I do not know of any prolongation of transverse ruptures of the vaginal entrance into the rectum; but I do not doubt that they do occur, espe cially when they are met by a rupture of the rectal mucous membrane. For when the perineal portion of the vagina is greatly distended, a primary longitudinal rupture of the anterior rectal mucous membrane occasionally occurs. In two such eases of fissures 1.2 inches long of the rectal mucous membrane, which I saw not long ago, I was able to prevent deeper vaginal rupture by free lateral incision of the vulva, and by relieving the perineum by lifting up the head per rectum. The rectal lesion healed quickly after suturing.
Fissures of the anterior parts of the introitus are never so extensive or so deep as those of the posterior portions. This is to be explained by the fact that when the head is passing, the longitudinal extension of the anterior wall is less than that of the posterior wall; and the fixation of the urethro-vaginal septum to the pelvic fascia is such as to admit of but little movement; and finally, that the arch of the pubis protects the anterior vaginal wall from hyper-distension. Thus the greater part of the tension falls upon the more yielding posterior segment. But in spite of this there do occur longitudinal ruptures of the anterior wall, which may be continued to the vestibule, or more rarely, to the nymplue. They may be of exceptional importance on account of the dangerous hemorrhage which may occur from the tearing of tissues so near the ure thra and clitoris. They will be considered elsewhere. A narrow vulva, a rigid perineum, and a hindrance of the descent of the occiput will es pecially favor their occurrence.
If the vaginal tube is small, and the pains severe, longitudinal ruptures of the vaginal mucosa may occur which may involve the entire length of the organ, and yet not invade the deeper strata. I myself saw in a peas ant girl, who had just been delivered of her first child under very insuffi cient care in the country, and who desired to become a wet-nurse, a fresh linear scar running from the posterior vaginal vault to the commissura post. This spontaneous cure was an excellent recommendation for her as wet-nurse, and she did her duty well.
In regard to the Prognosis of vaginal ruptures, the following points are to be considered: 1. The hemorrhage. 2. Complication with injuries of neighboring organs. 3. Infection. These will decide as to the dangers to life, as well a.s to the possibility of a restitutio ad integrum in case of cure. In complicated injuries the latter will only exceptionally be attained. Fis tula of rectum and of bladder, deforming scars, atresias and stenoses, de scents and fixations of the uterus, are often left behind.
Infection is of the greatest importance for the prognosis, since occa sionally, and very especially in childbed, slight traumatic losses of tissue may prove fatal. For in addition to the possibility in all vaginal rup
tures of the access of septic material from without at the moment of in jury and later, we have here two additional dangers—traumata during childbirth often e,ause extensive losses of tissue from contusion, and the wound is inevitably kept bathed in the decomposing lochial secretion.
The treatment may be prophylactic in a certain number of vaginal ruptures, mainly in those occurring sub partu. This presupposes that symptoms of the approaching danger of rupture are recognized; which has been found possible in many cases. Since spontaneous ruptures high up in the vaginal vault occur under precisely similar conditions as do cervical ruptures, the prophylactic treatment of the two are identical. When in cases of disproportion between the pelvic entrance and the ad vancing head, that contraction of the region of the uterine tumor corre sponding to the internal os over the child's head, to which 13andl has drawn *attention, has formed, the vagina itself will be markedly stretched, and is, with the cervix, in danger of rupture. But even when on account of an abnormal presentation, the constriction of the orif. int. is not plainly marked, or when the contraction of the orif. ext. has gone so far that the cervix has safely passed the point of greatest tension, the stretch ing of the vagina over the advancing part may yet show that there is danger of rupture And prophylaxis would here consist not only of the avoidance of all procedures which would increase the tension, and in the combating of very violent pains by narcotics, but also in the relief of tension by opera tive procedure.
In cases of stenosis, the incisions of which we have already spoken are available to prevent rupture. When the obstacle is situated at the vagi nal entrance, we may endeavor to enlarge the vulva by lateral incisions, at the same time endeavoring to guide the head and shoulders through the introitus in the most favorable way. When the head is in its nor mal position, this latter indication will depend chiefly upon the complete descent of the occipnt and on the slow advance of the head during this movement of flexion. In. my experience this can be most successfully done by the method of bi-manual protection of the perineum, the one hand taking care of the descent of the occiput, while the other by pres sing against the perineum during the pains, prevents the too rapid passage of the head. During the remissions of the pains the tips of the fingers should be pressed against the ischial regions, so as to favor the rotation of the head. I have abandoned Ritgen's method of guiding the face from the rectum for antiseptic reasons.