vironments they are freed in the one case from the otherwise relentless circulus vitiosus at least, and in the other case from the whole cause of the difficulty. That descended and inflamed ovaries will recover good or reasonable health when treated by conservative surgical measures which are based upon the principles enunciated, and do not need to be removed in most cases, is a fact that my experience has proven in many scores of cases; but their prognosis is very much better when associated with a retroverted uterus than otherwise.

CONCLUSIONS. 1. In all cases of retroversion and retroflexion of the uterus a knowledge of the ovaries, as to their location, mobility, and general physical condition, should comprise an essential part in the diagnosis, as determining largely the nature and urgency of the treatment.

2. The welfare of ovaries in general demands such a degree of anterior inclination of the longitudinal axis of the uterus as will enable intra-abdominal pressure to bear upon the posterior surface of the uterus, and thereby to act in unison with its other supports to retain it and its adnexa in normal position and function.

3. Inasmuch as in the female pelvis, as well as elsewhere in the human body, the natural and considerable abilities of healthy tissues to defend themselves against microbic invasion (infection) are lowered or annulled in direct proportion to any degree of mechanical embarrassment of the venous circulation in the tissues or organs, it behooves gynecologists especially to be alert in recognizing and correcting all material anomalies in place or posture of the female generative organs or in securing to them their normal freedom.

BIBLIOGRAPHY.

1. American Text-book of Gynecology, p. 552.

2. Luschka. Anatomie d. Menschen, 2ter Band, 2te Abtheilung, Das Becken, p. 325.

3. Olshausen. Die Krankheiten der Ovarien, 1886, p. 9.

4. Waldeyer. Anatomischer Anzeiger, 1886, No. 2.

5. Martin, August. Zeitschrift für Geb. und Gyn., Bd. xxxv., Heft 3, p. 498.

6. Schultze. Archiv für Gyn., 1876, Bd. ix., p. 262.

7. Nagel. Archiv für Gyn., Bd. xli., p. 244.

8. Symington. Edinburgh Medical Journal, 1886, vol. xxxii. p. 31.

9. Schultze. (1) Sammlung klin. Vorträge, 1879, No. 176; (2) Lageveränderungen d. Gebarmutter, Berlin, 1881; (3) Sammlung klin. Vorträge, N. F., No. 24: (4) Jenaische Zeitschrift, 1864, vol. i. p. 279, and vol. v. p. 113.

10. Kölliker. Sitzungsberichte d. Phys. Med. Ges. z. Würzburg, 1879-1880, No. 8.

11. Hasse. Archiv für Gyn., 1875, Bd. viii. p. 402.

12. Waldeyer. (1) Die Lage d. Innern weiblichen Beckenorgane bei Nulli paren; Anatom

Anzeiger, 1886, No. 2, S. 44. Also (2) Kenntniss d. Lage d. weiblichen Beckenorgane; Festschrift für A. von Kölliker, 1892.

13. His. Archiv für Anatomie und Physiologie, 1880, Anatom. Abtheilung, p. 393.

14. Schwerdt. Deutsche med. Wochenschrift, 1896, Nos. 4-6.

15. Swiecicki. Münch. med. Wochenschrift, January 7, 1890, p. 6.

16. Coe. American System of Gynecology, vol. ii. p. 881.

17. Mundé. Thomas and Mundé, 1891, p. 650.

18. Sänger. Centralblatt für Gyn., 1896, No. 9, p. 242.

19. Goodell. Lessons in Gynecology, p. 387.

20. Hanks. The Post-Graduate (New York), February, 1897, p. 43.

WHICH IS THE PREFERABLE OPERATIVE METHOD OF HOLDING THE UTERUS IN POSITION?

By C. C. FREDERICK, M.D.,

BUFFALO.

BEFORE passing to the subject of this paper as embodied in the title, I desire to occupy your attention for a few moments in consideration of some of the reasons why I believe that retrodisplacements need treatment. Some gynecologists have denied in toto that a retroverted uterus is ever pathological or that it gives rise to pathological conditions. I believe in a certain amount of scepticism. I believe in raising questions as to whether everything is as it appears to be. A certain amount of heresy is always salutary in its effect. I believe, however, that the broad statement that retroversions cause no trouble, therefore do not need treatment or operation, is going to an extreme which is unwarrantable.

