fairly well. Why did the ascites remain absent for such is, of course, excluded, except in the rarest instances, a long time following the three tappings? It is well- from surgical consideration. known that ascites sometimes disappears following the The union of the transversi, interdigitating with the reduction in size of an enlarged and congested liver ; but levator ani muscle, making the so-called perineal body, such can scarcely have been the case here, for the condi¬ with their connective tissue sheaths, is the more common tion was one of a markedly contracted liver. It is also part to suffer The lesion of these muscles may take after injury. known that adhesions occasionally place tap¬ be central or lateral, a factor of some importance to de¬ ping. The most probable explanation, therefore, is that termine before attempting restoration. the extensive adhesions which were found at the opera¬ The lack of the central due to such tion between the liver and abdominal support injury omentum, parietes, causes the transversi to contract toward their point of and which were of formed at evidently long standing, origin, resulting in a more or less marked patency of the the time of the first tappings, and the collateral circula¬ vulvar opening. Where the injury is within this limit, tion which resulted was sufficient to prevent the reac- the ani itself uninjured, is cumulation of the fluid for some time. If this ex¬ sphincter muscle, although in a measure disabled from the proper of be the case furnishes an excellent il¬ performance planation correct, its function no lustration benefits which be at by being longer supported anteriorly. of the might expected On this account the curve of the rectum is lost and times to Talma's under favorable con¬ follow operation the anal falls a saccation ditions. aperture posteriorly, inducing or forward of the rectum, resulting in a more The case also as does that of Mrs. E. C. pouching shows, S., or less marked rectocele. Pari the cervix is no most the passu, that, notwithstanding the extensive adhesions, longer held backward, and varying degrees of uterine time comes, sooner or later, when even a free collateral follow. insufficient to the of displacement circulation is prevent development When the lesion has the entire be¬ ascites the of the case to a fatal issue. destroyed septum and progress tween the and the laceration is called These cases also tend to confirm the statement of vagina rectum, Of the saccation of the rectum does the writer in the article above mentioned on this complete. course, subject not take place, and more commonly the uterus remains to the effect that the congestion of the portal radicles in its normal was not the sole cause of the but that the position. ascites, changes Since the dissections of Wm. undertaken to in the of a chronic nature Hunter, peritoneum inflammatory demonstrate the were its anatomy and the physiologic function instrumental in production, particularly during of the terminal The fact that the fluid taken from the reproductive organs during pregnancy, the most stage. valuable contribution to the of the abdomen was in the two cases, as shown proper understanding hypertonic the of the structures in the female are its effect on drawn blood cells from anatomy pelvic by crenating freshly those of Dr. of London. These the same patient, is another evidence of the inflamma¬ Henry Savage studies, tory character of the fluid. supplemented by the important teachings derived from In of the the study of frozen sections, greatly modify the previous conclusion, the writer is the opinion that of benefits to be derived from Talma's in alco¬ views the physiologic relationship of the pelvic or¬ operation The of the less than holic even under favorable are but gans. depth perineum is usually cirrhosis, conditions, described. The axis of the that of the temporary. (In 105 cases collected by Greenough, but anus, cutting 9 showed after two In order to vagina at nearly right angles, leaves in the external improvement years.) an flattened of tissue obtain the full benefit of the it should be per¬ angle irregular position rarely, operation, when examined on the more than one- formed at the first appearance of ascites or even to living subject, early, half an inch in thickness. In the woman this the ascites, if In cases nulliparous anticipate possible. showing is defined as a or of clearly firm portion of the pelvic floor, jaundice symptoms cholemia, cholecystostomy and is of elastic and connective tis¬ should be performed at the same time. composed skin, fat, sue, transverse muscles, sustaining fascia and the an¬ terior of the ani muscle. THE RESTORATION OF THE PERINEUM.