traction. I am inclined to think that both are the result of pelvic inflammation which results in relaxation of the superior ligaments, and from its proneness to attack the post-uterine cellular tissue, in contraction of the utero-sacral ligaments. Be that as it may, we have to encounter in any case of displacement of the uterus that is a fit one for an operation, these dual pathological states: contraction and relaxation, and both must enter in our plan for operating, or success will be most uncertain.

Relaxation is above, contraction is below, we will, therefore, in the majority of instances, find it more convenient to attack the former through the abdomen, and the latter through the vagina.

If the utero-sacral ligaments are not infiltrated and contracted to a high degree, they may be broken up through the supra-pubic opening, but usually I prefer to liberate them through the vagina, making this the first step in the operative technique.

The utero-sacral ligaments are discovered without difficulty as two bands passing from the cervix to the sacrum, and can frequently be sufficiently liberated by clipping with blunt scissors, without opening the peritoneal cavity. If, however, the peritoneum must be incised to complete this part of the operation, but slight additional risk is thereby run.

In suspending the fundus uteri from the anterior abdominal wall, I observe three principal points, which, I think, in no slight degree contribute to the success of the operation. First, I make an incision in the lower third of the space between the umbilicus and the pubes. Second, I am particular that like tissues shall be brought in contact for adhesion, that is, that the visceral peritoneum shall be fastened to the parietal peritoneum; and Third, I so place my sutures that the subsequent suspending band covers a considerable space in the direction of the long axis of the uterus.

The first point needs no further mention here, the method of closing the incision will be described later.

The second point I consider the most important in the technique of ventro-suspension. One of the primary principles in plastic surgery is, when adhesions are desired, to bring like tissues together, muscle with muscle, tendon with tendon, bone with bone, why not, therefore, peritoneum with peritoneum ?

I have recently seen a method advocated in which the fundus is held in contact with the rectus muscle, and the peritoneum sewed about this area of adhesion. Such a method can lay claim to no scientific accuracy, nor can I understand how permanently good results will follow its adoption. As a matter of fact, the peritoneum

will not establish enduring relations to the muscular fibres of the rectus, and whatever permanent band is formed must be wholly made up of the slender ring of parietal peritoneum stitched around this spot.

Considering the changes in the uterus attendant upon gestation, we have more to accomplish than to hold the fundus in contact with the abdominal wall; we must provide such a suspension as will permit of the degree of elasticity that the rising uterus requires. In other words, we must manufacture an abdomino-uterine ligament that will hold the uterus up, taking the place of the natural suspensory ligaments, and yielding, will accommodate itself to the ascending uterus of pregnancy.

We, of course, cannot make a ligament in the true sense of the word, but we can construct a band of peritoneum which will answer the purpose very well. A band possessing sufficient relaxation to meet the demands of pregnancy and still sufficiently firm to hold the unimpregnated uterus in position.

My method of making this ligament is the following: A male urethral sound introduced into the uterus in the hands of an assistant, holds the fundus against the lower angle of the abdominal wound. I prefer this means of raising the uterus to that with a volsulum, which wounds the peritoneum and sometimes the uterus at points not easily covered by the area of intended adhesion. The uterus being held firmly in the position it is desired to make permanent, the peritoneum covering its anterior surface for a space one inch long and half an inch wide, the upper end of which encroaches upon the fundus, is scraped with a scalpel.

The exact position of this denuded spot is important, for it must be remembered that we do not seek to establish a union between the fundus of the uterus and the abdominal wall, such would cause the uterus to deviate far from its natural axis; what we desire to do is to suspend the anterior surface of the upper segment of the uterus from the posterior aspect of the anterior abdominal wall. Our denudation, therefore, of the uterus will correspond to this area of suspension. If in making the abdominal opening the lower angle of the muscular incision extends beyond the opening into the peritoneum, it will not be necessary to draw this membrane up to cover the denuded uterus, otherwise this is accomplished with a pair of catch forceps.

Our area of parietal peritoneum is then denuded corresponding to the space on the uterus. The two surfaces are laid together and secured by means of from three to six buried silk sutures, taking care

that the sutures shall include the muscular wali of the uterus. If there is a high degree of tension of the uterus, which promises to tear out the sutures, it may be necessary to pass one or two silk-worm gut suspension sutures through the whole thickness of the abdominal wall into the fundus and out again on the opposite side of the incision, these to be removed in from two to four weeks, but I have rarely found this assistance called for.

If the utero-sacral ligaments have been operated on through the vagina the uterus will be supported by the then necessary vaginal packing, but if this has not formed a part of the procedure before closing the abdominal wound, I apply a well-adjusted pessary which removes all tension from the uterine sutures. The time for removing this support will depend upon the subjective sensation of dragging felt when it is taken away. The continuance of that sensation is an indication for the retention of the pessary.

