end was too small to admit a perforation for the end of a sound, and for this purpose I used a No. unannealed iron wire. The most important modification consisted in substituting for the enormous vaginal collar described by the author, a small adjustable vaginal flange of the least possible dimensions capable of answering its purpose. Theoretically, it should be of just sufficient size to afford grasp to the vagina to retain both stem and flange in position, and yet accommodate the changing positions of the womb. I found that the flange could be made five-eighth to threefourths of an inch in diameter, and when of this size, could be worn and perfectly retained for months. That I had, in a measure, answered the theoretical requirements, was shown by the fact that its presence afforded exemption from pain, and, of itself never

became a source of irritation. Its mode of operation it simple. The stem a. fig. 1, upon the end of the wire b, being in position, the flange, a, fig. 2, by means of its central perforation c, is placed upon the wire. Two slots e, upon opposite sides of the flange receive the wire, so that on being pushed up, it presents itself at the ostium vaginæ by its edge, entering the

parts without difficulty, and is gently pushed upon the stem until it meets the collar f.

Desiring to do any with the vaginal portion of the instrument,

I devised a more simple mechanism, consisting of a stem a, fig. 3, with a cross piece b, of rubber tubing, which expanding in the cavity of the womb, acted as a means of self retention. As this has been fully described, and is here figured,* I shall give no space to its description.

Dr. Thomas Savage, of Birmingham, who fully endorses the treatment of uterine flexions by intra-uterine support, says that any form of stem has an unaccountable tendency to slip out of the uterine cavity. I have also noticed this tendency, even after a stem had been worn- -in one instance nine weeks-it was suddenly found free in the vagina. This will happen with the best of instruments. I have in a measure corrected this tendency in the self-retaining stem by carefully observing each case and placing the cross section of tubing at different points on the shaft of the stem as the case demanded, so that the rubber would expand just after clearing the internal stricture of the neck. This careful study of each case and modifying the instrument to suit it, is the surest way of preventing the expulsion of the stem. Nothing can replace this mechanical adaptation of means to ends. The self-retaining, or any other form of stem, must therefore be made to meet the special indications in each case. If this is overlooked annoyance and failure will beset the physicians, no matter what instrument he uses.

I shall illustrate the results of the treatment of uterine flexions by the intra-uterine stem, with the manner of meeting some of the difficulties which obtrude themselves, by a few clinical details.

CASE I.—Mrs. L., aet. 28, native of England; occupation housekeeping. Eight years married. Mother of two children, the youngest two years old. No history of miscarriages. Was formerly a visitor to the Syracuse Free Dispensary, and was there treated for endometritis. It was also noticed that a sound passed with its curve backwards. The fundus could be felt in the retro

vaginal cul de sac, but well up and but slightly tender. At that time this partial flexions was not treated. Four months after she presented herself again and a most marked state of posterior flexion was found. The fundus was very sensitive to the touch, and *New York Med. Jour. Oct, 1873; and New York Med. Rec., Dec. 15th, 1873.

+ Obstet. Jour. Gr. Brit aud ire., Nov. 1873, p. 505.

the passage of the sound gave great pain. An attempt was made to pass the stem with the vaginal flange attachment, but it was found that the womb so quickly returned to its dislocated condition that it could not at that time be introduced. The womb was thrown into position by the sound, a small weight attached to the handle of the instrument so that it would not turn and was then dropped between the thighs. The organ was thus kept in position about fifteen minutes and she was directed to return the next day.

Jan., 15th, 16th and 17th, she was given about the same length of time upon the chair. At the last date it was found that several minutes passed before the womb was completely flexed. Coughing or any movement of the body on the chair, hastened the returning dislocation. The sensibility of the cavity of the organ to the sound was also much less. The stem now passed with ease. The presence of the stem made the woman very comfortable.

Jan., 30th.-Mrs. L. returned, the stem having suddenly slipped out. Replaced the stem. Was worn almost constantly until March 7th, when the self-retaining stem was introduced. Menstruation during the wearing of the stem so far was much less in quantity, and attended with less pain.

April 5th.-Self-retaining stem worn since last date, and found well in position. The instrument removed and the patient sent home without it, in order to test the results of the treatment.

