course is had to spirits of nitre, to watermelon-seed or parsley-root tea, and perhaps a dose of castor oil may be resorted to; but as relief can only come by some mechanical remedy, the medical man is at length, and reluctantly, sent for.

CASE.-A few years ago, I was called to a young woman who had been a short time married. She arrived in town by one of the public conveyances from the eastward. She had a constant and irrepres sible desire to urinate, and could only succeed in getting off a few drops at a time. She told me she was pregnant; had just arrived from a journey; and that she was suffering the most acute distress from the constant inclination to urinate. As the disorder had come on suddenly and in a state of high health, I at once told her she had a retroversion, the nature of which I explained to her, and she submitted to the necessary investigation; upon which I found her womb turned over, and upon repositing it she was immediately cured. I suppose that, in travelling, her bladder, for want of an opportunity to empty it, had become very much distended; that its bas-fond had pressed upon the anterior superior face of the womb more and more as it became more and more distended, until the fundus uteri, jammed under the promontory of the sacrum, could not get out again, without the aid of a physician.-See my Letters to the Class, sub voce. One of my critics condemns the rapidity of my diagnosis in the case. I respectfully refer him to the passages in which I explained that, by using the method of exclusion in the analysis of the symptoms, I could not possibly arrive at any other conclusion.

To see a healthy-looking woman seized with complete retention of urine, without having been before the subject of any urinary ailment, is always warrant enough for us to suspect a retroversion of the womb, especially if the patient be at the time pregnant, and not advanced beyond the fourth month. The symptoms of which such patients complain are either a total retention, a stillicidium, or a great dysury; with pains about the region of the pubis and sacrum; con. stant tenesmus, or bearing down, and a sense of obstruction or stoppage in the rectum.

No case like this ought to be suffered to pass without making an examination per vaginam. For this purpose, let the patient lie on her back, near the right side of the bed; the feet drawn up near to the breech; the head and shoulders raised with pillows. The physician should stand by the bedside, and with his left hand placed upon the hypogastrium, ascertain if the bladder be much distended: it will sometimes be felt almost as high up as the umbilicus. The forefinger

of the right hand may next be carried into the vagina in order to seek for the os tincæ, which is to be found behind the symphysis pubis, or even thrust over and above it: the vagina seems to be obstructed by a hard body, which is the bas-fond of the womb, whose fundus is turned down into the hollow of the sacrum, and jammed into the cul-de-sac composed of the reflexion of the peritoneum, which lines the upper posterior third of the vagina and the front of the

rectum.

Having thus verified the existence of a retroversion, the next steps required to be taken are those that are demanded for the repositing the womb. Among the most pressing indications of cure, is the relief of the suppression of urine, which in general is easily fulfilled by the introduction of the catheter. A long elastic male one is the best, because the womb, in changing its own position, carries up the neck of the bladder, and thus elongates the urethra so very considerably, that it will be found convenient to use a long instrument for the evacuation of the water.

Inasmuch as the most ordinary cause of retroversions is a distended bladder, it has been thought that the removal of this distension is the sufficient remedy, it being supposed that the uterus might recover its place as soon as the pressure which overset it should be taken off. Indeed, there are cases in which the restoration takes place soon after the bladder becomes emptied. I have related, in my Letters on Woman, &c., cases of retroversion cured by the catheter alone, and one, from an English authority, in which a most dangerous case of retroversion, in pregnancy, which could not be cured by the hand, gave way to the use of the catheter, left for a long time in the bladder, by which means that organ was completely hindered from filling up, and obstructing the tendency of the fundus to rise upwards to its natural situation. It has well been contended that, for retroversion of the gravid womb, a sound discretion indicates the propriety of leaving the case in nature's care, after this preliminary measure has been accomplished, lest, by any rude or too persevering attempts to replace the uterus, the ovum might suffer so much injury as to bring on an abortion. I admit that I am not prepared to decide as to the necessity for such great prudence, since I have only on one occasion put it to the test. On that occasion, I drew off the urine two successive days, the accumulation being very great; and then, finding that the malposition was not rectified, I was compelled to replace the womb with my hand: no inconvenience whatever followed the operation, although the patient was near four months complete gone with child. In a subsequent pregnancy, the same person suffered a retroversion of the

womb, nearly at the same period; and when I was called to see her, I immediately proceeded to restore it to the proper attitude. In this case also the pregnancy was not in the least interrupted.

Having succeeded in drawing off the water, the patient, if necessary, should have a copious enema, in order to unload the rectum, which, if replete with fecal matters, might offer considerable obstacles to the success of our attempt. In the next place, we ought to endeavor to raise the fundus, the patient lying on her left side, by pressing the bas-fond of the womb, which can be felt through the posterior wall of the vagina, upwards, with the fingers, so as to move the whole mass in a direction parallel with the axis of the brim. The cervix uteri is tied to the more anterior parts of the pelvis by the vagina and the vesicovaginal septum, so that, if we carry the mass considerably upwards, it must be by tilting the fundus in that direction. Attempts of this kind will not always succeed. Where they fail, a finger may be passed into the rectum, the forefinger of the left hand if the woman is on her left side, and of the right hand if she be upon her back. Before the finger has passed very far, it meets with the fundus uteri, which presses upon the canal of the intestine; in this situation, we have far more power to move the womb than when the effort is made only from the vagina. Pushing gently and steadily upwards, we find the mass gradually to recede, until at length the fundus, liberated from its restraint, suddenly emerges, with a sort of jerk, from under the promontory, from which instant the woman is cured.

