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DIET AS A FACTOR IN THE CAUSATIONOF MENTAL DISEASE.

BY CHAS. MERCIER, M.D. LOND., F.R.C.P. LOND.,LATE PHYSICIAN FOR MENTAL DISEASES TO CHARING CROSS HOSPITAL,

(Concluded from p. 513.)

"Forty years long was I grieved with this genera-tion and said : it is a people that do err in theirhearts, for they have not known my ways."

IT is just 40 years since I first ventured to callin question the accepted doctrines of the causationof nervous diseases. In an article in the Britishand Foreign Medicat and Chirurgical Review, anexcellent quarterly now long defunct, I likened theimagination of physicians in this respect to the

imagination of that fortunate sailor to whom wasgranted (nowadays we should say who was given)the fairy privilege of having three wishes fulfilled.After he had secured all the rum in the world andall the tobacco in the world by his first two wishes,he could think of nothing further to desire than" little more rum." So physicians, after they hadattributed every known nervous disease to sexualexcess and syphilis, had no explanation of a newdisease to offer beyond a little more sexual excess.The only nervous diseases that were not then attri-buted partly or wholly to syphilis were tabes andgeneral paralysis. Some five-and-twenty years ago,when an eminent physician was about to lectureupon the causes of insanity, I hazarded the con-jecture that we should hear a good deal aboutmasturbation, and I had no reason to repentof my prophecy. We may be pardoned a littlenatural exultation when we contrast the presentstate of etiological doctrine with that which

prevailed in those dark ages. We had then nomore reason for our belief than Aristotle had forthe belief that all heavy bodies tend to the centreof the universe, but now we know that the mentaldiseases that we used fondly to ascribe to sexualexcess and syphilis are, in fact, due to repressedcomplexes and infantile incestuous longings. Howfoolish were our predecessors! How enlightenedare we ! 1 Great is Freud, and Dr. Forsyth and Dr.Stoddart are his prophets. Behold ! how good andjoyful a thing it is that we should be taught tosing our Venite exnUemus, and say, 0 come let. usworship, and fall down: and kneel before theFraud our faker.Without impugning in the least the startling

discoveries that we owe to the cleanly imagina-tion of Freud, I think it possible that they maybe supplemented by researches less recondite.When I study his efforts to discover the causesof mental disease, I am irresistibly reminded ofthe story of the Purloined Letter. The detectivesknew that it must be in the room, so they gropedup the chimney, pulled up the floor, sounded thewalls, probed the furniture, and ripped up thecushions, without finding the letter, which waslying displayed prominently under their noses allthe time. It has occurred to me that our difficultyin discovering the causes of mental disease maypossibly be of the same kind. We may perhaps belooking in the wrong places, and instead of search-ing for them in the privy and groping in the night-stool, on the system of Freud, we may possibly findthem on the dinner-table, and in the sugar-basinand the butter-dish. At any rate, we can pursuethis method of investigation without filing ourminds; and even if we are unsuccessful, we canleave off with clean hands.

To this line of investigation I was directed byseveral considerations. First, it is beyond questionthat certain things, when taken into the stomach,are capable of producing mental disease. Alcoholis an example. Second, the defect of certain con-stituents of the blood does produce mental disease.Cretinism and myxcedema are examples. Third,whatever the immediate source of these con-

stituents, their ultimate source is in the food.If the ingredients of the products of the ductlessglands are not in the blood, those products willnot be produced; and if the ingredients are not inthe food, they must be absent from the blood also.Moreover, fourth, it may be that there are certainingredients in the blood, and therefore in the food,that are necessary to mental health, even withoutelaboration and transformation in the ductlessglands; for investigation has now discovered theexistence and the astonishing properties of vita-mines. Whatever the nature and whatever themode of action of these puzzling substances, it isbeyond question that their absence from the fooddoes profoundly affect not only the physical health,but the mental health also. Hence I conjecturedthat it was possible investigation might discover,in the antecedents of some cases of mental disease,.some error in diet that might have a causal con-nexion with the disease.

