making a flap, etc., but the especial feature is the manner in which the sutures are inserted.

Referring particularly to the Emmet operation, the only way I know to discuss it for mutual benefit is for every man to do like Dr. Anderson and give the results of his personal experience, so that others inay profit by his mistakes. I found in a great many of my earlier operations the mistake I made was in taking up too much tissue with the crown stitch, giving that stitch too much work to do. In passing the needle out after inserting it I took up too much tissue; I undertook to do too much; I found there was too great tension upon this suture, and some inflammation followed. I also found that more of the work should be done intravaginally.

As to catgut: While of course this will ordinarily do as well for sustaining stitches, the main sutures should be of silkworm gut, and I think silkworm gut is the best suture material. In one case a small abscess followed the use of catgut. I have frequently found little phlegmons at the angle of the wound where catgut was used.

One other point is the method of securing the suture. There is no doubt in my mind that there is a great advantage in fixing the suture with a shot instead of tying. By this method we can always locate the suture and it can be removed usually without any pain. The shot has been of the greatest advantage in connection with the suture in my experience. I have used silkworm gut, also catgut, in these operations, but have never tried the silver wire.

Before leaving the subject I desire to say that while the Emmet and Doleris operations may be regarded as the best for lacerated perinei, still the Tait operation has its field of usefulness. There are many cases of complete laceration, where a segment of the bowel has sloughed, which may be relieved by the Tait operation. In certain cases of complete laceration the Tait is the best operation that has ever been devised, and will give better results than any other method in my experience.

I can not agree with the essayist that there is no other operation indicated for the relief of prolapse except the radical one of removing the uterus. I do not believe such a statement can be substantiated. It would depend very largely upon the condition of the prolapse and the age of the patient. I do not overestimate the benefits of perineorrhaphy, but we should not depend upon it to do too much, but in conjunction with other operations upon the uterus many cases of

prolapse in young and middle-aged women can be relieved without hysterectomy. In some of these cases I have been in the habit of beginning very high up in the vagina, making a V-shaped denudation and suturing the tissues from there down; then by doing a perineorrhaphy you will find in many of them that the uterus, if not in a condition of subinvolution, will be retained in its normal position. If there is a lacerated cervix this should also receive attention; if the cervix is elongated it should be removed; then, if the perineum is restored as I have indicated, even if there was complete procidentia, you will find in many cases a cure will result.

Dr. J. L. Howard: Dr. Frank's paper is of especial interest to the general practitioner, who is usually the first to be consulted, as the patients are usually delivered by him. Dr. Goffe, of New York, claims that the perineum only serves one purpose, that it plays no part in procidentia uteri except that it yields and allows the uterus to descend. He explains that the perineum gives rise only to fibers of the levator ani muscle, and its sole function is to assist in defecation by pulling up the anus, also to assist in labor by pulling up the perineum over the child's head.

The question of when to operate, or whether to operate at all, upon these cases came up the other day when I delivered a woman of her fifth child. She has had five children in a little over six and a half years. She has never seen her menses from the time she was married. When her first child was born there was a median perineal laceration down to the fibers of the sphincter muscle. There was also a slight rectocele at that time, which has never gotten very much worse. I feel certain if this perineum had been repaired after delivery of the first child, there would have been another laceration when the next child was delivered, and so on; and her condition at the present time might have been worse than it now presents.

Dr. Louis Frank: I did not know to whom to give credit for the operation described; it seems to be like, yet in some respects unlike, the method used by several other gentlemen. I have always been impressed with its superiority over other methods for the reasons expressed by Drs. Anderson, McMurtry, and Cartledge, that more satisfactory results are obtained by it. I have been doing perineorrhaphies by what I took to be the method as devised by Emmet, but it never gave satisfactory results; but since I have followed the method of suturing which I attempted to describe the results have been eminently satisfactory, quite in contrast with my previous work.

In regard to the Tait operation, I think, in those cases where the fibers of the levator ani muscle are not involved, the Doleris or the Tait operation might be of benefit. Where we merely desire to bring the two lateral halves of the perineum together, for relief of the laceration, by a median line suture, it may be easily done by the Tait method, and the perineum restored. In cases of complete laceration I do not believe the extensive splitting advised by Tait is necessary. I have found the method devised by Emmet best suited to these cases, that is clipping away the loose tissues and freshening the ends of the retracted sphincter muscle, and that it is unnecessary to do any extensive splitting. Possibly by this latter method we may relieve tension on some of the sutures, but I do not believe this is absolutely essential.

As to prolapse being cured by perineorrhaphy: Where the prolapse is not great, and has not existed for any great length of time, the patient may be greatly benefited by this operation, if it is supplemented by amputation of the cervix if elongated, or by such other operative procedures as may be necessary; but where the prolapse has existed for any time, and where the ligaments have become so completely relaxed as we will find them in cases of long standing, I think no benefit can be derived from this or any other operation except an hysterectomy. The volume of the organ itself, as these uteri are usually very much enlarged, is sufficient to cause it to again descend. An operation which might be of benefit in the case of very old women, where the vagina. was not expected to be again used physiologically, might be that devised by Freund, of introducing silver wire sutures, surrounding the vagina and bolstering the uterus up in this way. Where prolapse is of long standing I fail to see how any benefit can be derived from mechanical means, unless it be by the Freund operation, the ligaments being so relaxed that the uterus will not remain in its proper position.

