The statement is made that it is bad surgery to leave any wound of the vagina and perinaeum, whether it occurs during parturition or from other causes, to heal by granulation; that it is the imperative duty of the accoucheur to make a critical examination of the genitalia after every labor, and if he finds any form of rupture, it should be repaired before he leaves his patient.
I grant that a through examination of the patient’s genital organs should be made immediately after each labor, but I do not believe that a surgical operation must necessarily follow labor immediately in a case of laceration of the cervix, vagina or perinaeum, one or all. In the majority of cases I hold that it is bad surgery to operate on distended and ecchymosed tissues which must undergo physiological involution; that in a case of extensive laceration of the perinaeum, the soft parts have been traumatized and predisposed to infection which a surgical operation does not hinder but rather invites; that the superficial and not the deep structures of the perineal body are united by immediate perineorrhaphy, provided that union of the parts takes place at all; and that, as a rule, the delayed operation in a case of laceration of the cervix or perinaeum requiring surgical interference affords the best results.
I have examined a good many women, from one month to several years after they had undergone the immediate operation, by different obstetricians for lacerations of the perinaeum extending down to or through the sphincter ani muscle, and I must acknowledge that I have not met with a perfectly restored perinaeum in the entire number. I am convinced that the obstetrician who invariably resorts to immediate perineorrhaphy not only deceives himself but misleads his patient into the belief that she has a good perineal body.
Let nature and good treatment do what they may towards restoring tears of the vagina and perinaeum, and wait until after the eighth week from labor to make a thorough operation on the lacerated part under aseptic and favorable conditions. Removal of scars at that time will be a trivial matter in comparison to the long list of evils following the delusion of a restored perineal body by immediate perineorrhaphy.
Deep ruptures of the cervix, with complicating metritis, accompany ruptures of the perinaeum as a usual thing, and under these circumstances the vagina remains in a state of subinvolution, and cystocele and uterine prolapse are frequently observed. The anterior vaginal wall is more easily displaced than the posterior. In multiparae, a small cystocele is often seen, especially when the bladder is full. It is not a pathological phenomenon, but is due to the subinvoluted and thickened vaginal wall.
When the perinaeum is deficient in tone, a vesical hernia is liable to occur, as the posterior wall of the bladder is adherent to the anterior wall of the vagina and is carried down with it. The posterior wall of the vagina is only loosely connected to the intestinal wall,a nd therefore rectocele occurs less frequently than cystocele. The uterus is soon affected by the constant dragging of a prolapsed vagina upon its attachments, and thus occurs uterine prolapse and hypertrophic elongation of the cervix. I commend the operation for cystocele which Dr. Green has described.
Stolz makes a somewhat different suture in anterior colporrhaphy. “After freshening an oval surface to correspond with the cystocele, two curved needles are threaded on a silk suture, one needle at each end, and beginning near the cervix, the suture is passed is and out of the while circumference of the wound about half an inch from the edge, something like the drawstrings like the drawstrings of a tobacco pouch. The denuded surface is pushed inward toward the bladder, and the ends of the silk closely drawn and tied.”.
However, I prefer the continuous suture in layers. I agree with Dr. Green that operations about the cervix or vagina should be performed with the knife or the scissors and not with either the ecraseur or galvano-cautery, and that denuded surfaces should be covered with mucous membrane. I approve of Dr. Green’s method of operating for incomplete laceration of the perinaeum. I would advise that the rectum be first tamponed with cotton, sponge or iodoform gauze covered with vaseline and furnished with a thread; the posterior vaginal wall is pushed forward by the tampon and displayed to a better advantage.
This operations for incomplete laceration of the perinaeum is a modification of Tait’s method, which is much employed. I Tartin recommends jumpier catgut and a continuous suture on superposed planes instead of silver sutures at separate points. The removal with the scissors of “a pear-shaped piece” from the flaps, as recommended by Dr. Green, takes out the slack and cicatricial tissue from the mucous membrane and prevents a puckered and pocketed vaginal lining in the completed operation. In this respect the operation is similar to Emmet’s which leaves but little scar tissue. The operation described can be done more quickly than the tedious operation of Emmet, and when well done accomplishes the same purpose.
Many procedures have been brought forward for complete laceration of the perinaeum, but I am convinced that the operation described by dr. Green is the best of all. Good result have been obtained by the Simon-Hegar, the Freund, the Hildebrandt, the Martin, the Emmet, the Tait, the Simpson, and other methods, but the great objection to each of these operations is that the women whose perinium have been operated upon by these methods and have the appearance of being perfectly restored, are very liable to complain that they have no power of retaining the gaseous and liquid contents of the intestine.
Whenever this complaint is made the operator will know that he failed to get a good union of the deep muscular planes and the divided ends of the sphincter-ani muscle. Again, the union may be complete superficially, but “a cavity may be left more deeply, with a resulting recto-vaginal fistula.” Since more care has been taken to pass the sutures through the perinaeum entirely, so as to bring the deeper parts in apposition, the recto-vaginal fistula has not been so frequent, but in the modified operation of Dr. Green this accident is guarded against in a very successful way.
According to his method, “the ends of the torn sphincter are loosened up and secured with medium-sized catgut and two or three heavy silk approximating ligatures, taking a good hold on either side to relieve the tension on the parts.” This procedure, combined with the American operation, more nearly meets the objections that I have mentioned than is done by any other operation, and is the most simple. The danger of sepsis is reduced to the minimum, as the admission of any discharge from either the vagina or rectum is prevented by the closed incision.
Even in the cases that involve a laceration extending up the rectovaginal septum more than an inch and a half, the American operation goes far toward simplifying the perineorrhaphy and rendering the result more successful.
L.C. GROSVENOR, M.D.: In one point the paper and the first disputant upon the paper take diametrically opposite positions, the one arguing for immediate repair of the perinaeum and the other criticizing that operation and stating his reason therefore. I have but few thoughts to give you after considerable experience in this matter. The first is to call your attention to the irritable and hurtful results of cicatrices which heal, in which there are hard tissues and fibres, and the immediate operation prevents all cicatrices if the operation is successful.
The other thought I wish to call your attention to is this: that raw surfaces are points of sepsis, and when a torn perinaeum is immediately coapted, and well coapted and well cared for after the operation, there is removed from the case a danger of sepsis.
T.L. McDONALD, M.D.: I want to add just a word in commendation of the paper by Dr. Green, and not altogether in condemnation of the statements of Dr. Runnels. I want to commend the ingenuity of a man who can devise such a plan of operation as Dr. Green has. I know it is excellent, and it is the best best one I know of. I have tried it. There are, however, some cases in which, like all good operations, it will not apply. All of us who do any work on the bowels, and most of us do, find occasionally bowels where there have been excessive and extensive syphilitic ulcers. In such cases the bowel, perhaps for inches, has been destroyed, and you have, in stead of a healthy tube, such a condition that it is impossible to bring down the bowel. In such cases as that I do not think even Dr. Green himself would apply this operation. I have tried it, however, in the better class of cases, and I know it works well.
I would differ from Dr. Green just a little with respect to his first division or classification of tears in the perinaeum. It may not be any improvement. I scarcely think it is. Instead of cutting out the mucous membrane in the similar form of tear, I would do Tait’s perinaeum operation; that is, sitting it up and converting a transverse incision into a longitudinal and leaving the mucous membrane right open; not cutting it out, but leaving it there. You are bound to have union by first intention, as far as my experience goes, because you have no possibility of secretion feeling into it. .
