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89 opening. The cure in these cases by operative treat- ment really depended on what part of the fascia was damaged, and the repair of that part of it. He did not believe in the necessity for the interposition operation. Where there was dropping of the cervix and cystocele, it was in his opinion never successful. Dr. A. H. DAVIDSON said that since seeing the Manchester operation carried out in Liverpool he had done most of his prolapse work by this technique and found it gave good results. He had supposed that abdominal operations for prolapse had disappeared, but in London recently he had seen ventral fixation done for prolapse of the uterus. He was not very favourably disposed towards the operation of interposition, but thought it had a place-though an extremely limited one-in cystocele. He did not believe that vaginal hysterectomy was a cure for prolapse. It seemed to him important to stress the setiology of prolapse : it was usually due to extremely bad midwifery. Dr. T. M. HEALY agreed that the interposition operation cured cystocele. The difficulty was that the patient had no guarantee that she would not afterwards get a descent of her cervix, and the cure of this condition was extremely difficult. Vaginal hysterectomy was not a cure for prolapse unless the supports of the uterus were used to keep up the bladder, and the number of cases in which vaginal hysterectomy was necessary to cure prolapse of the bladder were relatively few. If anything was wrong with the uterus it should be removed, otherwise removal was unnecessary if the Manchester operation had been properly learned and if the technique was carefully carried out. Abdominal fixation of the uterus was good in elderly women with prolapse of the vagina, and a small uterus, when short anaesthesia was desirable. Dr. O’DONEL BRowNE thought there was no doubt that anterior colporrhaphy and perineorrhaphy would cure cystocele and rectocele with one exception-high rectocele. Most of the cases in which good results were obtained by shortening the ligaments were cured by fibrosis. Prolapse of the rectal canal could be cured by injections of absolute alcohol.- Dr. A. W. SPAIN said he got very good results from the Manchester operation ; any trouble he had was in the posterior wall. He thought that patients should be kept in bed for three weeks beforehand and given hot vaginal douches. He would never remove the uterus unless it was absolutely necessary to do so, and if a woman in the child-bearing age could be kept comfortable by the insertion of a pessary this ought to be done.-Dr. BOUCHIER HAYES believed that the whole question was really one of pelvic fascia and fibrosis. Dr. R. M. CoRBET said it was possible to have a cystocele without any prolapse, and it seemed to him unnecessary to push up the bladder and shorten the ligaments unless those ligaments appeared to be lengthened. He was rather in favour of vaginal hysterectomy for the larger type of prolapse ; he agreed with Dr. Healy that it was not the hysterectomy but the bringing together of the ligaments that did good. He would advise spending more time in the preoperative treatment of these cases. Operation for high rectocele should if possible be postponed until the child-bearing period was over. Dr. BETHEL SOLOMONS said that the Manchester operation suggested the conclusion that the main thing in dealing with prolapse was to shorten the tissues about the cervix and to repair the hernias, from which he had evolved his present technique namely, (1) a high amputation of the cervix with shortening of the uterosacral ligaments ; (2) approximation of the bladder pillars with an extensive anterior colporrhaphy and colpoperineorrhaphy. The results had been good in his own hands and in the hands of some of his assistants. Le Fort’s operation was excellent for the old patient, but he did not believe that any abdominal operation was necessary, and unless the uterus was diseased hysterectomy should never be done. The PRESIDENT, in replying, said he was not an advocate of drastic surgery in prolapse cases, and was not enthusiastic about vaginal hysterectomy or interposition. The important thing for keeping the organs in place was the fascia. He had at one time done interposition ; then he had got enthusiastic about the Manchester operation and had done it ; but now he had gone back to interposition. If the uterus was too big he did some other operation, and if it was too small he never did an interposition. He did not think the operation suitable in cases of procidentia. Vaginal hysterectomy alone did not cure prolapse, and he regarded ventral fixation as a bad operation for prolapse. MANCHESTER MEDICAL SOCIETY AT a recent meeting of this society Prof. A. D. MACDONALD, opening a discussion on the Choice of an Anaesthetic said that the ideal local or general anaesthetic has yet to be discovered. Only the volatile anaesthetics possess the controllability which makes possible the adjustments to varying needs and varying suscepti- bilities. The action of mixtures of aliphatic com- pounds is the sum of the actions of its components y there is no evidence of potentation, such as exists. for morphine and other alkaloids followed by anaes- thetics. The use of mixtures, such as A.C.E. and Schleich’s, in which the volatilities of the com- ponents differ widely, is pharmacologically unsound. Premedication with non-volatile drugs is only justi- fiable in doses well below the average anaesthetic dose ; it is possible that some may affect vital centres before they depress ordinary reflexes. Dr. E. FAULKNER HILL, in all grave risks where time allowed, would invoke the aid of surgeon, physician, and biochemist as well as anaesthetist to estimate the survival power of the patient, and then enhance this power to the utmost by suitable prepara- tion, diet, rest in bed, and appropriate treatment before operation. In the course of time this would lead to a coordinated and unbiased opinion of the merits of the various methods in common use. But the organisation of such a service would seem to call for the appointment of a special officer. Mr. GARNETT WRIGHT, from a small personal experience of splanchnic anaesthesia, was hopeful that by its use (1) chest complications might be much reduced, (2) palliative gastrectomy for carci- noma might be safely undertaken more frequently, (3) operation for acute haemorrhage might be rendered safer. A lively discussion followed. TIVERTON AND DISTRICT HOSPITAL.-An up-to- date operating theatre, an X ray room with new plant. and an anaesthetising room are being added to this hospital which has been much enlarged during the last few years. The new extensions will cost about 3000.

