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 perineumsubcutaneous 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.

CHAPTER VII.

RESULTS OF LACERATION OF THE PERINEUM.

Rectocele. A rectocele (Fig. 56) is the tumor formed by the protrusion of the lower part of the posterior vaginal wall into the vagina or through the ostium vaginæ. The condition is due to a prolapse of the posterior vaginal wall, and is caused by the loss of the support of the perineum, usually the result of laceration at childbirth. Sometimes the mucous membrane of the vagina alone prolapses, the anterior wall of the rectum remaining in place. Usually, however, the anterior rectal wall and the posterior vaginal wall protrude together. If the rectocele is not so extensive as to protrude through the ostium, the woman may be unaware of its existence. In many cases, however, the prolapsing vaginal wall protrudes at the vulvar cleft when the woman is erect, or when she strains at stool or performs work requiring heavy lifting. The woman often says that under such circumstances the "womb" protrudes. On account of the accompanying prolapse of the anterior rectal wall the passage of feces does not take place in the normal direction, but the fecal mass is forced

into the pouch of the anterior wall of the rectum, and straining efforts push it forward into the vagina. The woman says she feels as though the passages were about to take place through the vagina. This discomfort is relieved by pressing the rectocele back with the finger

FIG. 57.-Median sagittal section of the pelvis of a woman in whom there has been a laceration of the perineum in the sulci, with rectocele and cystocele. The vagina is no longer a closed slit.

during defecation. Accumulation of feces in the rectal pouch may result in inflammation or ulceration. The condition is readily recognized by introducing a finger into the rectum, when it will be found to enter the rectocele.

A rectocele is cured by Emmet's operation, which restores the support of the perineum and the posterior wall of the vagina.

Cystocele.-A cystocele is a tumor formed by the pro

trusion of the lower part of the anterior vaginal wall into the vagina or through the ostium (Fig. 56). The prolapse of the vaginal wall is accompanied by prolapse of the posterior wall of the bladder. A sound introduced into the bladder through the urethra will be found to enter the cystocele. This test, and the soft, reducible character of the cystocele tumor, enable us to diagnosticate between cystocele and cyst of the anterior vaginal wall. The condition is caused by a loss of the support of the anterior vaginal wall that is furnished by the posterior wall and the perineum.

In a case of cystocele residual urine often remains in the pouch of the bladder-wall. In some cases the woman learns that, in order to empty the bladder, it is necessary for her to push the cystocele upward and forward at every act of micturition. The result of this inability to empty the bladder is decomposition of the urine and resulting cystitis.

Many cases of so-called irritable bladder and chronic. cystitis are caused primarily by laceration of the perineum, which produces cystocele or prolapse of the posterior wall of the bladder; and such cases can be cured. only by curing the cystocele.

A cystocele varies much in size. Every long-standing case of laceration of the perineum in the sulci presents a certain degree of prolapse of the anterior vaginal wall. The tumor may remain within the vagina and be rendered prominent only upon efforts at straining, or it may protrude through the vulva as a mass the size of a duck's egg.

As a cystocele is caused by laceration of the perineum, it can be cured only by repair of this laceration. The most important part of the treatment, therefore, is perineorrhaphy, which should always be performed. Usually this operation is sufficient. If the anterior wall of the vagina is supported, the tissues will recover their tonicity and contract, and the tumor will disappear.

In some cases, however, where the mucous membrane