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. [Illustration: FIG. 45.--An old laceration of the perineum in both sulci. Rectocele. The mouth of the vagina is held open to show the appearance of the parts before operation: _a_, apex of the rectocele.] 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. [Illustration: FIG. 46.--The rectocele is seized with the tenaculum at _a_, and is drawn to the right, exposing the left vaginal sulcus, _a_, _b_, _c_, which must be denuded. The point _b_ should be secured with a tenaculum before denuding.] [Illustration: FIG. 47.--Method of denuding the sulcus.] _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. [Illustration: FIG. 48.--The left sulcus denuded.] [Illustration: FIG. 49.--Both sulci denuded.]