fectly normal confinement. Recent examinations show in each of these cases that the uterus is still in position. Having in mind the mechanics of retrodisplacement in which the prolapse of the cervix is an important part, the operation upon the uterosacral ligaments should yield the best results. The suggestion to fold these upon themselves is very good, but is very difficult of accomplishment. Working in the depths of the pelvis with the great probability of obtaining only peritoneal adhesions, this does not offer any great advantages over the round ligament. This is certainly the most direct way of preventing retrodisplacement. If the cervix is held firmly the fundus must assume its normal position. Support to the cervix is so important that correction of any laceration of the pelvic floor is as necessary as any of the details of the retrodisplacement operation itself. CONCLUSIONS I. Fixation by broad attachment of the uterus to the abdominal wall in a woman of the child-bearing period of life is contradicted without the employment of accessory procedure to prevent subsequent pregnancy. In cases where pregnancy is not to be considered it should be the operation. of choice. 2. The objection to the suspension operations lies in the difficulty of obtaining the happy medium of a sufficiently strong attachment to give the surgical result and a ligament so placed as to be non-obstructive to uterine growth with the great probability that the effect of the operation has been nullified by the successful outcome of the pregnancy. 3. The use of the round ligaments in any way suggested offers no obstruction to enlargements of the uterus. and the discussion on their use must be limited to the methods best suited to obtain constant support to the uterus. 4. Since experience has shown that the uterus by its own weight will pull away from the artificial ligament when attached anteriorly to the face of the fundus, so should it pull away from the round ligament if so attached. 5. So far, the round ligament sewed to the posterior wall, although the cases are comparatively few, seems to meet the requirements. FOR DISCUSSION SEE PAGE 135 REPORT OF THREE CASES OF PREGNANCY FOL- J. C. LITZENBERG, M. D. Minneapolis As soon as I read the program for this meeting I discovered that Dr. H. P. Ritchie had chosen a subject so nearly akin to the one that I had selected that I thought best not to burden this association with a general discussion of the subject, which I knew he could handle so much better than I. So I have taken the liberty of changing the character of the original paper to a mere report of three cases which formed the foundation of that paper. It is not the purpose of this paper to discuss the ultimate value of the various operations devised to restore the retroverted uterus, nor to advocate ventral suspension or Alexander's operation as the operation of choice, but simply to report three pregnancies following these operations. My reason for reporting these cases is that I believe every case of pregnancy following any of the various operations for retroversion should be reported by the general practitioner, for he is the one who usually sees them, and the relatively small number of cases reported leads me to believe that many cases of this kind are allowed to go unreported. Dr. Franklin H. Martin in his exhaustive article on "Operative Treatment of Retroversion of the Uterus" was able to report only six pregnancies in 328 cases of ventral suspension, and but few more Alexander's, due most probably to the fact that he was unable to follow the cases. Others may have become pregnant and fallen into the hands of some one who did not realize the importance of each case as an aid to deciding which shall be the operation of choice. There is no question in gynecology over which there is so much controversy as to decide which is the operation of selection in retroversion. I believe we, as general practitioners, can materially aid our confreres, the gynecologists, by reporting every case of pregnancy we see following one of these operations. The reported cases are few enough, either because they are rare or because they are not reported. The gynecologist may devise various and ingenious operations for this trouble, as indeed he has, yet the supreme test is not merely, has the relief of disagreeable symptoms been attained? but has the uterus been left capable of fulfilling its highest function in pregnancy without dystocia? Unfortunately, the operator may never have the opportunity of observing the real test of his handiwork, but he must depend on us to report cases which were operated upon by him and delivered by us. I believe one derelict who does not report such cases, and therefore, I submit the following three cases of pregnancy in two women which may be added, for whatever they are worth, to the comparatively small list of reported pregnancies following operation for restoration of the retroverted uterus. All of them, when taken together, may enable our co-workers