rition. It also gives rise to pain in the course of the round ligaments, and the ligamenta lata. It is attended with pain in the region of the sacrum, loins and kidneys, and there is a sense of weight, pressure, or bearing-down, in the hypogastrium and pelvis.

3. When it occurs in the pregnant woman, it is fraught with danger both to the mother and child. If uncured, the mother is likely to be the victim of a dreadful death, from pain, inflammation, and from total obstruction of the pelvis.

4. The more advanced the pregnancy, the more dangerous the accident.

5. It is a diseased or debilitated state of the round ligaments that gives rise to the disorder. The cure consists in the restoration of the health and tone of those ligaments.

6. It is in some cases incurable, from adhesions tying the womb down in the excavation.

7. It should be treated-1st, by evacuating the bowel; 2d, by drawing off the urine; 3d, by repositing the womb; 4th, by supporting the reposited womb with a pessary; 5th, by carefully enjoining an attention to the state of the bladder, which should never be allowed to get too full.

able to cure the It is this: every

8. Lastly, I ask you why a pessary should be round ligaments? I am sure of your answer. tissue of living beings that is not compelled to extend, has a tendency to condense or contract itself. This is true, whether of muscle, cellular tela, lung, skin, and all the rest. While the round ligaments are extended by an overturned womb, they cannot become shorter, they cannot exert their natural tendency to condensation. To lift up the womb, and keep it up, to empty the bladder, and prevent it from being overfull again, is to give to the round ligaments an opportunity to act out their nature—that is, to regain their natural length, strength, and tension—which is effected by time, by tonics, by wholesome food, and by whatever tends to consummate the state which you call health. Take care that when they do recover, they go not beyond the state of recovery, and contracting too much, bring on the very antithesis of retroversion, I mean an anteversion of the womb, which shall be the subject of my next letter. Farewell.

C. D. M.

LETTER XVII.

ANTEVERSION OF THE UTERUS.

GENTLEMEN:-The state of the uterus described in my last letter, under the title of retroversion, is much more common than its opposite, the anteversion of the organ, a case in which the fundus is drawn or pressed towards the bladder of urine, and permanently maintained in that position. In such circumstances, the external signs are perhaps not different from those that attend upon the retroverted state; and they consist chiefly of pelvic pain, misery, bearing-bown sensation, micturition, and pain and weakness of the lumbar and sacral region, which are increased by exercise, and by the standing position. I do not think that I should be able, from any complaint, or relation proceeding from the patient, to discriminate between the affection attendant upon the anteverted and the retroverted state of the organ; nor do I suppose that any physician could correctly and confidently make such a discrimination, except upon information acquired by means of the

TOUCH.

I said that the anteverted is not so frequently met with, as the retroverted deviation. I am, indeed, of opinion that it is a rare malady, for, in more than thirty years, I have had few opportunities of observing it, whereas, I have met with a very considerable number of the contrary sort; a number so great, that I think it not very much disproportioned to simple prolapsus, as to frequency of occurrence.

The anterior face of the non-gravid womb, as high up as the middle of the corpus uteri, is in contact with the bladder; which, as I remarked in my former letter, pushes the womb backwards when filling, and draws it forwards towards the symphysis pubis as it becomes emptied; the round ligaments being put upon the stretch in the former, and completely relaxed in the latter pro

cess.

The only natural anatomical power that can draw the fundus uteri to the pubis, is to be found in the bladder of urine;-for the

round ligaments do not, as a physiological act, draw the womb nearer to the pubis than the middle of the pelvis, where it ought to be coincident, as to the direction of its axis, with the curve of Carus; whence it appears to me, that in all cases where the fundus uteri is permanently drawn against the bladder, and near the pubal bone, we must resort to one of two modes of explanation of the occurrence, one being, that it is pushed there by some body lying upon and behind it; and the other, that it is drawn or pulled in that direction by the ligamenta rotunda, which have become so short as to prevent the womb from retracting towards the sacrum when the bladder, being full, tends to send it off in that direction. Here, then, are two possible causes of anteversion; one, pressure from above or behind; and the other, traction or drawing from before.

Now, the causes that might act on the organ from above and behind it, are tumors fallen down into the pelvis, or developed in its superior parts; which, by their weight or volume, compel the uterus to assume a sort of horizontal attitude, pointing the os uteri backwards, and the fundus forwards;-or, the compressing cause may consist in a tumor, or tumors developed on the superior and posterior parts of the corpus and fundus uteri, extending backwards in their growth, until meeting with a point d'appui on the back part of the pelvis, and unable to extend farther in that line, continue to grow, but always finding space by thrusting the organ from which they spring towards the bas-fond of the bladder.

