whiskey until twenty years ago, when he reformed. His father, he said, was shot by a patrol in slave times, a sister was whipped to death by an overseer and a brother escaping from the slave quarters wandered in the South Carolina swamps until he contracted cholera and died.

The student in prostatic pathology, I am sure, would be able to find much valuable and instructive information in the study of the clinical histories and pathological findings in these three cases:

The prostate, discovered by mere accident, in the case of Brueggeman, who was only thirty years of age, had attained the size of a man's fist, with an equally large-sized intravesical projection. These tumor masses quite filled up the cavity of the bladder, and yet, so far as is known, the patient never complained of obstructive symptoms. In my next contribution to this subject, when describing the mechanism of obstruction, I shall explain the reasons for the absence of urinary interference in such cases.

An enormously enlarged prostate was also found in the case of Thornton; and this old negro enjoyed good health, except now and again an attack of rheumatism, until two days before death. What might have been simply a spontaneous hemorrhage which completely filled the cavity of the bladder, resulted in his death. Certainly there were "prostatic enlargements to a pathological degree," and yet producing no symptoms.

There were no marked pathologic changes observed in the bladder in the case of Rhoades, the patient who had attained the ripe old age of 105 years, except the plica ureterica had encroached somewhat upon the lumen of the vesical opening to the urethra, but aside from obstinate "dribbling" attending the act of micturition he was not otherwise a sufferer from the urinary function.

These cases teach important lessons in many respects, and especially in the case of Brueggeman as to age, and in Thornton's case as it relates to the absence of symptoms, and, too, the enlargement of the prostatic in the negro race, and in the case of Rhoades as to the showing of the prostate in the very old. I conclude that there may be stranger things disclosed under the limelight of the dead house than are ever dreamt of in the philosophy of the routine prostatectomist.

612 North Taylor Avenue.

ANTITOXIN IN CHICAGO.-Already thirty-six (36) antitoxin stations have been established in Chicago. From any of these physicians may obtain the serum free for indigent patients and at low rates for others.

A GENEROUS GIFT.-For the maintenence of a hospital to be established at Rosedale, Kansas, in connection with the State University, Doctor Simeon Bell has given that institution 440 acres of land. He has agreed that if $25,000 is not realized from the sale of land, which is in Jackson and Cass Counties, Missouri, he will make up the difference in cash.

Dr. Bell intends it to be a memorial to his deceased wife.

RELAXED VAGINAL OUTLET.

Chas. J. Simmons, M. D., Lawrence, Kan.

EAVER states that "When the pelvic floor has been injured, usually as a result of child-birth, a relaxation of the vaginal outlet takes place, and the perineal body becomes shallower owing to the tears of the sphincter ani and levator ani muscles and fasciae." The outlet that is normally less than one inch in diameter, dilates in labor to let a head pass that is four times as large, and if the labor is precipitous, presentation abnormal or instruments used or fetal head abnormally large-laceration and relaxation is a common sequence.

Most obstetricians examine the perineal body after labor and repair all rents. Some doctors never examine, and so never have such an unfortunate result as a tear, and so, I fear, do not know an injurious tear when they see it, or how to examine for one.

Many have for their standard of a good perineum, the integumental covering between the fourchette and rectum, and as the skin here often stretches and remains intact after the head and shoulder have plowed through the levator ani muscle, they fail to note that unfortunate injury.

What then are the best means of demonstrating a relaxed vaginal outlet, upon asking the patient to bear down, there is a prolapsus of the anterior and posterior vaginal walls, and with a finger upon the cervix uteri, its descent is noted.

With the patient standing the effect of exercise can be prognosticated. With the patient in Sims' position, a gaping introitus presents.

Taking the flabby perineal tissue between the thumb and forefinger its character, size and supporting qualities are estimated, or rather in a severe injury, its non-supporting qualities, for the "strong lower levator fibers extending from one pubic ramus to the other, and supporting the outlet have disappeared," and but feeble flabby tissue takes its place.

If the levator ani is torn on one side only a deep sulcus will be felt between it and the rectum.

