uterine displacements. So frequent are these displacements in this relation, that, as I have before stated, they are regarded as the causes of all the associated difficulties. While I cannot assent to this view of the subject, I believe them to be frequently, if not almost invariably, the effects of inflammation, and am confident they are most important and mischievous complications, and probably give rise to more suffering than any complicating condition whatever. As I have already stated, it is most frequently the displacements that cause stricture, hemorrhoids, and prolapse of the rectum. By the uterus being crowded down upon the rectum, these affections may be produced. It will not be expected that I shall dwell with any great degree of minuteness upon the different degrees or characters of displacements, or give a full description of them here, as I only wish now to speak of them as a complication of chronic inflammation of the uterus.

Subsidence of the Uterus.-The most common displacement I meet with is a subsidence, or lapse, of the organ, while its vertical axis remains what it was before the change of position. This does not bring the uterus, or any part of it, nearer the vaginal orifice; the lower end of it settles down upon the lower bone of the sacrum, while the fundus points upward toward the umbilicus. In examining per vaginam, instead of finding the os uteri upon, or nearly upon, a level with the inferior border of the symphysis pubis, and touched by introducing the finger almost directly backward, it is necessary to bend the finger over the upper edge of the perineum, and carry it back and downward to the lower end of the sacrum. This displacement is very frequent, according to my observation, and does more injury by pressing upon the rectum, and gives more distress than almost any other displacement. It almost always obstructs the passage of the fæces through the rectum, and makes the patient feel as though the bowel was constricted at the point of pressure. After long continuance, it induces, in many instances, organic diseases of the rectum, inflammation attended by tenesmus, mucous and even bloody discharges, hemorrhoids, &c. All these rectal complications above mentioned may arise in this way.

Anteversion.-The inflamed uterus is also anteverted, more or less, in many instances, so that the fundus presses heavily upon the bladder, while the os, higher up than in the first-named displacement, presses the rectum against the sacrum. But as most

of the weight of the uterus is upon the bladder and anterior wall of the vagina, the rectum is not so distressed.

Pressure upon the Bladder.-The greatest inconvenience is felt on account of its pressure upon the bladder. Frequent micturition, sense of weight behind the pubis, &c., are its symptoms.

Retroversion.-Retroversion is also not unfrequent as a troublesome complication. As the fundus presses upon the lower part of the rectum and perineum, while the neck and os press upon the urethra and bladder, there is dysuria and rectal tenesmus of greater or less intensity. The symptoms will be modified by the greater or less degree of malposition.

Prolapse. Common prolapse, with the mouth following the axis of the vagina, is the least frequent of these displacements, as I have observed them. It sometimes occurs, however, to a very great extent, and produces a great deal of distress. Compared with the other forms of displacement, it produces less inconvenience when present in the same degree. It certainly does not interrupt the function of the other pelvic viscera so much as subsidence, retroversion, or anteversion. Where excessive, it gives a sense of dragging and perineal tenesmus that are very disagreeable, but it does not cripple the patient, and render her unable to walk or stand, as is the case with the other displacements. While displacements aggravate the sufferings connected with diseases of the uterus, they render the treatment more difficult, and often imperfect, on account of the difficulty of exposing the os, and bringing the axis of the uterus to correspond with the direction of the speculum.

Theory of Displacements.—I cannot now enter into the theory of displacements as complications of inflammation. I believe they are one of the effects of the pre-existing inflammation; that they are brought about by the inflammation increasing the size and weight of the uterus, and thus causing it to settle down by virtue of its weight in spite of its supports; that the suffering caused by the displacement results from its pressure on morbidly susceptible organs, made so, perhaps, by a long continuance of the pressure, and by the sense of soreness in the inflamed uterus itself, and also in part by traction upon the lateral and round ligaments. Still, I have no question that in very rare instances the displacement re

12

sults from other causes than inflammation, and then I can easily comprehend how it may produce inflammation in the uterus. The circulation must be embarrassed, congestions will readily occur on account of pressure and forcible flexion of the veins and arteries, and inflammation is very apt to follow long-continued congestion, &c.*

* See Displacements.

