perineum naturally depend upon the extent of the lacerations. The remote symptoms are produced principally by the effect the laceration produces on the normal functions of the uterus. As I have already stated in treating of the local symptoms, the uterus is markedly influenced by the condition of the recto-vaginal septum. Almost invariably with chronic laceration of the perineum a prolapse of the uterus has supervened, and frequently this prolapse has become so marked that retroversion occurs. I also referred to the fact that the uterus is very liable to become the seat of a catarrhal or septic endometritis; these conditions being induced, first, by the blood stasis, or congestion of the uterus due to its displacement, and second, by the fact that it is the subject to infection through the open, gaping vagina.

Any irritation of the uterus due to displacement or infection gives rise to reflex disturbances through the sympathetic nervous system. One of the first remote symptoms complained of by a woman with prolapse or retroversion, or engorgement of the uterus due to any cause, is a disturbance of the rhythm of the heart. The patient will complain, as a result, of shortness of breath and palpitation of the heart. Foilowing closely upon the disturbance to the circulation is the disturbance of the stomach and intestinal indigestion. This gives rise to what the patient calls "heartburn," producing an eructation of gases and a feeling of bloating and distension in the intestines. With the disturbances of digestion and circulation there will soon follow a change in the mental condition, so that the patient will complain of feeling irritable, despondent and generally depressed, frequently with an indisposition to join in activities, either of work or pleasure.

For obvious reasons there will soon supervene, as a result of indigestion and the disturbance of the circulation, a failure in the nutrition, with general anæmia. In other words, the patient becomes an irritable, despondent, anæmic invalid, without being able to account in any definite way for her condition.

These remote symptoms vary markedly with the effect that the laceration has upon the condition of the uterus and other pelvic organs.

METHOD OF REPAIR OF THE PERINEUM.

It is not my object in this lecture to describe the multitudinous methods adopted by a multitude of operators in the attempt to restore the normal condition to the lacerated perineum. The plan I am about to describe is the outcome of several years of operation in this line of work, and represents, to my mind, the nearest approach to an ideal method. which will apply to all cases of laceration of the perineum. The method has been evolved from the "flap-splitting" operation given to the profession by Lawson Tait. To my mind if Lawson Tait had done nothing for the profession more than to give to it this operation, too much credit and honor could not be given him.

Briefly, the method involves a procedure which makes it possible, without the loss of any material, to restore the torn and lacerated tissues to their normal condition with accuracy and expedition. The operation, while varying slightly in the method of execution, does not vary in principle, whether the laceration be extensive or only slight.

Procedure as Applied to Partial Laceration.-The mode of procedure I shall describe first applies to all cases not involving the complete laceration of the sphincter ani. In order to understand the principle of this operation, it will be necessary for us to refer again briefly to what I have said in regard to the mechanics of laceration of the perineum.

In a partial laceration of the perineum, the sphincters of the vagina are torn through and the free ends of the torn muscles retract laterally, allowing the mucous membrane of the posterior vaginal wall to fall backwards toward the anus. If the laceration is more extensive, so as to involve the fibers. of the levator ani muscles, the transverse perinei muscles, the torn free ends of these fibers also are drawn forward and