COLPOPERINEORRHAPHY ANDTHESTRUCTURES INVOLVED

TH E V AG IN AAN D PER IN E UM AND H0 \V TO M END T H EM

BYRONROBIN N B . D. SO S M. ,

H I C G O I L L . C A ,

” Ath r of P rac t i c a l I n te st i n a l S u e r m r s i u o g y , a n d a k n ne co lo r L Gy gy , ” “ i fe- S i z e C ha rt f the S m athe t i c e ve T he Pe ri L p y p N r , i ts H i s to lo n s gy a d t i o lo gy . h Ad o m i r T e b n a l B a i n a n d A uto m a t i c V i sce ra l G a n i l . g a e tc .

P rofessor i n C h i c ago Post- G rad ua te S c hoo l of Gy ne co lo gy a n d A b d o m i n al S u rge ry ; P rofessor o f Gy n ecolo gy a n d A b d o m i n a l S u rge ry i n the a rve M ed i cal ol le e a n d i n the I l lln o ls H y C g , ’ M ed i ca l olle e n ecolo i st to S t . n tho n s C g , Gy g A y Hospi tal ; C o n sul t i n g S urgeo n to the M ary T ho m pso n Ho spi ta l fo r W m e n n i o a d C h ld re n .

C H I C AG O T H PUB I S HI N C O E CLINIC L fi .

1899. N R D A R E AT O F N R E I N E Y R 1 8 E T E E , C CO D I N G T o T H C CO G S S , T H EA 99,

B Y T HE PU B S OMP Y CLINIC LI HING C AN ,

I N T H E F F E B R R AT W H I N G ON . O I C E OF T H L I A R I A N O F C ON G ES S , A S T D ED ICATION .

Thi s m n a h e a ed for re se n tat n e f e o ogr p , pr p r p io b or my fe llows of the Am eric an M edic al Association

’ D e n v e r u n e 98 an d u li she d i n Tb e ou rn a l o ( , J , ) p b j f

' ' the Ameri ca n M edi a l ! Assorza tzon i s e s ec tfu ll , r p y d e d i cate d to the ° m ed i c al profe ssion with the hope that m la s su i cal re se a c hes an d e x er e n ce s y bor , rg r , p i as herein ou tlin ed wi ll b e of direc t i n te re st an d he lp to the m an d n d re c tl th u h the m to su ffe n i i y, ro g , ri g

n n e e hu m n i a d dy a ty. H E A R T UTHO . PUB LIS HER ’ S PREF AE C .

W e have taken gre at ple asure i n reprod u c i n g thi s book from the page s of Tb e j ourn a l of rice Ameri ca n

M ed ca l Assoc t on k r i i a i . L i e e ve ythin g that com e s

’ f m D r R n s n s i s f ro . obi o pen i t u ll of good thin gs an d e vid en ce s an am ou n t of labor that few are willi n g to

e to the w k t e u n e take t e e giv or h y d r o do . W th re fore he artily re com m e n d i t to e very physici an who thi n ks that he can or might b e he lped i n the tre at m e n t of the c lass of c ase s to c i t ef The whi h r ers. d rawi n gs for this profu sion of i llu stration we re m ad e

’ from life du ri n g the pro ce ss of the au thor s n u m e rou s

erat n s i n hi s e x ten si ve c li n c s an d are as tru e op io i ,

n h l fu l a i t i ss le f r su u a d e p s s po ib o c h c ts to b e .

The se wi t the fu ll an d c m le te te x t s u ld b e of , h o p , ho gre at he lp to those who have n o t re ached a perfe c tly sat sfac t te chn u e of the ow n an d m u st ce rta n l i ory iq ir , i y

f n l b e o i te re st to a l.

E L B L TH C INIC PU I S HING C o.

t n ! i S at C h c a o . io , g COLPOPEB INEORRHAPHY AND THE

STRUCTURES INVOLVED .

The structures involved i n the re of a defective u ro perineum are m scles and fascia . he operative cedut e consists I n denudation with coaptation or ap. s methods . Notwithstanding the succe sful Ior the varied surgical methods of i n eorrha by the anatomical basis 18 neither

e ec tl . nor p y understood It is probable, that the essential success lies In the reunion of the separated levator an i muscle by mean s of its fascia a superior and inferior with some other fasci , and also that thi s success has been chiefly due to deep sutur i n n t g. The object of this essay is to demo strate tha the chief factor In successful colpoperi n eorrhai by Is r ai d e fiiscia the resto ation by the de p sutures of the , i ll ec a a an d . mp y the levator ani fasci , superior inferior The muscles of the pelvic floor may be divided into two : a sr— oocc classes , the deep lay the levator ani y n a Ib s l — and pyriformis ; , th superficial ayer the

sversus b ulho- perinei , cavernosus and sphincter ’ am extem us. A peculiar characteristic of the muscles of the pelvic floor, and one which demands respect in colpoperi n eorrhaph is the extensive fascia! attach . o or The ments fone bot ends of the muscles . levator

- n v ani , the bulbo cavernosus and the tra s ersus perinei n i l have a fascia! attachmen t . We will co s der in detai the muscles and fascia involved i n oolpoperi n eor rha h n p y. The basis of this labor is a careful a atomic investigation with considerable clin ical an d surgical 6 Tan n ou n AND PKRINEUM;

THE LEVATOR ANI MUSCLE . The levator ani muscle is perhaps the most difi cult

‘ r r n an d . as rega ds its form , inse tio func sufi ci en tl tion . The origin of the muscle is y plain , and is considered established by an atomists . Few to at agree as exact insertion , even this late day , and

c n . opinions vary as to the exact fun tio , form and in M o sertion of this muscle . wn investigations demon strata that there is a oun dati on for these i op nions .

I . The insertion and origin of the levator ani vary as to the extent of distinct muscu lar loo which em r n u b ace the rectum and vagina, as to t e te dino s raphe (between muscle loops and distal ends also regarding the precise relation to the r l or v wall , whethe muscu ar connecti e tissue, as regards the exact relations to the muscle r M r ‘ of the lowe end of the rectal wall . oreove , its partial fascia! origin and insertion is sure to en dow the extremities with var ing appearances as to the length of the fascial or i n ous condi tions ; in other words the distance of the red muscular fibers from the extreme origin and insertion of the levator ani vary . Perhaps this variation i n insertion may be explained by considering the levator ani as a rudI men tary mus cle and to be disappearing with the tail . Its double ' fascial accompani ments complicate its 0 n and as i i o insertion , well as the nterpretat on of its n tion . 2 0 . The various inions as to the form of the levator ani are explained I) di fierences as regards s n crasi es i ndi vi u ls y of a , disturbances from and parturition , variation of the shape of the pelvis and fascial insertions and attachments . 3 f r . The dif e ent views as to the function of the levator ani lie in confusing its function with the la. e r v tor ani fascia , superior and inferior, in exagge ating its size and attributing to it function and uti lity be. H s ow TO mass T EM . 7

r longing to othe genital supports . It is especially erroneously inferred that a muscle will ac t as a con ti n uous tensi oni sed support for any viscus . The wledge of the levator ani muscle is u and diffic lt of access . Its dissection is far t i i s adjacent relations are compl cated . The mus cle does not resemble a fun nel with the r ectum of r to v a at the bottom or apex , but is more simila a m, a flat loop or a horseshoe, which does not pull ‘ u ward bu t the rectum or directly p , draws the two canals formand upward toward the pubic cord . The muscular loop of the levator ani muscle resem ’ bles a horse s collar encirclin g the rectum or the m vagina . In the fe ale it vigorously controls two canals—rectum and vagina—yet its control of the vagina d epends on that of the rectum . The rectum beI ng forced forward against the middle of the pos teri or - vaginal wall produces the H shape to the vagina . The excess of v al wall is compelled to fold at the r ci n l B sides odu g t e u ght columns of the . It is exce n t w very t in . In an fiz specimen hich I dissected from a good- sized woman the levator ani muscle is so h han d t in as to be really membranous,and the muscular between the vagina and rectum is bu t a few lin es in

l . thickness . It is real y a pelvic diaphragm l should to The musc e be considered as its origin , course and insertion . Ori i — ani : g n The levator muscle arises from bone , fro m the posterior surfac e of the pubis and i schial r spine ; or from fascia , a cus tendineus and vesico n n i ri o pubic ligame t . The bo y orig n is the poste r ub i surface of the i c bone and ischial sp ne . The larger portion 0 the levator ani of bony origi n arises from the posterior surface of the pubis . t begins about half an inch from the symphysis and one and

- l one ha f to two inches below the pubic crest . This point of origin is about two fingers wide or one and 8 THE vac ma AND resume s ;

- d o one half inches, and es not meet its fellow of the

- apposite side, one half to one em on . the posterior surface which is filled in by the obturator fascia

— - l o i n son 8cholor. i s cu t i s d n om em e e is . (R b ) Th raw fr a f al p lv by the a u thor an d i n ten ded to show the muscul ar fl oor of 0 v i th sci i ssecte d 0 8 . the e to a n i musc e a 2. i a fa a d l va r l : . w : i te i ne or o i in of the le to an i 8 8 the ob tur to i n te n us musc e wh l r g va r , a r r l e m l 5 the rifo mi e m the i nn e l a, 4 the coc g us usc e : 5 , p y r usc e : , c l r wal ys cru m H the o se-ehoe lco of the ev to an i musc e of e i s : , . p , p lv , a H h r l a r l ' - d n da r e r 8 the Y s e u e t 9. the i n cu t c ose to the raw : , hap d r hra : vag a , l e i c oor, whw e well d oes n ot fl e li ke the radI a l , 10: l l 11 the p lv fl ar _ l wal obtu to n erv es : 12 12 i n n e of a m s 13 ub i c c est : 14 i t, li k e ra r . r wall p l : , p r , loses 15 st sth umbe e te b . : , la ( ) l r v r ra

which is quite thick and stron in some a ct ra and membr nous in e . The which is applied inst t u the vagina and rect m , is often t e thickest part of o ns M 9 n w To ma THE .

muscle . The muscular bundles of the horseshoe loop join those of the opposite side of the levator ani pos teri or to the vagina and rectum without an i n terven I n i n g pcerineal tendon or raphe . some dissections it is absolutely plain that no tendinous raphe exists, while In others it can not be told . The smaller portion of the levator ani of bonyy c ri gi n is from the ischial spine immedi ately anterior to the i origin of the coccygeus muscle . uite a dist nct strip one- fourth to one- half inch wi e comes from the can ischial spine , and be plainly followed by the eye to the horseshoe loop . The li gamentous origin is from the anterior liga men t of the bladder (ligamentum puho- vesicule) and aren a o of from the tendin us (white line) . The fibers the levator ani which arise from the ligamentum puho vesi cale are of little practical i mportance . The white line extends in a slightly curved direction from the e posterior lat ral surface of the pubis, over the obtura n tor foramen to the spi e of the ischium . The anterior an d lies two and three - fourths inches below the ileo l e th pectineal in , with a len of about four inches . The White line (arcus tengIin eus ) is a part n m d tensio of the anterior true liga ent of the bla der, a an i thickening of the levator fascia superior . In the i fin e white l ne , the muscular fibers arise as tendinous n ds u ba , and may show their reddish muscular nat re n n Th at the white li e or a short dista ce from it . e muscle may shade into a flat ten dinous layer before it s xi m l reache the white line . The a tendon of the levator ani muscle varies muc as to its relations with W the hite line . It may arise below it as well as from W t it . The hite line may projec into the pelvis as a d e tendinous fol , and be ca ble of being separated from the origin of the muscl . The course of the fibers of the horseshoe loop of the levator an i muscle is backward and downward 10 THE vaoma AND PERINEUM ;

tw smaller to os in o fleshy bundles, the the side and p u n d s rface of the vagina, a the r to the side a or wall of the rectum . e

muscq fibers which rectum interweave with the muscu lar

la rge o n the i n feri or su rface f the pelvi c

oo . 8 u reth 9 i n 12 sum fl r . ra : , vag a : , : 18 i n i ll nm , flar g . bundles of the rectal

e an elevator . It would appear that in some cas s the HOW mss o 1 1 TO THEM . loops of the levator ani interweave with the mus r c ular fibers i n the wall of the vagina . The pa t of the levator ani which pa nectum is a of an inch t of the glly of the

ti on . I i close if not interwoven with ts fibers . The part of the m uscle of fm i al origi n which i d from the Wh te line, asses backwar and down ar ar or w d, becoming p t of t e levat loop and the tendinous perineal raphe and the

last bone of the m ccyx . Many of these fibers pass r e u m downwa d In a curv . and when the median raphe they turn acutely backward to become inserted into t the coccyx. A ow of the b rn as rom o the white line , well as f the other r shaped loop, to with some f om the ischial o spine, embrace t e rectum . The part of the levat r an i arising from the ischial spine becomes inserted Ye o r chiefly in the coccyx . t one may bm ve on e fourth of an inch in width pass around the rectu m i n terv n i n d n with no e ten i ous raphe .

The part of the evator ani muscle of special inter.

t n - fin rs r a to the ecologist is the two ge Wide, ho se

‘ shoe- shapg eli n Which arises from the posts surface of the pa is and passes backward and do r and ward to emb ace both rectum vagina . It Is the belly of this loop which gives the rectum its for. ward curve just before the anal an d is turned back t It Is the sphincter por ion of the muscle . It i s this part of the m uscle which becomes hypertro. phi ed In m a m as . It Is the portion of theymuscle I n an d n semrated in lacerated peri eum . It is the ti on create m of the muscle which retards labor, u va i i i “ n g nal and may prevent coitio , and In rare 12 vacma AND PERINEUM ;

F ig . 3 . Thi s figu re I d rewseml m ati cally to i ll ustrate the ra l i ew of the e i c ou tlet. 1 c li to s 2 c ur c i tori di s 8 v lv . : , r a l : , cli to i di s muscle pu e t 5 o ri fice o f a 6 u o -ca w r : r hra . va : , b lb ocus muscle : 7 al e - i n l len of u e n i of i st!e! , v v vag a g ( D v r y, T W S8 oste rlor va I n c l commi ssu e 9 n ? mu sc es , p g r : } l : 10 OLturn to r i n te n us musc e “ n us 1k s i nc te anl e te n us 18 , r l : a : , ph r x r : , cocc x 14 e to an m uscl 3 r i ti men t 16 the y , l va r i e 8 g ea t sac a c : , b u of the i n 17 ee e ”of e lb vag a : , d p lay r Nw 13 now To MEND THEM . cases prevents the pen is from escap unti l relaxed I n by an anesthetic . most cases e levator ani behind the rectum may be di vided i nto three quite dis

t . a 19 tinct par s, viz , theypart which connected to the last bone an d fasci a of the coccyx . The fibers aecom p n ying this portion of the muscle originate chiefly frhm the posterior end of the White li ne or at the i b n r schial spine . . A portio of the muscle fo ms a median tendinous raphe for about one third of an

n . i nch immediately in fro t of the coccyx c. The d ! n porti on of the muscle imme iate behi d the anus , n Wi 6 i n terven about three fourths of an i ch , has no i ng tendinous raphe (not always distinct) and con sists of the belly of the loops which originate and insert on the posterior pubic surface . In other l a words, the muscu ar fibers of e ch side anastomose , the forming horseshoe shaped loop, with no inter i n n n ven g te di ous raphe . Some of the loops inter twine with those of the sphincter ani, which pass

) m . back to the ti of the coccyx , also so e of the mus c ular fibers ofthe sphincter an i externus are con ti n uous with the loops of the levator ani . The fibers of the levator ani origi n ati ng from the white line pass backward and downward b ut on arri vi n at the a medi n raphe, many of the fibers turn Sharaback x ward to be inserted into the coccy , and soon an i tendin ous . The levator fascia superior is not n m e very i ti at ly attached to the muscle , and may be The compared to the fascia transversalis . levator ani a c i n f s a i ferior Is adherent to the muscle . Deduction s In regard to the levator ani muscle may b e numerous . Certain tical consideration s may ' be drawn from a oet efu study by dissection and in e i l gyn cologic practice . As it was orig nally a musc e becomi n i n of the tail it Is vestigial man , shown by ! i n its fascia connections . rom the orig , course and i insert on of the levator ani muscle , it must be viewed 14 THE VAGINA AND rs ams um;

- as the all important muscle of the pelvic floor . The levator ani fascia eu ri cr is the real visceral

r . suppo t I think it was Dr . eyers, i an t c , who firs happily named it the pelvi

In many subjects it is membranous . The

— Pi . 4 usc 1m . e n an d mo i e ts i e of g , (L hka , ) R draw d fi d a v w the e to an i m usc e . the mo i c ti on of L u e con l va r l , , d a g r L L fi fi ' ts i n m a the c l c u e m de b the e to an i muscl si s re t a rv a y l va r C, con ti n u ti on o the e to an i m usc e b c n ll hej a a l va r l a kward , draw The on the ectu m b the orse -s oe sli n of the fevagdr vagi n a . r y h h g fi lm tor sci i n e i o i s s o n o le u i n . ani . here pla fa a f r r, p , h w r l d p HOW ME NU E M 15 TO TH .

n muscle has the shape of a boat , and whe this boat

- i i m shape becomes cone shaped , the pelv c floor is

of . paired . The levator ani is composed many mus l r a to cu a bundles coursing chiefly p rallel each other, but also at varyi n distances . The bundles are

- flat , ribbon like , an of a bright red color . The bu ndles of muscular fibers are held at greater or less distance from one another by collection s of fat or con nective tissue i n varying d Fenestra or apertu res are commonly observ between the mus n cular loops . The capacity of the bu dles of the . levator ani muscle to separate and reunite without injury , serves a useful purpose in labor, when rapid n n elvi c and wide diste tio of the floor may occur . Too man figures i llustrate tg9 muscle as a di stinct plane wit no parallel gaps between the bundles. . The levator ani (the deep muscular layer of the is con n ected to the exte rnal sphincter ani of tum and vagi na (the superficial muscular layer of the pelvis) an d by this muscular connection to t e fixu m the perineal body ( h punctum ) , the deep and superficial muscular layers of the lvi s are brought into i n ti m u e relations of much u Afew fibers are lost in the perineal bod The evator ani is in closer organ ic relation wit the rectum than the va u a , beca se the rectum requires more frequent rfect a evacuations than the vagina . It is chiefly

s i n cter . a p muscle The weakness of its origin , insertion and direction of its fibers is in accordance with its fadi n g out of ' The forward curve of the rectum is due to the

rs - v r ho eshoe shaped loop of the le ator ani , which o ig ubrs instes chiefly from the posterior surface of the p . r t n e By the cont action of the lower, s ro g r fibers of the t u leva or, the lower portion of the rect m is forced against the perineal body , which compels the arms to ur to t n backward and evacuate its contents . 16 run m om AND PEB lNEUM ;

