the house and begin his boyish games. For a long time I have heard that there are cases of nephritis that have been cured by natural mineral waters-Waukesha has that reputation. In gaining that reputation it must have affected some cures, at least I think it must, or it would not have that reputation. My belief in the treatment of nephritis, chronic nephritis of the interstitial form, is that plenty of water should be given.

Dr. McLester (in conclusion): Chloroform has been recommended in nephritis. We all know that ether is irritating to the kidney. I remember a sad experience of mine; a child who had had typhoid fever, and had been previously operated upon; chloroform was the anæsthetic used; he went home apparently well, forty-eight hours afterwards had convulsions, and died in about twelve hours; we could only conclude that it was the chloroform that did it.

NON-OPERATIVE TREATMENT OF RETRO-DISPLACEMENTS OF THE UTERUS.

BY WELLINGTON PRUDE MCADORY, M. D., OF BIRMINGHAM. Member of The Medical Association of the State of Alabama.

When we speak of the operative treatment for uterine retrodisplacements, it is usually understood that we have reference to some of the fifty, or more, methods of holding the uterus forward by shortening the round ligaments, attaching the fundus to the anterior abdominal wall, or anterior viginal wall. By the subject, non-operative treatment, I mean the treatment of these conditions without any of the above operative procedures. In the short time given for this paper, I will not go into the causes and symptoms of the condition, except as I shall refer to them in the discussion of the treatment.

In reviewing the literature on the subject of the treatment. of retro-displacement of the uterus, it has been interesting to me to note that at one time the dislocation was given credit for

the production of all of the symptoms, and in a few years, the pendulum of expert opinion would have swung to the other extreme, and the complication been held responsible for the symptoms; again, the pendulum would return to its former extreme, etc., etc. Thus, the idea as to the cause of the symptoms, and consequently as to the treatment, have been vascillating back and forth, until at the present time I believe the dislocation is considered the chief pathological condition, and the treatment most frequently recommended is drawing the uterus forward without due regard to the complications that exist, or to the general conditions and habits of the patient; with the result that with practically every operator trying to invent a new operative procedure, and the attempt to treat all of these cases as a class, with one method of treatment, having frequent failures and resulting complications, we are in almost a constant controversy as to the best methods of treatment, and judging the future by the past, it is but a short time until the pendulum will again start in the opposite direction.

The uterus is a freely movable organ, whose position in the pelvis is constantly changing, and any method of treatment that fixes it in any position is wrong. In fact, the object of any method of treatment which has ever proven successful is, first, remove the cause and existing complications; afterward, hold the uterus forward in as near the normal position as possble, unt the normal supports of the uterus can regain their tone and properly perform their function. That we can accomplish this frequently without any of the above operative procedures, I am thoroughly convinced.

The most important non-operative method of treatment is the preventive treatment. It is claimed that the cause for the retro-displacement of the uterus in women who have not borne children, is most frequently lack of hygienic care as to the condition of the bowels and bladder. Constipation, with the resulting pressure upon the pelvic contents by a full rectum, and the severe straining at stool, together with the full bladder, is frequently the cause of beginning retro-displacement, and I believe is frequently the cause of the so-called congenital displacements and mal-formations. Again, the most frequent cause of this condition in women who have had children, or abortions, are injuries incident to child birth and abortion, such as lacerations of pelvic floor and cervix, or subinvolution. The preventive treatment in the first class of cases is really hygienic and should be begun in girlhood. Here the family physician

should really play the role of preventive gynecologist by carefully instructing the mothers as to what is best for the children. They should be encouraged to empty the bladder as frequently as the desire is felt, and not put it off from time to time, until the bladder becomes very much distended. They should be instructed as to the importance of having one healthy movement from the bowels daily, and if constipation already exists, the bowels should be thoroughly cleansed by free catharsis to begin with, and then by using a copious amount of water, fruit and vegetable diet, which habits will usually correct the trouble. These cases are often obstinate, and frequently catharsis is necessary for a considerable period of time. I find cascara sagrada works best when this is necessary; but I believe it is especially important to insist upon the importance of habit, and the injurious effects of the cathartic habit. Another important hygienic measure is the proper attention to exercise and rest. This is especially important in nervous women and children. Those who have too much work, or take too much or improper exercise, should be instructed as to the rest necessary. For those who do not take enough—especially outdoor exercise this should be insisted upon. It is frequently best with young girls who are of a nervous disposition that they be taken from school and required to stay outdoors as much as possible. These hygienic measures are important, as we all know, and I call attention to them as preventive measures, and insist upon the necessity of their being carried out as an important part in any method of treatment for the condition when it already exists.

