If rupture has already occurred, we must endeavor to control the hem orrhage; and, after thoroughly cleaning the wound, try to unite its edges with sutures. If this cannot be done, we must simply dress the wound and put it in as favorable a condition as possible.
If the injury has been caused by a foreign body, it must be removed with the precautions I have described. Under all circumstances a careful cleansing of the. wound and a minute examination is necessary. Irriga tion is our best method of cleansing in non-penetrating wounds, and it alone will often stop the hemorrhage. If larger vessels have been injured, they are almost always veins; cold and pressure will usually control the hemorrhage. But sometimes it will not do so. Then it will depend upon the nature and the accessibility of the wound whether the hemorrhage can be stopped by union of the edges of the wound, or whether temporary pres sure-sutures should be passed. In any case compression by sutures is not only the surest way of controlling hemorrhage, but it is also tho one which interferes least with primary union of the wound. If the rupture can be closed with sutures, irregular edges are to be trimmed off and the edges of the wound carefully united with wire or thread. Then complete rest should be enjoined, with cold cloths to the genitals and bypogastrium, a diet that does not give much fsecal residue, and the use of the catheter. If there is much vaginal discharge, lukewarm vaginal injections should be taken several times a day, (alum. acet. with addition of spir. lavand., or one of the various antiseptic solutions), always under very slight pres sure. and without the injection tube immediately touching the wound.
Sutural union can occasionally be done even when there are severe com plicating injuries, and is then always indicated. Naturally it must be carefully effected, though in an emergency operation; the couch, instru ments and assistants must be specially prepared, the wound being meantime provisionally attended to. Without doubt much will depend upon ex ternal circumstances, and much upon the energy of the physician.
If sutures cannot be applied, tampons soaked in an antiseptic fluid, or better, compresses of iodoform gauze, must be applied after the hemorrhage has been controlled, and the whole fixed with a T-bandage. The length of time which the tampon is permitted to remain in situ depends partly upon the material of which it is composed. and partly upon the amount of vaginal distension which it occasions. If it causes much distension it must not be left in place many hours; iodoform tampons remain aseptic longest. ln penetrating ruptures with prolapse of the internal organs
(uterus, adnexa, coils of intestine), the latter must be carefully cleansed, and replaced, even when they have become cold, since several cases of this kind have recovered. In these cases the collapse and the gaping of the wound usually prevent suture. The prime indication after replace ment is to prevent intestinal protrusion by suitable tampons. The re markable case which Breslau has described, where a midwife and a bath man succeeded in removing the uterus, tubes, and ovaries of a recently delivered woman with their fingers and nails, show that recovery may take place in high cervico-vaginal ruptures, and the intestines be retained even when the entire uterine body has been taken away.
And now as to the best method of completing delivery in large and high seat,ed vaginal ruptures occurring sub partu. Our choice between laps rotomy and extraction will depend upon the amount of disproportion between the fcetus and the pelvis or soft parts (stenoses, tumors, etc.), and also upon the extent of fcetal prolapse through the rupture. In a general way we can refer to the rules laid down for uterine ruptures, which are mostly applicable here.
If there is not too great a want of proportion between the kettle and the pelvic canal, and if the rupture is large and the child is wholly or mostly within the abdominal cavity, turning and manual extraction may be done. If the rupture is small, and the fcetus wedged in thenterus, perforation and cranioclasis may be employed. The after-birth is to be removed immediately after the fcetus, so us to put an end to hemorrhagre and give rest to the injured parts as soon as possible. Coils of intestine are to be replaced, and a bandage employed a,s directed above. Since union by suture is but rarely practicable, hemorrhage and displacement must be combatted by externally applied cold (ice-bags), a suitable posi tion, and as complete an immobilization of the wound as is possible by means of the dressing. If the uterus is well contracted, and the hemor rhage still persists, the bleeding point must be searched for as soon as it can be reached, and ligatured. In order to prevent lochial stagnation over the wounded region we must not allow the first tampons to remain in situ over twenty-four hours. It is desirable, in order to secure as com plete rest for the wound as is possible, to limit our vaginal antiseptic in jections as much as possible. Where, from septic changes, they become necessary, they should be done without employing too great pressure and without disturbing the patient too much.