Alternating Anterior and Posterior Version of the Uterus. BY SAMUEL C. BUSEY, M. D. WASHINGTON, D. C. REPRINT FROM VOLUME III. ffijmecologfcal 1379 ALTERNATING ANTERIOR AND POSTERIOR VERSION OF THE UTERUS. BY SAMUEL C. BUSEY, M. D., Washington, D. C. The above title has been selected to set forth succinctly and fully the distinctive feature of a case of malposition of the uterus, in which the organ, when unsupported by any mechanical contrivance, was always found in the position either of complete anteversion or retroversion. The history of this case is as follows: On April 28, 1878, Mrs. after a somewhat fatiguing journey reached the city of Washington, and was seen by me, for the first time, on the next day. She was an intelligent and accomplished woman ; twenty-nine years of age, above the average height and slender ; had been married seven years and borne tw< children, the elder 'daughter being six and the youngei three and a half years old. Previous to her marriage she had excellent health and was accustomed to active exer- cise— walking and horseback riding. Menstruation was regular and painless, lasting from five to six days, and usu ally copious during the second and third days. Her first child was borne eleven months after marriage. Labor was tedious and convalescence tardy. Since then she had never enjoyed vigorous health as formerly ; during the inter-preg- nant interval she suffered from debility, some pelvic distress, was unable to superintend her household duties, and after any unusual effort was compelled to seek relief in the re- cumbent posture, being frequently confined to her bed for a week or more. Menstruation, beginning at an indefinite period after the first labor, recurred regularly, but was al- ways accompanied with considerable pelvic pain and head- 2 ALTERNATING VERSION OF THE UTERUS. ache, continued during a longer period and was greatly in- creased in quantity. With the commencement of the second pregnancy, her general health improved, but she did not regain the vigor and freshness of her first gestation. The second accouchment was more difficult and protracted than the first, and was followed by a dangerous illness, which continued during several weeks. Since then she had been a confirmed invalid, passing most of her time either in bed or on a lounge. During the year succeeding the last par- turition she had not submitted to any systematic medical treatment, but mainly relied upon rest in the recumbent posture, which afforded comparative comfort, except during the catamenia, which returned with regularity, but were at- tended with augmented suffering and a greatly increased loss of blood, the flow uniformly continuing for nine or ten days. For the past two and a half years she had been con- stantly under treatment. She represented that she had suffered from some chronic inflammatory condition and displacement of the womb, and that she had been during several periods, varying from three to six months, subjected to very energetic local treatment, such as the weekly application of caustics which had oc- casioned severe paroxysms of pain, coming on a few hours after the applications, and only relieved by large doses of morphine. On one occasion, which was not the last, how- ever, after what she supposed had been an unusually severe cauterization, a painful and protracted pelvic trouble had followed, which endangered her life. Pessaries of various shapes had been tried, but none had afforded permanent ease ; the last, a Hoffman’s elastic pessary, which had been worn during her journey and for several days preceding her departure from home, had given more comfort than any previously employed. Her bowels acted irregularly, were usually constipated, but sometimes for several days consecutively she would have one or more loose stools. Defecation was at times painful. Frequent micturition had been only an occasional annoy- ance. Her appetite was poor and somewhat capricious ; SAMUEL C BUSEY. 3 she had lost flesh, and been much troubled with palpitation, which she feared was the symptom of some severe heart disease. She slept badly, but was markedly free from the psychical and sensory disturbances, which so frequently complicate these chronic uterine ailments. She expressed herself as feeling very greatly improved. As I found her she was feeble and anemic, had a small compressible and frequent pulse, and complained of con stant pain in the sacral and left iliac regions, which occa- sionally also invaded the middle and right hypogastrium, was sometimes diffused throughout the pelvis, and at times extended down the thighs. These pains grew worse when she was sitting erect, were greatly aggravated when walk- ing, especially when ascending or descending steps, and were intensified