tent with giving general directions in reference to the bladder and the rectum, and recommending the observance of the horizontal posture. That on the face or side, as advised by Dr. Tyler Smith, is evidently the best. I was guided in this by remembering cases of pregnancy in which I had observed the uterus previously retroflected and low in the pelvis spontaneously ascend even within a few days, and I feared lest my interference might accelerate that which I desired to prevent. The result of my practice, however, has been unsatisfactory enough, and a difference of opinion will doubtless exist as to how far it is advisable in cases under continuous observation to aid the uterus in its efforts to ascend by air pessaries or otherwise.

There is another point of interest related to the subject of this paper, which, in conclusion, I would simply mention. I refer to the influence of retroflexion in causing imperfect deliverance in cases of abortion. My own experience has been too limited to enable me to form an opinion of its comparative frequency, and I will merely state that some of the cases which I have seen of long retention of a portion of the ovum after abortion have been cases complicated with retroflexion of the uterus.

Dr. TILT admitted that any considerable amount of uterine displacement was a cause of abortion, but he asked Dr. Phillips whether his cases were instances of uncomplicated uterine displacement. Dr. Tilt had frequently seen chronic inflammation of the womb cause successive abortions, the liability to which ceased on the uterus becoming healthy, so he thought it would have been better if the author had stated the amount of pathological complication, if any, that had been noticed in addition to the uterine displacement, for, if considerable, it should be admitted as lending its influence to the determining of abortion.

Dr. BANTOCK could not agree with Dr. Tilt, for he had always believed that inflammation of the uterus was a decided bar to the occurrence of impregnation, but he agreed entirely with the accuracy of the observations made by Dr. Phillips as to the frequent occurrence of abortion as a result of displacement of the uterus whether backwards or forwards. He took exception to the looseness with which the terms retroflexion and retroversion were

employed by the author as if synonymous. He had notes of several cases of abortion from displacement. The first occurred about six years ago, in a patient the subject of anteversion. The use of a Hodge's pessary with long anterior limbs carried the patient over the fatal period, but its removal at her request resulted shortly after in abortion. The last case was one still under observation, in a patient suffering from retroversion. This patient had passed into the fourth month, and was still wearing the instrument, and his intention was to leave it till the uterus had risen well out of the pelvis. In reply to Dr. Barnes, Dr. Bantock contended that true inflammation did very materially interfere with impregnation, that the cases of repeated abortion at short intervals were not cases of inflammation at all, and that rest alone sufficed to tide them over the fatal period. He had before his mind the case of a lady who could not bear a living child without lying up for about six months, and who, so surely as she did not take this precaution, as surely aborted. He complained of the looseness with which the term inflammation was used.

Dr. ROUTH thought the remarks made by Dr. Tilt were more in accordance with his experience that those of Dr. Bantock. The existence of sores, ulcerations, &c., during pregnancy was common, and if complicated with a diseased uterus and much congestion, perhaps subacute metritis, would alone suffice to produce abortion. He had often met with such examples, and treated them. Flexions of the uterus, whether anteflexions, or retroflexions, were, in his experience, much more frequently the causes of sterility than of abortion. He did not then recall a single case in which he knew that pure uncomplicated flexion had existed before pregnancy, and in which afterwards pregnancy occurred, where abortion followed; but he was quite aware of cases where the flexion was complicated with ulcerations and congestions in which this had occurred. It appeared to him, therefore, that the flexion was not so much the cause of the abortion as was the complication which co-existed. This co-existence was, he thought, often the essential element to abortion; because it was indubitable that many women known habitually when not pregnant to have their uteri flexed, yet when pregnant, went the full term with several children, perhaps one after another, and never once miscarrying. In like manner ulcerations of themselves could not necessarily produce abortion. Many such cases got well. Besides, one observer, he thought Dr. Henry Bennett, had called attention to the fact that in a large number of cases when menstruation existed during pregnancy this was due to abrasion or ulceration of the cervix co-existing, and yet these women had not necessarily aborted. Lastly, in the cases mentioned by Dr. Phillips of successive and repeated abortions, Dr. Phillips had not sufficiently insisted that such cases were not affected

with syphilitic taint, a common and well recognised cause of repeated miscarriages. He, Dr. Routh, invariably in such habitually miscarrying cases gave small doses of bichloride of mercury, even in those instances where he had no certainty of the existence of syphilitic disease, and with the happiest results, even in cases of marked flexions. The class of cases related by Dr. Phillips were peculiar. He spoke of out-patients in hospital practice at Guy's; now, although Dr. Routh felt bound to pay the highest tribute to Guy's Hospital, which had produced some of the cleverest physicians and surgeons in the realm, yet the locality of Whitechapel and the Borough was notorious for the extent of syphilis prevailing there, and thus many of Dr. Phillips' cases might have been tainted. It was most important, therefore, that this source of fallacy should be especially noted in the cases brought forward as instances of abortion from flexions of the uterus.

