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BOSTON

CLINICAL LECTURE.*

BY ARCHIBALD MACLAREN, M. D.

St. Paul.

The first case to be brought before you this morning is a young woman of thirty years of age, who has been married six years and who has never been pregnant. She has suffered from considerable pelvic pain and an increased menstrual flow; but her chief symptom and grief is that she does not conceive.

She does not come for an operation to-day, but to be examined under an anesthetic, for the purpose of making a more certain diagnosis, and If we find that she has, as I believe she has, a retro-displacement, then at this time we will replace the uterus and fit a pessary, because that should be the first step in the conservative treatment of every case of movable or non-adherent posterior displacement of the uterus. Displacements are, as you know, four in number-two anterior, ante-version and ante-flexion; two posterior, retro-flexion and retro-version. The first two we may practically eliminate, for although every book on the subject of gynecology contains chapters on such diseases, wherein are given full descriptions of anterior displacement and its treatment, still from my own experience I have yet to see one case where it could be proven that such a condition was a disease at all. As the weight of the uterus is four ounces, while the normal intra-abdominal pressure is several pounds to each square inch, how then can we reason that this infinitesimal additional pressure of four ounces can produce so many bladder symptoms, for instance, as are ascribed to it by many of these authorities? But now, when this uterus gets over backward we have a very different condition of things, and the patient complains of headache, backache and all sorts of nervous symptoms, due to-what? To uterine congestion-the same thing that produces so many curious and obscure nervous symptoms in the woman who has but just conceived. Some women have no symptoms from posterior displacements, at any rate for long periods of time, but usually, sooner or later, they have the regular backaches, headaches, constipation and bearing-down pains, which are characteristic of retrodisplacements.

*Delivered to the Junior Class of the Minnesota State Univer sity, at St. Luke's Hospital, December 14, 1899.

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ments? First, we note that nine out of ten will be found in married women who have borne children. We occasionally find it as a passing temporary condition in any exhausted, over-tired woman. Any condition which produces an enlarged uterus, such as a laceration of the cervix or perineum, which prevents the uterus from going back to its normal size, leaving it too large, or in a condition of subinvolution, predisposes her to a backward displacement. Laceration of the cervix in this way is the most common cause of this trouble; laceration of the perineum is also a frequent cause. Any inflammatory condition. in the pelvis, which produces a chronic engorgement of the uterine vessels, predisposes the patient to retro-displacement. Some few cases are congenital or due to injury.

Now, I believe that when you can do so, the proper line of treatment is to put the uterus in place, and retain it there with a pessary. There are various forms of operations for retro-displacements, which we will consider later; but from the fact that all of these operations are more or less unsatisfactory, a pessary should first be tried. A pessary, when fitted accurately, is be worn for perfectly comfortable and can months; in fact, one can be worn a number of years. I have a woman under observation now who has worn one almost constantly for the last fifteen years, and comfortably, too, and she is very uncomfortable without it.

It has been very difficult to make a diagnosis in this case, due to the pelvic tenderness and the thick tense abdominal walls, without the use of an anæsthetic, but now it is very plain that this woman has no displacement at all, but a very interesting condition which almost exactly simulates it. I find that this woman has behind the uterus down in Douglas' cul-de-sac a smooth non-adherent ovarian cyst, just as large as the normal fundus should be. This patient will be put to bed, and after she has recovered from the anææsthetic she will be allowed to go home, to come to the dispensary on Friday. She will be advised to have an operation for the removal of this small tumor, because it will, undoubtedly, grow steadily and will ultimately take her life, entirely aside from the symptoms of pelvic distress which it is now giving her.

I think one can do better in making a pelvic examination to use the first two fingers of the left hand, and so leave the stronger right hand for counter-pressure on the abdominal wall. Two fingers are better than one-because thus the examiner can reach a greater distance. The distance which can be reached up into the pelvis