with reference to cases of some standing, where cicatrization has occurred; with respect to recent cases of the accident, the only variation of the plan is in the omission of the otherwise necessary denudation of the margins of the fissure.

After-Treatment.—The patient having been removed to her bed, should be placed on her left side on a water-cushion, with the thighs and knees close together, and flexed on the abdomen. Perfect quiet enjoined, and cold-water dressing to be continued. Ice given to suck for twenty-four hours is refreshing, and allays febrile reaction and nausea. Two grains of opium should be given at once, and one grain repeated every four or six hours. Beef-tea and arrowroot may be given within the first twentyfour hours, but not wine, unless there are signs of flagging: the wine I give is port. After the first day, four ounces of wine may be allowed; and a generous diet, chops, strong beef tea, &c., after the second or third day. This is supposing no symptoms occur to contra-indicate such regimen.

It is of great importance to draw off the urine by the catheter every four or six hours for three or four or more days, after the operation. As the patient lies in the common obstetric position, this is best done by introducing the catheter between the thighs from behind; and in withdrawing the instrument, the thumb should be kept on its end, in order to prevent any urine remaining in it from escaping into the vagina, whereby it might cause such irritation about the wound as to render our attempts to close it abortive.

After some days, as on the eighth or ninth day, if the healing go on satisfactorily, and the strength of the patient be equal to it, she may be allowed to pass water, resting on the hands and knees, so as to prevent, as far as possible, its contact with the lower or sutured surface of the vagina.

The deep sutures should be removed on the third or fourth day in hospital patients; in private cases on the fifth or sixth. I have found their retention after the periods named, of no service, but rather mischievous by their tendency to suppurate and slough, results of more rapid occurrence in hospitals than elsewhere; hence the earlier date proposed for their removal in hospital cases. On the sixth or seventh day the external sutures

may be taken away. In withdrawing the sutures care must be taken not to separate the thighs, for it is necessary to keep up their apposition for some time. The time for the removal of sutures above stated, does not correspond with my practice in the first cases I published; increased experience has led to the alteration.

If, after the operation, there should be any considerable bleeding, not controlled by the simple water-dressing, pieces of ice may be introduced, or ice-water injected into the vagina: other measures, as ligature or torsion, are scarcely ever required. For removing secretions, and keeping the parts clean, injections of tepid water may be used two or three times daily, especially after the employment of the catheter. By such, and by frequent sponging, perfect cleanliness must be attained. Should there

The

be an offensive discharge, chloride of soda may be added. opium should be persevered with, so as to keep the bowels constipated for two to three weeks after the parts have united; when union has become firm and complete, the bowels may be relieved by injections of warm water with castor oil, and by the latter given by the mouth. Attention should be paid during the passage of the first evacuation, and support given to the restored perinæum if any hardened masses should cause stretching.

The precise time for opening the bowels must be regulated by the strength of adhesion set up, and by the amount of reparation of lost tissue which has been attempted.

For some few days after the first evacuation, an enema had better be continued.

Should adhesion, unfortunately, from any accident, not be complete throughout, and a fistulous opening persist, the actual cautery is the quickest and surest means of closing it; but the application of a caustic or stimulating substance may be tried.

CRITICISMS AND SUGGESTIONS.

The history already given has sufficiently detailed the propositions made, and the plans of treatment pursued by others;