during the periods of menorrhagic discharge, which continued with unabated profuseness. So much were the pains augmented during locomotion that she but rarely attempted to walk, could not dress herself without assis- tance, and seldom left her chamber, not even joining the family at their meals. There was some tenderness on firm pressure over the left ovary, but it was not marked else- where. She had removed the Hoffman pessary the night previous. The vagina was tender and very greatly dis- tended, feeling like an inflated sac, with smooth, moist walls. The cervix uteri was pressing firmly against the anterior vaginal wall, the os looking towards the symphysis pubis. The neck was firm, hard, pale, and felt like cartilage. The body and fundus were correspondingly depressed pos- teriorly, occupying Douglas’ pouch, and pressing against the rectum ; were very tender, but not apparently enlarged. The probe passed with facility to the fundus without pro- ducing pain. The organ was movable in every direction ; measured three and one quarter inches, the excess of length being due to elongation of the infra-vaginal cervix. Its longitudinal axis occupied apparently an antero-posterior median direction. There was no discharge through the os, nor was the probe even tinged with blood, notwithstanding the manipulation to determine the mobility of the organ. 4 ALTERNATING VERSION OF THF. UTERUS. In the left lateral cul-de-sac there was moderate tenderness, increased by bi-manual pressure, and a sense of resistance and tension in the direction of the left broad ligament. The left ovary could not be distinctly felt. By pressure with the finger against the anterior surface of the infra- vaginal cervix the organ could be easily restored to its nor- mal position. In effecting reposition the os swept the pos- terior vaginal wall in firm contact, and, when the uterus was in position, seemed imbedded in its surface. The pa- tient alleged that pain, frequently felt when sitting erect, was relieved by shielding the perineum from pressure. The rectal ampoule contained large masses of feces. The im- portance of these details will be appreciated when I discuss the causes of the reversible malposition, which as yet had not been suspected. With this history and these facts before me, the indica- tions for treatment were : — 1. To reduce the displacement and retain the organ in position. 2. To rebuild her wasted physique. 3. To arrest the excessive menstrual losses of blood. After having communicated the result of the examination and indicated my purpose to adjust an instrument to sup- port the womb, the patient politely informed me that my suggestion was simply the repetition of the old story, and, directing me to where I found a Smith’s modification of Hodge’s closed lever pessary, added that it had been tried numerous times, without affording relief except at times for a day or two, followed by an aggravation of her discomfort. This protest was disregarded. The instrument was intro- duced and left. It simply lodged on the floor of the spa- cious vaginal cavity. With directions to meet the second indication, and to use vaginal injections of hot water morn- ing and night, we parted for the time being. The next day she was less complaining. The vaginal cavity had dimin- ished and the uterus was resting against the posterior arm of the pessary. On the 1st of May the menses began. The flow was excessive and continued during nine days, notwith- SAMUEL C. BUSEY. 5 standing the free administration of gallic acid from the close of the fourth day, and rest in bed during the entire period, but was unaccompanied with the usual pelvic pains and headache. She slept well under the influence of a single moderate dose of chloral hydrate each night. She aban- doned the bed the day after the cessation of the discharge and next day I found her suffering more than at any time since her arrival. To my great surprise the uterus occupied a right oblique direction, the fundus lying to the right of the median line, against the right ramus of the pubes and the os pointing towards the left sacro-iliac synchondrosis. Unwilling to acknowledge a mistaken diagnosis, I re-ad- justed the organ and left the instrument in position. The vaginal cavity had collapsed, and its walls closed around the cervix and the pessary. The following day the organ had resumed its right oblique malposition. The Hodge pattern was abandoned and a Thomas anteflexion instrument sub- stituted.1 I persisted for some days in attempts to utilize this instrument. My theory was that if I could succeed in stretching or displacing the intervening soft parts and effect close coaptation of the concavity of the body of the appara- tus to the cervix, so as to cover the anterior surface