divide the sphincter; a pair of long dissecting forceps; three large needles for deep sutures; small ones for the superficial interrupted sutures; a tenaculum; pieces of gum-elastic catheter or bougie, with twine well waxed; sponges, &c. The needles used for deep sutures are fixed in handles, and more or less curved to adapt them to different cases; the width of perinæum and the thickness of the tissues varying considerably in different persons. See figs. 1 and 2. Fig. 1. Fig. 2. *** These figs. 1 & 2 represent one-half the size of the Chloroform.-The operator will require at least two assistants. Unless contra-indicated, or opposed by the patient or her friends, it is desirable to place the patient under the influence of chloroform; for not only will she be thereby saved pain, but opposition and straining are avoided, and a favourable relaxation of the parts obtained. MODE OF OPERATING. The patient should be placed in the position for lithotomy, the knees well bent back upon the abdomen, and all hair closely shaved off about the parts. The sides of the fissure should be held by an assistant so as to insure sufficient tension for the operator; a clean incision is now to be made about an inch external to the edges of and equal to the fissure in length, and sufficiently deep to reflect inwards the mucous membrane, and so to lay bare the surface as far as another incision on the inner margin (see plate 1). The denudation of the opposite side of the fissure is then to be practised in a similar manner, and the mucous membrane from any intermediate portion of the rectovaginal septum to be also pared away. This denudation must be perfect, for the slightest remnant of mucous membrane will most certainly establish a fistulous opening when the rest of the surfaces have united. Some operators, especially the continental, remove the mucous membrane by scissors, but this is a clumsy and unsafe method, and the knife will be found to effect the purpose quicker and better. Division of the Sphincter. So soon as this stage of the operation is completed, the sphincter ani is to be divided on both sides, about a quarter of an inch in front of its attachment to the os coccygis, by an incision carried outwards and backwards. The incision should be made by a blunt-pointed straight bistoury, which, having been introduced within the margin of the anus, guided by the forefinger of the left hand, is quickly and firmly carried through the fibres of the muscle and through the skin and subcutaneous areolar tissue to the extent of an inch, or even two, external to the anal orifice. The degree of relaxation to be sought must be regulated by the extent and character of the laceration; it being remembered that the freer the incision the greater will be the amount of relaxation obtained. In every case, muscular traction must be destroyed, for so long as it exists it will oppose the union of the parts. Insertion of the Quill Sutures.-The sphincter having been divided in the manner just stated, the thighs are to be approximated, and then the quill sutures introduced. The left denuded surface and tissues external to it being firmly grasped between the forefinger and thumb of the left hand, a strong needle carrying a double thread is plunged, with the right hand, through the skin and subjacent tissue an inch external to the pared surface, and thrust downwards and inwards beneath it until its point reappears on the edge of that surface; it is then introduced at the corresponding margin of the denuded space of the opposite side, and made to traverse beneath it in a direction upwards and outwards until it escapes at a point equi-distant from the external margin with that at which it entered on the left side. Each of the three sutures is to be introduced in the same way, the one nearest the rectum first. The sutures are double, to allow them to enclose the quills, or (as actually used) the pieces of elastic catheter or bougie, around which they loop on one side, and are tied over, by their free ends, on the other. For sutures I prefer stout twine, well waxed, to silk, as I believe it to be less irritating and productive of less suppuration. skin, it is If this be Insertion of Interrupted Sutures.-Having firmly secured the three sutures upon the bougies, the sides of the fissure become approximated, the denuded surfaces in apposition. To bring together the outer margins, along the line of the advisable to pass three or four interrupted sutures. carefully done, union of the skin will speedily take that of the deeper parts be materially facilitated (see plate 2). As an accessory or superficial suture, the twisted form is used on the Continent; but I think the interrupted more simple, and have found it answer completely. place, and I should recommend, previously to bringing the operation to a close, that the forefinger of the right hand should be passed into the vagina, and that of the left into the rectum, so as to ascertain that apposition is complete throughout. Lastly, the parts having been well cleansed by sponging with cold water, a piece of lint steeped in cold water is applied, and over it a napkin kept in situ by a T bandage. Operation in Recent Cases.-The operation has been detailed |