(Fig. 27); the scissors are placed with the blades parallel to the surface to be denuded, and the strip is cut away

LENTZ & SONS

FIG. 27.-Tissue-forceps.

evenly, in one piece if possible. A similar contiguous strip is removed, and so on until the necessary surface is

FIG. 28.-Sponge-holder.

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.

FIG. 29.-Emmet's perineal needle.

The needle may be held in any kind. of needle-holder preferred. The Emmet needle-holder (Fig. 30) is very conve

nient.

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

G.TIEMANN & CO

G

FIG. 30.-Emmet's needle-holder.

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).

FIG. 31.-Perineal needle with silk carrier.

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

LENTZ&SONS

FIG. 32.-Shot-compressor.

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

FIG. 34.-Diagram representing the correct and the incorrect method of passing the suture for closure of slight perineal laceration.

passed directly through to the skin-margin on the oppo

FIG. 35. Recent slight median laceration of the perineum extending up the posterior vaginal wall: sutures introduced on the vaginal

and cutaneous aspects.

site 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