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 THE CLINIC PUBLISHING COMPANY, 
 
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COLPOPERINEORRHAPHY 
 
 AND THE STRUCTURES INVOLVED 
 
 THE VAGINA AND PERINEUM AND HOW 
 TO MEND THEM 
 
 BYRON ROBINSON, B.S.,M.D, 
 
 Chicago, III. 
 
 Author of "Practical Intestinal Surg-er.v," "Landmarks in Gynecolog-y," 
 "Life-size Chart of the S.vmpathetic Nerve," " The Peri- 
 toneum, its Histolog-.v and Physiolog-j." 
 "The Abdominal Brain and Auto- 
 matic Visceral Gan- 
 fflia." etc. 
 
 Professor in Chicago Post-Graduate School of Gynecolog-y and Abdom- 
 inal Surg-ery; Professor of Gynecolog-y and Abdominal Surg-ery 
 in the Harvey Medical Colleg-e, and in the Illinois 
 MedicalColleg-e;Gynecolog-ist to St. Anthony's 
 Hospital; Consulting- Surg-eon to the 
 Mary Thompson Hospital for 
 "Women and Children. 
 
 CHICAGO: 
 
 THE CLINIC PUBLISHING CO. 
 
 1899. 
 

 ENTERED, ACCORDING TO THE ACT OF CONGRESS, IN THE YEAR 189C 
 
 By the clinic PUBLISHING COMPANY, 
 
 IN THE OFFICE OF THE LIBRARIAN OF CONGRESS, AT WASHINGTON. 
 
CD 
 
 cm 
 
 •a: 
 
 DEDICATION. 
 
 This monograph, prepared for presentation before 
 
 my fellows of the American Medical Association 
 
 (Denver, June, '98) and published in The Journal of 
 
 the American Medical Association, is respectfully 
 
 dedicated to the medical profession with the hope 
 
 that my labors, surgical researches, and experiences 
 
 as herein outlined will be of direct interest and help 
 
 to them and indirect^, through them, to suffering 
 
 and needy humanity. 
 
 The Author. 
 
PUBLISHER'S PREFACE. 
 
 We have taken great pleasure in reproducing this 
 book from the pages of The Journal of the American 
 Medical Associatioii. Like everything that comes 
 from Dr. Robinson's pen it is full of good things and 
 evidences an amount of labor that few are willing to 
 give to the work they undertake to do. We there- 
 fore heartily recommend it to every physician who 
 thinks that he can or might be helped in the treat- 
 ment of the class of cases to which it refers. The 
 drawings for this profusion of illustration were made 
 from life during the process of the author's numerous 
 operations in his extensive clinics, and are as true 
 and helpful as it is possible for such cuts to be. 
 These, with the full and complete text, should be of 
 great help to those who have not reached a perfectly 
 satisfactory technique of their own, and must certainly 
 be of interest to all. 
 
 The Clinic Publishing Co. 
 
 Station X, Chicago. 
 
COLPOPERINEORRHAPHY AND THE 
 STRUCTURES INVOLVED. 
 
 The structures involved in the repair of a defectivo 
 perineum are muscles and fasciae. The operative pro- 
 cedure consists in denudation with coaptation or flap- 
 splitting methods. Notwithstanding the successful 
 claims for the varied surgical methods of colpoper- 
 ineorrhaphy the anatomical basis is neither generally 
 nor perfectly understood. It is probable, however, 
 that the essential success lies in the reunion of the 
 separated levator ani muscle by means of its fascise 
 superior and inferior with some other fasciee, and also 
 that this success has been chiefly due to deep sutur- 
 ing. The object of this essay is to demonstrate that 
 the chief factor in successful colpoperineorrhaphy is 
 the restoration by the aid of deep sutures of the fascise, 
 especially the levator ani fasciae, superior and inferior. 
 
 The muscles of the pelvic floor may be divided into 
 two classes: a, the deep layer — the levator ani coccy- 
 geus and pyriformis; 6, the superficial layer — the 
 transversus perinei, bulbo-cavemosus and sphincter 
 ani externus. A peculiar characteristic of the muscles 
 of the pelvic floor, and one which demands respect in 
 colpoperineorrhaphy, is the extensive fascial attach- 
 ments of one or both ends of the muscles. The levator 
 ani, the bulbo-cavernosus and the transversus perinei 
 have a fascial attachment. We will consider in detail 
 the muscles and fascise involved in colpoperineor- 
 rhaphy. The basis of this labor is a careful anatomic 
 investigation with considerable clinical and surgical 
 experience. 
 
6 THE VAGINA AND PERINEUM; 
 
 THE LEVATOR ANI MUSCLE. 
 
 The levator ani muscle is perhaps the most difficult 
 to understand as regards its form, insertion and func- 
 tion. The origin of the muscle is sufficiently plain, 
 and is considered established by anatomists. Few 
 agree as to exact insertion, even at this late day, and 
 opinions vary as to the exact function, form and in- 
 sertion of this muscle. My own investigations demon- 
 strate that there is a foundation for these varied 
 opinions. 
 
 1. The insertion and origin of the levator ani vary 
 as^ to the extent of distinct muscular loops which em- 
 brace the rectum and vagina, as to the tendinous 
 raphe (between muscle loops and distal ends of the 
 coccyx), also regarding the precise relation to the 
 vaginal wall, whether muscular or connective tissue, 
 and also as regards the exact relations to the muscle 
 of the lower end of the rectal wall. Moreover, its 
 partial fascial origin and insertion is sure to endow the 
 extremities with varying appearances as to the length 
 of the fascial or tendinous conditions; in other words 
 the distance of the red muscular fibers from the 
 extreme origin and insertion of the levator ani vary. 
 Perhaps this variation in insertion may be explained 
 by considering the levator ani as a rudimentary mus- 
 cle and to be disappearing with the tail. Its double 
 fascial accompaniments complicate its origin and 
 insertion, as well as the interpretation of its function. 
 
 2. The various opinions as to the form of the levator 
 ani are explained by difPerences as regards sex idio- 
 syncrasies of individuals, disturbances from gestation 
 and parturition, variation of the shape of the pelvis 
 and fascial insertions and attachments. 
 
 3. The different views as to the function of the 
 levator ani lie in confusing its function with the le- 
 vator ani fascia, superior and inferior, in exaggerating 
 its size and attributing to it function and utility be- 
 
HOW TO MEND THEM, 7 
 
 longing to other genital supports. It ia especially 
 erroneously inferred that a muscle will act as a con- 
 tinuous tensionized support for any viscus. The 
 knowledge of the levator ani muscle is fragmentary 
 and difficult of access. Its dissection is far from easy 
 and its adjacent relations are complicated. The mus- 
 cle does not resemble a funnel with the rectum or 
 vagina at the bottom or apex, but is more similar to 
 a sling, a flat loop or a horseshoe, which does not pull 
 the rectum or vagina directly upward, but draws the 
 two canals forward and upward toward the pubic cord. 
 
 The muscular loop of the levator ani muscle resem- 
 bles a horse's collar encircling the rectum or the 
 vagina. In the female it vigorously controls two 
 canals — rectum and yagina — yet its control of the 
 vagina depends on that of the rectum. The rectum 
 being forced forward against the middle of the pos- 
 terior vaginal wall produces the H- shape to the vagina. 
 The excess of vaginal wall is compelled to fold at the 
 sides producing the upright columns of the H. It is 
 very thin. In an excellent specimen which I dissected 
 from a good- sized woman the levator ani muscle is so 
 thin as to be really membranous, and the muscular band 
 between the vagina and rectum is but a few lines in 
 thickness. It is really a pelvic diaphragm. 
 
 The muscle should be considered as to its origin, 
 course and insertion. 
 
 Origin. — The levator ani muscle arises: from bone, 
 from the posterior surface of the pubis and ischial 
 spine; or from fascia, arcus tendineus and vesico- 
 pubic ligament. The bony origin is the posterior 
 surface of the pubic bone and ischial spine. The 
 larger portion of the levator ani of bony origin arises 
 from the posterior surface of the pubis. It begins 
 about half an inch from the symphysis and one and 
 one-half to two inches below the pubic crest. This 
 point of origin is about two fingers wide or one and 
 
8 
 
 THE VAGINA AND PERINEUM; 
 
 one-half inches, and does not meet its fellow of the 
 opposite side, one-half to one inch existing between 
 them on the posterior surface of the pubis, which is 
 filled in by the obturator fascia. The bundle of mus- 
 cles originating on the posterior surface of the pubis 
 passes downward and backward to embrace the vagina 
 and rectum. This is the pubic sling or horseshoe loop, 
 
 Fig. 1. — (Robinson-Scholer.) This cut is drawn from a female pelvis 
 dissected by the author and intended to show the muscular floor of the 
 pelvis with fascia dissected off. 1,1, the levator ani muscle; 2, 2. the 
 white line or origin of the levator ani ; 8, 3, the obturator internus muscle ;, 
 4, 4, the coccygeus muscle : 5, 5, the pyriformis muscle ; 6, 6, the inner wall 
 of pelvis; 7, 7, sacrum; H, H, the horse-shoe loop of the levator ani muscle, 
 drawn darker ;«8. the Y-shaped urethra; 9. the vagina, cut close to the 
 pelvic floor, whose wall does not flare like the radial wall, 10; 11, 11, the 
 obturator nerves ; 12, 12, inner wall of pelvis ; 13, pubic crest ; 14, 14, iliac 
 fossa; 15, last (5th) lumbar vertebra. 
 
 which is quite thick and strong in some cases, and 
 very thin and membranous in others. The margin of 
 the loop, which is applied against the sides of the 
 vagina and rectum, is often the thickest part of the 
 
HOW TO MEND THEM. 9 
 
 muscle. The muscular bundles of the horseshoe loop 
 join those of the opposite side of the levator ani pos- 
 terior to the vagina and rectum without an interven- 
 ing perineal tendon or raphe. In 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 bony origin 
 is from the ischial spine immediately anterior to the 
 origin of the coccygeus muscle. Quite a distinct strip 
 one-fourth to one- half inch wide comes from the 
 ischial spine, and can be plainly followed by the eye 
 to the horseshoe loop. 
 
 The ligamentous origin is from the anterior liga- 
 ment of the bladder (ligamentum pubo-vesicale) and 
 from the arcus tendineus (white line). The fibers of 
 the levator ani which arise from the ligamentum pubo- 
 vesicale are of little practical importance. The white 
 line extends in a slightly curved direction from the 
 posterior lateral surface of the pubis, over the obtura- 
 tor foramen to the spine of the ischium. The anterior 
 end lies two and three-fourths inches below the ileo- 
 pectineal line, with a length of about four inches. 
 The white line (arcus tendineus) is a part or an ex- 
 tension of the anterior true ligament of the bladder, a 
 thickening of the levator ani fascia superior. In the 
 white line, the muscular fibers arise as fine tendinous 
 bands, and may show their reddish muscular nature 
 at the white line or a short distance from it. The 
 muscle may shade into a flat tendinous layer before it 
 reaches the white line. The proximal tendon of tke 
 levator ani muscle varies much as to its relations with 
 the white line. It may arise below it as well as from 
 it. , The white line may project into the pelvis as a 
 tendinous fold, and be capable of being separated 
 from the origiil of the muscle. 
 
 The course of the fibers of the horseshoe loop of 
 the levator ani muscle is backward and downward 
 
10 
 
 THE VAGINA AND PERINEUM; 
 
 in two fleshy bundles, the smaller to the side and pos- 
 terior surface of the vagina, and the larger to the 
 side and posterior wall of the rectum. The loops 
 which pass along the sides of the vagina seem to be 
 attached to the vaginal walls by connective tissue 
 only, while the loops of muscular fibers which 
 embrace the rectum interweave with the muscular 
 
 jii^ '- " ->.- 
 
 -»- ■ - -^^ "->^-"^~' ^' 
 
 Fig. 2.—(Robinsoii-8ch.oler.) This is a cut drawn from a female pelvis 
 dissected by the author. It illustrates the inferior surface of the pelvic 
 floor. 0_n the left side (m the fig.) the levator ani fascia inferior is not 
 ^ssected oft, while it is on the right side, showing the inferior surface of 
 the levator am muscle. 1, 1, shows the levator ani muscle with its parallel 
 bundles; 2, the levator ani fascia inferior; 3,3, the obturator internus 
 muscle; 4, 4, the coccygeus muscle; 5,5. the gluteus maximus; 6, ano- 
 coccygeal structure; 7, 7, the horse-shoe loop of the levator ani, showing 
 some muscular bundles coursing between rectum and vagina. It is not so 
 large on the inferior surface as it is on the superior surface of the pelvic 
 V?^I' .81 urethra; 9, vagina; 10, anus flaring; 11, pubic arch; 12, sacrum; 
 13, flaring ilium. 
 
 bundles of the rectal wall, forming a strong connec- 
 tion. The part interwoven in the rectal wall acts as 
 an elevator. It would appear that in some oases the 
 
HOW TO MEND THEM. 11 
 
 loops of the levator ani interweave with the mus- 
 cular fibers in the wall of the vagina. The part of 
 the levator ani which passes between the vagina and 
 rectum is a small, thin band, one-sixth to one-eighth 
 of an inch in width, which arises from the external 
 part of the pubic origin and passes over the large 
 l)elly of the muscle to gain the rectovaginal situa- 
 tion. Its relations to the wall of the vagina are very 
 close if not interwoven with its fibers. 
 
