INJURIES TO THE PERINEUM.
The injuries to the perineum 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 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.]
[Illustration: FIG. 28.--Sponge-holder.]
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.
The needle may be held in any kind of needle-holder preferred. The
Emmet needle-holder (Fig. 30) is very convenient.
[Illustration: FIG. 29.--Emmet’s perineal needle.]
[Illustration: FIG. 30.--Emmet’s needle-holder.]
The point of the needle should be guided and held by the tenaculum. The
tenaculum must always be held in a plane parallel with the plane of the
needle-holder; otherwise the needle-point may escape from the embrace
of the tenaculum.
Silver wire and silkworm gut are the best sutures in the operation of
perineorrhaphy.
The suture is conveniently attached to the needle by means of a silk
carrier (Fig. 31).
[Illustration: FIG. 31.--Perineal needle with silk carrier.]
[Illustration: FIG. 32.--Shot-compressor.]
The sutures may be fastened by passing the ends through a perforated
shot which is slipped down to the line of union and compressed by
the shot-compressor (Fig. 32). All blood should be carefully removed
from the surfaces that are brought together. The sutures should only
be sufficiently tense to produce accurate apposition. A light gauze
drain should be introduced in the vagina, and should be removed in
forty-eight hours. Afterward one vaginal douche of about a quart of
warm bichloride solution (1:2000) should be administered every day.
After the douche the labia should be separated and the vagina carefully
dried by cotton held in dressing-forceps. Except in those cases in
which the sphincter ani is involved, the bowels may be moved on the
second or third day. The woman should stay in bed for two weeks, at
the end of which time the sutures should be removed. She should avoid
heavy lifting, long standing, and bicycle- or horseback-riding for two
months after the operation. Constipation should always be avoided.
Coitus may be resumed six weeks after operation.
The special forms of operation will be discussed in the consideration
of the varieties of perineal injury.
=Slight Median laceration of the Perineum.=--In this injury the tear
takes place through the fourchette. Posteriorly it may extend as far
as the sphincter ani muscle. Upward it may extend for an inch up the
posterior vaginal wall. The appearance of this tear is shown in Fig.
33. It will be noted that, as this tear takes place in the median
line, none of the muscles that support the perineum are involved, nor
are the planes of fascia injured. The perineum is slightly split, and
the insertions and origins of the muscles and the fascia are slightly
separated. The supporting structures of the perineum and the pelvic
floor are, however, uninjured.
[Illustration: FIG. 33.--Recent slight median laceration of the
perineum: sutures introduced.]
If this tear is detected after labor, it should be closed by the
immediate operation. A slight tear involving chiefly the cutaneous
aspect of the perineum should be closed by three or four sutures
introduced from the outside, as in Fig. 33. The needle should be
introduced about a quarter of an inch from the edge of the wound. It
should not be passed parallel with the plane of the lacerated surface,
but should be swept outward and then inward toward the angle at the
bottom of the tear (Fig. 34). It may either emerge at the angle and be
re-introduced, or it may be passed directly through to the skin-margin
on the opposite side of the wound. If the suture is passed in this
way, there will be perfect apposition throughout the whole surface of
laceration. If the sutures are improperly passed, there may result only
apposition of the skin-edges.
[Illustration: FIG. 34.--Diagram representing the correct and the
incorrect method of passing the suture for closure of slight perineal
laceration.]
If the laceration extends up the posterior vaginal wall, two sets of
sutures must be introduced--one on the vaginal aspect of the tear, and
one on the skin aspect (Fig. 35).
[Illustration: FIG. 35.--Recent slight median laceration of the
perineum extending up the posterior vaginal wall: sutures introduced on
the vaginal and cutaneous aspects.]
The secondary operation of perineorrhaphy is not indicated in slight
median lacerations of the perineum that may have been neglected at the
time of labor, as the integrity of the pelvic floor is practically
unaffected by them.
=Median Tear involving the Sphincter Ani.=--In this form of injury the
laceration takes place in the median line and extends backward through
the sphincter ani muscle, and perhaps upward for one or more inches
through the recto-vaginal septum. Permanent incontinence of feces
results.
