thenia, that does not admit having derived any benefit from the operation; this makes two cases, or 1.6 per cent., of all the reported cases as subjectively unimproved although the displacements are cured. After deducting the seven pregnancy cases, reporting by letter, as in good or excellent health, the twenty-nine remaining letter cases reported as follows: Ten, pelvic and general health "excellent;" fifteen, general health "good." One has good pelvic health, but has a ventral hernia; one, good health except for tuberculosis; two do not admit having been benefited, because of prolonged scanty menstruation or amenorrhea.

CONCLUSIONS.

(1) Retroversion of the uterus per se is an anatomical anomaly that gradually produces discomfort and has an inherent tendency to invite more serious displacement or inflammatory processes in the uterus and more so in the ovaries. Those who deny this, affirm it by their own action when they correct this displacement, incidentally only, while claiming to be operating chiefly for its complications. (2) The evil effect is produced by the embarrassment to the venous circulation, caused by torsion of the broad ligaments and by traction in descent of the uterus. (3) Clinical observation and experience indicate that the competency of the veins in the parametrium becomes impaired by the impediment when it is severe or long enough. With such a condition liable to be present, the best clinical results are obtained by not merely correcting the version of the uterus, but by adding also an overcorrection in the sense of a harmless suspension at a higher level than it normally occupies within the true pelvis. (4) One of the best operations to accomplish this is the Gilliam operation, provided that a generous amount of the enveloping peritoneum is utilized to reënforce the round ligament loops, which must be anchored in the recti muscles and their aponeuroses not more than 3 to 4 cm. from the border of the symphysis pubis, and should be drawn up so that the peripheral, unused, part of the round ligament and also its uterine origin come into apposition with the abdominal wall. (5) The efficiency of this operation is shown in the 127 examined cases, including the double test of pregnancy of twenty-one cases, all of whom experienced natural labors, with a return of displacement in only 1.6 per cent., with both pelvic and general health "good" or "excellent" in 88 per cent. There was improvement in 10.2 per cent. and no improvement in only 1.6 per cent. out of a total number of 164 cases observed from two to seven years, or over 3.5 years on an average. Its harmlessness is shown by the utter absence of any deleterious effect in the twentyone births noted; likewise, from the absence of intestinal complications and other discomforts.

2120 CLEVELAND AVENUE.

SHORTENING OF THE ROUND LIGAMENTS BY TRANSVERSE SUPRAPUBIC INCISION.*

BY

SIGMAR STARK, M. D., F. A. C. S.,

Cincinnati, Ohio.

(With eleven illustrations.)

Ar the meeting of the Mississippi Valley Medical Association, held at Cincinnati, October 29, 1914, it was my privilege to present a paper on the operation about to be described. Since then I have come to realize by experience that the steps of the same could be simplified. For this reason, and the fact that it has given me such

FIG. 1. Shortening the sound ligaments by transverse suprapubic incision. satisfactory results in curing retrodisplacements of the uterus and holding the organ in perfect suspension after the usual operations upon the cervix and outlet in cases of complete prolapse, do I assume the liberty of presenting the subject for your consideration.

The adage, "there is nothing new under the sun" is applicable now. The operation presents features embodied in many different methods, but in its purpose and ensemble presents sufficient essentials to entitle it to individuality. The principal feature though is a

*Read before the Twenty-ninth Annual Meeting of the American Association of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

Goldspohn derivative and consists in the inguinal liberation of the round ligament from its peritoneal investment to the necessary degree. The transverse suprapubic approach is that of Duret, Peterson, Rumpf, Palm, Küstner and many others. I have always been partial to the Goldspohn procedure and up to the autumn of 1913 employed it in a routine way. I did not limit the Goldspohn operation to uncomplicated retrodisplacements, but successfully employed it in those complicated with adhesions and tuboövarian disease, performing salpingectomies, oöphorectomies and conservative operations upon these organs, also frequently removing the appendix as a necessary or prophylactic measure. It was at such times

that I was frequently apprehensive because of bleeding in the depth and the greater difficulty of the operation and wished that I had made a median incision. In order to more readily cope with these possible contingencies, I took recourse to the transverse suprapubic incision, which in case of need could be terminated in the Pfannenstiel manner or even by the Peterson median incision after slight dissection of the upper wound flap from the underlying fascia.

A transverse incision down to the fascia is made just above the pubes and then carried upward on either side to correspond to the direction and length of the inguinal canal. Hemostasis is attended. to and all attached fat in the line of the future fixation of the round ligaments is removed from the fascial surface. An incision about

five centimeters in length is made through the aponeurosis of the external oblique in the direction of its fibers and corresponding to the inguinal canal.

The round ligament is caught up in a hemostat, completely liberated from its bed, a ligature passed about its distal end and then sectioned immediately above the ligature. By making traction on the

ligament in an outward direction with the assistance of the hemostat its peritoneal reduplication is brought into view. This is snipped into with scissors and the incision continued along the ligament on

either side to the desired height, and the same procedure is then carried out on the other side. The index finger is then inserted into each opening for the purpose of exploring the pelvic organs and to