past done it upon women of child-bearing age. Some of these have since borne children, none, so far as I have known, having had any serious consequences at labor. consequences at labor. But so many such have been reported that I have ceased for a year or more to employ it except as a means of attempting to hold up prolapsed uteri in women past the menopause, or to antevert the uterus in women from whom I have removed both tubes during operation. I have had occasion to do one section upon a patient who previously had had a ventro-fixation. I also saw an autopsy upon one whom I had operated upon several months before. In both of these there extended a band about three-quarters of an inch wide from the point of fixation to the fundus, about one and one-half inches long. The adhesion band draws out into a ligament, and eventually I do not doubt that the uterus in all of these cases drops to a normal level in the pelvis. I have never seen one in which the retrodisplacement had recurred, even those after labor were anteverted. Of course, I have seen only a small proportion of those upon whom I have done ventral fixation later than a few weeks or a few months after operation. I still use it to hold a uterus forward in those cases which by nature of the operation done will not bear children, when I am in a hurry. Of the ventral fixations which I have done for prolapse, two have recurred, the adhesions having either stretched or given way entirely.

I have also used quite extensively Dr. Mann's method of shortening the round ligaments internally, while having the abdomen open for other intra-abdominal work. I like it, and have always had good luck with it, except in one case. By his precept I used in a few of my first cases a buried suture of silkworm-gut in the ligament. In one case a sinus formed several months after the patient went home. With a crochet-hook I have at various times fished out in all four silkworm-gut sutures. It is over two years, and the sinus is still unhealed, and presumably other sutures will The patient is otherwise well, she says, and would be in perfect health if it were not for the annoyance which this sinus gives. I also saw three months ago one of Dr. Mann's own cases, which came to me for a sinus out of which I fished a silkworm-gut suture. The sinus formed two years after operation. I formerly used silk in ventro-fixations, till I had a sinus form, and the silk came away in about six months. I had two such experiences, and

come out.

thereafter have used only chromicised catgut with much greater satisfaction and much less apprehension. I use now no ligature or suture material in the peritoneal cavity other than catgut. For durability a chromicised-formalin gut answers all purposes, lasting from six to ten weeks, according to the method of preparation. I have also used Dr. Wylie's and Dr. A. P. Dudley's methods of folding the slack round ligament upon the fundus and stitching it fast. This has so far been successful in my hands. It is an easier and more rapid method than Dr. Mann's, and often, to save time, I have done it, the results being apparently as satisfactory as any other. The advantages of the method of Drs. Mann, Dudley, and Wylie are that the uterus is held as far forward as the round ligaments can bring it, but it is not lifted out of its normal plane, as in ventral fixation. There are adhesions formed, of course, but they are not of such character that they are liable to favor intestinal obstruction, which I have never seen in ventro-fixation, but have always feared. The method par excellence, however, and one which appeals to me as being the most natural and the most surgical, is the method of shortening the round ligaments by Alexander or some of its modifications. When there are in the pelvis no adhesions to be broken up, when the uterus can be brought forward readily, if the woman has borne children, there is no question in my mind as to the success of the operation. Women who have never been pregnant, as a rule, have not so large or well-developed round ligaments as those who have borne children. I sometimes have been obliged to abandon an external shortening of the round ligaments of a nullipara because the ligaments were so small that I found they would not hold the sutures without tearing. But when the woman had been pregnant six months or more I have never found the ligaments small or undevelopd. In those instances where I find the ligaments too small to hold, I open the abdomen and do one of the internal shortenings referred to above. I have never known a shortening of the round ligaments to fail, and I have done it about fifty times. I have seen the patient from a few weeks to a few months after operation-some may have recurred, but I do not know of any.

As to the vaginal methods of restoring the uterus, I know nothing, practically. I saw Mackenrodt while experimenting on the method. I also saw Leopold do Shücking's operation. Neither

of them appealed to me as being particularly desirable, and I have never tried them.

Neither method of shortenig the round ligaments externally or internally throws the uterus so far forward as we usually find a normally anteverted uterus. The uterus, however, is held forward enough to have the intra-abdominal pressure exerted upon its posterior surface, and that forces it farther forward into the normal position. I have often noted this when examining a patient several weeks after operation. I have always found the fundus farther forward than at the time of operation. When the abdomen is opened, if the round ligaments be grasped on either side and stretched taut, the uterus, if lying forward on the bladder, will immediately be raised from the bladder, and the axis of its body will assume a position more nearly perpendicular to the horizon than before. In other words, tension on the round ligaments prevents extreme anteversion. Therefore, at the time of shortening the round ligaments by either method it should not be expected that the fundus will be brought so far forward as a normal position.

