exist as to the treatment of congenital atrophy of the uterus and of foetal uterus. While most authors hold all treatment as useless for foetal uterus, Gusserow is of quite the other opinion. He says that all treatment is useless in congenital atrophy of the uterus because we have there to do with a malformation. But in foetal uterus, if the uterus has the infantile form, as characterised by the preponderance of the cervix over the fundus, we have to do with a failure of development only. An increased development of the uterus is to be aimed at by the use of hot douches, and especially by faradisation1 of the uterus. One pole is placed within the uterus. The general health must be raised by suitable nourishment and careful hygienic conditions. In chlorosis iron must be given. Marriage very often renders other treatment unnecessary. The diversity of opinion already mentioned is easily explained when we find that various transitional forms between the uterus fœtalis and the uterus atrophicus are met with. It would therefore be well to try the treatment in both conditions in case there be no corresponding arrest of development of the ovaries.

Stenosis of the Uterus.

Stenosis of the uterus concerns its lower segment, the cervix-and there are isolated stenoses of the external os, of the whole cervical canal, and more rarely of the internal os uteri. Stenosis may be congenital or acquired.

Congenital stenosis of the external os occurs under two conditions stenosis in a normal sized uterus, and stenosis in an atrophied uterus. In congenital or acquired stenosis of the whole canal the external os is naturally stenosed also. Congenital stenosis of the whole cervical canal is generally accompanied with elongation of the cervix, which lies in the axis of the vagina, with the small strongly ante

1 This is very useful in the acquired uterine atrophy caused by repeated or too long continued lactation. The uterus becomes larger, and menstruation comes on.

flected uterine body resting upon it (the anteflected uterus is in a position of retroversion). We have here to do with an infantile uterus and inflammatory hypertrophy of the cervix.

Acquired stenoses are most commonly caused by intrauterine caustics,-when care has not been taken to completely remove the excess of caustic by washing the uterus out after its use, also by cicatricial contraction as a result of ulcerative processes in the neighbourhood of the os uteri, from extensive lacerations in labour, and from operations. Even amputation of the portio, which is recommended generally to cure the stenosis, may produce cicatricial growth of this kind, so that stenosis of the external os results. Finally the too free plastic closure of a cervical laceration (Emmet's operation) may have the same effect.

Inflammatory swelling of the cervical mucous membrane also produces a contraction of the cervical canal, as does senile involution of the whole uterus. In the latter case the stenosis, in women who have borne children, affects the internal os only, since in multiparæ the lower section of the cervix is permanently more dilated.

There is also a relative stenosis, which consists in the cervical canal being perhaps normally dilated, but with abnormally copious or viscid secretion of the uterus. Retention of the secretion takes place, as in stenosis of the cervix; this leads to secondary dilatation of the cavity of the body of the uterus if corporeal catarrh is present, or to spindle-shaped dilatation of the cervical cavity in cervical catarrh.

Finally, there are temporary stenoses of the internal os uteri, which come from application of caustics to the cervical mucous membrane and from clumsy use of the sound. These are due to contraction of the muscular fibres of the inner os. Without contraction of this kind stenosis of the internal os may be suspected wrongly when the sound is not pushed in the direction of the uterine cavity.

Symptoms. These are dysmenorrhoea and sterility, and Sims says that they are due to the stenosis preventing the escape of menstrual fluid and the entrance of spermatozoa. The retention of blood leads to painful contractions of the uterus. This uterine colic may come on apart from menstruation in connection with catarrhal inflammation and stenosis, and arises then owing to the obstructed outflow of the catarrhal secretion. Sterility is not absolute, since spermatozoa can, by their smallness and activity, make their way through an abnormally narrow os uteri. It is more commonly caused by inflammation of the uterine mucous membrane, or defective development of the whole uterus and ovaries which accompanies the stenosis.

But there certainly is a difficulty thrown in the way of conception by the various stenoses, if only because they hinder the normal eversion and consequent retraction of a fringe of cervical mucous membrane during coitus, which thus becomes laden with spermatozoa. As a result the spermatozoa stay longer in the vagina, where the acid mucus kills them.