in gynecology to some day decide the vexatious problem. CASE I. Mrs. L- was well till first pregnant. First gestation was normal; at delivery she suffered a complete tear of the perineum, which was not repaired till she fell into the hands of my late colleague, Dr. R. E. Cutts. At that time she had prolapsed uterus and lacerated cervix and perineum, which Dr. Cutts repaired, and did an Alexander operation. All symptoms disappeared till she became pregnant three years after the operation. She then had prolapsus, which Dr. Cutts corrected with tampons till the uterus ascended into the abdominal cavity. When only a few weeks pregnant there was a marked general anasarca and hydramnios. I was called to assist Dr. Cutts at delivery. She was delivered with forceps of a hydrecephalous child. After a tedious involution the uterus returned to normal and no symptoms of retroversion were noticeable to the patient. CASE 2.-The same woman. Three years after this child was born, the patient came to my office with a prolapsed uterus; one menstruation had been missed. I found the cervix greatly elongated. I kept her under close observation, and she proved to be pregnant. The uterus was kept up with pessaries and tampons till it was large enough to be pushed above the promontory of the sacrum, and be held there on account of its own size. No other untoward symptoms were noticed till the fifth month, when she had a threatened abortion. Four times during the remainder of her gestation she was so threatened, but rest in bed thwarted the catastrophy. During the last three months of gestation she had pains every ten or fifteen minutes, no bleeding, cervix partially dilated all the time, patient in bed most of the time, pains uncontrollable. She came in labor at eight and one-half months, but after twenty hours forceps were applied, very little progress having been made. The position was R. O. P. She suffered very much with after-pains, the uterus having evidently not enough power to expell the clots, which had to be taken from her with placental forceps and dull curette. The puerperium was uneventful except that involution was very slow. Patient had to be kept in bed four weeks. This woman has been examined this week, when I found her womb in normal position, the cervix still being elongated. The remarkable thing about this case is that after prolapse twice recurring during pregnancy, the uterus should now, eleven weeks after second delivery since operation, be found in normal position. CASE 3.-Mrs. P——, mother of four children, consulted Dr. R. E. Cutts for prolapsed uterus. He found a lacerated cervix and perineum, which were repaired and ventral suspension performed, when all symptoms disappeared. Four years later she came to me pregnant. The early months of pregnancy were uneventful, but during later months she had continual pain in the scar. Uterus did not ascend above umbilicus till the eighth month, when it suddenly ascended to the normal height of an eight-months pregnant womb. When the uterus ascended the pain decreased, though it was not entirely absent. She had a long labor with breach presentation, L. S. A. She was slightly torn, but the tear was immediately repaired. This woman was examined this week, and the fundus was found well against the anterior abdominal wall. Evidently, in this case the intended suspension became a fixation, and at the eighth month there was a tearing away of adhesions, which, however, could not have been complete, for the uterus is now in good position, and the woman has no symptoms except when very tired, when she feels a dragging pain, as she felt before the operation, but the womb has never descended since the operation. These cases are presented for what they are worth, hoping that when added to the sum total they may throw some light on this most fruitful source of controversy. DISCUSSION DR. J. T. ROGERS (St. Paul): About five years ago I gave up ventrosuspension of the uterus in all cases except those that had passed the child-bearing period. To-day I believe that in those cases which have passed the menopause there is no operation which compares with that of ventrosuspension in its results. It has not been my misfortune to have had any recurrence following ventrosuspension. Four cases have gone on to pregnancy following the operation, all of them four or five years ago. In two of those cases there was a normal delivery. One of them was pregnant at the time ventrosuspension was made. The operation was done on account of threatened miscarriage. The patient was sent from a distance. She had had one or two miscarriages at three or four months of pregnancy. I opened the abdomen, liberated the adhesions and made the ventrosuspension, and the woman went through her pregnancy without difficulty. Another case, also from the country, became pregnant after ventrosuspension and went through labor without difficulty. Another case had a dystocia, and, following delivery in a neighboring city, became septic, and died either of sepsis |