Vol. 60, 1909 - University of North Carolina at Chapel Hill

386
THE CHARLOTTE MEDICAL JOURNAL.
tallied than can ever be secured by a sec- able instrument, and the floor of the vagina *J
oiidary operation, no matter how skilfully inspected while the blood is sponged away.
it may be performed. This of itself is a The mucous membrane is often pelled off
sufficient reason for endeavoring to estab- quite extensively, and it requires considerlish
a technic that will make secondary able care to make out the exact limits and
operation unnecessary. direction of the injury. If the tear is a
For purpose of classification, I know of median one, it will extend up the mid line
no better division than that given by Pen- for a variable distance. If it is in one or
rose in his text-book first published some both sulci, it will be seen to extend upward
years ago. It comes more nearly to describ- in an oblique direction, diverging like the
iiig the anatomical injury than any 1 have letter \" if both are involved,
seen; and so far as my experience goes. In either case, the first step is to make
whatever may be the direction or extent of out accurately the apex of the tear or tears,
the tears of the mucous membrane or skin, and from the apex the suturing is corn-
all lacerations fall into one of these divis- menced. If there is only one line, this is
ions. closed; if there are two, a separate line of
This classification is as follows: Slight suture is used in each. The suture is a
median. Median involving the sphincter continuous one and should be absorbable,
ani. Laceration in one or both sulci. Sub- I am in the habit of using iodized catgut,
cutaneous laceration. If two sutures are used, they are tied to-
Median lacerations, even when very ex- gether when the point of divergence of the
tensive, do not, as a rule, in any way inter- tears is reached. The object of this suturfere
with the supporting power of the peri- ing is to restore the vaginal tube, and in
Ileum, or, rather, its function of c losing the doing this two important results are achievvaginal
outlet. The slight mec'ian practi- ed: First, the absolute restoration to their
cally causes no disability: and the median proper relation of the injured structures
involving the sphincter ani causes the pa- and, second, the accurate approximation of
tient to lose control over the bowel but does the walls of the vagina.
not induce prolapse. As regards the first, I am well convinced
On the other hand, lacerations in the that even in the most expert hands it is
sulci seldom if ever tear into the bowel, but often a matter of impossibility to identify
do cause prolapse, as they tear across the and approximate the divided structures as
supporting muscles and more or less perma- they lie retracted and distorted in a recently
iiently disable them. Subcutaneous lacer- lacerated vagina. But the picture is imme- 'j|
ations belong in this class. diately reversed after the vaginal tube has
Bearing these facts in mind, the object of been restored, when the injured structures
the operation is to repair the essential inju- will beobservedto fall together in an orderly
rv. All lacerations should be repaired, and quite intelligible manner. These vageven
the slight median. An immediate inal sutures are absorbable because their
repair, however, covers the period of twenty- only object is accurate approximation. The
four or even forty-eight hours, and it is whole line of suture is supported by non- .'j
often advisable to defer operation until a absorbable sutures (which will be describsubsequent
visit within this period, unless ed), and by the time the catgut has been '
everything is at hand to perform the opera- absorbed, sufficient union will have been *
tion properly, or to secure necessary assist- obtained to maintain the accurate approxi- '
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aiice. Nothing is gained by operating mation. If chronic catgut is used, it re- j
under unfavorable conditions and inviting mains in the tissues so long that it invites
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failure. The first requisite in repair is suppuration. '<
proper exposure of the parts and indentifi- As regards the approximation of the vag- I
cation of the exact nature and extent of inal wall, it prevents pocketing and leak-
the tear. For this purpose sufficient light age of the lochial discharge into the wound.
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is an absolute essential The contusion In using interrupted sutures, it is often .j
and discoloration of the tissues are often so difficult or impossible to prevent thif, and I '!
great that it is only after a most thorough believe is a frequent cause of failure. ',
ocular examination that the physician can Having restored the vaginal tube accu- ;
make out which is mucous membrane and rately to the point of the hymen, we next .j
which is torn connective and muscular tis- introduce non absorbable sutures, prefer- \
sue. ably of silkworm gut, which remain in until |i
The hips of the patient should be brought union is firmly established, usually ten i
well over the edge of the bed or table, and days, when they are removed. By observ-
the feet properly supported. Then, under ing the injured structures, they can be in- ij
a good, strong light the vulva should be troduced in such a way as to approximate !!
separated, the anterior wall of the vagina them; but as a general rule, the following
retracted upward with two fingers or a suit- method should be followed. The first suture ')
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