vagina while he freshened the proximal part of the vaginal wall by having an assistant introduce a finger in the rectum and force the vaginal mucosa to protrude at the pudendum. Veit, Hegar and Spiegelberg aided to develop the operation. As time passed, instruments for support were gradually displaced by more perfect operations, owing to more perfect anatomic and pathologic knowledge. Most of the advances are due, chiefly, to the investigations of Freund, Huguier, Martin, Schroeder, Wilms (1879) and Staude (1880), Breisky, Huepfel, and others mentioned in this monograph. The practical execution of colpoperineorrhaphy by the celebrated Heidelberg surgeon, Simon, is the real foundation of subsequent labors. The success attending Simon's addition of colporrhaphy demonstrated that some form of vaginal operation is required in prolapse or deficiency of the peritoneal or sphincter apparatus of the pelvic floor.

Celsus, it is reported, recognized perineal lacerations, and suggested rest in bed, and tying the legs together, but gave no surgical views of repair. Ambrose Pare, a fertile genius, demonstrated the use of sutures before 1880. He had a pupil named Guillemeau, who restored the parts, applied the sutures, and secured the curves. Sancerotte and Noel secured success about one hundred years ago. In 1829, Dieffenbach, surgeon to the Charity Hospital of Berlin, devised useful methods of repair. The deductions which made Deiffenbach celebrated in perineorrhaphy were his methods of lateral incisions (to relieve tension), and confining the bowels and checking peristalsis of the tractus intestinalis by the aid of opium. Chelius opposed this view, insisting that the bowels should be loose. In 1852, von Langenbeck gave to the world his views through a memoir written by Verhæghe, of Ostend. This definitely advocates the use of flap, and splitting the recto-vaginal septum. Marcy, a fertile and persistent investigator, gives credit to Dr. Jenks for originating the flap. Zweiffel gives Mr.

Lawson Tait credit for the flap-splitting method, to which he is no doubt. entitled. Hart and Barbour credit A. R. Simpson with it. Baker-Brown published, in 1854, his first edition of the "Diseases of Women," in which he advocated Dieffenbach's lateral incisions, the use of deep-quilled sutures, confining the bowels with opium, and bilateral division of the sphincter. The perineal sutures were removed the third day, the remainder later, as late as twelve days. All sutures were silk. It appears that Dieffenback and Baker-Brown realized that the denudation should be carried up into the dorsal vaginal wall, the fact which Simon actually demonstrated. It is reported that Mettauer, of Virginia, in 1830, used lead sutures; other metallic sutures were also employed. In New York, in the Woman's Hospital, Drs. Sims, Emmet and Thomas further developed colpoperineorrhaphy.

At present the operation should be termed colpoperineorrhaphy. New aids have also been developed in regard to the operation, as A. Martin taught for years that one should begin the operation for colpoperineorrhaphy by initiating an involution of the uterus by amputating the cervix. I have amputated the pointed conical cervix to avoid the dangerous dilating wedge to the sphincter apparatus of the pelvic floor, to prepare for successful colpoperineorrhaphy. A new era appeared in this operation when the flap-splitting operation began to be formed. So far as records are accessible, the late Berlin surgeon, von Langenbeck, in 1852, first described the flap operation in perineorrhaphy. He describes the splitting the rectovaginal septum, making a vaginal flap ventralward, and a rectal flap dorsalward. Langenbeck's description of perineorrhaphy, as translated by Dr. Marcy, is the most important contribution to the subject previous to the time of Gustav Simon, of Heidelberg. In fact, it is almost equivalent to Simon's, and, in one sense, superior—in the use of the flap. Perineorrhaphy was also cultivated by Zary, Mursina, Mensel, Osiander, and Horner. Perineorrhaphy was performed first with silk sutures, the hot iron. and chemicals. About three-quarters of a century ago metallic (wire) sutures appeared. In 1879, Werth published views on the use of catgut (animal ligatures) for buried sutures. Schroeder chiefly introduced the buried spiral catgut sutures in perineorrhaphy. Silkworm gut is one of the best materials for sutures in general use at present. About 1872, Mr. Lawson Tait began the use of a certain flap method, consisting of resplitting the cicatrix, resulting from parturition by use of scissors, reuniting the produced wound surfaces by means of sutures which do not penetrate the skin or mucous membrane. The utility of this consists in its application to either, or both, perineorrhaphy or colpoperineorrhaphy. The flap operation was dimly begun by Dieffenbach, in 1829, by his lateral incisions to relieve tension. The flap operation was definitely introduced in perineorrhaphy by von Langenbeck, about 1850 ("Memoire," 1852, by Verhæge).

