should be employed just before going to bed; the douche is preferable to Higginson's syringe (v. page 137). The injection should be continued from ten minutes to a quarter of an hour. It is a decided advantage to have the douche given with the patient in the dorsal posture, as Gallard recommends. Occasional warm baths are useful in some cases; when the patient is in the bath, the vaginal douche can be used at the same time with greater freedom and effect. A cold hip-bath every morning is the best stimulus to the circulation. Medicinal baths have a peculiarly beneficial effect in chronic metritis. Amongst those the first place has always been held by Kreuznach, the waters of which are specially rich in bromides and iodides. The baths at Kissingen are rich in carbonates, and are of a lower temperature than those at Wiesbaden and BadenBaden which contain a smaller proportion of salts.

Further, the drinking of medicinal waters is also beneficial. The mineral springs at Ems and Vichy have, from their action upon the mucous membrane, always had a great reputation for the treatment of chronic uterine inflammation, Where there is much catarrh, they are specially serviceable. In scrofulous and chlorotic individuals, the advantage of waters which are rich in salts of iron is evident. Comparatively few of our patients, however, will be able to enjoy the luxury of a course of treatment at one of these watering places; but much benefit will be derived from change of air to the sea-side, or to the regular regime and cheerful surroundings of a hydropathic.

Attention to the action of the bowels is all important. Accumulations in the rectum and sigmoid flexure of the colon favour passive congestion, and interfere with the appetite and digestion. The mineral waters-Friedrichshall, Carlsbad and Hunyadi Janos-are the best

aperients.

The Carlsbad salts are specially useful in bilious patients; a teaspoonful should be dissolved in a tumblerful of water and drunk in repeated sips during the morning. Friedrichshall and Hunyadi Janos waters act best mixed with an equal amount of hot water; their dose varies from a wineglassful to a tumblerful. A good substitute for these waters is the tonic and aperient prescription given on page 185.

The iodide and bromide of potassium are given internally, as recommended at page 183.

Great care, and in some cases complete rest, should be enjoined at the menstrual period. As exacerbations usually occur at these times, a great deal is done towards a cure by prophylactic measures in regard to this.

Of local treatment the most important is counter irritation by

occasional blistering or repeated application of iodine or of croton oil to the iliac regions. French gynecologists recommend the application of the blistering fluid to the cervix; we have had no experience of this method. Thomas speaks highly of it, and practises it in the following way. A large cylindrical speculum is passed, and the cervix cleansed and dried with a pledget of cotton. The preparation of vesicating collodion, made with acetic acid, is painted in two or three coats over the whole of the vaginal portion; after it has dried, a stream of cold water is applied to wash off any superfluous collodion. In eight to twelve hours there is a free discharge of serum. The patient remains quiet for some days, and uses occasional warm water injections; a pledget of cotton wadding soaked in glycerine is applied afterwards. Many gynecologists apply iodine to the cervix and roof of the vagina ; Scanzoni recommended a solution of 4 gr. of iodide of potassium in 30 m. of glycerine. The simple tincture of iodine, or a solution of equal parts of iodine and glycerine, may also be applied in this way. Local depletion by scarification or leeches, as described under endometritis, is less frequently employed than formerly.

In speaking of Emmet's operation, we mentioned that it was sometimes followed by diminution in the size of the uterus. Carl Braun* has shown that after amputation of the cervix for hypertrophy the uterus sometimes undergoes changes which resemble those which occur physiologically in the puerperal uterus. Martin of Berlin strongly recommends the amputation of the posterior lip; in a paper read before the German Scientific Association at Cassell, he gives the results of the operation in 72 cases in all of which the uterus was stimulated to undergo subinvolution.

Dr Weir Mitchell† has introduced a method of treatment of chronic uterine disease which consists of complete rest associated with a fattening diet and massage of the body generally. The patient is isolated from her friends and subjected to the following regime for a period varying from one to three months. Milk, nutritious soups, eggs, cod liver oil and other fattening foods are given by an attendant every few hours. All voluntary motion is forbidden. Friction of the skin, massage of the muscles of the body generally, and passive movements of the limbs are made by the attendant as often and as long as the condition of the patient will allow; this stimulates the circulation and favours absorption of nourishment with a minimum expenditure of strength.

Uterine massage.

Massage of the uterus itself as a means of treating

* Zeitschr. d. Ges. d. Wiener Aerzte, 1864, s. 43.

+ Fat and Blood and how to make them.

chronic metritis was introduced by Brandt* of Stockholm. The difficulty of carrying it out has prevented its being as yet extensively tried, but it has been followed with such good results in certain cases that it promises to become a recognised mode of treatment. Reeves Jackson,† who has found it successful in certain cases, rightly draws attention to the fact that it will not be effective when "the stage of induration has been reached." In performing massage, we begin by manipulating the. skin of the abdomen; after the patient has got accustomed to this, we knead the uterus through the abdominal walls: if the uterus is so large that it reaches above the brim, this "abdominal massage" may be efficient; if it be smaller, two fingers are passed into the vagina to counteract the abdominal hand.

