irritation the instrument should be removed and vaginal injections used until relief is obtained, and the use of the instrument may be again resumed.

The rubber bag filled with water answers a very good purpose. To apply this, the patient should be placed in Sims's position, and through the speculum, the upper portion of the space between the uterus and vagina should be filled with prepared wool; then the bag should be introduced between the fundus uteri and the pelvic floor, and distended with water. A firm perineal band is then used to support the pelvic floor. Dr. Thomas recommends a strip of adhesive plaster for the perineal band, one end being fastened to the sacrum and the other to the abdomen, with two openings, one for the tube of the bag, and the other opposite the urethra to permit urination. I prefer the ordinary muslin or elastic band, because it is more easily removed and readjusted. The degree of pressure and the time which it should be continued must depend upon the results.

If there is much pain or irritation the treatment must be suspended. The combination of elastic pressure and taxis has been employed with advantage. After the pressure has been used for a time taxis should be tried, and in case this fails the elastic pressure should be again attempted. Care must be exercised in the use of taxis-it should not be too violent or long-continued; this must be decided by the operator in each case.

Dr. Charles Martin, of France, succeeded by using a stream of cold water projected against the fundus uteri, through the speculum. This he employed twice a day. The stream was thrown with considerable force; he also filled the speculum with cold water, and kept the uterus in it three or four minutes. Dr. T. G. Thomas, from whose work I take the above statement, approves of this method.

Dr. Thomas has devised another method, which I understand he employs or advises where other methods fail. The following is taken from his work on diseases of women: "Thomas's method consists in abdominal section over the cervical ring, dilatation with a steel instrument, made like a glove-stretcher, and reposition of the inverted uterus by any one of the methods mentioned, by the hand in the vagina. Fig. 129 will render this clear.

"This procedure, let it be remembered, is not offered as a method of treating inversion of the uterus, but as a substitute for amputation. Few cases will, I think, resist elastic pressure and judicious taxis; but that some will do so can not be questioned. It is to

save these few cases from amputation that I suggest abdominal section.

"One of the cases operated on in this way has proved fatal. Let it not be forgotten that a certain number of these cases treated by elastic pressure and by taxis likewise do so, for, as in my second case, these operations are often performed upon exsanguinated women whose blood is impoverished. One instance of death after reduction by elastic pressure is recorded by Dr. Tait in the eleventh volume of the London Obstetrical Transactions,' while one of the earliest cases on record reduced by taxis-that of Dr. White, of Buffalo, likewise ended fatally."

One other method is worthy of mention, namely, that of Dr. Brown, of Baltimore. He makes a free incision in the fundus uteri, and through the opening thus made he stretches the cervix and then reduces by taxis. In case of failure of all efforts, hysterectomy may be performed. This, I consider advisable, if the but it should not be un

patient is near to or past the menopause, dertaken until all other methods have failed.

There are several methods of amputating the inverted uterus. Dr. McClintock applied a string ligature around the highest portion which strangulated the uterus, and in two or three days when decomposition of the tissues began, he amputated. Hegar accomplished the same object by passing strong sutures through the cervix, and after drawing them tight enough to close the vessels and close the peritoneal cavity, the body was amputated.

It will suffice to simply mention amputation without giving elaborate details. It was frequently practiced in the past, but is seldom heard of now. Other methods succeed, and with the method of Thomas in reserve-in case pressure and taxis fail-amputation will seldom, if ever be called for. Cases might be quoted to illustrate the treatment of chronic inversion, but they would add nothing of value to the methods of operating given above.

CHAPTER XVII.

DISLOCATIONS OF THE UTERUS.

THE uterus is peculiarly subject to physiological changes of position. The bladder in front causes the uterus to move forward and backward according to its dilatations and contractions. In a similar but much less extensive way, distention of the rectum acts to push the uterus forward. The abdominal pressure from above is constantly changing, and is, therefore, constantly affecting the position of the uterus less or more. The movements of the uterus under the influence of the ever varying degrees of abdominal pressure are easily observed by watching the anterior vaginal wall and uterus through a Sims's speculum in the living subject. There is an up and down motion, very limited but constant, caused by ordinary respiration, and under extra exertion, such as coughing, the displacement becomes very marked.

Below there is the pelvic floor, which has least of all to do with changing the position of the uterus, and yet much to do in counteracting the inclinations to displacement produced by other influ

ences.

These changes of position, when limited in degree, are physiological, the organ promptly returning to its original position as soon as the displacing influence is removed. It is only when the uterus remains displaced permanently or is carried far beyond the physiological limits that the dislocation is to be regarded as pathological. When this occurs, the malposition gives rise to suffering from deranged menstruation, circulation, and innervation, and in some cases to sterility. Usually, the functions of the bladder and rectum are disturbed and the general system suffers from reflex influences. It is only when such symptoms as these are present that displacements of the uterus claim the attention of the gynecologist.

In order to fully comprehend displacements of the uterus it is very necessary that the normal position of the uterus should be

clearly understood, and this can only be attained by a knowledge of the anatomy of the pelvic organs.

Anatomy. In discussing this subject attention will be chiefly directed to the position of the uterus in the pelvis, its relations to neighboring organs, and the position and character of the structures which keep it in position.

One would naturally turn to the cadaver in the hope that by careful dissection the exact position of the uterus could be deter

卵

AXIS OF SUPERIOR-STRAIT.

mined, but after life is extinct the uterine supports lose their firmness, and changes of position usuaily take place. Moreover, it frequently happens that the pelvic organs are less or more displaced toward the end of life, so that a normal state of the parts is not often found in the cadaver. Dissection also tends to displacement, no matter how carefully it may be performed. To obviate this, sections of the frozen subject have been made, and much valuable information obtained from them. Still, the greater part of useful information on this subject must be obtained from careful and oft-repeated examinations of the living subject. With information obtained from all these sources there are still differences of opinion among authors on certain points.

FIG. 130.-Section of pelvis, showing its inclination and the axis of the inlet.

Under the circumstances, in place of giving a number of conflicting opinions, it will be better to give the views which I have adopted as the result of my own observations on the living subject, and after a careful investigation of the views of others.

In the first place, it may be said that the uterus is wholly within the true pelvis.

The line on the diagram running between the symphysis pubis and the promontory of the sacrum divides the true pelvis from the abdomen, and all the pelvic organs, the uterus included, are below this plane, the superior strait, as the obstetricians call it (Fig. 64). The long diameter of the uterus in the pelvis corresponds very nearly to the axis of this plane, as represented by the line (Fig. 130), and it is equidistant from the sides of the pelvis.

The position of the uterus varies from time to time, as already

stated, but in all its changes it returns to the axis of the inlet of the pelvis, slightly behind the center of the true conjugate. This is not mathematically correct, but is sufficiently so to form a basis from which further studies, both anatomical and clinical, may be conducted.

In order to obtain some idea of the position of the uterus and the influences which the other pelvic organs have in changing this position, reference should be made to Fig. 64, which shows a section of the normal pelvis. Fig. 131 shows the changes in the position of

FIG. 131.-The normal range of the uterine axis, varying according to the distention of the bladder; A, with bladder empty; D, with bladder full (Van der Warker).

the uterus during the several degrees of distention of the bladder. These physiological changes should be noted and the causes which give rise to them, in order that they may be recognized clinically. Next in the order of inquiry are the anatomical structures by which the uterus is held in position. This requires a consideration of the