FIG. 75.-4. The anterior vaginal wall is pushed backward by the staff, while on each side of the median line portions of mucous membrane are grasped by tenacula and brought together in order to determine the position of the strips to be denuded. B. Denudation on the anterior vaginal wall (Sims' operation).

8

B. The

FIG. 76.-4. The sutures have been introduced. The prolapsed vagina and cervix have been reduced. The cystocele is pushed upward by the staff, so that the denuded strips may be brought into apposition. B. The sutures are secured. The cystocele has disappeared. The area of the anterior vaginal wall and the caliber of the vagina have been much diminished.

FIG. 77.-4. A point on the median line of the posterior vaginal wall, about an inch below the cervix, has been seized by the tenaculum. This marks the apex of a triangle the base of which is at the ostium vagina and the sides of which are on the lateral vaginal walls. The triangle has been denuded. The sutures have been introduced.

Б.

to retain the uterus inside the body, yet something is always accomplished by it, and when supplemented by a second or a third operation, cure will often result.

The operative procedures required in a case of prolapse of the vagina and of the infra-vaginal cervix, with hypertrophy of the infra-vaginal cervix and elongation of the supra-vaginal cervix, are illustrated in Figs. 71-78. .

FIG. 78. The sutures in the posterior vaginal wall have been secured. The caliber of the vagina has been very much diminished. A strong sling or band of tissue has been formed immediately above the ostium vaginæ, which supports the lower portion of the posterior vaginal wall. The operation is completed.

The condition represented in Fig. 71 is that which is commonly spoken of as "prolapse of the uterus." It is the usual form of prolapse. It may be cured in the very great majority of cases by the operations which are here depicted.

A great number of mechanical devices have been introduced for the relief of prolapse of the uterus. Every vaginal pessary has been used for this condition.

None

of these implements cure the disease. All of them, if used continuously, produce ulceration of the vagina and of the cervix from pressure, and must be abandoned until such lesions heal. In those cases of prolapse in which. pessaries remain in the vagina and support the uterus, without producing ulceration, operation would effect a

cure.

Mechanical supports of this kind are only indicated in women in whom operation is contraindicated on account.

of old age or for some other reason. Perhaps the best instrument for supporting the uterus in such cases is Braun's colpeurynter (Fig. 79). The uterus should be reduced, and the col

FIG. 79.-Braun's colpeurynter. peurynter, well greased and containing about an ounce of water,

should be introduced in the vagina and then distended. with air. This instrument takes its support evenly from all parts of the vaginal outlet, and is therefore less apt to produce ulceration from pressure than the various pessaries. It should be removed at night.

CHAPTER X.

ANTEFLEXION OF THE UTERUS.

As has already been said, the uterus normally lies with its anterior surface in contact with the posterior surface of the bladder, and with its long axis approximately perpendicular to the long axis of the vagina. The forward inclination of the uterus varies with the degree of distention of the bladder; it is greatest when the bladder is collapsed.

In the normal woman the long axis of the body of the uterus is inclined forward at an obtuse angle with the long axis of the cervix. In other words, the uterus is normally anteflexed. This angle is subject to rather wide variations within the limits of health. It is greater in the multiparous than in the nulliparous woman. It varies with the distention of the bladder, the position of the woman, and the intensity of intra-abdominal pressure. The axis of the uterus when removed from the body is usually straight. The anteflexion found in the organ when in situ in the living woman rarely persists. The normal or physiological anteflexion is maintained during life by the utero-sacral ligaments, which hold the cervix back, and the intra-abdominal pressure, which, acting upon the posterior aspect of the fundus, pushes the body of the uterus forward.

In the fetus and in early infancy the cervix is relatively much more developed than the body of the uterus, and there is a very marked angle of flexion between them.

Anteflexion of the uterus becomes pathological when