tracted, but, as the new tissue was thicker and cicatricial, the degree of contraction was often greater, and the resistance of the cervical tissue to expansion was increased; so that the latter condition of that patient was probably worse than the first. Still, it occasionally happened that the lips healed separately and apart, leaving a perfectly patent cervix; and the relief experienced by such patients was so great and so permanent that it not only established the usefulness and the scientific advisability of treatment by incision, but it prevented the method from falling entirely into disrepute and disuse. Some years ago, a succession of patients, of some social importance, suffering from dysmenorrhoea and sterility led me to study the subject somewhat carefully. The clinical facts, to which I have briefly alluded, seemed to point conclusively, not only to the mechanical nature of the obstruction in these cases, but also to the obvious argument that the patients could only be cured by removing that obstruction. One remembered how commonly lacerations of the cervix occur during labor, and how these, in most cases, close up completely; while in others the lips remain widely separated, and heal in that condition. Further thought and inquiry led me to find that the former cases occurred most frequently when the patient was in perfect health, and had received the best possible surgical and nursing care; when there was comparatively little discharge from the uterus, and when douches were so regularly employed as to keep the entire genital tract, and especially the wounded surface of the cervix, in a surgically clean condition. On the other hand, I found that the widely separated lacerations of the cervix were very common among hospital out-patients, where the uterine discharges had been by no means aseptic, where the patient's health was depreciated, where cleanliness, in fact, was too often only conspicuous by its absence. In fact, whenever there is an unhealthy discharge from the uterus after the lips of the cervix have been torn, as one might almost expect, the wounds bathed with this discharge will not unite, but will separately heal. It was, therefore, plain that in the case of a surgical aseptic wound nature would give no assistance in keeping the edges of the wound apart, but would devote all her efforts to drawing them again together in order to repair the injury which surgery had caused.

It therefore seemed to me that the only possible method of preventing immediate adhesion between the incised cervical lips was to draw one entirely apart from the other whilst healing process was going on. I first attempted to effect this by means of a catgut stitch passed through the tip of the anterior lip and then higher up on the antrior vaginal wall, a similar stitch being passed through the posterior lip and the posterior vaginal wall, so that when these were tied the lips were dragged apart. But, after a few days, the catgut softened, the lips fell together again and united in the ordinary manner; and so I adopted, and have now for some years practiced, the following method, which is simple, surgical, and has proved to be perfectly effective.

I had not previously heard of the operation being done by anyone else, but I have shown it now for some years at The Hospital for Women, and am glad to hear that it has proved equally successful in other hands.

The patient being anaesthetised and in the lithotomy position, the vagina is well douched and cleansed. The posterior wall of the vagina is retracted by a weighted speculum, a double hook is passed through the anterior lip of the os, and the cervix is drawn down. The cervical canal is then dilated by graduated metal sounds up to No. 16 or 161; one blade of the scissors is then passed half way up the cervical canal-that is to say, in many of these cases of conical cervix, from half to three-quarters of an inch-and an incision is made to that extent on each side; the posterior lip falls back, the anterior lip is drawn forward with the hook. A small needle threaded with strong catgut is passed through the left side of the anterior lip close to the upper angle of the incision, and then across and through the corresponding point on the right side. The catgut is cut sufficiently short, and a similar stitch is inserted about midway between the former and the tip of the cervix. The anterior lip is sponged clean of blood, and, first the upper, and then the lower, stitch is tied. The result, of course, is that the anterior lip of the cervix is indrawn together; the raw surface being closed completely, whilst the posterior lip is left flat and open. Two or three wool plugs are then applied tightly against the cervix to check hemorrhage. These are removed in about sixteen hours, and then it is found that the posterior lip is glazed over with lymph and quite dry. In about a week, it is covered with mucous membrane extend

ing up to the angle of the wound. Meanwhile, the catgut in the anterior lip is gradually softening, and, as a general rule, the wound gapes open, while at the same time it is becoming glazed over with mucous membrane. At the end of ten days, I cut the catgut stitches and remove them, and then the anterior lip flattens out and lies nearly in its normal position, but with this difference-that both the apposed surfaces being covered with mucous membrane they cannot adhere together; and on passing the finger one finds that the cervix is widely patent. As a rule, there is no discharge, and at the end of a fortnight the patient is able to resume her home life.

