2. Where there is a conjugata vera not less than 25 inches and where there is good evidence that with a pubic separation, of say 21 inches, a living child may be extracted.

3. When the chin presents posteriorly and is so jammed down in the pelvic cavity as to render rotation impossible.

As symphyseotomy is at present engaging the attention of so many operators and interesting even those who never aspire to surgical distinction, it may not be out of place to run over briefly some of the technique necessary to its successful performance, even at the risk of tiring you.

First.-Observe the same aseptic precautionary measures as in cœliotomy.

Second. With the patient in the dorsal decubitus flex and thoroughly abduct the thighs.

Third.-Dilate the cervix, unless nature has already wisely anticipated you and made such interference unnecessary.

Fourth.-Introduce silver catheter and protect the urethra by depressing it to one side of pubic arch.

Fifth.—With scalpel make a vertical incision of about three inches in length over the pubes, beginning about three-quarters of an inch above the symphysis and extending to and a little to one side. of the clitoris, dividing skin, fat and recti-muscle attachments.

Sixth.-Separate the retro-pubic tissue with the finger, after first protecting the bladder by pushing it back.

Seventh.-Pass the left index finger beneath the arch and hook it around the posterior-inferior angle, using it as a guide for the Galbiati falcetta, or the small curved knife of Dr. Harris, or, in the absence of anything better, an ordinary blunt-pointed bistoury, cutting the interarticular space from within out and from below up, when the bones will separate spontaneously from an inch to an inch and a half. In case the symphysis be found ossified a chain saw will have to be substituted for the falcetta or bistoury.

Extreme care in dissection is necessary in order not to wound the urethra or the dorsal branch of the pubic artery, which supplies the clitoris. It passes close to the anterior surface of the horizontal ramus and near the symphysis.

Next apply the forceps and deliver, having an assistant press and support the ossa innominata during the passage of the foetus. If the uterine contractions are sufficiently strong to effect delivery, of course the forceps are contraindicated.

Eighth. After removing the placenta unite the adipose tissue and skin with deep and superficial silk sutures; dress with cotton; apply two or three wide strips of rubber adhesive plaster over the trochanters and entirely around the pelvis; bandage tightly the hips and more loosely the thighs, and put the patient to bed in the horizontal position, and by keeping her absolutely quiet for a period of four weeks perfect union may reasonably be expected.

This operation is the simplest and safest of any we have mentioned, and it is not now, as formerly, regarded as unscientific and dangerous, resulting either in death or in lifelong injuries to the patient. Works on obstetrics a year or two old treat the subject with supreme indifference; some of them (Lusk, for instance) not considering it worthy of mention. Parvin ends his lengthy discourse of four lines and a half with these prophetic words: "The American obstetrician will find no condition justifying its performance, and, therefore, it is dismissed with this brief reference."

Winckel, in his voluminous work, condescends to give the subject a passing recognition, but is unable to refrain from the expressed hope that the few lines he has given to its consideration may hasten the operation once more to a silent burial, to remain forever entombed.

Notwithstanding these and many other adverse criticisms, the fact remains that many operators are in the field claiming the best of results. These are notably Morisani of Naples, 22 cases without a failure; Noble and Harris of Philadelphia, the latter, as stated above, having 44 cases in six and a half years, with a loss of one woman and five children; Spinelli, 24 cases, with 24 mothers saved and 22 children. Charles Jewett of Brooklyn, who was the first American operator, September 30, 1892; Bullezzi of Bologna; Pinard of Paris; Leopold of Dresden, and a host of others who have had fewer operations, but relatively as great success.

This paper is offered to this Society, not with the intention of presenting anything new, nor for the purpose of deciding upon the merits of the operations under consideration, but rather to provoke a liberal discussion, such as will tend to throw more light upon the subject, especially in regard to symphyseotomy, of which Burford, of England, says: "The relative ease and the absolute efficacy of this operation, its freedom from the risks of Cæsarean section, and its immense superiority over perforation, bespeak for it a brilliant future."

WHY DOES PRIMARY PERINEORRHAPHY SO
OFTEN FAIL?

BY GEORGE WILLIAM WINTERBURN, M.D., NEW YORK, N. Y.

REPAIR of the perinæum is one of the most important duties connected with the obstetrical art. For reasons practically beyond the power of the obstetrician to control, rupture of the perinæum is a frequent accident. It is doubtless true that this accident occurs much more frequently than it ought to do, resulting sometimes from neglectful inattention on the part of the accoucheur and sometimes from over-meddlesomeness. Theoretically, the perinæum ought to be able to do work it is called upon to do during labor, without serious mishap. But mothers are not infrequently physically far below the standard of perfection, and obstetrical art is not always thoroughly known to the doctor in the case. If it could always be that from the time of conception all through the period of pregnancy, the woman could be under the observation of a thoroughly competent physician, the various ills which she suffers at that time, could be entirely removed and labor made in due time a purely physiological process.