At this point a great difficulty presented itself.Granted that one or more errors or peculiaritiesin diet were found among the antecedents ofmental disease, how would it be possible to assureoneself that such errors or peculiarities were actualcauses, and not mere casual associates or ante-cedents of the disease ? To ascertain this I naturallyturned to the writings of logicians, all of whom,and they are many, discuss this matter in theirchapters on Induction; but alas! I found that’upon this topic the logicians are as inept and asmanifestly erroneous as they are on every othertopic that they discuss. Not one of them affordsany trustworthy criterion or test by which a causemay be distinguished from a mere antecedent or-associate, and on this matter their writings are asconfused and self-contradictory as they are on

every other. It became necessary, therefore, toexamine afresh the whole subject, not only of thenature of causation, but also of the methods bywhich causation can be ascertained; and the resultsof this examination are embodied in a book whichis now in the press. From this I may extract forthe present purpose the following principles, whichare all that have a direct bearing on the subjectnow under discussion :-

First, that a cause is, strictly speaking, an action,more loosely speaking, an agent exerting an action,on the thing in which the change that we call theeffect is produced. That thing in the present caseis the patient.

Second, that before we can call an action upon athing the cause of any subsequent change in thatthing, we must prove a connexion between theaction and the change.

Third, that this connexion may be proved in atleast a dozen different ways, the only ways appli-cable to the case under consideration being thoseincluded in the Method of Association. When anaction upon a thing’ is associated with a subsequentchange in that thing we must not infer that the.action is the cause of the change unless-

(a) We can isolate the action-that is to say,unless we can be sure that it is the only action upon

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the thing at the time that could have produced thechange; or

(b) The association is constant-that is to say, theeffect always follows the action, and is never presentunless the action has taken place; or

(c) If, though neither isolable nor constant, theeffect is associated with the action more often thancasual concurrence will account for; or

(d) If, though the association is neither isolablenor constant, yet when the effect is associated withthe action, there is a constant peculiarity in theeffect.By applying these principles we can ascertain

whether a disease that is associated with what wemay conjecture to be a cause, is or is not due tothat cause. Such testing of conjectural causes hasnever yet been performed, except in the case ofinfectious diseases. With the discovery of para-sitic micro-organisms the causes of a large class ofdiseases have been ascertained, but our specula-tions as to the causes of non-microbic diseases aremuch the same as they were 40 years ago. With

respect to these diseases the custom is to hazard aconjecture, and to speak of the conjectural causeas if it were an ascertained cause ; and with respectto mental disease our attribution of cause is chieflydetermined by fashion. At one time, as I have said,the only causes attributed were sexual excess andsyphilis. These were followed by heredity; hereditywas followed by toxins; toxins were followed by

‘

repressed complexes. In vain have I called on theirsupporters for evidence of the truth of these idoctrines. Truth, as Dr. Johnson said, is a cow thatwill yield them no milk, so they are gone tomilk the bull. The utmost and the only resultof my endeavours has been that the Medico-Psychological Association has altered the title ofits Table of Causes, and now calls it a Table of

Etiological Factors. I do not think the changewas made merely for the sake of euphony. It wasmade, I believe, with the intention of eluding mycriticisms. Alienists have the most profound andcomplete conviction that they can alter the natureof things by altering their names, and that when anew name is given to a thing a new thing has beendiscovered. Thus, when that which has been knownfor many years as primary dementia is calleddementia preecox, they are lost in admiration atthe brilliancy of the new discovery, and can scarcelyfind terms strong enough to express their admira-tion of the discoverer. They seek to abolish theterrors of madness by calling it lunacy; they seekto abolish the terrors of lunacy by calling it

insanity ; they seek to abolish the terrors ofinsanity by calling it unsoundness of mind, whichit isn’t, or mental breakdown, or neurasthenia. Ilook forward hopefully to the time when they willcall it Mesopotamia. They seek to abolish theterrors of mad-houses by calling them asylums;they seek to abolish the terrors of asylums bycalling them retreats; they seek to abolish theterrors of retreats by calling them sanatoria, ormental hospitals. The last title carries a subtlesuggestion of self-complacency, for how great mustbe that mind which can contain an entire hos-pital 1 I suggest, with some diffidence, that it would Ibe still more impressive to call the hospital after apart or faculty only of the mind. We might call it,for instance, an imaginary hospital. Following thesame easy and efficacious method, alienists pro-pose, when I show that what they call causes arenot causes, to nullify my criticism by altering thename and calling them etiological factors. One ofmy ways is to call a spade a spade, but alienists

prefer to call it an agricultural implement. It isindeed a people that do err in their hearts, for theyhave not known my ways.