The r on and z levato ani , account of its shape si e, l fi i n are l e eaves de ciencies the pelvic floor, which fi l d i n front by the bulbo- cavernosus and behind by the com eus yg muscle, its continuation backward . The palpable rounded ed of the levator ani three- quarters of an inch a vs the anus and three rt r i a qua e s of an nch above the vagin l opening, making

Di cki naq The lav.‘ ani as seen thro gh the ski n ouwlet o Sthe pelvi s i s d otted a n d t he % rec ti on and couragof the chi ef l f the e to au i m o muscular bund es o l va r arked ut.

i n extern al o the muscle, fact, a regulator of the m ings of these two canals . Normally the orifices s a canals are always clo ed . They rem in open only by

internal or external force or from trauma . The levator aui will lift from five to twe nty poum a averaging about tea as noted by Dickinson . I

m a vac ma AND Pam um;

i n teresti this muscle . Browning wrote an ma rusfin on the subject . The levator ani y be a cu tary

l i n he e oluf musc e, disappearing with the tail and t v ti on si process of an erect attitude . zo a arise m the we kness of its origin , its fibers and insertion , as well as the requirement of i the double fascia . It is unphysiolog c for a m ascle

- F i . 6. n i e alt r i T d te n e e to ani . g (Ve r r e D cki nson . ) he i s d d l va r la e s h sis c c i to i s c con st i ctor of the u : . dd r : . . p ; . l r : , v . r v lva b ' y F lourchette g n te i o ri neu m O nus e i a r r : A . a ; P . p r eum Ii co c x S o t f c h R i s on m usc e i t : . . c : , . o s u m : . n C y P n a r , B . l w h i ts se te b un l es t he mid e R i s on he st on t b un e . i n t is para d d . dl t r dl h figure we observe how the m usc le ca n save i tself rom ruptu re b y the s ti on of i ts i us i I i e s t t n i t i t e e i n one epara var o fasc cu li . t y ld et er ha r te s t b w conn ec d hea h .

e to produc constant support, hence the levator ani can not be consi dered a support for the viscera ; it is rather a sphincter muscle . The levator ani muscle is snalo us to the buccina r uti on ar n to muscle . Perhaps from an evo y standpoi t D 19 n ow ro MB N THEM . we may look on the levator ani as having three func i a : a b tions, v , of a sphincter ; , of an elevator ; and r and c, of a tenso of the levator ani fascia, superior

A r l an i on e s p oof that the evator is a sphincter, used 0111 introduce the finger into the vagin a and Oruvei l request the subject to contract the muscle .

t . hier, Henle , Lesshaft and Budge insis that the leva tor ani is s sphincter of the anus an d lower rectum

n ot r. l chiefly , and an elevato That this musc e is an elevator on e need on ly dissect it to find the muscle a en ding definitely in the w lls of the rectum , and such n ac o terminati g fibers , when in ti n , could only elevate

the rectu m . The horse in defecation illustrates that or the levator ani is an elevat , as the rectal wall is l a t e evated , the rect l mucosa ever ed and completely

- . or i evacuated As an elevat , it resists intra abdom nal pressure . The levator ani appears as well developed in the he r male as t female, and hence labo does not appear ani u l to develop it . The levator m sc e is or i all those animals with a tail , and ig n its tion was to aid in managing the tsi from which it would appear that as a tensor of the levator ani fascia r r e n supe io and inferior, thes fibers take a active part .

They originate at a definite fixed point, lose them selves between the fascial blades and do not reach r ectal or vaginal walls . When a muscular fiber neither o g es to the rectum nor ends in its wall , it will not act as a sphincter, nor as an elevator . Lesshaft and Roux divide the levator ani into two

vi z . a r layers, , , the inner layer , which is an elevato , b r and , the oute layer, which is a sphincter.

THE ' INTERNAL PELVIC FASCIA . The internal fascia of the lesser pelvis has a poor r literatu e, and is not often described . As the pelvic 20 run VAGINA AND PERINEUM ; fascia has much to do with the permanent results of i t the fla or an perineal operation, I will write of somew at in etail . n The fascia of the greater pelvis, or that fascia lyi g o ecti n eal r w to the ile p line , is not he e i of n n The fasc a , the planes stro g, ti ssue here under lie below the

- - F i . 7 . Robi neou 8chc lcr t te the e i c g ( . ) A to illus ra p lv n no m wi t e en c tu e of s me . 1 i te i ne ; 2. 2 o ig i n of h a w la r a , wh l r veraa hs and i li c f sci a t the i i a c c est 8 3 le to an 1 sci su e i or a a a l r , . va r fa a p r ; ’ 4. 4 e to an i f sci i n fe i o Alcoclr s c n 6 o tu to i n tern ua , l va r a a r r ; a al ; . b ra r musc e 7 7 e to aui m usc e 8 in or ec tu m e te n 9 eter l ; , , l va r l ; vag a r ; x r al : ' 10. 10 i leo ecti n eal i ne 11 u o i n of e to ani f sci an or 12 12 , p l . . rig l va r a a : . . egi nni ng of o tu t fasci a n feri or 13 18 t nsve s li s ; M, M, b b ra or j ; , , ra r a a m ; i i c uscle ; lhac f sc 16 i ob tu to sci su eri o ; 11 , 11 , l a a ia , ra r fa a p r endi n of ob tu to mm n i o on he i tu e osi t . g ra r i fe r r isc h al b r y

e a As a t acher of anatomy , I have always maint ined that a fasci a should be named accordi ng to the muscle or other structure with which it is in the most in fi sow ro 21 MEND THEM .

mate relation . I s nomenclature to the coveri r i r l The fascia the obturato . nte nus musc e u r r i i will be termed the o t ato fasc a . As this fasc a vided by the white line extending from the posts. f ) ubi s l su r ace of the to the ischial spine, we wi l call that portion ofthe fascia above the white lin e eu i o the obturator fascia r r, and that portion of the fascia below the white e the obturai

ri or . The fascia above the levator ani , originally r Oarcasson e named by Ty rell the rectovesicale, and by r t he the pelvic a neurosis, b othe s vesical layer of asci s the pelvic , we wil name the levator ani fascia an d superior, that part of the fascia below the levator i r an i fasc . , the levator ani a infe ior The fascia cover oal an d r u ,ing the g pyrifo mis m scles will be f t e named a ter ose muscl s . The fascia covering the the name of the sacral

from the i leopecti n eal line on either side to the median i raphe of the pelvic floor . It not only l nes the pelvic

walls and floor, but enters into intimate relations with

e . n r the p lvic viscera It is a strong, shi y , fib ous mem n an brane, possessing a very varyi g quantity d qualit In a certain sense the fascia of the lesser pelvis shou d e n t be tr ated as an independe t struc ure, and not as a i l n l a continuation of the iac tra sversa is or other fasci . The i leopecti n eal line marks an absolute divi sion be

tween the iliac and obturator fasci a. The si mmest plan is to describe the obturator fascia su peri or and inferior and to consider the obturator fasci a as distinctly belon to the obturator (inter nu s su bse uen n muscle, q y to co sider the fascia of the e or an d v t ani superior inferior , with a lesser con sid r n n e atio of the coccygeus, pyriformis a d sacral fas ci a . The fasci a linin g the lesser pelvis are intimately connected with their respective associated muscles and rs s VAGINA AND se am en ;

ccamec~ structures by strong connective tissue . The tion of the fascia wi th the peritoneum is not intimate, e r l n a thick, loose lay r of connective tissue, ichly ade u the wi th fat lob les, lies between the peritoneum and c n fascia lini ng the lesser lvi s. This loose conne tio of lvi c peritoneum an pelvic fascia allows the e anger-apid spread of pelvic abscesses between the a vic fascia and the peritoneum in the subperitoneal tissue .

anney . ) of the faaci a of the h i s sfi03 t the evator an i fasci a an or an d i n feri o r above an d e o the e to an i m usc le. . t i lar men t : , . two b l w l va r T L . r a a P F la e rs of su e ci e i t at i n e n i o t i n y p rfi al p r neal fasci a . Observe a ter r r a i lar e i n e so t e e are five e s of sc i a vi a : 1 su e ci p r al a h r lay r fa , . p rfi al fl n of e i n sci : 2 ee e of su e c i l e i ne sci ; 8 p r fa a , d p lay r p rfi a p r al fa a . “an ula r i m en t ou te e 4 t i n u l r i men t i n ne e : 5 g l ga , r lay r ; , r a g a l ga , r la y r , e to a ni f sci su e i o I n t he oste i o i n e s ce t e e a re two l va r a —a p r r. p r r per al pa h r are of fasci a the leva to r ani fasci a su erior and the levator ani fasci a ' p Ol .

The obturator internus fascia surrounds the obtup r c . ator mus le at its origin , from the lateral pelvic sur ac f e of the innominate bone, and is the special fascia or of the obturator internus muscle . It is attached f a considerable distance to the iliac portions of the HOW TO MEND THEM .

i e brim . At this po nt the obturator becom s attached t to the upper border of the ob urator membrane . In

front, the attached line of the fascia passes below the i leopecti n eal line to allow the obturator vessels and

the nerve to enter the obturator foramen or canal . the perioste um and ap In front it i s attach to the the upper margin of the o li as i s oi n t obturator foram en by an b q l ne, to p about

one half an inch below the symphysis . Where the to allow the passage of the obturator vowels and nerves it 19 firmly attac hed to the perica teum and nerves by strong tendinous fibers. Poste ri orl 19 m teri or y, it attached to the surface of the oat sacrosciatic li gament and the anterior margin of g n n i s t sacrosciatic otch . I feriorly , the fascia attached to the margin of the obturator foramen of n f th n d i ns the desce ding ramus o e pubis, a it o the the e falciform process of great sacrosciatic m nt, which firmly connec ts it to the i n ner border of the

ischium and its ascending ramus . i i i n i leo ecti n eal With a firm nsert on the p line, the r i e anterior border of the g eat sacrosc atic foram n , the anterior and inferior m of the obturator foramen an d to the edge of the ci fcrm process of the great i e sacrosc atic ligament, the obturator fascia becom s a n r e e i fixed , stro g, thick , fib ous m mbran , in relat on s efiorly with the obturator n erve and vessels an d nf orly with the internal pudic vessels and nerves ’ — i n Alcock s canal . It has int mate attachme ts to the r i s obturato internus muscle above , but quite loose

below . c The obturator fas ia we divide into two portions, The superior and inferior . obturator fascia superior are as o is that portion above the white line or tendin us . It looks into the pelvic cavity from the lateral aspect and 18 covered by peritoneum . The peritoneum and ' 24 run VAorNAAND Psal uu ;

obturator fascia superior are separated by consider

s . e ti mue able loose , fatles , snow white conn ctive , com d n l an of many shi y , thin , cleavab e pl es, which mme easily dimected by the progress of pelvi c

abscesses . The structures of i mportance which pass over the

internal face of the obturator fascia superior just be. low the i leopectin eal line are the obturator vessels t t r nerves . These s ruc ures a e liable to be inj ured by the head soon after i ts engagement b the brim or 0 fixed bony ring of the lvis . The orator fascia ‘ an 0 or has a surface about ten square inches. he obturator fascia inferior is that portion below n the arcus tendineus or white line . It looks i ternally into the ischiorectal fossa and externally toward the i n t us x er obturator em m uscle . It forms the e t nal boundary of the ischiorectal fossa . At the lower part of the ischiorectal fossa about an in ch above the tuberosity of the ischium the obturator fasoi a plan es ’ a become sep rated , producing a sheath Alcock s Canal for the transmission of the pubic vessels and r r a i n teri or ne ves . The obturato f scia has a surface

- of some five square inches, one half the size o f the oh e tu t st r fascia superior . At the lesser sciatic notc h the obturato r fascia passes out of the pelvis with the muscles and gains the

- r taro femoral regions of the t h . The obturato ° ‘ a is inserted into the rsmus o the ischium and u bi r tri n u c, whe e it passes on and blends with the a g

e o ar ligament of the urethra, h nce the triangular liga men t is a continuation of the obturator fascia from each side . The arcus tendinous or white line appears as an aggregation of tendinous fibers of the obturator n the fascia . It exte ds from the posterior surface of i the pub s to the spine of ischium . It s a r e gentle curve with its concavity upwa d . 0 whit

rm: VAG INA AND m arsac m;

If one carefully removes the peritoneum and loose subperitoneal tissue the levator ani fascia superior may be plainly seen stretchi ng from the white line to

and . the bladder, vagina rectum It may be stripped ‘ 03 r v the levato ani muscle in several thin , clea able It is reflected on the bladder forming the r anterior true and lateral true ligament of the bladde , however the lateral ligaments of the bladder may be The le vator assisted by ligaments from the vagina. f ani fascia superior begi n s its anterior attachmen ts at m h sis n n the lower border of the p y , co tinues the along the white line late y to the ischial spine , con ti n ues from the ischial spine on the superior surface n of the levator ani muscle to the media raphe . The levator ani fascia superior covers an area of about six square inches on eac h side of the median line of the The levator ani fascia superior may be divided into r the anterior or vesical portion, the vaginal po tion and

the rectal portion . The vesical portion of the levator ani fascia supe~ rior is reflected from the pubis to the neck of the n m bladder, formi g the anterior true liga ents of the

bladder and part of the lateral ligaments . The vesi cal . portion is very thick and strong, even tendinous

It is reflected from the pubis in an arched manner. The vaginal portion of the levator ani fascia superior is analogous to that which su rrounds the prostate i n o the male . In the male , the pr state gland and vesi onlaa seminales are surrounded by a stronTcapsule derived from levator an i fascia superior . his por

tion of fascia surrounds the vagina in the female . in

cludin g the large ven ous plexuses . The vaginal portion is endowed with considerable strength an d it becomes blended with and is lost on w the vaginal all . The rectal portion of the levator s ani fascia su perior passes to the rectal wall , b com aow ro m o ra s u . 27

n ing continuous with the fibers and ble ding with it . There is a stron fillet passin between the rectal and The r gu e vaginal canal . pa t of l fascia which passes a to the rect l wall, has been termed the ligame nt of i r the rectum . Th s fascia forms a st ong support to l m the muscular wa l of the rectu . It is not an argument very rich in facts to say that the perineal body is to fill in the space in that region . It serves as an attachment for one end of the le vator n m n ani muscle . Asubject which I have not fou d e ti on ed in the books is that in many parts the fasci a of the pelvis consists of many distinct! d efined ot er layers , which can be cleaved from each . For r the example, the fascia ove coco geal muscle may an d a be cleaved off in several la ers, the same m y be s — e ree—of an i aid , but not to such a g the levator n superior . Several thin , tra sparent planes of fascia 06 of may be cleaved the obturator fascia superior . a i s ve n Even the levator ani f scia inferior, which thi

an d . compact, ma be cleaved into two or more p es The obturator fascia infe rior is a very powerful fibrous plane of fascia and may be cleaved on each i the side nto thin planes but central plane is a thick, rful e , individual, somewhat coarse , fibrous mem rful i o e . The we obturator fasc a inferi r is c i leaved, split, r the transmiss on of the pubic ves e s ls and nerve . The canal formed by the separation ’ is known as Alcock s canal . The several membranous planes of some of the fascia in the pelvis endow it with much more utility . On may tear without v the other . Se eral cleavage are characteristic of fascia in other localti es and are more capable of resisti ng trauma than a single plane The coccy cal muscle an ses from the spine of the ischium an lesser sacrosciatic ligament, becoming inserted into the side of the coccyx and two lower

erteb m usculo- i sacral v rw. It is a flat tend nous tri 28 ras vxc ma AND PERI NEUM ;

i angular plane, aid ng to close the posterior pelvic out rd 1a n let . Its anterior bo er in co tact with the cste r r u i E rior bo der of the levato ani m scle, of wh o it 1s practically a continuation backward and covered by

a . e i r the same f scia , viz , the l vator ani fascia super o . The posterior border bounds the anterior margin of

the great sacrosciatic foramen . The lesser sacro

sciatic ligament. which is formed the u u cocc e s of s perficial musc lar fibers of the yg n , takes the place of the contin uation of the levator ani

fascia inferior. The coccygeus muscle n to of existe ce, belonging originally a large tailed

animal . The origin and insertion of the us an d i muscle lesser sacrosciatic ligament are denti cal. They-are so strong that practically they n ever eld as o so to be involved in colpoperineorrhaphy . w the coco geus muscle is described in order to show that i ts ascia should be named the i fascia, wh ch can not admit of confusion . rior su rface of the coco geus muscle t the s rengthened, not only by

ament, but by the superior surface of the great ligamen t which represents the proxi mal tendon of the

ng head of the bicep femoris . The tendon lon g head of the biceps formed an attachment at the h tuberosity of the isc ium . The coccygeus fascia covers the coccygeus muscle and has an area of about 3§ square i nches on each side of the median line of

the pelvis . The pyriformis muscle arises from the r late al portions of the second, third and fourth pieces r of the sacrum , from the inferior bo der of thepgreat sacrosciatic notc h and from the t sacrosciatic r ligament . It passes out of the pe vis th ough the “ r n s s sac osciatic forame , becoming in erted into upper border of the great trochanter . It is g 1n ost posteri or muscle which aids closing the pelvic th a r outlet . It serves as a bed on which e s c al nerves 29 aow ro mam) re am.

may rest . It is covered by the pyriformis fascia, which 18 a continuation of the obturator fascia above and the coccygeus fascia After leaving the obturator an d ccooccc us fascia it rapidly thins yge m erfo out into a transparent t me brane . It is p rated by the intern al iliac vessels which leave the

by the great sciatic foramen . The pyriformis is attached to the surface of t nal to the on i n of the pyriformis muscle from the posterior borfgerof the coccy eus muscle to the ileo pectineal line which passes n the border of the wi ng of the sacrum to the sacro - i 1ac join t an d finally it is attached to the superior margin of the great sacrosciatic foramen from the ischi al spine to the

- l i sacro i iac point. The pyr formis fascia covers an area of about five square inches on each side of the lv n e i s. The sacrum is li ed by a thin fibrous mem g n i rane which we will ame the sacral fasc a , hence , the internal pelvis is lined by the obturator fascia ' o the r ani a the c superi r, levato f scia superior, coc ygeal

and a . fascia, the formis fascia , the s cral fascia o o e i This nom n ture we recomm nd as s mple, and as f c i l ati n g the easy acqui sition of the internal (i fit’ m t .

v . a The use of the le ator ani fascia superior is , to

s r 1s . sutain the pelvic visce a, and analagous to the fas tr ers li s- u cia snv a abdominalis ; b, to form a po ch on e l each sid for the pelvic viscera , which assists in c os 1n the u 0 g pelvic outlet above the musc lar floor , to fix d of the pelvic viscera ; , with its su perior pad fat and

w- i sno white connective t ssue, to sup ort the pelvic r t of n pe i oneum e, to resist the pressure the abdomi al an d u muscles the diaphragm ,pand f, to serve the usef l purpose of separating the perineal tissue from the r n pe ito eum . This latter anatomic condition limits inflammatory and infective processes from either perineal or peri 30 res vac ma AND Pssmmm ;

e u tons l F rther, the levator ani fascia superior r forms e pelvic floor, and by its strength p events r 1 - he n a . The blood vessels are placed nerves The levator

