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tine and isolation of the patient. This has been the great obstacle to the more general adoption of the method of compulsory notification by physicians.

This trouble is largely due to the difficulty in making people understand the particular way in which the disease is communicated from the sick to the well. As long as we speak of tuberculosis as a contagious disease this will continue. Notwithstanding the contention of Flick to the contrary, the writer feels very strongly that the method followed by Biggs of calling it a communicable, rather than a contagious, disease is more expedient, and will, in the end, accomplish more in the way of prevention. This makes a distinction between tuberculosis and other specific infections, and does away with unnecessary fear and antagonism. The latter always results from the popular dread of quarantine and isolation, which is suggested by the use of the word "contagious."

2. The disinfection of rooms, carpets, etc. If this is to be effectual, it should be under the control of the public health authorities. No argument is needed for this procedure. The protection to the friends of those who die from tuberculosis and the protection afforded those who live in rented houses are ample arguments for it.

Chemical disinfectants are not absolutely necessary, and are frequently used in such a careless manner that they do no good. Under these circumstances they are worse than worthless, as they give a false sense of protection. Thorough renovation is far preferable to inefficient disinfection by gaseous disinfectants, which are too often improperly applied. The former method is the plan followed by the New York Board of Health.


Every possible effort should be made to educate the people, and especially tuberculous patients and their friends, regarding the dangers of tuberculosis, the way it spreads, and the method of preventing it.

Much can be done in this direction by enforcing municipal ordinances which prohibit spitting on sidewalks and in public places. Printed circulars or pamphlets, which have been carefully pre

pared, should be distributed by the health authorities to the houses of consumptives, giving all this information in plain terms that can be understood by any one. When necessary, among the very ignorant or careless, the sanitary inspector should visit the house and give verbal as well as printed instructions.

Of course, the attending physician should be the chief factor in educating consumptives and their friends as to the dangers of tuberculosis, and the method of preventing its spread; but we are here dealing only with public health measures.

4. The examination of sputum by the city or State health authorities should be made free of charge. This not only removes doubts about the diagnosis, and makes the recognition of the disease certain, but it serves to give the health authorities some idea of the existence and location of tuberculous patients. In New York City more than 7000 cases are registered annually from information obtained in this way.

Where it is practicable, it is desirable to have inspection of dairy herds supplying milk to cities. Koch's view regarding the intercommunicability of bovine and human tuberculosis has now been proven incorrect by Ravenel and others, and we should endeavor to condemn tuberculous cows.

6. The establishment of hospitals for consumptive patients is very desirable. These should be provided for incipient cases in suitable localities, looking to the cure of the disease. Others should be provided in more densely populated districts for the care of advanced cases that can not be properly cared for in their homes. This would prevent the infection of many houses.

While these hospitals and sanatoria are very desirable, we should not lose sight of the fact that the majority of cases will still be treated in their homes, and that, even at best, only a comparatively small proportion can be cared for in hospitals.

We should not wait idly for the establishment of such hospitals, but should direct our energies toward securing compulsory registration, inspection, education and disinfection. These measures can be put into operation by every community without great expense.

The establishment of hospitals is an ideal condition, but very few places can ever meet the difficulty in this way. It has been well said that "every city and county must solve its tuberculosis problem for itself." We, as physicians, should lead in this movement and not hide our heads in the fashion of the ostrich in the sands of indifference.





To obtain the ideal result in repairing lesions of the pelvic floor, it is necessary to restore the normal anatomy and to bring about a return of the natural functions. This result has been placed within the reach of the modern operator, by the stages of development which have come through the genius of Emmet, Simon, Hegar, Tait, Kelly and others, who have done original work in one direction or in another, elucidating this detail and establishing that principle. It is our privilege to draw fully and freely from these rich developments and in the present paper, for the sake of brevity, and in order to get the central thoughts quickly and clearly before you, any attempt to give credit to this or that authority will be avoided.

Repair of injuries to the pelvic floor at the present time should include careful attention to the following requisites:

First-Restoration of the normal anatomy of the parts which have been injured.

Second-As consequent, a return to normal function.

Third-The protection of the field of operation and of the parts which it is necessary to unite by flaps in the vagina and where the rectum in involved in the injury, by a similar rectal flap, from infection by the vaginal and rectal discharges.

Fourth-The sutures should be arranged

(a) So as to approximate anatomical structures in their normal relation.


To leave no dead space for the accumulation of clots. (c) Only absorbable suture material should be used.

(d) The fewest number of sutures should be used compatible with nice approximation.

(e) The sutures should not pass through the skin or mucous membrane, where this can be avoided.

Only brief reference will be made to the anatomy. Passing the fascia, upon which much stress was laid by earlier operators, and which is of importance, yet can be in a measure disregarded, for the reason that it is necessarily restored to its normal relation by the same approximation that replaces the muscles, and the muscles can be accepted as surgical guides to the anatomy of the perineal fascia, the superficial group of muscles, viz.: the external sphincter ani, the superficial transversus perinei and the sphincter vaginæ, joining at a common point between the anus and the vulvar opening, constitute the important external support of the pelvic floor and are lacerated in labor most frequently along natural lines of cleavage, through the fouchette back to or into the rectum, or at one or the other side of the rectum. The deep transverse perineal muscles, the analogues of the constrictor urethræ in the male, are inserted into the same common point on a deeper plane and also have fibers that blend with the vaginal walls and others that pass along the side of the vagina to cross the urethra. The levator ani is inserted in its posterior two-thirds to three-fourths into the sides of the rectum, blending with the sphincters of that viscus, while the anterior fibers pass around the posterior wall of the vagina, blending with each other to form a support to that canal. These muscle structures constitute the important anatomy of the pelvic floor and are the anatomical structures which must be borne in mind, must be sought for and brought together in nice approximation in order to accomplish the restoration to normal function. The function of the anterior portion of the levator ani and deep transversus perinei is to give tenacity and support to the posterior wall of the vagina, converting that organ into a canal in the nulliparous woman, as can be very easily observed by introducing the

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