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suture. Mr. Ireland recommends the removal of a quadrilateral flap on each side. M. Velpeau prefers removing pieces both before and behind, so as to treat the recto. cele and cystocele, which he observes to habitually accompany prolapsus uteri. In the few cases in which excision has been practised, the prolapsus bas returned in a few months. The tediousness and difficulty of this operation, its liability to injure the bladder or rectum, and the chance of purulent infection, are objections to its performance.

Suture.-M. Bellini, an Italian surgeon, proposes to include a fold of the vagina in a suture, so as to produce sloughing. But the fold may be too deep; hemorrhage may be produced; or the long presence of the sloughs may irritate the organs, and expose the patient to the risk of purulent infection.

Narrowing of the Vulva.-Dieffenbach excised a series of longitudinal folds round the orifice of the vagina. But this only converts complete into partial prolapsus; and this would be a great point gained, if the patients were freed from the pain produced by the displaced uterus at the same time as from the projecting tumour. The merit of the operation is, however, doubtful. M. Malgaigne believed that the excision of the anterior or the posterior semicircumference of the vagina would be of more advantage than other methods; but the only case on which he operated in this way

was unsuccessful.

Fricke of Hamburg proposed to unite the walls of the vulva. internal faces of the labia majora, and united them by suture, as in perineoraphy. He pared the Care must be taken to leave an aperture behind for the passage of fluids, and one in front for the performance of the generative functions. The uterus is thus sustained by an artificial floor; but this is too low, and the radical cure is only the substitution of one grave infirmity for another.

All these modes of operation M. Desgranges believes incapable of fulfilling the object intended, while several of them are likely to produce danger. The opinion of M. Moreau, that pregnancy is a remedy for prolapsus, he answers by the statement that he has always seen it augmented after labour in persons in whom it previously existed.

The instruments used by M. Desgranges are small self-closing curved forceps, furnished at the end with projecting teeth; a holder resembling a pair of lithotomy forceps, but having the end of the branch channelled, for the purpose of applying the small curved forceps; a trivalve speculum; a lithotomy gorget; a pessary to distend the vagina; and a double T bandage.

Operation. The patient, having been prepared by rest, bathing, gentle purgatives, and an enema, is placed upon her back, with her thighs widely separated. The trivalve speculum is then introduced, with the handle turned towards the pubis, and the valves are separated to a circumference of about six inches. The vagina usually projects between the blades; but sometimes, when the tissue is less lax, it remains stretched. The cervix uteri must be carefully looked for, as it may lie between the valves of the speculum, like the portions of the vaginal wall.

Through the speculum, the vaginal forceps, with strings passed through their handles, are introduced by means of the holder; and, by strongly pressing on the handles of the latter, the blades of the forceps are separated. They are then placed on the projecting membrane of the vagina, and, by relaxing the hold of the handles, they are made to take firm hold of the tissues. Each projection between the blades of the speculum, or, as is sometimes found, each flat portion between them, may receive two or three of these forceps, so that from six to nine altogether are applied. The speculum being withdrawn, the pessary is introduced, and is firmly fixed by means of some turns of a double T bandage, of which the vertical bands meet the transverse one at the level of the hypogastrium; each of the vertical bands turns over the upper part of the thigh, to rest on the great trochanter. The string which attaches the pessary to the bandages ought to be rather behind than in front, as the passage of urine may otherwise be impeded or prevented by the pressure of the urethra against the pubis. The strings attached to the forceps are collected, tied together, and fastened to the bandage. The patient is then put to bed, and perfect rest is enjoined. The forceps generally fall off from the fifth to the tenth day, sooner or later, according to the size of the fold of the membrane which they have seized.

This operation is repeated on other parts of the vagina, the speculum being employed until the walls no longer project between its valves, or its being opened

causes pain or hemorrhage. The gorget or finger must then serve as a conductor. The gorget is passed in on the finger to the part intended to be operated on, and is turned with its convexity towards the vaginal wall. The vaginal forceps, fixed in the holder, are then introduced along the groove in the gorget. When they have arrived at the end, the conductor is withdrawn, and the forceps are made to seize the membrane. When the finger is used, the forceps are introduced along it, taking care that the finger be not wounded. On arriving at the destined spot, the blades are separated, and pressed against the vaginal wall.

The instrument is most easily applied on the posterior wall of the vagina; with more difficulty on the lateral wall; but, in regard of importance, the lateral walls have the preference. M. Desgranges has never made more than ten applications of the instrument. He says that the surgeon must be guided by circumstances in judging of the proper number of applications, but that it is better to make too many than not enough.