When the sphincter ani is torn, the ends retract. Dimples mark the ends of the retracted muscle. If they are obscure, pinching the muscle to make it contract will make them more prominent. There are said to be concealed relaxations that are only revealed under an anesthetic.

A relaxed vaginal outlet may usually be known by some of the foregoing symptoms, yet I saw a patient recently that when lying on the back the flabby hypertrophied labia concealed perfectly a tear that extended through the anal sphincter and that allowed the uterus and acompanying cystocele and rectocele to prolapse outside the vulva if she stood upon her feet for a few minutes.

My reason for taking a special interest in this subject at this time is because I believe that there are in every community a number of cases of relaxed vaginal outlet that practically make invalids of their possessors and because I believe that I have been remiss in noting this defect and

* Read before the Golden Belt Medical Society, at Wamego, Kan., January 7, 1904.

advising an operation in anything like the number of cases that I should. If we were as radical in advising operations for this trouble as we are for chronic appendicitis many cases that are now tied to the physician's office with no honor to the physician would be restored to health. I have seen in my practice this summer three cases of complete procidentia with histories covering from three to fifteen years, two of them from excessive modesty, had never consulted a physician, and would hardly believe that any operation could give them relief. For years they had been carrying the uterus and part of the bladder outside of the body. The uterus in both cases had several ulcers upon it and was foul smelling. Incontinence of feces kept them both physically and mentally upon the rack.

Other cases with backache, bearing down sensations, cystocele and rectocele and a multitude of reflex symptoms, such as headache, palpitation and dyspepsia, were leading lives that varied from semi-comfort, when they did little or nothing, to nervous prostration when they were much on their feet. For this class of patients I hope to see a revival of plastic surgery, for they do well when the perineum is repaired, and I find them very grateful for their restored health.

Different methods of repair are proposed, flap splitting, triangular denudation, and posterior bilateral exsection followed by suture.

All aim to restore as nearly as possible the normal condition of the pelvic floor. The Emmet operation seems to me to most nearly accomplish this result. As when properly executed it exposes the fascia, takes up the vaginal slack, lifts up the perineum, and restores to the levator ani its proper function.

The patient having been previously purged and douched, is anesthetized and the field of operation thoroughly cleansed. The labia are separated by the fingers of an assistant standing on each side of the patient. The crest of the rectocele is seized by a double tenaculum and a caruncle on each side by others. These are entrusted to the assistants, a fourth tenaculum is hooked into the commissure of the vulva. When these instruments make the tissues tense, they mark the outlines of the denudation. All within then is thoroughly denuded, this ought to reproduce the original injury.

The sulcus that appeared in the vagina when the tenacula grasping the rectocele and a caruncle on one side were separated, is first united. The chromocized catgut sutures are introduced under the denuded tissue so that the suture at the bottom of the sulcus is nearer the operator than its entrance and exit. The sulcus on the opposite side of the rectocele is next treated in the same way, the last suture on each side being silk worm gut. A silk worm gut suture then joins the summit of denudation on each side, passing under the apex of the arectocele. Perineal sutures are then passed, they all lift up the pelvic floor, and bring the posterior segment forward.

If the laceration has been complete, the first suturing is to restore the sphincter ani, the catgut sutures enter and emerge on the margin of the rectal mucosa, are tied and dropped into the rectum, a silk worm gut is passed carefully behind the torn sphincter so as to bring the ends together. A gauze and cotton pad and a T-bandage complete the work.

ADDRESS

Delivered at the Annual Commencement of the Central Medical College, Tootle Theatre, March 31, 1904, by

0. B. Campbell, A. M., M. D., St. Joseph, Mo.

ADIES AND GENTLEMEN: The faculty of the school has selected me to address you upon this occasion. I assure you I appreciate the privilege, and sincerely hope that I may interest you. The profession of medicine has very much to do with the public at large and with the individual in particular. The people of every civilized country in the world look to the profession of medicine for assistance in preventing and overcoming disease, being guided by their counsel and advice. I have fully realized for you your utter dependence upon the knowledge and skill of the physician. You can only procure, when sick, knowledge and skill commensurate with the age in which you live: no more. The knowledge and skill of the physician will never be a commodity upon the market to be purchased or rejected; it will ever be sought after for the reason that there can be no substitute.