So far I can follow Moses, but when he loses histemper and proceeds to swear at his recalcitrantpeople, I must renounce his leadership. Falstaffdeclared that he was as poor as Job, but not so

patient. I, on the other hand, may justly claim tobe more patient than Job, though perhaps not

quite so poor. His period of affliction was butbrief. His friends sat by him in silence for a week,and the whole of the subsequent discussion onMoral Conduct as a cause-I beg pardon, an

Etiological Factor-in Good Fortune could scarcelyhave lasted for more than another week, afterwhich his trial came to an end; but I have sufferedmy fellow alienists, as gladly as I possibly could,for 40 years, and for the whole of that time theyhave erred in their hearts and have not known myways.Moreover, though Job was less irritable than

Moses, and did not go as far as actually to swear inhis wrath at those who were so wrong-headed as totake the other side in the discussion, and to refuseto adopt his views, yet it must be confessed thathis patience and forbearance have been a good dealexaggerated, and fell far short of the meekness ofPatient Grizzel or the Nut Brown Maid. More thanonce he was within an ace of losing his temper.iso aouot, said ne, out ye are tne people, and

wisdom will die with you. But I have understand-

ing as well as you," and so on. No one can accuseme of such petulance, even towards psycho-analists.If they were to bring forward an argument, or any-thing that could be passed off as an argument,or even anything that colourably resembled anargument, in favour of their crazy system, I shouldexamine it, I trust, with patience, and with whatgravity I could muster; but though it is my way,it is not their way to give a reason for the faiththat is in them. It is a people that do err in theirhearts, for they have not known my ways.

I know it is hopeless to expect my colleagues whopractise in mental diseases, and whose spiritualhome is in Germany, to pay any attention to any-thing I may say, or indeed to any doctrine that isnot made in Germany; but it is not for them that Ihave recorded in the last number of THE LANCETthe cases that I will now proceed to examine. Theseare of general interest, and are such as are likelyto come in his daily work before the generalpractitioner; and he, at anyrate, can appreciatetheir significance.Here are recorded a number of cases of persons

who have sought relief from mental disease; andthe first comment that they call for, that theycry aloud and clamour for, is that, of 35 cases ofmental disease, only one could be certified as

insane. I insist upon this with special emphasisbecause of the universally accepted doctrine thatdisorder of mind is equivalent to insanity-thatdisorder of mind and insanity are the same thing.The contention that I have urged for so manyyears, that unsoundness or disorder of mind isnot necessarily madness, has always been receivedby the people that do err in their hearts withcontemptuous incredulity and open derision. Now,whatever my faults, and whatever my fads, I thinkeven this people will admit that a patient mustbe undeniably sane if I cannot certify that he isinsane; and of these 35 patients I could not havecertified more than one; that is to say, 3 percent. Of course, I do not expect this to makeany impression upon my alienist friends, but I beg

563

the rest of the profession to note this indefeasibledemonstration that mental disease, mental dis-erder, or unsoundness of mind, is not the samething as madness, but that many and variedmental disorders are compatible with completeEanity.The peculiarities in diet which preceded and

secompanied the mental disorder in these patientswere mainly of two kinds-deficiency of meat,or excess of fat, starch, or sugar. According tocurrent practice, the peculiarity of diet would beregarded as unquestionably the cause of the mentaldisorder; but so to regard it would be quite un-justifiable unless the association of the peculiardiet with the mental disorder satisfies one or moreof the conditions stated above; and the reason isclear. Vegetarianism is common enough: mentaldisorder is common enough. On the doctrine of