The pain, he says, is not great, unless the cervix uteri be seized: pain then is severe, radiating to the loins and abdomen. The free extremities of the forceps may cause excoriations, unless the tissues be protected by diachylon plaster.

Results of the Operation.-The febrile reaction is slight, and of short duration; and requires no treatment beyond low diet.

When the forceps have fallen off, a small suppurating wound is left. By digital examination, small hemispherical projections are felt, varying from the size of a pea to that of half a nut.

The vagina gradually loses its calibre and its mobility. At a later period, it becomes covered with nodular bands; the narrowing goes on until the finger can scarcely be introduced without a disagreeable sensation. In process of time, the nodosities become smaller, and even disappear; the vagina regains its suppleness, and, with the exception of its calibre, it returns far towards the normal state. The cervix is in the axis of the vagina; and the contraction affords no impediment to coitus or to delivery, as has been proved in one case.—Association Med. Journal, May 13, 1853, p. 415.

139.-On Vaginal Cystocele, or Prolapsus of the Anterior Wall of the Vagina and Bladder, and a new Operation for its Cure.-[At a meeting of the Medical Society of London, Mr. BROWN related a case illustrating the above affection. The patient was 52 years old, and had ten children. The case was so aggravated that with the least exertion the anterior wall of the vagina became so prolapsed that a tumour was produced by it of the size of a man's fist, producing several ulcerated patches from the friction of the parts. All means of relief which had been suggested having done no good, it was determined to try to effect this by means of operation] The patient having been prepared for the operation, by emptying the bowels, was, on February 15th, placed under the influence of chloroform, and then put in position for lithotomy, each leg being held by an assistant, and well bent back on the abdomen, a third assistant holding up the tumour with Jobert's bent speculum, and pressing it under the pubes in its natural position. A piece of mucous membrane, about one inch and a quarter long, and three quarters of an inch broad, was dissected off longitudinally, just within the lips of the vagina. The upper edge of the denuded part being on a level with the meatus urinarius, the edges were drawn together by three interrupted sutures, this being repeated on the other side of the vagina. The next stage of the operation consisted in dissecting off the mucous membrane laterally and posteriorly in the shape of a horse-shoe, the upper edge of the shoe commencing half an inch below the lateral points of denudation, taking care to remove all the mucous membrane up to the edge of the vagina, where the skin joins it. Two deep sutures of twine were then introduced about an inch from the margin of the left side of the vagina, and brought out at the inner edge of the denuded surfaces of one side, and introduced at the inner edge of the other denuded side, and brought out an inch from the margin of the right side of the vagina, thus bringing the two denuded surfaces together and keeping them so, by means of quills, as in the operation for ruptured perineum. The edges of this new perineum were then brought together by interrupted sutures, and the patient placed in bed on a water-cushion.

Two grains of opium given directly, and one grain every six hours; simple waterdressing applied to the parts; beef-tea and wine for diet. A bent metallic catheter was introduced in the bladder, to which was attached an elastic bag to catch the urine; by this means the bladder was constantly kept empty. This patient progressed satisfactorily from day to day without a single unfavourable symptom, and on the 22nd the deep sutures were removed, and the parts found firmly united; the lateral interrupted sutures were gradually removed, and firm union was found to have resulted. On the 26th examined very carefully the vagina, and found the deep union perfectly sound, about three quarters of an inch thick, the lateral wounds well contracted; the tumour could not be brought down by coughing. March 8: The parts are all firmly healed; the patient much improved in health, with a very cheerful aspect of countenance; she can walk about without inconvenience, and no amount of exertion produces any prolapsus; she can empty her bladder with comfort, and all the leucorrhoeal discharge, which was so distressing before the operation, has entirely subsided; the offensive smell from the decomposition of the urine has also disappeared. On passing the finger into the vagina, the os uteri can be felt easily in its normal position, and the ulcerated spots which formerly existed on its surface are healed. On the 10th she was discharged cured, and resumed her duties as domestic servant.

Remarks. It will be observed, that the object sought in this operation was the contraction of the calibre of the vagina, which, as may be imagined, was exceedingly enlarged and flabby. The first step of the operation was the contraction of the vagina laterally, so as to prevent the tumour from falling down from above; the second step of the operation was for the purpose of contracting the vagina posteriorly as well as laterally, and finally adding to the extent of the perineum by contracting the orifice of the vagina at least two-thirds, so that should the prolapsus not be restrained by the lateral contractions, it could not extrude beyond the orifice of the vagina, but must necessarily fall upon the new perineum. As is proved by the result, all the objects sought have been fully attained, and it is scarcely possible to imagine a more satisfactory result from any operative procedure. It will also be observed that the benefits from this operation for vaginal cystocele will be equally, if not more, applicable to vaginal rectocele, as well as to prolapsus of the entire vagina, and also, with some slight modifications as to denudation of the mucous membrane, to prolapsus uteri.-Lancet, April 30, 1853, p. 412.

severe.

