consequences of it. If the perineum, with the sphincters, is separated in the central line, an operation to restore the integrity of the parts will be indispensable to a cure. If the sphincters are not torn through, and there is no prolapse, the inconvenience will be so slight as not to demand such aid. In cases where the sphincters are not ruptured, much may be done immediately after the accident to close or fill up the chasm without a surgical operation. The student may be reminded that a very easy way of ascertaining whether the rent extends through the sphincters, without inspection of the part, is to learn whether the patient can control the escape of gas from the rectum. If she can, that muscle is not materially damaged. A good way to arrive at the same object, is to introduce the finger into the anus. The resistance to the introduction is a measure of the quantity of muscular fibre left. For the first four or five days after confinement, the patient must be confined to her side, and it would be better, also, to surround the limbs at the knees with a roller, or bandage, to keep them constantly in contact. By lying on the side with the limbs close together, the parts are kept in almost perfect contact, and the lochial discharges flow out anterior to the wound. These two circumstances are essential to a cure. A diligent observance of the position on the side for a number of days, and a close proximity of the knees, is apt to result in adhesion of a part of the wound by the first intention, and much more of it by granulation. After the lapse of eight or ten days, the parts ought to be inspected, and a healthy state of granulations encouraged by cleanliness, good diet, and, if need be, by a stimulating application of nitrate of silver every four or five days. It will not be best to use suture or other surgical measures in recent cases of this kind. After the opportunity for treating these cases in their recent condition is past, and prolapse of the bladder, rectum, uterus, or vagina, renders interference necessary, the operative procedure is so similar to that necessary for the worst cases, that I will consider them in this respect together, and point out the difference as I proceed. For the most destructive form of rupture, the operation taught by Mr. I. Baker Brown is so perfect, and has been so entirely successful in my own hands, that I will not apologize for recommending and describing it without variation. A patient, to undergo this operation and be cured by it, must be in good general health.

If she is not so, the operation ought to be delayed until proper means can be used to effect it. A firm, plastic state of the solids, without unusual tendency to suppuration, will be the most favorable condition; and I have observed that patients coming from the country will do better to have the operation performed at once, and that it is better, if practicable, to send our town patients into the country for a month or more. Thirty-six hours before the operation is to be performed, we must administer an efficient but not drastic laxative; castor oil or rhubarb will do very well. The patient should be placed in the lithotomy position before a strong light. If an anesthetic is administered,—and it will very much facilitate the management of the patient,—it may be given at this stage of the proceeding. One assistant is placed at each side of the patient to steady the knees and hold the legs, while another assists in the use of instruments. The instruments necessary are a scalpel, a blunt-pointed bistoury, a pair of scissors, three large curved needles armed with double hemp cord ligatures, eighteen inches long,-quite strong, common hemp twine,-three or four small curved needles with silver wire in them, and two pieces of flexible catheter, three inches long, for quills. Sponges, warm and cold water, of course, must be at hand. The surgeon seats himself in front of the patient within easy reach. He commences by removing the hair from all the parts on which he is to operate. After which the edges of the cleft part are to be thoroughly denuded. The cicatricial tissue should be all removed, smoothly and evenly on both sides and up to the septum, the lower end of which should be trimmed in the same way. No part of the mucous membrane or superficial tissue of any kind should be left, as it will inevitably prevent union. An incision on each side of the central line posteriorly, so as to divide most of the fibres of the superficial sphincter, must be made by introducing the blunt-pointed bistoury, about one inch and a quarter into the rectum, and then carrying the handle of the knife obliquely outward, so as to make the incision extend outward, from the verge of the anus between the coccyx and tuberosity of the ischium, about one inch. This will pretty thoroughly divide the external sphincter. After the bleeding ceases the rent is now ready to be closed. One of the large needles is made to enter the side of the wound, to the right of the operator, and at the upper angle, about an inch and a

half from the edge of the cut surface, and dip down deep enough to go to the bottom of the torn portion, inserted into the corresponding part upon the opposing side, and come out as far removed from the edge to the left hand of the operator. Another ligature should be introduced at the central part of the cut, in the same manner as the first, but it will be necessary to penetrate to the depth of the septum, and it would be very proper to include it. It must be deep. A third, at the posterior part of the wound, will suffice to adjust the parts well. In introducing the ligatures we must be careful to place them so as to make the approximation of the surface equable and true. The quill placed on either side, the

Shows the denuded surfaces and the insertion of the quill sutures before the parts are brought together, and also the division of the sphincter on each side of the coccyx. ligatures drawn and tied over them tight enough to bring the lips of the wound firmly and perfectly together, and from four to six silver sutures passed through the edges of the integuments and secured, and the operation is finished. It is advisable, I think, before, or immediately after the operation, to give the patient

about two grains of opium, or its equivalent in some of its preparations, and continue it at intervals, to keep the bowels from moving, and allay irritability and pain. The patient is to be placed on her side, and have the limbs secured by a bandage at

Shows the parts brought together by the deep and interrupted sutures.

the knees. The position may be carefully changed from one side to the other, being always particular to keep the legs close together, and not to allow them to be used so as to contract the muscles at the pelvis. Every six hours, or oftener, the catheter is to be used to draw off the urine, lest it runs into the wound and vitiates the inflammation. The wound should be kept covered with pledgets of lint saturated with simple cerate or cold water. The deep ligatures commence ulcerating on the third day, and sometimes sooner, and if this does not progress too rapidly, they may be left in place four days, but if the ulceration is active, they may be removed on the third. It will only be necessary to cut the ends of the ligatures over one quill, when they may be removed by drawing upon the other. Soon as the suppuration begins

we cannot be too careful about cleanliness. Plenty of clean tepid or cold water must be injected into the vagina and rectum two or three times a day, while the external parts are sponged and cleansed as often. The young operator need not be discouraged if, upon examination, the wound is not all closed by adhesive inflammation. My experience is that this immediate and perfect closure does not usually take place, but that much of the deep-seated portion is left to be filled by granulations, and it is sometimes several weeks before this is accomplished. The skin and integuments generally unite by the first intention, and when this is the case, there is not much danger of failure, provided we keep up a granulating surface all over the unhealed portion of the wound, and observe perfect cleanliness. The superficial silver sutures may remain for ten or twelve days, as they produce no irritation whatever. At the end of twelve days some laxative will be necessary if the bowels have not been moved. The diet and medicine of the patient while in bed, after the operation, cannot be uniform in all cases, and are to be governed wholly by the state of the system; it will be better, I think, to err in favor of good supporting diet, stimulants and tonics, rather than risk impairing the general health by abstemiousness. Adhesive inflammation is promoted by a high state of physical health, and the suppuration by a low condition of it, and aside from imperfection of the operator's proceedings, we have most to fear from early copious and persistent suppuration.

The operation for complete prolapse of the uterus is in all respects similar to the one for the restoration of the perineum with loss of the sphincters, except that the diagonal incisions in the side of the anus is not necessary. The denudation is carried a little farther forward, so as to extend the perineum slightly farther forward than before. In this case it is, of course, supposed that there is deficiency, but not complete destruction, of the perineum, the most, if not the whole, of the sphincters remaining entire, and that consequently the end of the rectum is left intact by the accident, and is not interfered with by the operation.

When the rupture is recent, the parts may be restored by merely using the sutures, and the incisions through the sphincters, in the case of complete rupture, or without these when the muscles are

not torn.