For operation upon the perineum the woman should be placed in the dorso-sacral position (Fig. 1, page 23).
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 thoroughly 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.
[Illustration: FIG. 24.--Emmet’s perineal scissors.]
[Illustration: FIG. 25.--Curved scissors for denuding.]
[Illustration: FIG. 26.--Tenacula for plastic operations.]
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 necessary. 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 made by means of scissors curved on the flat (Figs. 24 and 25).
The strip of mucous membrane to be removed is picked up with a tenaculum (Fig. 26) or with tissue forceps (Fig. 27); the scissors are placed with the blades parallel to the surface to be denuded, and the strip is cut away evenly, in one piece if possible. A similar contiguous strip is removed, and so on until the necessary surface is bare. Sponges in holders (Fig. 28) or continuous irrigation may be used to remove blood.
[Illustration: FIG. 27.--Tissue-forceps.]
For all operations on the perineum round-pointed needles curved at the tip should be used (Fig. 29). The tissues are always sufficiently soft for the passage of such a needle. A needle with a cutting edge is unnecessary and may increase the bleeding.