9 An i ust ti on emon st t t in d l c g. . ll ra to d rate ha pe a c o f l c u d a s ti ons the pe vi floor the le vator an i fa sci a s peri or an i n r to n i th i ts n te e n i ng m usc le . the e to c u t. The en t o r te is r w i rv . l va r r ar b R B an d o n the ht S d Th e e m d i t the s o n B B n e . e n e e h w , . g i dl ar w h t d § i l ss th o u h the m usc le an d i t two s o f sci in hrea w l pa r g s laye r fa a o d e to esto e the i nte i t of the e i c oo . 1L i li c sci ll the r r r r g r y p lv fl r , a fa a ; p n n i n of the ob tu to a sci su e i o at the i schi opec ti n ca l li ne : ra r f a p r r ’ the o tu ra to r sc i su e i o : W t he te i ne 0 the o tu tor fa a r r . h l ; . ra p w i o b - f sc i n fe i o di i d ed by the i te h ue z . 0 . the ob t u t i n te rnus a ia r r v wh . l ra r m us c e F the fa t i n the i sc i o ect f sc the e to an i l ; h r al a ia ; A , l va r h ob u t f i i n te i o V the in S i n tra elv c su e io ; the t o sc ; , ; . p p r r , ra r a a r r va a cs Y the ce i d ee t ns e se ri neal musege an d 2 the an ; , rv x ; P . p ra v r . ma! the s b i n ste an i e te n u s ; dee yer of t i n u ; B, r x r p la r a g lar men t su e d ee e of su e c e i n e f sc . : S, p l ; N , p lay r p rfi ial p r al a ia s ow ro re am 31 MEND . perior and inferior limits nearly all fistula in an d

- i of to one half inch above the anus . A d sadvantage the levator an i fascia superi or is that it is perforated by nerves and vessels which carry sheaths of con n ecti ve tissue ; these sheaths allow infective proc esses to pass from the perineal tissue to the su bperi to

D eal tissue and vice versa . Deficiencies occur in the

i are . fascia, excavat ons which filled with fat The fascia of the yri form muscles consists of an sion backw of the obturator superior and levator ani fascia superior . Both fascial planes blend , the on e from the anterior margin of the sacrosciatic fora. men and the other from the posterior margin of the cocy us i n to a thi n membrane which covers the i yr ormis muscle and the sacral plexus of nerves. he pyriformis fascia is perforated by the lute al ves i n sels and nerves to ga n the gluteal regio . his plane of fasci a is so thi n and delicate that one can scarcely i l r i n d ssect it without tearing it . The evato ani fascia feri or (an al or ischiorectal fascia) lies in immedi ate and i ntimate contact with the inferior surface of the u whi te levator ani m scle . This fascia begins at the n an d li e becomes lost on the rectal wall . It is very n m e i ti at ly connected with the muscles . The levator ani fascia superior and inferior blend with the rectal

- wallabou t on e - fo i n h a ove the half to three urths c b anus , and rectal perforations gen erally occur below the in se ri i ons th of the above fascia . The fibers of are included i n all deep suturi ng of exten sive colpo n perineorrhaphy . By i cludi ng its fibers in the su tu ms . , the relations of the levator ani may be par s ll n fi y restored to the normal relatio s . The sacral an d coccygeal fasci a lin es the anterior surface of the sacrum ; it has localized thicken i n gs an d thin nings The thickest portion s are those located along the lat eral margins of the sacrum and especiall aroun d the r a n tri an u e ante ior s cral forami a . The g ar ligam nt 32 r es VAGINA AND PER INEUM;

deep perineal fascia) closes in the lvi c floor in 1a 0 the 0 n t. It the result of the union n exten di g from both sides toward the center . It 18 a prolongati on of theobturator fascia across the u i n e p b s, and Winslow called it the ligame tum int r Oarcasson e ossei pubis ; , the ligamentum perineale i l a . Colles, the l gamentum triangu are urethr It is the deep blade of the fasci a perinei an d i s an i n tsgral ° u r I t 18 middl f i r . e asc a pa t of the obt rato fascia _ the ’

the . of perineum , or Camper s ligament It fills up the deficiency found between the anterior or pubic 1 insertions of the levator ani muscle . It 8 a wonder fully powerful structure 1n fixing the lower end of the

13 i n s . vagi na . It stronger males than in female It i a e n is the structure wh ch ret ins, with w rful g the anterior an d of the vagina forw and upw The vagin a pierces the triangular ligament whose 1D n fibers fix themselves and arou d the vaginal walls . It joins posteriorly with the lower margi n of the i n feric r edge of the superficial perineal fascia . If on e di mects away all structure from the vagina except the triangq ligament it wi ll become a parent at once what a powerful support it is to the power end of the vagina . The tri ligament, as its name i s ri 1n a t implies . t angular in s ape , aponeurotic t uo ture, extending as a tense septum between the anteri or m part of the perineu and pelvis . It is attached on a i n fe either side to the rami pubis nd ischium . Its i i ll rior or posterior inferior marg n is defined , blends with the su perfici al perine al fascia at the ischi operi n l cal fascia, where it gradually loses itse f on the lower surface of the levator ani muscle . It sustains and fixes the urethral can al . It is pierced by the vagina at i ts base or weakest portion . It serves the useful purpose of connectin g the bladder and vagi na c c i n to the hi , and of retaining adjacent organs i o fixed re tions . By its connection with the isch

34 ran VAc rNAAND Premi u m;

3 euroti c bands of a very resisting This? result from the union of the lower bord er of the trian ar ligament wi th the doc layer of the su i th e li amen ts l perfic fascia . The fibers of es g p ay an important role in extensive colpoperi n eorrhaphyi These ligaments form a conspicuous structure i n every i i d ssection of the female perineum . In the advanc ng ' head the ischioperineal l aments are u t on the stretch and gradually fo backward . bould they

n fla - rupture , by exte sive p splitting and dee suturing the two la era of fascia which blend to m e the lig con (1 ament be partially restored . Having examined the structure of the pelvis in we may now combine the anatomic factors n explai successful colpoperineorrhaphy . The

first is the restoration of damaged fasci a . A second i ek men t important factor is deep suturing . A th rd in a successful operation is the restoration of function by means of restored muscular relations . A fourth is the forc i n in the median line of adjacent cal an 0 r tissue , a fifth factor is the flap method ope a n d tio whereby there is no enudation or loss of tissue , and the flaps (s kin and mucosa avoid infection and a e insure primary healing. The p m thod enables to b the operator reach the seat of the lesion , either y splitting tissue or deep su turi n with a han dled

k- i needle with an eye in the en d . Si worm gut wh ch

u n - is used in s turi g, being non septic , may remain for

e e . we ks in position , like a splint, befor removing Among the fascia of importance are : The levator an i i n an d superior and inferior, the triangular l game t the an rfi i al deep la er of c fascia, and the ischio n col o eri n eor peri ea ligament . he operation of p p rhaphy is the result of evolutionary processes of lu e i n m n was fai res an d successes . In the b g it con sid ered sufli ci en t to unite the su perfici a or extern al u t n x tiss es at he site of the lesio . This e periment H 35 OW TO MEND THEM .

r i ts soon demonst ated own failure, and later it was deemed essen tial to restore the deran ged and lacer n i n ated muscular eleme ts the pelvic floor . The attempt at successful colpoperineorrhaphy by rennit ing external tissue at the site of the lesion or restor ing deran or lacerated muscles to normal relations ' proved a lure to such a (1 rec that it was evident that some other factor play a rOle ; this factor was

. r the fascia . The restoration of the lace ated tissue at u the site of the wound , with the deranged and r ptured f muscles, and the restoration of the deranged ascia are the three factors on which successful colpoperi

t . . n eorrhaphy res s . To Dr T A . Emmet must be given the credit of the view that the played an important role in successful c h h r r a . p y Experimental labo s on the perineum , in a on desultor manner, have been carried But years . only lately have experimental tomi c data been judiciously combined so as to ren der clear what are the useful methods in colpoperi n eor rha h u p y. All successf l surgical procedures demand n an anatomic basis . The dera ged and lacerated parts in colpoperi n eorrhaphy must be restored in a manner similar to that in ration for hernia . The success. ful su rgical pr urea in oolpoperi n eorrhaphy have passed through the same evolution ary rocess as have ' the various operations for herni a . In ernia we must the ‘ restore the anatomic relations, obliquity of the

- n inguinal canal, so that its valve like actio makes it the M rs impossible for to again protrude . eri n eorrha h n t p p y, not only the a atomic par s should g o a an d rest red, but the various c nals outlets must

t n n . also be res ored , to ensure perma e t success Deep suturing, so essential, is only groping after an ana tomi c base to restore the ground work . The same i deas are involved in the views of discerning surgeons, who suggest that if the sutures include sufli ci en t of 36 THE VAGINA AND PERINEUM ;

r tc v al u the ec septum , or if they are introd ced 1 en ou dee g to make forward traction , or if they inc ude the sulcus on either side of the bulgi n g vaginal wall, the operation will be successful. Dr . rehen si ve W . R . Wilson wrote a short but com eu eati n exce e cle on the subject, g ent principl s, but modestly claiming at the anatomic basi s is still imperfectly understood . In the subject of colpo perineorrhaphy the ori of the lesion demanding ' cd operation should be stu . The cause of the lesion , requiring repair, is almost always the result of (the r first) labor, more rarely other forces produce sac o

ubio hernia . The lesions of the perineum may come c m the forward movement of the head Bacerati ng ' the o an d th levat r ani fascia superior inferior, dam a e to the ischioperineal (ligament) fascia and tearing g l uen t n a o the triangular igament, with Pl i evit ble i i l! “ t les on of the deep perineal fascia . will des roy n the to e of the posterior vaginal wall , because the fascia has been separated from the vaginal wall near n its outlet . If the disti ct ischioperineal (ligament) ' i i n fascia be torn , which is qu te frequent labor, the vulvar end of the v a falls backward and condition of rectoce e ; its fascial (and doub s cular) support have been torn away . With a torn levator ani fascia superior the pelvic viscera will insv itably descend, for it is unphysiologic for a muscle to n n n e act as a co tinuous, te si o i z ed support for visc ra . But it must be remembered that the fascia! layers of the pelvis are not only of value as visceral su pporm by separate and distinct connection in themselves, but they are of significant importance as serving a means of visceral su pport and for a point of attach e ment for muscles lyin between their blad s . The 1s u levator ani , which t s most important m scular i apparatus on the pelvic floor. serves by its fasc al attachments as a visceral support to the rectal and n ow 11m m H M TO T E . 87

a vagin l walls as well as to the pelvic floor, for the

uterus is supported by the intact pelvic floor . The elv wfloor may be considered as composed of W1(F l overla Whatever di s two y ppin valves (Hart) . turbs the relations of t ese valves tends toward sacm ‘ I b 18 com o d of pubic hernia . e m teri orpelvic valve p se drethra n al r the bladder, , anterior wall and ret o u bi v com p c fa . The posterl or pelvic e is of the

o . posteri r vaginal wall , perineum and recta wall The pubi c ent i s attached to the symph sis pubis an d com e of loose connective tissue . he r tropubic fat 19 loose and s the peritoneum may be easily t tfi r s ripped away from e bladde , and the bladder from n the vagina . In labor, this segme t

and is the one which easily becomes deranged , or acquires pathologic conditions and y is liable

to prolapse or sacropubic hernia. e levator ani fasci a 811 or becomes torn awa from the walls of

and - the blad er , allowing e intra abdominal

pressure to force t e bladder and vagm a downward . When the uterus prolapses ( sacro- ubi c hernia)

the an terior vaginal wall appears at t e vulva first . The stron g levator ani fasci a has been torn from its walls an d when the same fascia has been extensively torn m l fro the bladder it prolapses also . In vesica the peritoneum with its many cleavable tissue becomes torn valve of the lvi c

floor , consisti ng of the posterior vagi nal wal , the b i perineum and rectum , is attached y strong fasc al connections interwoven by muscles to the coccyx and mcru m r backward . In labor, this segment is fo ced e t and straighten ed out . If it becomes d fec ive by laceration at the perineal body the vagina loses i ts

o t t d 1 an d sacro u i c a 1s mi i a e . e normal curve p b herni , , 18 r retroversion begins, which the inevitable facto in a l i s cropubic hernia . The uterus itse f has noth ng to 38 rss vac ma 1 1m exam s ; do with lapse ; the sacral the pubi c segment is movable . The functions required of the pelvic floor are to resist in traa bdominal pressure and to allow rectal n ‘ and vesical fu ctions . The structural anatomy of the pelvic floor must not on ly be studied i n general cu s as to it t , fascia but each crgan s ou studi as rsgards i ts su p r The uterus has its individual su ppo ts, which, t e b s h not separate from the fascia and muscle , (1 r sho be well considered, for colpope ineorrhaphy

- be re ui red for (prola s’ sacrc pu bi c . hern ia ls t wit out visi lacerations . fihs firs elemental indi vidual supports of the uter us are the uterorectal

(sacral) ligaments . They consist of two folds of peritoneum embracin m uscular and connective ti s sue extending from t e posterior surface of the cer vi : to the rectum (perhaps some fibers do extend to r i the sac al fasc a) . These ligaments are an extension of the muscular connective t1ssu e fibers of the upper te end of the vagina backward. As Dr . Frank Fos r i notes, the vag na and uterorectal ligaments form a t i t balance beam on which the uterus rests . Ye should be borne in mind that organs do not rest on are u bases, but sw ng on supports or mesenteries.

The brain , liver, heart and uterus are all suspended su orts 0 pp and do not rest on other or bases, a werfu e uterorectal ligaments are po peritoneal, m uscular an d con nective bands which vigorou sly sus ct pend the uterus by the neck . Careful disse ions and vaginal hysterectomy will demonstrate that the uterus could not descend without the uterorectal ligaments became elongated . These ligaments are a part of the m usculo- fascial support of the pelvic viscera . The vaginal tube sup 39 s ow ro msNo r un s .

ports the uterus by being well embraced by the leva

tor an i fascia superior and the levator ani muscle, and also by bei ng well pad ded an d su rrounded b fascial planes of connective tissue fixed in its we n su an d adjace t structures . Fat pads and acts as a p n port by sti fie i ng folds . i r In colpoper neo rhaphy , it is well to remember that we have a fixed pelvic segment and a movable or dis

lac blo W1 11 . p ea segment . It aid in repair The mov

able pelvic ent comprises the urethra, bladder ls e and vaginal wfi . This segment is bound togeth r by pen ton eu m on a very mobile base and by a con sider ab le mass of loose connective tissue . r d This segment becomes by labo , disten ed r bladde , vagina or rectum . its fascial connections i i become torn , sacropub c hernia is nevitable . The o i n fascial c nnect o s are considerable above the vulva , consistin g of the levator ani fasci aa superior and n inferi or and to some exte t of the levator ani muscle . i i Sacropub c hernia , arising from lacerated fasc a of the movable pelvic segment is recognized by the v a and bladder bulging downward at the vulva an making the vulva a pear as a waist with the n puckering string go e . he worst and most damag 1n g cases of laceration are those which begin from the

e . inside and progress outward, i . , the fascia begins to tear high up in the rectovaginal septum , on the of h sides the bladder and vagina. T ese are the cases which presen t distressi ng symptoms ; when standin g are worse on account of disturbed circulation and are “ " u en e I prono nced prolapse by the ral physician . n such cases the anterior vagi n wall appears first at fi the vulva, then the cervix and nally the posterior l a vaginal wa l . The bladder gradually s gs downward and difficult urination is added to the already existi ng m toms r train of s p . In lacerations of the sac al seg Th ment of t e pelvis the lesions are more visible . e 40 run vxc nu AND PEB I NEUM;

ff . perineal body su ers especially . It straightens out the fixed sacral segment and retroversion and i n evi ta ble subsequent sacropubic hernia results The visible laceration of the perineal body was ori i nally con si d~ cred the chief requisite for re ir and s the type of e colpoperin orrhaphy . But t e stud of the pelvic n fasci a shows why the operatio fails or succeeded. fi sq uen tly it may be observed that the perineal body tom n is visibly , but no evil conseque ces follow, the a c The because fascia rem ins inta t . rectum n n t belo gs to the fixed segment . It does o prolapse, i n ts tc n . but wall stre hes, elo gates As the advanci g head forces forward and tears the levator ani fascia superior an d inferior as well as the ischioperineal lig m r o a ents, the levato ani muscle als becomes deranged but practically the restoration of the fascia restores r r the muscles . The muscular laye s of the pelvic floo — — are two superfici al and deep con nected and blen ded at the perineal body both by the muscular an d fascial o relations . The dee la er is the levat r ani mus cle which descends m t e si des of the pelvis i n the form of a boat or bowl to its attachments on the pel i a vic floor . The superfic al l yer consists of the trans of n the verse muscles the perineum , which exte d from tuberositi es to the center of the perineum and also

- cavsm osus th the bulbo , which surrounds outlet . All the muscles are related to the levator ani inclosed in double blades of fasci a,

. an i r i . e , the levator fascia supe ior and i nferior . deep transverse muscles lie between the tri an gular

- ligament and Colles fascia . The bulbo cavernosus and superfici al transverse muscle lie between the two rfici al a ri n eal perineal fasci . The ischio fascia ut the thi cken i n of the lower be or of the tri u i ang lar ligament an Colles fascia . The sign ficant importance of the fascia of the pelvis becomes at once 1n the apparent, not only maintaining the integrity of

THE VAGINA AND PERINEUM ;

