The immediate sequeke of laceration of the perineum are in general more serious than they are thought to be. Rarely is there profuse hem orrhage. Hildebrandt relates a personal case where there was profuse venous hemorrhage, and I once saw in a case of complete rupture a fairly profuse hemorrhage from spouting artery, which required a deep suture. Every tear bodes ill to the puerpera during the lying•in period. I have seen high fever in puerperte with lacerated perinea, as was to be expected, since the rents are bathed by the lochia. The more the perineum and the vagina are bruised during labor, the greater the liability to gangrene, which may result in general sepsis. Frl. Vogtlin found in Winckel's service at Dresden that 68.5 per cent. of puerpera with lacerations had ex udations during the puerperium. Hildebrandt relates instances where the gangrenous perineum was the starting-point of pyemia. Too many and too tightly tied sutures may also lead to gangrene from interference with the blood supply and the nutrition of the parts.
If then it be granted that the course of the puerperium may be dis turbed by the presence of these lacerations, then should every rent be re paired and every injury in the vestibule carefully watched. If the first part of the puerperal period has passed by, and the laceration is granu lating or has cicatrized, then the danger of infection has passed, but the secondary symptoms supervene. As long as the cicatrix lasts many women complain of burning and pain on micturition, as well as in sitting, standing, and walking. In general, the vast majority of women with a, cicatrized perineal rent, provided it be not extensive enough to cause in continence of faeces, complain of nothing beyond the above-mentioned symptoms. Yet it may be the source of painful sensations, even as we see result from the cicatrix following the incisions made to prevent lacer ations of the perineum. At this site there may be present a burning sen sation or an itching, calling for scratching or slight scalding on micturi tion. The lack of closure of the rims, vulva3 is noticeable after the lapse of some time in all women. The patients complain of dragging sensa tions, and there exists hypersecretion from the vagina. On inspection we find the rims pudendi gaping posteriorly, and the anterior vaginal wall sags a trifle.
In case of complete rupture these symptoms are much intensified, and added to them is incontinence of faces. Except in the extreme degree, there is ability to retain solid fwees, but loose passages and flatus are not under control. This circumstance renders most women very despondent, although there are some who do not mind it, either women very much afraid. of an operation or else filthy in their habits. When, however,
there is superadded incontinence of urine the conditions are scarcely bear able. This incontinence results possibly from a paralysis of the sphincter vesicse, the outcome of long and great pressure during labor. That it is due to rupture of the constrictor cunni, as is claimed by Hildebrandt, I do not consider probable.
The great proportion of women with lacerated perinea are in a state of mental depression. To use Dieffenbach's expression, " Women with la cerated perineums are ashamed of themselves even as are women who have been castrated." It is more likely that this depression is the reflex result from the tenderness of the parts and the impossibility of keeping them clean. It is likely too that in certain cases, as Dieffenbach has sug gested, it is due to loss of sexual appetite.
In case the rent has healed, then the triangular surfaces we have spoken of in case of the recent rent have spread apart and become covered with epithelium. The spreading apart is the work of the transversus perinei. The mucous membrane of the anterior rectal wall is drawn downward, that of the posterior is seen often between the cicatrized borders red as a strawberry. The sub-involuted vagina and the rectocele hang down over the cicatrized parts. The anterior vaginal wall loses its support and hangs down into the introitus.
Although such prolapse of the vaginal walls may follow on laceration of the perineum, in previously healthy women it is not necessarily accom panied by descent of the uterus, particularly if the women are stout or not obliged to work hard. IIegar and others think that too much stress has been laid on the likelihood of laceration of the perineum causing de scensus uteri.
Lacerations of the perineum only exceptionally heal spontaneously during the lying-in period, and then only those of the first degree where the injury to the muscular layer has not been extensive. During the heal ing process the bottom of the wound fills up with granulations and there union begins. The non-united rent gapes apart during the puerperium, and at the end of six weeks seems much more extensive than it did at the outset. Central ruptures with intact commissure usually heal by second intention, because the apices of the rent are in contact and during the process of involution the granulations are close together. Complete lacer ations with rupture of sphincter ani have no tendency towards spontane ous union or only fill up partially with granulations. A single example of spontaneous union has been recorded by Pen, but Lamotte states that thirty years later he saw the same woman with a ruptured perineum.