Though this is a most extensive injury attended by most unpleasant
results, yet it will be seen that none of the supporting structures
(the fascia and the muscles) that support the pelvic floor are injured
by it.
The perineum is split in the middle, but the muscles attached to it,
being uninjured, are still able to draw the two halves of the perineum
forward, thus supporting the posterior vaginal wall and keeping the
vagina closed. There is but very little tendency to separation of the
two parts of the split perineum by lateral traction, the only muscle
that acts at all in this direction being the feeble transverse perineal
muscle.
Therefore, though there is loss of power of the sphincter ani muscle,
yet in this injury the woman may not suffer any of the consequences of
loss of power in the support of the pelvic floor, such as vaginal and
uterine prolapse.
After laceration of the perineum through the sphincter ani the divided
muscle retracts so that it embraces only the posterior margin of the
anus. If the injury be not repaired immediately, retraction and atrophy
progress, so that in time the sphincter muscle, lying posterior to the
anal opening, may be but half an inch in length and of very much less
than its normal thickness. Cicatrization takes place, and the parts
present the appearance shown in Fig. 37.
Notwithstanding the atrophy and retraction of the muscle, continence
may be re-established by operation, though many years may have elapsed
since the receipt of the injury.
Notwithstanding the very obvious reasons for the performance of the
immediate operation for the relief of this condition, it is yet very
often neglected, and the gynecologist is called upon to repair the
injury many years after its occurrence.
The important part of the operation for this injury consists in the
repair of the muscle. In many operations the recto-vaginal septum is
repaired and the cutaneous portion of the perineum is repaired, but
the operator fails to secure in his sutures the sphincter ani muscle,
and consequently the incontinence is not cured (see Fig. 36). The
mistake often made is that the sutures that are introduced to close the
anterior margin of the anus are inserted too far forward and too far
out to catch the ends of the sphincter ani muscle, which has retracted
so that, in some cases, it lies altogether behind the anal opening. Or,
perhaps, only the outer fibers of the sphincter ani are included in the
suture, and partial incontinence results.
[Illustration: FIG. 36.--Imperfect repair of the sphincter ani. The
muscle has not been included by the sutures, and does not surround the
anal opening.]
The position of the sphincter ani muscle is indicated by the
corrugated or wrinkled skin overlying it. The ends of the muscles,
being retracted, do not lie in the plane of the laceration, but their
position is marked by a depression or dimple (Fig. 37).
The technique of the primary operation is included in a consideration
of that of the secondary operation, the only difference being that in
the latter operation denudation is necessary.
The parts should first be denuded, so that they present the same raw
surface that was exposed in the original laceration.
The lower end of the recto-vaginal septum that forms the anterior
margin of the anal opening is usually thin and cicatricial where the
mucous membranes of the vagina and rectum unite. All this cicatricial
tissue should be cut away, and the mucous membrane of the vagina may be
drawn forward and separated by dissection from the mucous membrane of
the rectum, in order to make a somewhat broader surface through which
to pass the sutures.
Special care should be directed to the denudation of the ends of the
sphincter muscle. The tissue lying at the bottom of the depression that
marks the end of the sphincter should be picked up with forceps or a
tenaculum and carefully cut away. In removing tissue attached to the
mucous membrane of the rectum the operator should avoid cutting the
healthy portion of this mucous membrane, as bleeding from it is often
annoying.
[Illustration: FIG. 37.--An old laceration through the sphincter ani.
The sphincter muscle lies behind the anal opening. Its position is
indicated by the wrinkled skin; its ends are marked by the depressions
on each side of the anal opening.]