Probability it is certain that the two must coincidein the same person in a certain number of cases-in a number that cannot be exactly ascertained forwant of exact figures. There is, besides, anothersource of possible error. It is quite rare for vege-tarianism to be the only fad of the vegetarian.Almost always he has a stock of fads. Hecultivates a number of what may be calledanti-isms. He is anti-alcoholist, anti-vivisectionist,anti-vaccinationist, anti-capitalist, anti-bellumist,anti-patriotist. He is anti-penalist, and would

provide all gaols with pianos and newspapers, beerand skittles. He is anti-restraintist, and wouldabolish all lunatic asylums, rightly from his ownpoint of view, for so he would escape the risk of

losing his own liberty. It is, no doubt, possible tohold some of these opinions with reasoned con-

viction, and after examination of the evidence ; butit is not so that the faddist holds them. He holdsthem as mere prejudices. He attaches to them a

very disproportionate importance. He advocatesthem in season and out of season, and withintemperate zeal. He erects them into a religion,of which he is a fervent missionary, and of whichhe is proud to be a martyr in any small way whichdoes not interfere too much with his comfort, orif it does, brings him a consoling notoriety. He

regards any means of proselytising as justifiable,and lies conscientiously in furtherance of his fads.A mind of this nature is unbalanced. It is notinsane, but it occurs in people who have insanerelatives, and who are apt themselves to becomeinsane. We should expect, therefore, to find amongvegetarians an undue proportion of insane persons.For this reason I have omitted from the cases

adduced every case in which abstention from meatwas a fad, and have included those only in whichmeat was eschewed either because it was distastefulor because it was not procurable.That very definite peculiarities in diet did precede

and accompany the mental disease in the cases Ihave recorded is unquestionable. What is now to- be determined is whether this antecedent andaccompaniment can rightly be considered a cause.To this end we must make four enquiries :-

First, is the action that we conjecture to be thecause, that is, the action of the diet upon thepatient, isolable ? In other words, can we separateit from other actions on the patient so as to

Iascertain beyond doubt that the change in thething acted on is due to that action, and to that 1alone ? At first sight it seems that we cannot, for Ewe know very little of what other actions tendingto produce mental disorder may or may not havebeen incident upon the patient at the time. In ’Isome of the cases-viz., Cases 10 and 13-the

patient was alone from morning till night six daysin the week, which we may conjecture was inimicalto mental health; in other cases there had beenworry, anxiety, and other stresses. While, how-ever, we can never completely isolate the action,we can produce an approximate isolation by with-drawing the action that we surmise is the cause,and noting any difference in the effect during itsabsence, and, it may be, allowing it to act againand noting the effect of the addition. In severalof the cases the rectification of the diet wasfollowed by improvement of the mental health, andin some cases this improvement was rapid or

immediate, and was great. In this respect Case 5is extremely instructive. This patient improvedvery decidedly within a week of the rectification ofher diet. She continued to improve, until at lengthshe spoke of her recovery as a miracle. Then shehad a relapse. The relapse was not coincidentwith a return to the faulty diet, but it was coinci-dent with what, for the purpose in hand, amountedto much the same thing-that is to say, with herpregnancy. She now took, it is true, enoughproteid to nourish her own tissues, but it wasnot allowed to nourish her own tissues. It wasseized upon at once by the growing feetus, whosedemands were paramount, and she was deprived ofit. Nor did she improve when the child was born,but then, when the child was born, it was still herown food that nourished it. When, however, sheweaned the child she rapidly recovered. It isdifficult to avoid the conclusion that in this casethe mental disease was dependent on the deficiencyin the ration of protein, whose fluctuations itfollowed so closely.

It is one of the disadvantages of consulting andhospital practice that a large proportion of thepatients are seen once only, and the result of one’sadvice remains unknown. Of the 35 cases hererecorded, 14 were seen only once, and nothingcertain is known of their progress; but of othercases seen only once inquiries were made, and itwas found that they had so greatly improved thatthey did not think it worth while to come again.It is a fair inference, therefore, that some of thosewho were not heard of had the same reason forceasing to attend. Taking, however, those onlywhose subsequent history is known, all but onerecovered or very greatly improved when their dietwas rectified; and these were more than half ofthe whole number seen. The total number is toosmall, it is true, to draw any very large or confidentconclusion from, but as far as they go they show,among those as to whom the result is known, arate of between 94 and 95 per cent. of recovery orof very great improvement, and this is too strikingto be ignored.