Dr. RASCH said the thanks of the Society were due to Dr. Phillips for so ably bringing forward this practical subject, but it would decrease its usefulness to the practitioner, if in its discussion other well-known causes of abortion, like syphilis, were introduced. The subject of the paper was a certain well-defined mechanical cause of abortion, which must be familiar to all engaged in obstetric practice, and Dr. Rasch could fully subscribe to the author's views. In one point the paper might have been more distinct, as it affected therapeutics. The author had made no distinction whatever between two forms of retroflexion which to Dr. Rasch seemed not without practical importance. He gave two cases as types, one of the simple traumatic or acute retroflexion of the healthy gravid womb, produced by some external violence, with sudden retention of urine, in which repeated catheterism and one reposition cured the retroflexion acquired two days previously. A pessary was not necessary in this and in similar cases, and gestation was not interrupted. Different from these simple traumatic cases were those in which the retroflexion was due to alterations in the textures of the organ. Retention of urine was here no prominent symptom, in fact, Dr. Rasch never had observed it. If the uterus were redressed it would almost invariably fall back again unless a pessary (Hodge's) was applied, which should be left up to the fifth month of pregnancy. Dr. Rasch had not the slightest doubt that a great many abortions were thus prevented, especially if the patients be enjoined to lie on their knees and elbows whenever they feel uncomfortable as to the right position of the pessary. This prone position he could not strongly enough recommend, the more so especially if air was allowed to enter the vagina in the way he had shown on another occasion. But it should be done daily for half an hour while in bed. Patients very soon found out the value and comfort of it and

practised it. Dr. Rasch's experience of retained placenta after abortion made him fully concur with the closing remarks of the author's paper, that retroflexion was a frequent cause of the retention.

Dr. WYNN WILLIAMS, whilst fully agreeing with the author of the paper to a certain extent, also agreed with those gentlemen who had already spoken. As regards the observations made by Dr. Tilt no one for a moment could deny that ulceration and inflammation of the cervix uteri were opposed to impregnation and were occasionally the source of abortion, yet how often whilst treating diseases of the cervix do we find impregnation take place and the patient go the full time. Again, retroflexion and also other displacements of the uterus will act as a bar to impregnation, and are a frequent source, should impregnation take place, which no doubt occasionally does happen, of abortion, but not invariably. As to constitutional syphilis being a cause of abortion and premature births, every one connected with a public hospital could not fail to have observed it both in the "east" and in the " west," and yet this is not always followed by abortion or we should have no congenital syphilis; in fact, no hard and fast line can be laid down. Dr. Williams could relate a series of cases of displacements of the uterus where the displacement had been the cause of the abortion, but would content himself by stating that he, like the author of the paper, had long been in the habit of treating retroflexions of the uterus during the early months of pregnancy by the introduction of a Hodge's pessary and leaving it in situ until after quickening, or, more properly speaking, until the uterus had risen above the brim of the pelvis. He would only relate one case, and that a case of retroversion-not retroflexion, and would here remark that he considered retroversion a much more likely cause of sterility than retroflexion, especially when the os gets jammed under the pelvis, as in complete retroversion. A young woman, married some time without family, was found to be suffering from complete retroversion. This was rectified and a Hodge's pessary introduced. Soon after she became pregnant, and desired the pessary might be removed; this was unwillingly done. The uterus fell back into the old position, the patient aborting. A pessary was again introduced, and again she became pregnant and went the full time, the pessary having been left in until after the fifth month of utero-gestation.

Dr. BARNES assumed that the author of the paper clearly meant retroflexion as distinguished from retroversion. His own experience entirely confirmed the author's conclusion that retroflexion was a frequent cause of abortion. It had been observed by other speakers that retroflexion was a common cause of sterility. Both propositions, although seemingly contradictory, were undoubtedly true. It was necessary to bear in mind that

there were two different forms of retroflexion. The first kind he believed to be congenital, at least it often came under observation in young women who had never borne children, and who were suffering from dysmenorrhoea. This form was very common; it was often associated with narrow os externum uteri, and dysmenorrhoea and sterility were the consequences. These consequences were generally only cured by putting the uterus into its proper place and dilating the os. The other form was also not uncommon. It might be called acquired retroflexion. It arose generally after a labour; the heavy, imperfectly contracted and involved body of the uterus falling back whilst the parts were in a state of relaxation. In this case pregnancy would often occur and end in abortion. With reference to the suggestion of Dr. Tilt that the author might have overlooked inflammation of the cervix, or some other complication which might have been the cause of the abortion, he would observe that it was hardly possible to find a pure case of retroflexion. This displacement necessarily induced morbid conditions of tissue, especially engorgement of the body of the uterus, and dilatation of its cavity. These secondary conditions might be concerned in producing the abortion, but still the retroflexion was the essential cause. Nor could he, Dr. Barnes, assent to the observation of Dr. Bantock, that inflammation or abrasion of the cervix uteri was a constant cause of sterility. It must be familiar that women frequently conceived whilst under treatment for this affection, and that, in fact, they often conceived so quickly that they had no chance of getting cured. The great remedy for retroflexion was Hodge's pessary. He always urged that it should be worn during the early months of pregnancy where there was retroflexion, in order to obviate abortion. He thought Dr. Phillips' paper would be useful in drawing attention to an important clinical fact.

The PRESIDENT had little to add to the excellent remarks which had fallen from the last speaker (Dr. Barnes) except to say that from the position of the retroflected uterus a tendency to abortion might be à priori anticipated, for not only was the organ exposed to concussion from movements of the body, coitus, &c., but, in consequence of the dependent position, there were three inches addition to the column of blood, the gravitation of which would retard the return into the veins, and thus assist in extravasation and consequent death of the ovum. And, with regard to the increased difficulty in the discharge of the dead ovum alluded to by the previous speakers, he could say that, so far as his experience went, he had found that in eight cases out of ten of abortion, to which he was called in consultation, there was a retroflected uterus.

Dr. PHILLIPS said the object of the paper had been fully attained in the interesting discussion which had taken place. He