ward displacements, the vast majority of anterior displacements being found in sterile women. They further emphasize the fact that retrodisplacements are almost always acquired. A further study of these twenty-six nulliparous cases indicates that the position of the uterus had little to do with the symptoms which led to the examination by which the displacement was discovered. Nine of the patients had small, undeveloped uteri, with narrow cervices, and complained principally of dysmenorrhea

a symptom which is no doubt due to the same causes that produce the painful menstruation of patients suffering from cervical stenosis without reference to the position of the body of the uterus. Seven had endometritis with a purulent discharge; and since five of the seven were prostitutes it is more than probable that a majority if not all of these patients had gonorrhea. A gonorrheal endometritis is amply sufficient to account for all the symptoms in these

seven cases.

Three had salpingitis of undoubted gonorrheal origin. Two had enlarged ovaries. One had papilloma of the cervical canal which bled freely after each coition. Three had no symptoms that could be referred to the uterus. While only one of the twenty-six had symptoms that were undoubtedly due to the retrodisplacement and which were relieved by maintaining the uterus in a more correct position.

This brief review indicates that retrodisplacement in nulliparous women is at minor lesion which rarely gives rise to symptoms, and that if we hope to benefit these patients we must look beyond the displacement.

Taking up now the consideration of the seventy-four cases, all of which had been one or more times pregnant, and in the majority of which the displacement is presumed to have been not congenital but acquired, we find a series of symptoms which are without doubt due to the lesion, because they are relieved when the retrodisplacement is corrected. It is true that none of these symptoms is absolutely characteristic; that some or even all of them may be absent from

any given case, yet when a group of them is found with the history of dating from the termination of the last pregnancy, a guess that a retrodisplacement exists, even before a physical examination is made, will seldom be wrong. This statement is not to be construed as belittling the value of a physical examination which is essential to a diagnosis, but simply as an estimation of the symptoms in affording a basis for a probability.

An excessive loss of blood at the menstrual period was complained of in twelve cases. In nearly all of these patients the flow was either too frequent or long-continued, or both. The blood, as a rule, did not come in large quantities at a time as it often does when it is due to some other pathological conditions, but rather more than the normal amount continued to be lost each day for many days. The loss of more than the normal amount of menstrual blood is common to a much larger percentage of patients suffering from acquired retrodisplacements than shown by the figures, but in many instances the excess is not great and is overshadowed by other more distressing complaints. This increased flow of blood is probably due both to the obstruction of the veins by the displacement and also to a loss of tone in the vessel walls. It is also an important factor in reducing these patients to the debilitated condition in which they are so often found.

Twenty-eight, or more than one-third, of these patients had pain during their menstrual period. One of the most characteristic points in the dysmenorrhea associated with acquired retrodisplacements is that it almost invariably dates from the termination of the last pregnancy. This assists us to distinguish it from the dysmenorrhea associated with or due to other lesions. When the pain is due to an inflammatory condition either of the endometrium or the appendages, the pain comes on with the development of the disease. When the pain is due to a congenital cervical stenosis, either with or without a forward or backward displacement of the uterus, the dysmenorrhea dates from the first

menstrual period and is of the most severe character. As the lesions here enumerated cause 90 per cent. of all cases of dysmenorrhea, the importance of the history of the duration of the painful menstruation as an aid to diagnosis can readily be recognized.

More than one-fifth of the patients complained of painful defecation. This pain is usually not of a severe character and is not always constant. It is usually described as a feeling that there was something still in the rectum that could not be passed and the effort and straining to pass this supposed content of the rectum produced the discomfort. Not infrequently this pressure on the rectum gives the patient an ever recurring desire to go to stool. These patients are frequently constipated and this of course adds to their discomfort. These symptoms may be caused by any pelvic tumor which presses upon the rectum, but as a matter of fact all other causes combined are much less frequent than retrodisplacement.

