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observed in several instances operated | upon by others.

About three years ago I began the so-called "flap-splitting" operation, in connection with the continued catgut suture, as employed by Martin, of Berlin. Up to date I have performed this operation twenty-five times, with uniformly highly satisfactory results. Eight of these women have since been delivered of a child, four by myself, and no appreciable damage to the perineum could be found in any of them. The Tait "split-flap" operation I have not done until recently, performing it twice during the last month. So far the results have been good, but Tait's method also admits of improvement. Of this later on.

To determine which is the best method to be pursued in the restoration of a lacerated perineum we must ascertain which of the numerous operations devised will give us the most natural perineal body. The operation which will bring into apposition and reunite the structures torn is the one to be adopted. It is extremely doubtful whether this is ever accomplished in any case; but that this object may be attained to a greater or less degree will be admitted by all who are familiar with the various operations for the relief of this injury.

All operations which consist chiefly of "paring" the vulvo-vaginal mucous membrane and of the removal of the flap and cicatricial tissues closing the rent, are, as I have already stated, inefficient, faulty and unscientific, and should be abandoned. The operation which will bring, as nearly as possible, into their normal relations, muscle to muscle, connective tissue to connective tissue, integument to integument, without loss of tissue, will prove itself to be the most scientific. Can this be done? Yes! Let us look for a moment at the anatomy of the parts involved.

If laceration in a given case took place up to or even into the sphincter ani, we would observe, on either side, from before backward, (a) the torn surfaces of vaginal mucous membrane, (b) constrictor vaginæ, (d) the sphincter ani. Externally, the integument and

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FIG. 1.

If healing of the tear is secondary, the structures partially unite by subsequently yielding cicatrices, and, of course, the result is bad. If no attempt is made to unite the fresh rent, the torn ends of the muscles, blood-vessels and nerves retract; swelling and inflammation of the connective tissue, followed by granulations, takes place. As cicatrization goes on, the margins of the torn vaginal mucous membrane and of the integument marking the rent externally, gradually approach each other, and, with the cicatricial tissue between them, close up the wound. There is no possibility of a reunion of these parts after that, except by operative interference.

From this process of healing by granulation and cicatrization it is more than evident that the simple removal of a piece of mucous membrane and the cicatrix which covers the tear is not adequate to join the separated muscles of the one side to those of the other.

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A certain amount of union is obtained, | later, and if they cannot be reached

it is true, and for a time it appears as though the object sought had been attained. A careful search into the subsequent history of these patients will, in course of time, reveal a return of the trouble in many, if not all, the cases. This is my experience, and it is by no means unique.

they will be discharged by suppuration, which, just to that extent, will lessen the good effects of the operation. Vaginal sutures (high up) which require removal, are often permitted to remain, because they cannot be conveniently approached. They are then a source of irritation and annoyance to the patient, perhaps also to the husband, to say nothing of their deleterious influence upon the operated region. When deep perineal sutures alone are resorted to, we fail to approximate the denuded surfaces of the wound; second, the perineal body is drawn into a shape foreign to it; third, they cut into the integument externally; and fourth, if of silver wire or silkwormgut, the projecting ends annoy the patient when she turns in bed or uses the vessel, and they too make it difficult and painful to clean the parts thoroughly. Again, when the denuded surfaces are not perfectly adapted to each other, vaginal secretions will then bury into the space and thus prevent union. In other instances cysts have developed within the perineal body, no doubt in consequence of an imperfect coaptation of the parts. The continued deep and superficial cat-gut suture, properly prepared and sterilized, gives invariable satisfaction in my hands in perineorrhaphy, colporraphy, trachelorraphy and cervix amputation. With this suture every particle of the surfaces to be brought together is firmly held there until union is secured. Little or no discharge is apt to enter from the vagina, even when the flap is removed. When the flap is permitted to remain, there is, of course, no danger at all from that source.