Dysmenorrhoea and sterility occur also in a series of other gynecological affections, especially diseases of the appendages of the uterus, and in defective development of the whole uterus or ovaries.

The diagnosis of stenosis should never be made from the history only, but by means of a sufficient combined examination one should make out the size of the whole uterus, the condition of the tubes and ovaries, and of the pelvic peritoneum and cellular tissue. If nothing abnormal is found in these parts the possibility of stenosis may be entertained.

Diagnosis. With the exception of relative stenosis, the os uteri is so narrow at times in stenosis of the external os that one can scarcely feel it with the finger, and one can only recognise it in the speculum as a small dimple. When this high degree of stenosis is present the diagnosis is established in every case, even when the uterus is

abnormally small; while a slight stenosis in an abnormally small uterus is only a symptom of the want of development of the whole uterus. Every stenosis of the external os uteri, including relative stenosis, is recognised by secondary dilatation of the cervical canal, which appears to be distended, like a bladder, by retention. of the tough secretion. According to B. S. Schultze's careful measurements, a sound of 4 mm. thickness should pass the normally sized canal without difficulty if properly directed. We may further take stenosis of the external os as established if, in a uterus of normal size, a sound point 4 mm. thick cannot be passed, or can be passed only by using considerable force.

By using the sound mentioned we can discover stenosis of the whole cervical canal. This is present if the 4 mm. sound cannot pass through the cervical canal.

Stenosis of the internal os uteri is diagnosed when the practitioner finds that in spite of careful use of the sound, in spite of bending it to suit the curve of the uterine axis, and in spite of pushing the sound forwards in the direction of the uterine canal, notwithstanding the fixation of the uterus with the volsella, an ordinary sound of 4 mm. cannot be passed at all or only with some forcing after repeated attempts.

As regards prognosis stenosis does not endanger life, but it may cause suffering of many kinds, which finally renders the woman a permanent invalid. Menstruation is painful from its onset, and the patient has to keep her bed. As a result of retention of the secretion, endometritis with increased secretion sets in, and uterine colic now comes on which causes dysmenorrhoea apart from menstruation. By the more or less continuous cramplike pain the whole constitution, and specially the nervous system, is sympathetically affected-neuroses of the most varied character arise. The endometritis also spreads to the parenchyma of the uterus, to the peritoneum, and the ovaries. Thus, in addition to endometritis there arise, as a result of stenosis, metritis, perimetritis, oophor

itis, and perioophoritis. These lead to increased menstrual blood-flow and the onset of fresh pains.

Treatment.-Before the treatment of stenosis is undertaken one should find out whether with the stenosis the above-mentioned consequences are present or not. In recent febrile perimetritis all manipulations are contraindicated. If, on the other hand, old perimetritic adhesions of the ovaries, or perimetritic bands fixing the uterus, are present, the patient should be anæsthetised in order to free the ovaries bimanually from their adhesions, and to stretch or tear down the bands. When endometritis is present with the stenosis, one should endeavour to cure them both at once, the endometritis by curetting. The uncomplicated cases of slight stenosis are very simple to treat. They occur in young girls soon after the onset of menstruation. The simple introduction of a sound into the uterus is often sufficient in these cases to remove the dysmenorrhoea, and on marriage this enables conception to take place.

In more severe stenosis active treatment is indicated. In stenosis of the external os this consists in bilateral discision and suture of the surfaces of the incision, and this certainly cures the stenosis when carried out correctly (Courty). The operation is as follows:

The external genitals and vagina are first carefully disinfected, and then the cervix is exposed by one or two of Simon's specula. The anterior and posterior cervical lip are seized with volsella, and the uterus is washed out with 3 per cent carbolic lotion. The os uteri is then extended on each side by incisions -1 cm. (- inch) in width. Cowper's scissors are used. Two wound sur

faces are thus formed which are next the cervical mucous membrane, and which extend from the apex of the anterior to the apex of the posterior lip. These wounds tend to gape. The wounds are now closed by interrupted sutures of silk or catgut passed transversely under the wound surfaces, and bringing cervical and vaginal mucous mem