CHAPTER XIV.

POSITION OF INFLAMMATION.

SUBMUCOUS OR FIBROUS-HYPERTROPHY AND INDURATION-ATROPHY WITH INDURATION-MUCOUS INFLAMMATION-SEAT OF MUCOUS INFLAMMATION -IN CAVITY OF CERVIX-IN CAVITY OF CORPUS UTERI-ENDOCERVICITIS IN THE VIRGIN AND AGED.

Submucous or Fibro-Cellular Inflammation.-Chronic inflammation may originally attack any portion of the uterus, from the fundus to the lower extremity of the neck, and be seated in either the fibro-cellular or mucous tissues. The part of the organ most likely to be attacked, however, is the cervix, and of this the mucous tissue is nearly always the seat of disease. When the inflammation originates or invades the fibro-cellular tissue of the uterus, it is soon followed by enlargement of the portion inflamed. If the posterior wall is thus affected, this is on account of an effusion of serum to some extent; the part is thickened, and as more and more fibrinous coagulation takes place within the cellular tissue, it becomes hard as well as enlarged, and then we have a hard, tender tumefaction in that part of the uterus. When the substance of the cervix is chronically inflamed, with or without coexistent mucous inflammation, it is enlarged, or, as Dr. Bennett has it, hypertrophied, at first not very hard, but if the inflammation continues, there is hardness; hence we have hypertrophy, induration, and enlargement. Hypertrophy is not the word for this condition of things; the part does not enlarge by an increase of existing tissue or a development of more of the same kind, but it is enlarged by an effusion of fibrine, which assumes an imperfect arrangement. It is increased in size in this way and also indurated. This kind of enlargement should be distinguished from the enlargement of congestion,-a condition in which the uterus is injected with an unusual quantity of blood, and its substance distended by it. This is the case every month, but it becomes more permanent by the continuance of some point of irritation which

keeps up an afflux of blood, and yet the irritation is so moderate as not to induce that stress of circulation necessary to an effusion in the tissues. We can, therefore, have chronic enlargement of the neck, and even the body of the uterus, without induration or actual structural changes. This is often the case where the inflammation is confined to the mucous membrane. Enlargement is no evidence, therefore, of fibro-cellular inflammation; induration must be superadded to make the whole of the changes necessary to constitute a case of it. When, therefore, we meet with an enlarged and indurated uterus, or cervix, we may with safety conclude that it is suffering under chronic inflammation of the fibrocellular tissue, with certain provisions that I shall have occasion to mention in future. When the uterus is hypertrophied, as in pregnancy, or in consequence of a growth or other substance which causes a development of tissue, the fibro-cellular structure is softer than natural.

Hypertrophy. The hypertrophy from growth is general, including the neck, body, and fundus; the enlargement from congestion is not always, though most frequently, general; the enlargement accompanied with induration, and indicative of chronic inflammation, is apt to be partial; confined to the cervix, sometimes to one lip of the os uteri, or some part of the body near the neck. When the whole cervix is chronically inflamed, it enlarges in every direction; the thickness is increased from the size of the end of a man's thumb to half the size of his fist, or even larger than this, and it is hard and tender to the touch. The cervical canal is decreased in calibre in most instances, and somewhat lengthened. The induration is not always of the same intensity; its hardness. is often very great, at other times but little more than natural. As the induration and enlargement may be quite partial, the shape as well as size of the neck or portion of the body attacked, will seldom present its natural contour. The proportions of the different parts do not correspond in shape or size as they do in the healthy condition. Then we have in chronic inflammation of the different parts of the uterus increase in size, hardness, and disproportion of corresponding parts, and hence alteration in shape, to which is almost always added tenderness upon pressure or touch, particularly with instruments.

Hardness with Atrophy.-Although these statements will be