of both the infra- and supra-vaginal portions, I might, partially at least, fix the points around which the organ revolved in its movements of anteversion and retroversion. To accomplish this it was necessary to prevent the forward rotation of the infra-vaginal cervix, which must occur in retroversion, and the anterior deviation of the supra-vaginal neck which necessarily took place in anteversion. This I hoped to ef- fect by making the symphysis pubis the fixed base against which the curved extremity of the hinged wing of the sup- port would rest, thus securing uniform coaptation of the partially fixed parts of the womb and pessary, thereby lim- iting the oscillations of the organ to an arc of safety, be that arc the one described by the os or by the fundus. The surface of impingement should include the anterior face of the organ, extending from the lower margin of the 1 As described, Gynecological Transactions, p. 238, vol. ii., 1877. 6 AL TERN A TING VERSION OF THE UTERUS. attachment of the anterior vaginal wall to the cervix up to ancl above the level of the internal os, or else flexion might be promoted. The uterus perversely refused to obey my will or to verify my theory. The fundus would either dis- lodge itself from the excavation of the support and resume its right oblique position or follow the arc of posterior de- scent, forcing the os into and against the concavity of the body of the pessary. On a single occasion I found the neck riding over the top of the instrument. Reflection since has satisfied me that my failure was attributable as much to the mechanical construction of the apparatus as to any defect in my theory. If I had transferred the joint and attached the movable fulcral wing transversely to the con- vexity of the body of the instrument on a line correspond- ing with the axis of the organ in its antero-posterior oscil- lations, which must be located between the lower vaginal and upper vesical attachments of the anterior surface of the uterus, I might have had better success. To return, however, to the history of the case. Baffled in these efforts, I instituted a series of experimental observations to ascer- tain the causes of these erratic movements of the viscus, with the following results. When placed in complete re- troversion it would remain in that malposition, but when anteverted it invariably either glided into the right oblique position previously described or changed into a retrover- sion. These demonstrations brought me to the conclu- sion that several influences were concerned in the causa- tion of these changing relations,—to wit, rectal distention, vesical repletion and collapse, tension of the lower portion of the left broad ligament, the increased length of the organ, elongation and induration of the infra-vaginal cervix, and probable structural changes which added density, hard- ness, and rigidity to the body and fundus, as was manifestly the case with the infra-vaginal portion. This hyperplastic condition, together with the additional length, rendered ef- fective the resistance of the contiguous structures to the normal backward and forward motions, thus causing devia- tion of the longitudinal axis in the direction of least resist- SAMUEL C. BUSEY. 7 ance. The right oblique position was favored by the con- joint agency of a distended rectum and the abnormal trac- tion occasioned by the increased tension and diminished mobility of the lower border of the left lateral attachments, probably cooperating also with the action of a distended bladder, which would elevate the organ and press back- wards the cervix. If then the uterus, thus altered in structure, was lifted up and deviated obliquely through its longitudinal axis from right to left, by the conjoint opera- tion of these several forces, it can be easily understood why the body and fundus should follow the collapse of the bladder and finally rest against the right ramus of the pubes, and also why the organ was constantly dislodged from the Thomas pessary. For inasmuch as the region of the internal os anteriorly is the most firmly fixed portion of the uterus, because of its attachment to the posterior wall of the bladder, the fundus would necessarily follow the changing conditions of that viscus. So that when the organ was lifted up and away from the instrument, with backward and left lateral displacement of the cervix, it would maintain this oblique direction of its long axis in descent following vesical depletion, consequently escaping the excavation of the pessary and resuming the position of right antero-lateral version. So far the discussion refers to the causation of the ob- lique malposition, but the case presented other peculiar- ities which demanded investigation, to which attention is now