More important than the incision is the after-treatment. The patient must be seen on the following day, and every second day for a fortnight, and the finger passed in on each occasion to prevent union of the cut surfaces and dilate the cervical canal. To keep the canal open, Thomas

Fig. 157.

Glass Plug to keep the Cervix Patulous after division (Thomas).

recommends the use of a glass cervical plug (fig. 157), kept in position by a solid plate of the form of an Albert Smith pessary. This is useful after division of the posterior lip, but we think that it is not necessary after the bilateral incision.

CHAPTER XXV.

ATROPHY OF THE CERVIX AND UTERUS: SUPERINVOLUTION.

WE meet with an atrophic condition of the cervix and uterus under four different conditions :

1. As a congenital condition;

2. Associated with certain constitutional affections, as phthisis, scrofula, chlorosis;

3. In the puerperal uterus, as the result of superinvolution; 4. After the menopause.

Should the student find on vaginal examination that the cervix is small and projecting only slightly into the vagina, and on bimanual examination that the body of the uterus is found with difficulty and is smaller than it should be, he must next ascertain which of the abovementioned causes has produced the atrophy.

The history will enable him to form his diagnosis. With the con• genital condition there is a history of amenorrhoea or scanty menstruation since puberty, of sterility if the patient has entered married life, and of hysteria and other disturbances of the nervous system which usually accompany imperfect development of the uterus. The constitutional condition, and especially the state of the blood and of the lungs, in other cases enables him to account for the condition of the uterus. Probably the small uterus found in chlorotic patients is a congenital condition, and not secondary to the constitutional state. If the atrophic condition be the result of superinvolution, there is a history of childbirth with non-appearance of menstruation after it. With regard to the menopause, the age of the patient is the chief guide; we must remember the possibility of an early menopause, as early as at the age of thirty-five.

The only atrophic condition which we shall consider here is that occurring in the puerperal uterus as the result of superinvolution. To Sir James Simpson's description of this condition we are chiefly indebted.

SUPERINVOLUTION OF THE UTERUS.

LITERATURE. Frommel-Ueber puerperale Atrophie des Uterus: Zeits. f. Geburts. und Gynäk., Bd. vii., H. ii., S. 305. Jaquet-Berl. Beiträge zur Geburts. und Gynäk., Bd. ii., S. 3. Klob-Patholog. Anatom. der weib. Sexualorgane: Wien., 1864, S. 205. Simpson, Sir J. Y.-Med. Times and Gazette, 1861. Diseases of Women: Edin., 1872, p. 547.

PATHOLOGY.

The uterus is small. Its external length may be reduced from the normal 3 to 1 inches. The walls are thin and flaccid, sometimes of a dense and fibrous consistence. The vaginal portion projects only slightly into the vagina, and may be almost flush with the vaginal roof. The os may be relatively patulous, or contracted so as only to admit a probe. The uterine cavity is reduced to 21, 2, or even 1 inches in length. The ovaries are atrophied, and sometimes show an increase of fibrous tissue in their structure. The accompanying specimen (fig. 158), described by Sir James Simpson, illustrates these points.

ETIOLOGY.

As to the frequency of this condition, Frommel found it present in 28 out of 3000 gynecological cases, that is in almost 1 per cent. The reason why, in certain cases, the process of involution during the puerperium goes on till the uterine cavity is reduced to less than 2 inches in length is not known. Protracted Lactation seems the most important cause (Frommel). We have seen this in two cases, and Chiari has also drawn attention to it. In some instances there is a history of great loss of blood at the confinement; in a case of this, reported by Whitehead,* the atrophic changes had progressed so far that no trace of a uterus was found on the most careful examination. In other instances pelvic peritonitis has occurred during the puerperium: this can produce, we know, atrophy of the ovary through binding it down with adhesions; and atrophy of the ovaries may lead to atrophy of the uterus. It is also associated with the tubercular diathesis (Klob).

SYMPTOMS.

Continued amenorrhea is the symptom which leads the patient to seek advice. After she has ceased nursing, she expects the flow to return. It does not do so, however, even after months have passed. Pain in the back, weakness and hysterical symptoms are also present.

DIAGNOSIS.

The small cervix at once suggests what the condition is. We sometimes have difficulty in making out the uterus bimanually; here the examination per rectum, combined with the volsella, is useful.

Preparation of Uterus and Ovaries in a case of Superinvolution ad naturam. Weight of parts represented-one ounce, four drachms, twenty-five grains. Uterine cavity measures 1 in. Thickness of posterior uterine wall (laid open in figure) in. Tissue of uterus, dense and fibrous. Ovaries atrophied, with increase of fibrous tissue and no appearance of Graaflan vesicles. (Sir J. Y. Simpson.)

The best idea of the size of the uterus is gained by pressing the ball of the finger in the rectum against the isthmus of the uterus, and then moving the uterus upwards and downwards upon the finger which can thus estimate accurately its size; having done this, we make more traction on the uterus to bring it as far down as possible, and examine the ovaries.

The sound must be used with care, as it easily perforates the thin walls of the uterus. It does not pass into the uterus as far as the 2 in. knob.

Differential diagnosis must be made from—

Congenital malformation;
Congenital atrophy;

Senile atrophy.

TREATMENT.

This consists in stimulating the uterus to hypertrophy by placing a foreign body in its cavity. The galvanic intra-uterine stem pessary of Sir James Simpson is

should always be Galvanic intra-uterine Stem: a perforation in

shorter than the

uterine cavity by

bulb of Stem for the staff c, used to intro-
duce it; the Stem is of copper from 6 to d,
of zinc from d to the point (Sir J. Y.
Simpson).

a of an inch; otherwise it may
fundus. It is introduced as follows.

perforate the
The cervix is

laid hold of with the volsella to draw it towards the vaginal orifice and to steady it. The stem is held with the bulb between the finger and thumb, and passed into the cervix for about an inch. If the

vaginal orifice be too narrow to allow of this manipulation, the bulb is fixed on the end of a staff (fig. 159) and thus carried in. Once the stem