(the symptoms being due to the narrow os externum), or when sterility rather than dysmenorrhoea is the leading symptom, the indication is for Simpson's operation. This has been already fully described under stenosis of the cervix (Chap. XXIV.).

(2.) Marion Sims recommends that his operation be performed in cases where there is well-marked flexion, and the intra-vaginal portion unequally developed, i.e., where the posterior lip is elongated so that the os looks downwards and forwards. The intention of the operation is to correct the flexion of the canal by making the exit at the base of the posterior lip of the cervix instead of at its apex, that is, at the outer end of the dotted line a (Fig. 201). But as the flexion is too high up to be reached by this incision alone, it is necessary for the more complete

b

Fig. 201.

Sims' division of cervix; a, incision in posterior lip, b, incision at knee of flexion (Marion Sims).

straightening of the canal that the tissue of the knee-shaped bend in the anterior wall be partially divided-the incision to be made to the depth of the line b (Fig. 201).

This operation should not be performed indiscriminately in all cases of uterine dysmenorrhoea, but only after we have ascertained by careful examination that the flexion is sufficient to account for the dysmenorrhoea and that the latter is due to nothing else. The patient should be informed that sometimes the symptoms return afterwards; this is due to the partial closing up of the incision, which may occur in spite of the greatest precautions. When pelvic inflammation is present, we should not operate. If the cervix is drawn backwards and fixed, we are not likely to have a good result.

The operation is performed as follows. The speculum having been

passed, the cervix is drawn down with the volsella to the vaginal orifice. Marion Sims divides the posterior lip with his utero-tome. A pair of strong scissors does equally well. Kuchenmeister's scissors have the point of one blade turned in like a hook; this blade is placed externally in making the section, and the pointed hook keeps the scissors from slipping. The scissors in Fig. 111, Vol. I., have this peculiarity; and the form of the handles, with their greater length in proportion to that of the blades, gives the hand better purchase and enables the operator to cut steadily through the dense tissue of the cervix. The instrument is passed, with the straight blade in the cervical canal, till the incurved point of the external blade is opposite the line of reflexion of the mucous membrane on the posterior wall of the vaginal portion. The handles are now approximated, the ratchets on them enabling us to do this slowly and steadily. When they are brought together; the instrument is withdrawn. The finger is passed into the cut to see if it is of sufficient depth; if any projecting band of tissue be felt, it is divided with the knife. The mucous membrane of the anterior wall of the cervix at the seat of flexure is now divided as follows:-A curved tenotomy-knife, with a narrow probepointed blade, is passed into the canal; the sharp edge is turned forwards, but the back of the knife is pressed against the posterior wall so that the knife does not cut on being passed in; having passed it fairly to the point of flexion, we now withdraw it and at the same time press the blade forwards. We judge as to the extent of this incision from the amount of flexion present (ascertained by previous examination) and from the sensation of the hand in cutting through the tissue.

After-treatment. The incision must be kept open by the introduction of a glass plug (Fig. 157, Vol. I.). Unless this be done, the result is only temporary; we speak from experience, having operated in several cases. without the introduction of a plug subsequently. The patient in these cases derived great benefit for two or three menstrual periods, but after this the symptoms returned; and it was found, on examination, that the new opening had been obliterated by cicatrization.

The treatment of anteflexion by specially adapted vaginal pessaries is recommended by Thomas and others, but is not a scientific one. It is wrong in principle, because the fundus uteri cannot be propped up by an arm of the pessary projecting through the anterior fornix so as to diminish the angle of flexion. In some cases where the uterus is large and heavy we find that benefit is derived from supporting the uterus as a

whole. But this is best effected by an ordinary vaginal pessary (Hodge or Albert Smith), and is not a mode of treatment specially of anteflexion. We shall refer to this again under the treatment of anteversion.

ANTEVERSION.

PATHOLOGY AND ETIOLOGY.

The pathological change consists in a straightening of the uterine axis, so that the normal angle of forward curvature is diminished and the cervix passes more directly backwards. The uterus is usually enlarged and its texture is firmer. In this condition it is movable or fixed. If the former, its position varies with the distention of the bladder; if the latter, the fixed uterus will press more or less on the bladder as it distends, and thus produce one of the symptoms of anteversion.

