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.

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.

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.

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).

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.

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.

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).

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.

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.

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).

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 ?j, 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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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.