old she menstruated, and was irregular for about one year afterwards, became permanent and regular and of normal quantity up to her 16th year. During one of her periods she was fishing and accidentally fell into the water; this stopped her flow for eighteen months; during this time her health was perfectly good, but convulsions developed at the would-be regular period, and continued for four days, sometimes as many as twenty per day. After the fourth day the convulsions would cease, consciousness would return, and was well for four weeks. This had been repeated for about six periods when I saw her. I advised an examination, which was consented to, and made. I found all the generative organs in normal condition-the vagina, ovaries and uterus. The nutritive organs were acting well, and system well fed. I concluded the functions of the nervous system were seriously disordered, and causing all the trouble, and directed my treatment partly to this. In three days her period was due, so advised them to inform me at its appearance; was called and found her in convulsions; ordered chloral, bromide and morphine at once, which gave some relief after taking four doses; then I concluded to give her santonin, 10 grain doses, and ordered 10 more in twenty-four hours if necessary. I then left her, and told the mother to call me again at once, if she was getting worse, and that I would call again the next day. When I returned she was sitting at the sewing machine doing some work (as she was a girl of her own will). You can not imagine my surprise. I asked why was this? Her mother said: "In two hours after I gave the powder she became perfectly quiet and went to sleep, woke this morning well, and with a good menstrual flow," and that was the happiest family I ever saw. advised her to give the powders in the future at each menstrual period for three or four months, which she did, and her troubles were ended.

THE MANAGEMENT OF UTERINE DISPLACEMENTS.

L. P. McCUISTION, M. D.,

PARIS, TEXAS.

It is estimated that about one woman in every eight has some form of uterine displacement. This frequency and the consequent discomfort which it engenders is sufficient to invest the subject with importance, hackneyed though it be.

In presenting this paper I have no new idea to promulgate or untried method to advocate. The measures already in vogue for the correction of this deformity, while not altogether satisfactory, are sufficient to yield comfortable results in most cases, if judiciously applied. Gynecologists have long held opposing views as to what constitutes the best methods of treatment in the different dislocations to which the uterus is subject, and hence, many measures have been proposed and practiced from time to time, yet we are today without a satisfactory method which meets the requirements in all cases.

The measures which have been advocated for the correction of this deformity are too numerous to mention in detail, but in epitome are comprised under two heads, namely, surgical and mechanical.

A review of the literature of this subpect during the past few years shows the tendency of authoritative opinion to be in favor of surgical measures. My belief in the unwisdom of this teaching has suggested this paper. In making this statement I would not be understood as saying that the surgical operations for the relief of uterine displacements are entirely useless. On the contrary, I believe that they are often justifiable, many times necessary.

My contention is that most cases are correctable by mechanical means, and that the results thus obtained are more satisfactory and the method less objectionable than by any surgical procedure which has yet been proposed.

It is difficult for me to understand the prejudice which exists in the minds of medical men against the use of pessaries. This opposition must arise from an experience with the misapplication, and not the judicious use, of the instrument. It is true that a great number of pessaries are not only useless, but hurtful, and any pessary is capable of doing harm if improperly used. Yet the fact remains uncontrovertible that they are potent for much good.

In order to secure the best results in the treatment of malpositions of the uterus, it is necessary to have a clear understanding of what constitutes the normal position, and the amount of deviation which can take place in the range of health. Not all cases of uterine displacements are clinical abnormalities. It is only when the displaced organ excites local or constitutional disturbance that measures for its restoration become necessary.

It should be remembered that the uterus is not a fixed organ, but is suspended in the pelvic cavity, and under normal conditions has a comparatively wide range of motion. The further fact that it is not anchored by any one set of ligaments should be taken into account. The forces which retain it in position are derived from the broad ligaments, the utero-sacral, the utero-vesical and to a lesser extent, the round ligaments.

cess.

The perineum is not a controlling force in this suspensory proIt is only through the combined and harmonious influence of these several forces that the uterus is maintained in its normal position. When this harmony of action is disturbed from any cause, a displacement is the result, whether the causative influence be exerted on the uterus itself or upon its supports.

I will not undertake to describe the manifold disturbances which these malpositions cause, but desire to emphasize the importance of determining in all cases whether or not the manifestations present in a given case are due to misplacement, or whether some other causative influence is operative through which they may be explained. A displacement may be the cause of much constitutional disturbance, or the constitutional conditions may produce the dislocation.

Success in treatment depends largely upon accurate knowledge of the relation between the displacement and the existing constitutional disturbance. Then again, some forms of dislocation can only be regarded as anatomical, and in no sense pathological pro

cesses.

Lateral displacements, as a rule, are unimportant. Anteversions and anteflexions do not produce much disturbance and are not correctable. Then the only displacements which necessitate measures for relief, are backward and downward dislocations. These may exist in conjunction or separately. In dealing with either of these deformities, the first and most important thing to do is to restore the uterus to its normal position. If it is fixed in its abnormal situation, all efforts to replace it will be futile until the adhesions are broken up or absorbed. When this is accomplished and the uterus replaced, a pessary will, in the majority of cases, be all that is necessary to accomplish a cure. Nothing could be more unsatisfactory than an attempt to use a pessary in a case where the uterus was fixed by adhesions.

There is one point which I deem worthy of notice here, and it is, that in many cases where the uterus seems to be fixed, a closer investigation will reveal the fact that there are no adhesions, but instead, the fundus is clamped between the folds of the uterosacral ligaments, and is not adhered at all. A little perseverance in these cases will loosen this attachment, and the womb readily goes back to its proper position.

The kind, form and size of pessary are matters of the greatest importance. While many different shapes and kinds of pessaries have been used and advocated, there are only two, which, in my judgment, possess merit, and they are capable, if properly used, of meeting all the requirements. These are the Hodge-Smith and the Ring Pessary of Peaslee-no others are worthy of consideration, except, possibly, the Graily Hewitt Cradle pessary, adapted for use in cystocele.

There are numerous reasons why physicians fail in the use of pessaries. Chief among these is a mistaken idea as to the prin

ciples upon which they operate. A clear understanding of this principle is essential to that perfect adaptation which alone can succeed.

It is to be remembered that a pessary does not exert its influence by making pressure against the womb, nor by distension of the vagina alone, as has been asserted, but by its leverage action upon the ligaments which makes more tense the natural anchors. This pressure is exerted upon the posterior wall of the vagina in such a way as to force the cervix backward toward the hollow of the sacrum, and this in turn restores the fundus to its proper position.

Extreme care should be exercised to see that the fundus goes forward and that there is no flexion in the body of the uterus, otherwise the pessary may rest in the concavity of this flexion and not only fail in its purpose, but become an actual source of irritation. In order to succeed with a pessary it is necessary to have a clear and concise understanding of the condition of the patient, and to know what is expected of the instrument, and then to be sure that it is accurately and skillfully fitted to the case in hand.

There is no other remedial agent with which I am familiar that yields more prompt and gratifying results than a pessary properly adjusted, and there is certainly no measure more disappointing if not skillfully fitted. It is, in my judgment, this inattention to the details of the treatment which has brought this instrument under the ban of gynecological iconoclasts and created an unjust prejudice in the minds of medical men against their use and caused them to seek other means of correcting this deformity.

In this age of surgical triumph it is but natural that the resource of this art should be sounded in the hope that it might offer some better and more satisfactory method. The result is, that many operations have from time to time been proposed and practiced with varying degrees of success and failure.

It is not my purpose to enter into a detailed discussion of the merits or vices of these several operations. In a general way, I will say that they have been disappointing in their results and in most cases possess no advantage over the mechanical treatment.