' c r e l la the l la e at d, but the lapsed v g , bu ging rec vesi coce a aztlie vulva in a re mark blc d In fact, as Emmet remarks, it looks i r l ke a which has lost its puckering string . The e di is a fieren t explanation for each of the above classes. one f In , the pelvic asci a has sn fiered i n the lesion, the and in other, only a few muscle loops bl the perineal body . When the lesion pegvi c fascia its consequent result is that the circu la. i t on is deranged seriously , because the vessels are r held in definite elations by the fascial planes, hence the di scomfort on standi ng and exercising is from h n congestion . Baker Brown sim ly united t e tor tissue at the vaginal outlet . Se dom does this sim ple measure afiord an real relief from perineal lacer n suf atio , for subjects wit such visible slight traces e r the fer but little . In g ne al operations for the relief - rh i rsctova eal lacerat on are a failure . If the g i nfeseptum (fascia and muscle) be not brou ht i n the grasp of the deep sutures success will not ob tai ned even though the vulva be closed . The ’ of Emmet s success lay i n the denuding of th

e . i nal septum , i . , ut lizing the tissue posterior

ani s s! vaginal wall . In fact , if the levator fa cia rior and inferior be not lacerated the su bject 8gapera but little from the lesion , though the perineal body be torn through to the rectum . The levator ani cia superior forming the gutter or sulcus on each side of the vagina is firmly blen ded with the vaginal canal as the same strong fascia in the male surrounds the n prostate . In labor, in peri eal laceration we should not merely look for lesion s in the posterior commie. n sure of the vulva, for that is done by the escapi g head and shoulders, and is visible, but we should look for the on concealed lesions of the strong fascia , sulcus each side of the vagina . The most serious lesion of h labor may occ ur without visible external injury . T is o ro 11m m 4 s w THEM . 3 lesion is in general a separation of the fascia from l the vagina wall . If the fascia be torn from this, the posterior vaginal wall will not be drawn against the anterior and the canal will be filled within ; it will be r like an open collapsed bag . The fascia togethe with the muscles holds the vaginal and rectal canals in a

closed condition , excluding air . The ballooningout of the vagina with bu t little injury to the peri neal body is indicative - of fasci al lesions withi n the pelvic n cavity along the vaginal canal . The va i al recto cele 1s due to the drawing aside of the evator ani fasci a eu rior and but li le to the external lacera ' ° s begrn ning of iiiscomfort on assu ming ex n is due to dera ged pelvic circulation, to dila

n v - tio and straightening out of eins, to non uniform support of the blood - vessels an d nerves by the proper The r w connective tissue . advancing head c o ds the r r n d r fascia fo wa d, a if the labor is te minated without rc th e fo eps, the rents begin chiefly in rectovaginal

septum . It is well to decide what and where the lac o i s r n ration , so that tissues may not be eithe de uded i or split unnecessar ly , for it is not unfreq uent to see

tissues united whic h were never involved in the lesion . r f has an atomi Pe haps su ficient been demonstrated, l - cal y and clinically , to show that the lesions of the perineum which disable and discomfort the patient are chiefly lacerations of the fasci a and secon darily

o ur . of the muscles . On this view we base labors see If this be the case , we can easily that Emmet secured success by denuding an elli tical area of the m o on si de s vaginal uc sa each in t vaginal sulci . The curve of the d n uded area correspon ds to the ' r 0f i rec tova m al poste ior curve t e g septum , n u c situated within the i troit s . Now, by introdu ing u or s tures , the levator ani fascia su perior and inferior may be reunited, restoring the curve of the posterior . vaginal wall and the fascial 44 run vac mx AND Ps mxs uu ;

u l r layers at the vulvar outlet . In re niting the evato an i fasci a superior and inferior the levator ani m uscle

i n . becomes also reunited , but an imperfect degree The levator an i is closely embraced by its an an d inferior fascial planes , as from its origin, tion and relation it depends on its closely associated

fascia . The restoration of the function of the levator ani muscle must be accomplished through restoration

of its intimate lanes of fascia . If success depended i fl on the muscle 0 e y, it would be u cele to reun ite the separated levator to the rectocele in the median line

symmetrical muscular action would be restored. It is true that to secure muscular action of the levator the loop must be so repaired that the fibers shall start to act approxi mately from the but this is accomplished by reuniting the levator ani ' a li ne f scia as near as ml b1e 1n the median , which r n b i gs the muscuifr loops with it . The levator ani fasci a superior and inferior is really a sheath for the

levator ani muscle to aecom lish its functions . The sheath can not be torn wit out creating damage to t the muscle . In rectocele, his fascia is so torn and stretched that the anterior wall of the rectum loses

its muscular su pport and bulges forward . Whether the sutures be introduced antero- posteriorly or trans versel i t i y, it matters but little, if they nclude in he r the levator ani fascia exi sti n in the lateral

sulci of the vagina , and whatever is one, to be suc cessful m , the rectovaginal septu , composed chiefly of a fasci , must be restored to reproduce the normal curve

th . of e posterior wall of the vagina . Mr Lawson ’ Taits flap operation on the perin eum accomplishes ’ ' sxactl what Em met s operation in the late ral vs nal h o n . t sulci oes, with the excepti n of denudatio operations, when properly and successfully executed , result in the restoration of the con tinuity of the deep o ams 46 s w TO MEND r .

fascial layers of the pelvic the ent of partial or complete muscular u doc t f nction . The sutures reunite the struc ures (fascia and muscles? at or near their normal points of s attachment . Anatomically then, the object to be obtained in an operati on for colpoperineorrhaphy are l s r the a , the re to ation of levator ani f scia, superior 2 r the r and inferior ; , the eunion of fibe s of the leva tor ani muscle so that it will functionate—both fasci a and muscle must have relations at the perineal attach m 3 ent ; , the restoration of the transverse perinei i lateralward muscles which draw the vag na , causing : 4 i schi o ri it to remain open , the restoration of the pe i n eri n eal bod 5 neal ligaments regard to the p y , the posterior curve of the v u must be rsproduced by rectova i nzg: tum 6 the g p ; , a new perineal uld be restored so that the natural backward curve of the rectum and forward curve of the vagina l e estah shou d persist ; i . ., normal relations should be li shed a between the perine l center or body , on the

on e n . ha d, and fascia and muscle on the other The ”— perineal body punctum fixum of vulvar surface

relations should be restored . a The pelvic floor is com of muscles , fasci , ess t are r areolar and elastic tissue . struc ures inte The pelvic floor is structures arise from

medi um line . There two ligam ents of each

kind . If one will carefully study i n dissection the levator ani an d the bulbo cavernosus muscle he will

be impressed with their fu nctional comparison . Both are u nn sphincter m scles . Both have co ection with n t n ski as mos true sphi cter muscles possess . The three points of insertion of the b ulbc cavernosus may be considered as on e muscle . They contract together 46 run m oms sxn re sum es ;

m e of and have a similar function . The co mon featur the two muscles is their attac hment to the terminal fibers of the rectum and v a . is closely united to the musc es of the pelvic floor by e d n i the t n o s and fasc al attachme nts . The object of muscles of the pelvic floor is to control the lower s ends of the vag1na and rectu m . Fascial structure are common to muscles which have to afford sustai n ing power, as those of the abdomen, back and thigh .

G RA L W ENE VIE S . As we employ perineorrhaphy to repair uterine prolapse (sacropubic hernia) as well as defici ency of sxtem al hi n ctsr u the apparatus, the s bject covers a l 1 — . e vast fie d kinds of g nital suppor—ts peritoneal, fascial an d vaginal sphincter apparatus must be con d si ered . To have , both peritoneal and fascial

rts i rr . su po must y s1pdr,oalsapwseell as the occu ence of mus p on cu ar relaxation . No e support to the exclusion of all others can be claimed for the uterus . The utero - rectal (sacral) ligaments which consi st

o n n n fibro~ musc u lar of perit neal duplicatures , co tai i g ti ssue r n n t The , a e very efficie t uteri e suppor s . peri ton eu m m n itself, on account of its inti ate connectio the and e con to pelvic viscera fascia, doubtl ss gives iderable eu ) s ort . The dpi amen t roun g , with its peritoneal duplicature the broad ligaments holding some muscular fibers and the vesico- uterin e ligaments all assist i n support. n i l n ing the ta s. In the consideratio of sacropubic

- the hernia, t e intra abdominal pressure , the state of rt abdominal walls, as well as the visceral suppo s, n n should be weighed . Whether the patie t has e ter o i n n The r n e ptos s is a very significa t questio . pe ito al n n n on duplicatures, with their conte ts, co stituti g mes l n e terisa of the genitals, e c to in nteroptosis just as m i s and they do with the sto ac kidneys, intest ne now . m 47 TO 11m THEM .

fin r other viscera . It is not uncommon to d a ute us

x . excessively mobile , due to rela ed supports Dis placem ents of the w i tals not only involve their u ang hse elvi c special s pports p floor, but the whole peritoneum and the abdomi nal w It u sed not be doubted that the mechanism of the The is com li cated . o s pelvic viscera p levat r ani , clo ely e i n ensheath d its superior and inferior fascia, forms a di sph 111 through which the viscera find an 0 By int uci ug the finger three- fourths of an inch

i - e - A i u of F 10 Rob i holor. me m ee e e i g . . ( n on 8c ) d degr r lax d vag nal ou t et to be eme i b co o e i n eo . l , r d ed y lp p r rrhaphy d into the vagina, the le ge made by the fascia and u i can n m scle enclosing the vag na be disti ctly felt . The n he thsd a muscle normally e s a in its sc bbard , drives the vagi n a and rectum directly forward and u t i i r pward toward he pubic arch . The fasc a nse ts itse lf in to and embraces the lower third of the r The o i s the i m tan t support . levat r and musc ar) supports lend to the lower

vagina a firm fixation , quite immovable, 48 rs s vse m m o Pe nm an ; forcing i ts walls closely ‘ ed u d ucing a prono nce v nal sphincter apparatus . r11 marked contrast to the ower third of the vagi na er o n lax i l is the upp p rtio , which is , mobile and y e d surrounded b ti s onl ing, bein loose sue y.

' The ntot ral portion 0 the vagina and the neck of the bladder are firmly fixed by the vesi ubi c ti eats ofi g: m which dwindle into the white e . r can be seen duri respiration wi th M8 relaxed and displaced ggtsls ; the urethro - vagr23 porti on l remains stil , w ile the remainder of the organs move to and fro with each breath or diaphragmatic move ‘ ment . S u orly the lower va is extremely the firmly fix by three layers of m , fibrous fascia — r i the posterio layer of the tri ular l gament, the r the ou t ante ior layer of triangular , and the ' or the of superficial fascia . These three and dense fibrous layers originate at the of the ischiopubic rami and stretch across the ubis n of , surrounding the vagi a and i n ti mat l being e leaded in the vaginal walls . To be convinced o the fact that these fibrous lami na are the all - important sup ng structures that not ' only retain the lower on of the vagina in tion but prevent it from being torn away at la one needs only to dissect away all supports from the lower ' tu vagina except them , and then by gg and drag si r ging on the inlet of the vagina , note almost i i r r unyi elding ual t es . Parts of these fib ous laye s ( tn angular ment) frequently lacerated in fla - l labor, and must be included in the p sp itting deep sutures to restore the lower va inal tube . ra g Late lly , the vagina is firmly xed against m ubss b descending ra i of the p , not only y the b y the o ani called triangular ligament, but levat r ci a superior and inferior enclosing the levator b c d u i n er for nch muscle. By i n c g the fing about an i

50 rue vsc nva sac Paarus unr; uterc rsctal (sacral) men ts (extending from the rectum to the neck of te are the most import. a t the eri ton eal su , r h . t e cer n of p po ts f they relax , . W111 rd i the downwa and forward, wh le body us of i ll ass ac and fun the uterus W p b kward . In other words , elongation of the sacrorectal ligaments is the

Retro. initial s of retroversion and descensus . versi on c angas the i ntra- abdominal premure from the posterior surface of the uterus to the anterior and

~ superior . After retroversion the i ntra abdomin al pressu re is exercised on the t and anterior surface u l n ted i of the uter s, driving the op neck, like a con cal we e dow ward th ac dg n at every . The cervix ts in o raduall r retroversion as a wedge or c ne, and g y fo ces to h the sphincter apparatus yield. T e filling bladder forces the fundus backwardyand the full rectum pushes o a n the cervix f rw rd, all perfecti g the retroversion, the i u terou beginn ng stage of prolapse, by elongating the rectal ligaments . r In colpoperineo rhaphy , we must not only repai r

r bu - the deficient sphincter appa atus, t the con e shaped descending cervix must be amputated and its blunt en d turn i at downward, so it should poi n rd rsst against gl 0 sacro- coccygiiil regrou ( bone t‘zall ments) instead of attempting to dilate the levator gnt muscle at every breath by the change of i ntra abdom i n m nal pressure . When the cervix o ce gets fir ly into

1 . e . va r i r the vulva, , into the g nal sph ncter appa atus, 1s e r i the descent r p d and nevitable . The upper two the n ea n thirds of vagi al walls being loose, sily desce d the with uterus . In descensus uteri, the vagina is m inverted, showing in all probability that intra abdo inal pressu re hadgdisplaced the uterus first 1n the proc see i e of descent . An intact sph nct r apparatus will n Th r long retard a descendi g uterus . e ante ior vagi nalgwall appears first ln gprolapse ; however the vesico pubic li gam ents may still retain the bladder 1n posi ow o 11mm ru ns 51 n r .

s tion . Posteriorly , the peritoneum descend with the r cervix and upper portion of the vagina . In othe the are words, upper part of the rectum and vagina r t are separated, While the lower ec um and vagina muscu lc fa i closely connected by a sc al septum , with the thi n edge of the wedge upward . B ars forms of prolapse may occur where the cervix is elongated or Where the peritoneum i s loossn ed con stretc hed . Space forbids reference to many other n n di ti o s and kinds of perito eal supports .

’ 12. 0 o n s met o Fl‘ Bak r Br w h d. about lflbo. GENERAL VIEWS l N THE DEFICIENCY OF THE PHI NOTER S APPARATUS . The vagina should' engage more of our attenti on because it is on this apparatus that colpoperin eorrhaphy is applied . Th whi ch produces deficiency in the supports of the o sphincter apparatus is labor . Other fact rs play but u a secondary r le . 52 rs s vac n u m o rxarsxuu ;

not i n frequently lacerated near where the fascial uscu lar r sufisr acer 0 fibe s also l a o f ” H H ti n . The M “! are ci catri cm M d loss O ma be i n The er r which y felt by pal t o . ant io 00m “ mu m mt m0 " 2 1 ” H wall 8 , cl wall is 0 m m showing various si z ed x n omi n en t and formed lesions . Rela atio is m 01 m m incomplete . Instead of the curved canal with the perfect sphincter apparatus, tha n i n g

- ' F i . lax D o l s met o of col o erlnec rrha h . g r. G oda l h d p n p y

a u x am p t lous, rela ed , open mouth , resembling a tob ou r i o e p ch which has lost its pucke ing str ng . S m times the inal mouth is closed by an anterior and i oo! for i di stanm or gl fold, a cons derable up a the vagina . The c um of displacements of the — ual organs are so num erous as elongation of the ero re acera ut ctal ligaments , si on tion of the cervix, l i r t on of the levator ani muscles and tri an—gula l en t ro- a r s r t o o tb t am , int abdomin l p e su e, en er pt sis a

Lfipossible fac tors must be considered in repair. e s rc s as the Repair must consist in corr cting viciou fo e , U re am 53 HOW TO MEN . pointed cervix should be ampu tated and tu rned back d s n e tor war , the po terior vagi al curve should be r s ed with a perineal body to turn the rectal an d back an d the lacerated levator ani fasci a should be reu n ite d . An analysis should be made of the factors produc ing displacemen ts and lacerations in the genital e ho organs . Defici ncies of peritoneal su ort s uld be considered disti nctly from deficienciesppthe sp hi ncter i n a paratus ; however , both may be often comb ed .

st, after all, our chief attention will be directed to

for . deficiencies of the sphincter apparatus, on it de

da prolapse and lacerations, chiefly fici en t primary perito neal su pports r l s vaginal inve sion as rectoce e, ve icocele, loses rectal disturban ces, and the vaginal mouth its puckering string condition . In colpoperineorrhaphy, the whole of the tissue of the pelvic floor should be utilized for so port by forcing it into the median t r the line . This wi l res o e the tonicity of pelvic floor and form a firm cicatrix which will prevent sacro- pubic hern ia and normal

i or fl denudat ons aps are requisite . Successful colpoperineorrhaphy must make the pel vic floor as tense as possible and the n ewl formed cicatrix will aid materially in its success . he thick ened tissu e (columns) on the anterior and posterior ’ are vaginal walls remnants of Miller s ducts, which ’ r m an d should be and are p eserved in both Dr. Em et s

Mr . They furnish eviden t sup e m s. It may be observed that nearly all successful methods of peri n eorrhaph make the den udations in the vagi n al sulci on eacfi a side , and avoid s crificing the thickened tissue on the r s va rn al ante ior and po terior g walls . Reference to the r B i schotf n o Kalt n labo s of , Marti , H gar, e back, Schatz , an d W Emmet others ill show this to be correct . Afte r 54 was vac ma AND rsamaum;

r ormi n col orrha h M pe f p p y posterior, artin makes what

may be ed an extension of the perineum forward . Thi s is an excellent method of restorin g the r curve of the lowe end of the vagina . Any procedure , to be successful, must conform to

s . The denudation of the lateral vagi nal sulci or the flap operation s conform to anatomic an d a r f conditions, so far h ve p oved success ul . The

' - Pi . u u and b . D r. en n s met o of co o e i n eo y. c . B y h d lp p r rrhaph reason denudation in ermeorrhaphy is so successful is because healing in tEe vagina occurs with con sider able certainty .

THE METHODS PERF ORM I NG PEB I NEORR HAPHY. The methods of perineorrhaphy may be classified i nto three divisions , viz . : Those which start at the vulva (denudation) ; those which attach the lower vaginal portions (den udation) ; those which depen d am 65 s ow TO mass Te . on the flap procedure (which embraces colpoperi n e orrha h p y) . Numerous methods of perineorrhaphy have been r Pare Di efien bach tried since the days of Amb ose , and Baker Brown , when they simply united the super fici al ti ssue which was situated on each side the visi r o ble lace ation . This was a superficial vulvar ro ed ure and was of small value except to prepare t e way for more useful methods .