* portion sphincter The side is concave and the rectal side HENRY vaginal usually O. MARCY, A.M., M.D., LL.D. convex, owing to the interblending of the ani. BOSTON. sphincter If the finger is carried just within the perineum proper, Recent publications show that, notwithstanding the and a little to one side, there can be felt the firm en¬ study of the subject by many of our best surgeons dur¬ circling band of the levator pubococcygeus, attached to ing the present generation, there is by no means a gen¬ each rami of the pubes above and descending to join with eral acceptation of any well-settled method for the re¬ the posterior fibers of the sphincter ani and the coccyx. pair of the injuries of the perineum. On this account In the perineum, posteriorly, this is firmly inter- I add this contribution, although I have several times blended on either side with the transverse perineal mus¬ published monographs on this subject. cles. These muscles are under the control of volition, As a primary premise, it may be accepted that the in considerable degree, and, acting conjointly, serve to repair of any injured organ should be undertaken to draw the vagina forward toward the pubes. restore as as it, far possible, to its original normal con¬ The parturient and fecal canals are in the dition. to it be supported In order accomplish this, must first as¬ pelvic basin in close cpposition, and the functional re¬ certained just what the normal condition has been. In lationship is often such that the one may encroach on other words, it must consist of an accurate knowledge the other, in a way so as to occupy nearly all the space of the anatomy and function of the component parts. accorded to both. This is especially true in parturition, The injuries to the perineal structures vary widely. when the rectal space is reduced to a thin, folded, flat¬ In the minor degree, the hymen, or the vaginal four¬ tened tube; and often in elderly women, with old peri¬ chette, may be the only part involved, but such lesion neal lacerations, the rectum becomes saccated, pushing * Read at the Fifty-fourth Annual Session of the American forward the posterior vaginal wall, forming a consider¬ Medical Association, in the Section on Obstetrics and Diseases of able-sized external tumor. The floor is so formed Women, and approved for publication by the Executive Committee : pelvic Drs. A. Palmer Dudley, H. P. Newman and J. H. Carstens. and blended about these openings that it not only sup-

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 ports these canals, but also materially aids them in their which, for union and support, can not be readily over¬ physiologic function. In intimate relation to both are estimated. the bladder and uterus in their ever-varying functional On the posterior wall of the vagina, in its lower third, is a activity, and each surrounded by delicate plexus of longitudinal muscular fibers are found external to the, nerves and vessels. circular layer, and these intimately blend with the The sacral prominence throws a large proportion of pubococcygeus, giving a firm support to the vaginal out¬ on the the abdominal weight symphysis pubis and the let, quite as the outer longitudinal fibers of the rectum recti muscles in the support of the body, and thus re¬ unite with the deep layers of the sphincter ani. The lieves the pelvic basin and takes off undue strain on the physiologic action of the muscles, thus grouped, serve pelvic floor. The rectum is rarely entirely empty, is to draw the rectum forward toward the pubic arch, circular in shape, serves the digestive apparatus, in a and this explains, in large degree, why the circular measure, as a constantly receiving reservoir, and, when fibers of the vagina, left free to act in other directions, not the as a distended, may be felt from vagina flattened are intrafolded laterally, making in cross section an tube curving posteriorly. It is suspended and sup¬ imperfect letter H, first pointed out by Freund in 1883. ported, so to speak hung, by the levator ani muscles The of the at to the which intrafolding vagina right angles hold the vagina in their encircling loops. On the vulvar outlet is very important in its relationship of contrary, the vagina, entirely unlike the earlier dia¬ support to the uterus and its appendages. grams, is flattened anteroposteriorly on itself, and, The surgical procedures which have been devised for normally, its walls are, when at rest, ever in close ap¬ the restoration of these structures are manifold, and position. many of them are in the highest degree ingenious, but The vagina joins with the vulva at right angles to its too, often confusing and unsatisfactory. lateral opening at the entrance of its passage through The study of their history is instructive and profitable, the pelvic floor. but the field is to me more tempting for review than it The vulvar organs are all intimately blended with is to the junior practitioner, since these various proce¬ and go to form a part of the perineum proper. On each dures have been elaborated, for the most part, within side of the vaginal orifice are the erector clitoridis, the the period of my surgical experience. I purpose, how¬ bulbocavernosus and the transversus perineii muscles, ever, to limit myself to those only which have a bearing and these with the levator ani make up, in large meas¬ on the methods which I have especially commended. ure, the pelvic floor. The bulbi vaginas and bartolinian My earlier masters, Marion Sims and Thomas A. glands are covered by these muscles with their erectile Emmet, most ingeniously devised scissors with various plexus of vessels and abundant distribution of lym¬ curves and dcxtrously used them to denude the pos¬ phatics and nerves. terior V-shaped portion of the vagina which was thought The erector clitoridis and bulbocavernosus muscles, advisable for coaptation. So exceedingly dextrous were with the transversus perineii, join on each side to con¬ these men that I have seen them pare back and forth