The gynecologists are quite the butt of ridicule among the other branches of medicine for their fads and hobbyisms, and, I rather think, justly so. One sews up every tear he finds in the cervix, while his neighbor never believed in lacerations of the cervix and their repair; another is free with his curette, while still another never uses a curette, but thinks it a dangerous instrument. One pelvic surgeon never enters the pelvis except by the abdominal. route, and another never enters it except through the vagina (unless forced so to do), and then he usually removes everything in sight, and is styled a vaginal hysterectomist. And so I might go on showing to what extremes men ride their hobbies. There have always been fads in medicine and surgery. There have always been, and always will be, extremists among us. Some men are actuated even in this enlightened age by the same spirit of dogmatism which swayed their ancestors in the centuries past. Pelvic and abdominal surgery is old enough and operators have had experience in it ample to crystallize the facts of their experience into

quite well-defined modes of thought and action. It is largely the desire to originate some new idea, or to do something novel, which leads men to depart from the well-beaten path of experience. Despite all that the extremists write or do, there lies between their extremes a golden mean which contains more of the germs of truth than are to be found elsewhere.

So I believe it to be in this question concerning retrodisplacements of the uterus. I know perfectly well that all retroversions do not produce symptoms. I further know that many women who are not well and have retroversions are not sick because they have a displaced uterus. I often think it is a calamity that a woman has a uterus when she is sick, because it is so often made to bear the blame of so much for which it is not the cause. I know that many women with retroversions are as easily impregnated as though their uterus were normal in posture.

But these facts are not an argument that retroversions never produce symptoms or never need treatment. I have seen a bullet sent through a man's brain from one side to the other, the ball lodging against the skull on the opposite side from entrance, the patient never losing consciousness, and eventually getting entirely well, the bullet still in his brain. That is no argument against the facts of experience that such wounds generally kill promptly.

In general it may safely be asserted that if a retrodisplaced uterus is producing symptoms there will be local lesions, uterine hypertrophy, endometritis, tenderness or pain, excessive leucorrhea, or excessive losses of blood. When we treat these cases with change of surroundings, rest from household duties, tonics, and general restoratives for months, and they improve only slightly or not at all, we then operate as indicated, and find the operation followed in a few months by a return to health, what inference is a fair-minded observer to draw?

Two years ago I read before this society a paper on "Neurasthenia Accompanying and Simulating Pelvic Disease." In it I called especial attention to the fact that depressed conditions of the nervous system-anemia, chlorosis, etc.-did produce symptoms which patients themselves, as well as many physicians, ascribed to diseases of the pelvic organs; that these symptoms would pass away in proportion as the general condition of the patient was improved by rest, tonics, and everything that helped to the build

ing up of bodily vigor. I practised general medicine too long not to have learned that in general depressed states of the body we may get the counterfeits of many conditions which in reality do not exist.

It has been suggested by some one that it is not the displacement, but the state of the uterus associated with the displacement, which requires treatment. If this be so, I wish to ask what is the cause of this condition of the uterus, and why does not the condition get well by the same treatment that would relieve a uterus in normal position? This seems as reasonable a statement to me as though we were to say that a patient dead of typhoid fever did not die from the typhoid, but from the conditions accompanying the fever a distinction without a difference. We can seldom cure permanently an endometritis, an hypertrophied uterus, or any of the other conditions usually associated, so long as the uterus remains displaced backward. I believe that torsion of the vessels, infection of the endometrium, and defective drainage of the uterine cavity are the factors which prevent these cases from recovering by ordinary methods of treatment. A retroversion is well known to be the first mechanical step toward descent and eventual prolapsus uteri. We never see a uterus sliding down the inclined plane of the vaginal axis without it being retroverted. If for no other reason than to prevent this eventual prolapse, a retroverted and descending uterus should be replaced by operation and the necessary plastic operations done to restore the pelvic floor to the normal.

My case-books show a large proportion of these cases cured. I always depend a great deal upon general systemic treatment, and when I have them under the right circumstances I use the Weir Mitchell plan of rest, massage, and electricity for three or four weeks. In proportion as the symptoms are neurotic in character the less liable are the patients to be entirely cured, and the larger the local pelvic lesions predominate the more liable is the restoration to normal.

I have often seen sterility extending over a period of years relieved by replacing a uterus, by pessary or by operation. I have had pregnancies following several ventro-fixations and Alexander operations in women who before were sterile, miserable invalids. I do not believe in ventral fixation. I believe it to be unnatural and do not use it except in a limited class of cases. I have in the