anterior lip should be seized with the double tenaculum. Downward traction on the cervix straightens the cervical canal and renders easier the introduction of the dilator. The smaller dilator should first be introduced. No force should be used in passing it through the cervical canal. If an obstruction which cannot be gently overcome is met, the dilator should be introduced as far as the obstruction and the blades should then be separated. Slight dilatation of this kind below the angle of flexion will usually enable the operator to pass the instrument through the cervical canal at a subsequent attempt. After the smaller instrument has been introduced to the full extent the blades should be gradually separated, for a half inch or more, until the canal becomes large and straight enough to admit the large instrument. It should always be remembered that no force should be used in the introduction of either instrument. After introduction the blades of the large dilator should be slowly separated. On the handles of the Goodell instrument is a graduated scale showing the extent of the dilatation. In no case should the dilatation be carried beyond one and a half inches. In women in whom the cervix and uterus are small an inch of dilatation is sufficient. The maximum dilatation should be reached slowly and gradually. Laceration of the cervix or of the margin of the external os should be avoided. Sometimes ten or fifteen minutes are required before full dilatation is attained. When this point is reached the handles should be held the screw, and the instrument should be uterus for ten or fifteen minutes longer. the dilatation, the more permanent will be the result. After the instrument is withdrawn the cervical canal and the vagina should be washed out with a 1 : 2000 solution of bichloride of mercury, and a light gauze pack should be introduced into the vagina. The pack should be removed at the end of forty-eight hours, and a daily douche of 14000 bichloride solution should be administered for the following week. The patient should re

in place by kept in the The longer

main in bed for a week, or longer if there is any pelvic pain. Pain, however, does not follow this operation if we avoid operating upon those cases in which there is inflammatory disease of the tubes and ovaries. The too

early resumption of the erect position may cause the failure of the operation. The abdominal pressure exerted upon the fundus uteri, before the organ has become. fixed in its altered shape, may bring about a recurrence of the anteflexion. In case the external os be very small -too small to admit the dilators-it may be incised by small crucial incisions or reamed out with the closed blades of the scissors.

Dilatation of this kind usually produces a permanent broadening and shortening of the cervix. The cervical canal is rendered straighter and larger.

The

The good effects of the operation are not always apparent at the menstrual period immediately following the operation, because the results of the traumatism to the mucous membrane and the structures of the cervix are still present. At the periods after this, however, the dysmenorrhea is absent or is very much relieved. benefit usually derived from this operation is a strong proof of the truth of the obstructive theory of the dysmenorrhea. If, after dilatation, conception takes place, the woman may look forward to perfect cure. In some cases the dilatation does not seem to be sufficient to produce a permanent open condition of the cervical canal, and the signs of obstruction (dysmenorrhea) return. In such a case the dilatation should be repeated. The more thoroughly the dilatation is performed the first time the less often will the second operation be necessary.

CHAPTER XI.

RETROFLEXION AND RETROVERSION OF THE

UTERUS.

Retroversion of the uterus means a turning back or a backward rotation of that organ. The shape of the uterus may not be altered. The fundus, instead of lying forward upon the bladder, is directed backward, and sometimes lies in the hollow of the sacrum (Fig. 86).

FIG. 86. Retroversion of the uterus.

Retroflexion means a bending backward of the uterine axis. The axis of the body of the uterus is normally inclined forward at an obtuse angle with the axis of the cervix. When the axis of the body of the uterus is in

clined backward at an angle with the axis of the cervix, retroflexion exists. Retroflexion may vary in extent from an angle very little less than 180 degrees to an angle considerably less than 90 degrees (Fig. 87).

FIG. 87.-Retroflexion of the uterus.

Retroflexion and retroversion usually coexist. The conditions are due to similar causes. They may originate simultaneously, or one condition, occurring primarily, may induce the other.

An infinite number of degrees of retroversion may exist. For convenience of clinical description three degrees have been described. In the first degree the fundus uteri is directed upward approximately toward the promontory of the sacrum. In the second degree the uterus lies transversely across the pelvis, the fundus and the cervix being at about the same level. In the third degree the retroversion is extreme, and the fundus lies below the level of the cervix (Fig. 88).

Retroversion of the uterus is progressive. It usually proceeds from bad to worse. As soon as the downward

abdominal pressure begins to act upon the anterior face of the uterus there is a continuous force increasing the retroversion.

There are many causes of retroversion and retroflexion.

FIG. 88.-Diagram of the degrees of retroversion of the uterus.

The disease may be congenital. Extreme retroflexion has been found in the uterus of the new-born infant. Congenital retroversion and retroflexion may be due to imperfect development, and resulting imperfect invagination of the cervix. The condition may also be caused by arrest of development of the posterior wall of the uterus; the anterior wall thus outgrowing the posterior.

Many cases of retroversion undoubtedly originate during girlhood as a result of falls, blows, distortion of the body, or sudden efforts at lifting. The origin of the symptoms may be traced in many cases directly to some. such cause.

The uterus may be considered to be balanced upon an axis running transversely. Anything that turns the uterus backward, so that the intra-abdominal pressure may act upon the anterior wall, will produce retrover