The first suture should be introduced at the margin of the anal
opening, within the area of corrugated skin that marks the position
of the muscle, and behind the depression that marks the end of the
muscle. The end of the muscle may be seized with a tenaculum or with
tissue-forceps and drawn out to ensure that the suture includes
muscular tissue. The needle is then passed near the edge of the rectal
mucous membrane to the apex of the tear in the recto-vaginal septum.
whence it emerges. It is re-introduced here, and passed in a similar
manner to emerge upon the opposite side, behind the other end of the
sphincter ani muscle (Fig. 38). This suture is introduced very near
the edge of the wound, so that there may not be any inversion of skin
to prevent perfect apposition of the ends of the muscle. In case
there has been much retraction of the sphincter ani muscle, the ends
of the suture may appear to lie behind the anal opening. The second
suture is introduced somewhat outside of the first--still, however,
within the area of the sphincter muscle--and is passed in a similar
manner to emerge in the apex of the recto-vaginal tear anterior to the
first suture. The remaining sutures to close the perineum are passed
as already described in the operation for slight median tear of the
perineum. When the sutures are shotted, great care must be exercised
in making perfect apposition of the parts brought together by the
first two sutures. Sometimes such apposition is more easily secured by
shotting the anterior perineal sutures first. When the operation is
completed the first suture through the sphincter is sometimes drawn
upward, so that it disappears in the anal opening. If the muscle has
been properly secured, it will be observed that the anal opening is
surrounded by the ring of wrinkled or corrugated skin (Fig. 39).
[Illustration: FIG. 38.--Denudation and sutures for repair of
laceration. The two posterior sutures pass through the sphincter
muscle.]
[Illustration: FIG. 39.--Completed operation. The anal opening is
surrounded by the sphincter. One shot has disappeared in the anus. The
anterior suture is omitted.]
After this operation the bowels should not be moved for five or six
days. The intestinal contents should then be rendered as soft as
possible by the administration of small repeated doses of some saline
purgative, as Rochelle salts ʒj, every hour for five or six hours.
If the woman feels that she may have difficulty in having a passage,
a rectal injection of a pint of soapsuds and warm water should be
very carefully administered. The nozzle of the syringe should be well
greased and passed along the posterior margin of the anal opening.
After this the bowels should be moved every forty-eight hours. The
sutures should be removed at the end of two weeks.
[Illustration: FIG. 40.--Laceration through the sphincter ani,
extending up the recto-vaginal septum.]
=Laceration through the Sphincter Ani, involving the Recto-vaginal
Septum.=--In case the recto-vaginal septum has been torn, it may be
necessary to repair the tear before operating on the perineum and the
sphincter ani muscle. In some cases the laceration extends for three
or more inches up the septum (Fig. 40).
The edges of the septal tear should be denuded, the strip of tissue
being cut away to the line of normal rectal mucous membrane. Annoying
bleeding may occur if the mucous membrane of the rectum is injured. The
denudation may be extended on the vaginal aspect as far as is necessary
to obtain a sufficiently broad surface for approximation.
The tear in the septum should be closed by interrupted sutures
introduced from the vaginal aspect. The suture is passed through the
vaginal mucous membrane at about an eighth of an inch from the edge of
the wound, and emerges in the edge of the rectal mucous membrane. It
should not pass through the rectal mucous membrane.
[Illustration: FIG. 41.--Denudation. Sutures introduced to close the
laceration of the recto-vaginal septum.]
[Illustration: FIG. 42.--Laceration of the recto-vaginal septum closed.
The operation is completed by the introduction of sutures as in Fig.
38.]
After the sutures in the recto-vaginal septum have been shotted, the
operator may proceed to repair the perineum and the sphincter ani
muscle (Figs. 41, 42).
There is a variety of perineal laceration (between the first slight
median laceration and the second complete laceration through the
sphincter ani) in which only the outer fibers of the sphincter muscle
are injured. In this injury partial incontinence results. The woman may
be able to control feces when the movements are hard, but loses control
over liquid feces and flatus.
There is no loss of support of the pelvic floor, and the indication for
operation is the partial incontinence. The operation is performed in a
way similar to that already described for complete laceration. The ends
of the ruptured fibers of the sphincter muscles are usually indicated
by a slight depression on the overlying skin or mucous membrane.