 The part of the muscle of fascial origin which 
 arises from the white line, passes backward and down- 
 ward, becoming part of the levator loop and partly 
 inserted in the tendinous perineal raphe and the 
 last bone of the coccyx. Many of these fibers pass 
 downward in a curve, and when near the median raphe 
 they turn acutely backward to become inserted into 
 the coccyx. A few of the muscular fibers arising 
 from the white line, as well as from the horseshoe- 
 shaped loop, together with some from the ischial 
 spine, embrace the rectum. The part of the levator 
 ani arising from the ischial spine becomes inserted 
 chiefly in the coccyx. Yet one may observe one- 
 fourth of an inch in width pass around the rectum 
 with no intervening tendinous raphe. 
 
 The part of the levator ani muscle of special inter- 
 est to the gynecologist is the two-fingers wide, horse- 
 shoe-shaped sling which arises from the posterior 
 surface of the pubis and passes backward and down- 
 ward to embrace both rectum and vagina. It is the 
 belly of this loop which gives the rectum its for- 
 ward curve just before the anal end is turned back- 
 ward. It is the sphincter portion of the muscle. It 
 is this part of the muscle which becomes hypertro- 
 phied in vaginismus. It is the portion of the muscle 
 torn and separated in lacerated perineum. It is the 
 portion of the muscle which retards labor, creates 
 vaginal spasm and may prevent coition, and in rare 
 
12 
 
 THE VAGINA AND PEEINEUM; 
 
 Fig. 3. — CAuthor. ) This figure I drew semi-diagramatically to illustrate 
 the general view of the pelvic outlet. 1, clitoris ; 2, crura clitoridis ; 3, 
 erecto clitoridis muscle ; 4, urethra ; 5. orifice of vagina ; 6, bulbo-eavern- 
 osus muscle ; 7, yulvo- vaginal glands (of Duverny, of Barthalin, of Tiede- 
 man) ; 8, posterior vaginal commissure ; 9, transversus perinei muscles ; 
 10, obturator internus muscle; 11, anus; 12, sphincter ani externus; 13, 
 coccyx; 14, levator ani muscle; 15, great sacrosCiatic ligament; 16, the 
 bulb of the vagina ; 17, deep layer of superficial perineal fascia. 
 
HOW TO MEND THEM. 13 
 
 cases prevents the penis from escaping until relaxed 
 by an anesthetic. In most cases the levator ani 
 behind the rectum may be divided into three quite dis- 
 tinct parts, viz., a, the part which is connected to the 
 last bone and fascia of the coccyx. The fibers accom- 
 panying this portion of the muscle originate chiefly 
 from the posterior end of the white line or at the 
 ischial spine, h. A portion of the muscle forms a 
 median tendinous raphe for about one-third of an 
 inch immediately in front of the coccyx, c. The 
 portion of the muscle immediately behind the anus, 
 about three-fourths of an inch wide, has no interven- 
 ing 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 
 words, the muscular fibers of each side anastomose, 
 forming the horseshoe- shaped loop, with no inter- 
 vening tendinous raphe. Some of the loops inter- 
 twine with those of the sphincter ani, which pass 
 back to the tip of the coccyx, also some of the mus- 
 cular fibers of the sphincter ani externus are con- 
 tinuous with the loops of the levator ani. The fibers 
 of the levator ani originating from the white line 
 pass backward and downward, but on arriving at the 
 median raphe, many of the fibers turn sharply back- 
 ward to be inserted into the coccyx, and soon become 
 tendinous. The levator ani fascia superior is not 
 very intimately attached to the muscle, and may be 
 compared to the fascia transversalis. The levator ani 
 fascia inferior is adherent to the muscle. 
 
 Deductions in regard to the levator ani muscle may 
 be numerous. Certain practical considerations may 
 be drawn from a careful study by dissection and in 
 gynecologic practice. As it was originally a muscle 
 of the tail it is becoming vestigial in man, shown by 
 its fascial connections. From the origin, course and 
 insertion of the levator ani muscle, it must be viewed 
 
14 THE VAGINA AND PERINEUM; 
 
 as the all-important muscle of the pelvic floor. 
 The levator ani fascia superior is the real visceral 
 support. I think it was Dr. Meyers, a German physi- 
 cian, who first happily named it the pelvic diaphragm. 
 In many subjects it is membranous. The normal 
 
 Fig. 4,— (Luschka, 1864,) Redrawn and modified represents a view of 
 the levator ani muscle. L, L, the modification of Luschka's figure con- 
 sists in magnifying the rectal curve made by the levator ani muscle ; C, is 
 a continuation of the levator ani muscle backward, drawn lightly ; V, 
 vagina. ^ The grip on the rectum by the horse-shoe sling of the levator ia 
 here plain. The levator ani fascia inferior, p, is shown rolled up. 
 
HOW TO MEND THEM. 15 
 
 muscle has the shape of a boat, and when this boat- 
 shape becomes cone-shaped, the pelvic floor is im- 
 paired. The levator ani is composed of many mus- 
 cular bundles coursing chiefly parallel to each other, 
 but also at varying distances. The bundles are 
 flat, ribbon-like, and of a bright red color. The 
 bundles of muscular fibers are held at greater or less 
 distance from one another by collections of fat or 
 connective tissue in varying degrees. Fenestra or 
 apertures are commonly observed between the mus- 
 cular loops. The capacity of the bundles of the 
 levator ani muscle to separate and reunite without 
 injury, serves a useful purpose in labor, when rapid 
 and wide distention of the pelvic floor may occur. 
 Too many figures illustrate the muscle as a distinct 
 plane with no parallel gaps between the bundles. 
 
 The levator ani (the deep muscular layer of the 
 pelvis) is connected to the external sphincter ani of 
 the rectum and vagina (the superficial muscular layer 
 of the pelvis) and by this muscular connection to 
 the perineal body (the punctum fixum), the deep and 
 superficial muscular layers of the pelvis are brought 
 into intimate relations of much utility. A few fibers 
 are lost in the perineal body. The levator ani is in 
 closer organic relation with the rectum than Ihe 
 vagina, because the rectum requires more frequent 
 and perfect evacuations than the vagina. It is chiefly 
 a sphincter muscle. The weakness of its origin, 
 insertion and direction of its fibers is in accordance 
 with its fading out of existence. 
 
 The forward curve of the rectum is due to the 
 horseshoe-shaped loop of the levator ani, which orig- 
 inates chiefly from the posterior surface of the pubis. 
 By the contraction of the lower, stronger fibers of the 
 levator, the lower portion of the rectum is forced 
 against the perineal body, which compels the anus to 
 turn backward and to evacuate its contents. 
 
16 
 
 THE VAGINA AND PERINEUM; 
 
 The levator ani, on account of its shape and size, 
 leaves deficiencies in the pelvic floor, which are filled 
 in front by the bulbo-cavernosus and behind by the 
 coccygeus muscle, its continuation backward. 
 
 The palpable rounded edge of the levator ani lies 
 three-quarters of an inch above the anus and three- 
 quarters of an inch above the vaginal opening, making 
 
 Fig. 5.— (Dickinson, 1889.) The levator ani as seen through the skin; 
 the outlet of the pelvis is dotted and the direction and course of the chief 
 muscular bundles of the levator ani marked out. 
 
 the muscle, in fact, a regulator of the external open- 
 ings of these two canals. Normally the orifices of the 
 canals are always closed. They remain open only by 
 internal or external force or from trauma. 
 
 The levator ani will lift from five to twenty pounds, 
 averaging about ten as noted by Dickinson. Its 
 
HOW TO MEND THEM. 17 
 
 strength soon tires out assistants in vaginal hysterec- 
 tomy. From its insertion into the perineal body the 
 external sphincter, post-rectal raphe and coccyx, it 
 draws forward the post- vaginal structures of the pelvic 
 floor. In the excellent work of Savage, he names the 
 portion from the principal bony origin, pubo-coccy- 
 geus. This is erroneous, as these loops do not pass as 
 far back as the coccyx — <io not even come in contact 
 with it. The levator lifts the rectum and vagina for- 
 ward and upward to the pubic arch. The muscle has 
 but limited influence on the sides of the rectum. The 
 muscular fibers composing the horseshoe loop exercise 
 the chief influence over the rectum, while the portion 
 of the muscle arising from the white line (fascia) 
 serves its purpose by holding the pelvic diaphragm 
 in relation prepared for any immediate action, with 
 its superior and inferior fascia it makes a tense floor 
 for the superimposed viscera. 
 
 The levator ani fascia superior and inferior lends 
 the muscle its greatest utility by increasing its strength 
 and also producing harmonious action in its func- 
 tion. The horseshoe sling is inseparably blended 
 with the sphincter ani externus. The levator ani pro- 
 duces the H-shaped condition of the vagina and its 
 puckered or constricted appearance at the orifice. 
 The muscle becomes hypertrophied during pregnancy 
 and vaginismus. It resists the head in labor to a sur- 
 prising degree. It may be easily observed in slow 
 labor, when, if small forceps sufficient to overcome 
 the tension of the muscle be applied, labor proceeds 
 rapidly. 
 
 The comparison of the diaphragm and levator ani, 
 as to the capacity for strength, is in favor of the leva- 
 tor ani. Its strength varies much in different sub- 
 jects. The best descriptions of the levator ani muscle 
 are given by Henle, Luschka, Testut and Lesshaft. 
 Hart and Dickinson have made excellent studies on 
 
18 
 
 THE VAGINA AND PERINEUM; 
 
 this muscle. Browning wrote an interesting article 
 on the subject. The levator ani may be a rudimentary 
 muscle, disappearing with the tail and in the evolu- 
 tionary process of an erect attitude. This view may 
 arise from the weakness of its origin, the direction of 
 its fibers and insertion, as well as the requirement of 
 the double fasciae. It is unphysiologio for a muscle 
 
 Fig. 6.— (Varnier, after Dickinson.) The distended levator ani. V. 
 bladder; s, p, symphysis; c, clitoris; c, v, constrictor of the vulva; F, 
 fonrchette ; P, A, anterior perineum ; A. O, anus ; P, P, posterior peri- 
 neum ; C, R, coccyx ; P, S. point of sacrum ; R, R, R, is on the muscle with 
 its separated bundles, the middle R is on the strongest bundle. In this 
 figure we observe how the muscle can save itself from rupture by the 
 separation of its various fasciculi. It yields better than if it were in one 
 connected sheath. 
 
 to produce constant support, hence the levator ani 
 can not be considered a support for the viscera; it is 
 rather a sphincter muscle. 
 
 The levator ani muscle is analogous to the buccina- 
 tor muscle. Perhaps from an evolutionary standpoint 
 
HOW TO MEND THEM. 19 
 
 we may look on the levator ani as having three func- 
 tions, viz.: a, of a sphincter; h, of an elevator; and 
 c, of a tensor of the levator ani fascia, superior and 
 inferior. 
 
 As proof that the levator ani is a sphincter, one 
 need only introduce the finger into the vagina and 
 request the subject to contract the muscle. Cruveil- 
 hier, Henle, Lesshaft and Budge insist that the leva- 
 tor ani is a sphincter of the anus and lower rectum 
 chiefly, and not an elevator. That this muscle is an 
 elevator one need only dissect it to find the muscle 
 ending definitely in the walls of the rectum, and such 
 terminating fibers, when in action, could only elevate 
 the rectum. The horse in defecation illustrates that 
 the levator ani is an elevator, as the rectal wall is 
 elevated, the rectal mucosa everted and completely 
 evacuated. As an elevator, it resists intra-abdominal 
 pressure. 
 
 The levator ani appears as well developed in the 
 male as the female, and hence labor does not appear 
 to develop it. The levator ani muscle is greater in 
 those animals with a tail, and originally its chief func- 
 tion was to aid in managing the tail, from which it 
 would appear that as a tensor of the levator ani fascia 
 superior and inferior, these fibers take an active part. 
 They originate at a definite fixed point, lose them- 
 selves between the fascial blades and do not reach 
 rectal or vaginal walls. When a muscular fiber neither 
 goes 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 
 layers, viz., a, the inner layer, which is an elevator, 
 and 6, the outer layer, which is a sphincter. 
 
 THE INTERNAL PELVIC FASCIA. 
 
 The internal fascia of the lesser pelvis has a poor 
 literature, and is not often described. As the pelvic 
 
20 
 
 THE VAGINA AND PERINEUM; 
 
 fascia has much to do with the permanent results of 
 the flap or any perineal operation, I will write of it 
 somewhat in detail. 
 
 The fascia of the greater pelvis, or that fascia lying 
 superior to the ileopectineal line, is not here con- 
 sidered. The fasciae, the planes of strong, fibrous 
 tissue here under consideration, lie below the ileo- 
 pectineal line. 
 
 ^ Fig. 7.— (Robinson-Scholor.) A diagram to illustrate the pelvic fascia, 
 with a new nomenclature of same. 1, 1, white line; 2, 2, origin of trans- 
 versalis and iliac fascia at the iliac crest ; 3, 3, levator ani fascia superior; 
 4. 4, levator ani fascia inferior; 5,5, Alcock's canal; 6,6, obturator intemus 
 muscle ; 7, 7, levator ani muscle ; 8, vagina or rectum ; 9, external sphincter ; 
 10. 10, ileopectineal line ; 11, 11, origin of levator ani fascia superior ; 12, 12, 
 beginning of obturator fascia inferior ; 13, IS, transversalis fascia ; 14, 14, 
 iliac muscle; 15, 15, iliac fascia; 16, 16, obturator fascia superior; 17, 17, 
 ending of obturator fascia inferior on the ischial tuberosity. 
 