stitute the ovate muscular vaginal orifice, and in their a narrow ribbon from this portion of the vagina, leaving conjointed action perform a very important physiologic the dainty piece unbroken. function in sexual congress, often underestimated or My late friend, Dr. Edward Jenks of Detroit, separ¬ ignored. Their impaired function frequently underlies ated this portion of the posterior wall of the vagina as certain reflexive nervous conditions, distinctly patho¬ a flap instead of denuding with the scissors and then cut logic, which are easily overlooked, but are the causes of it away and sutured as Sims and Emmet had done. Not much suffering and unhappiness. long prior to this I had begun the use of buried animal The much-discussed, so-called perineal body has, in sutures in a considerable variety of wounds, and it oc¬ my opinion, misled some of our prominent authors curred to me that, by adopting the method of Dr. Jenks, into false positions, and caused great confusion and I could preserve the flap thus separated and coapt the misunderstanding among physicians. deep structures by sutures buried beneath it. I have been criticised in emphasizing the muscular I soon found that the line of division was not the floor of the pelvis, and that I underestimate the im¬ mucous membrane from the vagina, as these authors had portance of the variously distributed connective tissue supposed, but the attenuated posterior vaginal muscle, fascia. This is not by any means my intention. often so thinned out as to be hardly recognizable. For The superficial perineal fascia, in its deep layer in the obvious reasons the posterior vaginal fascia holds the male, as well as in the female, covers and encloses the vagina loosely to the subjacent structures and the sep¬ transversus perinei muscles, forming strong ligament- aration is not difficult except when united by bands of ous transverse bands, uniting in the perineum, desig¬ cicatricial repair. By this division, it is not difficult to nated by Savage as ischio-perineal ligaments. The pubo- differentiate the levator loop and bring it with the ends coccygei, acting in unison with the other muscles of the of the separated transversi into easy inspection. A pelvic floor, draw forward and thus aid, not only in clos¬ further dissection externally on either side of the sphinc¬ ing the rectum, but in holding both it and the vagina in ter ani makes the wound of sufficient size for easy manip¬ the anterior curve, so important to be retained for the ulation. This permits the reconstruction of the perineal preservation of normal function. structures in a simple and easy manner. A horizontal section made through the floor, just With various unimportant modifications, this is the above the sphincter vaginas, and posterior to the junc¬ method which I have practiced and taught for more than tion of the transversus perinei, shows the deeper fibers a quarter of a century. of the pubococcygeus, united in a loop behind the lower Finding that the catgut sutures did not always hold border of the rectum, holding it from its fixed point at the parts in coaptation sufficiently long, I devised a the pubes, as in a sling. This loop is connected with lateral support by means of two or more disjointed pins, the transversus perinei, bulbocavernosus, erector clitori¬ which united after their introduction, held the parts in · dis, sphincter vaginœ and sphincter ani muscles by juxtaposition after the manner of an ordinary safety strong layers of connective tissue, the importance of pin. I had the good fortune to obtain tendon sutures

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 from the tail of the kangaroo which proved reliable and closed, the reconstruction being made so complete that rendered the use of fixation supports unnecessary. Since the vulvar opening is entirely restored, even to the this period I have used only chromicized tendon sutures reformation of the hymen if desired. with entire satisfaction. These have been, and may be, When the laceration has been so extensive as to in¬ applied in a variety of manners. clude the sphincter ani muscle and a portion of the rec¬ The first step in the operation is to dilate the tum we have quite another problem. sphincter. The index and middle fingers of the left The posterior vaginal wall is not thinned out as in hand are introduced into the rectum and retained there rectocele. Quite the contrary, the vaginal muscle is until the end of the operation. contracted, often the vagina thick-walled. The rectum The septum is made tense by the retained fingers and and vagina are separated quite as freely as in the in¬ a button-hole incision is made on the median line by complete form of the injury. This permits the recon¬ either knife or scissors. I prefer a double-edged, pointed struction of both rectum and vagina by separately re¬ knife. uniting them with continuous sutures, care being taken Through this opening I introduce a knife of special not to penetrate the bowel or vagina by inserting the design. I am sure additions to our armamentarium stitches from side to side from the dissected surfaces should not be made without good reason, but this in¬ only. The rectal suture must penetrate the connective strument adds materially to both ease and safety of dis¬ tissue of the bowel, here much thicker than in the free section. The