The treatment, therefore, of procidentia must always include an adequate operation on the perineum, or, more comprehensively speaking, upon the posterior wall of the vaginal outlet. The operation must be performed so that it will carry the lower extremity of the vagina forward to the normal location close under the pubes; then, if the anterior colporrhaphy has been adequate, and has carried the upper extremity backward, the whole vagina will have its normal oblique direction, and its long axis will make the necessary acute angle to the long axis of the uterus.

Hysterectomy, if indicated, should be performed by the vaginal route. As an operation for procidentia, hysterectomy is open to the following comments: Procidentia, as already shown, is hernial descent, not merely of the uterus, but also of the vagina, bladder and rectum. Complete prolapse often occurs after the menopause, when the uterus has become an insignificant rudimentary organ, and therefore may be removed easily. Cases are numerous in which, after vaginal hysterectomy, the pelvic floor, and with it the vaginal walls, have protruded again through the vulva a result which may be expected unless the operation has included anchorage of the upper end of the vagina to its normal location by stitching the severed ends of the broad ligaments into the wound made by removal of the uterus. The indications for perineorrhaphy as a supplement to hysterectomy are the same as after anterior elytrorrhaphy.

As laid down in the foregoing paragraphs, the utilization of the broad ligaments is the essential factor in the treatment of complete procidentia. The operation of elytrorrhaphy, above described, unfortunately either may fail to bring the lower edges of the broad ligaments sufficiently in front of the uterus to enable them to hold up the uterus and vagina, or the ligaments having been stitched in front, the stitches may not hold. Consequently, in complete procidentia, elytrorrhaphy, even though well performed, may fail; at least, this has been my experience in a number of cases. Therefore, the completely prolapsed uterus may have to be removed in order to secure the entire outer ends of the broad ligaments to the upper part of the vagina, and thereby give absolute support. As before stated, the operation should include the treatment of the hernial factor in the lesion, that is, removal of the redundant portion of the anterior vaginal wall. Generally speaking, the indications are somewhat as follows:

1. Extreme cystocele, not associated with the most extreme procidentia, should be treated by anterior colporrhaphy and perineorrhaphy.

2. Cystocele associated with complete procidentia properly, may be treated by hysterectomy, anterior colporrhaphy and perineorrhaphy. Anterior colporrhaphy in all cases.

3. Conditions intermediate between the two conditions indicated above, and cases of very feeble or very aged women, will call for special judgment whether hysterectomy be omitted or performed. It is, however, a fortunate fact that the completely prolapsed uterus, even in aged women, is removed usually with ease and safety.

Other Operations of Questionable Value.-Other operations, designed to decrease the weight of the uterus by removel of it, are of questionable value. Amputation of the cervix to lighten the weight of the uterus has been practised much for the spurious hypertrophic elongation already described. Since this condition. is rare, if not indeed unknown, it follows that it seldom will furnish an indication for amputation of the cervix uteri.

Alexander's operation and abdominal hysterorrhaphy belong to the surgical treatment of retroversion and retroflexion, not of procidentia. The object of these operations is to suspend the uterus from above. Hysterorrhaphy, which perhaps fulfils this indication better than shortening the round ligaments, may be indicated in cases of extreme relaxation of the uterine supports and greatly increased weight of the uterus. The results of it in complete procidentia, however, usually will not be permanent unless it is supplemented by adequate surgery to the vagina.

Proceedings of Societies.

Ο

THE GREAT WEST AND THE VANCOUVER MEETING OF THE CANADIAN MEDICAL ASSOCIATION.

In a previous issue, through the kindness of a collaborator, a former resident of the North-West, we published a short, illustrated article on the beauty of the trip to the Coast, in order to try and infuse an added desire on the part of the members of the medical profession here to overstep all barriers and be among those present at this year's Canadian Medical Association meeting at Vancouver. As ever, L'homme propose et Dieu dispose, and many who had planned to go were detained: some were sick, others in England, and "some had friends who gave them pain,' usually relations, and so the treat of a trip to the great West was missed. One more opportunity, however, of a similar character, presents itself, to take the trip, and even a further one, out to Portland, Oregon, to attend the American Medical Association convening there in July of next year. We here insert the remaining number of half-tones illustrative of the picturesque beauty of the tarrying spots along the way to Vancouver, which we hope ere long all the delinquent members of the C.M.A. of this year may view with delight. We physicians need more holidaying and surely more change of scene.

Perhaps the wonderful mountains are to the traveller the most inspiring sight of all.

Not

Banff is the most famous pleasure resort of the Canadian Rockies. It enjoys a situation peculiarly advantageous for realizing the magnificence and charm of the mountain scenery. only are there mountains on every side with all the sublimity of snow-capped peaks and rocky steeps, but many valleys radiate from it, affording a delightful contrast. a delightful contrast. The Canadian Pacific Hotel stands at almost the point of the angle that the Bow River makes round the foot of Mt. Rundle, as its course changes from north-east to south-east. At the same point the Cascade River comes down from the north by the side of the mountain of the same name, and a considerable flat is formed-one of the most beautiful spots of the National Park, in the vast area of which it is included.

The course of the Bow River before its turn has been transverse to the run of the mountains. The heights are ranged in

almost parallel lines north and south, the valley of the Bow, when it has resumed its southerly direction, being between Mt. Rundle and the Fairholme Range. Between the ranges come down small streams that feed the Bow. Thus from the south the Spray has cut a valley for itself between Mts. Rundle and Sulphur, and the Sundance Creek is between Mt. Sulphur and the Bourgeau Range. From the north, besides Cascade, the Bow receives Forty Mile Creek, which flows between the Vermilion and Sawback Ranges and then winds round the spurs of Stoney Squaw Mt. An enlargement of the Bow forms the Vermilion Lakes, charming sheets of water, that with many meandering waterwavs occupy the low ground of the valley and give the visitor unexpected and

lovely views of the giants that surround them and unsurpassed opportunities for boating.

Banff Hotel stands on the south bank of the Bow, close to the mouth of the Spray. It has recently been enlarged, and now accommodates three hundred people. It is fitted up in the most. comfortable fashion, with rooms single and en suite, and may challenge comparison with any other summer hotel on the continent.

A drive of great charm can be made to Lake Minnewanka that, shaped like a huge sickle, lies just north of Mt. Inglismaldie. It is eight miles from Banff, and the road leads up the valley of the Cascade under the shadow of that glorious peak. The lake is nearly ten miles long, and its waters are strangely diversified in hue, deep blue and pale green giving way to yellow or grey, while