the texture of the rectum; and the bladder of urine is distorted by the dislocation of its neighboring organ.

The artist has made

a dotted line ending. at (b), which shows you how much the round ligament must have been stretched, to let it reach thus to the bottom of the pelvis. The other dotted line, marked (a), shows how long, and where, the unstretched round ligament ought to be, and was, before the retroversion took place. If you push the index into the vagina, you will press it on the fundus and corpus uteri, down near to the sacrum, while the os is high up near the pubis. I think the

drawing may explain the state of the case better than all the balance of this sheet.

In looking through the books again to find what the writers think on this subject, which, as you may remember, I have often presented in this light at our meetings in the lecture-room, I discover them not to be so clear and concise in their apprehensions of the true nature of the case, as I think you will be, if you adopt the opinions above expressed and set forth. They all know that retroversion is retroversion-but they seem not to know why. The famous Dr. Deleurye, in his Traité des Accouchemens, Par. 127, says of the round ligaments, "Hors le temps de la grossesse, les ligamens ne sont d'aucun usage à la matrice; pendant la grossesse, ils peuvent lui servir, étant tendus et droits." So that Mons. Deleurye appears to regard them as provisions against a

gestative want. Most of the authors, I believe, equally overlook the ligaments, as allowing by their failure the occurrence of a retroversion, except Velpeau, who, at p. 94, 2d edition, Paris, 1835, says, "but for them the womb would every moment be turned over backwards by the bladder, which is distended several times every day, with urine." They have escaped the attention of Robt. Lee, whom nothing escapes. Cazeaux passes them by with scarcely a remark; nor does Churchill seem to deem them worthy of notice. Even MM. Désormeau and Paul Dubois, authors of the article in the Nouveau Dict. de Médecine, pass over these organs without due regard, while Dr. Jacquemier's new Manual of Midwifery, which is the last novelty in our line, seems also to attribute this pathological condition to any tissue save the one really in fault. Authors say it is a full bladder that causes retroversion, or that retroversion causes the bladder to be overfilled.

For example, here is a brochure entitled Mémoire sur la Rétroversion de la Matrice dans l'état de la Grossesse, 76 pages, 8vo., 1843, by the distinguished Dr. Amussat, of Paris. I shall translate a whole paragraph from p. 22. It is in the following words: "A retention of the urine has been indicated as one of the causes of retroversion of the womb. In my opinion the effect has been mistaken for the cause; a retention of urine being an inevitable consequence of the displacement; since the cervix, provided it have not been really bent, must immediately press upon the urethra and obstruct the escape of the urine. Certainly where the retention of urine produced in this way is misunderstood, the distention of the bladder will tend to increase the displacement, and the use of the catheter, by drawing off the urine, might partly cause the organ to rise again above the promontory of the sacrum. But, it is incorrect to say that a retention of urine may produce a retroversion of the womb; it can only increase it-perpetuate it. However, I admit that where the bladder is habitually distended by a great quantity of water, and where this distention is a consequence of disease of the bladder or the urethra, there might in the long run follow a depression of the fundus from the weight of the bladder, and so, a tendency to a retroversion."

There, what say you as to Dr. Amussat's view of the case? In his whole pamphlet there is not one word of the round ligaments

and a man who teaches you mentioning them, is like a surgeon who should teach you the whole doctrine of dislocation of the hip-joint without the least allusion to the orbicular ligament or the capsule. You might ask such a teacher, can a hip-joint be dislocated without troubling the orbicular and capsular ligaments?-and you might ask M. Amussat if he thinks a womb could be retroverted with a pair of ligamenta rotunda not over two inches and a half long!

the doctrines of retroversion without

Dr. Samuel Merriman's "Dissertation on Retroversion of the Womb, including some Observations on Extra-uterine Gestation," is equally devoid of concision in the exposition of the causes of the accident, for his whole book from beginning to end has not one word on the subject of the ligaments.

Dr. John Burns, of Glasgow, whose work, with notes by the late Professor James, was so long a text-book of the University of Pennsylvania, has not an item on the subject of the round ligaments in the whole of his article, which you will find in vol. i. p. 186, of Burns' Midwifery. Dr. Robert Lee, of London, who in my opinion is one of the ablest men in his department now alive, does not hint at the existence of ligamenta rotunda in his article on retroversion, which is at page 207 of his "Lectures on the Theory and Practice of Midwifery, delivered in the Theatre of St. George's Hospital. London, 1842, 8vo." Nor does Dr. William Hunter, the father of all retroversion authors, say anything about them.

