5. Weight and dimension of uterus, which affords expanded surface for intra-abdominal pressure. OPERATIONS FOR PROLAPSE. I. 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). 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 The pudendal and vaginal operation of denudation should be superseded by the flap-extension method, which might be called perineo-episiorrhaphy.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. IO. 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 urethral 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 sequelæ, 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, be less time lost from business, and an immeasurably less amount of suffering, and beyond any question of doubt fewer of the innocent infected. For the slightest nasal or pulmonary inflammation we urge upon our patients the necessity of remaining confined to their apartments, and why not for this most serious of all infections when it occurs? There occurs to my mind but one reason, and that is simply that it is impossible to remain away from one's business, the necessities of at all times being in evidence in this respect. I concede to the reasonable demands of this kind, and truly realize that this becomes a most serious objection to the rational treatment of a disease which has in the past been considered but of slight importance, and from the manner of contraction has through all ages been considered more in the class of a joke. In admitting this to be true, I can only urge upon my colleagues the necessity of at all times carrying this form of treatment into practice whenever it does become possible to do so, and when not practical to do so, absolutely, then never forget or lose sight of the fact that so far as possible it should always be urged upon the patient. Place less dependence upon specifics promising abortive treatment of gonorrhoeal infection, and recall to your mind some of the rational ideas you have forgotten in your clamor for the something which has not yet been discovered. When I have been able to follow this course of treatment with the internal administration of balsams and urinary antiseptics, and the liberal use of lithia water, the most gratifying results have been obtained. The object to be obtained in these cases is an early resolution, which usually commences in ten days from the onset of the inflammation. It is not unusual when this course of treatment has been faithfully followed, and at the time resolution commences, when a mild astringent injection is instituted, to find the discharge completely arrested within a few days. The suffering to the patient during this system of treatment is of the slightest, and it is the belief of the author that the means justifies the end, as the results to the patient and surgeon are most satisfactory. 164 W. 92d street. DRUGS SIMULATING SUGAR IN THE URINE. Coleman states that the following drugs, when ingested, may cause the urine to reduce Fehling's solution, and respond to some other tests for sugar: Acetanilid; arsenous, salicylic and dilute hydrocyanic and sulphuric acids; alcohol, amyl nitrite, chloral, chloroform, copaiba, glycerin, mercury, morphine, strychnine, turpentine.-The Medical Council. CURRENT MEDICAL LITERATURE. Prolapse of the Female Urethra. G. F. Barbour Simpson (Surgery, Gynecology and Obstetrics, May 1908) says that it is not uncommon, on the one hand, to find slight eversion of the mucous membrane lining the female urethra, more especially in parturient women. On the other hand, it is rare to meet with cases in which the mucous membrane projects to such a degree as to give rise to a distinct bulging, or tumor. He gives the history of a case which came under his observation, a multipara of fifty-six years, complaining of hemorrhage and pain on micturition. The attacks of hemorrhage were periodic, sometimes lasting for an hour. Owing to no less than three attacks of nephritis during the past five years, she was in a very feeble state of health. Examination disclosed a red mass protruding at the meatus urinarius, which turned out to be the mucous membrane of the urethra, very red, congested and sensitive to touch. Under anesthesia, it was impossible to reduce this protrusion, so it was snipped off with scissors, and the mucosa was united all around by sutures, a catheter having been previously introduced to keep the canal patent. The hemorrhage was profuse. Ten days afterwards there was complete healing, and no pain or discomfort on micturition. The microscope showed the specimen removed to consist of angiomatous tissue. The causes ascribed by most writers for this condition are a sudden fall, causing a prolapse of the mucosa, or a large caruncle dragging on the mucous membrane, and producing gradual eversion. Or again, and not at all unlike in the foregoing case, the constant straining undergone by the patient at stool, and a degree of vesical tenesmus, combined with a relaxed state of the mucous membrane, due to the general debility of the patient, may have favored, if not altogether caused, the condition. Such conditions as cystitis, and the presence of a calculus producing more or less continual tenesmus, have been known to produce this state of affairs. Kleinwaechter has described two varieties of prolapse of the urethra, one in which the mucosa, near the meatus, is everted; the other in which it becomes loosened higher up, gradually extending down until it appears at the meatus urinarius. Observations on the Rectal Temperature after Muscular Exercise. Martin Flack (British Medical Journal, April 18, 1908) states that it is well known that the bodily temperature is increased by exercise, but a difference of opinion exists as to the normal extent of this increase, and also as to the degree to which the temperature may rise without pro |