MANCHESTER MEDICAL SOCIETY

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opening. The cure in these cases by operative treat-ment really depended on what part of the fascia wasdamaged, and the repair of that part of it. Hedid not believe in the necessity for the interpositionoperation. Where there was dropping of the cervixand cystocele, it was in his opinion never successful.

Dr. A. H. DAVIDSON said that since seeing theManchester operation carried out in Liverpool hehad done most of his prolapse work by this

technique and found it gave good results. He had

supposed that abdominal operations for prolapsehad disappeared, but in London recently he had seenventral fixation done for prolapse of the uterus.He was not very favourably disposed towards theoperation of interposition, but thought it had a

place-though an extremely limited one-in cystocele.He did not believe that vaginal hysterectomy wasa cure for prolapse. It seemed to him importantto stress the setiology of prolapse : it was usuallydue to extremely bad midwifery.

Dr. T. M. HEALY agreed that the interpositionoperation cured cystocele. The difficulty was thatthe patient had no guarantee that she would notafterwards get a descent of her cervix, and the cureof this condition was extremely difficult. Vaginalhysterectomy was not a cure for prolapse unless thesupports of the uterus were used to keep up thebladder, and the number of cases in which vaginalhysterectomy was necessary to cure prolapse of thebladder were relatively few. If anything was wrongwith the uterus it should be removed, otherwiseremoval was unnecessary if the Manchester operationhad been properly learned and if the technique wascarefully carried out. Abdominal fixation of theuterus was good in elderly women with prolapseof the vagina, and a small uterus, when shortanaesthesia was desirable.

Dr. O’DONEL BRowNE thought there was no doubtthat anterior colporrhaphy and perineorrhaphy wouldcure cystocele and rectocele with one exception-highrectocele. Most of the cases in which good resultswere obtained by shortening the ligaments were

cured by fibrosis. Prolapse of the rectal canalcould be cured by injections of absolute alcohol.-Dr. A. W. SPAIN said he got very good results fromthe Manchester operation ; any trouble he hadwas in the posterior wall. He thought that patientsshould be kept in bed for three weeks beforehandand given hot vaginal douches. He would never

remove the uterus unless it was absolutely necessaryto do so, and if a woman in the child-bearing agecould be kept comfortable by the insertion of a

pessary this ought to be done.-Dr. BOUCHIERHAYES believed that the whole question was reallyone of pelvic fascia and fibrosis.

