Caliber of the cervical canal, os externum, and os internum. Degree of sensitiveness of the different portions of the cavity of the uterus.

Sound and Palpation Combined.-Displaced uterus may be raised up to meet the touch of the hand upon the abdomen for examina

tion.

Mobility of the uterus with or without moving abnormal growths in the pelvis or lower portion of the abdomen.

Curette. Presence or absence of growths or tumors in the uterus. Removal of portions of growths from the cavity of the uterus for inspection.

Aspiration. Abstraction of fluid (encysted or otherwise) for inspection.

Dilators, tents, anæsthetics and head-mirror as aids with other means of exploration.

FIG. 18a.-Ether-inhaler. Its principle is the same as that of the nitrous-oxide apparatus. The reservoir, B, in which the ether is vaporized, is separated from the mouthpiece, A, by the long rubber tube. The valves, E, of the mouth-piece permit the expired air to escape without coming in contact with the ether-vapor. The valve, D, enables the anesthetizer to administer pure air or pure ether, or any proportion of air and ether. The advantages of the apparatus are that the ether-vapor is warmed, that reinspiration of expired air is avoided, and that the ether may be diluted with air to maintain the required anæsthesia. The stage of violent excitement caused by partial suffocation is avoided, and prolonged anæsthesia can be maintained without the slightest imperfection of aëration of the blood.

CHAPTER II.

DEVELOPMENT OF THE SEXUAL ORGANS.

THE Fallopian tubes, uterus, and vagina are developed from two primary elements known as Müller's filaments. These filaments when first visible in the embryo are solid, and are situated on either side of the vertebral column, a little in front of and on the inner side of two other primary elements, the Wolffian bodies. The changes which take place in Müller's filaments during the evolutions of development are as follows: From solid fibers, slightly enlarged and club-shaped at their upper ends, cavities are formed, and these become canals. Their lower ends approximate and coalesce, from below upward, less than half their length. This change, which takes place between the ends of the sixth and eighth weeks of foetal life, is represented in Figs. 19 and 20. At this stage of development, Müller's ducts are separated by a septum formed from their coalescent walls, so that the united. portion shows a right and left cavity. These two cavities are soon converted the septum

FIG. 19.-Muller's ducts.

FIG. 20.-Coalescence of
ducts.

FIG. 21.-Disappearance of septum.

FIG. 22. Appearance of
fundus and cervix.

into

one,

disappearing from united portion of the

below upward throughout the whole of the ducts. The lower single canal thus formed is the rudimentary vagina and uterus, while the two upper ends of Müller's ducts form the Fallopian tubes (Fig. 21). From this time to the fifth month there

is an increase of tissue, especially in the upper portion of the canal, which renders the distinction between the vagina and uterus apparent. The upper ends of Müller's ducts expand and become slightly fimbriated at their extremities. The upper portion of the uterus at this time is bifurcated and forms the two horns between which the fundus is subsequently developed. Fig. 22 shows the organs at this stage of development. In the sixth and seventh months the uterus increases in size, especially in the cervical portion, which at this stage is much larger than the body. There is also an increase of tissue between the horns of the uterus which renders their diverg ence less marked. The rugose arrangement (palma plicata) of the rudimentary mucous membrane of the cavity of the uterus extends very nearly to the fundus, its folds running outward to the uterine orifices of the Fallopian tubes. Ele

vations appear in rows upon the mucous membrane of the vagina which are the rudiments from which the transverse folds are subsequently developed. During the eighth and ninth months the thickness of the walls of the body of the uterus increases, the fundus becomes more prominent and rounded, but up to the time of birth the cervix is larger than the body of the uterus. At the time of birth the

FIG. 23.-Infan-
tile uterus.

FIG. 24. Palma plicata extending nearly to

fundus.

primary development of the uterus is complete, and it changes very little in form from that time until the period of puberty. The size

and appearance of the infantile uterus are shown in Fig. 23. The cavity of the uterus and the arrangement of its mucous membrane are represented by Fig. 24. Fig. 25 gives a side-view of the uterus and vagina, and shows their relations to each other. At this time the cervix projects but little into the vagina.

From the time of birth, when primary development is complete, up to the period of puberty, the uterus undergoes very little change except during the second dentition. At that time the body increases in FIG. 25.—Infantile uterus, an- size, becoming more nearly equal to the cervix. The palma plicata disappears

invagination.

from the body of the uterus, excepting one longitudinal fold. The uterus gradually descends into the pelvic cavity and the cervix is projected down into the vagina a little farther. From this time no changes occur worthy of notice until puberty, when secondary development takes place.

Secondary development consists in a general increase in the size of the uterus, especially in the body and fundus, which become much larger than the cervix. The length of the uterus is increased. The walls become thicker and firmer. The last trace of the palma plicata disappears from the mucous membrane of the cavity of the body, and the mucous membrane becomes thicker by the formation of its glandular tissues. In this way the uterus attains the shape and size of maturity. Together with the changes in size and form comes a change of position. The uterus descends into the pelvis and complete invagination of the cervix occurs.

Fig. 26 shows the general appearance of the mature uterus in outline, and Figs. 27 and 28 represent the relations in which the

FIGS. 26-28.-Virgin uterus (Sappey): 26, anterior view; 27, median section; 28, transverse section. 26. 1, body; 2, 2, angles; 3, cervix; 4, site of the os internum; 5, vaginal portion of the cervix; 6, external os. 27. 1, 1, anterior surface; 2, vesicouterine cul-de-sac; 3, 3, posterior surface; 6, isthmus; 7, cavity of body; 8, cavity of the cervix; 9, os internum; 10, anterior lip of os externum; 11, posterior lip. 28. 1, cavity of body; 4, 4, cornua; 5, os internum; 6, cavity of cervix; 7, arbor vitæ of the cervix; 8, os externum.

cervix and vagina stand to each other. By comparing Figs. 23 and 25, which illustrate the infantile uterus, with Figs. 26 and 27, the difference between the results of primary and secondary development will be fully comprehended.

MALFORMATIONS OF THE UTERUS.

The malformations of the uterus are naturally divisible into two classes those that occur during embryonic life, and those that occur at puberty, the period when secondary development takes place. The first class embraces the greatest variety. Nearly all of these malformations are due to arrest of development at different stages of that process. The malformations most frequently seen are the uterus

FIG. 29.-Double uterus and vagina from a girl aged nineteen (Eisenmann): a, double vaginal orifice with double hymen.

bipartis, uterus duplex, uterus unicornis, uterus bicornis, uterus bifundalis unicollis, and rudimentary uterus, generally known as ab sence of the uterus. A very rare condition has been described as hypertrophy of the uterus, and classed with the malformations. It is really not a malformation, but a complete development of the