:

Union seemed perfect. 27th The remaining threads removed.

On the 30th, the first desire to evacuate the bowels occurred— i. e., ten days after the operation. Two injections were given, and much hardened fæcal matter discharged. Notwithstanding every care the wound opened about half an inch, posteriorly; fortunately, the anterior half held good. Jan. 1st: After a laxative by the mouth, a loose evacuation followed, which the patient was enabled to retain some time. Granulation in the re-opened portion proceeded slowly; to stimulate it nitrate of silver was frequently applied. This closure by granulation, however, and the consequent contraction of tissue had the effect of shortening the perinæum. On the 27th she quitted

the hospital quite cured.

CASE III. A woman, æt. 22, employed in field labour, suffered laceration of the perinæum in her second labour, six months ago. The injury resulted from the efforts of the midwife to disengage the shoulders by introducing her hand into the vagina. The rupture was complete; the delivery was followed by puerperal fever, and an abundant suppuration of the lips of the laceration. The recto-vaginal septum is laid open for about three lines, and the sphincter ani involved; the incontinence of fæcal matters complete. The bodily health good.

After the preliminary baths, injections, and aperients, the operation was performed on the 17th March. The parts were highly vascular, and bled largely, so retarding the operation, and requiring torsion of the small vessels. Four sutures were placed; one to close the rectum, and the other three to form the new perinæum. The flap taken from the septum had been previously fixed by two sutures on each side. The Dieffenbach incisions that had been made on each side bled in an unusual

manner.

Cold-water dressing was used, and cold injections of infusion of camomile every three hours. The knees were kept together by a bandage. The oozing of blood, chiefly from the lateral incisions, did not cease till near evening. March 18th: Pro

gressing favourably. Pulse 75; no heat of skin. Vaginal injections as yesterday, but warm. Two doses of opium; nourishment, thickened rice water, lemonade. 19th: The patient finds she can control the escape of flatus. To-day allowed broth,

a wing of fowl, and the yelk of an egg. The suture nearest the anus has slightly cut the tissues. 20th: The twisted suture, and one other withdrawn. 21st Condition very satisfactory. An abundant muco-purulent discharge has taken place from the vagina. Injections, diet, and opium continued. 22nd: The vaginal discharge augmenting, an injection of sulphate of zinc was adopted, and the pledgets of lint externally were soaked in the same liquid. Only one suture, besides that closing the anus, was now left. 23rd: The appetite is very great, and the patient can hardly restrain herself from indulging it. The two remaining sutures removed. Union seems complete. 24th: The vaginal secretion less. The same regimen continued. 25th: Whilst administering an injection yesterday, a sanguineous flow from the vagina was observed, probably a premature return of the catamenia. To-day this discharge is copious. Astringent and cold injections therefore stopped, and the tepid camomile one repeated. Catheterism and opium continued. Diet: broth, and rice milk. March 26th: Menstruation still abundant. Catheterism omitted from this day; but patient made to pass the urine placed resting on her hands and knees, and the parts carefully washed afterwards. Opium discontinued. 27th: Catamenia ceased. Having a desire to empty the bowels, two linseed injections were given without effect, but the third brought away a scanty stool, of nodular portions. This is ten days after the operation. The diet still to consist of liquids, but now in larger quantity. 28th: A copious, formed, not hard evacuation followed an enema to-day. The perinæum was supported by a cushion of lint smeared well with cerate. The diet was improved. An enema to be given every morning; the vaginal injections but twice a day. 30th: The small sutures confining the flap of the septum were not removed till to-day. A first attempt has been made to walk. The new perinæum is

a good inch long, and very firm.

In concluding, M. Verhaeghe calls attention to the great

importance of minute attention to the details of the after-treatment, upon which, he truly observes, the success of the operation will depend.

Such is a summary of what has been said and written by others respecting the treatment of ruptured perinæum. It now remains for me to state my views, and to detail those operative proceedings which reflection on the deficiencies of other plans led me to adopt, and which an ample experience has convinced me to be the best. Further, as the results of operations are the best test of their efficiency and value, I shall hereafter detail those cases in which I have been concerned, and also any others which have been communicated to me by those who have pursued my plan.

Some few words are due to the consideration of the cases of a less formidable character than those of the complete rupture, and which constitute the three first cases I have enumerated (p. 6.)

