lines. The prominent feature of it is to promote longevity and lighten the burthens of the human family, shorten the daily period of labor, make effort more productive, and cheapen the means of living, of amusements and education.

Mankind live longer when the sanitary surroundings are growing more and more perfect, when the terrible struggle for life in this world of competition is lightened and made less wearing and tearing on the body and mind, when high moral principles prevail and less superstition hampers and embitters our lives.

We are brought face to face with the fact that a larger number of adults in advanced life die because fewer children go to the grave first. As a matter of course, there must be more marriages

and more births.

ELYTRORRHAPHY.*

BY DR. E. L. STANDLEE, ST. LOUIS.

Elytrorrhaphy or Colporrhaphy, as it is frequently called, is at the present time a well-recognized operation among surgeons generally, but seems on some account to be practiced much less than it should be; possibly because it is not very dangerous to the life of the patient, and cannot therefore be classed among laparotomies, hysterectomies, etc., as a capital operation; and yet, if properly practiced, I have found this a capital operation for the relief of the very unpleasant and annoying conditions of rectocele, cystocele, prolapsus uteri, and certain other displacements of the uterus, hereinafter to be mentioned.

This is also a splendid operation to forward the capital interests of the surgeon, because he may cure the cases that have only received palliative treatment at the hands of the general medical profession, without the loss of a single case (barring accident from the anesthetic, which must always be taken into consideration), and then your patient will bless you, properly advertise you among her friends, and swear by you always for such splendid relief.

The operation is slightly tedious, but quite simple when proper precautions are noted, and is done in the following manner:

The patient is prepared by dieting and salines for a day or two so that it will not be necessary to have the bowels move for a *Read before the Missouri State Eclectic Medical Society, June 11th, 1897.

few days after the operation. Parts are shaven and well cleansed, vaginal douche 1-2000 Bichloride Solution, and bladder emptied just before patient is placed upon the operating table, anæsthetic administered.

Now the legs and thighs are well flexed as in lithotomy or hysterectomy position, and the wall of the vagina exposed by retractors. A piece of antiseptic gauze or sponge is forced well up against the cervix uteri, to hold the uterus out of the field of operation, and acting as a tampon will somewhat relieve the flow of hemorrhage from the vaginal mucous membrane, which is now marked off with a scalpel and a longitudinal strip from the anterior or posterior wall, or both if necessary, is dissected out with tissue forceps and scissors. The strips removed must assume a general triangular or arrow-head shape, with the apex toward the mouth of the urethra in front, or the perineum behind, and the base toward the cervix uteri and well up.

The width of the strips will be in accordance with the quantity of relaxed and prolapsed vaginal tissue. In posterior elytrorrhaphy the surgeon should anticipate a partial or complete perineoplasty, for in most of these cases there will be found a partial or complete rupture of the perineum.

Only the mucous membrane is removed, taking care not to cut through into the bladder or rectum.

The edges are now stitched together with superficial sutures, from above downwards, until the perineum is reached, when deep sutures of silkworm gut, or silver wire, are applied as in ordinary perineal repair.

Close the perineum after the vaginal work has been completed, making this the last part of the operation. After the vagina has been flushed and bleeding points are well dried with a gauze sponge, the tampon is removed, and a long strip of Iodoform gauze loosely packed in the vagina, which completes the dressing, with a T bandage and a compress to the external parts. The patient is now placed in bed, and a cloth wetted with vinegar and water applied to the mouth and nose for some hours, to relieve or prevent nausea from the anaesthetic.

In vesicocele the bladder has a tendency to bag down or prolapse into the vagina, so that frequently a male catheter can be introduced upside down through the urethra, when the point can

easily be felt through the vaginal wall. This pouch will not fully empty when the urine normally passes, so that retention and consequently disintegration of urine soon causes the development of a cystitis, finally resulting in hypertrophy of the muscular coats of the bladder.

I do not know of any medicament or procedure that will so certainly relieve this condition as an elytrorrhaphy well done. The vagina is most certainly the normal and greatest support of the uterus. The ligaments will not hold the organ in place when the floor supports are faulty or wanting. Alexander's operation, as originally practiced, is difficult, tedious on account of finding the "lost cords" which are to be shortened, and not without danger, as the peritoneal cavity is really invaded on both sides. And the operation as modified in a ventro-fixation is even more dangerous, and surely does not leave the patient in a physiological condition after recovery, which is an end always at least to be sought, and as nearly as possible obtained.