=Laceration in One or Both Vaginal Sulci.=--In this form of injury the
tear takes place not in the median line, but in the direction of the
vaginal sulci or furrows. The left sulcus is usually the more deeply
torn.
In this form of laceration the sphincter ani muscle usually escapes
injury; the tear is directed toward the ischio-rectal fossa, and the
rectum and anus are pushed to one side. The structures of importance
that are injured are the fascia, the levator ani muscle, the sphincter
muscle of the vagina, and perhaps the transverse perineal muscle. All
the supporting structures of the perineum and of the posterior vaginal
wall are injured. If the laceration be bilateral, complete loss of
support of the perineum and the posterior vaginal wall results, and if
the condition be untreated, all the disastrous consequences of loss of
support of the perineum occur--prolapse of the vagina, of the uterus,
and of the other pelvic organs.
It is unusual that this form of laceration is entirely limited to one
sulcus, though one is usually more involved than the other. When the
injury is limited to one side, the perineum is still supported by the
muscles and fascia upon the other side, and the tendency to prolapse is
not so marked.
The nature of this injury may always be detected by examination after
labor. The anterior vaginal wall should be elevated by a retractor, and
the posterior wall should be carefully examined. An external tear of
the skin, generally in the median line, usually accompanies laceration
in the sulci; that is, the lacerations in the sulci converge toward the
fourchette.
The immediate operation should always be performed. The torn sulci
should be closed by sutures introduced on the posterior vaginal wall
(Fig. 43), and the external tear should be closed by sutures introduced
as in the first form of injury to the perineum, already described.
[Illustration: FIG. 43.--Sutures introduced for the closure of a recent
perineal laceration in the sulci.]
If this form of perineal injury is not repaired by the immediate
operation, cicatrization takes place, and the tears in the mucous
membrane and in the skin become healed. The fascia retracts, and the
integrity of the supporting planes of fascia is destroyed. The torn
muscles, the inner fibers of the levator ani and the sphincter vaginæ,
also retract and cease to furnish any support to the perineum. In
health these muscles embrace the lower portion of the posterior vaginal
wall like a sling, drawing it toward the symphysis pubis; after
laceration in the sulci the support of one or both of the arms of the
sling is destroyed.
The scars upon the mucous membrane and on the skin in time become
faint, with difficulty perceptible. By elevating the anterior vaginal
wall and closely inspecting the posterior wall immediately within the
ostium vaginæ we may detect a fine irregular white line running in the
direction of the vaginal sulcus and dividing the normal transverse
ridges and furrows of the vaginal mucous membrane. This is the only
sign of former injury to the vaginal mucous membrane. The injury to
the underlying structures--the supporting structures of the perineum,
the muscles and the fascia--is indicated by certain characteristic and
unmistakable signs. These signs are best recognized after a careful
study of the normal uninjured perineum.
If an uninjured woman be placed in the lithotomy position and the
perineal region be carefully examined, we observe the following points:
The anus is not prominent: it is drawn upward and forward; the anal
cleft is deep.
The perineum, or the surface between the anus and the fourchette, is
shallow; the distance from the anus to a fixed point like the external
meatus is relatively short: this surface is more or less convex,
showing muscular tonicity.
If the labia are separated, it will be observed that the anterior and
posterior vaginal walls are in close apposition. If the woman is made
to strain or to bear down, the vaginal walls appear to come into close
contact; the perineum is pushed directly downward, and becomes more
prominent under the increased intra-abdominal pressure, but there is no
tendency to eversion or rolling out of the vaginal walls.
If the vulva is pricked with a needle, reflex muscular action is
immediately observed: the anus is drawn still more upward and forward;
the perineum is shortened; the ostium vaginæ is closed more firmly by
the drawing forward of the posterior margin of the opening. The test
shows that the muscles supporting the perineum are intact.
If the finger be introduced into the vagina and be pressed backward and
outward in either vaginal sulcus, resisting structures are felt. There
seems to be a band, perhaps half an inch in breadth, immediately within
the ostium vaginæ, that holds forward the perineum and the posterior
vaginal wall and resists the pressure of the finger.
