coccyx, major sacrosciatic ligament, tuberischii and to the base of the triangular ligament. This fibrous cylindrical membrane should be known as the parietal pelvic fascia. Individually it includes the fascia pyriformis, fascia obturator and fascia triangulare dorsalis. It becomes firmly inserted into the bones projecting into the pelvic exit, viz., ischial spine, symphysis pubis dorsalis, coccyx. The white line or arcus tendineus, a thickened band of fascia, extending from ischial spine to the dorsal surface of pubis practically represents the division between the pelvic cavity and iliorectal fossa. The white line presents two important factors, viz: (1) It is the origin of the levator ani muscle. (2) It serves as the origin of the significant levator ani fascia proximal (recto-vesical or visceral pelvic fascia) and levator ani fascia distal this is the distal pelvic fascia. The levator ani fascia proximal divisible in to many cleavable planes blends with the muscular walls of the rectum, vagina and bladder.

APPLICATION OF STRUCTURE AND FUNCTION

TO METHODS OF TECHNIQUE. Having examined the structure of the pelvis in detail (muscularis and fascia) me may now combine the anatomic factors which explain successful colpoperineorrhaphy. The first is the restoration of damaged fascia. A second important factor is deep suturing. A third element, in a successful operation is the restoration of function by means of restored muscular relations. A fourth is the forcing in the median line of adjacent perineal tissue, and a fifth factor is the flap method of operation whereby there is no denudation or loss of tissue; and the flaps (skin and mucosa) avoid infection and insure primary healing. The flap method enables the operator to dissect to the lacerated structure or to reach the seat of the lesion, either by cleaving, splitting tissue or deep suturing with a handled needle with an eye in the end. Silk worm gut which is used in suturing, being nonseptic, may remain for weeks in position, like a splint, before removing. Among the fasicæ of importance are: The levator ani proximal and distal, the triangular ligament and deep layer of the superfiscial fascia, and the ischioperineal liga

ment. The operation of colpoperineorrhaphy is the result of evolutionary processes of failures and successes. In the beginning it was considered sufficient to unite the superficial or external tissues at the site of the lesion. This experiment soon demonstrated its own failure, and later it was deemed essential to restore the deranged and lacerated muscular elements in the pelvic floor. The attempt at successful colpoperineorrhaphy by reuniting external tissue at the site of the lesion, or restoring deranged or lacerated muscles to normal relations proved a failure to such a degree that it was evident that some other factor played a role; this factor was the fascia. The restoration of the lacerated tissue at the site of the wound, with the deranged and ruptured muscles, and the restoration of the deranged fascia are the three factors on which successful colpoperineorrhaphy rests. To Dr. T. A. Emmet must be given the credit of the view that the pelvic fascia played an important role in successful colpoperineorrhaphy. Experimental labors on the perineum, in a desultory manner, have been conducted for fifty years. But only lately have experimental and anatomic data been judiciously combined so as to render clear what are the useful methods in colpoperineorrhaphy. All successful surgical procedures demand an anatomic basis so that physiology may be restored. The deranged and lacerated parts in colpoperineorrhaphy must be restored in a manner simliar to that in operation for hernia. The successful surgical procedures in colpoperineorrhaphy have passed through the same evolutionary process as have the various operations for hernia. In hernia we must restore the anatomic relations, the obliquity of the inguinal canal, so that its valve-like action makes it impossible for the viscera to again protrude.. In colpoperineorrhaphy, not only the anatomic parts should be restored, but the various canals and exits must also be restored to ensure permanent physiologic success. Deep suturing, so essential, is only groping after an anatomic base to restore the ground work. The same ideas are involved in the views of discerning surgeons who suggest that

FIG. 15.

lesion demanding operation should be studied. The cause of the lesion, requiring repair, is almost always the result of the first parturition, more rarely other forces produce sacropubic hernia. The lesions of the perineum may arise from the ventral movement of the head lacerating the levator ani fascia proximal and distal with damage to the ischioperineal (ligament) fascia and tearing of the triangular ligament, with consequent in

bly move distal ward, for it is unphysiologic for a muscle to act as a continuous, tensionized support for viscera. But it must be remembered that the fascial layers of the pelvis are not only of value as visceral supports by separate and distinct connection in themselves, but they are of significant importance as serving a means of visceral support and for a point of attachment for muscles lying between their blades. The levator ani, which is

the most important muscular apparatus on the pelvic floor, serves by its fascial attachments as a visceral support to the rectal and vaginal walls as well as to the pelvic floor, for the uterus is supported practically by the intact pelvic floor.

The pelvic floor may be considered as composed of two widely superimposed, overlapping valves (D. Berry Hart). Whatever disturbs the relations of these valves tends toward sacropubic hernia. The ventral pelvic valve is composed of the bladder, urethra, ventral vaginal wall and retropubic fat. The dorsal pelvic valve is composed of the vaginal wall, perineum and rectal wall. The pubic segment is attached to the symphysis pubis and composed of loose connective tissue. The retropubic fat is loose and spongy, the peritoneum may be easily stripped from the bladder and the bladder from the vagina. In labor, this segment becomes elevated and is the one which easily becomes deranged or acquires pathologic conditions, and especially is liable to prolapse or sacropubic hernia. The levator ani fascia proximal becomes torn from the walls of the bladder and vagina, allowing the intra-abdominal pressure to force the bladder and vagina distalward. When the uterus prolapses (sacropubic hernia) the ventral vagina wall appears at the pudendum first. The strong levator ani fascia has been torn from its walls and when the same fascia has been extensively torn from the bladder it prolapses also. In vesical prolapse the peritoneum with its many cleavable planes of subperitoneal (fascia) tissue becomes torn from the bladder. The sacral valve of the pelvic floor, consisting of the dorsal vaginal wall, the perineum and rectum is attached by strong fascial connections interwoven by muscles to the coccyx and sacrum. In parturition this segment is forced dorsalward and straightened extended. It becomes defective by laceration at the perineal body, the vagina loses its normal curve and sacropubic hernia is initiated, i. e., retroversion begins, which is the inevitable factor in sacropubic hernia. The uterus itself has nothing to do with prolapse, it is inert. Intraabdominal pressure and effective sacral and pubic segments account for prolapse;

the sacral segment is fixed; the pubic segment is movable.

