Complete tears of the perineum (painted from life a few hours after the injury): 1, Tear involving some of the fibers of the sphincter, but not all; 2, median complete tear, with abrasion of the vulva, and two large hemorrhoidal veins exposed, one on either side; 3. complete median tear, with sphincter muscle hidden by three large hemorrhoids; 4, lateral complete tear, involving left vaginal sulcus. mode of suture is shown in figure 462. Silkworm-gut sutures are inserted first in the rectum and knotted there, with the ends left long enough to hang an inch or more outside the anus. Two stitches should be inserted from the rectal side, through the ends of the torn sphincter muscle; and directly above the sphincter a stitch should be placed triangularly in the torn perineum, skirting the whole extent of the rectal tear, entering and emerging upon the skin of the perineum just above the anus. This resembles somewhat the stitch recommended by Emmet for a torn sphincter and rectum, but of itself it is not to be depended upon. Vag. Sutures 5 Per. Satures Fig. 463.-Vaginoperineal laceration involving both lateral sulci. Three internal, or vaginal, and two external, or perineal, sutures in place ready to be tied. Fig. 464.-Complete laceration of the perineum; perineorrhaphy. Emmet's method; tightening the posterior suture, which includes the sphincter. As a reinforcement of the sphincter and rectal stitches, however, it does good service. The torn perineum is then repaired in the manner already described, either by long, deep stitches passed with a curved needle, as in the first operation described, or by stitches inserted as in the Emmet or Hegar secondary operation. In the rare cases of central tears of the perineum, an attempt should be made to repair the injury by vaginal and perineal sutures, but a secondary operation for a perineovaginal fistula may be necessary. Inversion of the Uterus.-This is the rarest of all the accidents to a parturient woman. In the Vienna Maternity, from 1 I have used this method in both primary and secondary operations for more than ten years, and have not had a single failure with it. 1849 to 1878, in more than 250,000 labors, there was not a case. In the Rotunda Hospital, in Dublin, there were 100,000 labors, with only one inversion of the womb. Winckel has not seen a case in 20,000 labors. My own experience amounts to six cases -five complete and one partial.1 In general practice, especially among the poorer classes, inversion of the womb is not so rare. The accident happens with equal frequency before and after the delivery of the placenta. It is reported to have occurred on the third Figs. 465, 466, 467, and 468.-Varieties of central tear of the perineum ("Précis d' Obstétrique"). and fifth day of the purperium.2 The inversion may be partial or complete, the former when the fundus simply protrudes into the uterine cavity, the latter when the womb is turned completely inside out. In a complete inversion the fundus is just within the 1 Three cases were seen directly after labor; two were reduced by taxis; the other spontaneously. One case of complete inversion was reduced five days after labor by taxis; another three months after labor by the author's operation. The sixth case of inversion was due to a myomatous polyp at the fundus. It was complete, but was easily reduced by taxis after the removal of the polyp. 2 Fisher, Br. Med. Jour.," 1896, vol. ii, p. 1178; and Burton, "Am. Jour. of Obstet.," vol. xxxvi, p. 548. vulva; the cavity of the womb is formed by the peritoneal surface, the orifice looking upward into the peritoneal cavity. From this cavity the tubes and the ovarian and round ligaments run upward; the ovaries are usually above and to either side of the orifice. In the rarest instances inversion of the womb may be associated with inversion of the vagina. In such a case the inverted womb is also prolapsed. Causes.-Inversion of the uterus may occur spontaneously. In the so-called paralysis of the placental site,-a condition in which this portion of the uterine wall becomes so relaxed and flabby that it sags down into the uterine cavity, the projecting portion of the wall, it is said, is seized upon by the remainder of the uterine muscle as a foreign body, and depressed further and further toward the cervical canal, a polypoid tumor might be expelled. The explanation, however, is strained. A contraction of the uterine muscle under these circumstances would reinvert the womb. A much more plausible explanation for spontaneous inversion is found in an adherent placenta and entire relaxation of the uterine walls. In this condition of affairs the mere weight of the placenta is enough to drag the fundus down into the uterine cavity. A most favorable predisposing cause is furnished by a complete inertia uteri at the close of the second stage of labor. The expressive force of the abdominal muscles not only expels the child's body, but drives down the uterus after it. uterus may be most frequently explained by traction on the cord in the third stage of labor, when the placenta is adherent. It may occur in consequence of a short cord pulling upon the placenta during labor. In a case under my observation the cord was wound three times around the child's neck. It is sometimes due to too vigorous compression of the fundus in efforts to express the placenta, and I have seen it occur on one occasion in an effort to extract an adherent placenta, in which the hand and the placenta grasped within it acted like the piston of a syringe and drew the fundus down into the uterine cavity. Another case under my observation appeared to be due to the universal ad uterus. Inversion of the |