treatment of retention tumors is referred to in the chapter upon "Atresia of the Uterus." Foetal, infantile, membranaceous, and primarily atrophied uterus require treatment locally and constitutionally, i.e., tonics, sea-bathing, iron, quinine, etc., for the system in general, and locally, sitz-baths, injections, and especially electricity are indicated; in the application of the latter one pole is placed upon the mons veneris, or the insertion of the round ligaments, and the other connected with a sound introduced into the uterus; or, one pole may be placed at the os uteri and the other in the rectum; or, again, both are placed in the rectum, the current acting upon the insertion of the posterior uterine ligaments.

Further, all medicines known as emmenagogues, both internal and external, are of great service here; their action will be considered under the subject of amenorrhoea. I must state, in conclusion, that I have seen little or no result even from protracted use of any of these agents, in fœtal, infantile, or the small atrophied uterus. If pregnancy occurs in a uterine horn having no inferior outlet, nothing remains to be done except a partial Porro's operation, i.e., laparotomy with extirpation of the pregnant horn, an operation which is certainly justifiable.

When septa are present either in the vagina, os uteri, cervix or body of the uterus, it may be desirable to divide, or to completely excise them. The shortest and least dangerous method is to sever them with the sharp point of a Paquelin's cautery.

Girls suffering from amenorrhoea dependent upon an infantile or malformed uterus such as uterus unicornis, bicornis, or septus, should be advised not to marry before menstruation becomes regular, and the whole body is well developed.

CHAPTER II.

CHANGES IN THE FORM AND POSITION OF THE UTERUS.

THE recognition of displacements of the uterus obviously depends upon our exact knowledge of its normal position, which is by no means easily established, as the very numerous treatises

upon this subject by anatomists and gynecologists will testify. B. S. Schultze has certainly contributed more than any other investigator to the solution of this problem. In 1865, I called attention to the fact that the puerperal uterus is normally anteflexed, and, since about 1870, Schultze has ably and successfully advanced his views upon this question and gradually converted most authors to his opinions. Our present knowledge of the normal position of the uterus may be summarized as follows: When the

FIG. 26.

400

Normal Position of the Virgin Uterus.-From Schultze.

bladder and rectum are empty, the virgin uterus lies with its fundus behind the symphysis pubis, the os uteri about 2 centimeters (inch) anterior to the sacral promontory, and the vagina and cervix forming almost a right angle (fig. 26), while in the parous woman the angle is even more acute.

In the erect posture the long axis of the uterus is, therefore, almost horizontal (fig. 27). The whole organ is also somewhat twisted, the vaginal portion towards the left and the fundus towards the right hand.

The uterus is retained in this position by the vaginal walls and muscles of the pelvic floor, and also by the adipose tissue of the vulva, nates and thighs, which assists in closing the vulvar orifice; further, by the pelvic fascia which encompasses the upper portion of the cervix-the pubo-vesico-uterine and sacro-uterine ligaments. The folds of Douglas contain strong muscular fasciculi which do not simply pass backward, as Luschka states, but almost directly

FIG. 27.

Normal Position of the Uterus in a Parous Woman.-From Schultze.

upward,* forming practically a musculus attollens uteri. They cross upon the uterus, and unite just below the body, while posteriorly they are inserted partly into the muscular tissue of the rectum and partly into the sub-serous connective tissue at about the level of the second sacral vertebra.

These folds are greatly hypertrophied during pregnancy, but,

* Schultze, 1. c., p. 110.

according to Schultze, are frequently atrophied or destroyed by pathological processes.

Two other sources of uterine support must be described, which act principally upon the anterior wall, viz., the connective tissue between the bladder and uterus, and the round ligaments. The former, though considered a loose tissue by anatomists, is, nevertheless, so firm that the connection is very seldom broken, and it causes the uterus to follow the movements of the posterior wall of the bladder. The round ligaments may serve to approximate the anterior uterine wall to the anterior pelvic and abdominal walls. The broad ligaments and the lax folds of the uterine peritoneum are likewise a means of support. Finally, the uterus is retained in its normal position by the peculiar structure of its own walls, their relative thickness and power of resistance and their relations to the above-mentioned supports being normal. The uterus is more flexible in childhood than in the virgin, and the unimpregnated more than the parous uterus.*

The normal uterus is by no means fixed in any particular position but is almost constantly mobile. Its movements depend upon the varying fulness of adjacent organs, upon respiration, intra-abdominal pressure, and the posture and movements of the individual. In the dead subject, where the influence of abdominal pressure and muscular action is removed, the passive mobility alone remaining, we frequently find the uterus to have become retroverted or retroflexed.

Our conclusions with respect to the normal position of the uterus in the living subject should, therefore, not be based upon the post mortem, but rather upon the results of exact clinical examination by experienced gynecologists.

The changes in position which the uterus undergoes with regard to the degree of fulness of the bladder, may be controlled by the introduction of the sound into the uterus. When the bladder is distended, the uterus is retroverted and retroflexed, while, when emptied, the uterine fundus again descends anteriorly. Schultze holds this descent to be a consequence of the subperitoneal connection between the bladder and uterus, and of the peculiar manner in which the walls of the bladder approach each other in the evac

* Schultze.

uation of its contents. These walls do not approach each other from all points, but from above downward, so that the longest diameter is the conjugate; the upper surface is slightly convex inferiorly, and the whole length of the uterine wall thus rests upon this depression. The empty bladder is, therefore, not circular upon cross section, but resembles a stem pessary, the urethra forming the stem. It is, as Schultze demonstrated, dish-shaped, the upper part of its connection with the uterus belonging not to the lower, but to the upper segment of the empty bladder, as may be easily proved by the sound.

When the rectum is full it pushes the vaginal portion forward, or, when the uterus is rigid the entire organ; if the uterus be relaxed, however, and the bladder empty, the former is even further anteflexed. But when the bladder is full, the descending fecal mass within the bowel elevates the uterus between the rectum and the bladder.

Fulness of the rectum is a transient condition in healthy persons, usually occurring but once daily, but its influence is not always manifest, and, if so, for only a short time. A marked and permanent projection forward of the cervix occurs only when the sacro-uterine ligaments become abnormally pliable, these ligaments in the normal condition elevating the cervix after evacuation of the rectum, i. e., assisting in the reduction of the anteversion. It is not yet known with certainty whether the round ligaments have the same influence upon the non-gravid uterus that they exert upon the pregnant and puerperal uterus-an action which corresponds anteriorly to that of the utero-sacral ligaments posteriorly.

Abdominal pressure influences to a great extent the movements of the uterus. In the erect posture, it is equivalent to the pressure of a column of water about 30 centimeters (12 inches), but it fluctuates with every change of posture.* If a patient is asked to cough while the vaginal portion is engaged within the speculum, the movements of the uterus may be plainly seen. pulsating movement may at times be found, similar to that which we observe in the tip of the upper foot after sitting awhile with the legs crossed. When the uterus is normally situated in the

* Schatz.

A