deep under the tissues so as to embrace the retracted muscles, across between the denuded surface and the rectum, to the center of the denuded surface, then down and out a quarter of an inch from the edge, at 2, situated on the right labium, midway between the point corresponding to 1 and the posterior commissure (D). It is then entered at 3, the point on the left labium corresponding to 2, brought under the denuded surface to its center, and then out at 4, which corresponds to 1.

The second suture (B) is passed in a similar way. It is entered at 1, a point just below the summit of the denudation on the left labium, and passed, buried close to the denuded edge, around the angle in the left sulcus to the highest point of denuded surface on the columna (C), and thence, still buried, across to 2, situated midway between the upper end of the denudation on the right labium and 4, where the first suture came out. Here it is brought out, a quarter of an inch from the edge, re-entered at 3, the corresponding point on the left labium, carried to C, then close to the edge of the denuded surface at the right lateral sulcus, and out at 4, which corresponds to the first point of entrance, B 1. As a protection a third suture (E) is usually introduced just above the upper end of the denuded surface on the left labium, carried through the labium, and out on the mucous membrane; then it takes up about a third of an inch of mucous membrane on the columna at C, and finally passes through the right labium. This protection suture should be of silver wire or silkworm gut. It becomes unnecessary if one of these materials has been used for the two other sutures.

The sutures are closed from behind forward in the order they have been put in.

In extreme cases of extension of the laceration into one or both sulci, the Emmet sutures may be used to close the angles, or the Cleveland suture may be applied separately to each angle before the two perineal sutures are inserted.

b. Complete Laceration.-Special care is taken to get the entire

FIG. 216.

Diagram of Broken Sphincter Ani Muscles (T. A. Emmet): DC, first suture; BA, second

suture.

ends of the broken sphincter brought together. The above-men

FIG. 217.

B

tioned pits marking these ends are seized with a tenaculum and removed, together with a strip of mucous membrane on the posterior vaginal wall and the internal surface of the labia majora, as in Hegar's operation. The first suture (Dr. Emmet uses always silver wire) is inserted a quarter of an inch behind and inside the end of the broken and retracted sphincter muscle, which now forms a convex surface (Fig. 216), and carried under the denuded surface parallel to the rent in the recto-vaginal septum, so as to unite the innermost fibers of the sphincter (Fig. 217, C, D). The second suture (A, B) is inserted at the outer end of the broken sphincter and carried around the rent in the septum, parallel to the first. These two sutures when closed bring the two ends of the broken ring together, and unite it at the same time with the lower end of the septum. Next, a couple of sutures (Fig. 218, 3 and 4) are brought from the perineum under the whole denuded surface over to the other side, the uppermost comprising the end of the undenuded part of the vagina. The last but one (5) goes through the labium majus, emerges near the side sulcus of the vagina just on the line of demarkation between the pared and unpared surface, enters the

FIG. 218.

Diagram of Broken Sphincter Ani (T. A. Emmet), showing how the ends are brought together by tightening the sutures.

Diagram for Emmet's Operation for Complete Laceration of Perineum: R, rectum; V, vagina; P, perineum. The figures mark the order in which the sutures are inserted.

corresponding point on the other side, and emerges on the skin opposite the point of entrance. The last (6) unites the tops of the denuded surfaces on the labia majora.

If the rent in the recto-vaginal septum is over one inch long, it should be diminished by denuding the vaginal surface near the edges, down to the sphincter, and introducing sutures from side to side. When these have been removed after about nine days, and the denuded surfaces have grown together, the above-described operation for the closure of the sphincter and perineum is performed.

Outerbridge uses his above-described three sutures after having overstretched the sphincter and united the edges of the gut either with continuous or interrupted catgut sutures, taking care to insert one suture through the ends of the broken sphincter.

Preparation and After-treatment.—In regard to preparations for any of these operations for lacerated perineum, the reader is referred to what has been said in the chapter on Treatment in General (p. 196). The bowels are emptied and the labia are shaved, but the hairs on the mons Veneris need not be interfered with. The knees are kept tied together for two weeks. The diet during the first few days, until the bowels have been moved, should be exclusively albuminoid (milk, beef extracts, raw oysters, and eggs), so as to have as little fecal matter as possible.

As a rule, some pain will call for small doses of morphine (gr. }); otherwise opiates should be avoided, as they render the feces hard. The patient may lie on her back or her side, but should move slowly and with the assistance of her nurse.

On the morning of the fourth day Ol. ric. flziij is given. When the patient feels that evacuation is near, four ounces of olive oil should be injected into the rectum. In this way an easy, loose movement or two are brought on. Thereafter every morning just enough castor oil (about 3ij) is given to have one easy movement. The urine should be drawn with a catheter. When, after a few days, there appears some discharge, a vaginal injection of carbolized water (3ss to Oij) should be given morning and evening, and, in complete laceration, half a pint of lukewarm water injected at the same time into the rectum. If the patient is troubled with flatus, much relief is afforded by the occasional cautious introduction of a well-greased soft-rubber rectal tube of the size of the little finger.

