a long, pointed cervix, which acts like a conic wedge, being driven in distalward at every breath or increase of intra-abdominal pressure, it will constantly dilate the vaginal sphincter apparatus, and should be amputated. The amputation may produce involution of the uterus. A long, pointed, conical cervix generally has proximal to it a retroverted uterus, which precedes prolapse. Again, if there is cystocele the patient should be prepared by a ventral colporrhaphy. It may be that amputation of the cervix and ventral colporrhaphy can be done at the same sitting and anaesthesia, as the flapsplitting colpoperineorrhaphy. We frequently perform colporrhaphy and colpoperineorrhaphy at the same time. To require cervical amputation is rather rare, but if there be a retroverted uterus, with pointed cervix, it should be amputated and turned dorsalward against the sacrum. In short, we must imitate nature as much as possible to secure success. All hernia - is the same; it is due to the destruction of normal valves, and the extending and straightening of oblique canals. Hence, in sacro-pubic hernia. the normal obliquity of the vaginal canal must be restored. Colpoperineorrhaphy restores the dorsal vaginal wall, and ventral colporrhaphy restores the ventral vaginal wall. This is not often needed if the colpoperineorrhaphy be thoroughly performed. Prolapse is prevented by perineorrhaphy, elytorrhaphy, episiorrhaphy (or checked by some abdominal operation). Prolapse may be considered as a distalward displacement of the pubic segment of the pelvic floor; the sacral segment of the pelvic floor shares in it by yielding of some of its parts. There are so many varied opinions as to the etiology of prolapse that one can safely say the subject is not fully settled. In my opinion, much credit is due Drs. Hart and Barbour for their excellent investigations on the structural anatomy of the pelvic floor. After considerable careful dissection, I feel quite sure that many previous views must be changed, but it is hopeful when the closest and most continued students of the pelvic floor come practically to the same conclusion. The subject of prolapse, I think, should be studied. anatomically, physiologically and clinically. The field of investigation is still large. With the progress of time the uterus itself will receive less. attention, and the pelvic floor more. The subject of relaxation and submucous laceration will be more studied, relaxation of the whole pelvic floor, due to repeated parturitions, infectious processes and prolapse. Insufficiency of perineal support should not be lost to view, and the sphincter apparatus of the pelvic floor will be more studied. From dissection, one would at once conclude that the levator ani fascia and triangular ligament were the main supports in the pelvic floor; however, relations of other supports must be considered. Dissection is the only intelligible way to understand the subject. For example, dissection of quite a number of bodies has thoroughly explained, in my mind, the conflicting views of anatomists and gynecologists as to the position of the uterus. As a gyne cologist, I have examined thousands of women, and I am sure that the uterus inclines ventralward, in the normal condition. Repeated examination on the dorsum, and while standing, will prove that slight anteversion is the normal position of the uterus in the cavity of the sacrum. I have repeatedly found in a dead subject that the uterus is in the cavity of the sacrum, precisely as the anatomist has described. Both gynecologist and anatomist are correct. In the living woman the normal position of the uterus is that of anteversion. In the dead woman, in dorsal decubitus, the uterus generally lies in the cavity of the sacrum. In just such a manner arise the differences of opinion relative to prolapse, which can be only cleared by personal anatomic and clinical investigation. A comparison of different causes will soon let in the light. The most valuable work in gynecology, as regards sacro-pubic hernia, will be produced by the combined labors of a gynecologist and an anatomist notably, the book by Tandler and Halban. Though the peritoneal supports of the uterus be deficient, they can be put at rest and finally cured by carefully-planned operations on the vaginal sphincter apparatus. All primary uterine supports are attached to the neck of the uterus, and before the uterus shows such signs of hernia the supports attached to the neck must be definitely elongated. Doubtless the uterine supports are frequently elongated by infective processes, and hence a rest by repairing and fortifying the sphincter vaginal apparatus will result in restoration. Especially is this true in certain forms of retroversion. If the uterus remains in its normal position (i. e., perfectly movable) no retroversion, and consequent prolapse, will arise. In chronic infective processes the pelvic organs at times hypertrophy, become edematous, ending in a form of hypertrophy from static congestion. I have frequently observed this slow-repeated process in clinical labors. ETIOLOGY OF PROLAPSE. 1. Insufficiency of sphincter apparatus: (a) Levator ani muscle; (b) triangular ligament (ventral and dorsal layers and fascia of Colles); (c) levator ani fascia, proximal and distal; (d) perineum composed of levator ani, bulbo-cavernosus, transversus perinei and sphincter ani ischio-perineal ligaments; (e) vaginal walls; (f) urethro-vaginal septum; (g) rectovaginal septum; (h) muscular and elastic tissue on lower third of vagina. 2. Insufficiency of peritoneal supports: (a) Utero-sacral ligaments; (b) round ligaments; (c) broad ligaments; (d) vesico-uterine ligaments; (e) perineum; (f) elongated cervix. 3. Intra-abdominal pressure increased or applied in abnormal directions. 4. Relaxation of ventral segment of the pelvic floor: (a) Repeated parturition; (b) submucous, concealed facial lacerations; (c) subinvolution of the pelvic floor and organs. 5. Weight and dimension of uterus, which affords expanded surface for intra-abdominal pressure. OPERATIONS FOR PROLAPSE. 1. Tait's flap operation (and extension) of perineum. 2. Perineo-episiorrhaphy. 3. Elytroperineorrhaphy. 4. Elytrorrhaphy. 5. Amputation of cervix. 6. Shortening of round ligaments (Alexander-Adams). 7. Shortening of broad ligaments. 8. Fixation of the uterus to the abdominal wall (hysteropexy). 9. Schucking's operation. 10. Herrick's operation. 