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.