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straightened by such means. This favour was greater even in Paris than in England, owing to the greater hold that these doctrines had over the medical mind. The late M. Valleix, like myself, an old pupil of M. Velpeau, more especially distinguished himself by his ardent and uncompromising advocacy of the displacement theory, and of the treatment of uterine displacements by the use of the intra-uterine stem pessary.

It would be vain to attempt to reproduce the various arguments that have been adduced on both sides, at home and abroad; it would take a volume. I shall therefore confine myself to recording my own opinions, and the data on which they are founded. Seven years' additional personal experience, and an attentive study of all that has been done and said during that time, have only confirmed the views which I advanced in the second edition of my work on "Uterine Inflammation" in 1849. I then said, and still believe, that the displacement theory, as an explanation of the morbid uterine and general symptoms of those who present uterine displacements, is an error. I also stated that most (not all) of these uterine displacements had their origin in modifications of volume, the result of inflammatory lesions, directly or indirectly; and that the rational treatment of these displacements consisted in the treatment of the inflammatory lesions which produce them.

I have myself had little experience of the fixed intra-uterine stem pessary: firstly, because, holding the above views, I did not often see its applicability, or the necessity for its use; and secondly, because I was afraid of it, for reasons which I shall give hereafter. The experience of others, however, now obliges me to say that its use is attended with considerable risk and danger. Although Dr. Simpson has himself, I believe, had no fatal accident in his practice, several fatal cases have occurred in England, and in Paris seven deaths from the use of the intrauterine pessary have been published-the one of M. Amussat, which occurred in 1826, and six recent cases. Of the latter, three have taken place in the practice of M. Valleix-two from acute peritonitis, and one from secondary pelvic abscess; one in that of M. Nélaton; one in that of M. Maisonneuve; and one in that of M. Aran.

The three last were also cases of acute

peritonitis. The discussion at the Academy of Medicine, on uterine displacements, and on their treatment by the intrauterine pessary, originated in the communication to the Academy of two of these fatal cases.

I shall now take into consideration the facts which have led me, individually, to repudiate the doctrine of uterine displacement as the principal cause of uterine suffering, and which have prevented my resorting, unless in exceptional cases, to mechanical means for the treatment of these displacements.

ANATOMICAL AND PHYSIOLOGICAL FACTS BEARING ON DISPLACEMENT OF THE UTERUS.

In order to appreciate correctly the intricate question of uterine displacements, there are various facts, anatomical and physiological, which should be known and borne in mind.

The principal anatomical feature to which I would draw attention is, the extreme mobility of the healthy unimpregnated uterus. This extreme mobility may be proved experimentally. If the index finger is passed into the vagina-the patient lying on her back, the pelvis elevated, and the knees flexed-and if pressure is made on the cervix with the finger, it will be found that the healthy uterus yields with the greatest readiness to the slightest impulsion. It affords so little resistance to the finger, that, if the bladder and rectum are empty, it may be either raised directly upwards, towards the upper pelvic outlet, or depressed posteriorly, anteriorly, or laterally, and that with the greatest ease, and without the patient experiencing even discomfort.

The anatomical explanation of this great freedom of motion of the healthy uterus is to be found in the smallness of its size, and in the laxity of its connexions with the pelvic organs and cavity. In the female who has not borne children, the uterus only weighs an ounce or an ounce and a half; even in the one who has borne children, it does not weigh more than two ounces in the healthy state. This smallness in size of the uterus is evidently a provision of Nature. A small, light organ could be supported and kept in situ without the necessity of strong, unyielding bands or ligaments; whereas such means of support

and retention would have been indispensable had the uterus been large and heavy, and at the same time would have been quite incompatible with the changes which it is destined to undergo in pregnancy.

On examining minutely the means of support which the uterus presents, we find that they are very slight. The lateral ligaments are not so much means of sustentation as peritoneal folds, enveloping the uterine appendages,―the ovaries. Fallopian tubes, and round ligaments. The latter, by their passage through the inguinal canal, and their firm cutaneous attachment, are really means of sustentation; but the support which they give to the uterus is very much like that given to a swing by the two ropes which suspend it, and which allow great freedom of motion in every sense. The insertion of the vagina

on the neck of the uterus, and the closure of the vaginal canal on the lower extremity of the cervical cone, evidently constitute another important means of sustentation. It is at the insertion

of the vagina on the neck of the uterus that the neck or lower segment of the uterus passes out of the pelvic cavity through the inferior pelvic fascia, which probably assists the vagina to support it. The connexion between the fundus of the bladder and the neck of the uterus also contributes, no doubt, to fix the uterus in its normal state; as does the pressure of the surrounding organs, the pelvic cavity being full and more or less closely packed during life.