140.-Ulceration of the Cervix Uleri Treated by the Application of Collodion.The 'Bulletin Générale de Thérapeutique' for January 15th, states that M. ARAN employs collodion with success in certain cases of ulceration of the neck of the uterus, especially those which depend on, or are kept up by, the friction of the vagina against the cervix, directed either forwards or backwards. An illustrative case is related of a woman, aged 29, who was admitted into the Hôpital de la Pitié, who had for two years suffered from headache, dyspepsia, leucorrhoea, and dragging pains in the lumbar and hypogastric regions. These symptoms had for six months become much more On examination, M. Aran found the uterus in a state of anteversion; the neck was large and extensively ulcerated, principally at the posterior part, which was directed towards the hollow of the sacrum. Rest, slight cauterization from time to time with nitrate of silver, baths every two days, poultices, enemata, and emollient injections, were tried for more than three months without any marked result. When lying down, the patient did not suffer; when erect, she was troubled with dragging sensations in the loins and hypogastrium. M. Aran applied collodion over the cervix, by means of a brush. The patient only felt a slight burning sensation when the speculum was removed. Three days afterwards, most of the collodion had remained, and the ulcer, which could be seen through it, appeared to be rapidly progressing towards cicatrization. The application of collodion was repeated three times within a month; and at the end of this period, cicatrization was nearly complete. At the same time, the dragging in the loins and the pains in the stomach had diminished, and the leucorrhoea had completely disappeared. The patient walked without pain or difficulty; her general health seemed excellent; and with the exception of a little weakness in the loins, and some heaviness of the head, she felt quite well.

This is satisfactory enough as far as it goes; but has the cure been permanent? On this subject we have some fears; for it is stated that "the anteversion is still much marked;" and in this case the tilting of the cervix backwards, and the consequent friction of its posterior lip against the vaginal wall, may reproduce the ulceration.-Association Med. Journal, May 27, 1853, p. 468.

141.-ON OVARIAN TUMOURS AS A CAUSE OF DIFFICULT LABOUR. By Professor LITZMANN, of Kiel.

The 'Deutsche Klinik,' for 1852, Nos. 38, 40, and 42, contains an article by Professor Litzmann, on the influence of ovarian tumours in producing difficult labour. The following is an abstract of this interesting paper.

It is a recognised fact, that conception is no more prevented by the degeneration than it is by the extirpation of one of the ovaries. Pregnancy seems in many cases to induce a more rapid growth of the ovarian tumour: this is especially true with reference to cystous and cancerous tumours. Fatty growths, as a rule, are not affected by gestation. Gestation is also prematurely interrupted by ovarian tumours; partly from their mechanical pressure on the uterus, and partly (especially in cancer) by the setting up of a profound disturbance of nutrition and innervation. Small ovarian tumours, which entirely or partially sink into the pelvis, are apt, from their pressure, to bring about abortion at an early period of pregnaney.

If pregnancy reaches its full period, the labour may end naturally, both as regards mother and child; but more frequently ovarian tumours give rise to impediments endangering the life of the mother as well as of the child. To thirty-one cases collected by Puchelt, jun., Dr. Litzmann has added fifteen from various sources, and one case described by himself-making in all forty-seven cases, in which labour was impeded by ovarian disease. Of these cases, in twenty-five the diagnosis of ovarian tumour was confirmed by section or by puncture: four of the tumours were simple cysts, three were compound, twelve were fatty cysts, and six were scirrhous growths. In the other twenty-two cases, the relation of the tumour to the ovary is not pointed out. The diagnosis during life is by no means easy, and can for the most part be considered only as more or less probable. In general, large tumours, lying entirely or partly over the entrance of the pelvis, are readily distinguished; while in small tumours, occupying the posterior part of the pelvic cavity, the diagnosis from other tumours which occur in this part is difficult. These ovarian tumours are always found in the space between the vagina and the rectum. The principal signs by which they can be distinguished from fibroid cystic growths, &c., between the vagina and rectum, are their gradual direction from the synchondrosis on one side toward the middle of the hollow of the sacrum, and the possibility of pushing them more or less easily above the entrance into the pelvis. But commonly the tumour is first detected only when it is entirely in the pelvis, and when its reposition during labour is not unfrequently prevented by the pressure of the gravid uterus or by adhesions. Fibrous and scirrhous growths from the inner surface are distinguished by their not easily mistaken place of origin, as proved on examination per rectum. More difficult, and often even impossible, is the diagnosis from other tumours in the recto-vaginal space, as cysts of the uterine ligaments, or of the Fallopian tubes, or tumours of the posterior wall of the uterus. As the latter are found very rarely to produce hindrance to labour, the detection of a tumour in doubtful cases affords a strong suspicion that it is ovarian. It is of especial importance to discover whether the tumour be solid, or a cyst, whose contents may be let out by puncture or incision. Fluctuation, if present in the least degree, will be best detected by examining the tumour simultaneously through the vagina and rectum in the intervals of the pains. The smoother and more equally developed the swelling is, the greater is the probability of its being a cyst.

