GALABIUS OPERATION.—In this opera tion the extent of surface to be denuded is generally that of the cicatrix resulting from the laceration, but. "it is well to go a little beyond the limits of this in all directions, especially up the median line of the vagina and toward the lower halves of the labia majora, both in order to se cure, if possible, a perineal body some what larger and deeper than the original one, and to allow some margin in case the surfaces do not unite completely up to the edges." The mucous membrane of the vagina is first slit vertically in the middle line from a little beyond the upper edges of the cicatrix down to the edge of the sphincter. From the anal end of this median incision semicircular in cisions are made outwardly on each side not extending farther than the lower ex tremity of the nymphm. This blocks out two triangular flaps on each side, which are to be dissected from the anal apex toward the base, which is transverse. All of these flaps when once mapped out are to be removed, excepting a transverse bor der at the base. They are then united by suture (silk-worm gut). In bringing out the sutures in the centre, Galabin ad vises that they be brought out "for spaces alternately short and long," so that the surfaces may be more easily brought into contact at all levels without undue ten sion.
The performance of secondary opera tions for ruptured perineum is advised during the puerperal period; that is, from the second to the twentieth day after labor. The operation is undertaken in those cases where immediate suturing after labor has not been done, or where, if done, has not been successful. The pa tient's vagina is carefully washed out with corrosive-sublimate solution and a tampon of sublimate gauze inserted to take up the discharge. The tampon is removed just before the operation, the vagina again syringed out, and a fresh tampon inserted, which remains in situ for twenty-four hours. After this the tampon is unnecessary, and careful vag inal douching is sufficient. The opera tion consists in first marking out the ex tent of the raw surface, and then remov ing the granulation or cieatricial tissue with a sharp spoon within that limit. The sutures are then inserted in the usual way, and the raw surfaces brought together. The sutures are removed on the seventh day. Khohnogoroff
No. 19, '98).
In complete tear of the perineum the following plan is personally used: The denudation is made so that there is no rectal wound. An incision is carried across the septum at least a centimetre above the margin between the junction of the rectal and vaginal mucous mem branes. This incision extends across the whole septum and above and beyond the sphincter-ends. Taking this as the base line, the operation on the vulvar and vaginal portion of the rent is then made in the usual manner, as in the case of re pair of an ordinary relaxed vaginal out let. Having completed this denudation, the operator turns his attention to the rectal tear. He inserts his left index finger into the bowel and draws the sep tum forward, and then carefully dissects above so as to free it and turn it dowl as an apron. At the sides of this flap tit ends of the sphincter-muscle are caugh up and liberated. The purpose of the flap is to turn down an apron or fold of tis sue, which, when the sutures are all in place, projects out of the anal orifice and points in a direction away from the im pact of the faecal masses.
When the denudation is complete and the apron turned down, the presence of dead spaces in the septum is avoided by the following plan: Three or four catgut sutures are applied in the form of a figure-of-eight. They are inserted above, and each suture grasps the fibres of the internal sphincter-muscle well to one side of the median-line sutures, is then car ried to the opposite side, and then pact the tissue of the septum well above the internal sphincter; it then returns to the first side and includes the corresponding area of tissue, and is finally brought out through the internal sphincter at a point corresponding with point of entrance. This entire suture is buried in the sep tum. Then the sutures (silk-worm gut) which approximate the triangles are in troduced, and then those of the perineal surface. The final step is the union of the edges of the apron, which now lie more or less crumpled together and projecting at the anus; by leaving these sutures long and making slight traction this entire line can be drawn well outside and fixed on the buttocks by a strap of adhesive plaster. Do ward Kelly (Amer. Jour. of Obstet., Aug., '991.