The after-treatment requires the self-retaining Sims's sigmoid catheter in the urethra for a week or frequent catheterization, absolute rest in bed, hot-water vaginal douches, regulation of the bowels, and the removal of the sutures on the twelfth day. After the completion of the operation the cervix is maintained near the hollow of the sacrum, and the organ remains normally anteverted and anteflexed, making an acute angle with the vesico-vaginal wall, which has now been restored to its normal direction and length. Unfortunately, it is not unusual to abandon the patient after this operation, in the vain hope that the uterus and anterior vaginal wall will maintain their normal relations without the support of the perineum and posterior vaginal wall. This is a great mistake, because the cystocele and procidentia almost always completely reappear within a few months. Anterior elytrorrhaphy, therefore, is simply one of the steps in the treatment. PERINEORRHAPHY.--This is the name usually applied to the repair of the ruptured perineum, but the scope of the operation has been extended to include also the surgical treatment of rectocele and relaxation of the posterior vaginal wall. The most scientific operation yet devised is the one proposed by Emmet,[8] which is performed as follows: The patient being etherized and in the lithotomy position, the operator seizes with a tenaculum the crest of the rectocele or posterior vaginal wall at a point which can be drawn forward without undue traction--point _a_. With another tenaculum the lowest caruncle or vestige of the hymen (point _b_), {164} and with another the posterior commissure of the vulva (point _c_), are hooked up. The triangle included between these points defines one-half of the surface to be denuded. The three tenacula are now placed in the hands of assistants, the sides of the triangle are made tense by traction, and the included surface denuded. The tenaculum at _c_ is then removed, and the middle point of the line _a b_ is caught and drawn toward the interior of the vagina in the direction of the vaginal sulcus on that side, and the sutures are introduced, as in Fig. 13. The same thing is then repeated on the other side, and the sutures are all tightened, forming a line of union running back into each sulcus, as shown in Fig. 14. [Footnote 8: _Trans. Am. Gynæcological Society_, 1883; _Principles and Practice of Gynecology_, 3d ed.] [Illustration: FIG. 12. _a_ is at the crest of the rectocele; _b_ at the caruncle just within the labium; and _c_ at the posterior commissure. The cut represents that half of the surface to be denuded which is on the operator's right. The dotted lines represent the other half, on the left.] [Illustration: FIG. 13. The Sutures in Place. When secured they will unite _a d_ with _b d_, and lift the perineum up in contact with the anterior vaginal wall.]