You are the beneficiaries of our advances, our achievements, our discoveries. You as well are the victims of our mistakes and our failures. It is your province to live in the most intelligent of all ages, human knowedge having advanced to a degree never before attained in the world's history. Primitive man in almost total ignorance of his environment, savage and vicious, has been transformed through the evolution of ages into an intelligent being Such an evolution has necessarily brought about a change of environment in accord with changed conditions. Civilization has been progressive, every age contributing something to its growth and development.

It is indeed pathetic to trace man from his primitive state through the various stages of evolution to the present time. His ignorance of nature and his wrong interpretation of her laws, his tyranny and savagery, mark the greater part of his history with bloodshed and superstitition. It is only in the history of the past century from which it may be said has been largely eliminated savage practices, tyranny and the vagaries of superstition.

Modern science which has raised man from the level of the savage to the high plane he now occupies had its birthplace at Alexandria. The almost universal opposition of the masses to its every claim through the different ages only demonstrates forcibly the innate savagery of primitive man. To knowledge must be given the credit of our splendid civilization of today, with all of its humane laws and the enforcement of justice and protection.

Knowledge has freed the yoke of bondage which enslaved man. In ignorance of right he was often brutish and inhuman. While we as a people should be justly proud of the great intelligence of this age, we must acknowledge that we have not as yet expunged from our natures the innate savagery of our primitive fathers. When we have accomplished this, then the necessity of war between civilized peoples will not arise. It has oc

curred to me that might not the history that we are now making at the beginning of this century, be looked upon by those who will make the history of its close, as the last relics of barbarism. We now behold two civilized nations engaged in war, with all of the brutishness and inhumanity which characterizes even modern warfare.

Does it not seem passing strange, with all of the wonderful reforms in all civilized countries in favor of human rights and human justice, that the necessity of war should arise? However, war is not the only existing relic of barbarism, indeed almost every phase of superstitious practices and beliefs of primitive man have their counterparts in some of the creeds and pseudo-sciences of today. Knowledge, however, is better disseminated among all classes than ever before, and its influence through the development of the minds of men will continue until we hope superstition will be finally dethroned.

The history of the growth of knowledge demonstrates an opposing force, ever constant and active This condition exists today, possibly not so apparent, but in reality the same as in past generations. The history of the science of medicine, as with all the kindred sciences, demonstrates its existence through every age and its existence today is recognizable. However true science is axiomatic, uncontrovertable, every age having demonstrated new principles and truths which have added to the storehouse of human knowledge. The greatest opposition to progress in the early history of the science of medicine was the universal belief of the people in evil spirits and the prevailing doctrine that all diseases were caused by their machinations. The prevailing practices for their eradication I will not enumerate as it is indeed humiliating to the intelligence of the present age to even refer to them. However, I shall remind you that the belief to some extent reached into the seventeenth century, and American history records the execution of witches at Salem, Massachusetts, at the close of that century. The opposing force to progress then in the early history of medicine was largely the ignorance of the people. At the present time the science of medicine is opposed by pseudo-sciences better known as pathies in medicine. However, the impediment furnished by such monstrosities may be likened to the ripples in a mighty river as it flows relentlessly on, heedless of the frail obstacles it may encounter. The present age is particularly characterized by discovery and achievement in the science of medicine. The true discoveries in medicine and surgery are not made by the rank and file of the profession, but by the few individual workers. These men, without hope of pecuniary reward, but with a paramount desire to benefit humanity and honor their profession, diligently keep to their task, being rewarded only by the satisfaction of having accomplished something for humanity.

Every discovery is at once given to the profession, so that the entire civilized world may enjoy the benefits which may accrue therefrom. Were this not the case, and discoveries were kept secret for monetary gain and self-aggrandizement, the science of medicine could not advance and the profession of medicine would retrograde into a mere trade. It has been declared by laymen that physicians have handicapped themselves by the