If the walls of the abdomen are removed, and the uterus is examined in situ, it will be found that the uterus and the lateral ligaments extend across the pelvic cavity, and divide it into two sub-cavities; one smaller, the anterior, which contains the bladder; the other larger, the posterior, which contains the rectum. The uterus and the bladder are generally in juxtaposition; but the uterus and rectum, especially when the latter is empty, are separated by small intestines, which fill up the pelvic cavity and form a posterior support to the uterus.

The healthy uterus, in its normal condition and position, especially in women who have never borne children, is, I have ascertained, generally slightly inclined forwards,—that is, slightly anteflexed. This fact is not mentioned by anatomists;

but if true, as I believe it to be, is of importance, from its direct bearing on the pathology of one of the forms of uterine displacement-anteflexion and anteversion. I became acquainted with the existence of this normal anteflexion accidentally a few years ago. Finding, as I have elsewhere stated, that the vital contraction of the os internum during life often opposes considerable resistance to the introduction of the sound into the uterus, I tried small wax or gum-elastic bougies, which generally pass with comparative ease. If these bougies are left a minute or two in the uterine cavity, the uterus being perfectly healthy and normal in size, on withdrawal they invariably present a slight anterior curve, as in the accompanying woodcut :—

The degree of the curve varies, as in the engraving, which represents two bougies that had been allowed to remain a couple of minutes in the uteri of two young sterile patients, perfectly free from uterine disease. One I had treated successfully, by dilatation, for dysmenorrhoea, the result of congenital narrowness of the cervical canal; the other I had treated for an inflammatory affection of the neck of the womb, and she had quite lost all morbid symptoms. Every precaution was taken to ensure correctness; the bougies being introduced by means of the speculum. This slight curve I find so constantly as I describe it, in the healthy uterus, and especially in females who have never been impregnated, that I cannot but consider it to be normal. Its existence, as the rule, moreover, is corroborated by the researches of M. Boullard, a young Paris surgeon, Prosector to the Faculty, who, after numerous and extended cadaveric investigations, has arrived at the same conclusion. Thus, his researches tend to establish by the examination of the dead, what mine tend to establish by the examination of the living,-viz., the existence of a slight degree of

anteflexion as a natural anatomical state. M. Boullard's statements were discussed, and partly substantiated, partly negatived, at the Academy of Medicine, but principally on data furnished by the digital examination of living patients. The least consideration, however, will show that such a slight curve as the one indicated in the woodcut on the preceding page can be scarcely appreciable to the touch, although pathologically very important, as a predisposing cause of morbid anteversion.

The axis of the unimpregnated healthy uterus is generally considered to be that of the upper pelvic outlet; but if the slight anterior curvature which I describe is recognised, we must admit that the axis of the upper portion of the uterus only, corresponds to the upper pelvic outlet, whereas that of the lower portion or neck would partly correspond to that of the lower pelvic outlet. M. Cruveilhier says that the uterus has no axis❞—meaning thereby that its changes of position are so variable and constant that it can scarcely be said, anatomically speaking, to have any normal axis.

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In speaking of the axis and normal position of the uterus, it is necessary to call to mind the fact that congenital modifications of form and axis are occasionally found. The uterus may be anteflexed, retroflexed, or lateroflexed as a congenital state, the inflexion varying from a scarcely perceptible degree to one in which the uterus is completely bent on itself, so that the cervix and body of the uterus correspond. These congenital malformations were ably described by M. Huguier a few years ago; and I have repeatedly met with illustrations of this form of deviation of the uterus from its normal standard.

The position of the uterus, and consequently its axis, is often changed or modified, owing to a physiological cause—marriage —which acts independently of disease of any kind or description. This really physiological displacement is of such constant occurrence, that it ought to be taken seriously into consideration, and I am much surprised that none of the speakers at the French Academy mentioned it. Under the influence of congress, in a great number of women entirely free from any morbid uterine state, sterile or not, the cervix is thrown mechanically backwards, and the body of the uterus forwards, that is

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