I think, that as retroversion is an accident very common, and in pregnancy, very dangerous, it is important that you should not only be well aware of the state of the womb under it, but of the implications it may introduce as to other tissues; and it is exigent, not only to know these things, but why they do happen, so as to enable you to direct aright your intentions and method of

cure.

Can you entertain any scruples in regard to my explanation of it? Let us try conclusions then.

The bladder, when it fills from the perpetual stillicidium of the two ureters, always fills first in a direction backwards, towards the sacrum; and when it cannot distend any farther, in that direction, its fundus mounts upwards towards the umbilicus. In Dr. Hunter's case, figured in his anatomical tables of the gravid womb, it

went up half way between the navel and pit of the stomach. Now, in a healthy strong woman, the bladder, in filling, cannot go back to the sacrum, pushing the womb before it, because, as soon as the round ligaments are put on the stretch, they cease to yield, and compel the bladder to develop its walls in an upward direction towards the navel. The womb is therefore safe; it repels the intrusion of the bladder, and makes it rise upward, in the belly, agreeably to the explanation of M. Velpeau, in his Midwifery. But, there are certain women, who, from insensibility of their nervous system, or from their situation in the world, habitually allow the bladder to become enormously distended, before they yield to the urgent call of nature. Such a habit must, inevitably, generate a laxity of the round ligaments, which being daily overstrained, yield more and more to the antagonizing force of the distended bladder, until they end, by becoming too long to hold the womb in due propinquity to the pubis; wherefore, it must fall backwards to the sacrum, since there is nothing devised for holding it forward, except these round ligaments, that can now no longer do their office. This slow, gradual elongation of the round ligaments, will explain to you the reasonableness of those writers who say, that retroversion may, in some women, come on gradually, and by small degrees, until it is at length completed. I have myself, no doubt, that the cases of retroversion in the unmarried, are mostly brought on in this slow chronical way; though, it is true, when the woman is prepared for it by this process, some sudden exertion or succussion of the body, may complete it in an instant. Suppose the round ligaments to have become habitually overstretched, until they have become four and one-fourth inches long. Do you not perceive, that a full bladder, suddenly jammed downwards in a fit of vomiting, or coughing, or straining, or jumping, might press the head of the womb down beneath the sacrovertebral angle, whence it would not be likely soon to be pulled up again by the said ligaments.

Any pressure upon the rectum, whether from within, or without the cavity of the gut; any inflammation of it, or any irritation acting upon it or the bladder, excites what is called tenesmus or a bearing-down. In tenesmus, all the parts contained within the pelvis, are pushed downwards towards the perineal strait, and, as the tenesmic feeling becomes more and more intense, it must hap

pen that the overturned organ shall be pushed down into the peritoneal cul-de-sac, betwixt the bowel and the vagina. The womb cannot come into this situation, without greatly augmenting the tenesmic feeling, and bringing on other complaints, such as strangury, or dysury, urinary tenesmus, rectal tenesmus, pain in the middle of the sacrum, in the ligamenta rotunda, sciatic pains, and pains along the distributive places of the obturator nerves in the groins and thighs, and a great disturbance of the entire splanchnic system of innervations.

You may very readily conceive of the disturbing influences, as to the general health, bodily and mental, of such a state of things; and in making up your notions of the modality of such disturbing operations, you will not leave out of the computation, that vast and dominant force, which the reproductive organs of the female ever exert upon her entire physical nature. How much greater that force when the womb and the ovaries, and the whole reproductive apparatus, indeed, is advanced in power by the sanguine affluctions, and nervous determinations to which they are subject under such circumstances. You should not be surprised to witness the wildest hysterical phenomena; nor, indeed, the whole protean genus of hysteria.

I have been accustomed to observe these influences for many years past, and have seen them carried to the extent of producing a temporary insanity and the various modifications of the nervous manifestation below that which constitutes insanity.

The disordered womb can, by its nervous connections with the spinal and sympathetic nerves, disturb and vex any and every organ in the body, from the brain to the massa carnea on the sole of the foot. It can vex the pharynx and oesophagus with spasm or globus-close the jaws through the masseters or temporals, jaundice the blood by its influence on the liver, cause ischuria or diabetes in a moment, bring on constipation or diarrhoea, simulate apoplexy and eclampsia, set the hemispheres in a rage of insanity, or excite the cerebellum to the manifesting of chorea, or abolish the sensorial and motor chords of the spinal marrow; but, if, in the non-gravid condition, the retroverted deviation of the uterus can cause such great derangements, what must be those that attend some of the terrible consequences of retroversion of the gravid womb. They are truly appalling. They consist in all the