Over one-quarter of the patients complained of disturbances of micturation. Retrodisplacements are responsible for the majority of disturbances of micturation in women which are due to disease outside of the bladder and urethra. These symptoms are more commonly due to retroversion than to retroflexions, because in the latter the cervix does not so frequently compress the base of the bladder against the symphysis. Painful and frequent micturation are most often complained of; often a burning sensation after the urine has passed gives much discomfort. Complete obstruction to urine by an uncomplicated retrodisplacement is very rare. A pregnant retrodisplaced uterus can easily so press upon the bladder as to entirely put a stop to normal micturation. These patients not infrequently say that they cannot retain their urine; that it runs from them constantly. An examination reveals an over-distended bladder. After the urine has been drawn with a catheter, if the uterus can be pushed up, as it usually can be, these patients suffer no further inconvenience.

Twenty-one of the seventy-four pa

tients complained of painful coition. This is an understatement, because in many of the cases this symptom was not inquired into. But, imperfect as the statistics are, they show how extremely common it is to have this symptom associated with retrodisplacements. The pain is not pain is not so acute as that due to pressure on a prolapsed ovary, but is much more frequently met with and is often continued for some minutes or an hour after the act of coition is completed.

A large proportion of these patients were affected by what for a better name we call extreme nervousness. They said that they were easily frightened; that every slight noise startled them; that their emotions were easily excited; laughing or crying without reason; that they were irritable and disagreeable to their family and friends without knowing why. Many remarked that they often felt as though they could only by great effort prevent their bodies from flying to pieces. Disturbances of the functions of the stomach, distention of the intestines, palpitation of the heart, are all extremely common. The whole sympathetic nervous system seems to be profoundly affected. Hysterical convulsions are met with in extreme cases. In short, we have an hysteria associated with a definite pathological condition and which is cured by restoring the uterus to its normal state.

The pain during the inter-menstrual period, aside from that in connection with the functions of the bladder and rectum, is usually described as a bearing-down pain or as a sense of weight and pressure in the pelvis without actual pain. These discomforts are much increased by walking or lifting and are abated or entirely relieved when the patient maintains the reclining posture.

The general physical condition of patients suffering from acquired retrodisplacements is as a rule bad. They are anemic, their whole muscular system is in an atonic condition. This lowered state of vitality is no doubt both a cause and a result of the special lesion. uterus becomes displaced backwards as a result of the atonic condition of its

ligaments and walls. The irritation of the sympathetic by the malposition tends to continue and increase the deficient nutrition by interfering with the digestion. The result being that these patients have very little tendency to get well without intelligent treatment.

Retrodisplacements of the uterus are much more frequent than forward displacements and while retroversions are more frequent than retroflexions, nearly all forward displacements which give rise to symptoms are anteflexions; retrodisplacements which give rise to symptoms are nearly all acquired; anteflexions are nearly all congenital. So that when we speak of a displacement of the uterus forward we almost invariably mean a small, not well developed uterus congenitally anteflexed.

I have recorded only about twentyfive uncomplicated cases of this character. Others have been observed, but when an anteflexion has associated with it a pyosalpinx or other gross lesion, it is evidently unfair to charge all the discomforts of the patient to the displacement. For this reason all such cases have been omitted from consideration in this paper and only such cases selected as were found to be simply anteflexions and in which the symptoms were presumably due to the lesion found.

Much has been said and written upon the etiology of anteflexions, but so far as I can learn the greater part of this had been purely theoretical and little or no actual evidence had been brought out to give a reasonable foundation to many of the elaborate theoretical essays upon the causation of this trouble. So far as I have been able to observe, the condition is almost invariably a congenital one. And if we are to find the true cause it must be sought for in the fetus in utero and in the growing girl.

(As diseases of the sexual organs in childhood are better studied much light will be thrown on these resulting conditions.)

The most constant and characteristic symptom complained of is pain during the menstrual period. Each of the twenty-five patients had this symptom. The fact that patients who have an ante

flexion nearly all have dysmenorrhea has led to some confusion in reference to the causation of painful menstruation. While it is true that women having an anteflexion which gives rise to symptoms always have dysmenorrhea, it is also true that only about 12 per cent. of women who have dysmenorrhea have anteflexions. The dysmenorrhea associated with and probably due to anteflexion is quite variable in its duration. With some patients the pain continues throughout the flow; in others the pain stops when the flow is fully established at the end of the first or second day. The pains are usually intermittent, not unlike those of the first stage of labor, and are the most severe of all the dysmenorrheas. When a dysmenorrhea is due to an acquired lesion, as a retrodisplacement, or a pyosalpinx, the pain will date from the time of the acquired lesion; but when painful menstruation is due to an anteflexion, the patient will almost invariably state that the dysmenorrhea began with her first menstrual period.

