[Illustration: FIG. 14. All the Vaginal Sutures Twisted. One suture, including the crest of the rectocele and the labium majus on either side, and three superficial external sutures, are yet to be secured. The lines _a d_ and _d b_, Fig. 13, have been brought into coincidence by means of the sutures, and now form the line of union _d b_. The tissues between the lines _a c_ and _c b_, Fig. 13, have been so lifted up and are so held under the line of union _d b_ that the line _c b_, Fig. 13, has been reduced to _c b_, Fig. 14, which makes the external portion of the wound insignificant in extent.] The essential part of the operation inside the vagina almost always succeeds, but the external part of the rupture at the posterior commissure often fails to unite; furthermore, the operation as described by Emmet does not overcome the patulous condition of the introitus vaginæ in case of great relaxation of the vagina. The author has sought to obviate the first of these difficulties by the use of deep silver sutures instead of the superficial ones described by Emmet. They should be introduced before tightening the vaginal sutures, and should be passed far around in the posterior vaginal wall, their points of entrance and exit being the same as for the three lower unsecured superficial external sutures in Fig. 14. The second difficulty may be overcome by further denuding a triangular surface in the vaginal sulcus on each side, the base of the triangle corresponding {165} to the line _a b_, Fig. 12, and its apex being in the vaginal sulcus at a distance corresponding to the degree of relaxation. This increases the length of the lines of union running into the sulci represented by _d b_ and _e f_, Fig. 14. In the vaginal portion of the wound silk or catgut is preferable to silver, the latter being difficult to remove. Emmet is entitled to great credit for having given to the profession an operation which brings the posterior vaginal walls up against the anterior more perfectly than any other, and which, being mostly inside of the vagina, is therefore followed by very little of the pain during convalescence which formerly rendered perineorrhaphy one of the most trying operations in gynecology. The operation furthermore has demonstrated the former teachings relative to the direction of perineal rupture[9] and the tissues involved to be incorrect, or at least inadequate. [Footnote 9: At the meeting of the American Medical Association in June, 1883, the author presented a paper describing the transverse laceration of the perineum and its operative treatment, which was published with illustrations in the transactions by the journal of the Association, Dec. 22, 1883. This communication referred only to the recent rupture and the immediate operation.] Retroversion.