invited. When the uterus was placed in complete retroversion it remained so, with its longitudinal axis apparently occupy- ing a median antero-posterior direction, but when restored to the normal position and left without support it might revert to the posterior malposition or assume the position of right antero-lateral version. If left in the latter devia- tion it would sooner or later return to the condition of re- troversion, and if supported in front by the Thomas pessary it would either resume the right antero-lateral or posterior displacement. Various agencies were combined in the 8 ALTERNATING VERSION OF THE UTERUS. production of these erratic movements, of which the essen- tial factor was the elongated and indurated cervix. Vesi- cal elevation, rectal distention, position of the body, the influence of the changing relations of the pressure of the superincumbent viscera to the longitudinal axis of the womb, and defecation under certain circumstances, were accessory, though subordinate elements. In examining the modus operandi of the lengthened neck in effecting these alternating dislocations, it must not be forgotten that in the reduction of the retroversion the os impinged against the posterior vaginal wall and was im- bedded in its surface. The vagina is a “ musculo-mem- branous tube, remarkable for its dilatability.” Its posterior surface is irregular, unstable, and crossed by numerous “ transverso-curvilinear ridges.” At varying parts and under constantly changing conditions it would offer greater or less obstruction to an os sweeping and indenting its sur- face in its antero-posterior movements, and, accordingly, the neck would deviate backwards or forwards in the direc- tion of lesser resistance. Especially might this occur should any accessory force be simultaneously operative in the opposite direction upon the body or fundus. The influence of these inconstant relations of the vulvo- uterine canal in determining the direction of the longi- tudinal axis of the uterus, when increased in length, is not always a passive agency, favoring or facilitating an ante- rior or posterior displacement, but may become an active force directing the course of the cervical deviation. In the case under review, the womb when left in position would rotate either backwards or forwards, but when supported by a closed lever pessary, the agencies engaged in causing these malpositions were ineffective except in producing version forward. That they were inconstant is shown by the fact that not unfrequently the organ would rest against the instrument behind for several days before the direc- tion of its long axis would be reversed. The dorsal decubi- tus promotes retroversion. Sitting erect or standing may favor, under varying circumstances, either retroversion or SAMUEL C. BUSEY. 9 anteversion, the resulting malposition being determined probably by some auxiliary force. How far posture was instrumental in promoting these alternating versions can- not be determined or even conjectured, but it is not im- probable that it was a subsidiary agency secondary only to the elongated cervix.1 I cannot assert the fact, but the conformation of her figure suggested acquired aggravation of the dorso-lumbar spinal curve, a compensating excessive pelvic obliquity, or vice versa, which would favor, in erect positions of the trunk, forward inclination of the fundus. In this connection it is also worthy of note that the liabil- ity to a change of the direction of the version, increased as the longitudinal axis approximated the axis of the superior pelvic strait, owing either to the more direct action of the posterior vaginal wall on the indurated cervix, or to the more effective influence of the accessory forces upon the body and fundus. The history of the patient does not determine the exist- ence of any developmental defect of formation of the uterus, neither does it exclude the probability of such a condition. The only abnormal symptom attending men- struation previous to her first pregnancy was an excessive duration of the periods. Neither the regularity of the periods, nor their freedom from pain preclude the presence of flexure of the cervix, for Emmet 2 has fixed the propor- tion of such cases as were regular from the first at 75.36 per cent., and of such as were free from pain at 74.87 per cent. These percentages are increased when the estimate is restricted to those who were fruitful. The same dis- tinguished gynecologist fixes the proportion of those in whom menstruation “remained unchanged in every respect from the condition at the beginning,” at 47.37 per cent, of “ all the cases with flexures of the cervix,” and estimates the average duration of the “ cases where the flow was always normal as to quantity ” to be 5.04 days. In the cases where the flow was too free, but the time remained 1 See paper by the author, Am. J. Obst., iv., 585. 