Application of our second principle, that of con-stancy in the association of the effect with thepossible cause, does not yield such a favourableresult. It is certain that the positive associationof an excess of fats or carbohydrates, or a defi-

ciency of meat, in the diet with mental diseasein the consumer is not constant. The denizensof Arctic climates, who live largely upon blubber,are not known to suffer disproportionately frommental disease, nor are those considerable popu-lations of Eastern countries who live upon anexclusively vegetarian diet; but then it is clearthat the circumstances are not the same, and noprinciple of logic is more important, though it is notmentioned by Aristotle nor acknowledged by pro-fessors of logic, than that circumstances alter cases.That indulgence in fat which may be disastrous

564

to the dweller in a temperate climate need notbe anything but beneficial amid eternal ice andsnow ; and that abstinence from meat which maybe fatal to an individual or a member of a race

that is accustomed to a carnivorous diet may beinnocuous to one who and whose ancestors havenever tasted meat. Moreover, there can be littledoubt that what is harmful in the absence ofmeat is the absence of protein, and this may bemade up by consumption of vegetable proteins.Nor is the negative association in the least

degree constant. There is abundant experiencethat mental disease is by no means confined tothose who indulge excessively in fats and carbo-hydrates and those who refrain from eating meat.The third principle cannot be applied for want of

data. When there are a great many people whosuffer from mental disease, and in the same popula-tion a great many who commit these errors of diet,the doctrine of Probability assures us that theremust be some in whom the two will be combinedcasually; and among the cases recorded No. 13seems to be such a case. But it is quite impossibleto apply this principle, and to discover whether orno the combination of mental disease with errorin diet is more than casual concurrence willaccount for, until we know (1) the total popula-tion ; (2) the number of cases of mental disease;and (3) the number of cases of error in diet, in thepopulation. In the absence of data no conclusioncan be drawn.The fourth principle, however, is more fertile in

results. It assures us that if a certain change ina thing follows, though only occasionally, an laction on that thing, then, although from the mereoccasional sequence we are not justified in callingthe action the cause of the change, yet if in eachcase of the sequence the change exhibits a constant !character, we may then properly infer that the

sequence is causal. To take a cognate instance:insanity follows, though only occasionally, exces-sive and prolonged drinking of alcohol; but sinceinsanity often occurs without this antecedent, andsince the antecedent often occurs without insanityfollowing, it would be quite unjustifiable to assert,on the mere ground of antecedence and sub-

sequence, that the drinking was the cause of theinsanity. When, however, we find that wheneverinsanity does follow prolonged and excessivedrinking the insanity always has certain peculiarcharacters, which are never found in insanityotherwise occurring, the case is different. Thisconstant quality in the result does justify us inpresuming that the constant antecedent of thatquality is the cause of the insanity. Can we thenapply this principle to the cases before us? Ithink we can. Here it becomes necessary toseparate the two factors of excess of fats andcarbohydrates on the one hand and defect of meaton the other, and to consider each by itself.

If the cases in which an excess of fat was con-sumed are examined it will be found that what-ever other symptoms they complained of, they all

Isuffered from severe headache. This is not a newobservation. The connexion has been thoroughlyestablished by Dr. F. Hare in his excellent book onthe "Food Factor in Disease.’ The cases hereadduced are a mere addendum to his observations,and pretend to no originality. They are, however,of value as corroboration by an independentobserver of his views. While, however, theheadache is the most prominent and troublesomesymptom in these cases, it is not the only one.

It is well known that attacks of migraine are often’accompanied by mental confusion, and it appears.from some of the cases here recorded that excessof fat in the diet is accompanied in them by con-fusion of mind, which occurs even at times whenthe patient is not suffering from headache. Thereis no case among those here recorded in whichheadache was complained of when there was noexcess of fat in the diet. From this it must not be

supposed that I suggest excess of fat as the onlycause of headache ; I suggest merely that denciencyof meat alone is not a cause of headache.