Compare these characteristic features of the uninjured perineum
with what we observe in a woman in whom there has been an untreated
laceration of the perineum in the vaginal sulci. Here the supporting
structures of the perineum have been destroyed.
[Illustration: FIG. 44.--Diagram showing the sling of muscle and fascia
supporting the perineum and the posterior vaginal wall. In A the parts
are intact; in B there has been a laceration in the left vaginal
sulcus; in C there has been a laceration in both sulci; a suture has
been introduced on the right side.]
The anal cleft is shallow. The anus is prominent; the surrounding
structures present the appearance of relaxation. The perineum is deep;
the distance from the anus to the external meatus is longer; the anus
has really dropped back. The skin-surface of the perineum is flat and
relaxed.
If the labia are separated, the anterior and posterior vaginal walls
will not be found in close apposition. The ostium vaginæ is patulous
and gaps open (Fig. 45). If the woman is made to bear down, the
anterior and posterior vaginal walls are not pushed together; they are
rolled out and protrude through the ostium vaginæ.
If the vulva is pricked with a needle, the woman draws herself away;
there is no reflex muscular action, closing the vagina and drawing up
the anus. The muscles of the perineum have been destroyed.
If the finger is introduced in the vagina and pressed backward and
outward in either vaginal sulcus, the tissues are yielding and soft; no
supporting sling of muscle and fascia is felt.
These phenomena have an unmistakable meaning, and indicate clearly the
loss of the supporting structures of the pelvic floor.
The student should acquire familiarity with these tests by repeated
experiments on injured and uninjured women. It will easily be
understood that the same phenomena characterize the fourth form of
injury to the perineum--the subcutaneous laceration.
[Illustration: FIG. 45.--An old laceration of the perineum in both
sulci. Rectocele. The mouth of the vagina is held open to show the
appearance of the parts before operation: _a_, apex of the rectocele.]
A perineum in this condition is often said to be relaxed. It is relaxed
because the muscular and fascial supports have been destroyed.
_Treatment._--The treatment is directed to the restoration of these
supports. Each vaginal sulcus must be denuded, so that the condition
existing in the recent injury (Fig. 43) is reproduced, and the sutures
must be passed so that the retracted muscles and the fascia are brought
back to their normal attachments. The best method of operating for this
condition has been devised by Emmet.
[Illustration: FIG. 46.--The rectocele is seized with the tenaculum at
_a_, and is drawn to the right, exposing the left vaginal sulcus, _a_,
_b_, _c_, which must be denuded. The point _b_ should be secured with a
tenaculum before denuding.]
[Illustration: FIG. 47.--Method of denuding the sulcus.]
_Emmet’s Operation_ (Figs. 45-55).--When the labia have been separated,
it will be observed that there is a bulging or prominence of the lower
portion of the posterior vaginal wall, which is called a rectocele. The
most prominent point or the apex of the rectocele should be held by a
tenaculum or by a silk ligature passed immediately beneath the mucous
membrane.
This point should be such that it may without undue traction be drawn
to either orifice of the vulvo-vaginal glands.
[Illustration: FIG. 48.--The left sulcus denuded.]
[Illustration: FIG. 49.--Both sulci denuded.]
If the apex of the rectocele is drawn to one side, there is formed on
the other side a triangular area (Fig. 46, _a_, _b_, _c_). The base
of this area (_a_, _c_) is at the ostium vaginæ. The inner side (_a_,
_b_) runs along the side of the rectocele. The outer side (_b_, _c_)
runs along the lateral vaginal wall. The apex _b_ is approximately the
highest point of the tear in the sulcus. The angle _c_ is immediately
below the orifice of the vulvo-vaginal gland. The angle _b_ is fixed by
a tenaculum held by an assistant, and the triangular area is denuded.
