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be carefully separated from the vaginal wall and the dissection should be carried along the sides of the rectum so as to permit the flap, constituted of the posterior wall of the rectum, to be drawn down and out sufficiently to entirely protect the sutured parts from the rectal contents. As the rectum is comparatively loosely fastened, this can be easily done without difficulty. If the laceration extend quite a distance up the rectum, it may be necessary to reflect a portion of this flap from the vaginal mucosa, as described and executed by Dr. Howard Kelly. After this flap is ready the dissection should be extended so as to expose the ends of the anal sphincters, which should be drawn forward, the muscle stretched and the ends securely sutured in approximation by continuous returning sutures of cat gut. Then the rectal flap should be brought out and fastened about the outer surface of these muscles in the natural position, leaving the rectal surface complete without an opening. The vaginal portion of the operation should be completed as described for incomplete laceration.
In operating for relief of relaxed vaginal outlet, the same principles should be followed. The initial incision should follow natural lines, so as to approximate labia naturally, the vaginal flap should be thrown up freely, the structures which have given way should be sought and brought together by carefully arranged sutures, so as to restore normal conditions.
The result of such procedures carefully and intelligently carried out will leave conditions which are not painful to the patient— as a rule morphine is not necessary-which unite promptly and securely without reaction, and which bear well the strain of subsequent labors.
DR. C. E. CANTRELL: I would like to thank the doctor for the description of his operation for a complete laceration, as I have been doing some work along that line, especially on those on the anterior wall of the rectum. You will find by referring to the proceedings of last year that I wrote a paper describing an operation that seemed the best in my opinion, and the operation that has given me less trouble than all others that I have attempted for complete laceration of the perineum; by advancing of
the rectum, you have no sutures of any kind in the rectum. I do not know where I got the idea; the few ideas that I get, I forget frequently where I get them. I am able to restore the sphincter ani satisfactorily, where it had been completely torn through. The first one I had operated on twice before I tried this method, and was not able to get union of the sphincter ani, but when you bring the rectal mucosa down and put your sutures over a solid mucous membrane, you haven't the same trouble to get it to grow that you have in a perineal laceration, where sutures are put in the bowel. I tried to describe this last year. I am very much pleased to see that some one else is having success with that operation.
DR. GEO. H. LEE, replying, said: Reviewing very briefly the discussion of my paper, I will say, with reference to stretching the sphincter ani before operation for the repair of incomplete laceration, that I have not found it necessary or advisable to stretch that muscle; such stretching adds to the suffering after the operation.
The vaginal flap can be lifted up, beginning along the anterior border of the scar up the laceration and can be peeled back, denuding the structures along the floor and sides of the vagina, and then the sutures should be passed so as not to include either the skin or mucous membrane. The parts should come together easily and naturally without tension, and the skin fit so nicely as not to necessitate a skin suture. The result should be the minimum of post operative pain. Morphine is usually not needed.
I am sorry my paper was not understood; the fault is mine, in that I probably read too rapidly. The suggestions I wished to make and emphasize are:
1. That the initial incision should be along the line indicated by the anterior border of the scar of the laceration.
2. The denudation should lift up the vaginal flap, preserving it from puncture, so as to furnish a protection from infection from the vaginal discharges. The rectal flap should be similarly arranged in operations for complete laceration, to protect from fecal contamination.
3. The denudation should fully and freely expose the divided muscular structures, so that these can be brought together in their normal relations without tissue between.
4. The muscle structures should be brought together by absorbable suture, placed with a view to approximating the different divided ends of muscles, and arranged subcutaneously, avoiding skin and mucous membrane.
It is not my purpose to ignore the fascias of the pelvic floor, and for this reason I called attention to the fact that in uniting the muscular struc
tures in the manner suggested, the fascias are necessarily restored to their normal relation.
Emmet's operation was not based on proper consideration of the anatomy to be restored. He aimed to fill up the space between the rectum and vagina, and narrow the opening of the vagina by putting tissue into the opening and building up a perineal body. The effect of his operation is most often not to closely coapt the ends of divided muscles, but to place and fasten tissue between those ends.
C. C. COMER, M. D.,
It is not necessary for us to go into the minute definition, causes, diagnosis and treatment of amenorrhea, in which every doctor here is well versed both from the text book and practical experience.
It is not the intention of this paper to be a scientific research nor an intellectual treatise, but a simple, practical experience of a few cited cases that will possibly be of some benefit to us.
Amenorrhea is defined as an absence of the menses in adult women who are not pregnant, and have not passed the menopause, or suffered from retention of the flow. It results from various causes which affect the general system, or the genital organs in particular.
Causes: That which affects the nervous system, as anger, anxiety, fright or grief.
The general nutrition; as protracted fevers, chlorosis, pulmonary tuberculosis, Bright's disease, malaria, and general anæmia, etc. Pelvic disorders; as absence of the uterus, or ovaries, or diseases of same.
Change in mode of living; school girls and nurses of a training school, from over mental work and not enough physical exercise. Traumatic injuries; renal insufficiency, obesity, luxurious living.
The most common we have is from taking cold during the period, and anæmia. The following cases are interesting to me for they demonstrate the beneficial effects of santonin, as a remedy for amenorrhea, especially as a nervous sedative and emmenagogue.
Miss D., age 17 years, gave a history of chronic chills and fever of three years duration, commenced menstruating at 12 years, as a normal flow. In the second year of chills and fever menstruation stopped. Was called to see her with a congestive chill. Twelve
hours after the chill convulsions appeared, which lasted for eighteen hours, possibly one every three or four hours. I found the spleen filled nearly the left side of the abdominal cavity extending two inches beyond the medium line to the right and tender, liver enlarged. Urine specific gravity 1008, and scanty, albumen. Feet and legs swollen, coated brown tongue. General appearance pale, and anæmia.
Treatment: For congestive chills, morphine, atropia and quinine, hypodermically. For the convulsions, chloral, morphia and bromide, and ordered 10 grains santonin at bedtime. The first dose santonin controlled the spasms, second dose the menses slightly appeared, and third dose a reasonable good flow, followed with Basham's iron mixture, calomel, podophyllin and ipecac, continued for three or four months; results, menses gradually became normal, spleen and liver greatly reduced and health restored.
Miss W. gave a history of typho-malarial fever, lasting sixtyfive days, with slow convalescence, producing a total cessation of the menses for twelve months; during this time she suffered from general anæmia, and occasionally with accompanying symptoms of general debility. She was 16 years old, and had normal flow and regular periods every month previous to the fever. Symptoms: Bowels constipated, urine specific gravity 1010, albumen, constant headache, periodical pains in bowels, swelling of feet and legs, no appetite, white coated, puffy tongue, general malaise. Did not examine blood.
Treatment: Basham's iron tonic as a blood builder, and calomel, podophyllin and ipecac as an eliminator. Santonin as an emmenagogue. Kept her on this for three months and the flow came on the second month slightly and the third month normal; continued the treatment five months, which resulted in a cure.
Mrs. M. brought her daughter, Miss Effie, to my office for examination and treatment. Miss E., age 18, was a robust and well developed woman, weight about 140 pounds. From all appearance in excellent health. She gave the following history: At 12 years