It seems, however, that it is a potent cause ofconfusion of mind. In case after case in whichthe diet was subsequently found to be deficient inmeat. the mental state is described in almost orquite the same terms : "I I feel muddled and dazed";." A wave of confusion comes over me ";

"

I am se>

muddled about my work "; "

I have such confusionin my mind"; "I I feel half-dazed, and don’t knowwhat I am doing "; "My mind is confused"; "Myhead is in a muddle ";

"

I cannot think "; " I have

a muddled feeling in my head"; "I cannot applymy mind to anything ";

" I am half-silly"; " There

is something in my head that causes everything tobe jumbled up "; and so on.Depression is almost as common, and is in some

cases very severe. In several cases it led to con.templation of suicide, and in one to repeatedattempts ; perhaps, since they were repeated, theywere not very determined, but still they were

ttempts.Screaming fits and motiveless weeping and

aughing occurred in several cases among theyomen.

Defects of memory, especially of the businessnemory-that is to say, forgetting to do things1t the proper time-was noted in several cases. ItLs a part or a form of the mental confusion.In three cases there were hallucinations, and in

ane of these the hallucinations were extraordinarilyvivid, and were of sight and hearing coördinated.Case 14 would of itself serve as a text for a. dis.course upon the origin of ghosts and the nature ofecstatic visions, of celestial visitors, of supernaturalrevelations, and so forth. It is unfortunate that Iwas unable to follow up this case, and I may saythat its very peculiar character makes it doubtfulwhether the mental state owed any of its origin tothe diet, which, however, was certainly very defec.tive. On the other hand, it could be urged thatCases 17 and 20 are halfway houses on the road tothe same destination.Many other inferences can be drawn from these

cases, and there is one inference that will certainlybe drawn, however much I may deprecate itand protest against it, and that is that I haveasserted that every case of mental disease is dueto excess of fat or to deficiency of meat in the diet.I make no such assertion. Obviously the cases hererelated form but a small proportion of those thathave come under my notice since I first began,several years ago, to investigate the diet of mypatients. In only a small proportion of casea

could I find any definite fault in the diet; andwhere a fault existed, it was not always excess

of fat or deficiency of meat. It surprised me tofind in how many cases people live very largely onmilky puddings, and I was in doubt in many caseshow far the symptoms were due to deficiency ofprotein, and how far they were due to excess ofstarch and sugar. In Case 27 I have little doubtthat much was due to excess of starch, and I

565

always made a point of inquiring into the relativeproportions of all the constituents in the diet.A word may be said as to the method of inquiry.

In this, as in all things, it is most important toavoid leading questions in opening the examination.31y practice is to ask, What do you have for break-fast and so on for each meal. The next questionis, Is there anything to eat that you are particularlyfond of? Meat ? Sugar ? Fat ? Milky puddings ?Then, Is there anything you particularly dislike ?It is important to remember that people do notreckon butter as fat. Many patients declare thatthey dislike fat, and never eat it, but when thequestion is put to them, they will admit aninordinate fondness for butter.

It should be remembered also that there are widedifferences in the capability of different persons todispose of the fat, starch, &c., that they consume,so that what is moderation for one may be grossexcess for another.A point that, to economise space, is not brought

out in the cases here recorded is that those sym-ptoms that seem to be due to excess of fat, starch,and sugar in the diet, and that are relieved bydiminishing these constituents, are almost alwaysworse in the morning, clear up towards afternoon,and are often absent in the evening. Hence I neveromit to inquire, What time of day are your sym-ptoms worst ? and whenever I hear that they areworst on waking in the morning and diminish;as the day goes on, I make very stringentinquiry into the diet, no matter what the symptomsmay be.

Finally, let me assert once more that I do nothold that there is only one cause of mental disease.If I did so hold, I should be little better than a

psycho-analist. My contention is, and I think itis borne out by these cases, and by the applicationto them of the true principles of ascertainingcausation, that in a certain number of cases ofmental disease, small in proportion to the whole,but considerable in the aggregate, the disease isdue to error in diet, and can be cured by rectifyingthe error in diet.

