or

intensity. Instances of sudden and forcible displacement, whether flexion, prolapsus, or inversion, approach more nearly to a true dislocation in the suddenness of the attack, and the direct mechanical violence to which the mischief is clearly attributable. Here reposition affords immediate relief, and rest completes the cure, just as in dislocation of a joint. But the cases of Uterine Disorder of Place which most frequently come under notice present a very different history. They vary in extent and direction, so as to defy exact classification. Thus the organ may be fairly bent on itself, may be bodily displaced upwards or downwards, may be removed from its normal position by mere increase of its natural curve, or by this curve assuming a new and unnatural direction. And so far may these conditions vary and mingle, that the classifications hitherto adopted have been rather for purposes of general description than as absolutely marking the exact displacement in each individual case. Some authors have attempted a more elaborate definition; thus M. Nonat tabulates thirty-nine different deviations of place, compounded out of the three forms of displacement chiefly recognised-prolapsus, version, and flexion of the uterus.

The uterus is tethered in the pelvis; having a considerable range of movement in every direction. The only approach to fixation is an attachment of its lower part to the bladder, this connexion being continuous with a similar attachment of the upper part of the vagina, so

that in health the orifice of the cervix uteri maintains a direction corresponding to that of the centre of the distended vaginal canal. This is obviously adapted to ensure insemination. The positional relations of the bladder to the uterus exercise also a further influence. The roomy pelvis of the unimpregnated woman allows the bladder to distend to an enormous extent; and habitual control up to the very extreme that can be borne (a custom not unfrequent with women), tends to increase the vesical capacity. The female bladder is emptied with great rapidity, and the recurrence of these conditions of extreme distension and sudden collapse necessarily implies an inordinate variation in the position of the uterus also, which has a certain importance in the treatment of its disorders of place. Equally mechanical in action is the influence, produced by distension of the rectum with scybalæ; for the gut has been found enlarged to the diameter of a tumbler by this cause, displacing the uterus by the pressure. The position of the uterus changes with each deep inspiration; and where the play of the ribs is restricted, the organ habitually occupies an unusually low position in the pelvis. With tight stays, having stout busks of wood or iron, such as working women wear, the diaphragm has to afford the room required for entrance of air into the lungs. But the movements of abdominal respiration in such cases are chiefly referred to the hypogastriæ parietes, since the weight of the manifold lower garments (which are supported by ligatures at the waist) serves to constrict the

very part which in men most responds to the influence exercised by the descent of the diaphragm on deep inspiration. By the uterine sound this variation in place is readily recognised; and the range of movement differs according to the conditions of the examination, whether the patient be loosely clad or compressed by stays. Working women wear these from a mistaken notion that they afford support-not from mere vanity; and under the same erroneous opinion have strong wooden busks, like flat rulers, let into the front of the garment. I have seen deep dents in the sternum and depressions in the linea alba produced by constant pressure of the ends of those abominable things; and I think I must have, in hospital practice, ordered the removal of enough wooden ones to build a boat. The elastic support afforded by the abdominal walls antagonizes the descent of the diaphragm only so long as the healthy condition of them is maintained. But in multiparæ, and in women with large and pendulous bellies, the sustaining power of the parietes is slight. This is well seen in cases of ovariotomy, where the contraction of the abdominal walls on either side the incision varies remarkably. I have known the parietes as lax as damp leather, and in other cases have felt the recti abdominis tensely draw together the internal edges of the incision after extraction of the tumour.

There is also another condition, which, though rarely met with, may be admitted as sometimes modifying the mechanical agency of the abdominal parietes. I have notes of fifteen cases of its occurrence, but have not met with any

statistical account as to its frequency. In all of these there was a depressed line, ranging from half an inch to two inches in width, corresponding to the direction of the linea alba. The bellying recti muscles forming a ridge on either side, as the patient raised herself by their action, thus demonstrated the extent of this abnormal chink. In all the cases examined I found evidence of previous pregnancy or miscarriage, the abdominal parietes being always thin and muscular, and the whole frame rather wiry than obese. Evidence of displacement occurred in only five out of the fifteen cases, and in these the splitting of tissue between the recti muscles, which constituted the remarkable chink described, could not be traced to hold any relation to the uterine displacement. Indeed, in only one of the fifteen cases had the patient noticed that there was any peculiarity in her abdomen. Whether such a condition is congenital or always acquired remains yet to be ascertained.

In all these cases of mechanical influence from without, the sustentative structures which surround the uterus may suffice to restore its healthy position, provided that there do not exist other and more important conditions which either overcome or tend to annul their natural elastic action. But it usually happens that the causes which immediately induce or lead up to such an unfavourable state exercise a twofold operation; increasing the weight of the uterus itself, either of the whole organ or some part of it, and at the same time diminishing the healthy condition of the connective structures around. The deviations

from the natural order of place which are thus produced find their most frequent and most marked illustrations in cases of prolapsus.

PROLAPSUS, or procidentia, includes those disorders of place, where the whole uterus is bodily depressed from its natural position. It comprises a wide variety of conditions ;—which may still be considered together, in so far as they all, more or less, represent an alteration of those provisions arranged for the maintenance of its order of place. In extent the prolapsus may vary from a slight external pouting of the recto or vesicovaginal mucous membranes up to so extreme a protrusion, that the uterus touches the ground when the woman is placed on her knees. But the extent of extra-vulval protrusion is of less importance than the recognition of the elements which compose it, and the discrimination of the manner of its production.

In prolapsus there may occur every conceivable variation in the adjustment of the two important agencies (the dynamic and vascular) described when considering the order of place; either may be disarranged, or both may be in fault.

In prolapsed vagina, the external protrusion may in size and shape resemble two oranges placed one over the other; the os uteri just coming into view between them. In a well-defined case of this kind, the womb may be of the natural size and length, and its structure healthy. It has simply followed the vagina in its descent, constituting a prolapsus dependent on a yielding of the sustentative structure; the uterus itself having