normal position, no pelvic pain, ovary with great difficulty could be palpated, and he stated that her condition and the result of the operation was ideal. After four months her old symptoms returned and she called for examination. Gave history of a slip from step of moving car and striking with great force upon her buttox and not feeling well since. Examination revealed uterus in its old retroverted position with descended ovary.

What lesson does this case teach?

First. That the operation is a success if it can be made perma

nent.

Second. That catgut is not sufficient; that it needs the assistance of a more permanent suture to hold the work.

Third. By the use of silk to unite the loops of the round ligament embracing the posterior wall of the fundus the work would be permanent, or would it be wise for the patient to wear a pessary for a time till the adhesions became firm, as is often done after the Alexander operation?

I witnessed Dr. Harris do his operation, which is taking a V-shaped piece out of the broad ligament, the base of the triangle being the round ligament. The ligament is reunited by a catgut suture and the uterus held in position. It is a beautiful operation. Still I prefer the Webster operation for there is no tissue removed. The continuity of the ligament is not interfered with and, if a silk ligature is used to unite the ligaments, the results in my opinion would be permanent.

OPERATION FOR COMPLETE LACERATION OF THE
PERINEUM WITHOUT LEAVING STITCHES
IN THE BOWEL.

C. E. CANTRELL, M. D.,

GREENVILLE, TEXAS.

So far as I have been able to find there has been but one method practiced, other than the one I am going to describe to you, without putting stitches in the rectum, in operating for complete laceration of the perineum, and that is to clamp the rectal mucous membrane and burn it with actual cautery after the other steps of the operation have been completed. This I have never tried, but should do so if I did not think I have a better method of keeping stitches out of the bowel, in this the most troublesome of all fields that I have ever left a stitch in.

I have found no suture material that did not give trouble if left there. There is danger of fistula, fissures or ulcers following, and the stitches when left are most difficult to remove, and do all sorts of mischief if left to come away or absorb.

The condition which this operation is intended to relieve is the result of child-birth, and as soon as the sphincter muscles are severed the situation is relieved so that I have never seen the rectovaginal septum divided to the extent of more than one and one-half inches.

The steps of the operation are, first, the preparation of the patient for an aseptic operation in this field, all of which you can find laid down in any text-book of recent date. Patient anesthetized and in the lithotomy position, legs elevated and held in place by Clover's crutch, or the leg rest usually found on a surgeon's table.

Begin at a point on a level with the upper part of the bowel if it were intact, make an incision through the scar around to a corresponding point on the other side with a knife, then make an incis

ion on either side from a point as high up as you have decided to go to close the vagina as low as the center of the rectum, crossing the points of beginning and ending of the first incision; this makes what is described as the "H" shaped incision, with the transverse bar much nearer the bottom of the letter.

This makes a vaginal and a rectal flap, each of which can best be handled with a "T" forceps, as more pointed instruments tear the tissues. Now comes the separation of the two walls which make the partition between the rectum and vagina. This is the most tedious step of the operation and should be done by blunt dissection with great care not to break through either one, always giving the greatest care to the rectal side.

Carry the separation high enough to liberate the rectum sufficient to allow the upper angle of the rectal wound to come to the outside without dragging on the vaginal wall, which should not be pulled down at all. This is an easy thing to do as the rectum is a loose pouch capable of being drawn down several inches without being taken loose high enough to reach the peritoneal coat. The bowel should be taken loose on either side far enough to allow the anterior wall to drop to the outside without traction. When this is done, and all spurting vessels have been either tied or twisted, the wound washed with sterile water, you are ready for the sutures.

Silk-worm gut is the material to be used, and the ones to close up the wound should be inserted as follows: Use a perineal needle, eye in the point, insert one-eighth inch from the edge of the skin at the lower angle of the wound on one side, being careful to pick up the sphincter muscles, emerge at the center of the anterior rectal walls high enough to hold the bowel in place, thread the needle and withdraw it, bringing the thread out with it. Insert on the opposite side in the same manner, emerging at the same place, take up the other end of the thread bringing out on the opposite side. This is the most important stitch as it should hold the sphincter muscle in place and the bowel as well. The next perineal suture should be inserted one-fourth inch above in the same manner, and so on until enough have been applied to close up the wound, when they should be drawn up, beginning with the lower one, and carefully shotted.

