The sutures thus far introduced are sufficient to close the sulci, and therefore to restore the supporting structures of the perineum. The remaining sutures are merely to close the skin-perineum. The first of these sutures is called the crown suture. The needle is introduced on the cutaneous aspect of the perineum, at the anterior end of the lateral denudation. It passes outside of the denuded area, and emerges within the denuded area, at the edge of the mucous membrane of the vaginal wall, immediately below the last suture of the 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 perineum--subcutaneous 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. [Illustration: FIG. 56.--Rectocele and cystocele.]