While I do not wish to detract in the least from the Emmet operation and the fame of the master who devised it, yet I believe there are injuries to the perineum that can be repaired as accurately, effectually and scientifically, by the dividing or the dissecting method, without removal of tissue, as by any denuding process. To be more explicit and definite I will class injuries of the perineum under three general divisions;

1st-Ruptures, visible or concealed, with relaxation of vaginal outlet and large rectocele.

2nd-Rupture, visible or concealed, with or without slight relaxation of vaginal outlet and small rectocele, if any.

cases it will require a deeper dissection of the tissues, often making as thick or even thicker vaginal flap than the rectal, especially if there has been more of a concealed rupture.

If much of a rectocele accompanies the median laceration, it is but fair to say that the Emmet or Hegar denuding process may meet indications best.

It is claimed median lacerations are not so common as the lateral, hence the necessity of modifying the operation to suit the individual case.

It is here the advocates of the Emmet operation claim its superiority over other methods, yet I cannot understand why it is not practical and scientific to accomplish the same result by a method of dividing or dissecting without loss of tissue when possible. If there is a redundancy of tissue, great relaxation and large rectocele, then denudation and removal of tissue is indicated, but if such is not the case then conservation of tissue is the most rational and scientific procedure. In these cases, classes two and three, removal of tissue is unnecessary, unjustifiable and renders the patient more liable to lacerations at subsequent labors.

If any of the muscles of the perineum are ruptured or torn across they retract towards the point of fixed attachment, and in operating the divided ends should be exposed and brought in apposition, if possible. Suppose there should be a concealed rupture of the transversus perinei or the anterior part of levator ani,

septum.

Cases of the first class or division are best relieved by the Emmet operation. The second class, in the majority of instances, is corrected equally as well as by synthetic perineotomy, while a portion is more successfully treated by that method. The third class is all corrected better by synthetic perineotomy than by any other method. All perineal operations are designed to restore the parts to their normal or original condition. The simplest operation that accomplishes this result, and without loss of tissue, is certainly the ideal method and should commend itself as scientific and rational.

It is agreed by all that the most important structures to be restored are the muscles and pelvic fascia. To restore these each case should be investigated as to the location and direction of the tear and what muscles are injured. If the tear be in the median line, what is more simple and accurate than dissecting up the tissue in the recto-vaginal septum to the full extent of the injury, exposing the injured muscles, coapting them and the other tissues by proper suturing. A simple lifting up of the mucous membrane in some cases may suffice, yet in most

Read before the Tri-State Medical Society of Ala., Ga., and Tenn.

drawing the relaxed tissues together by sutures restore the normal integrity and function of the injured muscles? In many of these cases to remove the necessary amount of tissue to expose the injured parts, so as to bring them together properly, is a reckless waste of tissue when it is possible to repair such injuries equally as well, and often better, without loss of tissue.

It matters not whether the laceration be median or lateral, the tissues can be lifted up on either side, in either sulcus, or higher in one than the other, and approximated by proper suturing without removal of the flap. The two most frequent mistakes made in this method of operating are in not elevating a thick enough flap and extending the dissection up the recto-vaginal septum to a sufficient extent, especially in the lateral sulci.

In cases of long standing lacerations we have retraction, loss of function and atrophy of injured muscles, rendering deep dissection essential to a proper approximation of the injured structures.

Again, it may be a submucous rapture of some of the perineal muscles, then how is it possible to repair the injury in the manner in which it occurred, except by synthetic perineotomy?

Even when mucous membrane is torn, making an open wound, it is at a time when there is hyperplasia of tissue, and the parts have a tendency to approximate or fall together, except when separated by contractions of injured muscles, thus favoring union of vaginal surfaces with but little scar tissue; then why is it necessary to remove a large surface and constrict the vaginal outlet to repair such injuries?

In most cases when we have a seeming redundancy of tissue it is but the hyperplasia that existed at time of labor and the after stretching of parts due to the injury. It is a sub-involution and is corrected by removal of the cause, i. e., repairing of the primary injury of the part.

If the integrity of the structures in the rectovaginal septum for a distance of 1 to 11⁄2 inches be restored, in the great majority of instances this will suffice to restore the normal condition and function of the pelvic floor. The principal muscular structures that are injured and need repair are within this distance. If the laceration is complete, involving the recto-vaginal septum, there is no rectocele or dragging down of the uterus; this demonstrates the fact that simple injury to the muscles or pelvic fascia is not the sole cause of the relaxation of the vaginal outletrectocele, cystocele, etc., but that such conditions result from incomplete lacerations where the rectovaginal septum is intact.

This being the case we are led to believe that the filling of the rectum and imperfect emptying of the same is the principal factor in the production of these conditions. We also conclude that any operation that restores the normal function of the rectum and supplies a good perineal body for attachment of muscles, deflection of the fecal matter, and support to the vaginal walls is practical, rational and scientific.