 As a teacher of anatomy, I have always maintained 
 that a fascia should be named according to the muscle 
 or other structure with which it is in the most inti- 
 
HOW TO MEND THEM. 21 
 
 mate relation. I shall therefore apply this simple 
 nomenclature to the fascia in the pelvis. 
 
 The fascia covering the obturator intemus muscle 
 will be termed the obturator fascia. As this fascia 
 is divided by the white line extending from the poste- 
 rior surface of the pubis to the ischial spine, we will 
 call that portion of the fascia above the white line 
 the obturator fascia superior, and that portion of the 
 fascia below the white line the obturator fascia infe- 
 rior. The fascia above the levator ani, originally 
 named by Tyrrell the rectovesicale, and by Carcassone 
 the pelvic aponeurosis, by others the vesical layer of 
 the pelvic fascia, we will name the levator ani fascia 
 superior, and that part of the fascia below the levator 
 ani, the levator ani fascia inferior. The fascia cover- 
 ing the coccygeal and pyriformis muscles will be 
 named after those muscles. The fascia covering the 
 sacrum very naturally takes the name of the sacral 
 fascia. The internal fascia of the lesser pelvis extends 
 from the ileopectineal line on either side to the median 
 raphe of the pelvic floor. It not only lines the pelvic 
 walls and floor, but enters into intimate relations with 
 the pelvic viscera. It is a strong, shiny, fibrous mem- 
 brane, possessing a very varying quantity and quality. 
 In a certain sense the fascia of the lesser pelvis should 
 be treated as an independent structure, and not as a 
 continuation of the iliac transversalis or other fasciae. 
 The ileopectineal line marks an absolute division be- 
 tween the iliac and obturator fascia. 
 
 The simplest plan is to describe the obturator fascia 
 superior and inferior and to consider the obturator 
 fascia as distinctly belonging to the obturator (inter- 
 nus) muscle, subsequently to consider the fascia of 
 the levator ani superior and inferior, with a lesser con- 
 sideration of the coccygeus, pyriformis and sacral fas- 
 ciae. The fasciae lining the lesser pelvis are intimately 
 connected with their respective associated muscles and 
 
22 
 
 THE VAGINA AND PERINEUM; 
 
 structures by strong connective tissue. The connec- 
 tion of the fascise with the peritoneum is not intimate, 
 a thick, loose layer of connective tissue, richly laden 
 with fat lobules, lies between the peritoneum and the 
 fasciae lining the lesser pelvis. This loose connection 
 of pelvic peritoneum and pelvic f ascise allows the easy 
 and rapid spread of pelvic abscesses between the pel- 
 vic fasciae and the peritoneum in the subperitoneal 
 tissue. 
 
 Fig. 8.— (Ranney.) Diagram of the fascia of the pelvic floor in a mesial 
 section. It illustrates the levator ani fascia superior and inferior above 
 and below the levator ani muscle. T, L, triangular ligament; P, F, two 
 layers of superficial perineal fascia. Observe that in the anterior trian- 
 gular perineal space there are five layers of fasciae, viz. : 1, superficial 
 layer of perineal fascia ; 2, deep layer of superficial perineal fascia ; 3, 
 triangular ligament, outer layer ; 4, triangular ligament, inner layer ; 5, 
 levator ani fascia siiperior. In the posterior perineal space there are two 
 layers of fascia— the levator ani fascia superior and the levator ani fascia 
 inferior. 
 
 The obturator internus fascia surrounds the obtu- 
 rator muscle at its origin, from the lateral pelvic sur- 
 face of the innominate bone, and is the special fascia 
 of the obturator internus muscle. It is attached for 
 a considerable distance to the iliac portions of the 
 
HOW TO MEXD THEM. 23 
 
 brim. At this point the obturator becomes attached 
 to the upper border of the obturator membrane. In 
 front, the attached line of the fascia passes below the 
 ileopectineal line to allow the obturator vessels and 
 the nerve to enter the obturator foramen or canal. 
 This portion is fixed to the periosteum and appears as 
 an independent organ. In front it is attached to the 
 body of the pubis and along the upper margin of the 
 obturator foramen by an oblique line, to a point about 
 one- half an inch below the symphysis. Where the 
 fascia dips under to allow the passage of the obturator 
 vessels and nerves it is firmly attached to the perios- 
 teum and nerves by strong tendinous fibers. Poste- 
 riorly, it is attached to the anterior surface of the 
 great sacrosciatic ligament and the anterior margin of 
 the great sacrosciatic notch. Inferiorly, the fascia is 
 attached to the margin of the obturator foramen of 
 the descending ramus of the pubis, and it joins the 
 falciform process of the great sacrosciatic ligament, 
 which firmly connects it to the inner border of the 
 ischium and its ascending ramus. 
 
 With a firm insertion in the ileopectineal line, the 
 anterior border of the great sacrosciatic foramen, the 
 anterior and inferior margin of the obturator foramen 
 and to the edge of the falciform process of thjB great 
 sacrosciatic ligament, the obturator fascia becomes a 
 fixed, strong, thick, fibrous membrane, in relation 
 superiorly with the obturator nerve and vessels and 
 inferiorly with the internal pudic vessels and nerves 
 — Alcock's canal. It has intimate attachments to the 
 obturator internus muscle above, but is quite loose 
 below. 
 
 The obturator fascia we divide into two portions, 
 superior and inferior. The obturator fascia superior 
 is that portion above the white line or arcus tendineus. 
 It looks into the pelvic cavity from the lateral aspect 
 and is covered by peritoneum. The peritoneum and 
 
24 THE VAGINA AND PERINEUM; 
 
 obturator fascia superior are separated by consider- 
 able loose, fatless, snow-white connective tissue, com- 
 posed of many shiny, thin, cleavable planes, which 
 become easily dissected by the progress of pelvic 
 abscesses. 
 
 The structures of importance which pass over the 
 internal face of the obturator fascia superior just be- 
 low the ileopectineal line are the obturator vessels and 
 nerves. These structures are liable to be injured by 
 the head soon after its engagement by the brim or 
 fixed bony ring of the pelvis. The obturator fascia 
 superior has a surface of about ten square inches. 
 
 The obturator fascia inferior is that portion below 
 'the arcus tendineus or white line. It looks internally 
 into the ischiorectal fossa and externally toward the 
 obturator internus muscle. It forms the external 
 boundary of the ischiorectal fossa. At the lower part 
 of the ischiorectal fossa about an inch above the 
 tuberosity of the ischium the obturator fascia plane& 
 become separated, producing a sheath — Alcock'& 
 Canal — for the transmission of the pubic vessels and 
 nerves. The obturator fascia inferior has a surface 
 of some five square inches, one-half the size of the ob- 
 turator fascia superior. 
 
 At the lesser sciatic notch the obturator fascia 
 passes out of the pelvis with the muscles and gains the 
 postero-femoral regions of the thigh. The obturator 
 fascia is inserted into the ramus of the ischium and 
 pubis, where it passes on and blends with the triangu- 
 lar ligament of the urethra, hence the triangular liga- 
 ment is a continuation of the obturator fascia from 
 each side. 
 
 The arcus tendineus or white line appears as an 
 aggregation of tendinous fibers of the obturator 
 fascia. It extends from the posterior surface of the 
 pubis to the spine of the ischium. It possesses a 
 gentle curve with its concavity upward. The whit© 
 
HOW TO MEND THEM. 25 
 
 line gives origin to that part of the levator ani mus- 
 cle which arises between the lower posterior surface 
 of the pubis and ischial spine. The white line arises 
 out of the ligaments of the bladder; a thickened por- 
 tion of the obturator fascia is the line of origin of two 
 planes of fascise. The upper plane I call the levator 
 ani fascia superior, and the lower plane the levator 
 ani fascia inferior. The white line varies in thickness 
 in individuals — generally is one-sixth of an inch in 
 thickness in the middle, but its greatest strength and 
 width is at the anterior end, where it assumes inti- 
 mate relations with the pubovesical ligaments. In 
 women the white line is about four inches long. Its ori- 
 gin at the pubis may be chiefly from the anterior and 
 lateral (true) ligaments of the bladder. The white 
 line allows considerable elasticity. It is quite firmly 
 fixed at the anterior end, and definitely at the poste- 
 rior end, but, like a long, tight rope, allows consider- 
 able range of motion and sagging in the middle. 
 
 The levator ani fascia superior (rectovesical fascia 
 of Tyrell, rectovesical aponeurosis of Carcassone or 
 visceral layer of the pelvic fascia) arises from the white 
 line and passing inward forms the floor of the pelvis. 
 The levator ani fascia superior, as its name implies, 
 covers the superior surface of the levator ani muscle. 
 The fascia finally loses itself in the median raphe be- 
 hind the rectum in the rectal, vaginal and vesical walls, 
 and in the anterior and lateral ligaments of the blad- 
 der. From this relation, the levator ani fascia supe- 
 rior becomes of significant interest in perineorrhaphy. 
 Anteriorly it is remarkably strong and short, being 
 attached to the back of the pubis above the obturator 
 fascia, from which it is separated by the origin of the 
 levator ani muscle; the levator ani fascia superior, the 
 levator ani muscle and the obturator fascia being all 
 three closely adherent to the pubic bone and to each 
 other. 
 
26 THE VAGINA AND PERINEUM; 
 
 If one carefully removes the peritoneum and loose 
 subperitoneal tissue the levator ani fascia superior 
 may be plainly seen stretching from the white line to 
 the bladder, vagina and rectum. It may be stripped 
 off the levator ani muscle in several thin, cleavable 
 planes. It is reflected on the bladder forming the 
 anterior true and lateral true ligament of the bladder, 
 however the lateral ligaments of the bladder may be 
 assisted by ligaments from the vagina. The ' levator 
 ani fascia superior begins its anterior attachments at 
 the lower border of the symphysis, continues then 
 along the white line laterally to the ischial spine, con- 
 tinues from the ischial spine on the superior surface 
 of the levator ani muscle to the median raphe. The 
 levator ani fascia superior covers an area of about six 
 square inches on each side of the median line of the 
 pelvis. 
 
 The levator ani fascia superior may be divided into 
 the anterior or vesical portion, the vaginal portion and 
 the rectal portion. 
 
 The vesical portion of the levator ani fascia supe- 
 rior is reflected from the pubis to the neck of the 
 bladder, forming the anterior true ligaments 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 surrounds the prostate in 
 the male. In the male, the prostate gland and vesi- 
 culse seminales are surrounded by a strong capsule 
 derived from levator ani fascia superior. This por- 
 tion of fascia surrounds the vagina in the female, in- 
 cluding the large venous plexuses. 
 
 The vaginal portion is endowed with considerable 
 strength and it becomes blended with and is lost on 
 the vaginal wall. The rectal portion of the levator 
 ani fascia superior passes to the rectal wall, becom- 
 
HOW TO MEND THEM. 27 
 
 ing continuous with the fibers and blending with it. 
 There is a strong fillet passing between the rectal and 
 vaginal canal. The part of this fascia which passes 
 to the rectal wall, has been termed the ligament of 
 the rectum. This fascia forms a strong support to 
 the muscular wall of the rectum. 
 
 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 levator 
 ani muscle. A subject which I have not found men- 
 tioned in the books is that in many parts the fascia 
 of the pelvis consists of many distinctly defined 
 layers, which can be cleaved from each other. For 
 example, the fascia over the coccygeal muscle may 
 be cleaved off in several layers, and the same may be 
 said, — but not to such a degree — of the levator ani 
 superior. Several thin, transparent planes of fascia 
 may be cleaved off of the obturator fascia superior. 
 Even the levator ani fascia inferior, which is very thin 
 and compact, may be cleaved into two or more planes. 
 The obturator fascia inferior is a very powerful 
 fibrous plane of fascia and may be cleaved on each 
 side into thin planes but the central plane is a thick, 
 powerful, individual, somewhat coarse, fibrous mem- 
 brane. The powerful obturator fascia inferior is 
 cleaved, split, for the transmission of the pubic ves- 
 sels 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. One plane may tear without 
 the other. Several cleavage planes are characteristic 
 of fascia in other localties and are more capable of 
 resisting trauma than a single plane. 
 