Y HISTOR .

eri n eorrha h If the ancients performed successful p p y , I 001 eri n eor am unable to obtain the records . p ' rhaphy as a modern operation can sw rce y boast of o to being more than a century old . Surge ns sought prevent prolapse by excision of the vagin al wall so that the resulting i nflammati on would produce a con tr c n x a ti g cicatri . Others applied caustics for the r Accordi n to r same easons . Schroede , Girardin u Laugier employed the b e stone . Phillips used n e di d Ken smoki g saltpetr so Laugier , Velpeau , n ed D i efl en baoh Oolles an d Chi en y, , Simon . pp dale sought to stir up inflammation and cicatricial contraction in the vagina by the very questionable method of it with gonorrheal virus . Opera

the vulva or vagina . The vulva was first attacked by such surgeons as Baker Brown P re and a . Fricke was the i oueer who performed epi siorrhaphy whic h con sist of den udation of both ’ n labia and u ion by sutures . The failures of Fricke s episiorrhaphy induced later surgeon s to operate higher e i n m up in the vagina, which finally r sulted the E met e e and Tait m thods . Mende suggest d denudation in m n the region of the hy e . Malgaigne thought it ‘ l n shou d be do e deeper in the introitus . Jobert caut eri ced n r an d the the vagi a when it p otruded . after l i n t u exfo iat on of the eschar, u i ed the raw s rfaces with 56 rue vxoma AND maxi mum ;

sutures . g employed chlorid of zinc to . Des ranges i i produce c catr cial contraction . Marshall Hall was r l among the fi st to emp oy elytrorrhaphy . He cut out oval or long segments of the vaginal mucosa and united the denuded surfaces with sutu a l e on e b ch formed flaps . Ve p au was of the first sur a n geons to do successful perineorrhaphy . L nge beck and Karl Braun were also pioneers i n the operation Early o rators failed on account of lack of anatomic knowle ge and preva It is not many nec essary anato m

y . It was learn

be elongated , but a s olid, must be con structed that t

haps Simon ,

berg, was the 1867 when , in ,

to it that of rior colporrhaphy . a r the vagina wall with a sc lpel , and a fenest ated speculum was placed 1n the vagi na while he freshened the upper part of the vaginal wall by bavin an assis tant introduce the finger i n the rectum an force the e vaginal mucosa out at the vulva . Veit, H S i l r fime pe ge be g aided to develop the operation . g n ad passed , i struments for support were gr ually dis c n placed by more perfe t operatio s, owing to more an a holo l1 perfect anatomic d p t gg c kn owledge . Most of the advances are due chi efl to the investigati ons of E u ui er r Wilma 1879 Freund, , b oeder, ( ) 1 Hue fel t r men and Staude 5 Breisky , p and o he s on ed a r ti in this mon l h . The p actical execution of co lpoperi n eorrhaggyy the celebrated Heidelber e 1a t su bse ueng surg on , Simon , the real founda ion of q ’ o of labors . The success attending Simon s additi n colporrhaphy demonstrated that some form of operation is required in prolapse or deficien cy the

M y , a r r- m i n; d i s c a o xf . -M t ' g i n . q c a l l i f b tu 1 . l u t “ M g I f. f - lr m wl cfl m r v a t- m , , p ra t ta n 1 n d n eed i m zs wa ve " g . a 1 fl ' ' ” t 1 . m m lm w f fl i h v m l 1 1 m m ta m n ‘n to n e w p a . 1. 1 . m u J. 7 . s n o

‘ “ Wm M l n /l n o f n wr fl n m n w he m t u rm a n d 113 «ma I f ne t l n u 1 ps e de .man .

' An e w M s up in thi s operati on wha the flap ‘ i n lfl armed S f f r 1 . ) a as 138 8 01 18 are l ac cessi b e , Hm i n i n Ha rli n sur eo n vo n la n e n bec k in 1 5 first . 3 2 g , g , ' l la-nM HN I Hm He a m'at in n i n eri n eo h h He p p p rr ap y. t ln nn i M r n Hm spli tti ng of the rcctov agi n a l se ptu m m a k n i g a vngi rm l tln p forward and a rectal flap bac k ' wn rl l lmn h n tw -k n de scri ti on of r r q p pe ineo rhaphy, 0m tm tmlntM l b In Marc is th y y, e most important 9 now ro me nu ram . 5

contribution to the subject before the time of Simon e of Heidelberg . In fact, it is almost quivalent to ’ —i n the Simon s, and in one sense superior the use of l ! flap . Perineorrhaphy was a so cultivated by ary ,

Mursi na Men eel Osi ander an d m er. , , , Ho rha h p y was first performed with silk sutures, the hot n e iro , and chemicals . About thre quarters of a cen a 1879 tury ago metallic (wire) sutures appe red . In , Worth published views on the use of catgut (animal

o d . ligatures) for buried sutures . Schr e er chiefly intro duced the buried spi ral catgut sutures in peri neor rha h eri p y. Silkworm gut is one of the best mat als n 1872 for sutures in ge eral use at present . About , Mr . Lawson Tait the use of a certain flap i n i method, consisting o resplitt g the old c catrix by n the use of scissors, reuniti g the produced wound surfaces by means of su tures which do not penetrate

. skin or mucous membrane . The utility of this con

to either,or both , perineorrhaphy col o rm eorrha h or p pe p y. The flap operation was dimly Di efien bach 1829 r i n cisi on s begun by , in , by his late al e d n to relieve tension . The flap op ration was efi itely r i n eri n eorrha h int oduced p y by von Lan beck , 1 g 85 b . 1861 about , y Verhaeghe) , olles i n i - v al O of Dublin , a case of ves co fistula, resplit, instead of parin the ed es, an united the 187 J g e l resultant flap . In ohn unc n resp it the edges of an artificial anus and reu nited them with t interrupted ca gut sutures . He forced the flap of mucosa u ward and drew the flap composed of mus culosa s n an serosa outward, thus morea i g vastly the denuded surface for coaptation , Hart and Barbour

. B . report that Dr . A Simpson applied this flap method ri n o rh e e r a h 1872 Mr. n to p p Not far from , Lawso a of Tait applied the p operation Langenbeck , Colles r and Duncan to the subject of perineo rhaphy . He added to all previous labors the use of sharp- pointed 60 ran m e n u AND res umes ;

re elbow scissors, and the introduction of the sutu s without pen etrati ng the skin or mucosa of vagi na or

rectum . Silkworm gut sutures are em loyed and remain in situ for ten days to six wee W e ;

, a; an e a s r an V to S ger, St in , a D ne, and Vo s, a No wegi , s 188 ra nd similar method Later , Hadra , 7 , cont ba v aluable views on the restoration ot the pelvic floor, Jenks r as well as Marcy , . Byfo d, and M y.

— ’ we. F i . let D r. han e s met o The a e D 8 odd wi th g S h d . r a . . n d f r The m b es t of H r an d S t. i si tu rea y o tyi ng . ethod rese m l tha m

The various ao- called operati h n orrhap are umerous . The

olv c in . i n v the vulva, the se ond both vulva and vag a

1 r s Pare 1 580 s s e . Hi . Amb o e ( ) u ed imply sutur s s ' 1 Gul llen n cau racfi sed and improved the methw 1 LaMotte g Murenn a ( , mellie , Noel, and rotte prac tised it. m 61 now TO n e w) rea .

2 n . 1830 Di efien bach i b sutures and te ( ) , un on , n u x 1834 sio relieved lateral incisions . fio ( ) intro duced n ce M it into , as well as ark See and Polai llon ( 8 1885 . Baker Brown , union by sutures of the ilme and S tands cultivated it

in Germany . 4 . The next important contribution and method ’ rin eorrhaphy was von Langenbeck s flap method ( 1gb It was described and performed with

a master hand . Von Langenbeck also suggests that i n as the lateral ncisions of Dieffe bach may be added, ro it obviates f m movements . He advocated r imm if ssi bl o o ation ately after the injury , po e. V n gen beck makes several distinct steps in the oper ation : vi vificati cn of the free border of the recto vaginal septum ' the undoubling of the septum an d the formation of the flap destined to form in the new su a s ace m, the anterior side of the triangul r p

ed by two canals , vagina and rectum , with the perineum as the b ase ; the vi vi ficati on of the two li u of the laceration ; the insertion of the sutures .

up into the he aid of a 62 rue VAGINA AND p amus un ;

r i ischofi 1879 an d K co d ng to B . In Hegar altenbach n 1877 rt made excelle t contri butions In Le Fo , and 1 Neu ebaum 1881 r . 877 Dr. g in , added their labo s In J a i n Edward W . enks of Detroit began the public t o on pcri n eorrh really a flap method of

- 17 . S hs cs of th e n ud ed e n rrha h I p e d ar as i col ” eo ’ t . S g : h i mon ; c oosen d i tc . I n and b c dot tcd Hugrc ro Ha ar , L ; , F h a . i p scn t thc su t ied b s u es bu ti ssue the b c li n es the e ose su tu e . r r y , la k xp d r

’ von Lan en beck out e . J of g procedure Dr. enks first fla b ut a e r th awa the p , ft rward p eserved it . The me od . is cat g 1 similar to the flap method attri : . 8. n buted to A Simpso by Hart and Barbour, o 1 m m n w To 1 THEM . 63

In 1 879 Worth to u se b uried catgut to suture ac 1883 i m the wound. Dr . r e , in , used buried an al M i i ligatures. H . O . arcy publ shed a series of art cles 8 ri n eorrha h ad vocati n ( 1 83 ) on ’e p y, the flap method ‘ cf n i and b uri e a imal l gatures, which e first used i n M of hernia in 1881 . A. artin Berlin contributed 2 188 . u 1880 excellen t labors about Abo t , Pro feesor Schroeder of Berlin obtained excellen t results “ ” c i by the use of the e e stit h , a cont nuous run ni ng suture of catgut uri ed in the tissues of As e the denuded surfaces . a pupil of Schro der and lt resu s . Martin , I observed excellent from this method B i schofi in part revives the flap operation of Langen i n beck. However, his operat on was quite i fluential i t D re r an d son in s day . . Byford, fathe , made valu o ti on s t able c u tri bu to the subject . History no es that ’ Simpson carried Duncan s fl ap- splitting to the peri u r - fla ne m . Simpson perfo med a kind of four p perine h o r P r Mr T t m orr aphy f r many yea s . e haps . ai i bi bed

some of his views. 887 n e In 1 Dr. Hadra of Texas co tribut d some valu on able articles the subject of perineorrhaphy . He osted vi vi ficati on of the posterior vaginal wall for orrha h n r co p p y, as is do e in anterio colporrhaphy . n 1880 Si ce , the laborers in the field are legion . Gradu ally the operation of perineorrhaphy . was modi fied Pare r Dletfcn bach n from , Bake Brown, , Lange beck m ti and Simon to Tait and Emmet. The od 1fica on i n consisted denuding not only the perineal tears, but i r also denuding h gher up in the posterio vaginal wall . Hildebrandt especially carried the denudation well up

into the posterior vaginal wall . u e As regards s ture mat rial, Sims, Thomas, Emmet and others worked out the application of metallic wire to plastic labors on the peri neum during the past r s thirty yea s . The modern tendency is to use ilkworm

- gut as a non absorbable suture . This may be left 64 r ue vxc mx w e seam en ;

weeks i n wound and t i n co tin h a , acts as a ap g t e

u c . ss . s rfa es It is e to remove . Dr . T . A Emmet is due the credit 0 introducing a method of peri n eor rha h i w on p y which , until recent as the e generall se m 1 practi d in A erica . In Dr . Emmet publish a new method, or rather a modification of his old erati on e u gp . Dr. Emmet d nudes the s lci on each the vagina and exten ds the perineum forward . His operation is intended to repair u Dr m scles . . Emmet holds that

’ 18A s o e ati on s h ostcri or . . mot r “ p D ” pr m w arm . afi n a.s m sn . m e lowing laceration i s not due to i njur of the perineal l f body . The oss o support after chil birth , he claims,

s . is due to rupture of perineal muscles and fa cia Dr. ’ Emmet s Operation is difficult to make clear b de n a fi scription , but it co sists in l teral denudation w olly within the v ' na to such an extent that when the sutures in used are drawn tight, the excess or slack in the posterior vaginal wall disappears. The ostium vagi na is not interfered with by any s eci al denuda m g rt tion . The clai of his operation is t a discomfo

66 ran vxc ma AND PERINEUM ;

r disappears immediately afte , and also that the posts rior vaginal wall is brought in proper position and r to the o i s o elation anteri r wall, as it in the n rmal on m a c dition . The view aint ined in this surgi cedars is that the perineal body is . 1 i n eu ort er i p , and that lac ation of it alone mpairs bu t pl i n i o lit e the tegrity of the en tal supp rts . But the tearing or excessive atretogi ng of the perineal muscles and fascia at their attachments to the genitals quickly disturbs the delicate balance of the pelvic

— ’ a b met o fla of i neor h . The d Dr. Jen s e F “ n . k h d ( p) p r rha p y - i mi n i s ed uca te i t two n e s i n the rec tu m md coal fl ap cl g d w h fi g r u a [n o tae fiap i s m rked ou t by a dottcd li n e z i n b ths fla p i s complc f r u ready o s tu ri ng .

’ i m er n There is one point aga nst Dr. E met s op atio , and that i s the relatively blind method of i ntroducing rs the higher sutures . In other words, the deep laye of the lacerated pelvic fascia may not be included in

e . . the sutures with any degree of c rtainty . Dr Gill m ’ l Wylie added the idea that Dr . E met s operation wou d be i mproved by den udi n the posterior vaginal wall a considerable distance an than continuing the dw e 11m m 67 n ow TO THEM .

dation well up i n to the posterior vaginal sulci . This w r method, ho ever, sac ifices a larger amount of poste

rior vaginal wall . 872 About 1 Mr . Lawson Tait of Birmingham erni n orr land, began to introduce a method of p e d a differed known as the method . It from all i n that he need s bow scissors and introduced the very deep sutures without penetrating the skin or mucous

. i rec membrane It involved no loss of tissue . The d ‘ n gthe Tait operation 18 to resplit the old t 18 modified accord in g to the condition of on e r the case , as may p oduce anterior and posterior ’ a cuts . Tait s fl perineorrhaphy 18 now quite gener r ti ally p ac wd . have not attemp ted to give all known or r hist ic methods of pe ineorrhaphy , but simply the c d r hief ones, out of which have been built the mo e n er op ation .

GENE A I O O B RHAPHY R L IND CATI NS F R PERINEO . vaginal function s 2 To restore lvi c fascise and muscles . Normal m fascia 18 re qui for nor al circulation . the 3 . To restore normal relation and support of col orrha h the posterior wall p p posterior) . The wall and bla i u the 4. To prov de as much s pport for pelvic g unsas the restoration of the perineal body will

e theni 5. To remove the n urae o conditions ; to reli eve the inn umerable nervous associations ; i n to h si oal short, relieve mental and p y

6 r . . To repai and check sacropubic hernia t 7 . . To narrow relaxed pelvic ou let The pelvic floor is closed from behind forward by the riformi s p y with its thin , delicate fascia , the firm sacrorectal ligaments, the coccygeus with its moder 68 m vac ma AND su mmon ;

e t on r at ly s r g fascia, the levato ani muscle with its le am fascia ri vator supe or and inferior, a strong rotecuve r double fibrous p muscula sheath , and also a u h amen t the tri n lar g , a powerful layer of fibrous

. g cocc ene tissue he g with its fascia, the levator ani with its double i n and the triangular ligament practically consti tute the pelvic floor and seem to i separate the pelvic cav ty from the perineum . These are ss u s r e ential struct re in colpoperineor haphy . The

a - n w am ea azsa a m s s r t mw s levator ani fascia (both la ers) pass from the side of r ml s the pelvis to the visce a , y attaching themselve to every pelvic organ , forming the . strong, fibrous e expansions known as li aments, which s rve to hold

g r t . the pelvic viscera in de nite fixed elations . In pe i n eorrhaph success depends on the restoration of these vi supports ' a significant anatomic fact in pelvi c pathology is that the blood - vessels lie superior to to the pelvic fascia and the nerves inferior it . The now To mes a runs . 69

blood - vessels which arrive in the peri ne al region pierce the pelvic fascia and pass chiefly out of the c great sacrosciatic not h . Th i e levator ani fascia, superior and inferior, s an r m i n important structu e to li it i nfect o . It separates the ischi orectal fossa from the pelvic cavity proper h n i where so much loose tissue exists . T e levator a

i s e v n d . fascia pierced by vessels and n r es, a these ves sole an d nerves are surrounded by lymphatic sheaths which are a source or th by which the infection vi i t ma travel from the pe a to the schiorec al fossa, I n i n r ni an vice versa. per eorrhaphy the levato a n d i 0 fascia, superior a nferior, is incised . The tion which is performed for the restoration o the t ff n a perineum exis s under di ere t n mes. It may be - e termed perineorrhaphy , perineo vaginal r storation , n t n eri n eaux esis i cal ex ensio , p , or the flap method. r m col o ri n eorr oweve , I think the best na e is p pe ha o ri o rha h n phy. Oolp pe ne r p y is a operation to restore

the integrity of the supports of the sexual organs . These supports i nclude those of the peritoneum and al u v sphincter apparat s. he perineal body i s situated between the lower i end of the vagina and the rectum . D fieren ce of opinion still prevails as to the utility of the perin eal the n m body in eco o y of the female genitals, but,from many and considerable work on the sub l 0 1 m, I c aim the following functions for the perin a Y I It ustains the low s of the anterior rectal wall an sposterior vaginswtands 2 an d di i en . It sup rts directs the scharg ng d of n orward li am the vagi a , aided by the triangular g en ts n d an a levator i . 3 en . It supports and directs the discharging d of the rectum backward ; the rectum is di rected

ward by the levator ani muscle . ra s vse mi AND m u s e um;

4 n . . It not o ly keeps the discharging ends r e ectum and vagina wid ly apart, but it gives both a support in a curved direction at their te rmina thus afiordi n mechanical advantages for maintai ni n g closure of hot aperture sand preven ting the easy escape n l of the conte ts of either cana . The wide divergence of the two ca nals avoids mingling of the secretions co uen t r m and irritation f o decomposition. The backward ook of the reotum and the forward hook the v of agina are an important factor in support, and

' — si mi to al . l te Pou l. e F ort s 889 met o i c i s F ig . (A r ) L (1 ) h d . h h lar ’ ’ w u 4- 18 an d i h rt An i n ci si on is m e i n the i n De marq ay s (186 15) R c e s. ad vag a tum ' then an i n cisi on is a t the i n t C , i n the m ed i an li n e dc wn w the rcc m d on the i ne D E nothe i n e C G i s c ied on g the re c ta a e a e l C. . a r l , . , arr al l b u t n ot i n to the ect mucos not e i n e oi n s i t b m e ns of all . r al a ; a h r l y a w i E G : t s m es isti n ct . H seen i n 0 . S ; the ci c t ic i , I . hi ak a d a r al m o d th W so the o ti on of the i n l ti ssue i s e e rom e t i n e g r v f r a g l . al p r va a l m ed D i s se i z ed and d issected from the ect ; the s ce e n u e wal . ark , r al pa d d d No the su tu es a re i tr d uce as s o n i n Nos } a n d 3 . i s D an d H ( . r n o d h w i s o i n N 4. The ( e ti o n 1s The d isposi ti on o the su tu res n te d o. ra a par ti ul fia metho bu t too co m ic te for o i n p rac acc. p d, pl a d rd ary o 11 a ) s w TO m ram . 71

n i e preven ts gapi g . The perineum is the sk n b tween

an d . n t n anus vagina The perineal body, co sis s of ski , n fat, muscles, fascia, elastic and co nective tissue . The perineal body as a support in itself for the i or ans has been much overest mated. gIt serves as the point of union of four muscles

