DELAYED OpERATioN.—When primary operation has been omitted or has failed, a plastic one is necessary for restoration of the perinea] body. These operations should not be undertaken until from six to twelve months after the original in jury. During this interval the general health of the patient should be looked after, and tonics administered if neces sary. For a week before the operation the bowels should be kept open by mild cathartics, so that all scybala may be re moved. in cases of complete rupture the bowels should receive like attention for two weeks, a compound cathartic or com pound rhubarb pill, or a saline laxative being given every twelve hours to secure free atonic evacuation; hypercatharsis should be avoided. During the same time the vagina should be thoroughly syr inged, night and morning, with warm borosalicylic or hydronaphthol douches. Immediately before the beginning of the operation the parts should be shaved and well scrubbed.
The instruments required will consist of a sharp bistoury, long-handled scissors curved on the flat, two pairs of mouse toothed forceps and pair of dissecting forceps, a dozen hemostatic forceps, a needle-forceps, two or more large curved needles, preferably llagedorn's, as many small curved needles, and a pair of suit able retractors for holding back the labia.
Sterilized silk is to be preferred for su tures, a coarse thread for the deep su tures, and a finer one for the superficial ones. Catgut is best for ligatures, and in some cases for sutures. The patient, dressed for bed, should be placed upon a table, under a good light, in the position for lithotomy, with the pelvis elevated on a hard pillow, and etherized. Four as sistants will be found useful, although three may be sufficient. One of these should administer the anesthetic, one should hold each knee, and the fourth should hand the instruments.
The operative procedures will vary ac cording to the preference of the operator and according as the laceration is partial or complete. The concealed variety should be transformed into the incom plete or partial by transfixion with the bistoury and incision as the initial step of the operation.