Professor of Gynecology, University of Tennessee; Adjunct Professor of Gynecological and Abdominal Surgery, University of the South; Fellow of the Southern Surgical and Gynecological Association; Secretary of the Section of Obstetrics and Diseases of Women in the American Medical Association; Member

of Tennessee Medical Society, and of the Alumni Association
of the Woman's Hospital of New York, etc.

The brilliant achievements in abdominal surgery have so far outshone the humbler plastic operations, that their perfection has been very much impaired. The apothegm that "whenever anything is as good as it can be, it cannot get better," is particularly applicable to the work of the early school of gynecologists. It is equally axiomatic that when progress approximates perfection it ceases to improve, and decadence ensues.

Plastic surgery of the vaginal walls and cervix uteri of the present is a polyglot of many methods, widely differing in principle and hopelessly diverging in practice. It is usually the bete noir of the practitioner, the unfruitful field of the general surgeon, and the negligé work of the gynecologist. It is not that we love it less, be it said, but that we love major

* Read at the meeting of the Southern Surgical and Gynecological Association, at Memphis, December 6, 1898.

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work better. In addition to these obvious reasons for the deplorable lack of excellence in much of this class of work, and to the general apathy in this department of surgery, there are more material and serious impediments to perfected results. A somewhat exaggerated idea of the importance of the perineal body, so-called; the lingering belief in its similitude to the keystone of the arch in its office of supporting the uterus; the failure to appreciate the role of the pelvic fascia in maintaining the integrity of the pelvic floor and its functional relations; and more especially the failure to grasp the results of its injury and the mechanics of production of rectocele, together with the exact methods for its correction; finally, the employment of other suture material than silver wire. Even when these elementary facts and their significance is known theoretically the mechanical difficulties in meeting the anatomical and physiological indications are very considerable. More, perhaps, than in other surgery. It has been said that much of modern surgery tends to dissociate it from the characterizing manual dexterity from which it derived its name. Yet the substitution of instrumental for manual maneuvers is essentially necessary in the class of operations referred to. Its successful execution requires a special aptitude, nicety of judgment, delicacy of manipulation, and the inherent modeling and coaptation of parts which is signified by the word plastic. In this branch is found one of the highest exemplifications of science wedded to art, because the creative feature, the object to be obtained, and the highly artistic means of attaining it, preeminently stamp it as essentially an art.

Plastic surgery received its first impetus from the pioneer work of that great master, Sims, when in 1845 he made the brilliant cures of vesico-vaginal fistula on the patients whose fortitude and high courage entitle them to share something of the gratitude of posterity for participating in those wonderful discoveries that made lacerated woman whole.

It is a unique circumstance in the annals of surgery that the instruments which made that feat possible and the fundamental principles of his success have remained unchanged.

It is not so much the tribute of homage to unprecedented genius as to the truth of the great principles he enunciated

and the perfection of his devices. It may be said, then, that the surgery of vesico-vaginal fistula has remained unchanged since the operation for its relief was given to a waiting world by its incomparable originator. It is a subject of regret that more of our art has not become crystallized into such classic perfection.

Trained in this embryo school, under the great Sims himself, possessed of a remarkable sense of adaptation, great patience, untiring energy, and a delicacy of touch rarely seen in man, was Thomas Addis Emmet. He utilized his unparalleled opportunities in extending the application of the methods of Sims in fistula to injuries of the adjacent soft parts.

In 1874 he read the historic paper on "Laceration of the Cervix as a Cause of Disease," which swept away the mythical "ulcer of the womb" from the nosology of disease, subtracted much from the sum of woman's sorrow, and forged the second link in the immutable trio of perfected plastic operations.

It would seem that an operation so accurately described, so universally practiced and by so many men, would be more correctly performed. Yet I have seen many operators simply cut a variable plug in the angles of laceration and sew it up by through and through sutures, very much as one would the corners of the mouth. No attempt was made to remove all the cicatricial and cystogenic tissue or to maintain the conical form of the cervix. In addition to attention to these cardinal points, it is extremely essential to preserve the continuity of the cervical canal down to the new external ostium, and in the suturing to avoid the formation of pockets which are caused by leaving irregular recesses unapproximated by the sutures. The denudation is the scientific aspect-the suturing the artistic consideration. Hard cicatricial plugs in the angles and the oft-associated honey-combed condition of the cystic tissue require careful excision with the sharp-pointed curved scissors, and very often amputation of the cervix. The raison d'etre of the operation is to remove all abnormal tissue. It may be compared in one sense to a sequestrum of bone and the further analogy of the necessity of complete removal be carried out, as we do in necrotomy. The hard tissue can

sometimes be peeled out like a corn, in one piece. The finger can best tell when all diseased tissue is removed. A proper appreciation of this fact causes one to regard instruments made to bite out an arbitrary piece of tissue as a biscuit cutter does, as extremely crude and in discord with the harmonizing indications and operative corollary.

The sutures when introduced to close the excavations are arranged like the ribs of a palm-leaf fan, the undenuded strip which is to constitute the new canal forming the rallying point, and each suture making a lesser angle with it until the last one on each side is almost parallel with the margin of the cervical canal.

The difficulty of passing the needle underneath the deepest portion of the excavation and drawing out the point of the needle when it presents, is overcome by pulling up the bottom of the cervical stump so that the needle may be shoved along on a plane and the point elevated. Counter pressure made with a tenaculum will facilitate the passage of this needle without breaking and tedious delay.

When the site of the proposed canal on the everted anterior and posterior lips is felt to be free of hard tissue, then the original operation of Emmet, Bi-lateral Trachelorraphy, herein described, will suffice, no matter how deep the laceration. However, the majority of cases seen at the present time requiring operation are the ones with large hypertrophied cervices with indurated tissue containing numerous cystic follicles. The rule "to remove all morbid tissue" when applied in these cases, necessitates an amputation of the cervix. It finds its analogy in the indication for removal of hypertrophied indurated tonsils, the relic of recurring inflammation. We also know that if we do not remove all dense cicatricial tissue in the cervix it will be only a resection of the disease, and "the vaginal flaps will be brought over the morbid tissue as a prepuce;" amputation can be substituted for trachelorraphy at any moment of the operation. The excision should be conoidal, and the sutures so arranged as to pass through the anterior lip and out through the canal. A sister suture through the posterior lip unites the mucosa of cervical canal to vaginal mucosa. Apposition sutures through the stumps