The functions required of the pelvic floor are to resist intro-abdominal pressure and to permit rectal and vesical functions. The structural anatomy of the pelvic floor must not only be studied in general as to its segments, valves, muscles and fascia, but each individual organ should be studied as regards its supports. The uterus has its individual supports, which though not separate from the fascia and muscles, should be well considered, for colpoperineorrhaphy may be required for (prolapse) sacropubic hernia without visible lacerations. The first elemental individual supports of the uterus are the uterorectal (sacral) ligaments. They consist of two folds of peritoneum embracing muscular and strong connective tissue extending from the dorsal surface of the cervix to the rectum (perhaps some fibers do extend to the sacral fascia). These ligaments are an extension of the muscular and connective tissue fibers of the promixal end of the vagina backward. As Dr. Frank Foster notes, the vagina and uterorectal ligaments form a balance beam on which the uterus rests. Yet it should be borne in mind that organs do not rest merely on bases, but are swung on supports or mesenteries. The brain, liver, heart and uterus are all suspended by supports and do not rest merely on other organs or bases. The uterorectal ligaments are powerful, peritoneal, muscular and connective bands which vigorously suspend the uterus by the neck which is blended in the pelvic floor. Careful dissections and vaginal hysterectomy will demonstrate that the uterus could not descend without the uterorectal ligaments became elongated. The uterus is supported by innumerable threads which extend from the pelvic wall to it. The so-called uterine ligaments are supports only in pathologic status. The uterus is said to be suspended by so-called ligaments (round, broad, sacro-uterine) fixed by intra-abdominal pressure; or supported by the pelvic floor.

(To be continued.)

[Written for the MEDICAL BRIEF.]

Syphilis.

BY J. DABNEY PALMER, M. A., M. D., Monticello, Florida.

Syphilis is a specific, contagious, chronic disease, communicable by inoculation, by contact of surfaces, by hereditary transmission, and, most commonly, by impure sexual connection. As early as 1380 John Gadisses gave ample proof of its contagious nature. About the year 1500 Benedict Victorius advanced the curious opinion that it was "epidemic, and originated from an unwholesome disposition of the air, and a spontaneous corruption of the humors, contracted by an error in diet, or the abuse of the nonnaturals." He wrote an elaborate essay going to prove that "the putrid humors are sufficient to produce it," and to put the matter beyond all doubt, he testified that he happened to know "some very worthy and religious nuns who were confined in the strictest manner, unfortunately contract the disease from the peculiar state of the air, together with that of the putrid humors and the weakness of their habit of body." This doctrine, though at the present day we smile at its absurdity, was really not only believed, but stoutly defended by physicians.

The question of the origin of syphilis has given rise to much fruitless discussion. It has existed ever since prostitution prevailed in the world; and this has been from the remotest antiquity and among all nations. Descriptions of it are found in the earliest writings, and traces of it are discovered in the bones of prehistoric people. Chinese accounts of it date back to the writings of Hoan Te, who lived about 2637 B. C. And the Japanese historians described it several thousand years ago. The Hebrews were familiar with it, and it is probable that many cases called leprosy were really syphilis. Hippocrates and his successors describe it as it existed among the ancient Greeks, and Celsus speaks of it among the Romans. It is found all over the world, and in its frequency and virulence is not modified by climatic or geo

graphical conditions; but it is worthy to note that the disease is unknown among savage peoples who have not come in contact with civilized communities. There is no disease so widespread in its dissemination, nor so potent in its influence upon the human species, and none so characterized in the different stages of its progress by a greater number of pathological changes in the tissues of the body. The negro race is believed to be more susceptible to it, and to have it in a severer form than the Caucasian. This may be explainable on the ground that the disease is a comparatively new one to that race, which has not had time to acquire immunity.

Syphilis belongs to what Dr. Farr calls the enthetic order of zymotic diseases, which have the property of being developed in the system after the introduction of a specific poison, and originates in morbid secretions, in conjunction with the disgusting want of cleanliness about the genital organs so common among a large portion of human beings. The term is derived from the Greek phor, filthy; and aptly indicates its origin. It is peculiar to the human species, and is always due to contact with a syphilitic individual or with his secretions or discharges, and produces no effect whatever on any of the lower animals, with the possible exception of the monkey. It can not be conveyed in the form of vapor, or, in other words, by breathing air which is contaminated by a syphilitic person. It is necessary that the poison should be applied to some part which is soft or covered with a mucous membrane, or else to some place where there exists either an excoriation, ulcer or wound.

The investigations of Schaudinn show that the disease is caused by the microorganism spirochæta pallida, a serpentine and flexile organism, resembling a corkscrew, having sinuous movements like the swimming of a snake or an eel, and found only in primary and secondary syphilitic lesions. It has no delicate, wavy filaments, called flagella, for locomotion, like other bacilli. Its size is about the one-twenty-five-thousandth of an inch. It was at one time believed by the greater number of the medical profession that syphilis and gonorrhea were