owing to failure of the dilating uterus to overcome completely the enforced anteflexion, the cervix and os are displaced posteriorly, and interfere with the delivery or even render it impossible.

The chief fault found with the anterior method is that the continued weight of the uterus on the ligaments formed between it and the abdominal wall, will stretch them until they will permit the organ to lie in a position of extreme retroversion, or a recurrence of the condition for which the operation was performed; this I believe is not so, for the reason that, while these ligaments are capable of a considerable amount of stretching, if it is done gradually, the uterus is held in place by intra-abdominal pressure and by resting upon coils of intestine, which very often lie in the pelvis posteriorly to the uterus, but principally because the ligaments contain elastic tissue.

This objection, is I think, one of theory, as I know of no cases in which it has been demonstrated, and it would seem that if these ligaments are capable of contracting after a full term pregnancy sufficiently to hold the uterus in practically a normal position, they are capable of supporting in good position an approximately normal-sized organ.

The great advantage of this method over a posterior suspension or a fixation from an obstetrical standpoint, is that it suspends the uterus with its axis in line of its future expansion, and consequently there is less liability to miscarriage in the early months of pregnancy-as there is when the organ is held in a fixed position, or in one of anteflexion-and we know that misplacements with adhesions are frequently the cause of miscarriage; the ligaments are called upon to stretch less, and consequently there is less liability of rupture of the ligaments; the stretching is more gradual, especially in the early part of pregnancy, the condition being then more normal and miscarriage being therefore less likely. There is greater freedom of movement and consequent ability of the organ to dilate equally in all directions, and therefore less chance of thinning. of the posterior uterine wall, with the dangers of rupture during expulsion.

The literature upon this subject is very meager, both as re

gards the effects of the several operations upon labor, and the condition and position of the uterus after labor, and the position of the uterus, which has not been pregnant a considerable time after the operation. I will give five clinical cases and we will then see if there are any deductions to be made from them. Case 1. Mrs. H., age 28, height 5 ft. 5 in., weight 110 pounds -American. Menstruated at 13, married 8 years, has two children, two and five years old, no miscarriages, very nervous. Suffers extremely from backache and headache at menstrual periods, and from former more or less all the time. This has been the condition ever since she first menstruated, and has gradually grown worse. During both pregnancies all these symptoms have been greatly relieved. The first labor was hard, lasting 36 hours, perineum lacerated and repaired, child weighed 10 1-2 pounds. A few months after birth all the old symptoms began to return, and continued to grow worse until the second pregnancy, when they were again relieved. This labor was normal except that the perineum was again lacerated; was not repaired.

The patient came under my care in April, 1900, complaining of all the above symptoms. On examination the condition was as follows: Heart, lungs, and kidneys O. K. Vaginal outlet greatly relaxed, perineum lacerated, bilateral cervical laceration, uterus 3 1-2 inches deep, extremely retroflexed, movable. On April 14, 1900, under ether, curettement, trachelorrhaphy. Post. Colporraphy and ventral suspension were done, the technique of the latter being as follows:

Median incision 5 cm. long, ending 2 cm. above symphysis, uterus elevated, and a catgut suture pased through the peritoneum and ant. surface of uterine cornua on each side, and tied, silkworm suture passed from without, through entire abdominal wall through ant. surface of fundus and out through abdominal wall of opposite side. (This suture should enter and leave the fundus at points toward the posterior surface of the uterus, so that when the suture is tied the points of exit from the internal surface of the abdominal wall and entrance into the uterus will not be in contact, as there would then be formed a cord of scar tissue following the course of the culture, thus making a fixation of our supposed suspension.) Median in

cision closed and silkworm suture tied over pad of gauze tight enough to relieve the strain from the catgut sutures until union had taken place between uterine surface at cornuas and peritoneum. This was removed on the 14th day. For four days the patient complained of a pulling sensation at site of attachment, but otherwise made an uneventful recovery. There was immediate and almost complete relief from all unpleasant symptoms, increase in weight, etc.