11. Mackenrodt's operation. The operations for prolapse have been as varied as the views of its causes. Operators have attacked the uterus, vagina, pudendum, and uterine ligaments to accomplish their purpose. The pioneer idea in prolapse was to close the pudendum, so that the uterus could not escape. Thus we have the early episiorrhaphy of Fricke and Kuchler. But surgeons soon realized that simply closing the pudendum was like attempting to board Mount Vesuvius. The forces at work were not at the pudendum, but deep in the interior. Then came the operations on the perineum, with all their variety, from Guillemeau's successful case through Dieffenbach, Langenbeck, Simon and Sims, to the modern flap operation. Finally, to episiorrhaphy and perineorrhaphy were added operations on the wall of the vagina (colporrhaphy and elytrorrhaphy). Elytrorrhaphy has been quite a successful addition to gynecology, but it is a denudation operation, and hence destroys valuable tissue. I have observed that the European operators attempt to save dorsal and ventral columns of the vagina. Men see in the column a valuable piece of supporting tissue, and some of them, like Martin, try to save it. Dr. Emmet has worked along the same line, and his operation is one of the most useful of its kind, and if mastered and performed thoroughly, is successful. In it he has combined the best principles of the denudation method. It preserves the vaginal columns and denudes the areas of least resistance. His idea of supporting the pelvic floor is certainly correct. If the flap-splitting method could be enlarged in this operation it would be a marked step in advance. The pudendal and vaginal operation of denudation should be superseded by the flap-extension method, which might be called perineo-episiorrhaphy. It is performed with no loss of tissue, and can be extended to the urethra. The quantity of flap and barrier tissue formed at the pudendum will depend on the depth of the scissors' clip, and the quantity of exposed tissue, and also much of the manner of the suturing the surfaces to be coapted. The flapextension method will form one of the best supports for prolapse. The objections against the Alexander-Adams operation are: 1. The ligamenti rotundi uteri are not uterine supports-they may act as a guy rope. 2. Unsatisfactory reports and the bias in selecting cases for operation. 3. In quite a number of bodies the round ligaments can not be found. In many cases which I have investigated no muscular ligaments could be discovered until one incised the internal abdominal ring. 4. No operator can decide in which cases the difficulty will occur. 5. The danger of opening the peritoneum. 6. The round ligaments are insufficient for a main uterine support. 7. Hernia may follow the operation. 8. In case of uterine adhesions the ligaments will not raise and support the uterus. 9. It is an irrational operation. It fixes the uterus, which is pathologic. The uterus belongs in the pelvis-not in the abdomen. The operations will require repetition about as frequent as one requires the hair clipped. 10. It attempts to substitute one alleged pathologic condition (i. e., that of excessive mobility) for another (i. e., that of fixation), and mobility is superior to fixation. Results will not be permanent. The round ligaments will gradually yield to the uterine weight, especially if there be an enlarged uterus, as often is the case in prolapse. Some of the above objections may be modified. The AlexanderAdams: as the round ligament neither maintains the uterus in position, nor suspends it. It is here mentioned, as an accessory operation to colpoperineorrhaphy, only to condemn it. Shortening the broad ligament is of questionable value. Hysteropexy, or the fixation of a movable organ, is against all pathologic principles. (To be continued.) THE PAIN OF SIGMOIDITIS. For the pain of an acute exacerbation of chronic sigmoiditis, opium, or any of its derivatives, for well-known reasons, should never be prescribed. Usually the evacuation of the bowels is promptly followed by the subsidence of the more intense pains. Hot applications and counterirritants may be applied to the abdomen, the buttocks, and the thighs. In case the painful sensations continue, suppositories containing belladonna, the extract of powdered leaves, should be inserted into the rectum, as high up as possible. If tenesmus is present, it is advisable to add lupulin in gram doses to the suppository, which should have for its base a glycerogelatinous mass.-Stern, American Medicine, March, 1908. MANAGEMENT OF THE EARLY STAGES OF GONORRHOEA-A PLEA FOR CONSERVATIVE AND EXPECTANT METHODS OF TREATMENT. BY E. STYLES POTTER. M. D., New York City. Late Assistant Visiting Surgeon Columbus Hospital and Instructor of Anatomy and Operative Sur. [Written for the MEDICAL BRIEF.] In the management of this very prevalent disease there appear each year many new remedies: prominent among them are many which appeal to the profession for recognition upon the ground that they possess power sufficient to abort the acute septic inflammation produced by the inoculation of the gonococcus in the urethra. In some cases certain of the silver preparations do seem to have an influence for good in this direction, at least when used in connection with other forms of rational internal treatment, but when employed locally, as an abortive measure, it has been the experience of the author that they result only in disappointment. In the management of acute septic inflammations of the male urethra we should never permit ourselves to be carried away with the idea that any remedy can be considered a specific; still we should never lose sight of the fact that gonorrhoea is an acute local inflammation, and when it is possible to place our patient in the proper hygienic condition, where rest in bed is possible, conjoined with a light, bland diet, and the liberal use of water, free from all sexual excitation, and under a normal psychopathic condition, combined with the simplest remedies, most cases would recover without further treatment in about two weeks, the time needed for the resolution of all other acute inflammatory conditions occurring in other parts of the body. Gonorrhoea will always continue to be a disease of long duration, with many complications and sequela, until we finally train ourselves and our patients to understand that they are seriously ill when the simplest forms of gonorrhoea infection occurs, and that it is eminently necessary that they should remain confined to their apartments, and discontinue all manual labor, and to place their mind at rest for at least the first week or ten days after infection has occurred. Then, and only then, will we be doing what is just to our patient and the uninfected members of the community. This may at first seem very impracticable; and, in fact, in many cases, is simply out of the question, but I am of the belief that should this system of treatment come in general vogue there would, in the aggregate, he |