Dr. R. M. CoRBET said it was possible to have acystocele without any prolapse, and it seemed tohim unnecessary to push up the bladder and shortenthe ligaments unless those ligaments appeared tobe lengthened. He was rather in favour of vaginalhysterectomy for the larger type of prolapse ; he

agreed with Dr. Healy that it was not the hysterectomybut the bringing together of the ligaments that didgood. He would advise spending more time in thepreoperative treatment of these cases. Operationfor high rectocele should if possible be postponeduntil the child-bearing period was over.

Dr. BETHEL SOLOMONS said that the Manchesteroperation suggested the conclusion that the mainthing in dealing with prolapse was to shorten thetissues about the cervix and to repair the hernias,from which he had evolved his present technique

namely, (1) a high amputation of the cervix withshortening of the uterosacral ligaments ; (2)approximation of the bladder pillars with an extensiveanterior colporrhaphy and colpoperineorrhaphy. Theresults had been good in his own hands and in thehands of some of his assistants. Le Fort’s operationwas excellent for the old patient, but he did notbelieve that any abdominal operation was necessary,and unless the uterus was diseased hysterectomyshould never be done.

The PRESIDENT, in replying, said he was not anadvocate of drastic surgery in prolapse cases, andwas not enthusiastic about vaginal hysterectomy orinterposition. The important thing for keepingthe organs in place was the fascia. He had at onetime done interposition ; then he had got enthusiasticabout the Manchester operation and had done it ;but now he had gone back to interposition. If theuterus was too big he did some other operation,and if it was too small he never did an interposition.He did not think the operation suitable in cases ofprocidentia. Vaginal hysterectomy alone did notcure prolapse, and he regarded ventral fixation asa bad operation for prolapse.

MANCHESTER MEDICAL SOCIETY

AT a recent meeting of this society Prof. A. D.MACDONALD, opening a discussion on the

Choice of an Anaesthetic

said that the ideal local or general anaesthetic has yetto be discovered. Only the volatile anaestheticspossess the controllability which makes possible theadjustments to varying needs and varying suscepti-bilities. The action of mixtures of aliphatic com-pounds is the sum of the actions of its components ythere is no evidence of potentation, such as exists.for morphine and other alkaloids followed by anaes-thetics. The use of mixtures, such as A.C.E. andSchleich’s, in which the volatilities of the com-

ponents differ widely, is pharmacologically unsound.Premedication with non-volatile drugs is only justi-fiable in doses well below the average anaestheticdose ; it is possible that some may affect vital centresbefore they depress ordinary reflexes.

Dr. E. FAULKNER HILL, in all grave risks wheretime allowed, would invoke the aid of surgeon,physician, and biochemist as well as anaesthetist toestimate the survival power of the patient, and thenenhance this power to the utmost by suitable prepara-tion, diet, rest in bed, and appropriate treatmentbefore operation. In the course of time this wouldlead to a coordinated and unbiased opinion of themerits of the various methods in common use. Butthe organisation of such a service would seem to callfor the appointment of a special officer.

Mr. GARNETT WRIGHT, from a small personalexperience of splanchnic anaesthesia, was hopefulthat by its use (1) chest complications might bemuch reduced, (2) palliative gastrectomy for carci-noma might be safely undertaken more frequently,(3) operation for acute haemorrhage might be renderedsafer.A lively discussion followed.

TIVERTON AND DISTRICT HOSPITAL.-An up-to-date operating theatre, an X ray room with new plant.and an anaesthetising room are being added to thishospital which has been much enlarged during thelast few years. The new extensions will cost about 3000.