Fig. 1 is intended to represent the appearance of the os after the operation.

Fig. 2 represents it after the introduction of the tent. When the tent is removed after six, twelve, or more

water.

Fig.2

Fig.1

*

hours retention, the patient is allowed to rest from twenty-four to forty-eight hours, with no treatment, except a free use of tepid injections composed of four drachms of glycerine and two drachms of laudanum to the half gallon of When the tent is again introduced it is, in most cases, well borne for twenty-four hours, after which it should be removed. After the removal of the first tent the, injections are to be used and continued to the end of the treatment, both while the tent is inserted and during the intervals. In forty-eight or seventy-two hours after the removal of the third tent, the cavities of the cervix and body of the uterus may be cauterized with nitrate of silver, chromic acid, or acid nitrate of mercury. If the first named cautery be used, it may be repeated at intervals of from six to eight days. If either of the other two be used, the intervals should be from ten to fifteen days, according to the condition of the patient. The epithelial coat should be completely formed before a reapplication of the cautery. The tent may be resorted to at any time in the after treatment, if there is tendency again to contraction of the cervix. The nicking operation, as above described, is only for the unbent womb. If the womb is not flexed upon itself more than 70° or 80°, as represented at Fig. 3, the same plan of treatment is pursued, with the exception that the nickings or divisions of the mucous membrane are made through the anterior and posterior walls exclusively, no

incisions being made laterally. If the flexion is greater

Fig. 3

than 80°, as shown in Fig. 4, it will be necessary to divide

Fig.4

the posterior or anterior lip, as directed by Dr. Sims, before the canal can be properly incised through the anterior and posterior walls.

For opening up the canal of the cervix in these various conditions, I have added three probe-pointed blades to Dr. Sims' uterotome. They can be used in ball-and

socket handle, or the pivot-and-rivet handle invented by Dr. Sims.

Fig. 5 represents the straight blade, which is 2 inches in length.

Fig.5

Figs. 6 and 7 are the curved blades for cutting the anterior and posterior walls of the flexed womb, each

Fig.7

Fig.6

blade 2 inches in length. Fig. 6 cuts upon the concave edge and Fig. 7 upon the convex. It is not advisable, except in rare instances, to divide the anterior lip in retroversions with retroflexions. Deep cutting, in this form of displacement and distortion, is sometimes followed by acute inflammation, and may result in abscess. I could give numerous examples of cases which I have treated by nicking and the use of the carbolized sponge tent, and in no instance have I seen injurious consequences result from the treatment. I give the folluwing, which were treated by me in St. Louis, each a type case of its class:

Case 1.-Miss, from Wisconsin, æt. 24; menstruated at 14 years of age; continued regular and normal until the age of 18, when she contracted violent cold, at a period, which resulted in derangement of menstruation;

had not been free of pain at a period for six years. At time of operation patient was laboring under severe dysmenorrhea; a slight degree of retroversion-about 45°; elongated, conical neck, with hypertrophy of body and cervix. Depth of cavity to fundus 3 inches. The os externum and canal of the cervix, for an inch, was contracted two-thirds below the normal size. Both cervix and body of the uterus were tender on pressure. Constipation a constant attendant. Almost continuous pain in sacrum and hypogastric region, but worse at the periods, and painful defecation with dysuria. Periods continued from six to eight days, but were never profuse -usually too scanty. The patient was subject to paroxysms of great mental depression.

May 16th, 1867.-Assisted by Dr. Feehan, I nicked the the os and cervix to the internal os by six incisions with the straight probe-pointed blade, cutting through the mucous membrane up to the coarctation, the incisions there being not so deep. After the slight bleeding was over the carbonized sponge tent was introduced and allowed to remain for twenty-four hours. When removed it was without odor and the canal so dilated that it ad

mitted my finger to the coarctation. The tent was introduced every third day until three were used. In the intervals, and also when the tent was within the canal, the injections of tepid water, with laudanum and glycerine, were freely used. After the canal was opened up the cavities of the body aud cervix were cauterized with chromic acid once in twelve or fifteen days, still continuing the injections. The bowels were kept soluble and, with a nutritious diet, the patient was in six weeks menstruating without pain, and with an os and canal well opened, which did not contract again. I examined this case the last of March, 1868, and found the os normal, the canal well open, the uterus in its proper axis,

the cavities 2.6-16 inches to the fundus, showing a natural size. Menstruation regular, of four day's duration; general health good.

Case 2.-Mrs., æt. 29; married; sterile; menstruated at 13 years and not again until 14 years of age. From that time continued regular and normal until her marriage, at the age of 23, after which menstruation became irregular and painful, and so continued up to the time of patient being placed under my care for treatment in August, 1867. The case was one of anteversion with anteflexion about 60°. Depth of cavities to fundus 3 inches. Os and canal for of an inch so small as only to admit my smallest-sized flexible silver sound, which is a fraction less than 1-12 of an inch in diameter.

In this case there was vaginismus with distressing pruritus; muco-purulent leucorrhoea (deep yellow) almost constant, but more abundant before and after periods. At menstrual periods, suffered greatly with nervous headache. Had frequent pain in the bladder and at monthly periods almost constant desire to make water. Was not troubled with constipation. Chronic inflammation of mucous membrane, of cervix and body; submucous tissue much involved; induration and elongation of vaginal cervix.

Operation on the 12th, assisted by Professor Maughs. Chloroform was administered on account of the extreme sensitiveness of the patient. I nicked through the mucous membrane of the os and cervix to the cavity of the body, by two incisions in the posterior wall, and the incisions in the anterior wall. After the bleeding, which was moderate, the carbolized sponge tent was introduced, and a cotton tampon, saturated with glycerine, placed in the vagina to prevent the tent from slipping out. The general plan of treatment as described in case 1 was carried out in this. The recovery was complete, the canal and os being fully restored to their normal size.