In 1861, Colles, of Dublin, in a case of vesico-vaginal fistula, resplit, instead of vivifying the edges, and united the resultant flap. In 1872, John Duncan resplit the edges of an artificial anus, and reunited them with interrupted catgut sutures. He forced the flap of mucosa intraintestinalward, and drew the flap, composed of muscularis and serosa, extraintestinalward, thus increasing vastly the denuded surface for coaptation. Hart and Barbour report that Dr. A. R. Simpson applied his flap method to perineorrhaphy. Not far from 1872, Mr. Lawson Tait applied the flap

operation of Langenbeck, Colles and Duncan to the subject of perineorrhaphy. He added to all previous labors the use of sharp-pointed elbow scissors, and the introduction of sutures not penetrating the skin or mucosa of vagina or rectum. Silkworm gut sutures are employed, and may remain in situ for ten days to six weeks. According to Sanger, Stein (a Dane), and Voss (a Norwegian), used similar methods. Later, Hadra, 1887, contributed valuable views on the restoration of the pelvic floor, as well as Marcy, Jenks, Byford, and Reamy.

The various so-called operations for (colpo) perineorrhaphy are nuThe first operation devised involved the pudendum, the second both pudendum and vagina.

merous.

I. Ambrose Pare (1580) used simply sutures. meau, practiced and improved the method (1649). Noel, Murenna and Sancerotte practiced it.

His pupil, Guille-
LaMotte, Smellie,

(1830) Dieffenbach, union by sutures, and tension relieved by lateral incisions. Roux (1834) introduced it into France, as well as Mark See (1855), and Polaillon (1855).

3. Baker-Brown (1855), union by sutures of the denuded surfaces. Wilms and Stauda cultivated it in Germany.

The next important contribution and method devised in perineorrhaphy was von Langenbeck's flap method (1850). It was described and performed with a master hand. Von Langenbeck also suggests that the lateral incisions of Diffenbach may be added, as it obviates dragging from movements. He advocated operation immediately after the injury, if possible. Von Langenbeck makes several distinct steps in the operation: Vivification of the free border of the recto-vaginal septum; the division, clearing, undoubling of the septum, and formation of the flap destined to form a new perineum, the ventral side of the triangular space formed by two canals, vagina and rectum, with the perineum as the base; the vivification of the two lips of the laceration; insertion of the sutures. In this operation of perineorrhaphy von Langenbeck started the flap method. The flap operation protects the wound from secretions (vaginal or rectal).

5. In 1867, Professor Gustav Simon, of Heidelberg, began the real modern steps in successful perineorrhaphy, which was a combination of perineorrhaphy and dorsal colporrhaphy. Simon simply improved on Baker-Brown's method by not only freshening the perineum, but also carrying the denudation well proximalward. Simon denuded the vagina by the aid of a well-fenestrated speculum. The proximal angle of the vaginal wall was denuded by introducing the finger into the rectum. Spiegelberg and Veit aid in developing the subject. Englehart wrote in 1871; Banga, in 1875, wrote a thesis on "Kolpo-perineorplastik," according to Bischoff. In 1879, Hegar and Kaltenbach made excellent contributions. In 1877, Le Fort, and Meugenaum, in 1881, added their labors. In 1877, Dr. Edward W. K. Jenks, of Detroit, began the publication of a series of articles on perineorrhaphy, which was really a clap method of operating a distant relative of von Langenbeck's procedure. Dr. Jenks first resected away the flap, but subsequently preserved it. The method is almost precisely similar to the flap method attributed to Dr. A. R. Simpson by Hart and Barbour. In 1879, Werth began to use buried catgut to suture the wound. Dr. Brose, in 1883, used buried animal ligatures. H.

O. Marcy published a series of articles (1883) on perineorrhaphy, advocating the flap method and buried animal ligatures, which he first used in hernia in 1881. August Martin, of Berlin, contributed excellent labors, about 1882. About 1880, Professor Schroeder, of Berlin, obtained excellent results by the use of the "etage" stitch, a continuous running suture of catgut, buried in the tissues of the denuded surfaces. As a pupil of Schroeder and Martin (1885), I observed excellent results from this method. Bischoff, in part, revives the flap operation of Langenbeck. However, his operation' was quite influential in its day. Drs. Byford, father and son, made valuable contributions to the subject. History notes that Simpson

transferred Duncan's flap-splitting to the perineum. Simpson performed

THE INCISIONS IN PERINEORRHAPHY.

FIG. 6. Represents the plan of incision by means of elbow scissors.

a kind of four-flap perineorrhaphy for many years. Perhaps Mr. Tait imbibed some of his views.

In 1887, Dr. Hadda, of Texas, contributed some valuable articles on the subject of perineorrhaphy. He suggested the vivification of the dorsal vaginal wall for colporrhaphy, as is done in ventral colporrhaphy. Since 1880, the laborers in the field are legion. Gradually the operation of perineorrhaphy was modified from Pare, Baker-Brown, Dieffenbach, Langenbeck, and Simon, to Tait and Emmet. The modification consisted in denuding not only the perineal lacerations, but also denuding more proximalward into the dorsal vaginal wall. Hildebrandt, especially, carried the denudation well proximalward into the dorsal vaginal wall.