 The coccygeal muscle arises from the spine of the 
 ischium and lesser sacrosciatic ligament, becoming 
 inserted into the side of the coccyx and two lower 
 sacral vertebrse. It is a flat musculo-tendinous tri- 
 
28 THE VAGINA AND PERINEUM; 
 
 angular plane, aiding to close the posterior pelvic out- 
 let. Its anterior border is in contact with the poste- 
 rior border of the levator ani muscle, of which it is 
 practically a continuation backward and covered by 
 the same fascia, viz., the levator ani fascia superior. 
 The posterior border bounds the anterior margin of 
 the great sacrosciatic foramen. The lesser sacro- 
 sciatic ligament, which is formed by a degeneration 
 of the superficial muscular fibers of the coccygeus, 
 takes the place of the continuation of the levator ani 
 fascia inferior. The coccygeus muscle is fading out 
 of existence, belonging originally to a large tailed 
 animal. The origin and insertion of the coccygeus 
 muscle and lesser sacrosciatic ligament are identical. 
 They are so strong that practically they never yield 
 so as to be involved in colpoperineorrhaphy. How- 
 ever, the coccygeus muscle is described in order to 
 show that its fascia should be named the coccygeal 
 fascia, which can not admit of confusion. The infe- 
 rior surface of the coccygeus muscle is doubly 
 strengthened, not only by the lesser sacrosciatic lig- 
 ament, but by the superior surface of the great sciatic 
 ligament which represents the proximal tendon of the 
 long head of the bicep femoris. The tendon of the 
 long head of the biceps formed an attachment at the 
 tuberosity of the ischium. The coccygeus fascia 
 covers the coccygeus muscle and has an area of about 
 3J square inches on each side of the median line of 
 the pelvis. The pyriformis muscle arises fsom the 
 lateral portions of the second, third and fourth pieces 
 of the sacrum, from the inferior border of the great 
 sacrosciatic notch and from the great sacrosciatic 
 ligament. It passes out of the pelvis through the 
 great sacrosciatic foramen, becoming inserted into 
 the upper border of the great trochanter. It is the 
 most posterior muscle which aids in closing the pelvic 
 outlet. It serves as a bed on which the sacral nerves 
 
HOW TO MEND THEM. 29 
 
 may rest. It is covered by the pyrifonnis fascia, 
 which is a continuation of the obturator fascia above 
 and the coccygeus fascia anteriorly. After leaving 
 the obturator and coccygeus fascia it rapidly thins 
 out into a transparent thin membrane. It is perfo- 
 rated by the internal iliac vessels which leave the 
 pelvis by the great sciatic foramen. The pyriformis 
 fascia is attached to the surface of the sacrum inter^ 
 nal to the origin of the pyriformis muscle from the 
 posterior border of the coccygeus muscle to the ileo- 
 pectineal line which passes along the border of the 
 wing of the sacrum to the sacro-iliac joint and finally 
 it is attached to the superior margin of the great 
 sacrosciatic foramen from the ischial spine to the 
 sacro-iliao point. The pyriformis fascia covers an 
 area of about five square inches on each side of the 
 pelvis. The sacrum is lined by a thin fibrous mem- 
 brane which we will name the sacral fascia; hence, 
 the internal pelvis is lined by the obturator fascia 
 superior, the levator ani fascia superior, the coccygeal 
 fascia, the pyriformis fascia, and the sacral fascia. 
 This nomenclature we recommend as simple, and as 
 facilitating the easy acquisition of the internal fascige 
 of the pelvis. 
 
 The use of the levator ani fascia superior is : a, to 
 sustain the pelvic viscera, and is analagous to the fas- 
 cia tranversalis-abdominalis; b, to form a pouch on 
 each side for the pelvic viscera, which assists in clos- 
 ing the pelvic outlet above the muscular floor; c, to fix 
 the pelvic viscera; d, with its superior pad of fat and 
 snow-white connective tissue, to support the pelvic 
 peritoneum; e, to resist the pressure of the abdominal 
 muscles and the diaphragm, and/, to serve the useful 
 purpose of separating the perineal tissue from the 
 peritoneum. 
 
 This latter anatomic condition limits inflammatory 
 and infective processes from either perineal or peri- 
 
30 
 
 THE VAGINA AND PERINEUM; 
 
 toneal spaces. Further, the levator ani fascia superior 
 forms the pelvic floor, and by its strength prevents 
 pelvic hernia. The blood-vessels are placed sijperior 
 and the nerves inferior. The levator ani fascia su- 
 
 Fig. 9.— (Author.) An illustration to demonstrate that in deep lacer- 
 ations of the pelvic floor the levator ani fascia superior and inferior is 
 torn with its intervening muscle, the levator ani. The rent or tear is 
 shown by R, R, and R, R, on the right side. The needle armed with the 
 thread (X) will pass through the muscle and its two layers of fascia in 
 order to restore the integrity of the pelvic floor. XL, iliac fascia ; Up, the 
 beginning of the obturator fascia superior at the ischiopectineal line; 
 OS, the obturator fascia superior ; W, the white line ; O, the obturator 
 fascia inferior divided by the white line; I. O, the obturator internus 
 muscle; F, the fat in the ischiorectal fascia; A, the levator ani fascia 
 superior; B, the obturator fascia inferior; V, the vagina; S, intrapelvic 
 space ; Y, the cervix ; P, deep transverse perineal muscle, and 2, the super- 
 ficial; B, the sphincter ani externus; M, deep layer of triangular liga- 
 ment; S, superficial; N, deep layer of superficial perineal fascia. 
 
HOW TO MEND THEM. 31 
 
 perior and inferior limits nearly all fistulse in and 
 to one-half inch above the anus. A disadvantage of 
 the levator ani fascia superior is that it is perforated 
 by nerves and vessels which carry sheaths of con- 
 nective tissue ; these sheaths allow infective proc- 
 esses to pass from the perineal tissue to the subperito- 
 neal tissue and vice versa. Deficiencies occur in the 
 fascia, excavations which are filled with fat. The 
 fascia of the pyriform muscles consists of an exten- 
 sion backward of the obturator superior and levator 
 ani fascia superior. Both fascial planes blend, the 
 one from the anterior margin of the sacrosciatic fora- 
 men and the other from the posterior margin of the 
 cocygeus into a thin membrane which covers the 
 pyriformis muscle and the sacral plexus of nerves. 
 The pyriformis fascia is perforated by the gluteal ves- 
 sels and nerves to gain the gluteal region. This plane 
 of fascia is so thin and delicate that one can scarcely 
 dissect it without tearing it. The levator ani fascia in- 
 ferior (anal or ischiorectal fascia) lies in immediate 
 and intimate contact with the inferior surface of the 
 levator ani muscle. This fascia begins at the white 
 line and becomes lost on the rectal wall. It is very 
 intimately connected with the muscles. The levator 
 ani fascia superior and inferior blend with the rectal 
 wallabout one-half to three-fourths inch above the anus, 
 and rectal perforations generally occur below the in- 
 sertions of the above fascia. The fibers of this fascia 
 are included in all deep suturing of extensive colpo- 
 perineorrhaphy. By including its fibers in the 
 sutures, the relations of the levator ani may be par- 
 tially restored to the normal relations. The sacral 
 and coccygeal fascia lines the anterior surface of the 
 sacrum; it has localized thickenings and thinnings 
 The thickest portions are those located along the lat- 
 eral margins of the sacram and especially around the 
 anterior sacral foramina. The triangular ligament 
 
32 THE VAGINA AND PERINEUM; 
 
 (deep perineal fascia) closes in the pelvic floor in 
 front. It is the result of the union of the obturator 
 fascia extending from both sides toward the center. 
 It is a prolongation of the obturator fascia across the 
 pubis, and Winslow called it the ligamentum inter- 
 ossei pubis; Carcassone, the ligamentum perineale; 
 Colles, the ligamentum triangulare urethrse. It is 
 the deep blade of the fascia perinei and is an integral 
 part of the obturator fascia. It is the middle fascia 
 of the perineum, or Camper's ligament. It fills up 
 the deficiency found between the anterior or pubic 
 insertions of the levator ani muscle. It is a wonder- 
 fully powerful structure in fixing the lower end of the 
 vagina. It is stronger in males than in females. It 
 is the structure which retains, with powerful grip, 
 the anterior end of the vagina forward and upward. 
 The vagina pierces the triangular ligament whose 
 fibers fix themselves in and around the vaginal walls. 
 It joins posteriorly with the lower margin of the in- 
 ferior edge of the superficial perineal fascia. If one 
 dissects away all structure from the vagina except 
 the triangular ligament it will become apparent at 
 once what a powerful support it is to the lower end 
 of the vagina. The triangular ligament, as its name 
 implies, is triangular in shape, aponeurotic in struc- 
 ture, extending as a tense septum between the anterior 
 part of the perineum and pelvis. It is attached on 
 either side to the rami pubis and ischium. Its infe- 
 rior or posterior inferior margin is ill-defined, blends 
 with the superficial perineal fascia at the ischioperi- 
 neal fascia, where it gradually loses itself on the 
 lower surface of the levator ani muscle. It sustains 
 and fixes the urethral can^. It is pierced by the 
 vagina at its base or weakest portion. It serves the 
 useful purpose of connecting the bladder and vagina 
 to the pubis, and of retaining adjacent organs in 
 fixed relations. By its connection with the ischio- 
 
HOW TO MEND THEM. 33 
 
 perineal ligament (fascia) and levator ani muscle it 
 serves to strengthen the inferior region of the pelvis 
 posteriorly, and aids to fortify the rectum with its 
 muscles. By dissection, it is plain to see how the 
 triangular ligament closes the anterior perineal tri- 
 angle, and the levator ani closes the posterior perineal 
 triangle. The triangular ligament extends posteriorly 
 on each side of the vagina and blends, not only with 
 ihe lower ledge of the superficial perineal fascia, but 
 very intimately interweaves and blends with the 
 ischioperineal ligaments, making a powerful fixation 
 for the vagina at its lower end. The triangular liga- 
 ment in conjunction with the ischioperineal liga- 
 ments lends to the perineal body a "Punctum Mobile." 
 In perineorrhaphy much attention should be given to 
 the factor of including considerable parts of the tri- 
 angular ligament and the ischioperineal ligaments in 
 the deep suture, which secures a forward curve to the 
 vagina, and also, by forcing medially adjacent tissues, 
 it aids in producing the normal curve of the rectum 
 backward. This ligament is a very important struc- 
 ture, serving many purposes of support, and aiding 
 in repair. It is continuous with the levator ani fas- 
 cia inferior, and above it is the levator ani fascia supe- 
 rior. The superficial layer of the deep perineal 
 fascia of Colles is a strong fibrous membrane. It 
 extends from one ischiopubio ramus to the other. 
 This membrane blends posteriorly with the lower 
 margin of the triangular ligament, producing partly 
 ischioperineal ligaments. The superficial layer of the 
 deep perineal ligament is less in extent in femalea 
 than in men, on account of being pierced by the 
 vagina. In perineorrhaphy it is of considerable aid 
 in restoring the relation of the parts by allowing the 
 deep sutures to draw the fascia median ward. The 
 ischioperineal ligaments extend from the ischial 
 tuberosities to the perineal body. They are strong 
 
34 THE VAGINA AND PERINEUM; 
 
 aponeurotic bands of a very resisting character. 
 They result from the union of the lower border of 
 the triangular ligament with the deep layer of the 
 superficial fascia. The fibers of these ligaments play 
 an important role in extensive colpoperineorrhaphy. 
 These ligaments form a conspicuous structure in every 
 dissection of the female perineum. In the advancing 
 head the ischioperineal ligaments are put on the 
 stretch and gradually forced backward. Should they 
 rupture, by extensive flap-splitting and deep suturing 
 the two layers of fascia which blend to make the lig- 
 ament could be partially restored. 
 
 Having examined the structure of the pelvis in 
 detail we may now combine the anatomic factors 
 which explain successful colpoperineorrhaphy. The 
 first is the restoration of damaged fascia. A second 
 important factor is deep suturing. A third element 
 in a successful operation is the restoration of function 
 by means of restored muscular relations. A fourth is 
 the forcing in the median line of adjacent perineal 
 tissue, and a fifth factor is the flap method of opera- 
 tion whereby there is no denudation or loss of tissue, 
 and the flaps (skin and mucosa) avoid infection and 
 insure primary healing. The flap method enables 
 the operator to reach the seat of the lesion, either by 
 splitting tissue or deep suturing with a handled 
 needle with an eye in the end. Silk- worm gut which 
 is used in suturing, being non-septic, may remain for 
 weeks in position, like a splint, before removing. 
 Among the fasciae of importance are: The levator ani 
 superior and inferior, the triangular ligament and 
 deep layer of the superficial fascia, and the ischio- 
 perineal ligament. The operation of colpoperineor- 
 rhaphy is the result of evolutionary processes of 
 failures and successes. In the beginning, it was con- 
 sidered sufficient to unite the superficial or external 
 tissues at the site of the lesion. This experiment 
 
HOW TO MEND THEM. 35 
 
 soon demonstrated its own failure, and later it was 
 deemed essential to restore the deranged and lacer- 
 ated muscular elements in the pelvic floor. The 
 attempt at successful colpoperineorrhaphy by reunit- 
 ing external tissue at the site of the lesion or restor- 
 ing deranged or lacerated muscles to normal relations 
 proved a failure to such a degree that it was evident 
 that some other factor played a role; this factor was 
 the fascia. The restoration of the lacerated tissue at 
 the site of the wound, with the deranged and ruptured 
 muscles, and the restoration of the deranged fascia 
 are the three factors on which successful colpoperi- 
 neorrhaphy rests. To Dr. T. A. Emmet must be 
 given the credit of the view that the pelvic fascia 
 played an important role in successful colpoperineor- 
 rhaphy. Experimental labors on the perineum, in a 
 desultory manner, have been carried on for fifty 
 years. But only lately have experimental and ana- 
 tomic data been judiciously combined so as to render 
 clear what are the useful methods in colpoperineor- 
 rhaphy. All successful surgical procedures demand 
 an anatomic basis. The deranged and lacerated parts 
 in colpoperineorrhaphy must be restored in a manner 
 similar to that in operation for hernia. The success- 
 ful surgical procedures in colpoperineorrhaphy have 
 passed through the same evolutionary process as have 
 the various operations for hernia. In hernia we must 
 restore the anatomic relations, the obliquity of the 
 inguinal canal, so that its valve-like action makes it 
 impossible for the viscera to again protrude. In col- 
 poperineorrhaphy, not only the anatomic parts should 
 be restored, but the various canals and outlets must 
 also be restored, to ensure permanent success. Deep 
 suturing, so essential, is only groping after an ana- 
 tomic base to restore the ground work. The same 
 ideas are involved in the views of discerning surgeons, 
 who suggest that if the sutures include sufficient of 
 
