not of the ordinary woman or girl. The prescriptions and directions for treatment are simple and well chosen, as is fitting in a work of this description. On Cancer of the Uterus there is an excellent chapter that ought to be useful in indicating the circumstances under which medical advice should be at once sought. The book is well printed, of handy size, and reasonable price, and is one of the best of its class. We have every confidence in recommending it as suitable to be placed in the hands of women and girls for whom it is intended. BOOKS RECEIVED. From Henry Kündig— Les Fractures de L'Humérus et du Fémur. Traduit de L'Allemand par Dr. L. SEIN. KOCHER. Le Ventre. Etude Anatomique et Clinique. I. LE REIN, par Dr. M. BOURCART. From Young J. Pentland Manual of Practical Ophthalmology. BERRY. From Hodder and Stoughton The Pathology of the Eye. PARSONS. Vol. I., Part I. From E. H. Arlegene— The Utero-Ovarian Artery. BYRON ROBINSON. ON RETROVERSION OF THE UTERUS. WITH the better knowledge of the conditions under which any morbid state of the body occurs, both with regard to cause and effect, and the more advanced and exact our methods of treatment, the more precise will the indications leading to the latter become. Such a general statement as this may be applied to backward displacement of the uterus, as, indeed, it could to any other abnormal condition of the body. In dealing with the modes of treatment and their indication in retroversion of the uterus, it is not intended in this short paper to give any detailed account of the anatomy of the uterus and the pelvis (which may be studied with profit from the writings of Dr. Berry Hart and others), but rather to consider the chief clinical varieties of this displacement and their causes, anatomical and pathological. By backward displacement of the uterus it is understood that it includes both Retroversion, when the organ is turned back in its relation to the axis of the vagina, and Retroflexion, when it is bent back at some point along its own axis, generally at the level of the internal os. For the sake of description the word retroversion will be used to include both, and, as a matter of fact, the two varieties of displacement are generally combined, although one or other is more often marked in any particular case. Retroversion may be temporary or physiological, and may be permanent or pathological; the former is often associated with retroposition of the uterus, which means that the uterus is simply displaced backwards in its position in the pelvis, and is due to occasional causes, as the pressure of a full bladder, such temporary displacement disappearing with the evacuation of urine; the latter or permanent retroversion is in the main due to pathological processes in the supports of the uterus, in the organ itself, and in the adnexa, although this may be predisposed to by a too infrequent emptying of the bladder. The Clinical Varieties of Retroversion. In a broad way a division of this displacement may be made whether it be considered from a clinical or from a pathological standpoint, into: -(1) Mobile retroversion, where the organ can be reduced bimanually or by means of the sound so as to assume a position of anteversion, in other words, where the uterus is free, and (2) Fixed Retroversion, where the organ is immobile and not reducible by the bimanual method of manipulation or by means of the sound, or, in other words, where the fundus is bound down in Douglas's pouch by adhesions or matted appendages as the results of inflammation. In the matter of diagnosis, it is not always. possible to clearly make out without an anesthetic if a retroverted uterus is fixed by adhesions or merely wedged backwards in between the utero-sacral ligaments or whether some complication may not also be present, as a myoma in the posterior wall of the uterus which projects into Douglas's pouch, or a prolapsed ovary which is adherent to the back of the uterus and one with it. Generally speaking, however, by careful examination it is possible to make out whether the uterus is mobile or not, and, in the event of doubt as to its being so, an anæsthetic may be given to clear up the diagnosis, while at the same time permission may have been obtained to deal with the condition. I. We may further sub-divide mobile retroversion into three groups: A. Congenital cases of retroversion with ill-development; in parous women, and which may or may not be com- A.—Congenital Cases of Retroversion with Ill-development.—There are many patients who seek advice on account of dysmenorrhoea, scanty flow at the menstrual period, and sterility (absolute). These symptoms may have commenced at the time of puberty, or may not have shown themselves until years later, and accompanying them often are chlorosis, digestive troubles, with constipation and neuroses; more often at the time of puberty not much pain or discomfort is complained of, nor again until after marriage, when the sterility makes the patient suppose that something is wrong. Then it is that all the symptoms become exaggerated and are made worse by the attention which is directed to them. It is fair to assume that a healthy uterus and ovaries poised in a healthy body should menstruate without pain and discomfort, so it would be easy to understand that when illdeveloped they would fulfil their functions imperfectly, producing pain and scanty flow. Anatomically, the body of the uterus is small, and some authors have described this condition as being associated with small ovaries. B.-Acute, so-called Traumatic Cases of Retroversion.It is more than doubtful if any blow or injury can, however suddenly produced, convert a normally-placed uterus into one having a backward displacement, but rather it is more probable that the organ was previously tilted somewhat backwards. The usual account is that a sudden strain, as lifting, has produced this condition; the fundus is caught by the utero-sacral ligaments and wedged in between them. The patient may be a nurse who has had to lift a patient. It is more common in virgins, for the reason that these ligaments are more tense in them; and the result of the sudden pressure on the veins of the uterus is acute venous congestion of the fundus, with pain and great tenderness. C.-Acquired or Secondary Cases of Retroversion which occur in Parous Women, and which may or may not be complicated by Lesions of the Uterus, Vagina, and Perineum.— Of these, most are puerperal in origin, but a few are a recurrence after the puerperium of a virginal retroversion (Flaischlen). This return, if true, does not confirm the oftrepeated statement that pregnancy is the only real cure of retroversion. It is recognised by all gynecologists that a great many cases of retroversion are unaccompanied by pain or symptom of any kind; that many of these patients are unaware of the condition of their womb, and in consequence require no treatment. Many cases, however, present certain symptoms of a varying nature and degree, the true importance of which can only be arrived at by a careful study of the local and general conditions of the individual cases. The symptoms most usually complained of are: Bearing-down feeling, backache, weakness in legs, constipation, difficulty and frequency in micturition, menorrhagia, dysmenorrhoea, leucorrhea, and tendency to abortion and sterility. Neuroses are common. 2.-Fixed Retroversion where the Uterus is Immobile and bound down in Douglas's Pouch by Adhesions or Matted Appendages as the results of Inflammation.—The main features of these cases are that although retroversion exists, it is only incidental to a disease of the ovaries and tubes. The condition is generally a complication of parturition, and is brought about by the extension of inflammation from the interior of the uterus either along the Fallopian tubes or through the walls of the uterus (the latter generally). All states of inflammatory appendages and peritoneum may be present from simple adhesion and serous effusion to the purulent condition. The omentum and portions of the small intestine may be involved. Parametritis may exist at the same time. The peritonitic adhesions may be either recent or old. Other causes of salpingitis and ovaritis may be mentioned as tubercle and gonorrhoea, the gonococcus being either alone or associated with other germs; again, extension of inflammation may be the cause, as from an inflamed appendix. THE PRODUCTION OF RETROVERSION. At the outset it may be remarked that no universal cause will explain and account for retroversion. In its normal position, the uterus is roughly described as lying in the axis |