’

THE LOWER UTERINE SEGMENT, ITSORIGIN AND ITS BOUNDARIES.1

BY E. HASTINGS TWEEDY, F.R.C.P. IREL.,EX-MASTER, ROTUNDA HOSPITAL, DUBLIN.

THE lower uterine segment, its origin and itsboundaries, is a subject which has held for gyneaco-logists of the nineteenth century an absorbinginterest. The most eminent specialists endeavouredwith the greatest assiduity to solve the problem,and yet the present century opened with the mystery I

still unsolved. -What is the uterine segment ? At what period what

does it make its presence apparent ? Is it caused ; iby a stretching of pre-existing tissue, or is it an ientirely new growth ? From what pre-existing (

tissue does it arise ? Whether from the structures pabove the internal os or from the cervical tissue ibelow it? These are the questions which call for (

an answer. (

Modern gynsecologists have lost interest in the <anatomical entity; not that their knowledge is any 1more precise than that of their predecessors, butrather from a conviction that the subject has been ttaAked out and that they have no further available {

Material to enable them to form any definite 11 A paper read before the Obstetrical Section of the Royal Academy

of Medicine in Ireland.

opinion. In this I think they are mistaken, forthe controversialists of the past did not appre-ciate the importance of the endo-peritoneal tissue,which we now know divides the body of the uterusfrom its cervix and forms an inpenetrable barrierbetween the two. Whether this tissue be derivedfrom the base of the parametrium or from thepelvic fascia seems a point of secondary Importance :What concerns us chiefly is that it exists ; that it isvery strong ; that it crosses the pelvic inlet andsupports the contents of the abdomen; that it isinserted into the muscle fibres of the uterus and, infact, becomes their tendinous extension (thisaccounts for its richness in unstriped muscle) ; andthat it fixes the uterus and forms the angle of theinternal os-" the fixation hinge."

It is unnecessary for me now to enter into adetailed account of this structure. I have doneso on two former occasions. Our President, too,has admirably reviewed its anatomical bearings.2Again, the brilliant results of the modern operationfor the cure of prolapse by the shortening of whatare know as Mackenrodt’s ligaments have made anyfurther remarks of mine superfluous, and it is no

longer needful to prove what I am sure all admitis a self-evident fact. It is certain that it con-stitutes the true boundary between the cervixand the body of the uterus and we can no longeraccept the artificial demarcations which were

relied on by our predecessors.This diaphragm depends for its tension on the

tone of the uterine muscles. With a tightenedinternal os the fibres become taut ; with a relaxedos they sag. One of the earliest phenomena ofpregnancy is slight dilatation of the internal os.This sign is difficult to demonstrate and has not, sofar as I know, been described. Its presence is at onceapparent when a sound is passed into the uterus,and so true is this that the phenomenon should besufficient to arouse suspicion as to the true condi-tion present. The relaxation of the sphincterbrings about the changes which we associatewith Hegar’s " early sign of pregnancy." The inter-dependence which exists between the circularfibres of the internal os and the endo peritonealtissue is also noted by the great tightening ofthe os which is observed in cases of procidentia.The sagging of the diaphragm is followed byslight dropping of the uterus and shallowing ofthe lateral fornices. This tendency to prolapseis soon arrested by the power of the uterinefibres to make again the fascia taut. This theydo by their continuous retracting force. Retrac-tion is a law of all unopposed muscle fibres, andthe uterine fibres are no exception to this rule.When the tension at their insertion is relaxed,consequent on the opening of the os, they retract.By this mechanism the internal os is graduallypulled upward and at the same time it opens moreand more, so that the opening of its attached fasciamay be compared to the swinging inwards of foldingdoors. Towards the later months of pregnancy thegrowing ovum is no longer able to accommodateitself within the body of the uterus, and must movedownwards through this naturally provided hernialopening ; in fact, we may consider the mechanismas constituting the most complete illustration of ahernial process within the body.

Before we consider the. changes which arise inthe cervix as a result of direct pressure nowexercised on it by the ovum, let me summarise thepoints which are at present established.2 Transactions of the Royal Academy of Medicine in Ireland,

Obstetrical Section.