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In order to bring the structures, as much as, ossible, into their former relations, we must dissect down deeply, quite beyond the mucous membrane within the vagina, the cicatrix within the vulva and the line of demarcation between it and the integument externally. Such a dissection will bring the severed perineal muscular apparatus into apposition, if properly sutured, even when the "flap is removed. But the removal of so extensive a flap is not a wise thing to do, especially when the patient is still within the child-bearing period. In cases where this plan is pursued sexual intercourse alone is sufficient to destroy the prospect of a permanently good result, and, in the presence of a hyperplastic uterus, yielding of the cicatrix by pressure from above, is an additional natural consequence which tends to destroy the newly-formed perineal body, because of an abnormal amount of tension created by the removal of the large and extensive "flap" necessary to reach the muscular mass beneath it. For these reasons it is much better that the flap should not be removed, but, like the newly-exposed sides of the perineal body, its raw surfaces should be united, so that the fold created points forward, and serves as a projecting and supporting buttress during intercourse, labor, as well as against any undue pressure from above.

As to the manner of suturing, and the material to be employed for this purpose, I pronounce myself unhesitatingly in favor of the deep and superficial cat-gut suture (Etagennath). This suture has superior advantages over the silver wire, silk or silkwormgut, and none of the disadvantages pertaining to them. The disadvantages common to all except the cat-gut, is that they must be removed sooner or

The fold resulting from the flap soon contracts into a firm mass over the newly-approximated halves of the perineal body, and assists in a permanent union by securely cementing the vaginal line of junction. Whatever function the vagina and perineum may be called upon to perform thereafter, the prospects are that they will submit and stand the strain as though an injury had never existed. The cat-gut sutures do not require removal. They disappear spon

taneously in the course of three or four | here it is carried towards the base of weeks. the tetrahedronal cavity, uniting on its way downward apex (a to b) and (c to d).

The " split-flap" operations which I have done, is, first, a modification of the Hegar operation and second, the Tait method. In the former I dissect off deeply, deep enough to get down on the muscular tissue, procuring, as Hegar does, a triangular surface, pointing with its apex to the posterior cul-de-sac, and with its base to the fourchette. The flap thus secured is thick and firm, and is not removed.

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FIG. 2.-Shows line and extent of incision externally.

The base of the flap is seized in the center of its base by a sharp hook and is then drawn forward. Thus a tetrahedronal cavity is produced, the apices of which unite at the vaginal extremity and the bases towards the vulva. Two of these triangles, Fig. 3, (a and b).are formed by the flap, the other two (c and d) by the surfaces which will unite the perineal body. These four surfaces I now bring into apposition by one continued cat-gut suture, so that the surface of triangle (a) is joined to the surface of triangle (b), and the surface of triangle (c) to triangle (d). The triangles (c and d) will form the perineal body. The triangles (a and b), which represent the flap, form the buttress spoken of above. The suture is commenced by fixing its end to a point close to the aspices of triangles (c and d), and from

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rent extends into and even beyond the | nosus and sphincter muscles of the sphincter ani muscle, though the prin- anus. If the wound thus made is pulled ciple of his method is applicable to all apart with the hands, from side to side, operations necessary to restore the peri- we will notice a gape, as shown in Fig. 5.

neum.

The bleeding which follows is, as a rule, quite profuse, but not alarming. The bleeding vessels are ligated. Sometimes twisting is sufficient to stop the hemorrhage. The sutures (Mr. Tait uses silkworm-gut) are introduced (Fig. 5) by passing a perineum needle from the perineal margins of the wound of the left side deeply into its structure to be brought out at the apex of the wound cavity, of the same side, reintroduced at a corresponding point on the opposite side, passed deeply through it in the same manner and brought out exactly opposite the point of entrance on the left side. From three to five sutures are thus inserted and tied, so that, as nearly as possible, the triangle surfaces (a) (b) (c) and (d) (b) (f) are placed in apposition. The triangle (c) (b) (f) is forced towards the vagina; triangle (a) (b) (d) towards the rectum.

Fig. 4 represents an extensively lacerated perineum (1), one in which but a partition seems to be left between rectum and vagina. The septum is first divided to the depth of one inch and a half, as the case may require. Mr. Tait proceeds as follows: With one or two fingers in the rectum, one blade of a pair of elbow scissors is introduced longitudinally at (a) to the necessary depth. It is then carried transversely across the septum and its point brought out again at (6). This is done with one, sometimes with two cuts of the scissors.

