the jacket is ready for use. In order to make the jacket a complete success in cases of lateral curvature, I have recently tried the application of force upon the curve by means of an india rubber air cushion, placing the cushion under the curve inside the jacket. I have derived great benefit from this. If the pressure is too great, the air can be let out and the pressure reduced. This cushion is in the form of an air-pad with a tube and valve attachment, so that constant pressure of any degree can be maintained. It also adapts itself to any changes in the curve which may take place, and thus saves frequent renewals of the jacket.

The process of making one of these jackets extends over some two weeks, and the cost thereof lies chiefly in the time and labor expended, which is considerable. The raw material costs probably less than $5.00 per jacket. The making of the jackets I have confided to my former pupil, Dr. S. C. Scott, and he has become quite expert, so that all I have to do is to examine them when finished.

We claim for the Pittsburgh jacket the following advantages over the Sayre and other appliances: 1st. Its light weight. 2d. Perfect ventilation. 3d. That it is removable and adjustable. 4th. That it is clean itself and allows of absolute cleanliness of the per5th. That it is adapted to the treatment of angular as well as lateral curvatures.

son.

If there is any other point upon which the members wish information, I shall be glad to be interrogated.

PERINEORRAPHY.

BY I. T. TALBOT, M.D.

Perineorraphy, like all other kinds of plastic operations, requires exact and careful adaptation of the freshly prepared edges. It is not enough that they are accurately fitted, they must be brought together by just the right amount of pressure, neither too much nor too little; they must be guarded from motion upon each other, and especially from any foreign substance being allowed to intervene. In my article upon Staphylorraphy presented to this body, stress was laid upon the importance of relieving the wound as much as possible from tension or strain, and for this purpose the practice was warmly recommended of division of the levator palati, the palato-pharyngeus, and the palato-glossus muscles, as one of the most important steps in the operation, and one which then easily allows the adjustment of the before widely separated edges. In the same manner in hare-lip, it is of the greatest importance that the cheeks be widely separated from the attachments and slid down upon the malar bone so as to allow new adhesions and let the separated edges of the deformity easily approach each other.

Less strain thus comes upon the pins, and the chances of complete union are much greater. In the operation for lacerated perineum there is little to be done in the way of dividing retracting muscles. There is, of course, less need of this, since, by bringing the knees together the parts are closely approximated. But in the ordinary form of operation for this injury, viz., the paring of the two edges of this deformity and bringing them together with the quilled sutures, there is not only danger of moving the freshly prepared surfaces, and thus interfering with the uniting process, but also by the permeation of the wound with vaginal or uterine leucorrhoea, or the accidental dribbling of a few drops of urine into the wound. The nature of the operation is such as to increase the liability to this accident. By paring the sides of the perineum and the somewhat absorbed and rounded posterior edge of the va

gina, and thus bringing these surfaces together, there is left at the upper and internal edge of the wound, at its junction with the vagina, an angle, almost a cul de sac, which is increased by approximating the lower and anterior edges, even to their natural position. This then forms a cup-shaped cavity, which retains any vaginal or uterine secretion, and, if the patient lies upon her back, it comes directly in contact with the internal part or edge of the wound. In the same position a small drop of urine is carried directly to the wound, often with the most unfavorable results.

To obviate.these difficulties the following method has been devised: instead of "paring the edges," thereby removing some portion of the integument and mucous surface, an incision is made commencing on the labia sufficiently far forward and outward for the desired line of union with the opposite side, and which will form, when the operation is completed, the medium line or raphe of the perineum. Carry this incision backward on the proposed line to the posterior commissure or division of the perineum, and then continue it in a corresponding manner upon the other side to an equal distance upon the labia. Carefully dissect the vaginal wall from the rectum, which, in case it is very thin, must be done with great care, the finger being passed into the rectum. Carry this dissection upwards a considerable distance and freely on both sides so as to form a large flap which can be brought into the front part of the vagina leaving the surface of the wound free. Four or five deep seated sutures may now be passed in the ordinary manner, care being taken to enter them sufficiently deep and far enough from the external edge. These sutures may now be tied over the "quill," or a piece of gutta percha bougie, and the wound carefully brought together with suitable pressure. The internal flap may now be gently pressed into its place to form the posterior wall of the vagina, and partly by contraction and by puckering or folding the whole of this flap is easily brought to the surface and retained by fine silver sutures, or serres fines to the anterior edge of the wound. This method of operation presents the following advantages:

1. In bringing together a larger freshened surface for adhesion. 2. By the internal flap it adds to the thickness of the newly formed perineum, giving greater strength.

3. By its greater thickness it brings the posterior vaginal wall into its natural position, and thus affords support to the uterus. 4. The vaginal folds left in the operation give greater expansive power to the perineum in case of subsequent labor.

5. By covering the wound internally with an unbroken mucous membrane, it is protected from any vaginal or uterine secretion, and effectually prevents any drops of urine from settling into the wound.

After the parts are carefully adjusted they may be freely covered with cosmoline, which affords additional protection. In regard to the quill or gutta percha used for the support of the sutures, the heat, moisture and exudation soon soften them, and leave them somewhat curved and misshapen. To obviate this, I have inserted a section of the wire stylet of the bougie. But it is difficult to keep this in place. There is also an objection to the "quill," in that, by separating the two cords which make the suture, it also enlarges the opening through which they pass. To obviate this, I would propose a bar made of hard rubber with smooth, rounded ends. This bar should be perforated so as to allow the suture to pass through it and be tied over a small rod. This would keep an even, steady pressure, would not bend or become displaced by heat or moisture of the parts, and would not dilate the opening through which the sutures pass. The following case exhibited excellent results from this operation :

Mrs. P., aet. 40; married at 18; has three living children, eldest 21, youngest 10. She had a complete rupture of the perineum, extending to the sphincter ani, at birth of last child. Two years ago she had a miscarriage, since which time prolapsus uteri has been very great; the womb and vaginal walls extending beyond the vulva. Is unable to stand or walk; feels as though the entire contents of abdomen would press out.

She entered the Massachusetts Homoeopathic Hospital, April 7th, 1881. Operation, April 9th. After etherization, the protrusion was larger than a fist. It was replaced and retained by curved wire spatulas. The operation already described was performed. The posterior wall of the vagina was freely dissected from the rectum and lateral attachments. The sides were brought

together by five sutures, the internal flap covered the inner border of the wound, and the edge of the flap was attached externally to the border of the approximated sides by serres-fines.

The recovery was rapid and without any untoward symptom. The serres-fines were removed on the third day; the deep sutures on the tenth, complete union having taken place.

By vaginal examination the internal mucous surface was found smooth and in good condition, the perineum firm, and affording all necessary support to the uterus.

She gradually assumed the erect posture with entire comfort, and was discharged on May 9th, entirely recovered.