or extra-uterine, this should be cured and removed; if from the weight of adventitious growths, they should be removed; if from an elephantiatic condition of the cervix, it should be removed (see case of amputation of the cervix uteri by myself, weighing over four ounces and a quarter, in the Bulletin of the New York Academy of Medicine for 1862). Amputation of the entire cervix is of rare necessity, but the removal of considerable portions, as the anterior or the posterior lip, although rarely done, should be a quite common operation. I am convinced by my own knowledge that it is far better to cut off a hypertrophied portion than to attempt to melt it down by strong caustics; not only is time saved, but suffering.

In many cases the tissue has become exceedingly dense, cartilaginous almost in its character, and creaking under the knife, and would only be eaten away by the acid-nitrate of mercury or caustic potash, with great sacrifice of time and suffering. We should not hesitate to cut off such portions with the knife or scissors, with little fear of any ill result. Sometimes gores may be cut out and the cut edges united by silver suture; after all amputations, the edges of mucous membrane should be drawn together and united by the silver suture.

If there should be only a general enlargement of the uterus, as is frequently seen after a sudden arrest of the menstrual flow, causing congestion, increase in weight, and a temporary falling, the appropriate treatment is evidently to be directed to removing the cause and not to the results.

It follows therefore that as a necessary consequence, the treatment of falling of the womb by the use of pessaries of any kind (except "medicated pessaries," which are falsely thus styled, and which being intended not to act mechanically but to melt and thus locally to apply medicaments, should be classed with ointments and lotions) is theoretically improper, and cannot be relied upon to effect a cure. But may they not be employed as adjuvants, not to cure the grand cause, but. while this is attended to by appropriate means, may not pessaries, skilfully constructed and judiciously applied, be resorted to, to relieve the distress of certain symptoms? Let us allow, merely for the sake of meeting the question properly, that where there is a strain upon the ligaments, accompanied by dragging sensations in the back and groins, with irritation of either bladder or rectum, or both, from the pressure of the decumbent organ, that relief may be obtained by the use of anything which shall hold up this organ, whether the temporary use of the finger,

or the more permanent application of a pessary. Are we justified in using these applications as palliatives and adjuvants?

If any one is in acute pain from any cause, we are justified in temporarily relieving it, by opium or chloroform, provided his condition is not seriously aggravated by the use of the opiate or anææsthetic. But, if the opiate produces convulsions, and the chloroform is followed by persistent faintings and long-continued cephalalgia, we may properly first count the cost of the proposed relief.

What then is the injury derivable from pessaries? If any, is it the usual result, or exceptional?

We will not for a moment allow that they are anything more than palliative, not even by accident curative agents. Falling of the womb is often extremely temporary. Any woman subject to ill turns, lassitude, and general debility, will tell you that not unfrequently upon these occasions she is sensible of a falling of the womb, and this is unquestionably caused by a simple want of tone in the vagina. This organ loses its tonic contractility somewhat analogously to the changes incident to the scrotum of the male, which is tense or relaxed, as the general system is vigorous or enervated. Surely, in such temporary inertia of the vagina, the physician, who finding a debilitated patient with a temporary prolapsus uteri, and who should say that this displacement was the fons et origo of all the parts, and who, instead of a proper system of tonics, &c., should treat the symptom by a pessary, intended either as a curative or a palliative, would greatly err. When we note the irritation, both local and nervous, excited by a simple mucous polypus, a condyloma, a little fibrous body projecting into the vagina, we cannot but be prepared to find like irritation and greatly intensified, from the presence of any hard body, inserted within the vagina and of necessity pressing upon some portion of its parietes. And we do find it so universally. Some women, indeed, have so little nervous sensibility that they receive trifling irritation therefrom, but there is in all more or less local abrasion, irritation, or ulceration. One case is peculiarly before my mind, where a lady, formerly under my care in a neighboring town, being unwell from the invasion of a chronic disease of the liver, her attending physician noticed this temporary relaxation of the vagina with its attendant slight prolapsus, and inserted a pessary, which remained some week or so, and he then for some reason removed it, and, as he stated at a subsequent coroner's inquest, that he

examined her carefully with the speculum, and that there was no disease of the organs observable; yet at the post-mortem examination, made shortly after, there was extensive ulceration of the vagina in the position which this pessary occupied. I think it indisputable that a pessary allowed to remain for a very short period will invariably produce irritation, and if continued longer, will produce almost as certainly, ulceration. I have removed many pessaries that have produced ulceration; one in particular, hollow and of silver gilt, was completely honeycombed by corrosion, its interior filled with exuviæ of the most horrible offensiveness, the vagina ulcerated through into the bladder, producing a vesico-vaginal fistula, and into the rectum, producing a recto-vaginal fistula; the vagina in some portion obliterated by adhesive inflammation and numerous. fistula made through the labia and around the mons veneris for the exit of the various discharges.

