the congenital form above (pp. 392, 393) as the fetal, the infantile, and the pubescent uterus.

Acquired atrophy is a normal condition after the climacteric (p. 123), senile atrophy, but in consequence of the atrophy closure of the cervical canal, especially at the external or internal os, may occur and give rise to hydro- or pyometra (p. 421).

The writer has also always found atrophy of the uterus in removing this organ after having previously performed salpingo-oophorectomy on the same patients.

Pathological Anatomy.-In the non-puerperal form the uterus is small, the vaginal portion disappears sometimes entirely, so that the vagina ends in a narrow funnel, at the bottom of which is situated the os. The tissue is hard, its arteries often calcareous, and it sometimes contains foci of extravasated blood. The cavity of the uterus is less deep than normal.

The puerperal atrophy differs in some respects from the non-puerperal form. The walls are thin and often very soft, and the uterine cavity may preserve its normal depth.

Etiology.-Puerperal atrophy, or superinvolution, is a rare disease. It is, perhaps, oftener connected with abortion than with childbirth. It is caused by loss of blood, protracted lactation, debilitating diseases, such as scarlet fever, tuberculosis, chlorosis, syphilis, diabetes, Bright's disease, and exophthalmic goiter.

Atrophy can also be caused mechanically by pressure of a uterine fibroid or an ovarian cyst.

It may be brought about by trachelorrhaphy, amputation of cervix, or oophorectomy.

Sometimes salpingo-oöphoritis seems to be the cause of it, and it has been found together with paraplegia.

Symptoms. Senile atrophy does not give rise to symptoms unless it is combined with atresia.

Before the climacteric atrophy is characterized by amenorrhea and sterility. Some patients complain of sacral pain, headache, insomnia, mental depression, anorexia, indigestion, and general weakness. Sometimes the uterine cavity measures only an inch or an inch and a half, but in the puerperal form the sound often enters to the normal depth (pp. 49 and 152). Its knob is felt with unusual distinctness through the abdominal wall.

Prognosis. Puerperal superinvolution is sometimes only transitory, whereas the other forms are permanent.

Treatment. The treatment is the same as for congenital atrophy (p. 393).

CHAPTER X.

GANGRENE.

GANGRENE of the uterus may occur as a result of puerperal infection. An inverted uterus, a fibroid, or a cancerous tumor, may slough, and in this way a spontaneous cure may take place.

Treatment. The patient's strength should be kept up by means of quinine, strong alcoholic drinks, and nourishing food. Locally, frequent antiseptic injections should be used in the vagina (p. 172), and even in the interior of the uterus.

CHAPTER XI.

HYSTERALGIA.

HYSTERALGIA, or neuralgia of the uterus, may be idiopathic or symptomatic.

Idiopathic hysteralgia is a rare disease.

Etiology. It is most common at the menopause, but may be found in young girls, especially before menstruation is well established. It is also found in anemic, nervous, and hysterical women. Sometimes it is of malarial origin or due to rheumatism.

Symptomatic hysteralgia may accompany any of the organic diseases of the womb, especially metritis and cancer.

Symptoms.-Hysteralgia is characterized by sudden attacks of severe pain in the uterus, often radiating to the sacral region, the iliac fossa, and down the leg, which recur with regular or irregular intervals.

Diagnosis.-The chief point is to discover whether the affection is

purely nervous or whether the neuralgic attacks accompany organic disease.

Prognosis.-The prognosis is favorable if the neuralgia is not grafted on malignant disease.

Treatment. During the neuralgic attack nothing equals in certainty and swiftness of action the hypodermic injection of morphine. In the intervals the underlying disease, if any, should be treated, and the idiopathic form should be treated, according to the etiology, with tonics (p. 225), antiperiodics, or antirheumatic medicines. The galvanic current, with the positive pole in the vagina or uterus (pp. 231, 232), is very effective, and so is the high-tension faradic current (p. 230).

CHAPTER XII.

DISPLACEMENTS.

THE normal shape and position of the uterus have been discussed above (p. 51), and we have seen how it changes position according to the degree of fullness or emptiness obtaining in the bladder and the rectum (p. 53). Every breath makes it perform a see-saw movement. During inspiration the fundus is pushed forward and downward, while the cervix moves upward and backward. During expiration the opposite movement takes place. During urination and defecation it is pushed down; during copulation it is lifted up. It is therefore clear that the uterus is an unusually mobile organ. But certain permanent changes and deviations from the normal take place under certain conditions, and constitute the so-called displacements. These are anteversion, anteflexion, retroversion, retroflexion, lateroversion, lateroflexion, anteposition, retroposition, lateroposition, prolapsus, elevation, inversion, and hernia.

Anteposition, retroposition, and lateroposition, if they are not due to pressure from a neighboring tumor, are developmental abnormalities of merely anatomical interest (p. 394).

A. Anteversion.

Anteversion (Fig. 242) is that position of the uterus in which the fundus points forward, and sometimes downward, to the symphysis pubis, the os backward, and sometimes upward, toward the sacrum. The uterine canal preserves its normal direction in a line that is straight or slightly curved forward (p. 52).

Pathological Anatomy.-The uterus is more or less enlarged and in a condition of chronic metritis. Sometimes adhesions are found

between the fundus and the peritoneum or signs of cellulitis round the cervix; or the ovary or tube may be found adherent to the anterior wall of the pelvis. Often the vaginal portion is unusually short.

FIG. 242.

Anteverted Uterus (Fritsch).

Etiology. Anteversion is due to inflammation of the parenchyma of the womb, in consequence of which the organ becomes larger and heavier and tips down in the erect and sitting posture; or to inflammation of the pelvic peritoneum or the appendages, in consequence of which the fundus uteri is dragged forward and downward.

Anteversion is sometimes due to subinvolution after childbirth or abortion, but is not rare in virgins.

Symptoms.-These are the same as in chronic endometritis and parenchymatous metritis (pp. 409 and 416), especially frequent micturition, dysmenorrhea, menorrhagia, leucorrhea, and sterility. The frequency of micturition is probably due to pressure of the enlarged uterus, just as we commonly find it in pregnancy. The dysmenorrhea may be mechanical, the exit for the blood being less free when the uterine canal is horizontal or even lies higher with its open than with its closed end; or it may be explained by the increased sensitiveness due to the inflammation of the uterus or its surroundings. The menorrhagia and leucorrhea are likewise probably due partly to me