This certainly can be done in many cases by dissecting up or splitting of the recto-vaginal septum with scissors, commencing at the muco-cutaneous surface in front of the rectal outlet, and separating the tissues sufficiently deep to elevate the vaginal wall and expose the ruptured perineal muscles and pelvic fascia to the height the laceration extended, going up, if need be, into one or both vaginal sulci. Dissect up not only the vaginal mucous membrane, but the vaginal wall and connective tissue, being certain to go deep enough to expose lacerated muscles and pelvic fascia.

It is here that the advantage of synthetic perineotomy is demonstrated; a thick flap can be elevated, as it is not destroyed, but enters into the reformation of the pelvic floor, rendering it more flexible and distensible for future functions.

By the denuding process tissue is removed or destroyed, and the caliber of the vaginal canal lessened,

If the dissection extends high up in the rectovaginal septum, then an over and over continuous buried catgut suture should be used, bringing together the parts at the apex first by superimposed layers of sutures placed in line antero-posteriorly and transversely to the axis of the body, the outer tier bringing together the skin in the line of the perineal raphé, winding up with an over and over suture of raw edges of the mucous flap at the vaginal outlet. If desired, one or two stay or tension sutures can be introduced to relieve strain on buried sutures.

If dissection does not extend high up in the rectovaginal septum, some five or six silk-worm gut sutures, introduced as in the Tait method, is all that is needed.

To facilitate introduction of sutures, I had made needles with open eye near the point and similar in shape to a Haggerdorn needle with solid square heel, so as to be held firmly by any needle holder.

As to complete lacerations involving the rectovaginal septum, I unhesitatingly advocate synthetic perineotomy as pre-eminently the best method and far superior to any denuding process. Denudation in these cases should be condemned.

The women and the profession owe Sanger and Tait a debt of gratitude for demonstrating to us this method of operating in these cases.

To obtain success the same precautions are necessary as in incomplete lacerations, i. e., dissect up the tissue deep enough to expose the injured structures and coapt them by proper suturing. Commence splitting the flap in the center, extending the dissection out on both sides to the cutaneous surface, then backward and deep enough to expose the ends of the sphincter muscle, indicated by a small pit or depression on either side; in some cases it may be necessary to remove a small bit of tissue from depressions to more effectually expose and approximate ends the of muscle. Then dissect up by use of scissors and scalpel-handle the anterior flap, extending the dissection up to the remains of the hymen on either side, and into the recto-vaginal septum a sufficient distance to approximate the perineal muscles and pelvic fascia, so as to build up a strong perineal floor.

Now, approximate the rectal-flaps by tenacula, and if they have been properly separated, they will prolong the anterior rectal wall out one-third to one-half inch beyond the posterior wall, thus allowing for subsequent retraction of the part thus extended; interrupted catgut sutures are introduced to be tied in the rectum, the remainder of the suturing being completed as above indicated, including as much tissue in the grasp of the suture as possible.

Although the bowels have been moved freely previous to operation, and the diet restricted, they should be moved again on the second or third day, throwing oil and boric acid into the rectum, and keep the bowels moving each day thereafter, the sutures being removed eight to ten days after operation. The catgut should not be hardened too much, as it will interfere with union-simple immersion of aseptic gut one to two days in alcohol will harden it sufficiently.

To further elucidate this method of repair, I select three cases demonstrating the efficiency of synthetic perineotomy:

Case 1. Mrs. N., primipara, aged 27, married eleven years. Complete laceration, involving rectovaginal septum, of ten years' standing. The septum was split out to the cutaneous surfaces, dissecting downward and backward, exposing the ends of the lacerated sphincter ani, thence upward on each side to the remains of the hymen, extending into vaginal sulci sufficiently to expose the perineal muscles and pelvic fascia, separating the rectal and vaginal walls for a distance of one-half inch. Five interrupted catgut sutures brought together the anterior rectal wall, tying them in the rectum, with six-silk worm gut sutures in the perineum proper, completing with a superficial over-and-over catgut suture, closing all exposed raw surfaces. The strip of gauze (which I prefer to cotton or sponge, as it does not put the parts on the stretch) was then removed, the wound dressed, the parts united and the functions restored.

Case 2. Mrs. S., multipara, aged 37, widow ten years. Complete laceration of eighteen years' standing. The patient was operated upon by the dividing method, once at Grady Hospital (City) Atlanta, with out benefit, as I saw and treated the case before and after operation. Synthetic perineotomy was performed as above described, putting six stitches in the rectum, six in the perineum, completing with continuous superficial catgut sutures. Union complete, excellent results, and functions restored.

