moral influence, as it might be designated. Oftentimes in their whims, their delusions, things are turned upside down to gratify the insane, and frequently that is the worst thing that can be done for the patient. A short experience in the state insane service impressed this lesson upon me-namely, that the very fact that their whims and notions and insane demands were largely ignored and simply their necessities administered to, had a most salutary influence upon the mental condition.. I believe there was a small percentage whose recovery was simply due to the fact that they were put in a place where their every whim was not gratified.

Dr. WILLIAM J. Howe, Scottsville: As a general practitioner from a country district, I am prompted to add that my experience has taught me that learned alienists are liable to err in their judgment as to the etiology of many of these mental conditions; at least, my experience has been such. A few years ago a strong, robust, young Irishman came to me, suffering with pronounced melancholia. He had been under the care of an eminent specialist who had treated him for nine weeks, with no improvement except as to his nutrition; he improved in flesh but mentally was no better. He came back to his country home, and I employed him as my coachman. I began an eliminative process to determine his condition or what was causing the melancholia. I found he had a double astigmatism. I stopped all medication at once. In a month, instead of sleeping one hour, he slept practically all night long; and, to shorten the story, he made a perfect recovery. He had been in the hands of eminent, skilful men, and yet they had overlooked the cause of the trouble; so it seems to me that in endeavoring to learn more of insanity we should endeavor to learn, first, more of the cause or causes of insanity.

In further illustration I may mention that a few days ago it was my misfortune to have a relative sent from a western city suffering from melancholia. She is a comely young woman, 26 years of age, who had been for two years affected with melancholia. Her physician was one of the most eminent in the west. He had treated her for two years for melancholia, but had never made an ocular investigation or local examination. He sent her east to the country for a rest. An examination showed her to have a marked ulceration of the os uteri, with a slight astigmatism in each eye, and considerable muscular tension. She has been in the country less than three weeks, and is decidely improved. The astigmatism has been corrected, the muscular tension has been somewhat modified, and she is improving with a fair prospect of recovery. In endeavoring to learn how to manage insanity let us learn, first, what the cause of each individual case is. It is a difficult matter to settle the treatment of a case unless we know the primary cause, so I would like to emphasise the importance of careful investigation as to the cause, and find out if pos

sible what produces the mental symptoms, then remove the cause, and the rest will become easier to deal with.

Dr. A. A. YOUNG, Newark: I wish to say one word in approval of Dr. Howe's remarks. Our books give us signs and symptoms of insanity; pathology and etiology largely are left out. We cannot sit and hear lectures fresh from the teacher. We have got to take patients as we find them. Friends say they are insane, and must be sent away. The ease with which we get them into our asylums is another element to take into consideration. Not a word ever comes back to us in regard to a patient's insanity, whether he is insane or not. The feelings of practitioners should never be taken into account, but if patients are not insane the superintendents of asylums should send them back promptly and so pronounce them. I find also another trouble: we cannot get from our asylums the information we want as to when the patient is about to cross the line from sanity to insanity. I plead for more information on the etiology and pathology of insanity and less on the technic of management. Give that to us and then we will send less to asylums.

Dr. CREGO: I desire to correct a possible wrong impression that my remarks may have caused. In the first place, I do not advocate keeping dangerous homicidal patients at home; I do not advocate keeping suicidal patients at home unless they are under strict guard. What I am advocating is that the general practitioner should study their cases with care, and then they will recognise the man that is going to kill his children, and the woman who is dangerous, and they will not keep them at home for a minute, but will put them in a proper place of detention. It is unnecessary to keep those cases at home, it is not right to do so. In the next place, they should not be put in a room by themselves and allowed to go without treatment. They need treatment the same as a man with pneumonia or typhoid fever. It is a disease they suffer from and they are not going to dream it away; it is not going to disappear unless the doctor gives them. some relief. Dr. Howe has hit the nail on the head; we must get at the cause and pathological condition,-pathology and etiology. I think the new books on insanity are pretty profuse and prolific on these points.

Dr. J. P. CREVELING, Auburn: I would like to say one word in support of Dr. Crego's first remark, that the student of today does not study insanity or attend the lectures on that subject. I believe that for the last four or five years the question has appeared in the questions put by the state examining board every year, "Define an illusion, a delusion, and a hallucination." Some of the most absurd answers have been given. As an illustration I give you one. A candidate, in describing an illusion, said it was "a belief a man has that he is God, when he isn't." Though this man was from Buffalo, I don't believe he ever attended Dr.

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Crego's lectures or he would not have made such an answer. heard only the last part of Dr. Stephenson's paper, where he paid a great deal of attention to diseases of fermentation, as I infer, of the stomach. It is my impression that more toxic conditions follow from a clogged colon than from a fermented stomach. Another class of cases where there has been a good deal of mental disturbance-not insanity-has come under my care which have been associated with a gouty condition, and I believe in many instances the cause of mental aberration may be traced to gout and, likewise, to kidney lesions that have not been recognised.

Dr. STEPHENSON: I have nothing to add. I believe the success of any paper must be admitted from the discussion which it has elicited, and as this has been going on for more than an hour, I think that I can congratulate myself. I thank the gentlemen very much for responding so liberally in the discussion.

The Alexander Operation-Its Immediate and Remote

Results.

BY JAMES E. KING, M. D., Buffalo, N. Y.,

Adjunct Professor of Obstetrics, University of Buffalo; Attending Gynecologist, Erie County Hospital; Assistant Gynecologist, Buffalo General Hospital;

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Fellow British Gynecological Society, London.