2 Tr. Am. Gynec. Soc., i., 56, 57. 10 ALTERNATING VERSION OF TIIE UTERUS. unchanged, the duration was 6.41 days. These data estab- lish the probability that flexure of the cervix did exist prior to the first pregnancy. It is also inferred from the statis- tics collected by the same writer that lengthened duration, and increase of the quantity, of the flow in after-life, belong to the natural history of such cases, but this circumstance alone would be insufficient to account for the extraordinary prolongation of the periods in the present case. From his study of the “ development and subsequent changes in the different forms of flexures,” Dr. Emmet concludes that — “ Flexures of the cervix have their origin at about the age of puberty by the balance being lost between the rela- tive growth of the body and cervix. From the earliest development of the uterus until pregnancy some degree of anteversion exists as a rule. With the uterus in this posi- tion the neck cannot be developed to an undue length with- out forcing the cervix forward in the axis of the vagina where the least resistance is offered. As the body lies forward, the cervix must become bent upon itself at, or near, the vaginal junction, and thus the flexure is formed. This condition must exist or the uterus will become retro- verted, the result being determined by the fullness or ab- sence of the posterior cul-de-sac of the vagina. If the cervix is small enough in diameter to be readily bent upon itself, the flexure takes place; but if the contrary be the case and the cul-de-sac be small, retroversion of the organ will occur. As the growth is not always completed at the time of the first menstrual period, a female may begin with flexure of the cervix and afterward from retroversion have retroflexion. With flexure of the cervix, the neck always becomes longer in after life than it was at puberty, from being crowded forward in the vagina, which condition will frequently produce retroversion.” The foregoing considerations brought me to the conclu- sion that the elongated and cartilaginous cervix was the pre- dominant, if not the essential factor in causing the alternate anterior and posterior versions. Holding this opinion, three methods of treatment sug- gested themselves. 1. Amputation of the cervix. 2. Organic fixation of the cervix. 3. Mechanical fixation of the cervix. To the first, as the primary procedure, there were many objections. The patient had reached the age of average maximum fertility,1 and pregnancy held out a hope of per- manent cure. With an elongated and hyperplastic cervix and probable involvement of the supra-vaginal portion of the organ in the same structural change, pregnancy was not very probable, but the probability would be greatly dimin- ished by amputation of the cervix. Again, it could not be determined, in advance, how necessary the infra-vaginal portion might be to maintain the body and fundus in the healthy position. For, if my theory that the condition of the cervix was the essential instrumentality in producing the alternating versions was incorrect, its amputation might have proven even worse than nugatory. Partial ablation might have obviated these objections, but it was deemed best to hold these procedures in reserve for subsequent de- velopments. The second method, which proposed to effect attachment of the lateral walls of the vagina to the sides of the cervix, was deemed impracticable for reasons which will appear manifest to the Fellows. The third and last method remained. This I attempted to carry out with variously devised pessaries. Hoffman’s, which had offered comparative comfort, was objectionable because of the material of which it was made, which ab- sorbed the secretions ; from the difficulty of adjustment ; and from its immobility and lateral dilatation of the vagina when in position. I finally succeeded with one of Fowler’s instruments, such as is shown in the cut (P'ig. 1.). This the patient soon learned to remove and readjust, at pleasure, with remarkable facility. It was removed on retiring and SAMUEL C. BUSEY. 11 1 Duncan, Fecundity, Fertility, and Sterility, 2d ed., Edinburgh, 1871, pp. 5, 6. 