VAGINO-PERINEAL INJURIES.
Surgery of the of the perineum may be described as a split ting of the perineal body, which latter directly or indirectly supports the blad der, rectum, uterus, and the intestines. Various degrees of laceration are de scribed which may be classed under the heads: "Complete" and "Partial Rupt ure." These include the following de grees of destruction:— Superficial rupture of the fourchette and perineum, not involving the sphinc ters.
Rupture to the sphincter ani.
Rupture through the sphincter ani.
Rupture through the sphincter ani and involving the recto-vaginal septum.
Not infrequently subcutaneous rupture of the muscular tissue and fascim of the perineum takes place, leaving the skin and mucous membrane intact. These latter are called concealed ruptures, and are followed, as in the other forms, by relaxation of the pelvic floor and loss of perineal support.
Symptoms.—The symptoms of perineal rupture are at first a feeling of weakness and dragging down of the pelvic viscera, and later the prolapse of the various or gans resulting, when the rupture is par tial, in subinvolution of the vagina; prolapse of the vagina, with cystocele or rectocele; and prolapse of the uterus. When the rupture is complete, to these may be added incontinence of faeces and intestinal gases and prolapse of the rec tum. As an exception, the patient may suffer but little even when the two pas sages are laid into one; but generally the patient's condition is a sad one. Recal matter and gases pass without control, and the pelvic organs tend so strongly to descend that exercise, muscular efforts, or tenesmus produce a sense of weariness, pain throughout the pelvis, and traction upon the broad ligaments.
Diagnosis,—The diagnosis of this con dition is made by inspection.
Etiology.—The most common cause of laceration of the perineum is parturition through rapid delivery with forceps, un usually large head, or one persisting in the occipito-posterior position; less fre quently through some accidental injury, as the passage of large tumors, a fall upon a sharp object, etc.
Pathology.—In partial perineal rupt ures there is the exposure of a more or less extensive raw surface, richly supplied with blood- and lymph- vessels, and in close proximity to the intrapelvic and in guinal chains of lymphatic glands. This raw surface is, as a rule, indisposed to heal by first intention and over its sur face for two or three weeks there is an uninterrupted flow of a foetid, semi putrid, irritating fluid consisting of dis integrated muscular tissue, decaying and flaking decidua, disorganized blood, and muco-pus. In complete perincal rupture the presence of fecal matter and intes tinal gases are added. Rupture of the
perineum in the puerperal state may lead to septicmmia, anterior or posterior dis placement or prolapse of the uterus, cys tocele, rectocele, uterine engorgement and hyperplasia, subinvolution of uterus and vagina, loss of power of uterine liga ments, development of a tendency to abortion, an impairment of sexual grati fication to the male, and neuralgia affect ing the site of the rupture.
Prognosis.—When the rupture is in complete and of slight extent and only a small portion of the perineal body is in volved, symptoms may be lacking and no evil follow. In first labors laceration of this kind and extent is the rule, and not the exception, and interference is not necessary. The first and second degrees of laceration mentioned above are often without evil consequences, and may be unknown to patient or physician unless through careful inspection; this is not the rule, but the exception. The third degree is always a grave accident. The fourth degree is the most serious form. The more serious the laceration, the less chance there is of spontaneous recovery and the more probable the complica tions and evil results before mentioned. Proper repair of the rupture is always productive of great gain to the patient.
Treatment.—Every perineal laceration should be closed by suture immediately after the expulsion of the placenta when ever the rent seems large enough to de mand repair, for the purpose of securing primary union, if possible. Rare excep tions to this rule might be made in cases of extreme exhaustion or where there is no chance of immediate union on account of the bruised condition of the parts. The worst cases of laceration usually fol low instrumental or manual delivery, and may be discovered while the patient is yet profoundly anesthetized. The cir cumstances are propitious for an imme diate operation, which, if successful, will save the patient much suffering, while failure will not make her condition worse. The obstetrical bag should always contain needles and sutures for this operation. T. Gaillard Thomas notes three factors which may tend to defeat the success of immediate operation: hasty operation; entrance of the lochial discharge into the wound; failure to close the upper portion of the perineal body, leaving a pouch for the accumulation of putrefying materials and leaving the anterior vaginal wall and bladder without support.
If failure of primary operation ensue, a second operation should not be done be fore the results of parturition have disap peared,—say, not less than two months.