But we will suppose that inflammation and ulceration may occur in a less formidable degree (and the case just quoted is allowedly an unusual result of the use of a pessary for too long a period and without proper care), and we will, for the sake of argument, allow that it is often of little importance, as it may be cured easily after the removal of the pessary when its desired end has been attained. What is then the result?

The more lax the vagina the larger will necessarily be the pessary, and the instrument in any case will necessarily impinge somewhat upon the hard tissues. In aggravated forms, with great uterine hypertrophy, whether of the body or the neck, no pessary, unless fastened externally, will remain within the vagina, but will be forced out.

In any case where the pessary remains for any period, the pressure of the cervix upon the pessary is invariably followed by more or less irritation, inflammation or ulceration, often to such an extent as to entirely neutralize the good desired from keeping the uterus in situ.

There is always more or less irritation, inflammation, and ulceration of the vagina pressed upon by the pessary, accompanied by more or less of an exhausting leucorrhoea productive of both physical and nervous debility.

After wearing through a period of irritation, the vagina in some instances, and under favorable auspices, becomes callous, and the pessary may remain innocuous, although the cases are far more numerous where the other extreme is attained, where the instru

ment is unbearable, and where the integrity both of the bladder and rectum is materially compromised.

But, if borne, what is the result? If there is no irritation produced by the instrument, it in the first place is quite evident that no pessary was necessary for so tonic a condition of things, and secondly, when it is removed there is left a hole made by the pessary around which the vagina has firmly contracted, and into which, as soon as the pessary is removed, the then unsupported uterus must inevitably fall; and thus, admitting that the relief derived from the instrument has been temporarily obtained and without other injury, the local condition of the patient is now worse than it was originally. The horseshoe pessary makes two very marked holes, hardened from the deposit of fibrin around (and these often ulcerated and discharging pus, while the vagina around in its irritated condition secretes an immense leucorrhoeal discharge) where the ends of the instrument press.

Thus it appears to me that vaginal pessaries, having for their aim either the cure or the temporary relief of symptoms attending prolapsus uteri, are not only useless but actually injurious, and that we should seek to cure by removing the causes, by general tonic treatment, by raising up the superincumbent intestines, and thus in some degree relieving the downward pressure, and by such other methods, some of which have been alluded to, as may be found necessary.

There are, however, a class of cases of an entirely different nature, where the uterus is not prolapsed, and indeed where not unfrequently the os and a large part of the cervix has not changed its position. These cases, called ante, retro and lateral flexions and versions, are acute and chronic, and for their relief an instrument has been devised, which has improperly been called a stem pessary, inasmuch as it is an instrument of an entirely different principle and mode of action from the ordinary pessary. Were our works written, and our nomenclature in the Latin tongue, the instrument would properly be styled, not pessary, but pessimus; for it is the worst instrument of all, and yet, although so often injurious, and to a very serious degree, it is, in my opinion, an instrument in very occasional cases of justifiable employ and of actual use, yet never without very considerable accompanying danger. So rare, indeed, are the cases where its services are demanded that I have not in six years seen one case calling for it. Still, I allow its occa

sional utility (especially where absorption of a stricture or uterine stimulation is desired, when the galvanic self-retaining stem is often of service). It is properly a uterine splint. Its purpose is to forcibly hold the uterus in a certain position, while certain lesions are healing. But it is only in acute cases where any benefit can be derived from it, and these are very exceptional in their number and character. A woman has had a fall which has dislocated the uterus. It is generally "verted" either anteriorly, posteriorly, or laterally, or it is partially flexed toward any direction. If this was immediately seen by a competent physician, by the aid of manipulation, often assisted by the uterine sound, the organ could speedily be restored to its normal position. But for some reason it is not, and after some days or weeks' delay, the sufferer comes under the auspices of one who understands the case, or submits to the examination requisite, and then for the first time an attempt is made to restore the organ to its proper situation. The uterus is easily replaced, but immediately upon the withdrawal of the sound, returns to the position to which it has been accustomed during the few previous weeks, on account of the relations it has there made. The introduction of the stem pessary and its presence there for a longer or shorter period will suffice to overcome these new and transitory predilections, and upon its removal finally, the cure is found to be effected and the abnormal tendency is overcome.

But there are other cases of a chronic and less propitious character; where the symptoms of disease are of long standing, and where, the displacement is of considerable duration. In some of these cases the original trouble has been from a dislocation of the organ originally, such as we have just described, which has become. aggravated by neglect; the uterus has been doubled upon itself and there has been absorption of the tissue at the angle of flexion, the destruction of the tissue being the direct consequence of the flexion and the pressure.

In others the flexure is the result of disease in the tissue itself, a fatty degeneration which destroys its vitality, vigor, and power (and this is noted in "Scanzoni's Diseases of Females," R. M. De Witt, N. Y.). The consequence is a giving way of the wall at some point and subsequent absorption of the parts pressed upon, and the case as seen in the latter stage differs but little from that previously described, but one is the effect and the other the cause.

In these cases whatever we may know of cure, we certainly do know something of arrests. After the absorption has taken place,