12 ALTERNA TING VERSION OF THE UTERUS. replaced before rising in the morning. Its greatest meas- urement corresponded with the axis of the vagina, and un- like Hoffman’s, which retained the uterus always in the same position, it admit- ted, within a limited arc, the antero-posterior oscil- lations of the organ and lessened the traction up- on the left lateral attach- ments. Thenceforward my patient improved very rapidly, gaining strength, vigor, and flesh. Her second menstruation began on June ist, ceased on the fifth day, and was free from any of the usual accompany- ing disturbances, without the aid of remedies. The third period commenced on July ist and lasted five and a half days. During the periods she was kept at rest in the re- cumbent posture. Fowler’s instrument was removed and Hodge’s pessary substituted, to prevent posterior descent. The hot water vaginal injections were assiduously employed during the inter-menstrual intervals. Time and space preclude the recital of the various adju- vants, both therapeutic and dietary, which were employed to rebuild her wasted physique. Suffice it to say they were adapted to the making of “ blood and fat,” relieving the con- stipation, and restoring vigor and strength to her constitu- tion. She was anxious and quite willing to return to her home, and on July 9, several days after the cessation of her third menstruation, departed for her home. Later ad- vices report continued improvement. I apprehend, and so informed her, that the case was not completed. Amputation of the cervix, either partial or complete, may yet have to be performed, or flexure of the body may occur and add its distressing disturbances to her protracted sufferings. Fig. i. NOW READY: Gynecological Transactions. VOLUME III. Being the Transactions of the American Gynecological " Society for the Year l8j8. CONTENTS. I. Annual Address on the Relation of Neurasthenia to Diseases of the Womb. By the first Vice-President, Dr. William Goodell. II. A Case of Rupture of the Perineum without Implication of the Vulva. By Dr- J. C. Reeve. III. On the Surgical Treatment of Stenosis of the Cervix Uteri. By Dr. J. Marion Sims. IV. A Case of Extra-uterine Pregnancy, with Discharge of the Fetal Bones through the Bladder. By Dr. J. P. White. V. A Case of Foot and Head Presentation; Fracture of the Spine in Utero. By Dr. J. T. Johnson. VI. The Necessity of Early Delivery, as demonstrated by the Analysis of One Hun- dred and Sixty-one Cases of Vesico-vaginal Fistula. By Dr. T. A. Emmet. VII. The Hand as a Curette in Post Partum Hemorrhage. By Dr. H. P. C. Wilson. VIII. The Treatment of Post Partum Hemorrhage. By Dr. R. A. F. Penrose. IX. Dermoid Tumors of the Ovary. By Dr. W. H. Byford. X. A Contribution to the Study of the Treatment of the Acute Parenchymatous Ne- phritis of Pregnancy. By Dr. W. L. Richardson. XI. Alternating Anterior and Posterior Version of the Uterus. By Dr. S. C. Busey. XII. Remarks on Gastro-elytrotomy. By Dr. H. J. Garrigues. XIII. The Pendulum Leverage of the Obstetric Forceps. By Dr. A. H. Smith. XIV. Rectal Alimentation in the Nausea and Inanition of Pregnancy; Intestinal Inhaustion, an Important Factor and the True Solution of its Efficiency. By Dr. H. F. Campbell. XV. Three Cases of Rupture of the Uterus. By Dr. T. Parvin. XVI. On the Early Delivery of the Placenta when Previa; with the Relation of a Case of Spontaneous Detachment of the Placenta without hemorrhage. By Dr. I. E. Taylor. XVII. Unexpected Narcotism induced suddenly on the Third Day of the Adminis- tration of Three-grain Suppositories of Opium. By Dr. J. P. White. XVIII. Treatment of Pelvic Indurations and Adhesions. By Dr. E. Van de Warker. XIX. On some Points in Connection with the Treatment of Sterility. By Dr. A. Reeves Jackson. XX. A Case of Extreme Anteversion and Anteflection of the Uterus at the Full Term of Pregnancy. By Dr. I. E. Taylor, of New York. XXI. Memoir of Edmund Randolph Peaslee, M. D., LL. D. By Dr. Fordyce Bar- ker. XXII. In Memoriam: Washington Lemuel Atlee. By Dr. T. M. Drysdale. XXIII. The Mechanism of Retroversion and Prolapsus of the Uterus considered in Relation to the Simple Lacerations of the Cervix Uteri and their Treatment by Bloody Operations. By Dr. Nathan Bozeman. Index of Obstetric and Gynecological Literature of all Countries for the Year 1877. Price of Vol. III., $5.00; Vols. I. and II., contents of which will be found on the following pages, will be sent to one address by mail or ex- press, prepaid, on receipt of $10.00 by the publishers. The three volumes supplied for $15 00. Address HOUGHTON, OSGOOD AND COMPANY, WINTHROP SQUARE, BOSTON. TRANSACTIONS OK The American Gynecological Society. VOL I., FOR THE YEAR 1876. 