The secondary operation in case of incomplete rupture may be per formed at any time with hopes of good result. In case of complete lace ration, however, the hope of cure is less the longer the patient defers the operation, since the muscles, the sphincter ani and the trausversus perinei, retract the more and undergo fatty degeneration. The time usually chopn for operation, six weeks after delivery, has been found too early by Hildebrandt, because the soft parts are still very hyperaemic and bleed more during denudation. He advocates with reason waiting till after the first menstrual period, since this time marks the return of the geni tals to the normal. This is sound advice, because the secretion panying defective involution may interfere with union. Hyperaemia is not to be feared, since under it the wounds heal better. We will de scribe, as typical, the operation where the rectal wall is still intact. At the time of rupture, there exist two triangular surfaces. If these. are not interfered with, they spread apart, and in the course of a few weeks become covered over with mucous membrane, constituting the cicatrized laceration of the perineum. To denude these surfaces and to bring them into contact by suture, such is the aim of the operation. In order to ob tain a broad perineum, the denudation must extend not alone over a small part of cicatrized surface, but also into the vagina. Superficial denuda tion will only result in building up a wall of skin in front of the vagina, and the conditions existing previous to rupture will not be secured. There results what is schematically shown in Fig. 74, a, and not the lift ing up or building up of the perineum, which is represented in Fig. 74, b. The simplest method of denudation in case of rupture to the first degree is shown in Fig. 75. The more, however, the rent extends back wards, the higher must the denudation be carried up into the vagina, and there results the appearance shown in Fig. 76, where the curved line a, c, e, b, d, extends from the top of the old posterior commissure at the junction of the skin and mucous membrane, around in front of the anus to a corresponding point on the opposite side. The angle itx extends above the apex of the rupture upwards into the vagina. The sutures first bring together the vaginal denuded surfaces and then the perineum, the needles here being passed as deeply as possible. We recommend in these instances very highly the quill suture shown in Fig. 73. By means of it we prevent with certainty pocketing in the centre of the wound, and the resulting retention of secretion and pus formation which nullifies the re sult. The operation in case of laceration of the perineum to the first and second degree, is very simple and successful. The result is apt to be the better the more carefully we attend to antiseptic rules.
The operation for complete rupture of the perineum is far less likely to succeed than the preceding. The rent in the rectum must also be re paired. The disturbance by the passage of faeces over the denuded sun faces, which have been brought together, is very likely to make the oper ation a failure. On this account constipation has been induced, but it has been found practically that the resulting hard scybala were also likely to separate the united surfaces at the first evacuation. Faecal evacuations should be limited to the minimum, the intestines being thoroughly cleansed for a week before the operation, and then by means of a fluid readily assimilated diet the formation of scybala is prevented. The bowels, however, should not be constipated, but rather kept fluid through the ad ministration of a gentle laxative during the after-period.
The denudation differs according to the operative method resorted to. We will at the outset describe Simon's method, to which he has given the name of the triangular denudation. The denuded surface is only slightly different from that which we have described in case of incomplete lacera tion. The rectal denudation is the only additional part. In case of extensive rupture, in order to obtain symmetrical denudation it is of ad vantage first to outline by the knife the surface to be removed. In the process of denudation we are likely to cut the large perineal veins, but the hemorrhage is rarely profuse, and compression by means of one finger in the rectum, and another in the vagina, will check it. The denuded
surfaces are to be trimmed off with the scissors, and then the sutures are to be passed.
Three sets of sutures must be used, the rectal, the vaginal, the peri neal. The deep sutures should only be inserted from the vagina. If passed from the rectum they would have to be taken out, else, if left above, they will cause suppuration, tear through and result in recto vaginal fistula. This may, however, be prevented through the use of catgut. The great point is to bring the denuded surfaces well together by suture, and to operate on strict antiseptic principles. It is especially essential that all hemorrhage be checked before passing the sutures. Heger and Kaltenbach, who have adopted Simon's triangular denudation, pass the chief series of sutures from the vagina. For the rectum they use carbolized silk or catgut. The sutures in the recto-vaginal septum, they pass from the vagina, and they leave them in situ for from four to six weeks. In case silk has been used in the rectum, it must also be re moved at this time, if it has not already spontaneously torn out.
Hildebrandt differs from the method of Hegar and of Kaltenbach in that he passes all his sutures before he begins to tie them, and in the second place in that he passes the perineal sutures deeply and under a wide extent of surface. In Fig. 80 the application of the sutures is shown, and in Fig. 81 the manner in which they lie when tied. This method has the disadvantage of causing more hemorrhage, and in that the deeply passed sutures readily dissolve higher up, and there is likeli hood, hence, of resulting recto-vaginal fistula. Reference to Fig. 81 will show the further disadvantage that equal traction on the sutures from the three sides leaves a pocket in between.
In my own operation in case of complete rupture, I first pull the rec tal mucous membrane upwards, and often it may be drawn forward greatly, so as to slope over the cicatricial border of the vaginal mucous membrane. The drawing forward is very necessary in order to obtain a symmetrical broad denuded surface throughout the whole extent. I next mark off the lower margin of the denuded surface at the anus. I then transfix with a knife the free border of the vaginal and rectal wall above, and de nude the recto-vaginal septum on each side. The cicatricial tissue in the vagina is then cut out, and the denudation extended up the vagina, and down along the margin of what is to constitute the new posterior commissure. I lift up the mucous membrane with forceps, and skin it off in broad strips by means of a knife even as the skin is peeled from an apple. In this way the entire mucous membrane is removed in a few minutes, although unevenly. The little undenuded portions are to be carefully trimmed off with Cooper's scissors under irrigation with carbolic solution. The sutures are next passed, and first the rectal, which are passed through the mucous membrane and knotted in the rectum, the entire rectal wall being sutured before the vaginal sutures are passed The rectal sutures are of catgut, but for the vaginal I have used both silver and silk, generally the latter. Before the first vaginal suture is tied, the denuded surface should be carefully disinfected with a weak 5 per cent. solution of zinc chloride. The vaginal sutures include the recto-vaginal septum, or else, guided by the finger to protect the rectal mucous membrane, they are passed entirely under the denuded surface. After the sutures have been passed down to the perineum, this is united by a quill suture passed deep under the tissues. A few superficial sutures are finally laid in the perineum, and in the vagina of silver, and the operation is at an end. The time for the removal of the quill suture cannot be definitely stated. From the third day on, the perineum must be carefully examined, and if a drop of pus appears along a suture the quill must at once be removed, and the surface sprinkled with iodoform. The vaginal sutures I leave for some time, although not for four to six weeks as do Hegar and Kaltenbach. After the third to the fourth day the patient receives a laxative (magnesia), and after each defecation the rectum is washed out. The diet is simple.