For the purpose of this paper, I have looked up my notes of all the hospital and private cases I could remember for whom I have performed this operation. They amount altogether to eighty-seven cases. In every case, my notes show that the first period after the operation was practically free from pain. In twenty-eight of the cases, I have a note of the patient at the end of two years, and in every one of those cases the relief had been permanent for that time. In another thirtythree cases my notes only extend to an average of eleven months after operation, and in each of those the relief was equally definite. Of the remaining cases, in ten I can only find a note for three or four months after the operation, but in those again the relief so far had been permanent. In eight cases, varying from four months to two years, some amount of menstrual pain had returned, but in each case to a much less degree than had been formerly experienced. In the remaining eight cases, I have no note after the first month; but, as I have asked every patient for whom I have done this operation to write to me if she had any return of her previous symptoms, and as I have not heard at all from these eight cases, I think I am almost justified in thinking that they have also been permanently relieved, and that therefore I am well within the mark in estimating that of the patients with dys menorrhoea from conical cervix for whom I have performed this operation, in 91 per cent. the relief from pain has been complete and permanent.

With regard to sterility, I find that out of the eighty-seven cases forty-one were sterile, having been married for periods varying from two to eleven years. I have heard, so far, from twenty-four of these cases, in eighteen of whom pregnancy has resulted after an average sterility of five and a half years.

On the whole, therefore, I think I am justified in saying that, in these cases of conical cervix, both the dysmenorrhoea and the sterility are directly due to the contraction and lengthening of the cervical canal, and consequently to mechanical obstruction; that the latter can be completely removed by incision of the cervix, provided that the incision can be kept permanently patent; and that, by the method I have described, which I submit is surgically sound, such patency can be secured; and, finally, that the actual results in practice are sufficiently good to warrant a more extended trial of the operation.Medical Times and Hospital Gazette, London.

INTERNATIONAL QUARANTINE BUREAU,-The following communication from the International Quarantine Bureau, issued Jan. 1, 1904, by the President, Dr. J. McG. Lindsley, discusses a subject of the greatest importance to all physicians, and particularly to those of the Southern States:

"Quarantine regulations against yellow fever must be based upon the demonstrated fact that yellow fever is transmitted only by the mosquito. In our previous letters we have shown that the great preponderance of testimony on the part of physicians and scientists who have made a special study of yellow fever agrees that it is transmitted in nature only by the mosquito. Since our last letter, in the annual meeting of the American Public Health Association, not one objected to this doctrine, and Dr. J. Y. Porter, Health Officer of Florida, said he accepted it in toto. So practically the only quarantine authorities not on record as accepting this doctrine are these: Surgeon General Wyman, of the Public Health and Marine Hospital Service, President of the Louisiana State Board of Health, and Dr. Tabor, Health Officer of Texas. With the bitter experience of Dr. Tabor in fighting yellow fever in Texas, without taking the mosquito into account, he will be open to new light on the subject.

"Last spring in a conversation which I had with Dr. Tabor in the St. Charles Hotel, New Orleans, before his visit to Havana, he ridiculed the idea of the mosquito being the only natural means of transmitting yellow fever, and would not agree to regulate quarantine upon that basis, stating to me that the Governor of Texas had told him if he let yellow fever into Texas he would ask for his resignation. Dr. Tabor has been a

bitter foe to scientific quarantine, based upon the mosquito theory, and as he has had the whole matter in his own hands in Texas, and has the commercial interests of New Orleans and other Southern cities at his mercy, they will do well to remember his attitude and protect themselves against a repetition of the mistake.

"Dr. Roux tells me Pasteur Institute Commission has absolutely settled upon the mosquito as the sole agent for the dissemination of yellow fever."-Dispatch from Dr. Giddings, of Public Health Service.

Following this are indorsements from the Army and Navy Departments, extracts from reports of Reed and Carroll, of the Yellow Fever Commission, and the remarks of Doty, Health Officer of the Port of New York, and Dr. Juan Guiteras, the celebrated yellow fever expert. It is regretted that lack of space does not allow us a full publication of this interesting document.-Cincinnatti Lancet-Clinic.

THE PATHOLOGY AND SURGICAL TREATMENt of Bright'S DISEASE. S. C. Gordon (Annals of Gynecology and Pediatry, November, 1903) says that Bright's disease is primarily an acute inflammation of the kidney structure, not dependent upon any specific infective germ, which if early recognized and properly treated will terminate by resolution. If neglected or not recognized, repeated acute attacks may occur, each one leaving products of the inflammatory process, which may organize or even suppurate. Acute attacks are always short, but leave more or less products, which interfere with the circulation, finally producing a chronic passive congestion incorrectly called "chronic inflammation." The result of these attacks is an enlargement of the organs, causing pressure of the fibrous capsule. Complete decapsulation relieves this pressure, depletes the distended vessels by more or less bleeding, and allows the circulation to resume its normal condition and absorb the exudate. Even one kidney alone may be involved, and the symptom be relieved by operation upon that one only. The surgeon may be justified in operating even in cases far advanced when the suffering is great, simply for relief of the suffering.— Medical Age.