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to present at or outside the vulva, but is more likely to be mistaken for a tumor than procidentia. I once saw a well-known operator amputate at the vaginal vault thinking he was removing a fibroid, but an examination of the removed specimen showed it to be the inverted uterus with the appendages inside. However, the absence of the cervical canal and of the body above the vault should lead to a correct diagnosis in this condition.

ENTEROCELE.

Prolapse of the omentum and intestine, one or both, occasionally occur by carrying down Douglas' culdesac until it protrudes from the vulva, or sometimes when retroversion exists, by crowding down the bladder, separating its attachment from the vagina and thus presenting externally. The latter condition I have never seen, but I have seen four cases of the former. The largest, which contained intestine, omentum, and some fluid, was as large as a child's head. One contained nothing but ascitic fluid.

TREATMENT. Procidentia.—This is certainly one of the conditions wherein prevention is better than cure, especially the prevention of procidentia, and most of all complete procidentia in which a cure, in the sense of returning the parts to a normal condition is practically impossible. I believe, however, that every case could be prevented if given the proper treatment at the right time.

Phophylactic treatment consists in the careful examination of every patient after confinement and the proper repair of all injuries. This, not only immediately after delivery, but again after the woman has been about for a time lifting her baby and doing such other work as would prove likely to effect a weakened condition of these parts. If at this time there is found a tendency to uterovaginal prolapse, it is, as I have previously stated, due to a weakened condition of the ligaments, and a properly fitted pessary will relieve them of their load and hold the uterus in position until they have time to regain their proper tone. This will require probably one month, possibly six. The patient should be watched for some time after its removal and if still a tendency to prolapse or retroversion exists the pessary should be woin for a longer time.

If a tendency to vaginal or vaginouterine prolapse is discovered it will indicate a lack of support at the outlet, and surgical repair of the part is the only remedy and should be done before the upper portion of the vagina and uterus are dragged down from normal position. If these conditions were borne in mind and corrected when found, as they should be, soon after confinement, procidentia would be so uncommon as to be regarded a curiosity.

Simple Prolapse. When the uterus sags low in the pelvis, resting, as it often does on the pelvic floor, and giving rise to backache, dragging, dysmenorrhea, and pressure on the perineum, the indications are for some support to take the weight off the overstretched and sensitive ligaments, as well as the perineum, and a well-fitted pessary will generally fulfill the indication, but should it fail an abdominal suspension may prove necessary to give relief or effect a cure.

It may be laid down as a law that when the prolapse is uterovaginal a pessary or some abdominal suspending operation is necessary to retain the organs in correct position. (This is equally true in simple prolapse, prolapse with retroversion, or prolapse with anteversion). When the prolapse is vaginouterine in nature a narrowing of the vagina and strengthening of the perineum is indicated. If both forms are present a combination of both measures is usually necessary to secure success.

Elongated Cervix and Partial or Complete Procidentia.- I called attention to the conditions present in elongation of different portions of the cervix for the purpose of showing you how it differed anatomically from prolapse, and now I will attempt to demonstrate to you the difference in prognosis and treatment.

When the vaginal portion of the cervix only is elongated, the body, vagina, and bladder being in position, the treatment amounts to a simple amputation. I make an anterior and posterior flap near the vaginal vault, strip them back from as much of the cervix as seems advisable, cut off the cervix and stitch the flaps to the mucous membrane of the cervical canal in the center, and unite them at the sides. If the perineum is weakened it should be repaired as a prophylactic measure. When the intermediate portion is longated, the anterior vaginal wall inverted, and the bladder prolapsed, the incision for the anterior flap must be made below the bladder attachment in order to avoid wounding that organ. This flap is dissected from the cervix as far back as necessary, the posterior flap is made as before, near the vault, and the operation completed in like manner. This procedure carries the anterior vaginal attachment to where it originally belonged and replaces the bladder. Owing to the fact that the vaginal wall and bladder have been severed from their attachments to the pelvis to a greater or less extent, depending upon the amount of inversion, it is sometimes necessary to do an anterior colporrhaphy as well as a posterior colporrhaphy and perineorrhaphy in order to obtain further support. When the elongation is supravaginal both flaps must be made low down in order to avoid wounding the bladder, and peritoneum then dissected back to the lower portion of the body where the cervix is amputated, the flaps stitched to it as before, and anterior colporrhaphy, posterior colporrhaphy, and perineorrhaphy done if necessary. Frequently the peritoneal cavity is opened, in Douglas' culdesac, during the operation, but it is of no consequence and does not interfere with its completion in any way. The prognosis in these cases is good. There should be no mortality and every case should be cured.

