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the nulliparous woman by introducing the finger in the vagina and pressing backward and outward toward the ischio-rectal fossa. We then feel plainly, immediately within the ostium vaginæ, a firm resisting band of tissue, apparently about half an inch broad, embracing the posterior portion of the lower vagina. This band is formed by the inner edges of the various muscles and planes of fascia that have been described.

The vagina extends, as a transverse slit in the pelvic

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FIG. 22.--Sagittal section showing relations of the several layers of fascia within the pelvic floor (Dickinson).

floor, upward and backward, approximately in the direction of a line drawn from the ostium vagina to the fifth sacral vertebra. It is approximately parallel with the conjugate of the brim, so that when the woman is erect the long axis of the vagina is inclined at an angle

of 60° to the horizon. The vagina is not a vertical open tube: it is a slit in the pelvic floor, in health always closed by the accurate apposition of the anterior and posterior walls (Fig. 21). The anterior vaginal wall is about 21⁄2 inches long in a vertical mesial line. The posterior vaginal wall is about 31⁄2 inches long. The vaginal walls

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FIG. 23.-Section illustrating the characteristic form of the vaginal cleft (Henle): Ua, urethra; Va, vagina; L, levator ani; R, rectum.

are triangular in shape, being broader above than below. The shape of the normal vagina at the pelvic outlet is shown by Fig. 23. The section here shows the vaginal slit of the shape of the letter H. The portions of the slit extending backward and somewhat outward are called the vaginal sulci or furrows. They are directions of diminished resistance in which tears are liable to occur.

CHAPTER VI.

INJURIES TO THE PERINEUM.

THE injuries to the perineun that may result from childbirth are classified according to the position or the direction and extent of the laceration. They are as follows: slight median tear; median tear involving the sphincter ani; tear in one or both of the vaginal sulci; subcutaneous laceration of the muscles and fascia.

All these injuries demand operative treatment. The operation for the repair of injuries to the perineum is called perineorrhaphy. It is called immediate or primary, intermediate, and secondary perineorrhaphy, according to the time after the receipt of the injury at which the operation is performed. The primary operation. is done during the first twenty-four hours. The primary operation should always be performed. A careful inspection of the perineum and the posterior vaginal wall should always be made after labor, and any laceration should be repaired within twenty-four hours. The advantages of the primary operation are many. The parts are usually so numb that it is not necessary to administer an anesthetic. No denudation is necessary, and therefore no tissue need be sacrificed. The woman is spared the pain and discomfort of granulation and cicatrization.

The bad results that follow neglect of the primary operation are very numerous, and will be studied hereafter. The injured muscles retract, and, being functionally useless, undergo atrophy, and when finally repaired never possess their former strength. Involution in the vagina and the uterus may be arrested, and all the disasters incident to subinvolution may appear. Vaginal and uterine prolapse occur; the natural supports of the

vagina and uterus become stretched, and, though afterward the perineum may be restored, yet it may be found impossible to retain the uterus in its proper position. It is always good surgery to repair an injury as soon as possible.

When practicable, a certain amount of preparation of the patient should be made before the operation of perineorrhaphy. This is most easily effected before the intermediate and secondary operations. The vagina and the vulva should be sterilized, and the intestinal tract should be emptied. Thorough evacuation of the bowels is most important when the sphincter ani has been injured, because it is desirable, after operation for this lesion, that the bowels should not be moved for five or six days. A saline purgative should be administered on an empty stomach about five hours before the operation, and a rectal injection of soap and water should be administered about one hour before the operation. Whatever purgative be employed, it should be administered at such a time that its action shall have ceased by the time of the operation. If this precaution is not observed, there may be a discharge of feces that will infect the wound and interfere with the manipulations.

For operation upon the perineum the woman should. be placed in the dorso-sacral position (Fig. 1, page 25). The intermediate operation is performed during the granulation period-ten days or two weeks after labor. At this time the raw surfaces are covered with granulation-tissue and bathed with pus. The edges of the wound and the surrounding tissue may be hard and swollen from infiltration with inflammatory products. In the intermediate operation it is necessary to administer an anesthetic or to anesthetize the parts locally with a 10 per cent. solution of cocaine.

All cicatricial tissue, granulation-tissue, and rough edges should be scraped away with the knife, the scissors, or the curet. The raw surfaces should be thor

oughly washed with a 50 per cent. solution of peroxide of hydrogen and a 1: 1000 solution of bichloride of mercury. The sutures should then be introduced.

The secondary operation is performed at any time after cicatrization has occurred-often many years after the receipt of the injury. This operation is at present one of the commonest in gynecology, because the injury is not detected, is neglected, or is improperly repaired after labor. In the secondary operation an anesthetic is neces

G.TIEMANN &00

FIG. 24.-Emmet's perineal scissors.

sary. The mucous membrane must be removed or denuded on the posterior wall and about the mouth of the vagina, in order that the lacerated structures may be brought again in apposition. The denudation is best

EMANN-CO.

FIG. 25.-Curved scissors for denuding.

made by means of scissors curved on the flat (Figs. 24 and 25).

LENTZ

LENTZ.

FIG. 26. Tenacula for plastic operations.

The strip of mucous membrane to be removed is picked up with a tenaculum (Fig. 26) or with tissue forceps

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