400 pages. Many illustrations. The Annual Address by the President, Dr. Fordyce Barker, of New York, and the following papers : — I. Etiology of Uterine Flexures, with the proper mode of treatment indicated. By Thomas Addis Emmet, New York. II. Cicatrices of the Cervix Uteri and Vagina. By Alexander J. C. Skene, M. D., New York. III. Extirpation of the Functionally Active Ovaries for the Remedy of otherwise Incur- able Diseases. By Robert Battey, Rome, Ga. IV. On Central Rupture of the Perineum. By J. Matthews Duncan, M. D., Edinburgh, Scotland. V. Viburnum Prunifolium (Black Haw); its Uses in the Treatment of the Diseases of Women. By Edward W. Jenks, M. D., Detroit, Mich. VI. An Illustration of Xenomenia. By Theophilus Parvin, M. D., Indianapolis, In- diana. VII. Relations of Pregnancy to General Pathology. By Robert Barnes, M. D., Lon- don, Eng. VIII. The Spontaneous and Artificial Destruction and Expulsion of Fibrous Tumors of the Uterus. By W. H. Byford, Chicago, 111. IX. Case of Abdominal Pregnancy, treated by Laparotomy. By T. Gaillard Thomas, M. D., New York. X. Pneumatic Self-Replacement in Dislocations of the Gravid and Non-gravid Uterus. By Henry F. Campbell, M. D., Augusta, Ga. XI. Hydrate of Chloral in Obstetrical Practice. By W. L. Richardson, M. D., Boston, Mass. XII. Labor Complicated with Uterine Fibroids and Placenta Previa. By James R. Chadwick, M. D., Boston, Mass. XIII. Latent Gonorrhea, with Regard to its Influence on Fertility in Women. By Emil Noeggerath, M. D., New York. XIV. Death from Urinemia in Certain Cases of Malignant Diseases of the Uterus. By Alfred Wiltshire, M. D., London, England. XV. Clinical Memoir on some of the Genital Lesions of Childbirth. By William Good- ell, M. D., Philadelphia, Pa. XVI. Hermaphroditism. By Lawson Tait, F. R. C. S., Birmingham, England. XVII. Cases of Cystic Tumors of the Abdomen and Pelvis. By George H. Bixby, M. D., Boston, Mass. XVIII. Case of Solid Uterus Bipartitus; both ovaries removed for the relief of epileptic seizures ascribed to ovarian irritation. By E. Randolph Peaslee, M. D., New York. XIX. The Origin and History of Calculi found in the Bladder after the Cure of Vesico- Vaginal Fistula by Operation. By Henry F. Campbell, Augusta, Ga. XX. Rare Forms of Umbilical Hernia in the Fetus. By James R Chadwick, M. D , Boston, Mass. XXL In Memoriam Gustav Simon By Paul F. Mund<5, M. D., New York Price of Volume I., $5.00. As contributions to advanced gynecology they exceed in value anything which we have ever before seen collected in any one volume. — N. Y. Aledical Record. This volume of Transactions is certainly superior to any book of the kind that has been issued by the American Press.— St. Louis Clinical Record. Now we have the first of, we hope, a long row of volumes which will bear comparison with the Transactions of European Societies. Indeed, these must look to their laurels in this noble emulation. — Edinburg Medical Journal. This volume is one of the best collections of gynecological papers that has been published this year. — A tinates de Gynicologie. VOLUME II., FOR 1877. 650 pages, 12 chromo-lithographs and many other illustrations. Contains the following papers, with the discussions to which they gave rise : — I. Annual Address, on Medical Gynecology. By the President, Dr. Fordyce Barker, of New York. II. The Functions of the Anal Sphincters, so called. With two wood-cuts. By Dr James R. Chadwick, of Boston, Mass. III. Excision of the Cervix Uteri; its Indications and Methods. With one wood-cut. By Dr. John Byrne, of Brooklyn, N. Y. IV. Report on the Corpus Luteum. With twelve chromo-lithographic plates. By Dr. John C. Dalton, of New York. V. The Pathology and Treatment of Puerperal Eclampsia. By Professor Otto Spiegel- berg, of Breslau, Prussia. VI. Dilatation of the Cervix Uteri for the Arrest of Uterine Hemorrhage. By Dr. George H. Lyman, of Boston. VII. The Principles of Gynecological Surgery applied to Obstetric Operations. By Dr. A. J. C. Skene, of Brooklyn, N. Y. VIII. On the Necessity of Caution in the Employment of Chloroform during Labor. By Dr. William T. Lusk, of New York. IX. The Present Status of the Intra-Uterine Stem in the Treatment of Flexions of the Uterus. By Dr. Ely Van de Warker, of Syracuse, N. Y. X. Supplement to the report of a case of Xenomenia made at the first Annual Meeting in 1876. By Dr. Theophilus Parvin, Indianapolis, Ind. XI. A Case of Vaginal Ovariotomy. By Dr. William Goodell, of Philadelphia, Penn. XII. Is there a Proper Field for Battey’s Operation? By Dr. Robert Battey, of Rome, Ga. XIII. Subsulphate of Iron as an Antiseptic in the Surgery of the Pelvis. By Dr. H P. C. Wilson, of Baltimore, Md. XIV. Tetanus after Ovariotomy. By Dr. Theophilus Parvin, of Indianapolis, Ind. XV. Sarcoma of the Ovaries. By Dr. Washington L. Atlee, of Philadelphia, Penn. XVI. The Value of Electrolysis in the Treatment of Ovarian Tumors, as seen in the Light of Recent Experience. By Dr. Paul F. of New York. XVII. Congenital Absence and Accidental Atresia of the Vagina; Mode of Operation to Establish the Canal, and to Evacuate retained Menstrual Blood. With three wood- cuts. By Dr. Thomas Addis Emmet, of New York. XVIII. Case of Sarcoma of the Kidney in a negro child. With Heliotype. By Dr. W. H. Geddings, Aiken, S. C. XIX. The