It cannot be denied that this operation is a very ingenious one, and commends itself very highly in cases of extensive tears. If union takes place by first intention, a large and firm perineal body is the result. But I have reason to doubt whether Mr. Tait, or anybody else, secures union per prima intentionem, even in the majority of cases, when this mode of suturing is employed. Of this I am certain, that in not a single case operated upon in my presence while with him in Birmingham did Mr. Tait, nor Mr. Martin, succeed in bringing the perineal integumentary border of the wound into absolute proximity; every one of them showed a gape, from one-quarter to one-third of an inch in width, throughout the whole length of the wound.

As Mr. Tait and his followers have claimed excellent results for this method, I followed his mode of operating in two of my cases during the last month. In both, the "gaping" could not be prevented, and, while the final result was satisfactory, I must confess that neither

1 The artist failed to show extensive lacer- recovered as rapidly as those of my cases in which I employed the con

ation,

d

FIG. 5.-Represents the distended wound after incision according to Tait's method. The letter b in right upper corner should be an f.

The one blade of the scissors is then again introduced at (a) and the tissue divided to point (c). A similar cut is then made from (b) to (d) on the right side. This is followed by another from (a) to (e) on the left, and from (b) to (ƒ) on the right side. The cut, (a) to (b), separates the posterior vaginal wall from the anterior rectal; (c) to (e) and (d) to (f) expose the remaining portion of the transverse perineal, bulbo-caver

tinued catgut suture. The delay, no

doubt, being caused by a failure of INTUBATION OF THE LARYNX.

REPORT OF FIVE CASES.

complete union, the result of the impossibility of perfect coaptation of the wound surfaces, with sutures of this kind. In all of my former operations the wound healed completely within two weeks. In the two Tait " splitflap" operations four weeks passed before union of the wound was perfected. As I believe the manner of suturing to be the fault of this delay, I am inclined to modify Tait's perineorrhaphy by resorting, in my future operations, to the continued catgut suture in connection with the same.

[FOR DISCUSSION SEE P. 8].

A NEW TREATMENT FOR COM

POUND FRACTURES.

According to the London correspondent of the New York Medical Record (November 14, 1891), Mr. Mansell Moullin read a paper before a recent meeting of the Clinical Society of London in which he advocated the treatment of compound fractures into joints by immersing the injured part in a bath of corrosive sublimate at the temperature of the body. If the accident were recent and the would clean, the strength of the solution should be I in 10,000, with a few drops of hydrochloric acid added, and two hours' submersion night and morning would be sufficient. If, on the other hand, the injured part was foul, or some time had elapsed, and inflammation had already set in, the bath should be continuous, night and day, for forty-eight hours, and the strength of the solution should be I in 1000 for the first two. Over thirty primary cases of severe injury had been treated in this way with perfect success, except in two instances, in both of which the failure was traced distinctly to an escape of sewer-gas. Almost the same could be said of the secondary cases; but in one, in which a period of five days had been allowad to elapse, a secondary abscess formed (without a rigor or other sign of pyæmia) in the iliac fossa on the opposite side of the body.-Therapeutic

Gazette.

A Paper read before the Cincinnati Medical
Society, December 8, 1891,

BY

W. D. RICHARDS, M.D.,
DAYTON, KY.

My object in consenting to report these cases to-night is the hope that it might inspire confidence in the operation of intubation among those who have been halting between two opiniions (as I myself have been until recently), and by so doing be the means of saving some precious lives.

Since I first heard of" Tubage of the Larynx" I have been favorably impressed with it, but there seems to be but little to encourage those who have not practiced it to prepare themselves for, and make themselves proficient in, the operation. Literature upon the subject is extremely difficult to find, and what little there is does not seem encouraging, and when making inquiry of those whom we have learned to consider informed on all things pertaining to the prolonging or saving of life, we then also find but little to encourage us.

One prominent surgeon of this city, in whom I have great confidence, when I asked him his opinion of intubation, said that he had intubated the larynx quite a number of times, but had been successful in but one case so far as saving life was concerned; he said it was quite a difficult operation, both in introducing the tube and extracting the same; and that he had found it much easier to put the tube in the stomach than it was to introduce it in the larynx; but still he thought that every physician should prepare himself for intubation, as doubtless it might succeed in some cases, and the friends of the patient would think you were doing something.

In an article on croup in the "Reference Hand-Book of Medical Sciences," the author, in speaking of intubation, says: "Tubage of the larynx is not a practical method of relief, especially in children, although successful cases are reported. The ob

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