cutting part is something the size and portion of the large intestine. The vaginal suture is shape of the little finger nail and is placed at an angle given to an assistant and held forward. The rectal with the handle, so that when pushed in a direct line suture is held by the weight of a pair of forceps. The the edge is at an angle of about forty-five degrees to the wound is now restored to conditions not unlike those part to be divided. The parts are made tense by the of the incomplete rupture when ready to introduce the fingers in the rectum and the knife is guided so that parallel double fixation sutures for the reunion of the neither rectum nor vagina is injured. The lateral transversi, and the operation is completed, as above de¬ dimpled depressions in the vagina mark the site of the scribed, only the separated retracted fibers of the sphinc¬ separated retracted transversi. Even with a sharp knife ter ani muscle must be freed and sutured. The short these are divided with some difficulty. Elsewhere the wound in the median line is closed by a light-running separation is easy and is often made almost entirely with buried suture, the wound dried and sealed with iodo- the fingers, dividing an occasional cicatricial band by form collodion. scissors. The Emmet scissors serve admirably for the IN RESUME. separation of the vagina from the vulva. The little lat¬ By free dissection and the use of buried absorbable eral fold of mucous membrane on either side shows the sutures, the parts are entirely restored to their former inception of the original lesion. To these points the normal anatomic condition and physiologic function. dissection is carried anteriorly. Thus the posterior third Aseptically maintained, the repair is rapid and painless. or more of the vagina is separated from its attachments The urine should be drawn for the first days. The quite to the crest of the rectocele. bowel is never allowed to become distended with hard This flap is held anteriorly by an assistant. A large fecal masses. In complete laceration, a large rectal tube curved needle, firmly set in a handle, with the eye near of soft pure rubber should be used. the point, carries the suture. The fingers in the rectum RESULTS. aid in the needle. It is carried materially guiding I have within a few seen a on whom I the left side the transversus and days lady oper¬ through penetrating ated the as levator and thirty years ago by methods above outlined. unthreaded withdrawn. Rethreaded, the I since have several hundred times. needle is made to above the operated penetrate just vaginal junc¬ a surgeon, the tion with the rectum and then is carried the Recently visiting seeing operation, through asked our matron: "How a of Dr. unthreaded and withdrawn. This large percentage right transversus, cases have failed of results ?" She looked makes the border of the stitch. The suture Marcy's good upper upper but : "I do not know of a case." is as¬ surprised, replied single centered at this point of fixation and held by an "How have been in of the sistant. The suture is carried the needle long you charge hospital?" again by "Over sixteen So an to the first introduction—about one-third of an years." seeming unimportant parallel has it become with us that a careful statis¬ inch below rethreaded with the operation it; unthreaded, oppo¬ tical table could be made an amount of research site end and withdrawn. This makes a double stitch only by work not deemed necessary, but I am sure the of like that of the the needle as car¬ reply exactly cobbler, serving our matron is essentially correct. rier of the suture from opposite sides. In this way three stitches are usually taken. When drawn on mod¬ DISCUSSION. erately tight, the widely separated structures are evenly Dr. A. H. Goelet, New York—I doubt whether the deep coapted on the median line and are held in fixation. through-and-through suture would succeed in the hands of all who should this The is that it The tissues are united a continu¬ attempt operation. objection remaining by light, constricts the parts, cuts off the circulation and nutrition and ous best effected a rather running suture, by large-sized, often results in failure. I have tried on the full-curved The end every operation Hagedorn needle. distal is fixed by perineum, except the Tait flap-splitting operation, which I do a loop knot and the needle, carried deeply from side not approve, and have abandoned them all for the Hegar- to side, places the suture at right angles to the long Martin operation in which the denuded surfaces are united by axis of the wound. Where drawn on, the tissues are means of buried layer sutures of chromicized catgut. That has evenly coapted in the median line, with no suture ma¬ given me far better results than any other operation on the and I never a terial in the line of union save where it crosses at a right perineum now have failure. It seems to me a to it. valuable point to avoid as much as possible handling the de¬ angle nuded and instead of to I have called this stitch the suture, since the area, sponging keep a continuous parallel stream of normal salt solution playing on the wound to keep needle is inserted parallel to the long axis of the wound. the field clean. This will aid materially in securing primary In this way the entire wound is easily and rapidly wound healing.