But before we reach the period when this can be the rule, the public must be educated to understand that the doctor's duties begin with pregnancy, and the medical profession itself must be aroused to its true relation to child bearing. This is missionary work which we should all endeavor to do, realizing that it will be many decades before this ideal standard can be realized. As a matter of fact, at the present time, the accoucheur very frequently does not see the expectant mother until labor has actually begun, and, therefore, has to take the case as it is then, and not as it might have been if properly supervised for the previous months. The result is that various accidents occur for which the doctor is not primarily responsible, and among them is more or less serious laceration.

Laceration having occurred the question at once arises, what shall

be done with it? A war of words has long been waged on this topic, but at present there is no universal agreement as to a proper course of procedure. As a rule, those doctors that are more obstetricians than gynæcologists, incline to the immediate operation. Those who are gynæcologists or surgeons rather than obstetricians, advocate the secondary operation. A number of articles have appeared in current medical literature of the past two or three years, taking very advanced ground against the primary operation. It is not only claimed that the operation cannot, as a rule, be successfully performed and as good results obtained as by secondary perineorrhaphy, but that it is actually criminal to attempt the primary operation.

So widely broadcast have these views been spread that even the laity have come largely to consider a primary operation as bad practice, and although none of my own families or patients to whom I have been called accidentally have rebelled against it, I have known of cases in the practice of my colleagues in which the family was strenuously opposed to the performance of the primary operation, alleging that Professor "So-and-So" had said that it ought never to be attempted. It is because of this sedulous endeavor on the part of our gynæcologists-or, at least, of very many of them—to instill into the public mind the idea that the operation should be deferred for some months, until the woman has fully recovered her strength, and then should be performed secundum artem, that I here enter my protest against such doctrine. From a careful observation of a large number of cases in which the operation has and has not been performed as an immediate sequel to delivery, I am very firmly of the belief that the sooner the repair is made after the damage has been done, the better.

I recognize how difficult it is, amid the depression both of body and mind on the part of patient and physician, in the period immediately succeeding labor, to make a thoroughly good operation; but if the doctor thoroughly understands what he is about to proceed to do, he need not really fail to accomplish good results. Although the sooner the operation is performed-if it is to be performed-the better; still, the delay of a few hours makes no practical difference. If the delivery has occurred during the night, the operation may be made early the next morning, thus allowing both the woman herself and the attending physician a few hours of repose. Or if the delivery has occurred in the forenoon, the operation may be delayed until

late in the afternoon for the same reason. Equally good results can be obtained six or eight hours after delivery as they can when the operation is performed at once. I have seen good results even in cases where the operation was delayed a whole twenty-four hours. Still, unless there is some exigent reason, the delay ought not to be prolonged, and, if the condition of the patient will permit, the operashould be performed at once. An advantage which is lost by delay is that immediately after delivery the parts are benumbed, and an anæsthetic is not needed.

The apparent cause of failure in the primary operation is that sufficient attention is not given to the vaginal side of the wound. The object of the practitioner seems to be to close up the evident wound and to neglect that which is hidden. But as a rule, the greater damage is within and not without; and, in fact, there may be very serious rupture when there is no appearance of it upon the outside. In making the examination, therefore, at the end of labor, ocular inspection is not sufficient. The accoucheur must demonstrate to himself not only that the vaginal wall is intact, but also that the muscular fibres beneath it have not given way. It is not at all unusual for both the cutaneous and mucous surfaces to present a normal appearance, while the muscular tissue contained between them has been badly damaged and left in such a distended and weakened condition that the perinæum can no longer perform its functional duty. To discover this form of laceration requires skill and care, but every accoucheur should endeavor to possess the first and can readily perform the other. I think it may be laid down as an invariable rule, that repair of the perinæum should begin from the inside, and that special care should be used to completely coapt the torn vaginal membrane by a series of stitches beginning at the upper end of the wound and set as closely together as possible, terminating at the commissure. In order to do this properly, the patient should be placed in the lithotomy position, fronting a good light, the vagina washed out with Calendula lotion, and then tamponed, so as to keep the parts clean. After the vaginal side of the wound has been thus carefully reunited, the exterior, or perineal, side may be brought together with deep stitches beginning at the anal end of the wound and passing forward to the commissure. It is well to use catgut or silkworm-gut for the vaginal side of the wound, and the work is more easily and expeditiously done by means of the uninterrupted