lip is removed in a similar manner. The stump of the cervix is then closed by sutures. Two or three sutures

are introduced on each side of the cervix to close the angles, just as in the operation of trachelorrhaphy for a bilateral tear, and two sutures are introduced on each flap to attach the mucous membrane of the cervical canal to the mucous membrane of the vaginal aspect, to form the new external os. The first sutures should be passed well

FIG. 109.-4, the sutures have been introduced; B, completed operation.

up in the angles at the lateral vaginal fornices, to control bleeding. Bleeding is more likely to be free in this operation than in a simple trachelorrhaphy, but it may always be controlled by the proper application of the first sutures placed in the angles.

The post-operative treatment is similar to that after the operation of trachelorrhaphy.

Amputation of the cervix does not interfere with conception, with the course of pregnancy, or with labor.

CHAPTER XIII.

INFLAMMATION OF THE CERVICAL MUCOUS MEMBRANE (CERVICAL CATARRH).

THE mucous membrane of the cervical canal may be the seat of acute or chronic inflammation. Acute inflammation usually occurs as part of a general acute process affecting the whole of the endometrium, and is commonly the result of gonorrheal or septic infection. It will be considered under General Endometritis.

Chronic inflammation of the mucous membrane of the cervical canal (cervical catarrh or cervical endometritis) is an exceedingly common affection. Unless caused by gonorrhea, it is nearly always secondary to some local or general condition.

The pathological changes that take place in the mucous membrane resemble those found in a similar process in other parts of the body. There is a very marked congestion and hypersecretion of the racemose glands of the cervical canal, so that the most prominent symptom of cervical catarrh, a profuse cervical leucorrhea, is produced. This discharge resembles the normal secretion of the cervical glands. In its physical properties it is characteristic. It is a thick, tenacious mucus, and differs decidedly from the thin, more serous discharge from the vagina or from the body of the uterus. The discharge is often opaque; it is rarely purulent, and is very rarely streaked with blood. The mucous membrane of the cervical canal becomes swollen, and may project or prolapse beyond the limits of the external os, so that the external os has around it a ring of red congested mucous membrane. A similar condition is observed on the

eyelids in conjunctivitis. Such a prolapse of the mucous membrane would bring the orifices of some of the racemose glands upon the vaginal aspect of the cervix, where it will be remembered they are not normally present. The inflammatory action extends beyond the limits of the external os on to the vaginal aspect of the cervix. The squamous epithelium exfoliates over a limited area around the external os, and there is produced an erosion resembling that already described under Laceration of the Cervix. Consequently, the red eroded area surrounding the external os that appears in many cases of chronic inflammation of the cervical mucous membrane is due to extension of the inflammatory process on to the vaginal aspect (with desquamation of the superficial squamous cells) and to prolapse of the mucous membrane of the cervical canal. The racemose glands may become obstructed, either as a result of thickening in the character of the secretion or of occlusion of the orifices, and small retention-cysts are formed, which often fill the body of the cervix, and, extending peripherally, appear beneath the mucous membrane of the vaginal aspect. The cervix is then said to have undergone cystic degeneration. Deep-seated inflammatory changes may also take place as a result of cervical catarrh, so that at first a slight hypertrophy from inflammatory exudate results, and later the formation of connective tissue produces a sclerotic condition of the cervix.

As has been said, chronic cervical catarrh, unless of gonorrheal origin, is nearly always secondary to some local or general condition. The most usual cause of the disease is laceration of the cervix, which causes inflammation of the mucous membrane by direct injury and exposure.

The various flexions and displacements of the uterus are often accompanied by cervical catarrh, which probably is caused by the chronic congestion brought about by interference with the circulation of the body and cervix. The use of frequent douches of cold water to prevent

conception is said to result in chronic inflammation of the cervical mucous membrane.

Imperfect involution after labor, miscarriage, or menstruation may cause cervical catarrh from the chronic congestion that results.

Gonorrhea seems in many cases to be communicated directly and primarily to the cervical mucous membrane, and results in a most obstinate form of chronic inflammation.

The scrofulous and tubercular diatheses seem undoubtedly to predispose a woman to chronic inflammation of the mucous membrane of the cervix, as of other mucous membranes of the body. Cervical catarrh often appears in such women without any local lesion to account for it. The severity of the local trouble depends upon the general condition, diminishing when the general health improves.

In all cases of cervical catarrh, even though dependent upon a distinct local lesion like a laceration of the cervix or a flexion of the uterus, the severity of the catarrh, as measured by the quantity of the discharge, is very much dependent upon the general health. The woman is often troubled by leucorrhea only at those times at which her general health is impaired by overwork, anxiety, or from some other cause; and even though the disease may be apparently cured by appropriate treatment, the symptom, leucorrhea, is very apt to reappear whenever the woman is subjected to such depressing influences.

The most conspicuous symptom of cervical catarrh is the leucorrhea-the discharge from the cervical glands. As has already been said, in its physical properties it is characteristic. It is a thick, opaque, tenacious mucus. The quantity is often so great that the clothes of the woman are soiled and she is obliged to wear a napkin.

There may be present slight backache and a feeling of vague discomfort or pain in the pelvis as a result of the inflammation of the cervix. It is difficult, however, to separate symptoms referable distinctly to the cervical

inflammation from those due to the primary trouble, to which the cervical inflammation is also to be attributed. The only one distinct symptom of cervical inflammation is the leucorrhea.

Digital examination in a case of cervical catarrh usually reveals an altered condition of the cervix. The vaginal cervix may be somewhat enlarged and soft in the early. stages of the disease, or cystic and sclerotic in the later stages. The external os is usually enlarged, often admitting the tip of the index finger even in those who have not suffered with laceration of the cervix. The prolapsed mucous membrane is present, and the erosion may be readily felt around the external os, being easily distinguished from the smooth, less velvety squamous mucous membrane of the vaginal aspect.

Speculum examination shows a congested vaginal cervix and a patulous external os around which is the red erosion already described. Escaping from the external os is seen the thick cervical mucus, which is often so tenacious that it may be lifted from the cervical canal with forceps.

The diagnosis of cervical catarrh is usually very easily made from a consideration of the signs described. The important thing in any case is to determine the cause of the inflammation of the cervical mucous membrane, in order that the proper treatment may be directed to it.

Treatment.-As has been said, cervical catarrh is always secondary to some local or general condition, except in the case of direct gonorrheal infection. The gonorrheal cases must be determined by the history of the disease and by the distinctive signs of gonorrheal infection which will be described later.

In every case of cervical catarrh a thorough examination to determine the local cause of the disorder must be made. If, as will usually be the case, such a local cause is discovered, the treatment should be applied to it, and the inflammation of the mucous membrane may be disregarded, with confidence that it will disappear when the