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 Dr. F. . Dunsmoor, Minneapolis, Minn.—One of the es¬ indication. Those who talk of the operation of exposing the sential things brought out in the paper is that the reason for muscle where it is torn, Reed, Harris and others, claim that so many failures in repair of the perineum is that the sutures Emmet's operation will not do what he claims for it. If the are not introduced properly; not that they fail to close up the denudation is properly made all the separated fibers of the denudation, but the result is not what we should wish it to be. muscle are exposed, and if the stitches are properly applied If we are to get any real benefit from this operation in the all the parts must be brought into apposition. If you pass vagina we must increase the depth of the vagina from the vulva the suture downward from the very apex of the denudation to the region of the cervix, and narrow it from side to side, and bring it down into the muscle, you catch the principal thus tightening up the relaxed walls. This can be done fibers of the muscle, and passing it down, the lower fibers are whether the freshening is made by the flap-splitting method or caught, thus bringing all the fibers in apposition. There is no by any other plan, but it is extremely important that the operation that can improve on the Emmet method if it is sutures are passed horizontally and are not to be introduced learned from Emmet or his students. Dr. Marcy's operation then carried an near from the margin of the vulva, to apex is the first of what are termed modern operations and he is the emergence of the cervix, returning by a corresponding entitled to credit for having formulated a method of intro¬ oblique line to a point opposite that starting. In the latter ducing a buried absorbable suture that fixes the parts and ease, when we tighten the sutures, we bring the upper part of keeps them fixed without strangulation. Dr. Graham has the the is widened vagina down toward the lower, and vagina introduced a very practical point, the idea that the first stitch and shortened. As time goes on the posterior wall relaxes usually throws the apex of the rectocele high up where it more and more, forming a rectocele. There is a way of over¬ should be after the method of Andrews of Chicago. the made Dr. Goelet. If we introduce the coming objection by Dr. A. H. Goelet, New York—I overlooked a point in sutures in two one-third of an inch inside my layers, beginning previous remarks which is very important in obtaining prim¬ the of the denuded wall on the side and margin right depress ary wound healing, and that is to keep the wound dry. Many the middle of the denuded emerge for half an inch, septum, practitioners who are compelled to do this operation are and then up the side, to within one-third of an pick opposite obliged to practice without the aid of a nurse and who must inch of left every one-third we will margin, repeating inch, care for the patient after the operation, can avoid the make all the down a backbone or thick Then necessity way septum. of coming back a number of times a to catheterize. I have while the second of the needle in day passing layer sutures, pass had made a rubber shield which has a little the to the perineal tongue first instance horizontally across accurately adjust that is inserted into the vagina and catches under the urethra wound Next the new made the first margin. through body by a for the urine. It is with adhesive tier of sutures and include fascia and muscles of forming gutter strapped supporting plaster to the so that when the urinates the each side. Alternate these two of sutures until the vulva thighs, patient styles urine passes down the gutter into a bedpan beneath without is reached. The circulation is not cut off. Further, we a get soiling the perineum. The perineal wound can then be dressed more then any other method, lengthened perineal body by with gauze beneath this shield and can be kept dry just as and a for the rectum, thus the rectocele support correcting any other wound. This shield is. not, of course, and the of fecal matter from the necessary assisting expulsion rectum; when the services of a skilled nurse is but it adds the from side to side and its obtainable, narrowing vagina increasing greatly to the comfort of the patient if repeated introduction Th:s on the should have for its ob¬ depth. operation perineum of the catheter can be and I it to of the of the avoided, regard important ject the restoration normal supports perineal prevent contamination of the wound by the urine. and it in a definite Dr. body holding up position. Marcy's Dr. Walter B. St. Louis—I to word de¬ method of the divided muscles at Dorsett, object the reuniting by suturing right nudation. It little. when we of angles to axis of vagina accomplishes the desired result. implies very Usually speak denudation we mean that we take off the mucous membrane. Dr. A. M. Ind.