36 THE VAGINA AND PERINEUM; 
 
 the rectovaginal septum, or if they are introduced 
 deep enough to make forward traction, or if they 
 include the sulcus on either side of the bulging 
 vaginal wall, the operation will be successful. Dr. 
 W. R. Wilson wrote a short but comprehensive arti- 
 cle on the subject, suggesting excellent principles, 
 but modestly claiming that the anatomic basis is still 
 imperfectly understood. In the subject of colpo- 
 perineorrhaphy the origin of the lesion demanding 
 operation should be studied. The cause of the lesion, 
 requiring repair, is almost always the result of (the 
 first) labor, more rarely other forces" produce sacro- 
 pubic hernia. The lesions of the perineum may come 
 from the forward movement of the head jlacerating 
 the levator ani fascia superior and inferior, with dam- 
 age to the ischioperineal (ligament) fascia and tearing 
 of the triangular ligament, with consequent inevitable 
 lesion of the deep perineal fascia. This will destroy 
 the tone of the posterior vaginal wall, because the 
 fascia has been separated from the vaginal wall near 
 its outlet. If the distinct ischioperineal (ligament) 
 fascia be torn, which is quite frequent in labor, the 
 vulvar end of the vagina falls backward and begins its 
 condition of rectocele; its fascial (and doubtless mus- 
 cular) supports have been torn away. With a torn 
 levator ani fascia superior the pelvic viscera will inev- 
 itably descend, for it is unphysiologic for a muscle to 
 act as a continuous, tensionized support for viscera. 
 But it must be remembered that the fascial layers of 
 the pelvis are not only of value as visceral supports 
 by separate and distinct connection in themselves, 
 but they are of significant importance as serving a 
 means of visceral support and for a point of attach- 
 ment for muscles lying between their blades. The 
 levator ani, which is the most important muscular 
 apparatus on the pelvic floor, serves by its fascial 
 attachments as a visceral support to the rectal and 
 
HOW TO MEND THEM. * 37 
 
 vaginal walls as well as to the pelvic floor, for the 
 uterus is supported by the intact pelvic floor. 
 
 The pelvic floor may be considered as composed of 
 two widely overlapping valves ( Hart) . Whatever dis- 
 turbs the relations of these valves tends toward sacro- 
 pubic hernia. The anterior pelvic valve is composed of 
 the bladder, drethra, anterior vaginal wall and retro- 
 pubic fa , The posterior pelvic valve is composed of the 
 posterior vaginal wall, perineum and rectal wall. The 
 pubic segment is attached to the symphysis pubis and 
 composed of loose connective tissue. The retropubic 
 fat is loose and spongy, the peritoneum may be easily 
 stripped away from the bladder, and the bladder from 
 the vagina. In labor, this segment becomes elevated 
 and is the one which easily becomes deranged, or 
 acquires pathologic conditions and especially is liable 
 to prolapse or sacropubio hernia. The levator ani 
 fascia superior becomes torn away from the walls of 
 the bladder and vagina, allowing the intra-abdominal 
 pressure to force the bladder and vagina downward. 
 
 When the uterus prolapses (sacro-pubic hernia) 
 the anterior vaginal wall appears at the vulva first. 
 The strong levator ani fascia has been torn from its 
 walls and when the same fascia has been extensively 
 torn from the bladder it prolapses also. In vesical 
 prolapse the peritoneum with its many cleavable 
 planes of subperitoneal (fascia) tissue becomes torn 
 from the bladder. The sacral valve of the pelvic 
 floor, consisting of the posterior vaginal wall, the 
 perineum and rectum, is attached by strong fascial 
 connections interwoven by muscles to the coccyx and 
 sacrum. In labor, this segment is forced backward 
 and straightened out. If it becomes defective by 
 laceration at the perineal body the vagina loses its 
 normal curve and sacro-pubic hernia is initiated, i. e., 
 retroversion begins, which is the inevitable factor in 
 sacropubic hernia. The uterus itself has nothing to 
 
38 THE VAGINA AND PERINEUM: 
 
 do with prolapses. Intra-abdominal pressure and 
 defective sacral and pubic segments account for pro- 
 lapse; the sacral segment is fixed; the pubic segment 
 is movable. 
 
 The functions required of the pelvic floor are to 
 resist intra-abdominal pressure and to allow rectal 
 and vesical functions. The structural anatomy of 
 the pelvic floor must not only be studied in general 
 as to it segments, valves, muscles and fascia but each 
 individual organ should be studied as regards its sup- 
 ports. The uterus has its individual supports, which, 
 though not separate from the fascia and muscles, 
 should be well considered, for colpoperineorrhaphy 
 may be required for (prolapse) sacro-pubic hernia 
 without visible lacerations. The first elemental indi- 
 vidual supports of the uterus are the uterorectal 
 (sacral) ligaments. They consist of two folds of 
 peritoneum embracing muscular and connective tis- 
 sue extending from the posterior surface of the cer- 
 vix to the rectum (perhaps some fibers do extend to 
 the sacral fascia). These ligaments are an extension 
 of the muscular conneclive tissue fibers of the upper 
 end of the vagina backward. As Dr. Frank Foster 
 notes, the vagina and uterorectal ligaments form a 
 balance beam on which the uterus rests. Yet it 
 should be borne in mind that organs do not rest on 
 bases, but .are swung on supports or mesenteries. 
 The brain, liver, heart and uterus are all suspended 
 by supports and do not rest on other organs or bases. 
 The uterorectal ligaments are powerful, peritoneal, 
 muscular and connective bands which vigorously sus- 
 pend the uterus by the neck. Careful dissections and 
 vaginal hysterectomy will demonstrate that the uterus 
 eould not descend without the uterorectal ligaments 
 became elongated. 
 
 These ligaments are a part of the musculo-fascial 
 support of the pelvic viscera. The vaginal tube sup- 
 
HOW TO MEND THEM. 39 
 
 ports the uterus by being well embraced by the leva- 
 tor ani fascia superior and the levator ani muscle, 
 and also by being well padded and surrounded by 
 fascial planes of connective tissue fixed in its walls 
 and adjacent structures. Fat pads and acts as a sup- 
 port by stiffening folds. 
 
 In colpoperineorrhaphy, it is well to remember that 
 we have a fixed pelvic segment and a movable or dis- 
 placeable segment. It will aid in repair. The mov- 
 able pelvic segment comprises the urethra, bladder 
 and vaginal walls, This segment is bound together 
 by peritoneum on a very mobile base and by a con- 
 siderable mass of loose connective tissue. 
 
 This segment becomes displaced by labor, distended 
 bladder, vagina or rectum. If its fascial connections 
 become torn, sacropubic hernia is inevitable. The 
 fascial connections are considerable above the vulva, 
 consisting of the levator ani fasciae superior and 
 inferior and to some extent of the levator ani muscle. 
 Sacropubic hernia, arising from lacerated fascia 
 of the movable pelvic segment is recognized by the 
 vagina and bladder bulging downward at the vulva 
 and making the vulva appear as a waist with the 
 puckering string gone. The worst and most damag- 
 ing cases of laceration are those which begin from the 
 inside and progress outward, i. e., the fascia begins 
 to tear high up in the rectovaginal septum, on the 
 sides of the bladder and vagina. These are the cases 
 which present distressing symptoms; when standing 
 are worse on account of disturbed circulation and are 
 pronounced "prolapse" by the general physician. In 
 such cases the anterior vaginal wall appears first at 
 the vulva, then the cervix and finally the posterior 
 vaginal wall. The bladder gradually sags downward 
 and difiicult urination is added to the already existing 
 train of symptoms. In lacerations of the sacral seg- 
 ment of the pelvis the lesions are more visible. The 
 
40 THE VAGINA AND PERINEUM; 
 
 perineal body suffers especially. It straightens out 
 the fixed sacral segment and retroversion and inevita- 
 ble subsequent sacropubic hernia results. The visible 
 laceration of the perineal body was originally consid- 
 ered the chief requisite for repair and also the type of 
 colpoperineorrhaphy. But the study of the pelvic 
 fascia shows why the operation failed or succeeded. 
 Frequently it may be observed that the perineal body 
 is visibly torn, but no evil consequences follow, 
 because the fascia remains intact. The rectum 
 belongs to the fixed segment. It does not prolapse, 
 but its wall stretches, elongates. As the advancing 
 head forces forward and tears the levator ani fascia 
 superior and inferior as well as the ischioperineal lig- 
 aments, the levator ani muscle also becomes deranged 
 but practically the restoration of the fascia restores 
 the muscles. The muscular layers of the pelvic floor 
 are two — superficial and deep connected — and blended 
 at the perineal body both by the muscular and fascial 
 relations. The deeper layer is the levator ani mus- 
 cle which descends from the sides of the pelvis in the 
 form of a boat or bowl to its attachments on the pel- 
 vic floor. The superficial layer consists of the trans- 
 verse muscles of the perineum, which extend fropa the 
 tuberosities to the center of the perineum and also 
 the bulbo-cavemosus, which surrounds the vaginal 
 outlet. All the muscles are related to fascia, as 
 the levator ani inclosed in double blades of fascia, 
 i. e., the levator ani fascia superior and inferior. The 
 deep transverse muscles lie between the triangular 
 ligament and Colles fascia. The bulbo-cavernosus 
 and superficial transverse muscle lie between the two 
 superficial perineal fasciae. The ischioperineal fascia 
 is but the thickening of the lower border of the tri- 
 angular ligament and Colles fascia. The significant 
 importance of the fascia of the pelvis becomes at once 
 apparent, not only in maintaining the integrity of the 
 
HOW TO MEND THEM. 41 
 
 pelvic floor, but in all repair of the same. The pelvic 
 fascia is the chief element in maintaining perineal 
 muscular relations. The pelvic fascia may be divided 
 into deep and superficial layers, according to the deep 
 and superficial layers of muscles. The deep pelvic 
 fascial layers are united to the more superficial pelvic 
 fascial layers in the perineal raphe, holding the pelvic 
 fascia as a unit. The superficial fascial layers of the 
 pelvis are attached from the ischial tuberosities to the 
 pubic rami and stretch across the anterior perineal 
 triangle. They shut off the pelvic outlet except at the 
 vulvar orifice. Fascia may be torn without its asso- 
 ciated muscle being torn. In perineal laceration the 
 muscles lying between the fascial layers may become 
 separated as to loops or as to the attachments of one 
 or both ends. Also the fascia of the levator ani muscle 
 may be lacerated in different localities and this allows 
 complete repair. 
 
 When the muscular layer between the fascial layers 
 separates, the muscular fibers retract irregularly 
 toward the proximal end, leaving gaps which are dif- 
 ficult to effectually repair. The rupture and retrac- 
 tion of the levator ani with its fascia makes the deep 
 sulcus found on each side of the bulging rectocele, 
 because the fibers of the levator ani retract later- 
 ally toward the pelvic walls. It is evident there is a 
 deeper factor in perineal lesions than visible lacera- 
 tions. The deficiency in perineal lesions is not in 
 proportion to the apparent extent of the injury. 
 Every physician has noticed multipara with consider- 
 able external laceration of the perineum, with appa- 
 rently little discomfort, and with the pelvic organs 
 but slightly disturbed, while in other cases, with 
 slight apparent lesions, complaints are serious. I 
 have seen extensive visible lacerations with almost 
 no complaints and apparent health. Again, we may 
 observe cases when the perineum does not appear 
 
42 THE VAGINA AND PERINEUM 
 
 lacerated, but the prolapsed vagina, the bulging rec- 
 tooele and vesicocele appear at the vulva in a remark- 
 ble degree. In fact, as Dr. Emmet remarks, it looks 
 like a bag which has lost its puckering string. There 
 is a different explanation for each of the above classes. 
 In one, the pelvic fascia has suffered in the lesion, 
 and in the other, only a few muscle loops and possi- 
 bly the perineal body. When the lesion involves the 
 pelvic fascia its consequent result is that the circula- 
 tion is deranged seriously, because the vessels are 
 held in definite relations by the fascial planes, hence 
 the discomfort on standing and exercising is from 
 congestion. Baker Brown simply united the torn 
 tissue at the vaginal outlet. Seldom does this sim- 
 ple measure afford any real relief from perineal lacer- 
 ation, for subjects with such visible slight traces suf- 
 fer but little. In general the operations for the relief 
 of perineal laceration are a failure. If the rectovag- 
 inal septum (fascia and muscle) be not brought in 
 the grasp of the deep sutures success will not be ob- 
 tained even though the vulva be closed. The secret 
 of Emmet's success lay in the denuding of the vagi- 
 nal septum, i. e.. utilizing the tissue posterior to the 
 vaginal wall. In fact, if the levator ani fascia supe- 
 rior and inferior be not lacerated the subject suffers 
 but little from the lesion, though the perineal body 
 be torn through to the rectum. The levator ani fas- 
 cia superior forming the gutter or sulcus on each side 
 of the vagina is firmly blended with the vaginal canal 
 as the same strong fascia in the male surrounds the 
 prostate. In labor, in perineal laceration we should 
 not merely look for lesions in the posterior commis- 
 sure of the vulva, for that is done by the escaping head 
 and shoulders, and is visible, but we should look for 
 concealed lesions of the strong fascia, the sulcus on 
 each side of the vagina. The most serious lesion of 
 labor may occur without visible external injury. This 
 