According to Fritsch, the fixation of the uterus is never to the pubis; this is because the bladder, lying between the fundus and the symphysis, prevents adhesions from forming. On post-mortem examination of a case in which he had diagnosed anteversion with fixation, he found that the fundus was bound down at its left angle.

The microscopic changes have not been described, but we should expect an increase in the amount of connective tissue (v. Chronic Metritis).

ETIOLOGY.

As anteversion is the form and position taken up by the uterus when it is enlarged through chronic metritis, the causes which produce anteversion are those which produce chronic metritis-subinvolution, laceration of the cervix, and other causes of pelvic inflammation (v. Chronic Metritis).

This position also occurs physiologically in early pregnancy; probably because the increased weight of the uterus causes it to fall more forwards.

SYMPTOMS.

There are no symptoms characteristic of anteversion, per se, but we generally find present, in the first place, the local symptoms of chronic uterine and pelvic inflammation.

Thomas draws attention specially to loss of power in walking-when the version was treated, power was restored; this was probably a reflex

VOL. II.-3

phenomenon. Sometimes there are symptoms due to interference with the functions of the bladder and the rectum. Pressure of the fundus (when the uterus is fixed) on the bladder produces frequent calls to micturition; pressure of the cervix on the posterior wall of the vagina produces erosion and catarrh, and on the anterior wall of the rectum produces painful defecation.

Further we may have the train of general symptoms which follow on any long-standing disturbance of the reproductive system, viz., derangements of the digestive and nervous systems. Schoerder draws attention to the fact that discomfort is often produced when the uterus is enlarged but freely movable, and that this is due to the heavy organ's becoming displaced on the movements of the patient; further, that it is relieved if the uterus be fixed by a vaginal ring pessary.

DIAGNOSIS.

There is usually no difficulty in diagnosis. The finger in the vagina feels the cervix passing directly backwards, the os looking towards the hollow of the sacrum. The body of the uterus is distinctly felt through the anterior fornix; and on tracing it back to its junction with the cervix we do not feel the normal forward curvature. The whole organ is usually enlarged and firm in texture. From the distinctness with which the uterus is felt when the bladder is empty, we might infer that only the anterior vaginal wall lay between it and the finger. But, if we make the examination when the bladder is partially distended, or if we pass the sound into the empty bladder, we find that the bladder passes backwards almost as far as the cervix uteri. Perhaps the bladder symptoms, which are present in marked cases, might be explained through the traction thus made on the bladder and its abnormal position; these interfere with its dilatation.

The bimanual examination shows that the body felt in the anterior fornix is the fundus uteri. The student should not, however, be content with this knowledge, but should examine carefully the size and mobility of the uterus; and, when it is fixed, should ascertain the cause of this.

The introduction of the sound is difficult on account of the high position of the os, and its use is unnecessary except in cases of doubt as to whether the body felt anteriorly is the fundus uteri.

The only case in which there is difficulty in differential diagnosis is

when there has been inflammatory deposit in front of and around the cervix, simulating the anteverted fundus. In these cases the combined examination is difficult from existing inflammation. The examination with one finger in the rectum enables us, in such cases, to ascertain that the fundus uteri is at least not lying to the back.

TREATMENT.

From what we have said in regard to the symptoms, it follows that the treatment, in the first instance, is that of endometritis, metritis, cellulitis, or peritonitis, according to the condition which is present. As regards the supporting of the uterus, great benefit may be derived from the glycerine plug, which in this case should be well packed into the posterior fornix. The simple vaginal pessary (Hodge, Albert Smith, ring) is useful in supporting the uterus as a whole, and in fixing the cervix.

As already said under anteflexion, the fundus cannot be immediately

Graily Hewitt's cradle pessary. a is in posterior fornix; b at vaginal orifice; c in anterior fornix (Barnes). supported through the anterior vaginal wall. Various forms of pessary have been devised, but the principle is the same in all. There is the "cradle pessary" of Graily Hewitt (Fig. 202), made of vulcanite. Mundé strongly recommends Gehrung's anteversion pessary (Fig. 203). Its position in the vagina is seen at Fig. 204. Thomas has devised several forms of anteversion pessary, of which one is represented at Fig. 205. It is simply a Hodge pessary, with a projecting bar which passes into the anterior fornix and tilts the cervix forwards and thus slightly retroverts the fundus. To facilitate its introduction the bar moves on a hinge so that it may be brought parallel with the pessary as it is passed in, while a con