SYMPTOMS AND COURSE.--A dragging sensation and pelvic and abdominal pain are generally present. Rectocele and cystocele and rectal and vesical catarrh often cause painful and severe functional disturbances of the rectum and bladder. In descent of the third degree excoriations of the exposed vagina and cervix sometimes cause extreme suffering. The course is ordinarily chronic, but attacks of acute vaginitis and pelvic peritonitis are not uncommon. The peritonitis sometimes effects a spontaneous cure by peritoneal adhesions which fasten the uterus in an elevated position and hold it permanently. The symptoms of descent may be so severe as to necessitate absolute rest in bed. In other cases they are often attended with very little discomfort. {159} DIAGNOSIS is by inspection, palpation, and exploration. The prolapsed uterus may be distinguished from cystocele, rectocele, inverted uterus, and fibroid tumor by the presence of the os externum. The sound may be passed through the urethra into the cystocele, and the finger through the anus into the rectocele. The length of the uterus may be determined by the sound, the size, shape, position, extent of descent, and difficulty of replacement by conjoined manipulation. PROPHYLAXIS.--This requires such measures during labor as may be necessary to prevent long and powerful pressure upon the pelvic floor. After labor any injury to the perineum should be promptly repaired. The vagina should be kept clean by irrigations. The urine, if necessary, should be regularly drawn and the bowels moved daily without straining. If conditions be present likely to induce subinvolution--such, for example, as pelvic inflammation or laceration of the cervix--they should receive treatment at the proper time. Undue relaxation of the pelvic floor necessitates a more prolonged rest in bed, the use of astringent douches, and the application of a pessary when the patient resumes the upright position. TREATMENT.--The first indication is replacement, which in the first and second degree of descent is not difficult unless the uterus be held down by cicatrices or by a tumor. Complicating pelvic cellulitis and peritonitis may render replacement dangerous or impossible, and may for a time contraindicate all direct treatment. Replacement of the organs from the third degree of prolapse is accomplished in the inverse order of their descent: first, the posterior vaginal wall, then the uterus, and last the anterior vaginal wall. Not infrequently the completely prolapsed uterus and pelvic floor, hernia-like, become strangulated. Then taxis will usually suffice if supplemented by hot applications, elastic pressure, anodynes, and the knee-chest position. Should these fail anæsthesia may be required.