—I have made it a Hayden, Evansville, point If we are going to make a perineum that is going to be of any to the without I de¬ absolutely coaptate parts any wrinkling. service, whether for rectocele or simply for a relaxed outlet, nude and take out the as much as I want so as not to flaps we have in the first place a stretching of the mucous membrane, narrow the caliber of the and then use or vagina, interrupted together with a stretching of the vagina, a stretching of the continued sutures, at the lower border and catgut commencing circular muscle fibers of the vagina; therefore, in order to re¬ them in back and forth. After I the muscle all putting get pair that properly we must do something more than a simple I suture the mucous membrane from coapted nicely, vaginal denudation; we must take out sections from the vagina. I the down to the skin without the muscle upper part catching commence on one side and cut deeply until I get beneath the at all. The skin of the I suture in the same perineum way vagina, then I take hold of it with a pair of forceps, pass my with sutures. I use two or three of sutures superficial layers fingers up and dissect the vagina from the rectum. Then I to all the and them coaptate parts bring together nicely. begin at the upper angle and introduce the sutures. (Dr. Dr. Hannah have used a method Graham, Indianapolis—I Dorsett illustrated his technic. ) When I draw on the upper of the for the last four but have not repairing perineum years, suture I lift up the whole perineal body. If we simply de¬ it. I insert a tenaculum on each side and published Kelley nude, as I have seen many surgeons do, we fold the con¬ the scissors cut across. I into the with straight slip the finger nective tissue together, and if we get any union at all it is with I make sort of bib- rectum and an ordinary scalpel a only by slight adhesions, and it is of absolutely no benefit. of down and a shaped denudation. Instead cutting making The operation I do is essentially that giv^n us by Emmet. I denude Then I Y-shaped denudation, perfectly straight. pull Dr. J. H. Carstens, Detroit—Concerning the denuded sur¬ down the center of the denuded area point the upper edge of face, what is there in the first place ? A ruptured perineum, to about the site of the fossa navicularis, where I unite it on torn fascia everywhere and a muscle that is torn completely each side with a continuous suture, after having united catgut through. If there is an Emmet suture put in, I do not care the of the transversus with a buried suture. I edges perinei which way it is on drawn it up. have used this method in cases of uterus and it has pulled, being together puckers prolapsed One can not do anything different with a large suture. One held the uterus up very well. The perineum does not stretch can not get the parts accurately together. (Dr. Carstens then out as I have seen it do with other methods, and I have ex¬ illustrated his method on the blackboard.) I put in thirty or amined patients who have had as strong a perineum after four stitches and build up a that is as near like the years' as after the work. forty perineum standing immediately original perineum as I can make it. Ideal surgery is to use R. H. Pa.—If Dr. stitch is Dr. Gibbons, Scranton, Marcy's the buried suture, and not the big en masse suture, which is a and fixed it can not cause of the properly introduced choking catch-as-catch-can suture. If you hit it, all right; if not, then muscular structures or vessels; nothing but good can happen. you don't. I tried it on many occasions and it was the fault of the ab- Dr. A. Palmer Dudley, New York—What is the pelvic floor ? sorbable material that 1 gave it up and also because I went The levator ani muscle; the transverse perineal muscle from back to my first love, Dr. Emmet's method. I can do this the ramus around to coccyx and to anus. What is split? The operation better than any other and I believe it meets every perineum. What is the perineum? The two halves of the

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 have a levator ani muscle. You get them together to returned of puckering up the loose tissues by merely empirical sphincter action. I am going to reverse the order of operation methods, and have not searched intelligently for the on the perineum entirely. The muscle is surrounding the anatomic of the wall and sutured them it is If make Emmet's operation supports directly vagina; ruptured. you to each other. If the is ever to be on a where is the fixed point, and from where are you drawing operation put the in must an in¬ tissue? You are drawing movable vaginal tissue. If you will rational basis, first step the process be do a proper operation you must denude and use some suture quiry into the anatomy of the anterior vaginal wall; which will unite the muscle end to end and not to cellular tis¬ and to state the results of such an inquiry is the first sue or mucous tissue. (Dr. Dudley demonstrated his points purpose of this paper. on the blackboard.) The structure usually spoken of as the anterior Dr. H. O. Marcy—The premises I took at the opening are vaginal wall is really two structures and is composed of verified. There is as yet an entirely unsettled idea as to what the wall of the blad¬ should do in of the Two or three loose, elastic, non-resis.tant posterior we restoration perineum. der in combination with the sheet of muscular should be settled on here and and the discussion strong things now, tissue which true aids in elucidating this matter. I omitted much in the reading and connective forms the anterior but which be here called for distinc¬ of my paper in order to save time. The whole idea is that we vaginal wall, may must reunite the ruptured muscles in the median line, where tion the vaginal plate of the anterior wall. The vaginal the interdigitation of the transversi with the levatores make plate is but loosely attached to the bladder, is normally the so-called perineal body. How this can best be effected is firm, non-distensible, and strongly fastened to support¬ the problem. That which I claim to be of advantage is, that in ing tissues on all