- the levator ani, the sphincter ani , the bulbo caverno sus as , and the transversus perinei . It serves also a a point of union of the various f scia . s 6 . It acts as a partial upport of the t 7 . It streng hens a tried point in labor. acerat1on r m an r 8. L of the pe ineu to y conside able extent destroys the nice balance between anatomic structure and physiologic function in the female n ge itals . The object of peri n eorrha hy is : To restore partial ruptures ; to restore rectal un ctions afte r complete ruptures ; to preven t prolapse of the pubic segment

of the pelvic floor . The methods of rformi n g perin eorrhaphy are

denudation with fix coa tion , and the flap method . r u The etiologic factors of tions a e labor, coit s c r and trauma . Partial la e ation of the perineum may be accompanied b vulvar patency ; increased vaginal secretion ; i rri tab i ity of i s; pathologic con d1 ti on of nerve structure ; neura i c or n e urotic conditions induced by long- con ti n u ed local lesions ; descent (dis n r i w tentio ) of anterio rectal wall , posterior vag nal all , e h m and uterus . Compl te laceration of t e perineu may be accompan ied by vulvar and anal patency ° increased vaginal an d rec tal secretion ; incontin en ce o b cwal contents and occasionally of bladder conten ts ; irritabi lity and disease of the surrou n ding parts from the abnormal secretion s ; neu ralgic and neurosal con di tion s from chan in nerve structure ; melancholia (neuraethen i a ; t e xati on of the displaceable se men t of the pelvic our and consequent prolapse or ernia 72 run vac ma AND Paamatm ;

ti n t ac of the pubic seg m . The result may be tion from a di sturbance of the fascia which holds the

$3“ - r I f - ow a i n elation . the blood v els become s l distorted in their bed, disturbed circulation re ults. In discuss ' the operation for col perineorrhaphy by Emmet and si t I shall consider i see both founded i h on anatomic princ ples, bot practical and successful

n n h a . operatio s, a d bot rriving at the same end by dif feren t methods. However, since I can accomplish by a flap method exactly what Dr. Emmet accomplishes by den udation I have preferred to follow the flap pro ed ur d a o c e . I have employed the method f r over si x

over one hun operations per. all kinds of perineal laceration and ol I n on e c uterine pr apse . ase the uterus was com letel o n p y prolapsed for f urtee ears. Another case ’ . an lacerati o x te of thirty four years st din ,wit n e nding r en 0 the up the ectum the l gth index finger, was oper ated successfully after three previous denudi ng oper. ’ ati on A twen t o ei ht s. third case of y g years standi ng was M en tad up the rect um for four in ches and had :hree s r passed through unsucce sful ope ations . On e of ’ n - v n eara an - n twe ty se e st ding, with three i ch rectal ’ er

74 m s "c m AI D m u m s ;

has h hi nd i t a rstm va ted n tem s v hich p ecedes

the pati en t shon ld be

same time. r er are , but if th e be cervi x i t should be amputated and turn ed backward t a m t e t against he s crum . In short we must i i at na ure ou i ble to secn re s All hem i “ much as p succes . a is the same ; it is due to the destructio n of normal valves and the straighteni ng out of obli ue canals Henc e i n sacropubic herma the norm obliquity of the Col vaginal canal must be restored . poperi neorrhaph restores the posterior vaginal wall and anterior orrha h restor p p es the anterior vaginal wall. This i s not 0 ton needed if the colpoperi n eorraphy be n r thoroughly performed . Prolapse is preve ted by pe i neorrha h el trorrha li e p y, y p y, episiorrhaphy (or som l rola se abdominal operation ) . p may be consi dered as a downward displacement of the pubic en t of the pelvic floor; the sacral segme nt of the pe vic floor shares in it by a yieldingof some of its parts . There are so many varied opin1ons as to the etiology of pro lapse that one can safely say the subject is not fully r settled . In my opinion much c edit is due to Drs . Hart and Barbour for their excellent investigations on the structural anatomy of the pelvic floor . After considerable careful dissection I feel quite sure that

r . many p evious views must be changed, but it is hope ful when the closest and most con t1 n ued students of the pelvic floor come nearly to the same conclusion .

The subject of prolapse , I think , should be studied out 75 s ow ro MEND THEM.

i clinically . The field of nvestiga As time goes on the uterus itself e wi ll get less attention an d the pelvic floor mor . The subject of relaxation and submuoous laceration will l be more studied . Re axation of the whole pelvic du r r n s floor, e to epeated labo s, i fectious proces es and lesi ons will be foun d to be a large fac tc r i n Insufficiency of perineal support should i sight of, and the sph ncter apparatus of di ssec the pelvic floor will be more studied . From

s b - W F i . a an d i tsc alz be me t d The fi u re i s acc or g Fr h ho . g di ng

Pou l . The ce ti on extends i n to t e ectu m . rec tova i na l se tu m la ra r S , g p w m h a se tum ce te eri ne u m . I n 6 the ecto in g p la ra d ; P, p r vag al i ptum gS Dli tl tion on e would at once conclude that the levator ani fascia and the triangular ligament were the main sup. the ports in pelvic floor, and the relations of other 19 n sup must be considered . Dissection the o ly o rts n th ible way to u derstand e subject . For exam m p e, dissection of quite a nu ber of bodies has n thoroughly explained, in my mind , the co flicting views of anatomists an d gynecologists as to the posi 76 m VAGINA u se W ;

’ ti on cf the u e As n n lo u t en ma t rns. s g ec I hsve sevm l thousan d w m f snre ths t th o en , and am e

— ’ r am h alten hach. B ischofl s met o of ti . ut“ Haga h d u g B e dec ades i l b 11 on ‘si de of the p y. a ' ho i f h J co um n 9 B . is met t l o es o e v l . A . A Th d par al y r ad w d o ti on ote i116 u tte fl i n s 1 z a . M 08 a n d ra . N b r y w g . . . . d. d t-tor n S te vagi al. mm'um a t has the , is ly as the anatomis d i n Both gyn aec og et a d anatomist are correct . In the living woman the normal positi on of the uterus i s r ma that of anteve sion . In the dead wo n in dscubi ti s the uterus en erally li es i n the hollow cf the difiere m m. In just se e a manner arise the can n b e of opinion relative to prolapse , which o ly HO n e w!) W TO THEM . 77 cleared up by careful personal anatomic an d clinical i n A d f r nvestigatio . comparison of i fe ent causes will n le t soo in the light. Though the periton eal supports of the uter us be deficient they can be put at rest and fin al cured by carefully plann ed operations on the sphincter m apparatus . All pri ary uterus supports are attached to the neck of the uterus and before the uterus shows such signs of hernia the an ports attached to the neck must be definitely elo Doubtless the uterine supports are frequently elongated by i nfective pro. c eases and hen ce a rest by repairing and fortifyi ng the sphincter vaginal apparatus will result in restora n i tio . Especi all i s this true in certa n forms of rstroversi on r . I? the u terus remains i n its no mal ri tl l t r i n d s . e . oo a po ition (i , y movab e) no re rove s on n i l i n i co sequent pr W l arise . In chronic fect ve ‘ r vi c or aus at s p ocesses the g times swell, often, a become edem tous, en in a form of hypertroph r observ f om static congestion . have frequently slow repeated process i n the clinics

m o r w e on PROLAPS E . 1 or . Insu s : a , levat

r d rio and inferior; , perineum (composed of levator ani, - rn bulbo cave osus , transversus perinei and sphincter ani i schi o erin eal en e al ligam ts) ; , walls ; f, urethro

g - v m h a v septum ; g, recto in septu ; , muscul r an elastic tissue on lower t i rd of vagina . 2 I n ufi ci en c t : a uteru . s y of peri oneal supports , n m sacral aments ; b, rou d liga ents ; c, broad liga

- e e ments ; vesico uterin ligaments ; , i ted cerv x.

3 n - u i in . tra abdominal press re ncreased or applied b m t a nor al direc ions. 78 m m e n u AND n am es ;

l i n o r: 4. Re axation of anter or segme t of pelvic fl o

tion of vic floor and ’ 5 h i o . We t of uterus, wh abdorni nfi

P0 3 OPERATIONS PROLAPSE .

’ l fla e n an d ri eu m . Tait s p op ratio ( extension) of pe n .

3 - i . Elytro per neorrhaphy

4 r r . . Elyt o rhaphy

5. Amputation of cervix. 6 8 h rte i n Al x . o n of round ligamen ts ( e ander a g Ad ms ) . b road i a men ts 7 Shorten ing of l g . 8 u mi . Fixation of the uter s to the abdo nal wall

’ Macken roat s l 1 . o operati n. The operations for prolapse i ts u r the views of ca ses. Ope ators have attacked the r and n e e ute us, vagina , vulva uteri e ligam nts to a com i pli sh their purpose . The p oneer idea 1n prolapse was to close up the vulva. so that the uterus could n ot of escape . Thus we have the early episiorrhaphy n Fricke a d Kuchler . But surgeons soon saw that simply closing up the v ulva was like attempting to v board up Mount Vesu ius. The forces at work were e 111 n n not at the vulva but de p the i terior. The came

the operations on the perineum with all their variety, ’ ‘ ' from Gui llen n eau s successful case through D i eiren c 8 1 ms mo e ba h , Langenbeck , Simon and , to the dern fi p n d i operation . Finally to episiorrhaphy a r n eor rhaphy were added operations on the w of the h h an d el trorr El r r vagina (col ap y y ha hy) . yt o rhaphy has mquite a succcceessssffuull addi ti on to gyn e E D s ow TO M N THEM . 79

oology , but it is a denudation operation and hence destroys valuable tissue . I have observed that the European operators attempt to save anterior and pos teri or colum ns of the vagina . Men see in the column i c of a valuable e e of supporting tissue , and some

ti . them , like ar n , try to save it Dr . Emmet has n n e hi s o worked alo g the same li , and tion is ne i ts and of the most useful of kind, mastered e done thoroughlyis successful . In it he has combin d rmci les of the best p p the denudation method . It

Marti ” ColpOporin eorrhn p1) y poster!or accordi ng to newly- bui l t pc ri n c saves the column s and denudes the areas of least i Hi res stance . s idea of eu porting the pelvic floor is

n a - m certai ly correct . If the p splitting ethod could be made use of in this operation it would be a marked etc v an d i in ad ance . The vulvar vaginal operat on of en udati on should be superseded by the fiap exten

l eri n o~ e i i or sion method, which mi ht be ca led p e p s rhaph It is done wit no loss of tissue and can be carrie right up to the urethra . The amount of flap and consequent barrier of tissue built up at the vulva 8) THE m e nu AND p s amsum will depend on the depth of ‘ the scissors’ clip and the u a amo nt of exposed tissue, and lso much on the man

' n er suturi n . of the surfaces to be coa ted . The flap exten sion me cd will form one of t s best supports

s . for prolap e . The objections against the Al exander : Adams operation are l . Unsatisfactory reports

ta - m " i t m a ti on . n a les el t o bar n A Marti . t y ru s wo fl tcu li . Th a t st i s to esec t o r e n udc the t e e p r sid e i s freshen ed an d su tu red : the ri ght si de freeb

but n ot ti ed . a a the en ude i n . . d d vag al

2 . I the bias i n selectin cases for the oration . n ' quite a n umber of se the roun ligaments can m i n ves not be found . In any cases which I ted muscular ligamen ts could be discovered unti one 1 r No r got inside the n te nal abdominal ring . 3 . ope

84 rs s vaoma AND Ps arss um;

12 ea . The stitches l ve no cicatrices and therefore r will cause no i ritation . One can observe the most practi cal and best observers trying to save the column and trying to perform denudations i n the vagi nal i i ’ sulc . The super ori t of Tait s flap operation is that it saves all tissue and uilds a n atural perineum in a an d thus subserves natural forces

' - 29. Harti n s o e tion i t hu rled on “t et p ra w h . pn t i o co l orrha b the o s? t rineau xgz haphy) pos e r r p y : l w par ( pe l pe i neo b the u e en d 0 t re ; 0, lo e end of the c tgu t. r rrhaphy ; , pp r h ad w r a ’ la struc. accordi ng to nature s original w, and anatomic tures are not much violated by cicatrices and cicatricial con traction .

A fact not generally appreciated is the neurosis, the n euraetheni o condition produced by perineal lacera s ma s TH 85 ow ro s EM .

he si u tions . T vi ble wo nd is not always sn eri n woun with the fi g. There may be a visible ' - e fi an infecti on atrium , or simply an over str tch i muscle and fascia, which stretches and traumat zes i c the er pheral nerves, produ ing nervous irritation. The pasci al planes which hold the blood- vessels in dis t i n do. tm o relat o , are so damaged that congestion and

pelvis frequently arise . Healthy should be spiral and iform in caliber The

— ’ ml. P rofile i e of M ti n s col o eri n eorrha teri or. v w A . ar p p phy M . trorrha h D E eri neaux esis . A B, p y ; . . C . p lacerati on of the o fasci a allows the veins to n straighte out and mme irregularly dilated . This mhte ni n out and dilatation produces not only g l r and !mph congestion , but periphera ne ve pressure . T e frequent pelvic co tion and de

- congestion from defici ent blood vesse support, pro. duce conditions which favor the development of

pathogenic microbes in the genital mucosa . The gyn 1 1 13 n e w ; m m un ;

resemble thc old

closely that on e can scarcely tell after six mon ths that an operation has been pp0erf fformed

F orcystocele the flap o rati on can also be performed. ' The fiap method is al e applicable to partial and i r best complete perineal lacerat on . The ope ation is d emonstrated on complete lacerations . OW mssn re am H TO . 87

NE GE RAL CONCLUSIONS . ‘ ur 1 . To c e sacropubic hernia (uterine prolapse) , perform amputation of the (sharp) cervix ; anterior h ’ colporrhap y ; Tait s flap perineorrhaphy . n 2. The amputatio of the cervix is for the purpose of removi the sharp cervical poi nt ; directing the cervix bac ward ; restori ng the uterus to normal

' F i . [u d in i n m l g Pou t. ) a ten bach s metho co p ete ru ptu re of t e e i neum . l sut e of the an n le 3 su b muoous su tu e of h p r , ur r a g : . r the i n 8 b on ed su tu es es i n the oun . vag al wall ; , r p w d The ri r 3 . ante or colpo rhaphy is for the purpose of a r n n r owing the vagina ; elevati g the bladder, directing r the cervix lu ckward and the fundus fo ward . 4 T . The ait flap perineorrhaphy is for the purpose of testori the ri n eu m; restoring the obliquity of the ge n i cana restoring such a central floor as 88 wa s m oms AND PERINEUM ;

r and will emci en tly support the rectum , bladde , n ge itals . 5 i n ted rstroversi on . If the cervix be not and does not exist amputation o the cervix may be omit ted i n the above procedure d n 6 . If the uterus and bla der be in normal positio r r r rr and the vagina not p olapsed, ante io colpo haphy ml tted may be o . 7 ’ . The permanent success of Tait s operation consists in exte n sive flaps front and back cuts ) and the

— ' F i . a Ls uen stei n s su tu e i n com et e ce ti on . l i n troducti g r l la ra . p ° of su tu es i c co t the i n an d ect m ucos 2 i n t o ucti on fi r wh h ap vag a r al a . r d the e i ne su tu es te the i n an d ect e heen stene p r al r af r vag al r al hav fa d . li n e masses l r of large of lateral tissue for a pe vic floo . These lateral masses are drawn in and secured for u e weeks by deep sut res of silkworm gut . These de p ei l for sutures, six to ht in number, act like sp ints four to eight wee and thou gh part of the woun d au u ratea i pp , the sutures maintain it in coaptat on while ulates it and heals . Our operation s have proved definitely that the rectal sphincters may be practically restored to normal, a hi even fter long periods of rupture . One case of t rty ’ u u ful four years standing, with two previous ns ccem s 9 ow ro mass mas s . 8 denuding perineorrhaphies and a complete laceration of three inches up the rectum was restored to perfect

9 . The three surgical procedures described will obviate hysterectomy in many cases . 10 o . The flattening out of the operati n , or or atretchi n ing of the union . the g of the i es eci all o n ing prolapse . w ll depend p y t flaps and the amount of tissue permanen tly into the

- A Fleur0 84 . 12 oh . We especially insist that better results are tai n ed by allowing the si lkworm gut sutures to remain i n position for from four to six weeks . Should any an suppurate they may be removed at y time . Wounds do not heal firmly under three weeks . We feel eci ded i n stating from our own experi on ce that the H operation should not be disturbed by dressi ngs a patient should be kept t ui et for he three days, an d then a vaginal douche may given 90 rs s n orm AND PERI NEUM ;

d il After the first half day the wound is hermet aaly n i sealed by its own oozi g . The limbs should be

tied together at the knees . The bladder will generally r use equire the of the catheter for two to four days . Morphin in jections of of a grain may be given

14 . The the rectum from the vagin a

for hr i one to t ee nches , was added from n hi s at t . p ience , as I ever saw Mr . Tait do ti on al procedure lengthens the operation to fifteen i um e hi s i n to thirty m nutes ; Mr . Tait perf operation mi n u ws five to ten . r r 15. The result of the foregoing surgical p ocedu e has been grati fyi ri gly successful . f 6 . r 1 The fiap ope ation fits any and every case , or

m . 5 u 1 mm.

