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

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386<br />

THE CHARLOTTE MEDICAL JOURNAL.<br />

tallied than can ever be secured by a sec- able instrument, and the floor <strong>of</strong> the vagina *J<br />

oiidary oper<strong>at</strong>ion, no m<strong>at</strong>ter how skilfully inspected while the blood is sponged away.<br />

it may be performed. This <strong>of</strong> itself is a The mucous membrane is <strong>of</strong>ten pelled <strong>of</strong>f<br />

sufficient reason for endeavoring to estab- quite extensively, and it requires considerlish<br />

a technic th<strong>at</strong> will make secondary able care to make out the exact limits and<br />

oper<strong>at</strong>ion unnecessary. direction <strong>of</strong> the injury. If the tear is a<br />

For purpose <strong>of</strong> classific<strong>at</strong>ion, I know <strong>of</strong> median one, it will extend up the mid line<br />

no better division than th<strong>at</strong> given by Pen- for a variable distance. If it is in one or<br />

rose in his text-book first published some both sulci, it will be seen to extend upward<br />

years ago. It comes more nearly to describ- in an oblique direction, diverging like the<br />

iiig the an<strong>at</strong>omical injury than any 1 have letter \" if both are involved,<br />

seen; and so far as my experience goes. In either case, the first step is to make<br />

wh<strong>at</strong>ever may be the direction or extent <strong>of</strong> out accur<strong>at</strong>ely the apex <strong>of</strong> the tear or tears,<br />

the tears <strong>of</strong> the mucous membrane or skin, and from the apex the suturing is corn-<br />

all lacer<strong>at</strong>ions fall into one <strong>of</strong> these divis- menced. If there is only one line, this is<br />

ions. closed; if there are two, a separ<strong>at</strong>e line <strong>of</strong><br />

This classific<strong>at</strong>ion is as follows: Slight suture is used in each. The suture is a<br />

median. Median involving the sphincter continuous one and should be absorbable,<br />

ani. Lacer<strong>at</strong>ion in one or both sulci. Sub- I am in the habit <strong>of</strong> using iodized c<strong>at</strong>gut,<br />

cutaneous lacer<strong>at</strong>ion. If two sutures are used, they are tied to-<br />

Median lacer<strong>at</strong>ions, even when very ex- gether when the point <strong>of</strong> divergence <strong>of</strong> the<br />

tensive, do not, as a rule, in any way inter- tears is reached. The object <strong>of</strong> this suturfere<br />

with the supporting power <strong>of</strong> the peri- ing is to restore the vaginal tube, and in<br />

Ileum, or, r<strong>at</strong>her, its function <strong>of</strong> c losing the doing this two important results are achievvaginal<br />

outlet. The slight mec'ian practi- ed: First, the absolute restor<strong>at</strong>ion to their<br />

cally causes no disability: and the median proper rel<strong>at</strong>ion <strong>of</strong> the injured structures<br />

involving the sphincter ani causes the pa- and, second, the accur<strong>at</strong>e approxim<strong>at</strong>ion <strong>of</strong><br />

tient to lose control over the bowel but does the walls <strong>of</strong> the vagina.<br />

not induce prolapse. As regards the first, I am well convinced<br />

On the other hand, lacer<strong>at</strong>ions in the th<strong>at</strong> even in the most expert hands it is<br />

sulci seldom if ever tear into the bowel, but <strong>of</strong>ten a m<strong>at</strong>ter <strong>of</strong> impossibility to identify<br />

do cause prolapse, as they tear across the and approxim<strong>at</strong>e the divided structures as<br />

supporting muscles and more or less perma- they lie retracted and distorted in a recently<br />

iiently disable them. Subcutaneous lacer- lacer<strong>at</strong>ed vagina. But the picture is imme- 'j|<br />

<strong>at</strong>ions belong in this class. di<strong>at</strong>ely reversed after the vaginal tube has<br />

Bearing these facts in mind, the object <strong>of</strong> been restored, when the injured structures<br />

the oper<strong>at</strong>ion is to repair the essential inju- will beobservedto fall together in an orderly<br />

rv. All lacer<strong>at</strong>ions should be repaired, and quite intelligible manner. These vageven<br />

the slight median. An immedi<strong>at</strong>e inal sutures are absorbable because their<br />

repair, however, covers the period <strong>of</strong> twenty- only object is accur<strong>at</strong>e approxim<strong>at</strong>ion. The<br />

four or even forty-eight hours, and it is whole line <strong>of</strong> suture is supported by non- .'j<br />

<strong>of</strong>ten advisable to defer oper<strong>at</strong>ion until a absorbable sutures (which will be describsubsequent<br />

visit within this period, unless ed), and by the time the c<strong>at</strong>gut has been '<br />

everything is <strong>at</strong> hand to perform the opera- absorbed, sufficient union will have been *<br />

tion properly, or to secure necessary assist- obtained to maintain the accur<strong>at</strong>e approxi- '<br />

I<br />

aiice. Nothing is gained by oper<strong>at</strong>ing m<strong>at</strong>ion. If chronic c<strong>at</strong>gut is used, it re- j<br />

under unfavorable conditions and inviting mains in the tissues so long th<strong>at</strong> it invites<br />

J<br />

failure. The first requisite in repair is suppur<strong>at</strong>ion. '<<br />

proper exposure <strong>of</strong> the parts and indentifi- As regards the approxim<strong>at</strong>ion <strong>of</strong> the vag- I<br />

c<strong>at</strong>ion <strong>of</strong> the exact n<strong>at</strong>ure and extent <strong>of</strong> inal wall, it prevents pocketing and leak-<br />

the tear. For this purpose sufficient light age <strong>of</strong> the lochial discharge into the wound.<br />

j<br />

is an absolute essential The contusion In using interrupted sutures, it is <strong>of</strong>ten .j<br />

and discolor<strong>at</strong>ion <strong>of</strong> the tissues are <strong>of</strong>ten so difficult or impossible to prevent thif, and I '!<br />

gre<strong>at</strong> th<strong>at</strong> it is only after a most thorough believe is a frequent cause <strong>of</strong> failure. ',<br />

ocular examin<strong>at</strong>ion th<strong>at</strong> the physician can Having restored the vaginal tube accu- ;<br />

make out which is mucous membrane and r<strong>at</strong>ely to the point <strong>of</strong> the hymen, we next .j<br />

which is torn connective and muscular tis- introduce non absorbable sutures, prefer- \<br />

sue. ably <strong>of</strong> silkworm gut, which remain in until |i<br />

The hips <strong>of</strong> the p<strong>at</strong>ient should be brought union is firmly established, usually ten i<br />

well over the edge <strong>of</strong> the bed or table, and days, when they are removed. By observ-<br />

the feet properly supported. Then, under ing the injured structures, they can be in- ij<br />

a good, strong light the vulva should be troduced in such a way as to approxim<strong>at</strong>e !!<br />

separ<strong>at</strong>ed, the anterior wall <strong>of</strong> the vagina them; but as a general rule, the following<br />

retracted upward with two fingers or a suit- method should be followed. The first suture ')<br />

'

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