changes presented and in the further fact that these changes are often temporary in character, i. e., the lesions are frequently such as are recoverable.

Having now briefly considered the modern aspect of the pathology of functional nervous diseases, what bearing have the evidences presented upon the question of treatment? To my mind the indications are both clear and imperative. In neurasthenia, for instance, a disease in which we have reason to believe that the cell has lost substance,-is diminished in volume,-the indication is evidently to restore the wasted cell by rest and food. Experience shows, I need hardly tell you, that under rest and with abundant food, plus other factors of course, the fatigue symptoms disappear. A second indication of treatment is that offered by the behavior of the frog muscle in the experiment briefly described a few minutes ago. That waste products are present in neurasthenia in excess is well known and that they exercise a most powerful depressant action there can be no doubt. Evidently the indication is to apply such measures as will favor their elimination. How this is to be accomplished I need hardly point out. A liberal use of liquids, the free or even forced administration of water, the stimulation of the activity of the skin by various forms of hydrotherapy, the stimulation of the functions of the kidneys and bowels are all factors in securing a successful result.

What are the indications presented for the treatment of hysteria? Principles similar to those which are indicated in neurasthenia always find an application in hysteria and in addition mental and emotional suggestion, that which many writers call "moral treatment," has here a powerful influence. The treatment of hysteria by means of hypnotism is to be discouraged. It is true that brilliant results are occasionally noted after its use, but unfortunately the relief is often found to be temporary, or the place of the old symptoms is assumed by new ones, if possible more difficult of treatment than those which they replace. Suggestive moral treatment, which is practically suggestion without hypnotism—associated with the rest, quiet and good hygiene— almost invariably bring about a successful result.

It is entirely beyond my time to speak of the treatment of the insanities. However, the indications presented are very clear. They comprise among other things, rest, food and the elimina

tion of toxic agents. Many of the toxins of insanity doubtless have their origin within the organism, others again are due to poisons introduced from without. The auto-intoxications embrace, first, the substances normal to the blood and secretions, but present in excess; secondly, those substances due to general disturbance of tissue-change met with in diathetic conditions; and thirdly, the poisons formed by the disturbed action of special viscera.

Among substances introduced from without, we have first, substances absorbed from the intestinal tract, some of which are produced by disordered chemic action and morbid fermentation of its contents and others normally excreted by the intestinal tract, but under abnormal conditions reabsorbed; secondly, we have the poisons that are the direct result or accompaniments of infection. It is readily seen that the problems presented by the poisons are exceedingly complex. We know comparatively little of their chemistry; and yet the mere recognition of the fact that they play a great rôle in insanity is of the most importance from the standpoint of treatment.

If in this brief outline of the subject of functional nervous diseases I have presented any considerations worthy of attention, or if I have suggested thoughts that may be of value in treatment, my object will have been accomplished.

1719 Walnut Street, Philadelphia.

WHY ARE RETROVERSION AND RETROVERSIOFLEXION OF THE UTERUS PER SE PATHOLOGICAL DURING THE MENSTRUAL LIFE OF THE HUMAN FEMALE?*

ALBERT GOLDSPOHN, M.D.,

Professor of Gynecology, Post-Graduate Mcdical School; Senior
Gynecologist of the German Hospital; Attending Gync-
cologist to the Post-Graduate and to the Charity Hospitals
of Chicago.

My reason for dealing with this apparently commonplace subject is, that while the number of all kinds of articles which deal with the treatment of retroversion and flexion of the uterus

*Read before the Mississippi Valley Medical Association at Louisville, Ky., October 5-8, 1897.

is legion, and while they assume retroversion to be an evil as a self-evident fact, still if the question be asked, how is this displacement an evil or what harm does it do, the answers would be quite varied, indefinite and incomplete. Again, it behooves gynëcologists from a sense of duty in prophylaxis to return occasionally from their major exploits and achievements, which partake oftentimes too much of the nature of amputations to some, less pretentious, but no less important—and in a preventive sense, more fruitful issues in minor gynecology. The majority of those gynecologists who reap the gratification of producing the best objective as well as subjective results in preventing or allaying the excessively prevalent ailments of women are convinced that a uterus that is constantly retroverted, even though it be not adherent, is in an essentially evil position, which tends invariably to induce in it also a diseased condition. Those practitioners who harbor the greater degree of real sympathy for these, their patients, and are least annoyed by their whims, hysterical manifestations and sometimes persistent complaints, because they find physical causes to account for these symptoms, to their own satisfaction, those men who do not, in desperation, grasp at such phantoms as faith cure, imagination, suggestion and similar visionary agencies to explain the appearance or disappearance of such clinical phenomena. They generally recognize that there is a place and position for the uterus as for the stomach and every other internal organ, and that abnormal position alone without fixation of the uterus is a stealthy but frequent and fruitful pathological entity. But there is a respectable minority of honest and zealous laborers in the field of gynecology, for instance Theilhaber (1), who really believe in fixation only as an abnormal feature, but not in any harmfulness from position of the uterus, as such, that is, from backward inclination of its longitudinal axis. These gentlemen cannot consistently admit that aside from descensus (prolapse) any wrong position of the uterus exists at all, for they really recognize fixation only as a pathologic entity. And yet when they meet a retroverted uterus that is bound down they do not, consistently with their doctrine, speak of it as a uterus in normal position simply deprived of its normal mobility, but they strangely borrow the expression retroversion.