The method of closing the abdominal wound after a cœliotomy has given rise to much discussion, unnecessary discussion it seems to me. The object is, as in other wounds, to obtain firm union and reduce to a minimum the risk of rupture. Why not apply the same rules here that we apply elsewhere? I must confess that the subject has never given me any great concern, and as far as I know, I have been quite as successful in obtaining firm permanent union as other surgeons. I have not found it necessary to resort to the unsurgical folly of using buried silver wire sutures, believing that properly prepaired silk will resist any degree of tension that may be put upon it. Nor have I found it necessary, save in cases of very thick abdominal walls, to introduce successive layers of sutures. In the majority of instances, two layers will suffice. One of cat-gut-continuous-for the peritoneum, the other of silk-worm gut, including integument and muscle.

In laying the sutures, the principal points for consideration are, not to bring the peritoneum up between the incised muscles, hence the separate layer of absorbable sutures; and to hold the surfaces of the wound everywhere in absolute contact. Therefore, the silk-worm gut sutures should be introduced with the greatest care. The point of emergence must correspond accurately with the point of entrance, and a sufficient number must be introduced to avoid pockets or even relaxed spaces in the course of the wound. General operative skill will determine these points and also the degree of tension put upon the sutures.

ess.

The final dressing of the wound is, with me, a very simple procI formerly used a moist bichloride dressing and with it cer

tainly obtained very satisfactory results. But a key-note of my operative surgery is discontent; however good the results may be, I constantly wish for better and therefore I frequently change my methods. My work of to-day resembling my work of yesterday only in so far as both are based upon the general principles of operative surgery.

Last winter I began using Formaline gelatine Glytol to dress. all wounds, granulating and closed, and the results were quite remarkable. In not a single case was there a drop of pus, the open wounds granulated under a scab formed of the Glytol, and the closed wounds healed, without an exception, by first intention. Usually it is not necessary to disturb the primary dressing for seven or eight days, or even longer, then it may be renewed and left on until the sutures are taken out.

I am in no haste to remove the sutures from any abdominal wound, generally deferring this step if there is no stitch irritation, for three or even four weeks. Thus, I believe, I eliminate one of the factors in causing hernia.

As to results. Since performing the operation for ventro-suspension of the uterus which I have described, I have not failed to obtain a firm, permanent "utero-abdominal ligament." Two of the patients subsequently passed through gestation uneventfully, the new anatomical structure serving the double purpose of holding the uterus in suspension, and following it as it ascended with the growing fetus.

The operation itself has, thus far in my hands, been devoid of mortality, and convalescence has been unattended with the slightest anxiety on my part.

INTRA-UTERINE TRANSMISSION OF VACCINAL IMMUNITY.-At a recent meeting of the Acadèmie de Médicine Ausset (Bull de l'Acad. de Med., 1896, No. 3, p.51) communicated a report of the case of a man, 27 years old, who had been vaccinated several times without success-once during infancy and twice at the age of 20 years. The fourth attempt, at the age of 27, was followed by the development of characteristic lesions. It appeared upon inquiry that the individual's mother had suffered from an attack of variola during the pregnancy, (the exact period could not be ascertained) but the patient presented no lesion of the disease. It seemed, therefore, probable that his resistance to vaccination was due to the protective influence of substances that passed from the mother to the fetus through the placenta.

EDITORIAL DEPARTMENT.

EUGENE H. PORTER, A. M., M.D.

GEORGE W. ROBERTS, H. B., M.D.

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THE IMPERILED DIGNITY OF MEDICINE.

F WE consider the value of expert testimony in matters of medical jurisprudence it must be confessed that the system prevailing here has not tended to increase the value of such testimony. The newspapers, the common people, the profession of medicine, the bar, and even the bench itself have each in turn given expression to a notable lack of confidence in experts and their evidence. Judge Davis, of the Supreme Court of Maine, in Neil's case (Wharton & Stille, Volume 1, Section 294), said: "If there is any kind of testimony that is not only of no value, but even worse than that, it is in my judgment that of medical experts. They may be able to state the diagnosis of a case more learnedly, but upon the question whether it had at a given time reached a stage that the subject of it was incapable of making a contract or irresponsible for his acts, the opinions of his neighbors, of men of good common sense, would be worth more than that of all the experts in the country." And Lord Campbell, in the case of the Tracy Peerage, said that "skilled witnesses come with such a bias in their minds to support the cause upon which they are embarked that hardly any weight should be given to their evidence." These quotations serve to show how some judges regard expert testimony and the criticisms of other observers have been, if possible, even more severe. There is no doubt, however, that such criticism is unduly severe. Mr. W. B. Hornblower gives as his opinion that the function of expert witnesses is a most valuable one, and is in fact indispensable to the