Pathological report of this appendix showed hemorrhage under the serous coat, exudate of leukocytes in the muscular, submucous and mucous coats; some atrophy of the glands and hyperplasia of the lymph tissue of the mucosa. The lumen contained pus and blood. Diagnosis: Acute exudative appendicitis.

Case 2. Mrs. L.R. I was called in consultation and found this patient suffering intense pain, with a very rigid abdomen, temperature 101°F., a white cell count of 16,000 and polynuclears 87. Immediate operation was advised and she was taken to the Hospital in an ambulance. She was four months pregnant and there being every evidence of an abscess, a median incision was made from the umbilicus to the symphysis. On opening the peritoneum a considerable amount of cloudy fluid poured out which was immediately taken up by a small Blake suction tube. The fluid later showed colon bacillus infection. During the operation the patient was kept in Fowler's position as much as possible in order that the infection might not extend.

The omentum was found to extend down over the right tube and ovary, being firmly adherent to the uterus over this area. The omentum was tied off, then the appendix which was in this case imbedded in this mass, was tied off and the stump buried with Pagenstecher thread. This left a mass consisting of a piece of the omentum, right tube, ovary and appendix in one mass attached to the uterus and right broad ligament. Having walled off all the rest of the peritoneal cavity from this, the right tube was very gently tied off and cut away, and the adhesions which held the appendix, omentum and ovary were then removed from the uterus. This left somewhat of a raw surface which was carefully sponged and the whole returned to the abdominal cavity. A stab wound drainage was provided for at McBurney's point and the main wound closed. There was some breaking down of the fat layer in this a few days later but eventually the recovery of the woman was complete except for the fact that within twelve hours of the operation, she aborted with a four and one half months fetus. This in no way seemed to complicate the case.

THE EFFECT ON SUBSEQUENT LABORS OF OPERATIONS FOR UTERINE DISPLACEMENTS.*

By GEO. W. KOSMAK, M.D., Attending Surgeon.

THIS important question has been argued pro and con ever since the proposition was first made to cure uterine displacements by means of a variety of corrective procedures applied to the various suspensory ligaments of the uterus or the muscles of the pelvic floor. In all operations of this kind, the important fact to be born in mind, is their effect on subsequent labors. The necessity of such corrective operations are to be measured by the symptomatology. Where deviations from the normal position of the uterus produce disturbances, these undoubtedly demand correction, but after being cured they should not place the woman in a position where her life may be jeopardized in case of subsequent pregnancy. The two great divisions into which we may divide cases demanding operative relief for malpositions of the uterus, are retroversion and procidentia. In every case the object is to restore the uterus as nearly as possible to its normal position. This result is accomplished very frequently by shortening one or more sets of the suspensory ligaments of the uterus or using these to secure new points of suspension. Artificial ligaments are likewise employed for this purpose and the necessity has now become quite generally recognized that if lacerations of the pelvic floor are present, these must be repaired. In addition, owing to the failure of some of these operative procedures to retain the uterus in its new position, other methods have been devised for this purpose which displace the organ to such a degree that under no circumstance could be considered normal but which serves the purpose by causing the same to be retained in a position where it does not produce symptoms. Reference is here made to that particular class of operations in which the uterus is firmly fixed in a position below the bladder. The type of operative procedure depends somewhat on the age of the patient and whether she is still capable of bearing children. In certain cases it has nevertheless been thought necessary to actually sterilize the woman rather than have her become pregnant with the uterus in a position that did not permit of its proper growth during gestation. Unfortunately this care is not always exercised and we meet with cases of serious dystocia where the possibility of subsequent pregnancy has not been taken into account in doing the operation. It is my purpose to present certain abnormalities in labor as noted in a series of cases in which various operations for the relief of uterine displacement had previously been performed. These cases were observed either in private practice or in the wards of *Read at the Annual Meeting of the Medical Society of the State of New York, Section on Obstetrics and Gynecology, April 29, 1914, at New York City. Appears also in the New York State Medical Journal.

the Lying-In Hospital and for the privilege to report the latter I am indebted to my chief, Dr. A. B. Davis, of the Second Division.

The first class of cases concerned are those in which a retroverted uterus is corrected by means of the Kelly or Gilliam operation. The two cases herewith presented may be accepted as examples of a class which offer comparatively little resistance to normal labor except as noted. Mrs. L., para iii, had two moderately difficult labors. She was operated on by the writer for retroversion with symptoms, in 1908 and a Kelly suspension with anterior and posterior colporrhaphy done. She again became pregnant and was due October 4, 1910. She was comparatively free from any abdominal discomfort during her pregnancy and went into labor on September 22, 1910 slightly before the expected time. After being in strong labor for several hours an examination showed a thinned out cervix with four fingers dilatation and ruptured membranes. The head was slightly engaged but the uterine contractions seemed to force the same against the sacral promontory rather than into the pelvic canal. After a number of hours however, assisted by pressure from above, the head descended and the child which weighed about 7 pounds was finally born. A slight external laceration resulted.

One other case also operated on by the writer in which a Gilliam suspension operation was done, the patient complained of considerable pain of a tugging character during the last month of her pregnancy. When the end of her term arrived a large child was found to be present but no signs of labor.

