observed in several instances operated | subcutaneous tissue, (though this not upon by others. always) as well as the ligaments, nerve and blood-vessels found within the perineal body. Immediate careful suturing will at once place these structures into their normal relations, secure union by first intention, and a sound perineum will be the consequence.

A certain amount of union is obtained, | later, and if they cannot be reached it is true, and for a time it appears as they will be discharged by suppuration, though the object sought had been which, just to that extent, will lessen attained. A careful search into the sub- the good effects of the operation. sequent history of these patients will, Vaginal sutures (high up) which rein course of time, reveal a return of the quire removal, are often permitted to trouble in many, if not all, the cases. remain, because they cannot be conThis is my experience, and it is by no veniently approached. They are then means unique. 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. 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.

In order to bring the structures, as much asossible, 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

With

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.

FIG. 3.-Shows the cavity of the wound, flap being drawn forward by tenaculum.

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

rent extends into and even beyond the sphincter ani muscle, though the principle of his method is applicable to all operations necessary to restore the peri

neum.

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.

b

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

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

ation.

nosus and sphincter muscles of the anus. If the wound thus made is pulled apart with the hands, from side to side, we will notice a gape, as shown in Fig. 5.

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.

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

tinued catgut suture. The delay, no doubt, being caused by a failure of INTUBATION OF THE LARYNX.