A rupture of the muscular wall of the vagina may occur during a confinement without the mucous surface suffering. This will weaken the normal pelvic floor, which should be normally strengthened at the base or foundation of any structure which has been weakened.

This will correct many of the malpositions of the uterus, and seems to be the proper and normal way of supporting the organ in its original physiological position, giving all the pelvic viscera an opportunity through the normal support given them to regain their original tonicity.

After an elytrorrhaphy the cicatrices will soon absorb, leaving the vaginal surfaces normal, but the organ permanently contracted. A future gestation may be safely accomplished and labor properly terminated, as in ordinary primipara cases, which is hardly to be said in ventro-fixation cases, where the adhesions of the uterus to the abdominal wall distort the enlarging uterus, becoming painful and burdensome, interfering with normal contractions of the organ, if, perchance, full term be safely reached. After shortening the round ligaments, a rupture of the same has been noted in after gestations, caused by the rise of the uterus into the abdominal cavity. If this very severe and almost fatal accident should be escaped, the action of the shortened cords must necessarily cause

sufficient tension to make the gestation an abnormally painful one, always with the possibility of accident.

The safety of this operation, with the excellent results accomplished, will certainly commend it to your favorable consideration. You can practice it without hospital advantages; as the peritoneum is not invaded, simple asepsis will insure a favorable result. Many of these cases have a chronic endometritis, and therefore it is necessary to do a light or thorough curettement, as the circumstances demand. This, when necessary, is the first step in the operation, and is done before the sponge or tampon is packed around the cervix, as hereinbefore mentioned. This also assists in arousing and stimulating the two principles in organic construction, viz.: homogeniety and heterogeniety, or the laws of demand and supply, which are brought so prominently into play in all orificial surgery, influencing waste and reproduction, improving the nutrition in parts, and thereby furnishing the most favorable conditions for general bodily resuscitation, improved muscular tonicity, and in all a more perfect and regular organic function, with necessarily a much better vital energy and resistance.

The accompanying cuts will suggest the steps of procedure.

CLINICAL MEMORANDA.

Purgatives-Cough Mixtures.-Editor of American Medical Journal: Purgatives and cough mixtures are more frequently used by the laity than any other classes of remedial agents. Nor should I confine such to the laity, for there are many-manyM.D.'s that are just as profuse and as unscientific in the use of these agents.

The medical profession in the past (and even now in many respects) has taught the uses of purgatives and cough mixtures until their uses have become necessary fixtures, as the people think.

Physicians have fixed in the minds of the people the necessity of liver medicines. So common is it now for the M.D., when he visits his patient, to pronounce the liver wrong, and hence to send in a chologogue (mild Chloride perhaps) to right that wrong by purgation. "Bilious," says the doctor. "Bilious," repeats grandma. "Bilious," cries Aunt Jane. "Bilious," "bellows" the old cook. Little Johnnie gets a purgative; his feces are kept in the chamber for the physician to see. The M.D. returns, the chamber is brought out, and learnedly does he peer within it. He declares that lots" of bile has been "worked out of " Johnnie. They all agree. The women pronounce praises upon the physician. They believe him the best liver doctor" in that neighborhood, if not in the world; and if Johnnie dies, as is often the case, the doctor is fully exonerated, for he used "liver remedies."

66

Purgatives-Cathartics.-Constipation calls for them, says my brother; nausea, diarrhoea, dizziness, and pain under scapula demands a free use of them, so he informs me. Such a wholesale use of cathartics have hurried many to the grave, and are daily damaging the recuperative forces of thousands.

Let us remember that constipation does not necessarily call for a purgative; that diarrhoea, nausea, dizziness, etc., are not competent indications, abstractly considered. Let us also remember that biliousness is a guess, and that the liver deserves but little censure. Seek first the cause of stomachic and intestinal lesions, and with appropriate measures remove them, if curable, and purgatives will have quite a limited application.