In view of her previous difficult labors it was decided to initiate the process in this case. Voorhees' bags were accordingly inserted and pains started up promptly but for a number of hours the head refused to engage as it seemed that the contractions of the uterus were ineffective in pushing the same downward. As the abdominal wall was very relaxed it was possible to aid the engagement of the head by pressure from above and when this was once accomplished the delivery proceeded without any trouble. In these and similar cases reported by others, the only difficulty seemed to reside in the engagement of the head. When this was once complete the labor seemed to progress without difficulty.

In both of the personal cases referred to above, no adhesions resulted as the uterus was found freely movable through a restricted area after the operation.

The second class of cases to be considered are those in which a fixation of the fundus of the uterus to the abdominal wall has occurred either by deliberate intention or accidental adhesions following the performance of a Gilliam, Kelly or similar suspensory operation. It will be seen that in this group the dystocia is somewhat more serious and an operative delivery is often found necessary to avoid dangerous consequences to the mother.

A typical case of this class is as follows:

Mrs. Italian, para viii, gave a history of having had an abdominal operation done three years previous to her present pregnancy after which she had a living child without any trouble. The patient had gone into labor with weak pains on the afternoon of December 10th, when seen by a staff doctor from the Lying-in Hospital. Several hours later she had not made any progress and the pains had become tonic in character. I was called to the case and found on examination a poorly developed woman of medium stature with an abdominal enlargement entending up to the costal arch, consisting of a pregnant uterus in a state of tonic contraction. The fetal heart could be heard in the right lower quadrant and was of good character. The abdominal wall was very thin. Vaginal examination failed to reveal any cervix within reach but under light chloroform anesthesia, the anterior vaginal wall was found markedly stretched and high up in the left lateral fornix a small opening was found into which the finger could be introduced. This was determined to be the external os and the greater portion of the uterus and its contents were over toward the right side. The uterus seemed firmly fixed and in a condition of tonic contraction. The high position of the cervix, the tonic uterine contractions, the fixation of the uterus, the exhausted condition of the patient and the liability to uterine rupture, determined the decision to send the patient to the hospital for delivery by Cesarean section. This was accordingly done. After opening the abdominal cavity the wall of the uterus was found to be very thin and the great tension present, was shown by the forcible expulsion of the liquor amni, as soon as the uterus was incised. The child was readily extracted and lived. After removal of the placenta and membranes the uterus was sutured in the usual manner and contracted promptly. As it was impossible to restore the uterus to its normal position before incising the same, it was subsequently found that the Cesarean incision had been made in the right half of the anterior wall about an inch away from the insertion of the round iigament. The patient made a good recovery.

On examining the uterus before closing the abdomen a broad band of adhesions was found which firmly attached the anterior wall to the lower segment of the anterior abdominal wall and prevented a uniform enlargement of the organ.

In another case, the patient, a para iii, gave a history of two previous labors in which forceps were employed. Sometime after her second pregnancy a supposed ventral suspension operation was done. This patient went into labor at term and although she continued to have severe contractions for forty-eight hours, failed to cause any engagement of the head or dilatation of the cervix. At this time a large child in the L. O. A. position could be palpated with a fetal heart of good quality. The cervix was short and very firm so that it could not be dilated manually. The lower segment of the uterus, however, was soft and thin. The head could be felt at the brim and was not engaged at all. The

pelvis was normal in its measurements but in view of the large child, the undilatable cervix and the difficulties attending the closure of the necessary incisions for a vaginal Cesarean section, the abdominal form of delivery was decided on. On opening the abdomen the uterus was found to be turned over to the left and broad irregular bands of adhesions were found on the right side near the internal inguinal ring. A loop of intestine was also found in the angle between the lower uterine segment and the anterior abdominal wall which was slightly adherent. After closing the uterine wound, the various adhesions present were ligated and cut in order to avoid any possible postoperative intestinal strangulation.

In addition to these cases, others might be cited from the records of the Hospital where dystocia resulted from some suspensory operation. The third group of cases concerns those in which an interposition operation has been done without effective means having been taken to sterilize the patient at the time of the operation. Here the degree of dystocia is apt to prove of serious consequence to the mother and the number of cases of this kind which have thus far been reported, constitute a serious warning to those who have done this operation without the usual precautionary measure referred to.

Mrs. M. D., a multipara between six and seven months pregnant, stated that she began to bleed without apparent cause on the morning of April 19, 1913. She was not in labor when admitted to the Lying-In Hospital about two hours subsequently. The vagina was full of blood clots and a search for the cervix disclosed the same at the extreme upper end of an elongated vagina in a position above the brim of the pelvis. It was very rigid, admitted one finger and the canal was about two inches long. The cervix could not be pulled downward and free exploration showed the presence of a centrally situated placenta previa which had separated from the lower uterine segment. In view of the necessity for immediate delivery on account of the constant hemorrhage, an abdominal Cesarean was decided on and carried out. A small fetus was extracted which lived for a short time only. The placenta was found almost separate from the lower segment of the uterus over the cervix. The history subsequently obtained, showed that the patient had been operated upon less than a year previously for procidentia, the so-called interposition procedure being employed. Her last period extended from September 21 to 26, 1912 and was normal. The patient stated that she was well except for inability to urinate readily and it was necessary to catheterize her several times.

The patient made an uninterrupted recovery. In December 1913, the patient was seen by the writer again and found to be about three months pregnant. She was bleeding slightly and an examination disclosed the cervix in the same relative position as previously and slightly dilated. In view of the unfortunate outcome of the previous pregnancy,