But these gentlemen either forget, or have never discovered that aside from inflammatory retractions and indurations in the

parametrium and aside from peritoneal fixations, there are other equally potent forces within the abdomen and pelvis, that hold the uterus either for weal or for woe without much medium ground in the antero-posterior range of its mobility. Without the overpowering influence of these forces no inclination of the long uterine axis would probably be a pathologic entity.

These forces have been classified by Schwerdt (2) and others substantially as follows. 1. A variable degree of tension peculiar to the interior of each hollow viscus. 2. Gravitation of the abdominal organs which is zero at the diaphragm and attains its maximum in the pelvic cavity. 3. The principal one, a general diffuse intra-abdominal tension, created, according to Swiecicki (3), by sixteen abdominal and pelvic muscles. This force is greater during exertion than while standing passively. It is developed more in the erect than in the horizontal posture, and while it is everywhere equal in the abdomino-pelvic cavity, still it induces a temporary physiological displacement or crowding downward of abdominal organs into the pelvis, by virtue of proportionately greater power vested notably in the diaphragm and other muscles of the upper part of the abdominal walls. The resulting diminution in volume of the abdominal cavity and temporary recession of viscera toward the pelvis is the principal factor in intraabdominal pressure. It is the greatest force that is exercised anywhere in the interior of the human trunk. Voluntarily and involuntarily it acts in frequency next to respiration itself. It is the sovereign factor in emptying the rectum and the greater power in the second stage of labor, and it naturally is the greatest force that acts upon the uterus from any direction. It does not allow this little member to roam and to stand retroverted now and anteverted at another time interchangeably, or as a matter of chance, as the members of the "respectable minority" imagine it does. Here they are mistaken, and they imagine more than their patients do, whom they charge with imagining that they have pain or discomfort. These intra-abdominal downward and centrifugal forces hold the uterus either constantly retroverted or constantly anteverted (when the bladder is not distended), and which of these it shall be, i. e., whether the fundus or the cervix points into the sacral hollow, is not determined by chance, but by the absence or presence respectively of normal patency and function of the pelvic floor and of the guiding and retaining ligaments

of the uterus. When these structures do not guide the fundus back safely to its anterior moorings, after it has been made to project dangerously into the pelvic straight by distension of the bladder and other temporary causes, then intra-abdominal pressure (Bauchpresse) will very soon hold it as constantly in retroversion or retroversio-flexion and will confine it to nearly as small a range of motion as is retained in most cases of peritoneal adhesions. That this is true will become evident to almost any one on anatomical ground alone, aside from prolonged clinical observation of many individual cases, if one will but carefully note the action of these internal forces, as, for instance, with a finger in the vagina against the markedly retroverted uterus of a patient standing erect, when scarcely a minute will pass without recording the downward impulse from some sufficient contraction of the diaphragm, as in deep breathing, etc., not to mention the more forcible action during laughing, lifting, coughing, screaming, vomiting, and chiefly while straining, as at defecation or micturition. Furthermore, that the retroverted uterus, adherent or not, can scarcely escape the partial or complete loss of its essential mobility, and that it must suffer in time from the now alway viciously applied domination of intra-abdominal forces, is practically proven by the universally accepted fact that an unimpaired pelvic floor is essential not only to maintain a normal habitat for the uterus, but also to preserve the pelvic and general health of the woman. To explain: We all know that the uterus does not normally lie constantly upon or against the pelvic floor, but that it is suspended at a higher plane in the pelvic cavity by a system of elastic slings which hold it aloof from the pelvic pelvic floor floor during the intervals between forcible contractions of the diaphragm and other straining efforts. But when the essential foundation in the pelvic floor is absent, which serves as a buffer to the pelvic organs during all more forcible acts of intra-abdominal pressure, then these elastic ligamentary supports of the uterus are generally overpowered by the superincumbent forces spoken of, and allow the uterus to descend indefinitely and always with its fundus turned over backward. If, then, these intra-abdominal forces can and do so generally, in the absence of the essential buffer in the pelvic floor, drive the uterus from an erect anteversion to prostrate retroversion or flexion and descensus, is it not nonsense to assume that they can