P4 b

In Lu ge - u . 4 a 1 y ea r.“

and i s t rough! wi t h m u ch sacri fice d ( i n i f the operati on b eck. B ut Mr i v . a e t s d al Ta t g it a new impe u , an so eri l /m us! i t w n ew p ith phases . He performed it wi th elb ow scisw rs and introduced sutures whi ch n ei ther HOW ro mas s n 9 ru s . 3

penetrated skin nor mucous membrane . As a pupil si x of Mr . Tait, for months, I had ample opportunity hi s r to observe methods of ope ation . The principle of operation con sists in respli tti the old perineal . wi cicatrix without loss of tissue, fixed coa ti on ’

a. a of the flapps After observing Mr . T it s met ods I n aturall practised the operation as ot i ormad by hi s a s n ts bout a him an a i sta . A year flor I began to modi fy the o ration by dissect the rectum and vagina from eac other for a variab a but long dis l 2 us tance ( to § inches) above the vulva or an . This modification enabled me to apply it to almost all forms r i a r of p olapse, relaxed vag nal w ll or perineal lace a 1n i r tion ; in short, all condit ons equiring e rha h r o p y and colporrhaphy posterio . The bjecti ghs a i n r isedy ga st the flap method we found , after over a ’ s1x r ears trial, we e not well founded . One objection ’ is that Tait a flap perineorrhaphy 1s a akin opera an rfici ll tion . If performed a y it may be subject

. owe er to the above criticism v , such criticism can r n only be applied to impe fect executio . The opera tor muat w efully guard against closing the vulva too eaai l far . One can make an excessive perineum by the flap method . his objection is, as a matter of i r . s fact, wo thless Another objection that the flap Thi s ob ec method i n no way narrows the vagina . j i n ot be n arrowed t on will hold, as the vagina can so as m x to embrace tightly a single de fin r . In fact, we can dissect the rectum and vagina m each other for three inches, up to the peritoneum , or as high as e w i d sired, and narrow the lo er third of the vag na as much as the o ator sees fit The upper two- thirds t of the vagina oea not req u1re narrowing . Ano her objection 18 that it does not approximate the fibers of n i 1a l the levator a . It the operation par exce lence to r e unite the deranged or torn levator ani fibe s, becaus the dissection la carried beyond the levator ani fascia 94 m n on “ u m resumes ;

r s r On u b ace the levato ani muscle . e m st secure

— ' 35 te Pon d . i m son s met o . i t i s e l F i . (Af r ) S p h d r al a flap o raao n . I n the e t n d cut b an d 6 e esen t the i n es o f In ci si on w l f ha , a. r pr l to m e the fin s : 8 vagm a : l . l g n : 2. 2 e ct l . The ak . va i al flap , r a flap are st cuts at b an d the oi n t e me es at n and than cli i s fir , p rg . p secon d the sci sso s are en te a t l an d us ed b et een e gi n l and . r red , p h w va a ect s o e to i and cl1 m es the ec t an d i n fia r al wall v r . a p ak r al vag al th f om th e ct a s the se c d o e v flap r e r al s hi gh a ca req ui res. se i ne t e i n i t se e l smal fo ce s i c the assi sta i t can vag al flap w h v ra l r p , wh h tl h d me th rec l ti i t s m an ‘i y ol ; also so e ta n w h everal s all forceps em to n as t ei ei t i s an cic n t to u t the on e nsi on ; ha g . h r w gh flap t the two fin era i n the rectu m a nd a pai r of h n u t -po i n te d sa sso ra the ti on f s i n n i en t m s s a i n t od as sec o t e flap s co ve ly ade . The ut u re re r uced s o n se e s o and h w i n the cu t . Ob rv that in thi pe rati on fou r flaps a re made that the rec ta l and vag i n al walls a re su tu red se parate ly: a lso note that the su tu es l 2 8 are en te e h ssi n th o u the sln n. The a r . . r d a g r gh p ’ n ti e m i n i s sol u te d e r n t o m t t t s a d ak g ab ly e fr ha of Mr. Tai flap m i n whi onl on e fl is m d e an d n o sutu es en te the s i n or muc s y ap a r r k o a. d o are i n en u e ti s an a r tures d d d sue. aow TO mass 95 THEM .

l w i an d e musc e. h ch is guarded embraced by a definit s fascial sheath . The flap operation reunite the pos f m tcrim vagin al ascial septu without denudati on , as ’ n n s Emmet s operatio u ite it with denudation . Both ’ ’ Emmet s an 'l T ait s operatio ns are based anatomi c m i e — en the sa e princ pl one denudes however. n ot am [e e and the other does , but y a flap to n c i ssect the wou d. My pra tice is to the rectum and a e vagi n i n the lat ral sulci . In the American Text “ book of Gynecology the w riter on F lap li tti n g ” Pea'i neorrhaphy makes the following absu ggstate “ n men ts : Its field of usefuln ess is very li mited i deed . Practically it is applicable to those cases in which on l the superficial and most exterior fibers of the y ” su m are torn . The above views can certainly m ed on m only i perfect knowledge , execution . or e n We can afii rm obs rvatio of the operation . that it i s on e of the most certain and effective of all opera

ti on s on the perineum . The flap method of col 0 perineorrhaphy is the on e above all others that enab es reun ite the levator ani fascia superior with the enclosed levator ani muscle u r an d to witho t blind sea ching. to abolish a rectocele ,

repair prolapse of the uterus . The same writer cited above makes a further statemen t as ridi culous as the “ I n can first, that, no way possible this operation

fla - n l ( p splitting ) arrow the vagina, abolish a rectoce e , or bring together the separated fibers of the pelvic ” “ ” - fasci a . It is fortunate that this American text book n ot re n h does pm t the views of all Ameri ca s. The fla s littin p p g perineorrhaphy , in the hands of those who h have thoroug ly practised it, has proved absolutely n i i that it will arrow the vag na, abol sh a rectocele, and bring toge ther the separated fibers of the levator ani fascia superior and inferior with the fibers of the an i r levator muscles . Also it secu ely unites the liga heo- l menta isc perinei . The flap method is a ike use 96 rs s vac ma AND PEB INEUM;

r e ful in pa tial and complet operations , and in rectovaginal dissections does all that Emmet's with no denudations, and with a better avoi i n healing, by d the infectious atrium . ’ ’ fis s li t n Emmet s operation , ait s p p ti g is founded on anatomic structures and designed to restore physi o n logic functions . Both operatio s stay.

F e i ne ce ti on to th tum . Two ti left ig . p r al la ra e rec n d ar h tu m th - g: te ral han e i n t e rec e mete vagi n al septum i s put on by the tracti on force ps on each si de : the b lad e o f the sci ssors i s et een the ect an d i n l s and the d otted h oe m s ou t the b w r al vag al wa l . ark flap to be produced The conception of the flap li tti ng operation rastac a ex the patho i c conditions 0 the wound . If one a fiva ci w amines with lacerations, he will see linear r r trices, narrow white lines which are t ansve se in dis s e are section . The e white lin s the healed cicatrices of the old perineal lacerations The linear cicatrix is a s H n ow TO m s T EM . 97

or r n original wound e t . t r e direction of the ea . of the cicatrix bein at ‘ the wound is based the flap - sph ng r 18 s li t Tait . The transve se cicatrix p

and sutured at right angles to itself . It simulates the i cz pyloroplasty when the wound is sutured exactly in the opposite direction to its i nci on e sion . It is the same procedure as may employ

to u . e. in varicocele shorten the scrot m , i , incise the scrotum alm the spermatic cord for three inches and eature i c then scrotal wound at right angles to the cli n l c c B en 8 . incision as is pra tised in Dr . In turing the split cicatricial wound at right angles to itself we restore exactly the ori normal structures od the n of the perineum . this met peri eum and n r t ed relatio s a e res or to the normal condition . which

alone will withstand subsequent labors . The patient s hould be pared for three days before the ope n cathz ti cs c tio by , so that the estive tra t may be c thoroughly evacuated. The cat arti s should be a dministered that all defecation should cease 8 to 10

hours before the operation . There will then be no feces 1n the rectum during the operation nor for some n 1s i e an d hours subsequent . The patie t anesthet z d . 1n lies on the back . The instruments useful this oper a n e wi th tio are elbow scissors . a handled needl an e n t The in its pointed end, and stro g silkworm si lk worm gut should be thoroughl was ed with a n i n soap and water . The index and mid fi ger are troduced n u n i to the rect m , and the recto vagi al sep t um is divided in the linear cicatrix . The scissors poi nt is then forced under the ski n of the labi a and

carried upward as far as desired and clipped . The s opposite side 15 treated exactlyy the ame . Back cuts are n ow made on each side of the rectum as long as d i es red . In slight operations the back cu ts are not 98 THE vac ma AND PERINEUM ;

The anterior vaginal flap is sei zed w dra n forward. while the rior

backward . e dissect the rectum from the vagina as high as dear-ed (Ii to 3 n i ches) . At the same time the lateral

A e - i on i . tensi e ecto ani F i 37 . (Hod ii ed from P ) v x v r vagl gf old s n i t e i ci catri oi al ti ssue s i ati on ta w h larg rad a l m i n es The sso r b d es o n e c s do i n t o uced be t een the heali ng l . la a h r d w t nd i n s at the ci c t i ci m i ns i ust te how the rec al a vag al wall " a r al arg ll ra d cu s e d to the s i the ack on are rod uce . ac t xten c sso r han d les p B k ' b to ’ e uce i ne bod Ai ms u m i are made ’ r d a larger per al y B specul s va rrl a n te i o l . i n to the g . a r r y

100 rm: m oms AND ramm uu ;

. if slowly two to four weeks) a fistula will arise and §o er remain a ng or shorter time . In one case a fistula u persisted for three years . The posterior s tures are

u m . mtrod ced si ilar to the anterior However, they should be deeper and should thoron hly include the a superior and in eri or with

u . As i n e of d A thor ) tage progre e the ormi the su tu s as i t t $ 38 3 e M Here re appear he b the safest and m ost pra cti cal m eth i s to begi n to i n tre d uce sutu es an d ti e fro m the n ten o en ll su tu es are thread r a r d . A r the m n lin e The need le ma be t ust the n ti re edi a . y hr a cross e “ e “ can mak e mo e ect and su tu i n do one ld. re rf deeper r g fi lf 2 m p by hn a a ct H 1 HOW TO MEND T EM . 10

n enclosed levator a i muscle . The point of the n the ed of needle 18 passed i to ge the wound, avoiding n r the ski , and pushed onwa d to the median line, m r where the e erges, is th eaded and drawn out . . point It is in introduced on the opposite si de and in the all cases requirin e sive di w eoti on the needle should be passed gthrough exten si ve art o half of the wound only . In the less p the wou nd the needle may pass throu h the whole n l wou d at once . Mr . Tait emp oyed t to five l sutures . We emp oy five to seven sutures . The third step i s to tie the sutures of silkworm All the sutures are sei z ed at the distal en d by the q t the hand while right hand .pushes the tissues of the wound as far toward the loop of the sutures as possi

. 13 i n ble This a part al step, as it arrows and uckers n the wou d very much , so that when each in vidual e l sutur is tied it assumes its fina location . The n ot sutures should be tied too tight , as they are apt n e to cut through co si d rable tissue . After the sutures n ea e are tied , a li r gap of consid rable width will exist n n r in the median li e, for the sutures do not pe et ate l the skin , and hence wi l not draw it in close coapts ' tion . Here some of the inexperienced will be tempted to place a few skin sutu res to avoid the a in the n g p g of wou d . Be sure not to do it, for they ca use pain and may produce an abscess ; when the legs are placed to8gether the edges of the wou n d will The ends of the sutures should be left long

t n e - tied in o a single bu dle . The aft r treat men t consists 1n appl n g no dressing or chemicals to n n the wound . If there aco siderable pai small hypo dermic doses of morphi n may be used for thirty - six

. i n t l a i hours Most pat e s wi l re uir catheteriz ng, from

trauma to the distal ends of t e pubic nerves . After forty eil ght hours we begin to give two uarts of a va l n al an m s g douche, evening d orning bowels 102 THE m e n u AND m axi mum; should be moved on the third or fourth day by means of calomel given in small doses (1 grain two or three M t oou ful 80 . times) and followed by easp doses of g , Diet should be regulated an d limited for three days days subsequent

— - u t p f o f r r and (Robin son Holla d . Me hod f rmati on o an te i o ost fl i n th m t of u ti n o i n o p s r aps e flap e h ex ec g c l poper e rrhaphy .

The patient should lie in bed for at least two weeks, t r and af erwa d get u as she is able . The sutures l should be watched . f one becomes loose it shou d be m removed . If none beco e loose or separate the may Thr remain for three , four or even six weeks . ee

104 rm: vac uumAND rs axmzuu ; tenaculum on each side of the vagina at the hi ghest poi nt of the triangle of denudation in the sulci and one on each side of the posterior vagi n al wall at the u n on e j nction with the ski and mucosa , can mark the outline of the denudation with a scalpel . It is i s well, before denudation , to test whether the area too large to i nsure coaptation of the wound without n The a e the n i undue tensi o . r a defined by te acula s

F 40. Me t o of i n trod uc t i g . h d he su tu res m the fla m of i n eo t th d n p ethod col pe r rrhaphy. No e a t the en led eedi e i th th m 11 i n is cu t was s readed i n e l e. Th drawn from a photog raph t en f ti t d uri n the o e ti on ak o a pa en g p ra . denuded by the operator cutting off long strips of o mucosa with sciss rs curved on the flat. a denude with the sc lpel, rolling the denuded a n vaginal fi p on a stsfi or o the fingers . With expe s risne , lar e areas may be rapidly denuded . The area requiring en udati on i n the lateral sulci depends on for the amount of slack in the posterior vaginal wall, e s 05 s ow TO m s rs sm. 1 this operation has the special merit of n arrowi n the

. vaginal canal . With a axed vagina out and let a large area of den be required, especially high in the right and left v al walls . The den udati on should consist of the who e thickness l n of the v inal wa l . Continuous hot water irri gatio over the en uded surface will check the hemorrh e n col rrha g The operatio is eminently a posterior po g , and the success will depend on denudation in the r u c and n ot late al vaginal s l i , on the denudation of the

ao- n called peri eum . In case

the vagi na is no law than that employed in the introduction of the - v e well de ised lan of sutures . The chi f materials for

i u t u . sutures are si ver w re , silkworm g , and catg t To suture the denuded surface ex on e of the triangles n u in the lateral vaginal wall . fi to sut re at its

, passingthe suture transversely across the angle, 223 1 m m tel which edi a y tie it . The second suture is

‘ paswd one - quarter of an inch from the first (four u e s tur s to the inch) . The needle is passed throu h the vaginal wall an d subvaginal tissue toward ge o n operat r (in an a terior posterior direction ) , whence

1t m i s re- e erges, and entered at the same point and passed m an antero- posterior direction un der the sub i n ls em e vag nal tissue through the de uded trian , in g on the va inal mucosa at the edge of t e woun T 118 g r n tr1 1 makes t e suture , before tying, eprese t a 106 r aa VAGI N A AND ream sum;

angle, with its apex at the em den ud ls suture in the trian ) operator,

t 0 . e . and charac erizes the plan suturing ; i , they are

- r introduced in an antero poste ior direction , and by i ty ng, they lift the vaginal outlet toward the pubi c

arch. The next suture is introduced by passi the needle through the vaginal wall (on the internfifside

' u i m of the n of i s co o . D ag ra pla Ta t flap lp 8 s c um B ectum i n t ct e i n e bo V as i t a . , a r : r : P , a r al dy : . h p " w o e i t b has had the to n e i n e o ( 3 1e dy. , ab v . r p r al b P 99 - ( su tu es m e b st s ; 0 s o s the H s e n te n o cuts (1 b ; e, L r ark d y ar , h w ha p d a r , , the oste i o cu ts 8 ectu m V i n . p r r ; , r ; , vag a of the trian gle ) deep into the sub va 1 tissue of the denuded triangle (directly tow the operator) . whence it eme and is re - entered at the same point an d carri u ward an d outward (away from the o r n emer pe ator) very deep y u der the denuded area, g

we ran m e n u are m un ;

F i . 43. 'g te ( . B 111 the A ,) t r L. an e io r vagi nal v hal acl ori fice 1. wi de not each the ectu m r r . vaginal septum as there appears re dundancy of e l l post rior v a wall (rectoce le) . Nothing am t n 4 cu . cure the pa The perineal body , in its e s i fibromuscul r s n e, is a resistant l gamentous, a s ow 14m m E 109 TO TH M .

l ture which c oses the abdominal cavity below . The be an from the curved white m the pelvis, as one e be o impressed by looking int a pelvis from above . t is

- bowl shaped, and as soon as this peculiar shape i becomes lost, the supports have g ven away at some n ar point . Observed from below the perineum is w The rowed to the space bet een rectum and vagina . flap operati on is capable of repairin g any defect in the pelvic floor . In complete laceration the anal and fi vulvar ori ces are in direct communication , like a close t s . The rectovaginal sep um may show a boot jack angle or an i lar arched outline . The ularl - torn outli ne o the rectovagi nal septum shows a n - de e walled layer or curved s1des . At the upper angle of the lacerated rectovaginal septum the rectal mucosa pouts, rolls and appears as a red or pink which aids in locating the line to split the the rectovaginal septum has been lacerated for a long time it presents irregular cicatricial bands , di fier some of which are thin , others thick, assuring ent stages of atrophy and contraction . Bri dges or bands of tissue may stretch from one poi nt to another

a penetrated condition . Again , the lower the lac erated rectov al septum may be upward by the fibers 0 the levator ani still embraci n the parts by the aid of its double fascial '

. m l o sheets des s all, irregu ar de r ssions may be felt or observed where the stump o a bundle of the n levator muscles has bee to rn away and retracted . The deep sutures applied after splitting the septum will in clude these stump ends of the muscles by means of fascia so that they me be in forced to the n a an d hr 9 media r phe fixed t e e . flap operation does not need to observe whether the sphincter, anus or n e a rectovagi al s ptum be l cerated, for it is alike

1 12 THE vac ma AND re amsum;

n of m tio with the aid a large Si s speculum . In the diagnosis a notably stri k1ng feature is the changed a appe rance of the vulvar outlet . Normally the peri i s neum widest at its upper end . With lacerated perineum or relaxed vulva the whole external appear The ance is changed . narrow puckered chink or slit like aperture of the natural vulvar orifice is trans. m formed into a patulous gaping . Again , the nor al vagina presents a sigmoid curve with the posterior vaginal wall coapting an d embraci n the e n a valve . But in defici nt vagi a paratus these two con centric coapted curves have ost their rela n the osteri or s tio s, especiall v curve . It be rem embe m p1agn os1n g t s8 defici en cy at the n on o es eci vulva, that the cl sure is not due p l 1n ow of the perineal bod , but to defect the The ani muscle and its dou e fascial layers . levator ani muscle en dows the rectum with its anterior cu rve and drags the lower end of the v n a upward and forward against the pubic arch . is fact can be demonstrated by introducing the finger into the vag i ns an d and forcingy backward downward, when by i ts removing the finger. the vagina quickl returns to n yas normal positio . The vaginal orifice no distinct sphincter like the mouth or anus, but has an indirect n sphi cter, the horseshoe loop of the levator ani , aided by the pubic arch . The arch acts like a fixed point

shorten 1n con . by g, f the levator an i

ina at its external orifice by means of

- u bu bo cavernosus muscle , but practically this amo nts n to nothing in physiology and a atomy . On of the position of the rectum in relation to the lava. r tor muscle it p oduces a sigmoid curve to the rectum , ‘ s ow Mssn re am TO . 113 This is due to the fact the levator muscle enci r cle the rectum about an inch above i ts orifice or lower contraction it yields at the point of

rc e . i t fo e , , at the s gmoid bend . On account

—" F i 45. l la o m ti on i n c se o f w l ts ti o n of the r c o g . f r a a a no e lacera e t u m T tt n t i n l va i n -l septum to the rect . he scissor bl ad e i s s li i e he vag a ' h em the rectal wall to fo rm the flap F whose m co mes from the mueoeu taneous i ne ! P i s the b c ou t to the O osi te back l . P ; P. a k ; A pp ou t It the n te i o sc isso cli . ; A. , a r r r p

od ti on v of the p of the vagina , le ator ani and pubic arc h , the lower end of the va ina is upward , ro u gorward e p d cing its sigmoid curve , in t e opposit 114 THE VAGINA AND PEB I NE UM ;

i a u . d direct on to th t of the rect m In other wor s, the lan e of the pubi c arch is anterior to the plane of the ' ator c an d n n ev ani mus le , whe it co tracts it must nec swari ly dr gthe lower end of the vagi na upward and ah forward . ese considerations may be ' by introducing the finger in to the v na an d the i s 1 thumb into the rectum . It best stu cd first on a

multipara and second on a nullipara , and third on one

with a deficient vaginal sphincter apparatus . The closure of the vagina well forward toward the pubic ar ro e kmd ch p duc s a of valve , which acts almost as a n certainty agai st prolapse while intact . This is one of the elemen ts of success in both the Emmet and

