one or two for the wound in the commissure. This operation is without danger, there is but little hemorrhage, and it requires but a short time; the os is left in better condition, and is wider than after the other operations. Union is perfect in eight to ten days, though the sutures may be allowed to remain for weeks. It is a matter of comparative indifference what material is used for sutures.

Esmarch, A. Martin, and Galabin employ a different method: After the cervix is drawn down, two hare-lip pins are passed through it at right angles to each other. The cervix is then constricted by an elastic ligature, and one flap is dissected up upon the outer surface and another upon the inner surface of each lip; the portion of the lip between them is then excised and the upper united to the lower lip with catgut sutures.

When the vaginal portion is but little if at all thickened, the hypertrophy being confined to the body of the uterus, the local and internal use of the preparations of iodine is indicated.

A simple solution of the iodide of potassium 10: 200 may be applied on cotton tampons each evening, or iodized glycerine tampons of the same strength, or an ointment of iodide of potas sium, 3 grains to 45 grains of cocoa butter, may be substituted if desirable. This treatment must be continued for months, being suspended only when symptoms of iodism appear. The beneficial effects are seen in the diminution of the swelling and discharge, and lessening of the general hyperesthesia.

Painting the portion with the tincture of iodine, as is recommended by Breisky, is very expensive in chronic metritis, since the application must be made by a physician or midwife; moreover, it has no advantage over the tampon, and is not always well borne, exfoliation of the mucous membrane, erosions and pain not infrequently being caused by it. Internally, iodide of potassium may be administered in solution. A more agreeable preparation and, eventually, a more active form, is drinking the waters of different mineral springs containing this salt, as we find in Kreuznach, where the " Elisenquelle" is used with warm milk, or in the "Thassiloquelle," at Hall, and in the "Johanngeorgenquelle," at Tölz. In addition to the baths, compresses and vaginal injections are employed. Sitz-baths afford agreeable variety

to many patients, but they are otherwise of but little utility. They form a change in the monotony of the treatment, and are especially appropriate when the affection is complicated by vulvitis or hemorrhoids.

It is unnecessary to state that the diet, the bodily functions, bodily and mental employment, activity and rest, must all be regulated. The patients must be made to know that they are being treated by a physician who understands their complaint, and whom they must obey, for it is evident that they, during their protracted course of treatment and under different physicians, have become acquainted with a long series of remedies. Many, indeed, have a domestic apothecary shop about their beds, and quietly vary the remedies to suit their own fancy. They are especially liable to make free use of narcotics, and to them such agents are poison; these reduce their energy, slow the peristalsis, favor stasis in the pelvic viscera, and increase the irritability of the patient.

There are dozens of watering places which have been recommended for chronic metritis; indeed, there is scarcely one which has not worked wonders in this affection. I share with C. von Braun in the opinion that during convalescence they are often of service, but that they can never be a substitute for rational treatment. The resort chosen will often be determined by the chief symptoms, e. g., the constipation, the leucorrhoea, and the menorrhagia, or dysmenorrhoea. It may be necessary to use several in succession, as Marienbad at first, and then Franzenbad. Again, anemic patients should first visit Elster, Pyrmont, Driburg or Franzenbad, and afterwards the North Sea baths. But few patients are so situated that such a course of treatment can be carried out; neither is one visit usually sufficient, but it must be assisted from time to time by local treatment. With respect to the latter, it may be stated that some have attempted to cure by energetic cauterization of the walls of the uterus, thus increasing the blood supply and promoting metabolism; chromic acid, Vienna paste, fuming nitric acid, and even the actual cautery have been employed for this purpose. Again, curetting the uterus and cauterization have been used, followed by injections of carbolized and corrosive sublimate solutions. Mitchell's cure, which is

warmly recommended by Playfair, has seemed to me more effectual than those previously mentioned. Its chief characteristics are as follows: First, the patient should be removed from her old surroundings; secondly, she must be treated without the use of narcotics; thirdly, massage must be energetically employed to strengthen her muscles and increase their activity; fourthly, an appropriate diet must be ordered, this consisting chiefly of large. quantities of meat, eggs and milk; and, finally, the induced current must be simultaneously applied to bring the patient out of bed and upon her feet. I have treated many patients by this plan, and can assure the reader that the results are very favorable. It does not always render local treatment superfluous, but it has a happy effect so far as constipation is concerned, and with the restored circulation, the uterus often perceptibly diminishes in size; the secretions are likewise profuse, and local treatment is not so essential as formerly. The patient finally has a suitable diet substituted for the host of medicines; the hysterical symptoms gradually disappear, the cold hands and feet grow warm, and her former blank existence develops new life.