Now the anterior lip of the anus should be sewed with interrupted sutures of silk-worm gut to the skin, being careful to make it fit as well as possible. If there are bruised or superfluous bits of tissue they should be clipped off with scissors before sewing. Next sew up the vaginal membrane as you would for a denuded colotomy, shotting all sutures. The patient is now ready to dress, which should be done in the ordinary way with iodoform gauze and a "T" bandage. You may put a drainage tube wrapped with gauze in the rectum if you like. I have never tried this, but at times wished I had, to allow the escape of gas; have always been afraid to try it for fear the muscle which had not been in use for so long would rebel against it.

The after treatment is the same as for operation for partial repair of the perineum. If the nurse can be trusted to catheterize the bladder I prefer not to leave a self-retaining catheter; if not, I would put one in, so that the bladder can be relieved regularly. The bowels should be moved on the third day, after which the patient has her first dressing. From this on the bowels should be moved by enema and the wound dressed daily.

I douche every case thoroughly every day, being careful to dry out the vagina as thoroughly as possible before redressing. Begin to remove the stitches on the seventh day, taking away those that fret most, leaving the others for the eighth and ninth days. The early removal of a single stitch will frequently give great relief without doing any damage to the result.

I have performed eight operations by this method, with good results in every case. Seven of these had been operated on before by other methods. One of these cases I had operated upon twice by other methods. My third effort was by this method and was successful. I hope the surgeons with a wider field will take up this operation and see whether or not it will be as successful in their hands. This is a rare condition, but a most difficult one to relieve by the methods laid down in the text-books.

I am sorry I had not decided to write this paper before I did the last operation so that I could have had it photographed. I had three of the cases reported in my house at one time, and had no

thought of its being a hard matter to find a case to photograph, but I have not heard of a case for more than a year, notwithstanding the fact that I have proposed to my medical friends to do the operation free and go any reasonable distance to do it for the privilege of photographing the different steps of the operation.

DISCUSSION.

DR. NORSWORTHY: I have been very much interested in the doctor's description of this new and original operation. I read a paper last year on a somewhat similar subject, dealing more particularly with deep suture. My custom is to use three rows of stitches, taking them from the vaginal side, but taking care not to penetrate the mucous membrane. I use catgut, and tie a knot in the inside of the vagina. The object of this procedure is to re-establish the floor with a thick substance. I stitch backwards and upwards, getting as near to the vaginal wall as possible. By the process described by Dr. Cantrell, I am afraid you will not get a sufficiently strong floor. Besides, you leave exposed a larger raw surface, which is liable to get contagion from the rectal substances.

DR. CANTRELL: I do not go to the mucous membrane of the vagina at all.

DR. NORSWORTHY: Still, what we want is a thick, strong support, and that can only be obtained by acting on geometrical lines. It seems to me that under any other system than the one I use there is a tendency to draw down the vaginal wall.

DR. CROUSE: There is an operation described by Goelet which obviates some of the objections alluded to by Dr. Norsworthy. The great object is to avoid any cul-de-sac or pocket. This is accomplished by bringing together the ends of the sphincter muscle by the Tait process, and then applying a continuous suture. By the process described by Goelet, you do not go through the mucous membrane of the bowels, and you have only two knots and no pocket. The operation is slow, but it will compensate for the time and trouble it involves.

DR. CANTRELL, replying: I prefer to clamp and cauterize the mucous membrane to leaving it free. As to the dragging down of the vagina, that is the very point I wished to emphasize. You do not require to drag the vagina down at all. If you only go high enough, and the operation is performed properly, you will find that there will be no tension. The operation is easy to perform, and it will be found that the ends of the sphincter muscle will soon grow together.