Hystero-Neuroses. By Dr. George J. Engelmann, of St. Louis, Mo. XX. Cases illustrating Important Points connected with Ovariotomy. By Dr. Gilman Kimball, of Lowell, Mass. XXI. The Radical Treatment of Dysmenorrhea and Sterility by Rapid Dilatation of the Canal of the Neck of the Uterus With one wood-cut. By Dr. Ellwood Wilson, of Phil- adelphia, Penn. XXII. Dr. Uvedale West’s Views of Rotation, as illustrated by the Contrast between the Mechanism of Simple Occipito-Posterior Positions and those of the Bregmato-Coty- loid Variety. By Dr. John P. Reynolds, of Boston, Mass. XXIII. Vascular Tumors of the Female Urethra; wiih the Description of an Instru- ment devised to Facilitate their Removal. By Dr. A. Reeves Jackson, of Chicago, 111. XXIV. Lying-in Hospitals; especially those in New York. By Dr Henry J. Gar- rigues, of Brooklyn, N. Y XXV. The Simpler Varieties of Perineal Laceration; their Consequences and Treat- ment. By Dr. Thaddeus A. Reamy, of Cincinnati, Ohio. XXVI. The Cyclical Theory of Menstruation By Dr. John Goodman, of Louisville, Ky. XXVII. In Memoriam Charles E. Buckingham With a Heliotype Portrait By Dr. George H. Lyman, of Boston, Mass. Index of Obstetric and Gynecological Literature of all Countries, from July i, 1876, to January 1, 1877. The price of Volume II. is $6.50. Vols. I. and II. will be sent by mail or express, post-paid, for $10.00. Address, HOUGHTON, OSGOOD & CO., Boston. Opinions of the press. As contributions to advanced gynecology they exceed in value any- thing which we have ever before seen collected in any one volume. With- out exception, every paper has an interest and value attached to it which is intrinsic, and which reflects the best efforts of the respective authors. .... The work is elegantly printed, neatly and tastefully bound. — N. Y. Medical Record. This volume of Transactions is certainly superior to any book of the kind that has been issued by the American press. The papers read and here presented are well written and well digested ; and the discussions re- ported have almost as much value as the papers themselves. — St. Louis Clinical Record. We think that never before was such a number of excellent monographs collected together in one volume of Transactions. It is a model in every respect. It is a volume that should be in the hands of every general prac- titioner as well as specialist, as in it may be found most useful suggestions for every day practice. We cannot commend the work too highly, and it is our earnest hope that future meetings of the society will give origin to volumes of Transactions equal to the one before us. — The Hospital Ga- zette. In conclusion, we cannot but regard this volume as a fitting monument of the progress of this most progressive department of medicine. The discussions are rich, and are full of such epitomized good sense well ex- pressed, as is rarely found in any volume of Transactions, while the whole contents exhibit the most careful supervision of the editor. — Toledo Medi- cal and Surgical Journal. Organized amid the whirl and bustle of last summer, the American Gynecological Society bids fair to realize the brightest hopes of its found- ers. Its first volume of Transactions, now before us, will bear the closest scrutiny, and safely challenge the severest criticisms, so superior is it in its breadth of thought and observation, scientific worth, and literary excel- lence ; the writers of the papers in these Transactions being no mere novices, but men skilled in the profession they represent, and experts in the branch of study and practice which they especially call their own. — Philadelphia Medical Times. It is not a trifling matter to be able to say of this volume that it is the handsomest of the kind anywhere produced But this is not only an elegant volume, it is a good one ; creditable to the authors, creditable to the great republic Now we have the first of, we hope, a long row of volumes which will bear comparison with the Transactions of European Societies. Indeed, these must look to their laurels in this noble emula- tion. — Edinburgh Medical Journal. This book of nearly 400 pages contains a series of excellent articles upon gynecological topics, written by the most prominent gynecologists of America and England. — Allg. Wiener Med. Zeitung. This volume is one of the best collections of gynecological papers that has been published this year We do not doubt that it will confer the greatest honor upon the medical literature of America. — Annales de Gynlcologie. Few volumes that have recently come under our notice have been so ex- tremely interesting and instructive. The papers reach a very high order of excellence, and some indeed are superlatively good. — American Jour- nal of Obstetrics.