Tait perineal operations . The vast di fieren ce in appearance between the virgin and the relaxed vaginal sphincter apparatus of the multipara is due to the y1eIdin g of supports by the process of labor in n early t all cases (visceral p osis excepted ) . This does not appear so strange when we consider that the virginal asse e h e n p g of the v is about an i ch in diameter, the an d while passin ead , shoulders breech demand i n ten to twelve c es in diameter . It is not strange that tissues forced to stretch from one to twelve inches n i should forget to return . The levator a m uscle is un arranged in fasciculi or b dles , or it would become m en an d defective ore frequ tly . The sphincter vaginal apparatus may be injured by external accidental

m . trau a, but labor is the chief factor '

Relaxed v nal outlet, concealed lacerations or m usculo deep ial tears of the pelvic floor , can not be too forcibly brought to the n otice of the physician as an importa nt di agn ost1 c indication for colpoperi n e r o e o rha h K l ce lls . p y. el y such , c ncealed r laxation n This is a co dition of loose , gaping vulva, compared to the mouth of a bag without its puckerin g- strin b ati en t k gy Dr . Emmet . If the lie on the bac the or 100 a n a of the buttocks flatte ed, the anus appe rs

1 16 rue VAGINA AND PERINEUM ;

' Occasi onall on e involution) . y can introduce the four fingers of the hand and put the long relaxed perineum n on a stretch . It is in these lo g, lax skin perinei that i i on physic ans d sagree as to conditions, the e asserting that the perineum is plen ty large enough and does not re ui re i i q an operat on. while the other r ghtly asserts that the perineum is but a small part of the su pport ‘ l of the sexual organs. The fact is, the who e vagina and sphincter apparatus has become the

— F i . 41 . not e st of fie t i n se e g A h r a e am g . Ob rv teri or su tu e i s ei n i n grod q the n e om ons et“ ! r b g b edle passi ng fr the enud ed oun to the ot e use the s ce i s s o t bu t the d d h r . a h r . - w p den uded sunfae u n der the fi n i s gen e rally so i d e that i t i s most prac ’ w ti cal to tk: han d led n eedfe fro m the la te ral margi n of the woun d to the l i nm whem the needlc ia allowed to emerge and become h ea d hus the su tures are t ou of the oun at one r de . T passed hr gh half w d a-e . new 10 u s e H M 11 7 T E .

vu v lva pouts , the anus e erts, and the floor of the pel I f vis flatte ns out . the patient is r nested to bear r down, the anterior and posterio vagin walls will roll u astoni shi n o tward , often to an de By the act of ra x can n di n st ining. the cervi be elt esce g. The

- o - r utero pt sis. The sacro pubic he nia is

— o ti on i n case of com e te ce on m Fi n i shed ’ ra a l la rati . R gste ri or en d of n e - bui t i n m A . e e e a a and . p ly l r al ra h : : F t w p p A ossus eni i s a li ttle pate n . more marked if on e examines the patient in the smud an d ing positi on . By careful inspection palpation l on back the whi e the patient lies the , one may feel ted ci catricial stump en ds of the lacerated levator , ci catrioi al ani muscle, and b irritating the little ele vated or depressedstumps we can see the contractions 118 rss m e n u AND m axi mum;

m and relaxations in them . So etimes the perineum v n al or lower posterior . wall is so relaxed that it 1s lar e g enough to c u the vulva like a valve . the evator The horseshoe loop of ani , which extends u to r from one pubic ram s the other, presents no mo e resi s r 1n bu t b oad, elastic loop felt the virgin, in the mfi e one feels an irregular sharp edge o

- ut o . et o of formi n the ti e i t non com ete A h r M h d g " w h a pl m th n te i o and oste io cute n h a e a i n l fla . r , a r r p r r vag a p narrow di mensions . Also the loops of the levator are the va imn more displaced to the side of vag aa . Though c r et r the patient can generally ont ol stool , the vigo ous elasticity of the muscular loop is gfinitely i m on paired. With the patient the back and the two i n s can index fin rs in the v , one quickly test the degree 0 deficien cy o the sphi ncter vaginal appara~ w v tus by pressing down ard and backward . The vul a

120 THE m e n u AND Psam stm ;

The chief origin ators and promoters of bilateral ool o eri neorrhe h s F ren n p p p are Emmet, Stand , d, B i schofi oodell K Martin , , and elly . Some of the pi oneer originators and advocates of the teri or flap L n beck 83:10a colpoperineorrhaphy were , mTait, Janka s i i a , Vos , S mpson, Mar l es, S nger. Whatever the apparen t B aroness of the e three classes of procedur , all

- - F i . . obi S c l fo m ti on i t the scies rs at g 51 R nson ho er . ) Flap r a w h ottom o i !te r et ee n ect a nd i n ii a l l i n l ga e r al vag al , , va a p b b w' g 9 3 8 b c cu ts s e by the s e e s c oo s 6 6 2, ec t l , , : a id h ph rd r k . , ; r a a a k ec t um en 5 o u Th re rem n com le te ce ti on t ne of cer ix. is p r al l . li v p a la ra i u i nto the ec tum h gh p r . cally agree that definite denudation (fiap or other x a xi m i o u an d wise) , e act at n of wound s rfaces, d eep sutures without tension ) , based on anatomic M o . lesi ns, are the prereq uisites of success ethods and modificati ons are n ot so important as attention to of anatomic and surgical principles . The physiology now ro mss n THEM . 121 structure being disturbed by an overstretched peri n e neum or elongated supports (e t roptosis) , it must be restored by reproducing as near as possible ana tomic i n tegri t The relaxed tissue must be corrected with deep sutures and dissection ; the bloodw essels must have a bed i n which to functionate ; the must be protected against continued

su tu es i n osi ti on Fi i 52. The r p sgon i l 1 the re n al fl s held si b ee u i n to the ec tu m . de b r h gh p r . ap a y the she e s c oo s 2 2 ec t s b e i n ce b the c oo s h rd r . . r al fla la y r ° k p p k 7 7 8 oi n ts to theM3 or an le of un cti on et een the ec t and , j , p g b w r al i n a s vag al p .

t m u ms repeated trauma, and the organs mus a nor to the mal position , all of which belongs domain of

r n e The . colpope i orrhaphy . genius of Emmet estab li shed the utility of surgical procedure in the vagin al The tf sulci . grand o rations of Ei scho spari the osterior vagin al co u mn or median vaginal an ace poreshad owsd ém et and aided , as well as the sch 122 THE vxc mx Am) Ps amsum;

arly labors of Schatz on the lvi c floor . As a pupil . i 1884 I thi of A . Mart n in , saw contemporaneous and ’ independen t development of Emmet s operations i n ' i n the v nal sulci . the hands of the most skilled gyn soo ogi c surgeon s of German It may be remembered that e Emmet and Tait operations are alike valuable in operations for relaxed

— - b i nsou 8c o e . not u tu i n . A F i 53 . Ro c se e to the ectu m g ( h l r ) a r p r d r . r os o The su tu whi ch the sutures a e i n p i ti n . res are threaded from the me i n i ne as see n i n the cu t . se e tha t the su tu es en et te n ei t e d a l , Ob rv r p ra h r ski n or m ucosa . vaginal outlet; with the advantage in the Tait o ra to rotect m tion of a flap p the wound . The reason ’ O met s operation 1s about of equal value is tha t healing h a n in t e vaginal sulci is almost cert i , hence but little

i e n o - li dan of loss of valuable t ssu by n hea ng . Not ing is gai ned by denuding an area of vagin a over

124 m m e n u are m un ; n m e cenk the abdomi n al brei n —i s found at the root of the celi ac axi ust hi om Aj be nd the st ach . Three

n ti o n s i ca n with the gen ital orga s . Many h ade of nerves connect each ganglion with the pelvic It 1s the numerous n erve strands whi ch play the n rule n t d racts importa t , because ma y s ran s , t , will an ls can many m ages, and a fewyganglion cel care of i nnumerable peripheral reports. A few on cells will receive and dispose of many go111 m n — any lines . Now the ga glion cells tho HOW w as E TO TH M . 125 — vic brains assume a certai n e control of their respectiv viscera . is the most inti mately con nected to thoee three brains by many nerve strands wi ll examine significant power over the rhythm of the One i organs . of the chief functions of a v scn s is rh If thi s be disturbed the organ becomes ° 1 vs and fails in ts final object.

- i n son c ole . n ot er st e i n i c the tri e i n S h r A h ag . wh h ri t su cu s i s c i t tw o su t u es su tu es i n osi t o n g l w h r ; r p .

Let it be remembered that the irritation from a dis. ( ls e fitt d at all ti r es re ard to rgan il , without g ’ physi oiogi c r l ytgm gy whl ch tlpe o accom hes i ts e The c h . mode of lif . oc asion of r ythm is e nat ur al stimulus of an organ , as food for the digestive ra the n t ct, air for lungs, blood on the e docardium , n u e urine in the uri ary tract, a fet s in the ut rus, fluids n an d m r in the Fallopia tubes , food ate ial in the liver, 126 THE vac mx AND PERINEUM ;

' di s carried to it by the portal vein . If we follow a eased m emitted from the patho logic gen—itals p to the a omi n al brai n ove1 the lateral chai n the — ‘ gy tri o ovarian lex us wi\are it is reorgam sed an s v emitted to the tive tract, we may obser e the following disturbances : Excessive secretion in the digestive tract ; deficient secretion; disproporti on . n i n ar ate secretio . Excessive secretion may duce di rhea;

— — F i . 57 Robi naon c o er. The two d n b g . ( S h l ) e uded tri ang les closed y su tu res ; the remai ni n g sutu res i n si tu .

n n a deficient secretion , consti tio ; and dis roportio te secretion may produce ermen tati on (bpoati ng) ; the continuation of such reflex factors institutes in n n the a tio . The reflex irritation , passi g from dise sed to n 18 an i sed genitals the abdominal brai , reo and transmitted to the liver over the hepatic p exus. This i rr c di ro or patholog c i itation produ es excessive, sp p

128 rue vas mx AND rsarss um;

teric - t m whi le lion has a four to six hour rhy h , the 24 eri or mesenteric angli on has a hour rhythm . Any one knows that (fisturbi ng the rhythm causes e n all m constipation , and ve tu many neurotic sympto s maln arise . Long continued i ndi gestion produces u tri ti n all o . Pathologic irritation passes to viscera at a d n any times, in season and out of season, day and n 1 ht h 0 t or g , w ile are at empting to rest to pass rh tEm u n Or through a y , always causinggdist rba ces . . gans secure rest and repair between—rhythms . Malnutri tion 18 followed by anemia a disproportion s a between the blood vessels yd plasm . Long con tinued i is f ollow i anem a ed by neuros s . The numerous gan

- and l lia are bathed 1n waste laden irritating b ood . um erable local and distant n euraethen i o conditions are s m manifest . We have, then, as a train of evil y p

— ’ F i . 69. ut o s e in eo n g A h r p r rrhaphy eedle . toms following genital defects inf t 2 t ec ion atrium ; , reflex irrita ion to the abdomin al brai n where i t i s reor ani z ed an d sen , g t out to the i 3 n 4 var ous viscera ; , i digestion and malnutrition ; , 5 anemia ; and , neurosis . In the w oomplets cases of laceration the disturbance is attributed to gaping of the vulva and the co uen t i favoring of rectocele and cystocele . Th s con tion r r is followed by ute ine prolapse , endomet itis and met u f ill ritis. The patient s fers from defined pains while ' These standi ng and walking . patients complain m a manner similar to that of those who are ami cted with tero tosi s e . When the lac rations become complete, 015 3 physical defect of control of feces and gas 5213 ta gu t a train of mental symptoms follow oom pi stte lacerations or serious lesions and gravely afl ect HOW has!) TO THEM . 129

a life, both physically and ment lly . The patient is sect easily fatigued , neurotic constantly , liable to ex 1n fec ti ous processes. One of the most unfortunate results of extensive rectov al tu laceration of the sep m is diarrhea . When the sphincter m es have been so far drawn 11 the e t at nds that they are almost a s raight line, $ u e Ast rect m has lost all control of fec s . raight hi n cter is a symptom of complete laceration ; the hes accompanyin g the straight sphincte r is very h exhausting . The amount of separation in the sp i n c ter muscle the the tells story of de e of laceration . i the When one can find the dee d mp es in skin , on each the vu v due ci catri i side of gaping s, to the c sl ends of the muscular bundles contracting . it may be estimated that the vaginal sphincter is extremely de fecti ve and that over half of its arc is wide open . On l a carefully planned operation can relieve this conditi on . The widely gapin g vulva is exposed to i much trauma and consequent infect ous processes . The con gested genitals and rectum produce excessi ve l l i n i fu u g andu ar secret o , wh ch rnishes a c lture medium i c not only to the path bacteria, but tends to mul ti ply the regular resi cu ts of this locality into execs r i n sive numbe , and in all probab lity dangerous ki ds . for doubtless bacteria rs idly change from one kind to another by chan 0 food and temperature . It would be strange i n eed if all the scores of uterine tubular glands could long remain normal with fre quent congestions and decongestions . Excessive bac teria in any locality must produce their dangerous ec awa toxins, which b ome absorbed and carried y by i the vei ns and lymphatics . The rectal ve ns are known to stan d i n direct communication with the liver a ' 130 rss VAGINA AND PERINEUM ;

sider the innumerable reflexes which must necessarily

f re ~ from the in ected, f quently co occa i on ll n or m asi ons s a y acute, i flammat y v o the genito t l r fl rec s o gans . These re exes arise in all degrees and i es ti bl cond tions, and the patient almost imper y i malgutn passes through the stages of ind gestion ,

r . tion, anemia and neu osis Again , man of these patients are operated on by inexperienced

with consequent imperfect results . Then a conflict of opinion arises as to the ri n eal defect being the cause of the trouble or whet er the eti ol is to be

located in the nervoussystem , for one of e evils of today is the confoun d m of nervous and sn i tal dis i m o e . s t eas s After an operation on t e genitals, i with a consequent mperfect result, the operator is liable to throw the whole defect on the nervous sys the tem . As the nervous system and liver are the chief scs ts of ignorance (and knavery ) it is

i f to e . d ficult monstrat the error It requires wisdom, knowledge and ex ricuce to di scrimmsts between genital d1esases an their consequent train of n eurotic l effects, and the diseases which definitely be o to the nervous system itself or to other causes than e gem l I v i . ta s must insist, howe er, that this requires more ti me and skill than any general surgeon or physician is able to give . r s Until one comp ehend the practical anatomy , it is almost impossible to interpret the rational symptoms of the deficiency of the sup rts of the sexual organs . The ular view of on e physicians that the peri neal is the chi c support is on e illusion which I o l n th find, c nsiderab e experie ce in teaching, di n i i cult to eradicate . It is the indefe s ble mechan cal

that the perineal bod is the keystone, the cork t t 11 which s ops the bo tle, or e wedge which plugs u romi n en t the pelvic outlet . Unfort nately , a Ameri r can gynecologist at one time a this false theo y .

132 U ran m ama u m seam e n ;

s fa cial beds, the veins elongated, i losing thei r sp ral form , and the s nerve put on the stretch or tra umatiz ed .

su i i not re med the r normal ntegrity . s fi n ts z oi n m uch pa e , as Schat p out,

ar an or a ei r neum may be much l ger th n m l, b ngove tr s etched.

more overlooked practitioner than 1883 Emmet and Schatz first clearly announced thei r The vi ews in regard to relaxed pelvic outlet. very r n the a s a deep pe ineum is deficie t, while sh llow, h t

bed some two or .11 ak l wmk er e , unab e to “ a“ 13 ° a back ell eral ami n ae “ v P in in the . g l

The relaxed pelvic floor is mmt ( erator b exami ne , y tig o m'ate re the m etic, when he is about to p . Befo theti c the pelvi c outlet is held in parti al tend on by ro 1) H s ow m T EM . 133 the remnants of the muscular and fascial supports ; the loops of the levator ani muscle being irritate d by t tom of par s being , the patient is constantly losing nerve force b the attempts of the 1n kse t s W reflex irritation tension . hen the patient is fully anesam the parts of the pelvic floor show vast relaxation and it becomes at once ap parent to the hand and eye of the operator that a sig n i fican t x hi s s tati on defect e ists , beyond , in the the sexual apparatus . The perineum back , anus s r flattens and evert , the vaginal walls roll outwa d, and the deep anal furrow assumes a plane approximatin g u t i n that of the b t ocks . Vast changes subcutan eous an r l d submucous supports have occur ed, capab e of repaired on l by an operation which restores t had t vows to a s able . nerves to a protected shea h , an d organ s to a position which will insure normal ' an d n —i n mrculati on i nervation short, proper nour s 1n i shmen t. With such patient the erect posture the i nns - abdominal pressure i s con ti n ually di splacing the by forci n g them into and through the weak

d slvi c . en e outlet The pelvic outlet, beyond the S floor is full of prolapsing organs which often deceive the practitioner by closing up the gap . The len th of ti me allowed to relapse between the i n am? the operation on the perineum should not The n o be less than three months . do t heal 1d n eco o 1ists well shortly after labor . 0 gy g , as Byford, recommended at least six months to elapse before the r o ration should be pperformed . Pe haps four months

injury it would be fairly safe to operate . The

old cicatrix can not always readily be found, but by pulling on the vagm a in various directions the pucky

ering tissue about the scar will be discovered . The

pal i ti ng finger ma also find it . Ths ci catri x p uces new points for the attach ment of the torn fibers of the levator ani muscles rm: m oms AND PEB INEUM;

c which may give the outlet a peculiar, irr pu k ered a nce when the muscular bun es con tract si r from new points of attachments . The flap for beyon d the cicatrices so that the ends of the muscular bundles may be included 1n u the s tures . The time for operationyshould be mid wa between the menstrual peri e ri fn regardto th pe n eal body . The posterior curve of the vagina must be reproduced by restoring the um rectovaginal sepptt . eri n ealb od ul r A new p y sho d be estored, so that the rd o natural backwa curve of the vagina sh uld persist , i . e l ., normal relations shou d be established between the perineal center of body on the on e hand and fas i a c on . m the other The perineal ,body, the punctu fixu m r n of vulvar su face relatio s, should be restored . In writi ng this essay I have derived aids and sug gestions from all accessible authors and have at. d r tempted to duly cre it the labo s . 1n