Case 3. Mrs. S., multipara, aged 28, married six years, children. Complete laceration of five years' standing, having been operated upon twice previously by the dividing method with failure, and so much loss of tissue as to preclude a third operation by the denuding process. There was such little tissue from which

to construct a perineal floor, that I told the patient that two or three operations would probably be required to get satisfactory results. Synthetic perineotomy, as described above, was performed upon this patient, putting eight stitches in the rectum, seven in the perineum, completing with continuous superficial catgut closing all raw surfaces. To my surprise, union was complete, a good pelvic floor being formed and the functions restored,

A CASE OF FRACTURE OF THE PELVIS, WITH EXHIBITION OF FRAGMENTS.*

By W. F. BREAKEY, M. D., Ann Arbor, Mich.

Mr. about sixty years of age, while working on a building, in consequence of the breaking of a scaffold fell about ten feet to the ground, striking on his left side on some stones. He was helped up and stood alone while he urinated, the urine appearing normal in color. He was taken to his home on a dray, where I saw him, soon after, with my son, Dr. Jas. F. Breakey. Breakey. He was suffering from considerable shock, but conscious enough to complain of severe pain in the left pelvic region and right fore-arm, in which later was found a Colles, fracture of the radius, with dislocation of the ulna. He was given stimulants and anodynes. Dr. Nancrede saw the patient at this stage, and Dr. Kapp and others saw him later. A cursory examination of pelvis and left lower extremity showed marked flattening of the left lateral pelvic and trochanteric outline, with slight apparent shortening of the thigh. There was eversion of the left foot, and inability to voluntarily move the thigh in any direction in but slight degree, though the limb could be moved with abnormal freedom so far as resistance opposed. Movement, however, greatly aggravated the pain. There was crepitus, felt rather than heard, which with the apparent shortening of the limb and flattening of the hip suggested fracture of the neck of femur, but the trochanter on rotation. of the femur described a normal arc. Traction of the limb in the line of extension restored the length, but did not restore the contour of the trochanter and

hip, which had the appearance of lateral compression, though the femur seemed to be intact and not dislocated from the acetabulum. Further examination discovered great mobility of the left pelvic brim, spine, and ramus of the pubes, on that side, and fracture of the pelvis was diagnosticated, though without supposing such comminution of bone, as is shown in the fragments.

*Read before Surgical Section, Mississippi Valley Medical Association. Detroit, Sept. 1895.

The nerve supply and cutaneous sensibility of the extremity were not impaired. There was inability to evacuate the bladder after the first effort, and the catheter had to be used. The secretion of urine was not interrupted. There was little to be done in the way of surgical treatment proper. The fractured fore-arm was appropriately dressed. The treatment of the fractured pelvis consisted chiefly in securing rest and support for the injured parts, slight traction being applied to the thigh and leg, which favored restoration of contour of the hip and gave some relief from pain.

Though conscious for two days, the patient did not rally from the effects of shock, and died on the third day after the injury, becoming partially comatose a few hours before death.

It is so rare that the extent of such injuries can be demonstrated by post-mortem examination, much less, by the fractured bone itself, that it was believed the exhibition of the wired fragments of this bone would interest the Section.

The exsected head and neck of the femur are shown. The capsular and teres ligaments were intact, though lines of fracture run through the acetabular socket. There was much bruising of the soft tissues, contiguous to the fractured innominatus, and to the rectum and bladder, though no lesions of the viscera were observed. There were some small fragments of ileum lost in maceration, as were also, I regret to say,

some fragments of the radius, showing an interesting case of Colles' (or more nearly Barton's) fracture.

I was indebted in a large measure for both specimens to the professional enterprise and aid of my friend Dr. Kapp, who assisted at the post-mortem, and also of Dr. Jas. F. Breakey who wired the fragments. The bones were suspended by a thread by the photographer to secure a better view. A section of the sacrum is seen wired to the ilium. There were about twenty fragments of the os innominatus.

The literature of the subject shows fracture of the rim and processes of the iliac arch to be comparatively frequent; of the ischii and one ramus only, more rare; but such extensive comminution as is shown in this fracture is very rare.

Holmes gives illustration of a case where the head of the femur was driven through the acetabulum, and the appearance of this bone would indicate that a considerable part of the impact had been through the head of the femur.

I have seen two cases of fracture of the rim and processes, one in a young person and one in a man of sixty, both of which made complete recoveries.

FIMBRECTOMY.

By J. E. ENGSTAD, M.D.

Attending Surgeon to St. Luke's Hospital, Grand Forks, N.D.

One of the serious deformities we find, happily not often, but often enough to require the earnest consideration of every conscientious physician, is contracted pelvis of such extent that the birth of a living child at full term, without mutilation, is an impossibility.