To summarize : 1. Certain patients can be cured only by holding the uterus in position, either by pessaries, by resting, or by operating on the normal supports of the organ. 2. The external shortening of the round ligaments, known as the Alexander operation, or some of its modifications, when there are no adhesions and the ligaments are well developed, is the preferable operation. 3. When the round ligaments are poorly developed, or there are intrapelvic conditions necessitating opening the abdomen, the internal shortening of the round ligaments is preferable, and the results from it are satisfactory. 4. Ventro-fixation should never be used in women liable to bear children, and it should only be used in women past the menopause, or in whom both tubes have been removed, thus precluding the possibility of conception.

SOME OBSERVATIONS UPON VENTRAL FIXATION.

BY HERMAN E. HAYD, M.D.,

BUFFALO.

WITHIN recent years the various deviations and displacements of the uterus have been corrected by operative measures, and, on the whole, with very satisfactory results. The Alexander operation and the various intraperitoneal operations on the round ligaments have relieved and cured a great number of women hitherto doomed to more or less chronic invalidism. So ventral fixation and ventral suspension, when properly performed in well-selected cases, bring their reward in comfort and happiness. However, an operation which forcibly fixes an organ in an unnatural position cannot be ideal; but when nature's beautiful symmetry has been distorted by mutilation and disease, anatomically ideal procedures cannot be expected.

Much has been written on the influences exerted by these operations upon future pregnancies, and it is by studying carefully these disappointments and complications that one narrows the field of indefinite surgical possibilities and its ever-increasing failures and shortcomings to possible surgical triumphs.

Ventral fixation, or suspension of the uterus, coupled with the various plastic operations upon the cervix and vagina, is the only means, surgically or anatomically, which will fix and support for future comfort and well-being an extremely prolapsed uterus. However, because that uterus sometimes offers a serious impediment to delivery by interfering with the proper dilatation of the organ, is no reason why the operation must be relegated to oblivion; but, on the contrary, it should be employed to relieve that large class of suffering women who have passed beyond the childbearing period and who most frequently are the victims of extreme procidentia uteri. In common with every operation certain dis

appointments and unexpected shortcomings appear, but I am satisfied that to the unbiased and unprejudiced there is less to complain about and to annoy in the future progress of these patients than any other class upon whom major operations have been performed. By some operators indefinite nervous symptoms are attributed to the fixed uterus. An irritable bladder may result or a persistent backache. But these vague symptoms so often exist after various surgical operations in persons with neuropathic tendencies and with little nerve force that we must not be too ready to accept them as evidences of surgical failure.

In my earlier operations I used the buried silkworm suture, and had in view the necessity of thoroughly anchoring the organ in its new position; but I am satisfied that this course is not necessary. Suture material which will insure the safety of the organ in its new location for a few weeks is all that need be looked for, because by this time sufficient adhesive union has taken place to hold it there. It was the fashion a few years ago to use catgut as thick as a whip-cord in tying the pedicle of a hysterectomy stump, or silk thick enough to fly a big kite; but this practice has been abandoned by many men, because experience has demonstrated that No. 3 catgut is strong enough for the most important operations, and if chromicized will be retained in situ as long as any suture material is required. Morris says that No. 25, American gauge, will remain ten days and No. 20 twenty days. These numbers correspond to No. 1 and No. 3 catgut.

The Alexander operation has very properly appropriated many cases upon which many of us would have performed a ventral fixation; but I am inclined to believe that we are pushing the pendulum too far, and in our enthusiasm with the new are forgetting the splendid successes of the old. Of course it should be the design of every operation to have the organ operated upon functionally strong, and the great advantage of the Alexander operation over its fellows is that it insures a movable uterus which, with its shortened ligaments, is capable of undergoing the changes consequent upon pregnancy like any other uterus, with the capacity to hypertrophy and subsequent involution.

In cases of prolapse, and even procidentia, when the ovaries and tubes are healthy and future pregnancy is desirable, one can be reasonably certain that the organ can be retained in position and