In incomplete procidentia the conditions present must decide what measures are to be taken for their relief. If the uterus be small and not too sensitive, and the pelvic floor in a condition to sustain a pessary, patients may be made very comfortable with this instrument. In cases wherein operation is contraindicated as, for example, in feeble elderly persons or those suffering from diseases which make operations inadvisable, a well-fitted pessary will give great relief.

When a large, heavy retroverted uterus with lacerated cervix and prolapsed and diseased appendages present, and the patient be nearing the menopause, I believe the best treatment is to remove the diseased organs and complete the operation in the manner I shall describe later.

If the patient be younger or object to having the organs removed, I would curet thoroughly, amputate or repair the cervix, perform an anterior or posterior colporrhaphy, as indicated, and strengthen the pelvic floor. Then, if necessary, I should perform a ventrofixation or shorten the round ligaments, as seemed best.

In complete procidentia, with inversion of vagina and prolapse of bladder and rectum, any of these measures seldom prove satisfactory.

I have seen cases with the cervix and vaginal vault hanging outside the vulva within one year after all this had been done, the attachment of the uterus to the abdominal wall still remaining.

All kinds of procedures have been tried, from hooping the vagina with silver wire to crowding the organs inside and closing the vulvar opening and all have proven unsatisfactory. When carried into position and the pelvic floor restored or even the opening closed, they immediately drop down again, and, resting on the newly-restored tissues, either prevent good union or soon distend it and again lie outside. I cannot see that any benefit is to be derived from fastening the uterine body to the vagina, peritoneum, or bladder in front, when all alike are loose from their attachments and supports, and all drop down together. It would certainly result in nothing better than dragging the bladder that much more out of position if the retroversion returned, or, crowding it that much farther down in front if it remained anteverted.

Experience has proven in many cases that even anterior fixation does not prevent a speedy return of the prolapse. As I mentioned a moment ago, I have seen patients in whom even the prolapse was incomplete and amputation of the cervix, curetting, anterior colporrhaphy, posterior colporrhaphy, perineorrhaphy, and ventral fixation had been done, and well done, return in a short time with the cervix again outside the vulva.

I believe there is a way, however, by which even the worst cases can be given permanent relief, providing the patient be in a condition to undergo the necessary operation. It would probably not be advisable in all cases, however, as, for example, in aged and feeble persons who have but a short time to live at the best, and to whom other measures, such as a perineal bandage and pad or pessary, give a fairly comfortable existence, although I have done the operation successfully a number of times in patients over seventy.

When considering the etiology we found the causes of the procidentia to be a weakened condition of the pelvic floor, a weakened condition of the ligaments, increased pressure from above, and a heavy uterus. In procidentia it is common to have all these causes acting, and even more. The uterus is not only large and heavy but it has become a dilating wedge, and strengthen the outlet as you will unless this constantly-acting dilator is kept off the parts the work will soon be undone and the uterus again be outside.