Charpentier gives the anterior posterior diameter of nearly four inches as the limit of contraction at which parturition can be completed without mutilation to either the mother or child.

Men of eminence in the medical profession have been divided into two factions as to the best means of remedying this defect. To one class belong those who believe in expediency. They prefer to bring on a miscarriage at the end of three months by the slow method of uterine irritation or by removing the contents of the uterus by forcible dilatation and curettage. Or they prefer to let pregnancy progress to full term; then operate either with the view of saving the mother alone or of saving both. To the first division of this class belong the advocates of the brutal and revolting craniotomy. To the second the champions of the socalled Cæsarean section, by the Porro, Sanger or some modification of these methods.

Although through improved technique and surgical dexterity, if I may say, the mortality in later years

has been brought down to a low percentage, it is yet too high to make it satisfactory from a humanitarian or surgical standpoint.

To the second class belong those members of the medical profession who think it a better expedient to prevent conception. In Porro's operation or its modifications, of course, by the removal of the uterus, the woman is rendered safe from future conception. But a hysterectomy, even with the low death rate lately published, is, and will remain a formidable operation. Senn, I believe, reports about forty hysterectomies by his cuff method without a death.

The removal of the ovaries, or Battey's operation, is fraught with less danger; but it has the same serious disadvantage of unsexing the female and making, so to say, a neuter of her, with its train of abnormal changes both physical and mental. It is admitted that exceptional cases, now and then, may escape the singular changes of the organism following the removal of the reproductive organs, but the majority of authorities agree that, sooner or later, peculiar nervous manifestations will appear.

For some time I have had in mind an operation, for which I thought the term "fimbrectomy" proper, that will leave the sexual organs in perfectly normal condition. The woman is not unsexed and no great mutilation has to be undergone. The operation would be fraught with as little danger as a minor operation, in fact it is in reality only an exploratory incision. A small opening is made in either iliac region, as in Battey's method, or a larger one in the median line. The incision is made in the usual manner and with all approved surgical technique. The abdominal cavity opened, two fingers are inserted and the ovary, with its tube and fimbriated extremity, are lifted up into view. If the ovary be tied down by adhesive bands, they should be torn and the ovary loosened. Then a catgut or, preferably, silk ligature is thrown around the tube near the fimbriated end, or a threaded needle is passed through the edge of the fold of the broad ligament, so as to enclose the tube. Tie in the usual manner, and with a pair of scissors cut the fimbriated extremity away. Ovulation can and will take place as usual. The ovule, being a perfectly aseptic body, will fall harmlessly into the abdominal cavity and will be rapidly absorbed. By closure of the tube the ovule cannot enter the uterus and uterine gestation cannot occur nor can the spermatozoa enter the abdominal cavity and cause extra-uterine pregnancy.

The operation is simple, comparatively without danger, and will accomplish absolutely the object in view-prevention of conception-while the patient is left as much a woman after as before. The mechanical obstruction of the passage way of the ovule will

effectually prevent future laceration or mutilation by craniotomy.

The majority of cases of this class will not come under observation before the first confinement; but then the doctor's assistance will be called for without fail. It is the physician's duty in cases where pregnancy will reasonably occur again, to radically and without delay take steps that will permanently remove this great danger to the unfortunate woman.

Clinical Department.

INGUINAL HERNIA AND VARICOOELE-INJURY TO ELBOW-GANGRENOUS APPENDICITIS-CARCINOMA OF THE BREAST-BASSINI'S OPERATION.*

By CHARLES MCBURNEY, M.D.

Professor of Surgery in the College of Physicians and Surgeons, New York.

Inguinal Hernia and Varicocele.—This is a young man operated upon last week for right inguinal hernia and left varicocele. The hernia was a congenital one, although not descending so as to be in contact with the scrotum; the tunica vaginalis had been shut off, but the pouch above was of the congenital variety, and was in intimate contact with the cord. The chief reason for operation was the fact that his truss caused constant pain. The operation performed by me was the Bassini method. The hernial wound, you see, is absolutely aseptic. On the other side, I operated for varicocele, exposing a considerable portion of the veins. This wound has healed completely. The man will remain in bed for another week, and then will spend another week here in getting about.

Injury to Elbow.-I also operated at the last clinic upon a boy who had received some injury to the elbow joint, which had resulted in limited extension and flexion, and had left the limb in a position of partial flexion. I believed that there had been a fracture in

volving the lower end of the humerus on the inner side, and that nothing but operation would improve the condition. I found, on operation, a considerable deviation of the lower end of the humerus. This was cut away to allow of greater flexion, and the limb then dressed in plaster of Paris. It will be kept in this position probably for another week, and then we shall begin to bring it down gradually to the proper position. The main point in the treatment was to place the limb in a favorable position for use in case

* Clinical lecture delivered at the Roosevelt Hospital.