in anteversion. This is more especially the case when the vagina is short, or when the cervix is long from the vagina being inserted high up on the uterus, so as to expose in the vaginal cul-de-sac a considerable portion of the uterine neck. This frequent existence of deviation or displacement of the cervix backwards and of the uterus forwards, as a really postmarital physiological state, independently of any morbid uterine condition, or of any kind of pelvic change or influence, must be considered an important element in the appreciation of the pathological importance of anteversion of the uterus. Indeed, its non-recognition, in my opinion, renders to a great extent valueless the conclusions of many who have spoken and written on the subject.

Owing to the laxity and freedom of the anatomical connexions. which I have above described, the uterus moves, as we have seen, with the greatest freedom in the pelvic cavity, readily adapting itself to the ever-varying positions which it is called upon to assure. Thus, if the bladder is full, it presses on the uterus and retroverts it, a fact which can easily be ascertained. If the rectum is loaded with fæces, it displaces the small intestines, presses on the uterus from behind, and anteverts it. In walking and riding the uterus sways to and fro, more or less, according to the degree of tightness with which the pelvic viscera are packed, and according to the degree of support it receives. Both in walking and in standing it falls slightly; indeed, I much question, whether, in every woman, however healthy, the uterus is not always lower when she retires to rest at night, than when she rises in the morning. Moreover, in the married condition, it is constantly exposed to physiological displace

ments.

The freedom of motion which its ligaments and modes of attachment allow to the uterus is, however, most forcibly illustrated by the change of position which occurs in pregnancy. After the first few months of pregnancy, the enlarged uterus ascends and leaves its former position and connexions in the pelvic cavity, becoming for the time an abdominal organ. admit of this entire change of position, the lateral ligaments unfold, and the round ligaments are elongated as the uterus

To

increases in size. At the termination of the pregnancy, the uterus, which in a primipara has increased from one ounce to thirty or forty ounces, rapidly returns to all but its former size, to about two ounces,-passing through a series of vital changes. This marvellous return to all but the original size and weight no doubt takes place, in order that the means of support which we have enumerated may again be sufficient to support the uterus, and to maintain it in situ. These changes, from small to large, and from large to small, moreover, are capable of being reproduced an indefinite number of times, during the period of ovarian activity. It is to this end that the uterus is made an organ apart from all others; that it is endowed with vital powers which no other either requires or possesses.

From what precedes, and the facts which I have advanced cannot be denied,—it is evident that even the unimpregnated uterus, in health, is by no means destined to remain constantly in the same anatomical position, to preserve constantly the same axis. It is also equally evident that the healthy uterus bears changes of position, and considerable pressure from surrounding organs, &c., without either pain, discomfort, or inconvenience.

The explanation of this fact is to be found in a physiological law, which, although well known, appears to me to have been all but entirely lost sight of in the discussion of uterine displacements. All our organs, internal and external, when in a healthy state, are capable of bearing, without pain or inconvenience, considerable pressure, and any degree of displacement of which their means of fixity can admit. Thus, if a healthy person lies on the side, say the right side, the heart, the left lung, the stomach full of food, obey the laws of gravity, fall more or less, and press on the organs beneath them; and that, as I have said, without occasioning pain or inconvenience. Were any

:

of these organs inflamed, however, the result would be far different great pains would be experienced. Thence it is that patients suffering from inflammation of any thoracic or abdominal organ lie on the back, to avoid the pressure of the surrounding viscera on the diseased organ, pressure which it can no longer bear.

It may be objected that physiological pressure, the result of

change of position and of functional conditions, is essentially temporary, and that, were it permanent, it would not be so easily borne. Here, however, general pathology comes to our assistance, and teaches us that non-inflammatory morbid growths and tumours, slowly developing themselves, may exercise considerable permanent pressure on the organs which surround them, in any part of the economy, without the supervention of any symptoms of distress or inconvenience. This fact, which has not received the attention it deserves, I developed at considerable length in the third edition of my work; and I shall conclude this rapid survey of the anatomy and physiology of the uterus, with reference to its mobility, by the following extract, page 405:

vene.