HOW TO MEND THEM. 43 
 
 lesion is in general a separation of the fascia from 
 the vaginal 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 
 like an open collapsed bag. The fascia together with 
 the muscles holds the vaginal and rectal canals in a 
 closed condition, excluding air. The ballooning out 
 of the vagina with but little injury to the perineal 
 body is indicative of fascial lesions within the pelvic 
 cavity along the vaginal canal. The vaginal recto- 
 oele is due to the drawing aside of the levator ani 
 fascia superior and but little to the external lacera- 
 tion. The beginning of discomfort on assuming ex- 
 ercise is due to deranged pelvic circulation, to dila- 
 tion and straightening out of veins, to non-uniform 
 support of the blood-vessels and nerves by the proper 
 connective tissue. The advancing head crowds the 
 fascia forward, and if the labor is terminated without 
 forceps, the rents begin chiefly in the rectovaginal 
 septum. It is well to decide what and where the lac- 
 eration is, so that tissues may not be either denuded 
 or split unnecessarily, for it is not unfrequent to see 
 tissues united which were never involved in the lesion. 
 Perhaps sufficient has been demonstrated, anatomi- 
 cally and clinically, to show that the lesions of the 
 perineum which disable and discomfort the patient 
 are chiefly lacerations of the fascia and secondarily 
 of the muscles. On this view we base our labors. 
 If this be the case, we can easily see that Emmet 
 secured success by denuding an elliptical area of the 
 vaginal mucosa on each side in the vaginal sulci. 
 The curve of the denuded area corresponds to the 
 posterior curve of the rectovaginal septum, and is 
 situated within the introitus. Now, by introducing 
 deep antero-posterior satures, the levator ani fascia 
 superior and inferior may be reunited, restoring the 
 curve of the posterior vaginal wall and the fascial 
 
44 THE VAGINA AND PERINEUM*, 
 
 layers at the vulvar outlet. In reuniting the levator 
 ani fascia superior and inferior the levator ani muscle 
 becomes also reunited, but in an imperfect degree. 
 The levator ani is closely embraced by its superior 
 and inferior fascial planes, as from its origin, inser- 
 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 planes of fascia. If success depended 
 on th« muscle chiefly, it would be necessary in recto- 
 cele to reunite the separated levator ani loops anterior 
 to the rectocele in the median line or raphe, so the 
 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 approximately from the raphe on both sides, 
 but this is accomplished by reuniting the levator ani 
 fascia as near as possible in the median line, which 
 brings the muscular loops with it. The levator ani 
 fascia superior and inferior is really a sheath for the 
 levator ani muscle to accomplish its functions. The 
 sheath can not be torn without creating damage to 
 the muscle. In rectocele, this fascia is so torn and 
 stretched that the anterior wall of the rectum loses 
 its muscular support and bulges forward. Whether 
 the sutures be introduced antero- posteriorly or trans- 
 versely, it matters but little, if they include in their 
 grasp the levator ani fascia existing in the lateral 
 sulci of the vagina, and whatever is done, to be suc- 
 cessful, the rectovaginal septum, composed chiefly of 
 fascia, must be restored to reproduce the normal curve 
 of the posterior wall of the vagina. Mr. Lawson 
 Taits' flap operation on the perineum accomplishes 
 exactly what Emmet's operation in the lateral vaginal 
 sulci does, with the exception of denudation. Both 
 operations, when properly and successfully executed, 
 result in the restoration of the continuity of the deep 
 
HOW TO MEND THEM. 45 
 
 and superficial fascial layers of the pelvic floor, with 
 the establishment of partial or complete muscular 
 function. The deep sutures reunite the structures 
 (fascia and muscles) at or near their normal points of 
 attachment. Anatomically then, the objects to be 
 obtained in an operation for colpoperineorrhaphy are 
 1, the restoration of the levator ani fascia, superior 
 and inferior; 2, the reunion of the fibers of the leva- 
 tor ani muscle so that it will functionate — both fascia 
 and muscle must have relations at the perineal attach- 
 ment; 3, the restoration of the transverse perinei 
 muscles which draw the vagina lateralward, causing 
 it to remain open : 4, the restoration of the ischioperi- 
 neal ligaments in regard to the perineal body; 5, the 
 posterior curve of the vagina must be reproduced by 
 restoring the rectovaginal septum; 6, a new perineal 
 body should be restored so that the natural backward 
 curve of the rectum and forward curve of the vagina 
 should persist; i. e., normal relations should be estab- 
 lished between the perineal center or body, on the 
 one hand, and fascia and muscle on the other. The 
 perineal body — " punctum fixum " — of vulvar surface 
 relations should be restored. 
 
 The pelvic floor is composed of muscles, fascise, 
 areolar and elastic tissue. These structures are inter- 
 woven into distinct though complicated relations and 
 fill the gap of the pelvic outlet. The pelvic floor is 
 composed of two halves, whose structures arise from 
 the lateral walls and join in the medium line. There 
 are two muscles, two fascise and two ligaments of each 
 kind. If one will carefully study in dissection the 
 levator ani and the bulbo-cavernosus muscle he will 
 be impressed with their functional comparison. Both 
 are sphincter muscles. Both have connection with 
 skin as most true sphincter muscles possess. The three 
 points of insertion of the bulbo-cavernosus may be 
 considered as one muscle. They contract together 
 
46 THE VAGINA AND PERINEUM; 
 
 and have a similar function. The common feature of 
 the two muscles is their attachment to the terminal 
 fibers of the rectum and vagina. The sphincter ani 
 is closely united to the muscles of the pelvic floor by 
 tendons and fascial attachments. The object of the 
 muscles of the pelvic floor is to control the lower 
 ends of the vagina and rectum. Fascial structures 
 are common to muscles which have to afford sustain- 
 ing power, as those of the abdomen, back and thigh. 
 
 GENERAL VIEWS. 
 
 As we employ perineorrhaphy to repair uterine 
 prolapse (sacropubic hernia) as well as deficiency of 
 the external sphincter apparatus, the subject covers a 
 vast field. All kinds of genital supports — peritoneal, 
 fascial and vaginal sphincter apparatus — must be con- 
 sidered. To have prolapse, both peritoneal and fascial 
 supports must yield, as well as the occurrence of mus- 
 cular relaxation. No one support to the exclusion of 
 all others can be claimed for the uterus. 
 
 The utero-rectal (sacral) ligaments which consist 
 of peritoneal duplicatures, containing fibro- muscular 
 tissue, are very efficient uterine supports. The peri- 
 toneum itself, on account of its intimate connection 
 to the pelvic viscera and fascia, doubtless gives con- 
 siderable support. 
 
 The round ligament, with its peritoneal duplicature 
 the broad ligaments holding some muscular fibers 
 and the vesico-uterine ligaments all assist in support- 
 ing the genitals. In the consideration of sacropubic 
 hernia, the intra-abdominal pressure, the state of the 
 abdominal walls, as well as the visceral supports, 
 should be weighed. Whether the patient has enter- 
 optosis is a very significant question. The peritoneal 
 duplicatures, with their contents, constituting mesen- 
 teries of the genitals, elongate in enteroptosis just as* 
 they do with the stomach, kidneys, intestines and 
 
HOW TO MEND THEM. 
 
 47 
 
 other viscera. It is not uncommon to find a uterus 
 excessively mobile, due to relaxed supports. Dis- 
 placements of the genitals not only involve their 
 special supports and the pelvic floor, but the whole 
 peritoneum and the abdominal walls. 
 
 It need not be doubted that the mechanism of the 
 pelvic viscera is complicated. The levator ani, closely 
 ensheathed in its superior and inferior fascia, forms 
 a diaphragm through which the viscera find an outlet. 
 By introducing the finger three-fourths of an inch 
 
 Fig. 10.— (Eobinson-Scholer.) A medium degree of relaxed vaginal 
 outlet, to be remedied by colpoperineorrhaphy. 
 
 into the vagina, the ledge made by the fascia and 
 muscle enclosing the vagina can be distinctly felt. 
 The muscle normally ensheathed in its scabbard, 
 drives the vagina and rectum directly forward and 
 upward toward the pubic arch. The fascia inserts 
 itself into and embraces the lower third of the 
 vagina and is the important support. The levator 
 ani. (fascial and muscular) supports lend to the lower 
 third of the vagina a firm fixation, quite immovable, 
 
48 THE VAGINA AND PERINEUM; 
 
 forcing its walls closely in contact for about an inch, 
 producing a pronounced vaginal sphincter apparatus. 
 In marked contrast to the lower third of the vagina 
 is the upper portion, which is lax, mobile and yield- 
 ing, being surrounded by loose connective tissue only. 
 The urethral portion of the vagina and the neck of 
 the bladder are firmly fixed by the vesicopubic liga- 
 ments which dwindle off into the white line. This 
 can be seen during respiration with highly relaxed 
 and displaced genitals; the urethro- vaginal portion 
 remains still, while the remainder of the organs move 
 to and fro with each breath or diaphragmatic move- 
 ment. Superiorly the lower vagina is extremely 
 firmly fixed by the three layers of firm, fibrous fascia 
 — the posterior layer of the triangular ligament, the 
 anterior layer of the triangular ligament, and the 
 deep layer of the superficial fascia. These three 
 powerful and dense fibrous layers originate at the 
 margins of the isohiopubic rami and stretch across 
 the arch of the pubis, surrounding the vagina and 
 being intimately blended in the vaginal walls. To 
 be convinced of the fact that these fibrous laminae 
 are the all-important supporting structures that not 
 only retain the lower end of the vagina in position 
 but prevent it from being torn away at labor, one 
 needs only to dissect away all supports from the lower 
 vagina except them, and then by tugging and drag- 
 ging on the inlet of the vagina, note their almost 
 unyielding qualities. Parts of these fibrous layers 
 (triangular ligament) are frequently lacerated in 
 labor, and must be included in the flap-splitting and 
 deep sutures to restore the lower vaginal tube. 
 
 Laterally, the vagina is firmly fixed against the 
 descending rami of the pubes, not only by the so- 
 called triangular ligament, but by the levator ani fas- 
 cia superior and inferior enclosing the levator -ani 
 muscle. By introducing the finger for about an inch 
 
HOW TO MEND THEM. 
 
 49 
 
 into the vagina and palpating the i^osterior and lateral 
 parts, one can feel a blunt band running from the 
 pubic ramus on each side downward and uniting be- 
 hind the vagina in a still thicker and more blunt 
 band. This is the free edge of the levator ani and its 
 double fascia, where they come in contact and em- 
 brace the vagina. The vaginal canal, below the free 
 edge of the levator ani and its fascise, is directed for- 
 ward by the perineal body and triangular ligament 
 vrhile the same body directs the rectal canal back- 
 ward. 
 
 Fig. 11. — Robinson-Scholer.) A high degree of relaxed vaginal outlet, 
 to be remedied by colpoperineorrhaphy. 
 
 The lower third end of the vagina is quite thick, 
 very vascular, possesses turgidity and is surrounded 
 by some circular fibers. In short, the lower third of 
 the vagina possesses a distinct, vigorous sphincter 
 apparatus which plays an important r6le in the sup- 
 port of the sexual organs and in perineorrhaphy. 
 
 In making a division of the supports of the pelvic 
 viscera into those of the peritoneum and those of the 
 sphincter apparatus, we may first make a few remarks 
 on the deficiency of the peritoneal supports. The 
 
50 THE VAGINA AND PERINEUM; 
 
 utero-rectal (sacral) ligaments (extending from the 
 rectum to the neck of the uterus) are the most import- 
 ant of the peritoneal supports. If they relax, the cer- 
 vix will pass downward and forward, while the body 
 and fundus of the uterus will pass backward. In other 
 words, elongation of the sacrorectal ligapaents is the 
 initial stage of retroversion and descensus. Retro- 
 version changes the intra-abdominal pressure from 
 the posterior surface of the uterus to the anterior and 
 superior. After retroversion the intra-abdominal 
 pressure is exercised on the top and anterior surface 
 of the uterus, driving the pointed neck, like a conical 
 wedge downward at every breath. The cervix acts in 
 retroversion as a wedge or cone, and gradually forces 
 the sphincter apparatus to yield. The filling bladder 
 forces the fundus backward and the full rectum pushes 
 the cervix forward, all perfecting the retroversion, the 
 beginning stage of prolapse, by elongating the utero- 
 rectal ligaments. 
 