Y object or, perhaps better, my apology for asking your attention to the much discussed Alexander operation, is not that I have a new technic to offer, but only to consider a few of the clinical features which are results, immediate or remote, of the operation. It is an operation that has been much criticised favorably and unfavorably, but the results of the discussion and the experience of many operators, whose cases number in the hundreds, has been to place it upon a firm foundation as one of the surgical resources of gynecology. Successful results are only possible when the indication for it is carefully observed. It is agreed by all that it never should be undertaken in the presence of any complicating condition of the uterus or adnexa unless such condition may be treated satisfactorily at the same time. This, then, reduces the indications to very simple terms-namely, simple uncomplicated retroversion which implies a most careful diagnosis. We do not expect an Alexander operation to relieve symptoms with complicating disease of uterus or adnexa and it is therefore unfair to condemn the procedure when done under such circumstances.

In the correction of simple retroversion we are dealing with tissue which is in no sense pathologic and the operation aims at a mechanical result. The correction of the retroversion is usually

permanent. Cases of relapse may often be traced to suppuration or to the presence of unusually small ligaments. The latter failures should not be charged to the operation but to the unfortunate choice of the method in those particular cases. Granting that relapse may occasionally occur, it is rather from the patient's viewpoint than from the mechanical results that the few clinical features will be discussed. It is unfortunate that the surgeon and patient cannot agree always as to a successful result in operations.

One of the unpleasant sequelæ is pain. It is usually unilateral, extending up in the abdominal wall about three inches. It is sometimes quite severe and is intensified by pressure or walking. It may come on directly following the operation, or it may be delayed for a few days. It often remains four or five months, gradually improving until ultimately it entirely disappears. When it is severe, the patient may be unable to wear her corset. The cause for this pain seems to be injury to the ilio-inguinal nerve. The nerve as it passes through the inguinal canal from the abdominal muscles to its cutaneous distribution, lies in very intimate relation to the round ligament. It may be injured in its separation from the cord or in pulling the ligament out; and, finally, it may be sewed in with the fascia when the canal is closed. It is also often seen in the wounds that have suppurated, the nerve doubtless being held in the resulting scar tissue. Great care should be observed in avoiding further handling of the nerve than is necessary for its separation from the ligament, and in closing the canal the nerve should be carefully placed and not sewed in with the fascia. To the patient, the pain is often very troublesome and unpleasant and, unfortunately, there is little that can be done for its relief.

Another result which is sometimes seen, and which is far from satisfactory to the patient or surgeon, is the failure of the corrected retroversion to relieve all the symptoms. The fundus may be well forward and held so, but the patient is conscious of a feeling of dragging and weight in the pelvis. Nearly all cases of retroversion are accompanied by some relaxation of the uterosacral ligaments and consequent descent of the uterus, depending upon the amount of relaxation and the condition of the pelvic floor. In some cases the symptoms seem largely to be due to the condition of these uterosacral ligaments. Two cases of my own will best illustrate these observations.

Mrs. B., age, 27; married five years; three years ago labor was induced at seven months for dangerous kidney symptoms; eighteen months later she became pregnant again, but aborted at four months, the fetus presenting the appearance of having been

dead about ten days. When first I saw the patient she describe:1 symptoms of retroversion, the history indicating its existence for some time before marriage. Examination showed a freely movable displaced uterus. No prolapsed ovary could be felt nor was there evidence of uterine or adnexal disease. The uterosacral ligaments were much relaxed, allowing descent of uterus. Examination at the time of operation verified previous findings. The Alexander operation was done, the ligaments being found of good size. Following the operation a pessary was worn for three months, during which time the patient was quite free from unpleasant pelvic symptoms. A short time after removal of the pessary, symptoms of weight and dragging in the pelvis were complained of. Examination showed fundus of uterus well forward and normal in size; ovaries apparently in position. There was, however, still marked relaxation of uterosacral ligaments and descent of cervix. A pessary was again placed with the relief of symptoms. Removal of the pessary was each time soon followed by recurrence of symptoms, so that for a year and a half the pessary has been necessary for the patient's comfort.

The second case is Miss M., age. 22. She gave the usual history of retroversion and dysmenorrhea of four years standing. Examination disclosed a freely movable retroverted uterus, with no adnexal disease, but marked relaxation of uterosacral ligaments. Examination under ether at the time of operation gave the same results. The Alexander operation was done and a pessary worn for two months following operative intervention. Three weeks after its removal the patient returned, complaining of backache with dragging and weight in the pelvis. The fundus of the uterus was found well forward, but the cervix was low, due to the relaxation of uterosacral ligaments. A pessary was fitted with complete relief. For six months past she has worn the pessary and has made no complaint.

These two cases may be regarded as a type of the "successful operation" that does not cure the patient. That the symptoms in both cases were due to the relaxation of the uterosacral ligaments seems conclusive, inasmuch as refitting a pessary afforded relief. Such a sequence does not, however, always follow in the presence of relaxation of these ligaments, for in many cases in which there is marked descent the symptoms are completely relieved by the operation alone. It is simply a difficulty which results from the lack of uniformity in the symptoms produced by the same condition in different individuals.

The appearance of hernia following the operation is sometimes seen. Many such cases have been collected. Faulty technic and suppuration are in nine cases out of ten often responsible for it. The same care should be observed in sewing up the canal as in the radical operation for the cure of hernia. When so done