Even

"The impunity with which pressure may be exercised on viscera and organs by tumours, the growth of which is very gradual, may be observed in every part of the economy. the brain, the most sensitive of all to pressure, will bear it if very gradually applied. Thus, we often see exostosis and tubercular formations greatly compressing the cerebral substance without the supervention of any symptom until the growths have reached a considerable size, or until inflammation superIt may, indeed, be considered an axiom in pathology, that all organs will largely accommodate themselves to pressure, provided such pressure be gradually applied, not carried to the extent of seriously interfering with their functions, and be unaccompanied by inflammatory action. . . . . The history of fibrous growths (of the uterus) permits no room for doubt on this question. These growths almost invariably attain a considerable size, and deeply modify the position of the uterus, giving rise to retroversion, or anteversion, and exercising considerable pressure on the pelvic viscera, before they occasion any appreciable symptoms. In fact, my experience shows that patients thus suffering seldom complain at all, unless there be some concomitant inflammatory affection of the cervix or of its cavity, until either the external appearance of the abdomen be modified by the size of the tumour, or until hæmorrhage supervene. The first period of the existence of the tumour, and the displacement which it occasions, pass unperceived and unnoticed by the patient herself, and by her medical attendant."

THE PATHOLOGY AND THERAPEUTICS OF DISPLACEMENTS OF

THE UTERUS.

In my preceding remarks I have drawn attention to the smallness of size and lightness of weight of the uterus; to the great laxity of its means of support and fixity; to the extreme mobility which it consequently evinces; to the ease with which it obeys the many physiological causes of displacement to which it is subjected; and to the complete immunity from pain, or even inconvenience, with which these displacements are borne.

I have explained the immunity from pain evinced by the uterus when displaced under the influence of physiological causes, by referring to the law through which all our viscera bear, without inconvenience, any amount of displacement compatible with their means of fixity, and any amount of pressure to which they can be exposed from the proximity and functional activity of surrounding organs. I have pointed out that this capability of our organs to bear considerable pressure without inconvenience is not only observed in the temporary physiological conditions described, but is also found to exist under the permanent pathological pressure of non-inflammatory morbid growths, such as tumours, aneurisms, &c. I have laid stress on the very important fact, that when once inflammation supervenes, this immunity from pain and inconvenience on pressure ceases;—as evidenced by the inability of patients suffering from inflammation of the abdominal or thoracic viscera to lie otherwise than on their back or as evidenced by the pain which is experienced on the pressure of an inflamed finger. Finally, I have recalled the rapidity with which the uterus increases in size and weight under the influence of the physiological stimulus of pregnancy, and reverts to its natural size and weight when that stimulus is removed. This brief recapitulation is necessary, as in the above facts is found the key to the history of uterine displacements or deviations, as I have interpreted them.

The uterus may be displaced or deviated in various ways. Its position and form may be modified with reference to its own

axis, or with reference to its conventional anatomical pelvic axis, which corresponds, as we have seen, to that of the upper pelvic outlet. When the axis of the uterus itself is modified, the uterus is said to be flexed, anteriorly, posteriorly, or laterally; and we have thus antero-flexion, retro-flexion, and latero-flexion. When the uterus is displaced in toto, without any abnormal bend or flexion taking place, so that its axis is changed with reference to that of the upper pelvic outlet, it is said to be antero-verted, retro-verted, or latero-verted.

Practically, these two forms of uterine displacement are so often met with in the same uterus, and are often so evidently stages, degrees, of the same morbid state, that Dr. Simpson has merged them into one, and only recognises, practically, three forms of uterine displacement-antero-version, retro-version, and latero-version. Theoretically, however, we must accept the two; for if these displacements really do exercise an important influence in the production of morbid uterine and general symptoms, the modus operandi in both, or at least in the more simple cases of both, must be quite different. In simple flexion, unaccompanied by uterine enlargement, the pressure is merely intra-uterine,—is only felt, in an appreciable degree, by the walls, vessels, and nerves of the bent uterus. In actual displacement of the uterus in mass, the uterine structures themselves remain as they are; the pressure is on the surrounding organs, and the strain is extra-uterine; on the ligaments and extra-uterine vessels and nerves.

Simple or combined, these morbid conditions of uterine position to which we must add prolapsus, more or less complete, of the entire organ-are generally found to co-exist with the uterine suffering or ailment to which I have so repeatedly alluded, and with the inflammatory lesions which so usually accompany it. The extreme partisans of "The Displacement Theory" attribute to the existence of these displacements primary importance, and think that, in the majority of cases, they are the real cause of the mischief existing; that they constitute the morbid condition which principally requires treatment. In their eyes the co-existing inflammatory lesions, the ulcerations, hypertrophies, and indurations, are, in many, if not in the