Pregnancy progressed without trouble, and labour left. no after effect which was at all connected with the previous operation. The improved position of the uterus obtained by the operation continued also, after pregnancy and labour, with simple care for good involution of the uterus (regulated diet, frequent action of the bowels and bladder, and the lateral abdominal position from the eighth day on). In order to make the field of operation more visible, and to separate the adhesions of the uterus and ovaries, in case of fixed retroflexion, directly under guidance of the eye, I have opened the peritoneum in my last sixty cases. The method then became exactly like the already described vaginal laparotomy (see p. 54). If the adnexa are quite normal, the fundus is only drawn down as far as the wound and sutured with two silkworm gut sutures to the vaginal wound wall. In other cases the uterus is drawn down to the vulva, the perimetritic adhesions of the uterus with the tubes and ovaries, and of these with one another, are divided upon a director with Paquelin's cautery, and cystic ovarian follicles are opened with this also. Then two silkworm gut sutures are passed through the fundus and the vaginal wall, the adnexa and the uterus are replaced, the sutures tied, and the vaginal wound sutured up in a sagittal direction. With this intra-peritoneal vaginal fixation I have observed no septic disease, no fatal case, and not a single relapse. Technically ventral fixation is easier, especially in fixed retroflexion, but I prefer the described intra-peritoneal vaginal fixation on the following grounds : 1. The intra-peritoneal vaginal fixation is less dangerous. 2. There is no possibility of a ventral hernia, of omental adhesion to the abdominal incision, or of ileus. 3. The patient does not, as in ventral fixation, exchange one bandage for another. 4. The convalescence is much shorter (eight to nine days), and capability for work comes on much sooner. 5. The anxiety of the patient is much less for vaginal than for ventral laparotomy, and one can therefore much oftener replace palliative by radical treatment, which Fritsch points out to be thoroughly correct practice. 6. The subjective troubles immediately after operation are also much less after vaginal fixation. 7. By intra-peritoneal vaginal fixation normal anteversioflexion is obtained. The indications for an operation depend upon its practicability and freedom from danger, as well as on the importance of the affliction. My vaginal fixation, in combination with curetting, is not more dangerous than curetting alone. In 250 cases I had only one death (0.4 per cent), while the mortality of curetting in well-conducted clinics is 0.5 per cent. In 99 per cent of cases of retroflexion there is endometritis present which does not disappear on reposition and retention of the uterus by a pessary, and for the cure of which curetting is necessary. Since curetting and vaginal fixation are not more dangerous than curetting alone, it would be quite illogical if we confined ourselves to a symptomatic treatment when the radical treatment is not more dangerous. Certainly in my opinion it is our duty to carry out vaginal fixation in the following cases, or at least to propose it to the patient : 1. In cases of retroflexion where any vaginal operation ought to be undertaken, such as curetting, operations on the portio, colpoperineorrhaphy. 2. In cases where a pessary is not tolerated on account of pressure on perimetritic bands or fixed ovaries. 3. In cases of fixed retroflexion. 4. In cases where there is no guarantee that the patient will be under the care of a physician while wearing a pessary. 5. In cases where the patient, owing to a feeling of continuous depression due to her dependence upon her physician, lapses into a condition of psychical depression or hysteria. I only exclude from treatment by vaginal fixation those cases of retroflexion which one meets with soon after labour, and where complications which require further treatment are wanting. The frequency of retroflexion-16-19 per cent of all gynecological cases-justifies the detailed description of its treatment, especially as no such extensive series of operations, together with the knowledge of their later results such as I have gained by my method, are available. Descent and Prolapse of the Uterus and Vagina. Definition, Etiology, and Varieties of Prolapse.By descent of the vagina we mean the condition in which the vaginal walls come down between, or partly outside, the labia; by prolapse of the vagina we mean the condition in which the vaginal walls have passed outside the labia altogether. The uterus suffers an alteration of position in these conditions, so that in descent of the vagina the cervix comes below the ischial spinal line; and in prolapse of the vagina outside the vulva. In the latter case the os uteri is exposed to view. The fundus uteri retains its normal elevation, as a rule, in these cases 1 (F, Fig. 85). Of course this is only made possible by marked extension of the neck of the uterus, effected through the vaginal walls which are inserted into it. (elongatio colli). Since the cervix is drawn forcibly to the front the uterus cannot retain its normal anteflexion, but is retroverted. It is only in rare cases where the uterine supports are much relaxed that the uterus is truly prolapsed, that is, it lies outside the vulva in a sac formed of the prolapsed vagina. Usually the vaginal 1 [Hypertrophic elongation of the cervix is not so common, at all events in England, as might be supposed from the author's description. In most cases of prolapse or protrusion the sound will not be found to pass beyond the usual distance. Hypertrophic elongation occurs in a minority of the cases.--J. W. T.] prolapse is primary even in these cases. The uterus only exceptionally prolapses primarily, and then draws the vaginal walls with it. The causes of such primary uterine prolapse are relaxation of the suspensory ligaments of the uterus and increase of abdominal pressure. Both causes can produce primary prolapse of the uterus even in virgins. The term prolapse of the uterus should not be given indiscriminately to these two different positions of the uterus. FIG. 84.-After B. S. Schultze. It would be much better to term the first condition "Vaginal prolapse with cervical elongation." The commonest cause of vaginal prolapse is labour, and of the accidents of labour, perinæal lacerations of the first and second degree play a leading part in producing this condition. When a perineal tear does not unite at once, the anterior vaginal wall loses its support from the posterior wall. The lower portion of it soon prolapses and graduEven without rupture ally drags the other part after it. of the perinæum prolapse of the vaginal walls can take place. The reason lies in the overstretching or subcutaneous rupture of the musculature of the pelvic floor (Schatz), or in defective involution of the genitals. In all three conditions there is gaping of the vulva, while the perinæum is intact. As a consequence the loose folds of the vaginal walls easily come outside, especially on getting up and working too early after confinement. Thus we see vaginal prolapse as a very common disease in the labouring classes, where the women cannot even keep their lying-in owing to their poverty. Ascites can also sometimes cause vaginal prolapse. Hegar and Kaltenbach were able to allow the fluid to drain off in such a case by opening the depressed plica vesico-uterina. Finally, the vagina may prolapse in old women as a result of the disappearance of fat around it. The posterior FIG. 85.-Prolapse of the anterior vaginal wall with elongation of the cervix and descent of the retroverted uterus. Diagram of a frozen section of a preparation from the obstetrical clinic of the Charité. vaginal wall is partly exposed to view in old perineal lacerations, it is everted, but it seldom is completely prolapsed (as in Fig. 84), because it is retained in its place by the muscles of the pelvic floor. In most of the cases of vaginal prolapse with cervical elongation one therefore finds that the anterior vaginal wall is com |