CHAPTER V.

STENOSIS AND ATRESIA OF THE UTERUS, HYDROMETRA
AND HEMATOMETRA.

WE have, in previous chapters, considered the subjects of congenital stenosis and total or partial atresia of the uterus, and will now discuss the acquired forms of these anomalies.

Amongst the numerous causes of these are, injuries, chronic catarrh and circumscribed inflammations, continued fevers (such as measles, scarlatina, and diphtheria), endometritis, especially of the puerperal form, injuries from blows, falls, or instruments, cauterization with too powerful agents, prolapsus of the uterus, and the retrograde changes of the tissues in advanced In age. the slighter grades we have simply a stenosis; while, when severe, the occlusion may be complete.

Pathological Anatomy.-The most common seat of the affection is the lowest portion of the uterus, i. e., at the external os; occasionally it is in the cervical canal, and still more rarely at the internal os. It is infrequent at the internal orifice of the Fallopian tube.

When the external os is affected, its border, which is covered with pavement epithelium may be adherent, or the adhesions may be firm, and formed by fibres of muscular or of connective tissue. The usual breadth being 1 centim. ( in.), it is obvious that an os which is hardly as large as a pin head, as shown in fig. 73, is much narrower than normal.

FIG. 73.

These stenoses are usually associated with displacements, the os forming a round instead of a transverse orifice, while the surrounding portions are more pointed or, as in prolapsus of the uterus with stenosis, more flat than in the normal condition.

Sometimes the cervical mucus is retained by the stenosis, as illustrated in fig. 74; in other cases there are other cicatricial contractions near the small opening, or the os is divided into

two portions by a partial atresia. In some the stenosed os is situated at the bottom of a depression, the subjacent tissues forming a wall about it. Small translucent cysts are occasionally found upon the lips. When the stenosis is extreme, an opening nearly resembling a point marks the site of the os, which grows smaller and gives place to an indistinct depression. The same conditions may exist in stenosis of the internal os, or of the cervical canal, though its occurrence in the latter is much less common than at the external os. The stenosis may be small and thin, or it may be thick; stenosis in the region of the internal os often has a thickness of more than 1 centimeter ( in.).

The symptoms of stenosis of the cervical canal are, first, collection of the cervical and uterine secretions, with dysmenorrhoea and sterility; later, chronic inflammation of the whole pelvic viscera, pelvi-peritonitis. The dysmenorrhoea depends upon the condition of the cervical mucous membrane, especially upon the existence of a mucous catarrh with a thick viscid secretion, and also upon the profuseness of the menstrual flow, and the time in which it is discharged. When the latter is scanty, and is discharged slowly, dysmenorrhoea may not be severe, notwithstanding the stenosis is very great. The symptoms of dysmenorrhoea are those of nausea, and a sensation of discomfort and tenseness in the abdomen. When large quantities of blood are rapidly poured out, the tenacious material in the cervical canal obstructs its passage, and violent and extremely painful colicky pains may arise, often lasting for hours. Hence dilatation of the uterine cavity is gradually produced; eccentric hypertrophy ensues, and the uterus takes an hour-glass form. Perimetritis is frequently present; pain and exhaustion continue after the menstrual flow has ceased. The patient becomes emaciated and anemic, very nervous, and finally passes into the hysterical condition, which we described under the subject of myoma. Though not dangerous to life, such affections are exceedingly distressing, and, when neglected, may lead to inflammations and adhesions of the pelvic organs, the effects of which may continue long after the meuopause. Sterility is very often attributed to stenosis of the os uteri. In my address on "Anatomische Untersuchungen zur Etiologie