The denuded area does not correspond exactly with the original tear
in the sulcus, but the denudation exposes the sulcus, so that sutures
may be passed in such a way as to include the muscles and fascia. The
sulcus on the opposite side is then denuded in a similar manner, and
the lower face of the rectocele is denuded. It is best to begin the
denudation by seizing with tissue-forceps the mucous membrane of the
posterior vaginal wall at the ostium vaginæ, at the junction of skin
and mucous membrane, and to remove contiguous strips of tissue by
cutting upward toward the apex of the vaginal sulcus (Fig. 47).
[Illustration: FIG. 50.--Introduction of the sutures. The point of the
emerging needle is held by the tenaculum.]
[Illustration: FIG. 51.--Sutures introduced in both sulci.]
In the denudation no skin is sacrificed. The denudation is not carried
below the line of junction of vaginal mucous membrane with skin.
Each sulcus is closed by sutures separately, as in the immediate
operation. The first suture is passed across the upper angle _b_.
[Illustration: FIG. 52.--Method of securing sutures with perforated
shot.]
[Illustration: FIG. 53.--Both sulci are closed. The support of the
perineum is restored. The posterior wall of the vagina is brought
forward. The rectocele is cured.]
The second suture is introduced about an eighth of an inch from the
edge of the mucous membrane on the left vaginal wall, is passed
backward, downward, and outward so as to grasp retracted muscular
fibers, and is made to emerge at the bottom of the sulcus. It is then
re-introduced and passed forward between the mucous membrane of the
rectum and the denuded surface, and somewhat upward, to emerge on
the edge of the mucous membrane of the rectocele. A third and, if
necessary, a fourth suture are passed in a similar manner. Similar
sutures are then passed to close the right-hand sulcus.
[Illustration: FIG. 54.--Sutures for closing the superficial perineum
and fourchette. The anterior suture is called the “crown suture.”]
[Illustration: FIG. 55.--Emmet’s operation of perineorrhaphy completed.
Compare this figure with that representing the condition of the parts
before operation (Fig. 45).]
The sutures thus far introduced are sufficient to close the sulci, and
therefore to restore the supporting structures of the perineum. The
remaining sutures are merely to close the skin-perineum. The first of
these sutures is called the crown suture. The needle is introduced
on the cutaneous aspect of the perineum, at the anterior end of the
lateral denudation. It passes outside of the denuded area, and emerges
within the denuded area, at the edge of the mucous membrane of the
vaginal wall, immediately below the last suture of the sulcus. It
is then passed so as to transfix the rectocele beneath the mucous
membrane, and across the lateral denudation on the other side. When
this suture is shotted the fourchette is restored. A second suture
behind the crown suture is usually necessary to complete the closure of
the skin-perineum.
The sutures in the sulci are shotted first, then the external sutures
are shotted.
The second and third varieties of perineal injury are sometimes found
associated in women who have borne more than one child, the injuries
having in all probability occurred at different labors. In such a case
the sulci should be denuded and closed as already described, and then
the skin-perineum and the sphincter ani should be repaired.
=Subcutaneous Laceration of the Muscles and Fascia.=--The fourth
variety of injury to the perineum--subcutaneous laceration of the
muscles and fascia--is not uncommon. The structures which compose the
pelvic floor are of different degrees of elasticity, and sometimes the
mucous membrane and skin at the vaginal outlet will stretch, and not
rupture, before the advancing head of the child, while the underlying
structures--the muscles and fascia--may give way. Therefore the injury
is said to be a subcutaneous laceration. The sphincter ani is never
involved in this form of injury. The injury always takes place in the
direction of the vaginal sulci, and the supporting muscles of the
pelvic floor and the planes of fascia are the structures which are
torn. The disability is exactly the same as in the third variety of
perineal tear, with the absence of laceration of mucous membrane and
skin.
It is not to be expected that this injury will be positively recognized
at the time of labor, and therefore the immediate operation cannot be
applied to it. The condition is often described as relaxation of the
perineum. The disabilities following this injury, and the tests by
which it may be recognized, are identical with those already described
under old lacerations in the sulci. The treatment is also the same.
The vaginal sulci must be denuded as though the mucous membrane had in
reality been torn, and the sutures must be introduced in such a way as
to bring back the muscles and the fascia to the former attachments.