The patient became pregnant about six months after operation (I had advised her to wait a year). Between the 3d and 6th month she complained of a great deal of pulling at the site of the wound; after the 6th month it disappeared almost entirely. Otherwise she had less trouble carrying this child than with either of the others. Labor was uneventful and comparatively easy, lasting 6 hours. L. O. A. Direction of os normal, no lacerations. Placenta expelled intact 15 minutes after fetus. Uterus contracted nicely, recovery uneventful. Six months after delivery on examination the uterus was found of normal size, lying in very nearly normal position, movable, and held in place by ligaments, as could be determined by attempting to tip it backward. The general condition of patient was very good.

On February 4, 1904, I operated upon this woman for appendicitis, and found the uterus supended by two bands, one from each cornu, that from the left being much thicker; the interval between these bands was about 2 cm. The uterus was freely movable and the interval between it and the anterior abdominal wall about 4 cm. (See illustration.)

Case 2. Mrs. E., age 31, menstruated at 15, married II years. As a girl and until after first baby was born was of a somewhat nervous disposition, but not extremely so. Four miscarriages; three children, 8, 6, and 4 years old. First child weighed 12 pounds. Both cervix and perineum were badly torn and repaired. Was also torn with each of the other children, the last not being repaired. Otherwise the labors were normal and recovery uneventful. The patient first came under my care in August, 1900. American, family history neurotic, height 5 ft. 7 in., weight 118 pounds, excessively nervous, the beginning of which dates back to about eight months after first

baby was born. Has always been much better while carrying children, but has been worse after each birth, and the present serious condition has been growing worse ever since last birth, four years ago.

Headaches almost constant, and nearly unbearable during menstruation. Does not sleep well, and dreams nearly all night, and does not feel well in the morning. Walks in sleep.

Incessant backache, and bearing-down in pelvis, constipated, cross, and irritable, cannot walk or do any housework without being exhausted, faints frequently.

Examination: Heart, lungs, and kidneys O. K. Hood of clitoris adherent, perineum slightly torn, vagina slightly relaxed. Urethral meatus inflamed and painful. Cervix eroded with bilateral tear, large amount of thick yellow leucorrhoea. Uterus 4 1-2 inches deep, retroverted and retroflexed, resting upon rectum, movable, endrometritis. This woman was in a deplorable condition, a burden to herself. Operation was

refused at the time, and she was treated locally and with pessary for six months, which only gave temporary relief.

On March 5, 1901, under ether, the uterus was curetted and the cervix repaired. Clitoris freed, but suspension was not permitted, and as only very slight improvement followed the operation, on October 17, 1901, the uterus was again curetted and suspended from the abdominal wall as in case I. The patient suffered greatly from shock, and for ten days complained greatly of pain in region of wound, otherwise made a slow but uneventful recovery; home in five weeks, but not able to be on her feet to any extent until January 1, ten weeks after operation. From this time her improvement was surprisingly rapid. Practically all nervous symptoms disappeared, backache, sleeplessness,' and pelvic symptoms. Gained twenty pounds in four months, and was able to do" as much as the average woman. In January, 1903, she became pregnant. Suffered considerably from nausea for eight weeks. From 9th week to middle of 5th month complained of pulling at site of operation.

During last six weeks of pregnancy was unable to be on her feet much on account of exhaustion, otherwise nothing unusual. Gained considerable in weight, weighing 128 pounds at term. Labor began at II A. M. on 28th of October, dilating pains continuing regularly until noon on the 29th when expulsive pains began. The os at this time was fairly well dilated and soft and pointing in normal direction. Position L. O. P. Waters broke at 3 P. M., and shortly after pains became extremely severe. At 6 P. M. the pains continued severe but with apparently little effect, the head had not descended during the last three hours, chloroform was given during pains. At 6.30 P. M. there was a considerable hemorrhage and as patient was considerably exhausted, the anesthesia was deepened to the point of relaxation, high application (axis traction) forceps were applied and the child,—a boy, weighing 9 pounds, rapidly delivered at 7 o'clock.

Delivery was followed by a considerable hemorrhage, 25 mm. of ergot were administered hypodermatically, followed by 1-30 gr. strychnia and 1-100 nitro-glycerine. There was no effort of the uterus to expel the placenta. It was delivered manu