JOHN MASON WILLIAMS, M. D., Secretary.

MEMORIAL TO Professor BILLROTH.-A memorial to the late Professor Billroth was unveiled in the University of Vienna. A very large and representative assembly, including many of the late surgeon's most eminent pupils, attended the ceremony. After Professor Gussenbaur had delivered a speech in which he described the career of Professor Billroth, the memorial was formally presented to the university by members of Professor Billroth's family, and accepted by the rector in the name of the university.-British Medical Journal.

Foreign Correspondence.

LONDON LETTER.

[FROM OUR SPECIAL CORRESPONDENT.]

The Nice Hospital; Use of the Roentgen Rays; Oxygen in Wounds; Gift to the London Hospital; A New Aseptic Ward; A Case of Pleural Effusion; The Treatment of Sewage; Sickness in the Army; The Army Medical Department; The Maidstone Epidemic Again.

The Victoria Ward of the Foreign Hospital at Nice, which was to be erected to commemorate last year's Jubilee, is now reported to be finished. The building is to be opened during the Queen's stay at Nice, and it is hoped that some member of the Royal family will inaugurate the new ward. The cost has been covered, as well as the endowment fund for a free bed therein.

At the annual meeting of the Liverpool Royal Southern Hospital the increasing value of the use of the Roentgen Rays was said to be daily becoming more apparent. Between March and September of last year the hospital Roentgen Ray apparatus had been used for fifty-seven cases. The fact was also mentioned that the hospital was the first of its kind in the world to practice the straightening of spinal curvatures, and the success of these operations proved that in the future deformity would seldom or never occur.

Dr. George Stoker, in his book, "The Oxygen Treatment of Wounds, says that his experience affords strong evidence that the continuous action of dilute oxygen has the most beneficial results. Not only does it bring about healing in cases which seemed hopeless, but the new skin is quite unlike ordinary scar tissue, being soft, thick, smooth, fair, loose, warm skin, not rigid or seamed, and hardly to be distinguished from healthy structures.

Twenty-five thousand pounds have been given anonymously to the London Hospital for the construction of a new out-patients' department outside the hospital. The gift is made on two conditions - one that the patients pay a small sum toward the cost of the medicines or dressings supplied, and the other that the hospital letter system shall be abolished. It has long been considered by many that the system of hospital letters is bad from all points of view, converting a charity into a commercial speculation. The donor of a guinea receives so many letters, which are in too many instances distributed with no sort of regard to the merits or demerits of the case.

The new aseptic ward of the London Temperance Hospital is claimed by its authors to be an ideal ward. It is for the use of one patient only at

a time. The walls and ceilings are of enameled glass tile of pale pink

color, with all the angles rounded off. The floor is of marble mosaic, the angles also being rounded. Almost the whole of the wall facing west is plate glass window. By this means a splendid light is obtained, which can on occasion be screened by an external blind. Below this large window is the fireplace, the flue being diverted to either side. The upper fifth of the window is so contrived as to open valvewise inward, this result being obtained by mechanism external to the ward. A small area of the glass-tiled east wall is correspondingly made to open, but when closed it is flush with the wall. Thus free aeration can be insured. For ordinary ventilation a glass-lined air-shaft is provided delivering obliquely upward; in this shaft is placed a fan worked by electricity. The air supply for this is drawn from high above the hospital buildings, being also filtered through cotton wool in its passage down the shaft. Artificial lighting is effected by electricity by means of a sunlight in the center of the ceiling. In a small glass-tiled recess are additional electric lights; when not required, this recess is closed by a glass door fitting flush with the wall. The furniture is entirely of metal, and can be washed with boiling water without fear of injury.

There has recently been an alarming recrudescence of influenza throughout England. For some time London had been comparatively free, but at the present time the outbreak almost approaches the proportions of an epidemic.

At the recent meeting of the Clinical Society of London Dr. Samuel West mentioned a case of serous pleural effusion of fifteen months' standing, which upon being treated by incision, the lung at once re-expanded, the patient making a recovery. Dr. West did not find it necessary to remove any portion of a rib, but at the present time, twelve months after the operation, although the man is able to follow his employment, he has to wear a tube in the opening in the chest wall. Dr. West thought that in cases of effusion into the pleural cavities it was most useful to use enforced respiration by the Silvester method, as through long faulty movement the muscles of the chest wall did not act efficiently and the increased movement improved the circulation through the parts and thus increased the absorption of the effused fluid.

It is stated that the Government have decided to immediately appoint a Royal Commission to inquire into the bacterial treatment of sewage. The remarkable success of the experiments at Exeter, Leeds, Sutton, and other towns has, it is stated, moved the Government to action.

The Army Medical Department Report for 1896 has been issued during this month. It appears that in the United Kingdom the ratios for sickness. and mortality were lower than during the the previous year, and considerably lower than the average of the preceding ten years, enteric fever showing a satisfactory decline. In India enteric and other continued fevers and cholera caused a great increase of sickness. Malarial fevers accounted for about one fifth of the admissions into hospital in India; one third were due to venereal diseases.