As a rule, perineal sutures must be removed at the end of a week (compare Tait's method); vaginal, which are difficult to reach without risking the destruction of the union in the perineum, are left in for three to four weeks, or more if necessary; rectal are left to themselves. In removing vaginal sutures a virginal Sims speculum and Hunter's depressor (p. 147) will be found very useful. The ends of each suture are seized separately with the suture-twister and lifted a little. Great care should be taken to insert one of the points of a pair of pointed scissors into the loop, and cut close up to the entrance of the stitch-canal. The sutures should be removed from below

upward, and when the rent begins to bleed the removal of the others should be postponed.

The patient may leave the bed after two or three weeks. Coition should not take place for two months.

CHAPTER II.

GARRULITY OF THE VULVA.

UNDER the queer name "garrulity of the vulva" has been described a condition which is characterized by the entrance of air into the vagina and its expulsion with a noise from the same. Another name for the same phenomenon is flatus vaginalis.

Etiology. It is a rare disease. It is only possible when the vulva and vaginal entrance gape. It may be due to tears of the perineum and vaginal entrance, episiotomy, loss of flesh, and varicose veins of the vulva.

Treatment. The indication is to diminish the entrance to the genital canal by the performance of one of the operations described above for laceration of the perineum, or by excision of cicatrices and union by suture.

CHAPTER III.

COCCYGODYNIA.

UNDER the name of "coccygodynia" are united different and partially unknown pathological conditions, the common feature of which is intense pain at the coccyx, whence it may radiate into the perineum, the hips, the uterus, and the bladder.

In

Pathological Anatomy.-Sometimes there are palpable diseases or deformities of the coccyx, such as caries, fracture, ankylosis, too great a length, luxation, or other displacement. In other cases the condition is combined with diseases of the uterus, ovaries, or rectum. a third class it is of a purely neuralgic nature. It is not unlikely that the coccygeal "gland" (p. 103), with its exceedingly rich nervesupply, has something to do with it. Still, this gland is found in both sexes and at all ages, while the disease is never found in man, and is exceedingly rare in childhood.

Etiology. The disease is only found in women, especially adults who have borne children, but occurs also in virgins, and very rarely in children. By far the most common cause is childbirth. As a rule, it appears after tedious labor with long-sustained pressure, tears, or

straining of muscles or ligaments, or after instrumental delivery; but it may also begin before delivery, and is then probably due to the pressure of the head against the last two sacral and the coccygeal nerves. The disease is sometimes due to violence from without, such as a kick, a fall, or horseback riding, or to exposure to cold, especially in individuals suffering from rheumatism. Sometimes it seems to be a reflex neurosis due to muscular contraction of the sphincter ani, the levator ani, or the bulbo-cavernosus muscles, such as is found in consequence of painful caruncle or hemorrhoids.

Symptoms. Severe pain is felt in sitting, especially in sitting down or getting up; nay, the tenderness may be so great that the patient can only sit on one-half of the nates, near the edge of a chair, using her hands to get up and down. All movements of the coccyx and the ligaments and muscles attached to it, induced by walking, riding, defecation, coition, etc., increase the pain enormously.

Diagnosis. The condition is easily recognized by placing the patient on her left side and introducing the index-finger into the rectum, while the thumb rests on the skin over the coccyx. The slightest movement of the bone causes severe pain, and sometimes it may be possible to feel a diseased condition of the bone or the surrounding parts.

Treatment. The general treatment consists in tonics or antirheumatics. Suppositories with five grains of iodoform or one-third of a grain of morphine; hypodermic injection of cocaine or morphine; inunction with ointments of veratrine or aconitine; blisters; cauterization; and galvanism or faradization with the secondary current with high tension (p. 230); besides treatment of concomitant diseases in neighboring organs,-have each effected cures. But cases that have resisted all other remedies have yet been cured by the extirpation of the coccyx, whether diseased or healthy. This operation, which may be called coccygectomy, is performed by placing the patient on the right side or on the abdomen, introducing the index finger of the left hand into her rectum, pressing it outward, and making an incision in the median line, about four inches long, and reaching from half an inch below the tip to one and a half inches above the base, down to the bone. The soft tissues are pushed aside with a blunt instrument and a few touches of the knife, until the whole bone, inclusive of the projecting transverse processes of the uppermost vertebra, is laid bare. The attachments of the bone throughout its whole length are freely separated on each side, and the knife passed through the articulation with the sacrum and the lateral ligaments. The left hand is now disengaged, and, armed with Fergusson's bulldog-forceps, used to seize the bone, which is pulled firmly outward, while some flat, blunt instrument like Hay's director is passed behind it and severs all remaining connections, except the tendon of the levator ani muscle,