Only two of the twenty-five patients had ever been pregnant and only one of these had had a child at full term. Probably not one had not been in a position to become pregnant and a majority were married. Many complained as much of their sterility as of their dysmenorrhea. When a young married woman, apparently healthy, states that she has had dysmenorrhea all her men. strual life and that she has never been pregnant, the most common condition found upon physical examination is a small, narrow cervix and usually an anteflexed uterus.

Nine patients complained of pain between their periods. These pains are difficult to account for, though they are probably due in the majority of cases to inflammatory conditions of the uterus or tubes which were not sufficiently pronounced to give rise to other symptoms, and where there is no tumefaction to be detected by physical examination, I have known of two cases of anteflexion with inter-menstrual pain, where the pain was due to an intermittent pyosalpinx.

It

LET us return to the treatment of hyperacidity by diet. If after an experiment with the proteid diet the patient is no better or even worse, it is advisable to make repeated quantitative analyses of the urine for urea and uric acid. is my experience that in the majority of these cases, in which the symptoms and consequences of hyperacidity are aggra. vated by a preponderance of meat and eggs in the diet, it will be found that the disease is based upon a uric acid neurasthenia. Now as proteid diet largely increases the amount of uric acid taken in with the food, if the trouble is caused by uric acid diathesis, it will most probably not be improved by introducing such food as will add to the amount of uric acid and urates already present. It might be objected that all neurasthenias are due to uric acid, but this objection has no experimental or clinical foundation. It is not difficult to observe intense neurasthenias without uric acid diathesis. As a result of these considerations then, if in renal insufficiency with albuminuria there is gastric hyperacidity, the prac titioner should not hesitate to order a diet rich in proteids, all kinds of meats, all egg foods, fish and milk. Order this at first in spite of the fact that the albuminuria would contra-indicate a meat diet. In seven out of ten cases he will strike the right diet. If this diet does not improve the symptoms, and the amount of ethereal sulphates increase in the urine, then a vegetable diet, and carbohydrate diet, rice, all wheat flour preparations, tapioca; farina leguminose-cerealine, with milk and occasional egg food. If this latter If this latter diet is given it should always be accompanied by a diastasic ferment, such as malt extract or ptyaline, and at other times pancreatine. Care should be taken to procure a reliable product. In all cases where the HCl is increased

M. Sig. One half a teaspoonful 3/4 hour after each meal.

In hyperacidity there is starch indigestion and the alkaline juices of the duodenum do not suffice to neutralize the chyme. the chyme. Now as there is a good starch inverting ferment present in the stomach in these cases and the only reason it does not act is because it is in too much acid, it will in most patients not be absolutely necessary to give a diastase at the beginning. Try this neutralizing powder and see whether the ptyalin will not suffice to do all that is required of it when it reaches the duodenum.

If the analysis of stomach contents shows anacidity or subacidity, establish above all things the diagnosis between nervous suppression of the gastric juice where the peptic glands are intact and the fault is due to nervous inhibition, and chronic atrophic gastritis where the peptic glands are partially or totally destroyed. In anacidity or subacidity a diet which will not require much HCl for its solution will be the most logical, a mixed diet with little meat- not more than two eggs a day and an abundance of milk, rice and carbohydrate food. In these cases pancreatine at times gives good results (gr. iii to gr. v with sodium bicarbonate). Whenever excessive quantities of mucus are present, gastric lavage twice weekly can hardly be dispensed with. Anacidity. and subacidity have been successfully treated by gastric lavage with strong sodium chloride solution used quite warm. Also the constant current employed with the Einhorn intra-gastric electrode, the positive pole in the