* Nouvelle Methode gymnastique et magnetique pour le traitement des maladies des organes du bassin et principalement uterinés: Stockholm, 1868. + Uterine Massage as a means of treating certain forms of enlargement of the womb: Am. Gyn. Trans., 1880.

CHAPTER XXXI.

DISPLACEMENTS OF THE UTERUS: ANTEFLEXION; ANTEVERSION; RETROVERSION; RETROFLEXION.

LITERATURE.

Barnes-Diseases of Women: London, 1878, p. 679. Campbell, H. F.-American Gynecological Transactions, Vol. I., 1876. Duncan, Matthews-On the Displacements of the Uterus: Edinburgh, 1854. Emmet-Gynecological Transactions, 1876. FritschDie Lageveränderungen der Gebärmutter, Billroth's Handbuch: Stuttgart, 1881. Hart-The Structural Anatomy of the Female Pelvic Floor. Hewitt Graily-The Mechanical System of Uterine Pathology: London, 1878. Mundé-The Curability of Uterine Displacements: Amer. Jour. of Obst., Oct. 1881. Routh-London Obst. Trans., Vol. XV., p. 252. Ruge -Zeitschrift für Geburtshülfe und Gynäkologie, 1878, Band II., p. 24. Schroeder-Op. cit., S. 140. Schultze, B. S.-Volkmann's Sammlung klin., Vorträge, 50. Simpson, Sir J. Y.-Op. cit., pp. 253, 245, and 764. Skene-American Jour. of Obst., Vol. VII., 1874, p. 391. Thomas-Op. cit., pp. 363, 408. Van de Warker-The relation of symptoms to Versions and Flexions of the Uterus Amer. Gyn. Trans., 1879, p. 334.

As the uterus is a movable organ within the pelvis, it is subject to various changes of position; as it is composed of a soft pliable tissue, it is liable to alterations of its normal curvature. Both of these changes are described in English text-books as "displacements," although, strictly speaking, this term should be applied only to the former.

The normal form, position, and relations of the uterus have been already described (see Chap. II).

The uterus is constantly exposed to forces producing a temporary displacement. In front there is the bladder, the dilatation of which displaces the uterus backwards and somewhat upwards (fig. 44). Behind there is the rectum, which normally should have little influence on the position of the uterus; but, owing to inattention to its regular evacuation, it is frequently over-distended and thus acts as a displacing cause operating from above and behind. Above there is the aldominal pressure, which is constantly acting on the uterus especially during inspiration. One has only to watch the movements of the anterior vaginal wall during respiration to see that this factor is always

operating. Its action is of course increased by whatever increases the intra-abdominal pressure, that is, by any straining efforts which bring the abdominal muscles into play. Below there is the pelvic floor, which has a constant action in supporting the uterus against the abdominal pressure.

We must distinguish between physiological and pathological displacements. The former is transient, and passes away when the cause has ceased to operate; the latter is persistent, and produces permanent alterations in form, position, and structure. It is difficult to draw the

line between those two. The pathological condition is frequently due to simple overstepping of the limits of the physiological. Thus the carrying of the uterus backwards into a retroverted position by the distention of the bladder is physiological, while its remaining permanently in that position is pathological.

It is evident that the uterus can be displaced in at least three ways: first, the different parts of it may alter their position relative to one another; second, it may rotate round the transverse axis; third, the organ may be displaced as a whole. Any great rotation round the vertical axis is prevented by the attachments of the uterus.

1. Alteration in the relative position of body and cervix constitutes flexion of the uterus, in which there is a change in the curvature of the long axis, i.e., in the direction of the uterine canal.

2. Rotation of the organ round an imaginary transverse axis constitutes version of the uterus.

3. Displacement of the organ as a whole, although frequently observed, has not been described in English works by a precise term. We might use the term position with the suitable prefix. Thus when the uterus lies "back as a whole" in the pelvis, it might be described as “a retroposition" or as "retroposed" (Germ., retroponirt).

The uterus, in its normal condition, is anteflexed, anteverted, anteposed-placed as far forward as the bladder will allow.

Various deviations from the normal condition may occur.

(a.) There are three possible changes in flexion. To understand these, suppose the direction of the cervix to be fixed. The uterine axis may be (pathologically) anteflexed (fig. 194 a), so that the normal curvature is increased; this is sometimes associated with retroposition. The axis may become straight, as occurs in so-called anteversion (fig. 1946). It may also be retroflexed (fig. 194 c); this condition occurs rarely by itself, but associated with retroversion it is a common displacement.

(b.) Version round a transverse axis is either forwards or backwards.