The second class are those women who have borne children; the preventive treatment is the proper care of the woman at and after child-birth. Before the days of operations, for a woman to become pregnant was considered the surest way for her to be relieved of her retro-displacements, because of the fact that if the proper care was taken the uterus in undergoing involution along with its supports, the chances were good for recovery, and now all text books tell us that abnormal conditions following child-birth and abortion are the most frequent causes. By cleanliness, properly repairing perineum and cervix at the time of birth, and care to attend to the involution of the uterus by instruction as to the importance of not lying on the back too much during the puerperium, will usually prevent the condition; and a careful examination as to the size and position of the uterus before the woman is allowed to get

up is essential; and if the uterus is not undergoing involution rapidly enough, or if there s a tendency to retro-displacement, tamponing the vagina after the uterus has been replaced, the woman in the knee-chest position, with cotton tampon, moisened with glycerine or ichthyol and glycerine-instructing the woman to lie in the Sims position as much as possible, and to assume the knee-chest position three or four times a day and remain in that position for ten minutes each time, removing the tampons every other day, and using the hot douche after removal, replacing the tampon-in this way involution can be assisted and the weight of the uterus held off the supports, so that they can at the same time undergo proper involution. I sometimes keep a woman in bed three, or even four, weeks, and would keep her in bed longer if necessary in order that the uterus may come down properly, and the cases that have had retro-displacement before the pregnancy, I support with tampon for two or three weeks after they are up.

What about the non-operative treatment for cases that already exist? There are a great many women who have a dislocated uterus and suffer no inconvenience, and in my opinion require no treatment, and those cases that do present symptoms that require relief, practically each one requires a different method of procedure. The main principles of the nonoperative method, are briefly; Replacing the uterus, and maintaining it in the normal position with tampons or pessary; or, if the case presents complications, removing the complications first, and then replacing and maintaining position of the uterus. My personal experience with pessaries has been nothing, and when I can get the consent of the patient, in a case that hequres support for a long time that a pessary is required, I insistupon operating. But to those cases which refuse operation, the pessary gives relief at times, and I hope some one who has had experience will discuss this side of the question. To replace a non-adherent retro-displaced uterus, I have found that I can get the best results by placing the patient in the knee-chest position and retract the posterior vaginal wall; with the ballooning of the vagina, and falling downward of the abdominal contents, the uterus will frequently fall back in normal position. If it does not, I then press forward on the fundus with finger or firm ball of cotton held in dressing forceps, and if this does not work, I then pull down on the cervix, at the same time pushing forward on the fundus; sometimes it is necessary to give the patient an anæsthetic in order to replace the uterus.

After the reposition, if the patient is in the knee-chest position, I have her lie on her back and examine carefully to determine the new position of the uterus. If in proper position, I place the patient again in the knee-chest position, and with the posterior wall of the vagina retracted, I support the uterus with tampons of cotton or lamb's wool. My experience has been that several small pampons, carefully placed, work better than two or three large ones. The first tampons, which are usually moistened with ichthyol and glycerine, are placed in the vault of the vagina, which is practically filled, then one or two are placed in front of the cervix. The woman is then instructed to lie in Sim's position as much as possible, and to assume the knee-chest position three or four times each day. The tampons are left in for forty-eight hours, when they are removed and a hot douche given-this, to do all that it should, must be as hot as the patient can bear, allowing the water to run slowly so that at least twenty minutes are consumed in giving the douche. This aids in relieving the congestion that exists in most of these cases. After the second or third treatment, allow the tampons to remain out all night, giving careful instruction that the patient is not to sit up, but remain lying down, preferably on her side or stomach. I usually keep them in bed about two weeks, and have them wear the tampons about one month after they are allowed up, and then for a week after each menstrual period for three or four months, and if necessary, keep them in bed during menstrual periods.

This, with proper care as to the hygienic condition of the patient, will usually cure the acute cases, and they are not kept in bed longer than is required by the injury that produced the dislocation. The fact that these acute cases can usually be so easily cured, and the trouble given by the chronic cases, should cause every physician to determine the true condition when acute retro-displacements are suspected, and institute treatment at once. The chronic cases that present only an enlarged boggy uterus as a complication, should have this treatment for a week or ten days before operative interference. The nonoperative treatment is not sufficient to cure on account of the length of time it is necessary for the uterus to be artificially supported, but frequently on account of the fact that these patients refuse operation, and on account of the danger, unless the operator is properly experienced and in good surroundings. I mention this treatment of these chronic cases as a means of giving at least temporary relief from the symptoms, and if the