 In colpoperineorrhaphy, we must not only repair 
 the deficient sphincter apparatus, but the cone-shaped 
 descending cervix must be amputated and its blunt 
 end turned downward, so that it should point and rest 
 against the sacro-ooccygeal region (bone and liga- 
 ments) instead of attempting to dilate the levator ani 
 muscle at every breath by the change of intra-abdom- 
 inal pressure. When the cervix once gets firmly into 
 the vulva, i.e., into the vaginal sphincter apparatus, 
 the descent is rapid and inevitable. The upper two- 
 thirds of the vaginal walls being loose, easily descend 
 with the uterus. In descensus uteri, the vagina is 
 inverted, showing in all probability that intra-abdom- 
 inal pressure had displaced the uterus first in the proc- 
 ess of descent. An intact sphincter apparatus- will 
 long retard a descending uterus. The anterior vagi- 
 nal wall appears first in prolapse; however the vesico- 
 pubic ligaments may still retain the bladder in posi- 
 
HOW TO MEND THEM. 
 
 51 
 
 tion. Posteriorly, the peritoneum descends with the 
 cervix and upper portion of the vagina. In other 
 words, the upper part of the rectum and vagina are 
 separated, while the lower rectum and vagina are 
 closely connected by a musculo- fascial septum, with 
 the thin edge of the wedge upward. 
 
 Rare forms of prolapse may occur where the cervix 
 is elongated or where the peritoneum is loosened and 
 stretched. Space forbids reference to many other con- 
 ditions and kinds of peritoneal supports. 
 
 Fig. 12.— (After Hegar and Kaltentoach.) Baker Brown's method, 
 about 1850. 
 
 GENERAL VIEWS IN THE DEFICIENCY OF THE 
 SPHINCTER APPARATUS. 
 
 The vagina should engage more of our attention, 
 because it is on this apparatus that the operation of 
 colpoperineorrhaphy is applied. The primary factor 
 which produces deficiency in the supports of the 
 sphincter apparatus is labor. Other factors play but 
 a secondary role. 
 
52 
 
 THE VAGINA AND PERINEUM; 
 
 The pelvic fascia is not infrequently lacerated near 
 the ischiopubic rami; where the fascial sheath is rup- 
 tured the contained muscular fibers also suffer lacera- 
 tion. The results are cicatrices and loss of substance, 
 which may be felt by palpation. The anterior vagi- 
 nal wall generally escapes laceration, but the posterior 
 vaginal wall is often damaged, showing various sized 
 and formed lesions. Relaxation is prominent and 
 closure incomplete. Instead of the curved lower 
 canal with the perfect sphincter apparatus, there is a 
 
 Fig. 13.— Dr. Goodell's method of colpoperineorrhaphy. 
 
 patulous, relaxed, open mouth, resembling a tobacco 
 pouch which has lost its puckering string. Some- 
 times the vaginal mouth is closed by an anterior and 
 posterior vaginal fold, for a considerable distance up 
 the vagina. The causes of displacements of the sex- 
 ual organs are so numerous — as elongation of the 
 uterO' rectal ligaments, elongation of the cervix, lacera- 
 tion of the levator ani fasciae, muscles and triangular 
 ligament, intra-abdominal pressure, enteroptosis — that 
 all possible factors must be considered in repair. 
 Repair must consist in correcting vicious forces, as the 
 
HOW TO MEND THEM. 53 
 
 pointed cervix should be amputated and turned back- 
 ward, the posterior vaginal curve should be restored 
 with a perineal body to turn the rectal end back and 
 the lacerated levator ani fascia should be reunited. 
 
 An analysis should be made of the factors produc- 
 ing displacements and lacerations in the genital 
 organs. Deficiencies of peritoneal support should be 
 considered distinctly from deficiencies of the sphincter 
 apparatus ; however, both may be often combined. 
 Yet, after all, our chief attention will be directed to 
 deficiencies of the sphincter apparatus, for on it de- 
 pends prolapse and lacerations, chiefly arising in it. 
 Deficient primary peritoneal supports give rise to 
 vaginal inversion as rectocele, vesicocele, bladder and 
 rectal disturbances, and the vaginal mouth loses its 
 puckering string condition. In colpoperineorrhaphy, 
 the whole of the tissue of the pelvic floor should be 
 utilized for support by forcing it into the median 
 line. This will restore the tonicity of the pelvic 
 floor and form a firm cicatrix which will prevent 
 sacro-pubic hernia and also reproduce the normal 
 curves of the canals. To accomplish this, extensive 
 denudations or flaps are requisite. 
 
 Successful colpoperineorrhaphy must make the pel- 
 vic floor as tense as possible and the newly formed 
 cicatrix will aid materially in its success. The thick- 
 ened tissue (columns) on the anterior and posterior 
 vaginal walls are remnants of Miller's ducts, which 
 should be and are preserved in both Dr. Emmet's and 
 Mr. Tait's flap operations. They furnish evident sup- 
 port from their fibrous masses. It may be observed 
 that nearly all successful methods of perineorrhaphy 
 make the denudations in the vaginal sulci on each 
 side, and avoid sacrificing the thickened tissue on the 
 anterior and posterior vaginal walls. Reference to the 
 labors of Bischoff, Martin, Hegar, Kaltenback, Schatz, 
 Emmet and others will show this to be correct. After 
 
54 
 
 THE VAGINA AND PERINEUM; 
 
 performing colporrhaphy posterior, Martin makes what 
 may be called an extension of the perineum forward. 
 This is an excellent method of restoring the anterior 
 curve of the lower end of the vagina. Any surgical 
 procedure, to be successful, must conform to the ana- 
 tomic structures. The denudation of the lateral vagi- 
 nal sulci or the flap operations conform to anatomic 
 conditions, and so far have proved successful. The 
 
 a) 
 
 ^nus 
 
 Fig. 14, a and b.— Dr. Kearny's method of colpoperineorrhaphy. 
 
 reason denudation in perineorrhaphy is so successful is 
 because healing in the vagina occurs with consider- 
 able certainty. 
 
 THE METHODS OF PERFORMING PERINEORRHAPHY. 
 
 The methods of perineorrhaphy may be classified 
 into three divisions, viz. : Those which start at the 
 vulva (denudation) ; those which attack the lower 
 vaginal portions (denudation); those which depend 
 
HOW TO MEND THEM. 55 
 
 on the flap procedure (which embraces colpoperine- 
 orrhaphy). 
 
 Numerous methods of perineorrhaphy have been 
 tried since the days of Ambrose Par6, Dieffenbach 
 and Baker Brown, when they simply united the super- 
 ficial tissue which was situated on each side the visi- 
 ble laceration. This was a superficial vulvar proced- 
 ure and was of small value except to prepare the way 
 for more useful methods. 
 
 HISTORY. 
 
 If the ancients performed successful perineorrhaphy, 
 I am unable to obtain the records. Colpoperineor- 
 rhaphy as a modern operation can scarcely boast of 
 being more than a century old. Surgeons sought to 
 prevent prolapse by excision of the vaginal wall so 
 that the resulting inflammation would produce a con- 
 tracting cicatrix. Others applied caustics for the 
 same reasons. According to Schroeder, Girardin- 
 Laugier employed the blue stone. Phillips used 
 "smoking saltpetre;" so did Laugier, Velpeau, Ken- 
 nedy, Dieffenbach, Colles and Simon. Chippen- 
 dale sought to stir up inflammation and cicatricial 
 contraction in the vagina by the very questionable 
 method of infecting it with gonorrheal virus. Opera- 
 tors have attacked the vulva or vagina. The vulva 
 was first attacked by such surgeons as Baker Brown 
 and Pare. Fricke was the pioneer who performed 
 episiorrhaphy which consisted of denudation of both 
 labia and union by sutures. The failures of Fricke's 
 episiorrhaphy induced later surgeons to operate higher 
 up in the vagina, which finally resulted in the Emmet 
 and Tait methods. Mende suggested denudation in 
 the region of the hymen. Malgaigne thought it 
 should be done deeper in the introitus. Jobert caut- 
 erized the vagina when it protruded, and after the 
 exfoliation of the eschar, united the raw surfaces with 
 
56 THE VAGINA AND PERINEUM; 
 
 sutures. Desgranges employed chlorid of zinc to 
 produce cicatricial contraction. Marshall Hall was 
 among the first to employ elytrorrhaphy. He cut out 
 oval or long segments of the vaginal mucosa and 
 united the denuded surfaces with sutures. Dieffen- 
 bach formed flaps. Velpeau was one of the first sur- 
 geons to do successful perineorrhaphy. Langenbeck 
 and Karl Braun were also pioneers in the operation. 
 Early operators failed on account of lack of anatomic 
 knowledge and prevailing sepsis. It is not many 
 decades since surgeons learned the necessary anatomy 
 to employ in colpoperineorrhaphy. It was learned 
 that the perineum must not only be elongated, but a 
 solid, thick, unyielding pelvic floor must be con- 
 structed that the sexual organs can not escape. Per- 
 haps Simon, the predecessor of Czerny at Heidel- 
 berg, was the real founder of colpoperineorrhaphy. 
 when, in 1867, he had not only performed but added 
 to it that of posterior colporrhaphy . Simon freshened 
 the vaginal wall with a scalpel, and a fenestrated 
 speculum was placed in the vagina while he freshened 
 the upper part of the vaginal wall by having an assis- 
 tant introduce the finger in the rectum and force the 
 vaginal mucosa out at the vulva. Veit, Hegar and 
 Speigelberg aided to develop the operation. As time 
 passed, instruments for support were gradually dis- 
 placed by more perfect operations, owing to more 
 perfect anatomic and pathologic knowledge. Most of 
 the advances are due chiefly to the investigations of 
 Freund, Huguier, Martin, Schroeder, Wilms (1879) 
 and Staude (1880), Breisky, Huepfel and others men- 
 tioned in this monograph. The practical execution 
 of colpoperineorrhaphy by the celebrated Heidelberg 
 surgeon, Simon, is the real foundation of subsequent 
 labors. The success attending Simon's addition of 
 colporrhaphy demonstrated that some form of vaginal 
 operation is required in prolapse or deficiency of the 
 
HOW TO MEND THEM. 57 
 
 peritoneal or sphincter apparatus of the pelvic floor. 
 Celsus, it is reported, recognized perineal lacerations 
 and suggested rest in bed and tying the legs together, 
 but gave no surgical views of repair. Ambrose Par^, 
 a fertile genius, demonstrated t^e use of sutures be- 
 fore 1880. He had a pupil named Guillenneau, who 
 restored the parts, applied the sutures and secured 
 curves. Sancerotte and Noel secured success about 
 100 years ago. In 1829, Dieffenbach, surgeon to the 
 Charity Hospital in Berlin, devised useful methods 
 of repair. The deductions which made Dieffenbach 
 celebrated in perineorrhaphy were his methods of 
 lateral incisions (to relieve tension) and confining the 
 bowels* by the aid of opium. Chelius opposed this 
 view, insisting that the bowels should be loose. In 
 1852 Von Langenbeck gave to the world his views 
 through a memoir written by Verhaeghe of Ostend. 
 This definitely advocates the use of the flap and split- 
 ting of the rectovaginal septum. Marcy gives credit 
 to Dr. Jenks for originating the flap. Zweifel gives 
 Mr. Lawson Tait credit for the flap splitting method, 
 to which he is no doubt entitled. Hart and Barbour 
 credit A. R. Simpson with it. Baker- Brown published 
 in 1854 his first edition of the " Diseases of Woman," 
 in which he advocated Dieffenbach's lateral incisions, 
 the use of deep quilled sutures, confining the bowels 
 with opium, and bilateral division of the sphincter. 
 The perineal sutures were removed the third day, the 
 remainder later, as late as twelve days. All sutures were 
 silk. It appears that Dieffenbach and Baker-Brown 
 realized that the denudation should be carried up into 
 the posterior vaginal wall, the fact which Simon ac- 
 tually demonstrated. It is reported that Mettauer of 
 Virginia in 1830 used lead sutures; other metallic 
 sutures were also employed. In New York, in the 
 Woman's Hospital, Drs. Sims, Emmet and Thomas 
 further developed colpoperineorrhaphy. 
 
58 
 
 THE VAGINA AND PERINEUM; 
 
 At present the operation should be termed oolpo- 
 perineorrhaphy. New aids have also been developed 
 in regard to the operation, as A. Martin taught for 
 years that one should begin the operation for colpo- 
 perineorrhaphy by setting up an involution of the 
 uterus by amputating the cervix. I have amputated 
 the pointed conical cervix to get rid of the dangerous 
 dilating wedge to the sphincter apparatus of the pelvic 
 floor, to prepare for successful colpoperineorrhaphy. 
 
 Fig. 15. — Colpoperineorrhaphy according to Bischoff. The tongue- 
 ehaped portion of the posterior wall of the vagina, d, is not dissected 
 away. The denudation in this operation is severe and bleeding is active, 
 and should the operation fail much damage is done, a, a, and b, b. show 
 the method of introducing the sutures and the shape of the denuded area. 
 