Doubtless such may be the true rationale of some of the cases, yet admitting this to be true, it is still clear to me, that a contraction of the ligamenta rotunda is much more generally the cause of anteversion. I can form no other conclusion from my own observations, and, on several occasions, I have had opportunities to test the thing in my practice; I having, in some of the samples, in vain tried to push the fundus off from the vicinity of the pubal symphysis, with one, or with two fingers, introduced far upwards behind the shear-bone. Upon making such attempts, having failed to move it out of its fixed position, I have been obliged to adopt the opinion, that the womb was tied down by a contraction or condensation of the tissue of the ligaments, so often named. What other opinion, indeed, could, or can be reasonably adopted in a case where the most careful exterior palpation clearly

proved that no tumor, fallen from above, or developed behind the womb, had pressed it against the front bone of the pelvic cavity. I saw to-day, June 10th, a case in which the womb was jammed hard against the pubis, by a tumor in the pelvis.

It is pretended that the front, or the posterior half of the womb, may, by some vicious condition of the development force, grow to so great a size as to overthrow the womb, either in a backward or in a forward direction.

I have not had any opportunities of seeing such samples, and cannot, therefore, speak from experience, as to such causes of anteversion. I may, however, say that I have met with several cases of unequal lateral development of the uterus, giving to the organ a tendency to fall or become oblique, to the right or the left side, according as the right or as the left symmetrical half of the womb was the largest.

Dr. Tiedemann showed me two or three such specimens, in the Anatomical Museum at Heidelberg, in 1845, and I have had two such in my own collection. It should be observed, that as the uterus originally consists of two symmetrical lateral halves, we might reasonably expect to meet with such unequal developments occasionally. It is probable the other sort, or that wherein the anterior and posterior halves are so unequally developed, must be from the nature of the embryogenic development law, much more rarely observable.

Allow me to repeat, that I have not met with a great many instances of anteversion. In all that I have met with, however, there has been left upon my mind, after careful exploration, no doubt as to the shortening of the round ligaments; and why not? The round ligaments are very subject to disease, being often inflamed after parturition; so much so, as to constitute a cord as large as the fore-finger of a man, or even as large as a thumb, very painful upon pressure, and traceable in its course not only through the abdominal canal, but backwards towards the angle of the womb, through the thin integuments of a scrawney woman. I have met with several samples of this sort, that I have been obliged to treat by leechings, fomentations, cataplasms, and by small doses of tartar of antimony and potash.

Morgagni, in his forty-fifth epistle, tells us, that he found them so in his dissections. He regards them as constituted chiefly of blood-vessels; but Velpeau considers them as endowed with a

considerable portion of muscular fibres. I deem it quite reasonable in M. Velpeau, to hold such an opinion, since, as they spring directly from the womb, and proceed to be inserted upon the exterior of the pelvis, they could not but carry with them a structure like that of the womb, as well as like that of the Fallopian tubes, of whose muscularity no doubt can be entertained.

Seeing, then, that the womb naturally rests on the top of the vagina; that it is wholly without attachments on its posterior face; that it has none but those of the two ligamenta lata on its sides, and that its only connection in front is a partial one to the bladder, and its sustentation by its round ligaments, we cannot doubt, when we find it held firmly against the pubis, of its being held there by means of some tumor behind or above it, or by a pair of contracted ligamenta rotunda; contracted, I say, either by a simple process of hypertrophy, by the consequences of inflammation, or by some spasmodic innervation of its muscular fibres.

To cure it, we must push the top of the womb off from the vicinity of the pubis, or we must cure the ligaments of their hypertrophic or inflammatory vice.

It is possible that Dr. Grauiex's seton, mentioned at page 58, Letter V., might profitably be applied to the subduction of the morbid activity of the ligaments, and in any case where the pessary and other means of countervailing pressure should be deemed inadmissible, I hope you would take into consideration the question of this especial seton. You are aware that the seton, in a cure, is like money in the funds, it works while you are asleep, it works day and night, for weeks, and months, and in general, only well, only with beneficence. I advise you to think of the seton, therefore. I confess I have not met with the case that I have deemed suitable for its trial, but I should certainly recommend it to a patient of mine, whom I should deem likely to be benefited by it.

The pessary, after all, is the most probable and most convenient remedy.

A globe of two and a half inches, will lift the uterus very high upwards in the pelvis. Its action must be to push the womb upwards and backwards, and therefore to resist the contractility of the round ligaments. But, by resisting it steadily, gently, and protractedly, it will at length draw them out, elongate, stretch, or restore them to their due and normal length; which, being done,