Ovarian tumours are most dangerous to the progress of labour, when they are wedged more or less deeply in the pelvis; but tumours lying above or upon the entrance into the pelvis may, in certain circumstances, produce a great mechanical impediment.

The forty-seven cases related contain a notice of the progress of, in all, fifty-six

labours. In ten, natural delivery took place, mostly after tedious labour and severe pains. In two cases natural labour was assisted by the death and putrefaction of the child, in another by the pliability of a hydrocephalic head. One child was born alive; the reports do not state the fate of the others. Four of the mothers died.

In seven cases, the tumour was pushed above the pelvic entrance. In three of these cases, turning was performed; in one, the forceps were applied; and in three the labour proceeded naturally after the reposition of the tumours. Two of the children were still-born; and of five born alive, two soon died. One of the mothers died.

In nine cases, puncture or incision of the tumour was performed; once through the abdominal parietes; twice through the rectum; and in all the other cases through the vagina; always with the effect of diminishing its volume. In three cases, labour proceeded naturally; in three, perforation and extraction had to be performed; in one case, turning was necessary; and in one, the forceps were applied. Only one child was born alive; and five of the mothers died.

The forceps were applied in altogether eleven cases; once after puncture; once after reposition of the tumour; once to extract the head in a case of turning; and in one case they were ineffectual, and delivery had to be effected by embryotomy. In al. the other cases, the forceps were the only instrumental means employed; in these, two of the children were still-born, and four of the mothers died.

Turning was performed in eight cases; in three after reposition of the tumour, and in one after puncture. The results to the life of the mother and the child are not stated with sufficient accuracy. Extraction in foot-presentation was performed in three cases; all the children were dead.

Embryotomy was performed in seventeen cases; in four after puncture (in which three of the mothers died), and in one case in artificial premature labour; of the remaining twelve cases, five were fatal to the mothers.

Premature labour was induced in two cases.

Of the whole, seven children were born alive, thirty-five were still-born, while there is no account of fifteen; of the mothers, thirty-two recovered, and twenty-four died.

In the treatment of these cases, a principal rule is not to delay operative interference too long, as it is very rarely that a favourable termination to the labour, as regards both mother and child, is to be hoped for from the powers of nature. By delay the life of the child is almost always sacrificed; its skull usually undergoing pressure between the tumour and the wall of the pelvis, as in a case of narrow pelvis. As regards the mother, besides the tediousness of the labour, the unavoidable bruising of the tumour and of the weaker parts of the pelvis is to be feared; and when the pains are violent, there is risk of rupture of the uterus or of the tumour. The result of every operation, to which recourse has been had at a late period, is doubtful.

During labour, we must first attempt to push the tumour, per vaginam or per anum, above the pelvic entrance. The most convenient period for this appears to be immediately after the rupture of the membranes, or as soon as more active pains have set in. If reposition is not possible, no time must be lost in ascertaining whether it is possible to diminish the size of the tumour by evacuation of its contents. This is best performed by puncture through the vagina with a curved trocar ; and if the contents are too firm, the aperture may be enlarged by incision. If this operation is ineffectual, the choice lies between embryotomy and the Cæsarean sec tion. Extirpation of the tumour during labour seems to have not yet been attempted. No help can be expected from the forceps or from turning, unless the size of the tumour have been previously reduced. With regard to the indication of premature labour, Dr. Litzmann thinks it but rarely indicated; as the narrowing of the pelvis by ovarian tumours is mostly so remarkable, that without previous reposition, a living child cannot be delivered even prematurely. He says that it should be performed only in those cases in which there is narrow pelvis as well as an ovarian tumour.— Association Med. Journal, May 27, 1853, p. 469.

142.-Tuberculosis of the Vagina. By M. R. VIRCHOW.-Some time ago, I had