The intraabdominal pressure is, as a rule, greatly increased in these cases, for they are generally fleshy, having thick, heavy abdominal walls containing large quantities of adipose tissues and large fatty deposits within the abdomen. Because of the fact that they are unable to exercise this is likely to become greater as time ensues, and thus the pressure from above be increased. It is possible to do something for this condition in the way of diet, exercise, such as the patient can take, and massage, especially of the abdomen, but the benefit is slight. It seems to me not only necessary to diminish the weight of the uterus and increase the support of the pelvic outlet, but quite as necessary to obviate the dilating wedge, and at the same time obtain support at or near the pelvic brim capable of sustaining the abdominal contents and vaginal vault. How can this be done? It is easy enough to remove the wedge by hysterectomy. This I know is strongly objected to by some, on the ground that hysterectomy has proven a failure for the cure of this condition, and once the uterus is removed the prospects for benefit by anterior suspension are forever lost. These objections are valid. Hysterectomy alone has proven a failure; anterior suspension, however, has not proven more of a success. Nevertheless, we remove the wedge by hysterectomy and secure the severed stumps of the broad ligaments, the wherewith for the support, near the pelvic brim, necessary to sustain the abdominal contents and hold up the vagina and bladder.

Right here I would like to say a word in justification of the removal of the uterus and appendages. In practically all such cases as we are considering, the ovaries, uterus and tubes are in such a diseased condition as to be a decided detriment to the patient, and if in their proper positions would in many cases require removal. It is not always conservative to attempt to save diseased parts, for in many cases it renders subsequent operations necessary.

After removal of the uterus and appendages in the ordinary way, per vaginam, I draw down the broad ligaments and pass a ligature as near the pelvic wall as convenient, usually two or three inches beyond the severed end, passing these through the end of the ligament of the opposite side so that when drawn up they cause the ligaments to overlap two or three inches. The anterior and posterior flaps of peritoneum are then approximated and sutured, beneath which the broad ligaments are united, overlapping as stated, and sutured firmly together. Thus we have a strong bridge across the pelvis, strong enough when well united to support the abdominal contents, vagina, bladder and rectum. To this bridge the anterior and posterior walls of the vagina are fastened, thus bringing the bladder and rectum into position.

Whatever is necessary in the way of narrowing the vagina is then given attention, the pelvic floor restored, and a light packing placed in the vagina. When put to bed the patient's hips should be kept elevated for a week or ten days in order to relieve the pressure on the parts until they are well united. Three weeks is little enough time to keep the patient in the prone position, for if allowed to assume the erect posture before union is strong the parts will not hold. With good union we have the indications fulfilled and there will be no further prolapse.

I have now operated in this manner on over twenty cases and there has not been a single relapse. The photoengravure represents the condition in one of the first cases I did this operation upon. The patient had been an invalid, in bed most of the time, for two years. Now she is as well and strong as ever, never has any dragging or sagging of the parts, and can do as much work as any ordinary woman.

It is an easy matter to diagnose an elongated cervix as procidentia and by an amputation and operation on the vagina and perineum obtain a cure. In partial procidentia the same measure may give complete or partial relief, but my experience has been that the major part of the suffering, such as the backache, dragging pressure and pain, are only partially, if at all removed, and the patient complains of nearly as much discomfort as previously, which, considering the condition existing, is certainly nothing more than we should expect.

I would not have you gain the impression that I advocate hysterectomy in all cases of prolapse, or even in all cases of procidentia, but I believe there is a class of cases which nothing short of the proceedings I have described will give relief. Each patient must be more or less a law unto herself, however, and it requires a thorough and careful study of the case to decide upon the best treatment. There are probably but few conditions that require greater judgment in deciding upon the best measures of relief, in modifying details of operations than the one under consideration.

TRANSACTIONS.

CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN.

STATED MEETING, JUNE, 26, 1903. THE PRESIDENT, pro tempore, WILLIAM F. BREAKEY; M. D., IN THE CHAIR.

REPORTED BY JOSHUA G. R. MANWARING, M. D., SECRETARY.

REPORTS OF CASES.

A CASE OF ACTINOMYCOSIS. Doctor DARLING: I will read the student's history of the case I wish to present.

The man was admitted to the hospital on the 3d day of May, 1903. He is forty-one years of age, and comes here because of abscesses in the

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