The first variety, in which the rent extends to only an inch or less, requires, as already stated, no special treatment, at least of an operative description. Such a laceration needs only quiet and an attention to cleanliness to heal it.

The second form is rare, and demands special treatment. Mostly, in order to secure the closure of the perforation, it is necessary to divide the anterior band at the fourchette, and then to bring together the edges by quill and interrupted sutures. It almost seems unnecessary to point out that, where the accident has existed some time, and the edges have become covered by mucous membrane or otherwise cicatrized, the latter must be pared before sutured.

The third variety, in which the perinæum is lacerated but the sphincter remains entire, is still more an object for treatment. Although the functions of the rectum are not disturbed, yet a rupture of this sort, left to itself, entails many evils; for, besides those immediately attendant on the enlarged vulva, there are others due to the want of support to the pelvic viscera;

For when

hence, prolapsus uteri, displacement of the bladder (cystocele), or of the rectum (rectocele), and symptomatic disorders consequent on such dragging down. Wherefore, every instance of this degree of laceration requires operative treatment. left to nature, even if closure of the fissure occurs, adhesion is apt to be superficial, and the contraction ensuing upon the process of reparation, is such as to draw backwards the parts towards the anus, enlarging the vulva, and so predisposing to pelvic displacements.

In examples of this form of ruptured perinæum, the treatment is pretty much the same as for the next and severest form, and most of the steps of the operation to be presently detailed belong to this degree of the accident, and, to avoid repetition, will not be here described. (See Case XVI.) However, it will not always be necessary to divide the sphincter ani, and all the sutures used will be introduced in advance of the rectum. Both quill and interrupted sutures are desirable.

In my second "Essay on Rupture of the Perinæum," I introduced it as a proposition, "that those forms of rupture, where the sphincter is not torn through, should be cured, to prevent prolapsus uteri, &c.," and I illustrated it by two cases, which appear as the sixteenth and seventeenth in the subsequent series. In those cases I thought it desirable to divide the sphincter ani. They were both of long standing, and great stretching of the parts had followed the displacements. In Case XVI., indeed, the pressure of the prolapsed uterus had been so great as to rupture the rectum. Case XVIII. is an additional example of this variety of lacerated perinæum, where I operated on the occurrence of the accident, one interrupted suture introduced answered the purpose, without any further measures. In this last case, I should state, necessity-from the want of instruments-was the chief reason of this considerable departure from the practice generally pursued. Indeed, in deciding on the operation in any particular case, we must be guided by its special circumstances.

Other instances of rupture of the perinæum, not involving the sphincter ani, occur in the chapters on vaginal cystocele and rectocele, in which, however, the usual operation was modified

to adapt it to the cure of the complication, which in those cases was the leading feature.

Contra-indications to Operating.-Before deciding on an operation, certain circumstances are to be taken into account. For instance, if pregnancy has advanced beyond the fourth month, if suppuration and inflammation exist, then the operation must be delayed; in the former case till after parturition, in the latter, until the arrest of these processes. The presence of leucorrhoea need not deter from operating, when it cannot be removed by simple measures: a postponement, however, is desirable until after a menstrual period. Cough, if present, should be relieved, on account of the straining it causes.

It seems almost unnecessary to add that, if the patient's health be impaired, an endeavour should be made to improve it before surgical means are resorted to, for the condition of the patient has much influence over the success of the operation.

Time of Operating.—The operation may be performed immediately after the completion of labour. The surfaces of the wound are then fresh, and in a condition favourable to union by the first intention, and consequently the paring of the edges required in old cases is not here necessary. Should, however, surgical means not be resorted to on the day of delivery, the advantages accruing from the recent nature of the wound will be lost; the mischievous effects of the vaginal discharges will have placed the edges in a disadvantageous position for healing, and it will therefore not be desirable to attempt an operation until after the third month, by which time the parts will have recovered themselves, be capable of undergoing the necessary denudation, and be sufficiently strong to carry the sutures.

As immediately preparatory measures, the bowels should be well cleared out by aperients-such as ox-gall, castor oil, and by injections of salt-and-water. Warm baths are not objectionable, but generally sponging with warm water is sufficient. The diet for some days prior to the operation should be unstimulating, plain, and nutritious. As a last point, the bladder should be emptied.

Instruments required.-The instruments required are, a common straight scalpel; a blunt-pointed straight bistoury, to

D