I have sometimes failed of success, until I placed the patient in a more favorable attitude; one in which she could not bear down, and thus oppose the success of my measures. I have directed that she should turn on her face, then draw her knees up under her until the thighs were in a vertical position, giving to the pelvis the highest possible elevation: the cheek was to be placed on the bed without pillows, and the point of the thorax was also to be touching the bed. Lying in this posture, the power of mere gravitation might suffice, in time, to unhitch the fundus uteri from beneath the promontory; since all tenesmus and bearing down are thus arrested. After waiting a short space, until the effects of the position were secured, I have pushed up the fundus very easily by acting either through the vagina or the

rectum.

A pregnant woman, who has just recovered from a retroversion, ought to lie in bed two or three days, and should not, for a few days, be left more than six or eight hours without evacuating the bladder, either spontaneously or by the catheter; lest that organ, filling again,

should unhappily a second time depress the fundus, and so cause us to lose all our trouble through want of a moderate precaution.

The gravid womb, doubtless, becomes, in four months and a half, too large to admit of the occurrence of retroversion: but the accident may occur at any period short of it; it may take place not only in the non-gravid, but in the virgin uterus.

CASE. On the 22d of February, 1828, I was called to visit Elizabeth B., aged about twenty years. She had complained for several months past of dragging pain in the left side of the abdomen, with a sense of weight and great uneasiness within the pelvis. She has menstruated regularly. For the last three weeks she has been persecuted with constantly repeated and painful desire to go on the stool, and with symptoms of strangury, or dysury, amounting often to stillicidium urinæ. After a careful inquiry into the history of her case, I informed her of the nature of my diagnosis; and she at length agreed to permit an examination by the Touch, as I assured her that I had no means of relief for her, if there were really a retroversion, short of the Touch. In this painful necessity she submitted, with a laudable unwillingness, to the operation, and it was with no little difficulty that I at length carried the finger beyond a remarkably strong hymen, into the vagina. The os uteri was found near the symphysis of the pubis, and the fundus was discovered overturned into the Douglass's cul-de-sac. After a long perseverance in endeavoring to raise the fundus, I was compelled to attempt it with the forefinger of the left hand passed into the rectum, by which method I pushed the uterus up; whereupon she immediately declared that she was fully relieved of the sense of weight and pain that had so long been tormenting her. She continued well from that moment. I consider this a case of considerable interest, inasmuch as it further proves the possibility of a long-continued retroversion of the womb in the non-gravid and virgin state of that organ. I have seen many such cases since 1828.

There are some persons to be met with, in whom retroversion takes place so readily, that the least exertion of strength brings it on. In a single individual, I am sure that I have been called on to restore it to its position twelve or fifteen different times. So great, in that case, is the tendency of the womb to turn over, that it has several times occurred, notwithstanding the presence in the vagina of a very large globe pessary, and I did never regard her as exempt from the probability of an attack, except when in a state of advanced pregnancy. I presume that, in her case, there was not only a great relaxation of the vagina and its connecting media, the recto-vaginal and vesico-vaginal

septa, but there must also be supposed to exist a condition of the ligamenta rotunda et sacralia, which has allowed them to become elongated to such an extent, that the least pressure on the anterior face of the womb pushes it backwards and downwards. No one, I think, could suppose a case of retroversion without, at the same time, implying that the round ligaments, which pass from the angles of the organ out of the abdominal canal, and abdominal rings, are lengthened—and even stretched. A permanent elongation or laxity of those ligaments would add a great facility to the disposition to oversetting of the organ.

As there is reason to believe that there is a character of muscularity attached to the round ligaments, proceeding as they do from, and being composed of the same tissues as the womb, we may indulge, in any case, the hope that time, if not drugs and medicines, will bring them back to their natural tension and length, so as to obviate the evil propensity to the retroverted state of the uterus.

The accident of retroversion may be considered serious and dangerous just in proportion as it occurs at a more advanced period of pregnancy; for, according as the pregnancy is of an older date, is the necessity greater for a speedy reposition of the organ. I have, I think, pointed out sufficiently at length, the dangers to be apprehended from a retroversion continued until the whole mass becomes so impacted into the excavation, as to render its extrication, without abortion, impossible. As I have met, hitherto, with only two examples in which it was impossible to replace the gravid organ, I do not feel it incumbent upon me, at this time, to do more than refer to the severer methods of extricating the woman these are, first, the artificial rupture of the amniotic sac, which, by allowing the water to escape, reduces the size of the womb so much as to enable the operator to succeed in restoring it to its proper position; or, lastly, the puncture of the womb itself, when it is found impossible to reposit or pass a bougie into the os uteri.

The Student ought early to become aware that some of these retroversions are rendered incurable by the formation of adhesive deposits, that tie the fundus uteri close down to the back part of the pelvis, and that as these adhesive bands cannot be approached with the bistoury, nor otherwise broken up, the womb is liable to remain in a state of permanent retroversion. M. Amussat mentions two such cases in his essay on retroversion, and I have met with three, two of which were verified by the necroscopy. I shall publish one case, as drawn up by Dr. Yardley, and illustrate it by a cut copied from a drawing by Mr. McIlvaine, who had the specimen before him, and which constitutes one of the most interesting preparations in the museum of the