sides. It is attached at its lower end to dissecting up the posterior two-thirds of the vagina we are the tissues behind the bone. At its and structures. Into immediately pubic up¬ enabled to reach reunite the separated per end it is inserted its central into the cervix the vulvar thus restored, we suture the thinned-out by portion opening, which is of more its lateral corners into muscle sheath, much as the tailor the sleeve into the and, moment, by vaginal the masses of connective tissue and arm hole of a coat. In this reconstruction, all the tissues are important unstriped muscular fiber which the lower utilized. Nothing is dissected away. The process of restoring extend through portions the and uterosacral to the soft parts is simple and easy. The operation is really of broad ligaments find their at¬ done in half the time I am discussing it. Dr. Goelet's criticism tachments in this vaginal plate and in the supravaginal is well taken if too much force is applied in the constriction cervix. By its lateral edges throughout it is attached of the sutures. Retention at rest of the reconstructed tissues to the pubococcygeal and the allied group of transverse without constriction is of vital importance in the application muscles which here find their only insertion into the of all buried sutures. Continuous suturing is safer than inter¬ vagina. To recapitulate: In the normal state these the force must act on rupted stitches, since equally every strong supporting structures are inserted into the four stitch. The wound must be protected from the urine. With of the sheet of muscular and connective the assistance of trained nurses I have operated on several edges strong tissue which we know as the anterior and hundred cases without a single failure. vaginal wall, are by it bound together into a firm floor which supports the bladder, the whole being in its turn reinforced, but THE REPAIR OF CYSTOCELE only reinforced, by the support of the posterior vaginal BY UTILIZATION 0E THE ANATOMICALLY FIXED POINTS wall below it. IN THE ANTERIOR VAGINAL WALL.* This being the normal anatomy of the anterior vaginal E. REYNOLDS, M.D. wall, we should next inquire into the anatomic condi¬ BOSTON. tions which prevail in cystocele, and this is perhaps best A I read before the American reached by considering the conditions which are found year ago Gynecological and at the close of labor. Association a on this same forth during paper subject, setting It must be remembered that the wall what I believed to be somewhat new and important posterior vaginal in the of in this present is mainly, and the anterior wall is wholly, supported by points repair cystocele. My object structures from the anterior half of the paper is to restate the facts and conclusions then brought springing pelvic forward, with the developments which have been ob¬ bones, hence it happens that while the walls themselves are labor to almost tained in another year of work, and supported by the exposed during equal distending the of the anterior wall are ultimate results of the cases then reported. forces, supports subjected to but little and even be relaxed its forward We hear nothing nowadays of new methods of opera¬ strain, may by tion in the of the lacerated and for several distension during labor, while the supports of the pos¬ repair cervix, terior are to strain have heard of new methods in the wall subjected great during its back¬ years nothing repair ward in the of the These are and downward distension, and concluding perineum. operations satisfactory. of labor the wall and its The anatomic on which were founded stage posterior attachments principles they receive almost the whole strain of the head. are well worked out, and there is little more to say about advancing them, hence the silence. The third great plastic—the The result is that the distended posterior wall is ex¬ for the of on very posed to laceration, while the anterior wall, though always operation repair cystocele—stands is the different New are still proposed distended, seldom lacerated. At conclusion of labor, ground. operations attachments almost as as in the early days of plastic then, the of the anterior wall are intact, frequently is and we should most of us agree at once that but the wall itself between the attachments greatly dis¬ operating, tended and therefore forward and downward no one of all these many and no group of sags under operations influence of is operations has overcome the others and become accepted. the gravity. The natural result that I believe that this uncertainty and unsatisfactory state when the support of the posterior wall has been lost the of the cystocele operation has been due to our failure vaginal plate often fails to recontract during involution, to comprehend until recently the anatomic conditions, loses resiliency, and no longer supports the bladder, its are still inserted into the intact an observance of which must necessarily underlie all suc¬ though edges sup¬ structures. This the of cessful repair, i. e., I believe we have been in the habit porting is, then, anatomy cysto¬ cele, and the condition is, in effect, a hernia of the * Read at the Fifty-fourth Annual Session of the American Medical Association, in the Section on Obstetrics and Diseases of bladder through the foramen formed by the attachments Women, and approved for publication by the Executive Committee : Drs. A. Palmer Dudley, H. P. Newman and J. H. Carstens. of the anterior vaginal wall, carrying before it as its

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