April 8th.-An examination revealed the unpleasant fact that the flexion was yet uncured. Stem again introduced.

May 20th.-Stem has been worn continuously since the 8th ult. The instrument was again removed and the patient sent home. May 30th.-Patient presented herself for final examination. The parts were in the normal position. Discharge cured.

Nov. 15th.-Mrs. L. again presented herself with the return of all her former painful symptoms. An examination showed that the retro-flexion had returned in as marked form as before. She stated that these symptoms had been coming on for about a month. That from May 30th, until then, she had never felt better in her life. She could give no reason from exposure or over-work for the return. The self-retaining stem was introduced, since which time I have not heard from my patient.

There are two points in.this case, to which I shall direct attention. The first is the preliminary restoration of the organ. By this means the stem was introduced as quickly and with as little pain as a sound would be. Without keeping the bent organ straight while the stem is being passed into its cavity, it would be a matter difficult, as well as painful to introduce the instrument. Dr. Thomas Chambers in his clinical details of many cases of uterine flexions continually refers to the difficulty of introducing the stem.* This difficulty may, in many cases, be avoided by the manipulation I have described in this case. Endometritis is usually present in cases of flexion of long standing. The stem should pass without using any force, if not great pain and considerable flowing will be the result of prolonged endeavors. If it is found that the stem does not easily pass, the organ ought to be again straightened, and possibly again, and again, until the stem is readily passed. This of course implies accurate curvature and great care in the use of the sound.

The other point is that a flexion, once established, has a spontaneous tendency to recur after a more or less lengthened period of restoration to a normal position. I state this that the physician may be on his guard and not too hastily pronounce his patient cured.

CASE II.-Mrs. G., aet. 27, English, mother of eleven children, youngest three years old. Has always been a hard working woman. For a year previous to my seeing her had suffered from backache, bearing down, pain in defecation, tenderness over the hypogastrium, inability to walk. I found her in bed. The most painful feature of the case came from the marked nervous disturbance; sinkings, a feeling of impending death. Sleep difficult, appetite gone, and general health much impaired. An examination showed an acutely retro-flexed womb, os patulous with lateral rents. The sound penetrated 31 inches, and cavity of the organ was tender and disposed to bleed. The flexed organ was easily returned to its normal position but quickly recoiled to its dislocated position on the withdrawal of the sound. For several weeks the only treatment given was to the general health.

* Obstet. Journal, Gr. Brit. and Ire. Vol. 1, five Nos.

June 20th.-Introduced the flanged stem.

June 24th. The stem is well borne, the pain and hypogastric tenderness abating.

July 13th. The patient is now going about the house attending to her domestic duties. She is sleeping well, appetite good, gaining flesh and strength. The nervous attacks are less frequent and severe.

July 30th.—The patient at this visit complained of pain and difficulty in passing water; an examination found the womb strongly retro-versed, the flange pressing the neck of the bladder. The womb was put into its proper position and the posterior vaginal cul de sac tamped with carbolized cotton wool, forming a broad, soft bed for the organ to rest upon.

Nov. 10th. Since the last date the stem has twice escaped, remaining out on one occasion ten days. Without the support of the stem the uterus gradually returns to its flexed position. The general health of the patient is good, and she is leading a useful

life.

When this patient will be cured of the flexion I shall not venture to predict. All that I can claim for the treatment is, that this woman has been taken from her bed and made useful to herself and other. A positive cure after wearing the stem for six months almost continuously, seems as distant now, as when the treatment was commenced.

The correction of the retroversion in this case is a point of interest. There is, I have noticed, a tendency to retroversion after the correction of a retro-flexed uterus by means of the intrauterine stem. The flexion removed by the presence of the stem, the fundus of the organ has a disposition to at once drop backward into the Douglas space. To correct the double tendency to displacement by a vaginal appliance connected with the stem, is precluded by my theory of the intra-uterine stem. The office of the stem is to correct a flexion, and any other indication is to be met independently of the stem or its necessary attachments. The best means I have found to prevent the retroversion is--as in this case--to fill the posterior cul de sac of the vagina by a mass of cotton wool, saturated with a solution of carbolic acid in glycer