Treatment after bi

lateral

on the cut surface and a vaginal tampon of lint soaked in carbolised oil is applied.

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, division of 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

Cervix.

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.

One result of Emmet's work on laceration of the cervix has been to draw the attention of gynecologists to the fact that ectropion of the mucous membrane and secondary cervical catarrh may follow artificial division of the vaginal portion of the cervix. When this operation is necessary, we recommend, therefore, that it be done by three or four shallow notches round the margins of the os externum.

CHAPTER XXV.

ATROPHY OF THE CERVIX AND UTERUS: SUPERINVOLUTION.

WE meet with an atrophic condition of the cervix and uterus under Conditions 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 congenital 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.

under

which

Atrophy of
Uterus

occurs.

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. A. R. Simpson-Superinvolution of the Uterus: Edin. Med. Jour., May 1883, in which the literature is fully given.

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 24, 2, or even 14 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, A. R. Simpson found it present in 22 out of 1300 cases, that is in about 17 per cent.; Frommel estimates its frequency at 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. A condition of transitory superinvolution-in which the superinvoluted uterus returns to the normal length again—has been observed. 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; A. R. Simpson found this in 10 out of his 22 cases, and 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 amenorrhoea is the symptom which leads the patient to seek advice. After she has ceased nursing, she expects the flow to return.

British Med. Jour., Oct. 1872.

FIG. 158. 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 Graafian vesicles. (Sir J. Y. Simpson.)

It does not do so, however, even after months have passed. Pain in the back, weakness, and hysterical symptoms are sometimes 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. 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 down

a

FIG. 159.

wards upon the
finger which can
thus estimate ac-
curately its size;
having done this,
we make more
traction on the uterus to bring it as far down as
possible, and examine the ovaries.

GALVANIC INTRA-UTERINE STEM; a perfora-
tion in bulb of Stem for the staff c, used
to introduce it; the Stem is of copper
from b to d, of zinc from d to the point
(Sir J. Y. Simpson).

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 21⁄2 in. knob. Differential diagnosis must be made from

Congenital malformation;

Congenital atrophy;

Senile atrophy.

PROGNOSIS.

This should always be guarded. In a few cases, local treatment has been followed by re-establishment of menstruation. As to the possibility of conception, the chances of its occurring are small.

TREATMENT.

From the unsatisfactoriness of treatment, such cases may, as a rule, be left alone. Iron and other constitutional remedies may be tried.