 A new era appeared in this operation when the flap 
 began to be formed. So far as records are accessible, 
 the late Berlin surgeon, von Langenbeck, in 1852, flrst 
 described the flap operation in perineorrhaphy. He 
 describes the splitting of the rectovaginal septum 
 making a vaginal flap forward and a rectal flap back- 
 ward. Langenbeck's description of perineorrhaphy, 
 as translated by Dr. Marcy, is the most important 
 
HOW TO MEND THEM. 59 
 
 contribution to the subject before the time of Simon 
 of Heidelberg. In fact, it is almost equivalent to 
 Simon's, and in one sense superior — in the use of the 
 flap. Perineorrhaphy was also cultivated by Zary, 
 Mureina, Mensel, Osiander, and Homer, Perineor- 
 rhaphy was first performed with silk sutures, the hot 
 iron, and chemicals. About three-quarters of a cen- 
 tury ago metallic (wire) sutures appeared. In 1879, 
 Werth published views on the use of catgut (animal 
 ligatures) for buried sutures. Schroeder chiefly intro- 
 duced the buried spiral catgut sutures in perineor- 
 rhaphy. Silkworm gut is one of the best materials 
 for sutures in general use at present. About 1872, 
 Mr. Lawson Tait began the use of a certain flap 
 method, consisting of resplitting the old cicatrix by 
 the use of scissors, reuniting the produced wound 
 surfaces by means of sutures which do not penetrate 
 skin or mucous membrane. The utility of this con- 
 sists in its application to either, or both, perineorrhaphy 
 or colpoperineorrhaphy. The flap operation was dimly 
 begun by Dieffenbach, in 1829, by his lateral incisions 
 to relieve tension. The flap operation was definitely 
 introduced in perineorrhaphy by von Langenbeck, 
 about 1850 ( "Memoire," 1852, by Verhaeghe) . In 1861, 
 Colles of Dublin, in a case of vesico- vaginal fistula, 
 resplit, instead of paring the edges, and united the 
 resultant flap. In 1872, John Duncan resplit the 
 edges of an artificial anus and reunited them with 
 interrupted catgut sutures. He forced the flap of 
 mucosa upward and drew the flap composed of mus- 
 culosa and serosa outward, thus increasing vastly the 
 denuded surface for coaptation, Hart and Barbour 
 report that Dr. A. R. Simpson applied this flap method 
 to perineorrhaphy. Not far from 1872, Mr. Lawson 
 Tait applied the flap operation of Langenbeck, Colles 
 and Duncan to the subject of perineorrhaphy. He 
 added to all previous labors the use of sharp-pointed 
 
60 
 
 THE VAGINA AND PERINEUM; 
 
 elbow scissors, and the introduction of the sutures 
 without penetrating the skin or mucosa of vagina or 
 rectum. Silkworm gut sutures are employed and may 
 remain in situ for ten days to six weeks. According 
 to Sanger, Stein, a Dane, and Voss, a Norwegian, used 
 similar methods. Later, Hadra, 1887, contributed 
 valuable views on the restoration ot.the pelvic floor, 
 as well as Marcy, Jenks, Byford, and Reamy. 
 
 Fig. 16.— Dr. Skene's method. The area D, S, is denuded, with sutures 
 in situ ready for tying. The method resembles that of Hegar and Staude. 
 
 The various so-called operations for (colpo) perine- 
 orrhaphy are numerous. The first operation devised 
 involved the vulva, the second both vulva and vagina. 
 
 1. Ambrose Pare (1580) used simply sutures. His 
 pupil Guillenneau practised and improved the method 
 (1649). LaMotte, Smellie, Noel, Murenna and Sance- 
 rotte practised it. 
 
HOW TO MEND THEM. 61 
 
 2. (1830) Dieffenbach, union by sutures, and ten- 
 sion relieved by lateral incisions. Roux (1834) intro- 
 duced it into France, as well as Mark See (1885), and 
 Polail]on(1885). 
 
 3. Baker Brown (1885, union by sutures of the 
 denuded surfaces. Wilms and Staude cultivated it 
 in Germany. 
 
 4. The next important contribution and method 
 devised in perineorrhaphy was von Langenbeck's flap 
 method (1850). It was described and performed with 
 a master hand. . Von Langenbeck also suggests that 
 the lateral incisions of Dieffenbach may be added, ss 
 it obviates dragging from movements. He advocated 
 operation immediately after the injury, if possible. Von 
 Langenbeck makes several distinct steps in the oper- 
 ation : vivification of the free border of the recto- 
 vaginal septum ; the undoubling of the septum and 
 the formation of the flap destined to form in the new 
 perineum, the anterior side of the triangular space 
 formed by two canals, vagina and rectum, with the 
 perineum as the base; the vivification of the two lips 
 of the laceration; the insertion of the sutures. In 
 this operation of perineorrhaphy von Langenbeck 
 started the flap method. The flap operation protects 
 the wound from secretions (vaginal or rectal). 
 
 5. In 1867 Simon of Heidelberg began the real 
 modern steps in successful perineorrhaphy, which was 
 a combination of perineorrhaphy and posterior col- 
 porrhaphy. Simon simply improved on Baker- 
 Brown's method by not only freshening the perineum, 
 
 .but also carrying the denudation high up into the 
 vagina. Simon denuded the vagina by the aid of a 
 fenestrated speculum. The upper angle of the vagi- 
 nal wall was denuded by introducing the finger into 
 the rectum. Spiegelberg and Veit aided in develop- 
 ing the subject. Englehart wrote in 1871; Banga in 
 1875 wrote a thesis on " Kolpo-perineorplastik " ao- 
 
62 
 
 THE VAGINA AND PERINEUM: 
 
 cording to Bisohoff. In 1879 Hegar and Kaltenbach 
 made excellent contributions. In 1877 Le Fort, and 
 Neugebaum in 1881, added their labors. In 1877 Dr. 
 Edward W. Jenks of Detroit began the publication 
 of a series of articles on perineorrhaphy which was 
 really a flap method of operating — a distant relative 
 
 /?■ 
 
 x\ 
 
 Pig. 17.— Shapes of the denuded areas in colpoperineorrhaphy ; a, 
 Hegar; b, Simon ; c, Lossen ; d, Fitch. In a, and b, the dotted line repre- 
 sent the sutures buried by tissue, the black lines the exposed sutures. 
 
 of von Langenbeck's procedure. Dr. Jenks first cut 
 away the flap, but afterward preserved it. The method 
 is almost precisely similar to the flap method attri- 
 buted to Dr. A. R. Simpson by Hart and Barbour. 
 
HOW TO MEND THEM. 63 
 
 In 1879 Werth began to use buried catgut to suture 
 the wound. Dr. Brose, in 1883, used buried animal 
 ligatures. H. O. Marcy published a series of articles 
 (1883) on perineorrhaphy, advocating the flap method 
 and buried animal ligatures, which he first used in 
 hernia in 1881. A. Martin of Berlin contributed 
 excellent labors about 1882. About 1880, Pro- 
 fessor Sohroeder of Berlin obtained excellent results 
 by the use of the "6tage" stitch, a continuous 
 running suture of catgut buried in the tissues of 
 the denuded surfaces. As a pupil of Schroeder and 
 Martin, I observed excellent results from this method. 
 Bischoff in part revives the flap operation of Langen- 
 beck. However, his operation was quite influential 
 in its day. Drs. Byford, father and son, made valu- 
 able contributions to the subject. History notes that 
 Simpson carried Duncan's flap-splitting to the peri, 
 neum. Simpson performed a kind of four-flap perine- 
 orrhaphy for many years. Perhaps Mr. Tait imbibed 
 some of his views. 
 
 In 1887 Dr. Hadra of Texas contributed some valu- 
 able articles on the subject of perineorrhaphy. He 
 suggested vivification of the posterior vaginal wall for 
 oolporrhaphy, as is done in anterior colporrhaphy. 
 Since 1880, the laborers in the field are legion. Gradu- 
 ally the operation of perineorrhaphy was modified 
 from Pare, Baker Brown, Dieffenbach, Langenbeck 
 and Simon to Tait and Emmet. The modification 
 consisted in denuding not only the perineal tears, but 
 also denuding higher up in the posterior vaginal wall. 
 Hildebrandt especially carried the denudation well up 
 into the posterior vaginal wall. 
 
 As regards suture material, Sims, Thomas, Emmet 
 and others worked out the application of metallic wire 
 to plastic labors on the perineum during the past 
 thirty years. The modem tendency is to use silkworm 
 gut as a non-absorbable suture. This may be left 
 
64 THE VAGINA AND PEKINEUM 
 
 weeks in a wound, and acts as a splint in coapting the 
 surfaces. It is easy to remove. To Dr. T. A. Emmet 
 is due the credit of introducing a method of perineor- 
 rhaphy which, until recently, was the one generally 
 practised in America. In 1883 Dr. Emmet published 
 a new method, or rather a modification of his old 
 operation. Dr. Emmet denudes the sulci on each side 
 of the vagina and extends the perineum forward. His 
 operation is intended to repair perineal fascia and 
 muscles. Dr. Emmet holds that loss of support fol- 
 
 Fig. ISA.— Emmet's operation (elytrorrhaphy posterior) for prolapse : 
 1 and 2 show the lines of union of denuded surfaces in the vaginal sulci 
 on each side of the vaginal column, 3, which still remains. 
 
 lowing laceration is not due to injury of the perineal 
 body. The loss of support after childbirth, he claims, 
 is due to rupture of perineal muscles and fascia. Dr. 
 Emmet's operation is difficult to make clear by de- 
 scription, but it consists in lateral denudation wholly 
 within the vagina to s-uch an extent that when the 
 sutures introduced are drawn tight, the excess or slack 
 in the posterior vaginal wall disappears. The ostium 
 vaginse is not interfered with by any special denuda- 
 tion. The claim of his operation is that discomfort 
 
HOW TO MEND THEM. 
 
 65 
 
 Fig. 18 B.— Staude s operation (elytrorrhaphy posterior) for prolapse ; 
 1, £., 6, 4, and 5, 6, 7, 8, represent the denuded vaginal sulci ; a, 5, shows the 
 intact column, which is utilized in coaptation and fixation of the denuded 
 surfaces. The principle of saving and utilizing the column is the same as 
 in Martin's and Emmet's operation. 
 
 .KoS^* 18 C- Various shapes of the denudation in posterior elytror- 
 rhaphy, represented by superimposed diagrams: 1, 1 1 He^ar's- 2 2 2 
 faXthlcolum^ ^^'*^''' ^'^'^^^.'^ Winfkel's. Observe thtt BischoS 
 
66 
 
 THE VAGINA AND PEEINEUM; 
 
 disappears immediately after, and also that the poste- 
 rior vaginal wall is brought in proper position and 
 relation to the anterior wall, as it is in the normal 
 condition. The view maintained in this surgical pro- 
 cedure is that the perineal body is insignificant in 
 support, and that laceration of it alone impairs but 
 little the integrity of the genital supports. But the 
 tearing or excessive stretching of the perineal muscles 
 and fascia at their attachments to the genitals quickly 
 disturbs the delicate balance of the pelvic organs. 
 
 (a) m 
 
 Fig. 19 a and 5.— Dr. Jenks' method (flap) of perineorrhaphy. The 
 flap-splitting is executed with two fingers in the rectum, and a scalpel. 
 In a the flap is marked out by a dotted line ; in b the flap is completed, 
 ready for suturing. 
 
 There is one point against Dr. Emmet's operation, 
 and that is the relatively blind method of introducing 
 the higher sutures. In other words, the deep layers 
 of the lacerated pelvic fascia may not be included in 
 the sutures with any degree of certainty. Dr. Gill. 
 Wylie added the idea that Dr. Emmet's operation would 
 be improved by denuding the posterior vaginal wall a 
 considerable distance and then continuing the denu- 
 
HOW TO MEND THEM. 67 
 
 dation well up into the posterior vaginal sulci. This 
 method, however, sacrifices a larger amount of poste- 
 rior vaginal wall. 
 
 About 1872 Mr. Lawson Tait of Birmingham, Eng- 
 land, began to introduce a method of perineorrhaphy 
 known as the flap method. It differed from all others 
 in that he used elbow scissors and introduced the very 
 deep sutures without penetrating the skin or mucous 
 membrane. It involved no loss of tissue. The direc- 
 tion for doing the Tait operation is to resplit the old 
 cicatrix. It is modified according to the condition of 
 the case, as one may produce anterior and posterior 
 cuts. Tait's flap perineorrhaphy is now quite gener- 
 ally practised. I have not attempted to give all known 
 historic methods of perineorrhaphy, but simply the 
 chief ones, out of which have been built the modem 
 operation. 
 
 GENERAL INDICATIONS FOE PERINEORRHAPHY. 
 
 1. To restore rectal and vaginal functions. 
 
 2. To restore pelvic fasciae and muscles. Normal 
 fascia is required for normal circulation. 
 
 3. To restore the normal relation and support of 
 the posterior wall (colporrhaphy posterior). The 
 posterior vaginal wall sustains the anterior vaginal 
 wall and bladder. 
 
 4. To provide as much support for the pelvio 
 organs as the restoration of the perineal body will 
 afford. 
 
 5. To remove the neurasthenic conditions; to 
 relieve the Innumerable nervous associations; in 
 short, to relieve mental and physical disturbances. 
 
 6. To repair and check sacropubic hernia. 
 
 7. To narrow relaxed pelvic outlet. 
 
 The pelvio floor is closed from behind forward by 
 the pyriformis with its thin, delicate fascia, the firm 
 sacrorectal ligaments, the coccygeus with its moder- 
 
68 ' THE VAGINA AND PERINEUM; 
 
 ately strong fascia, the levator ani muscle with its 
 levator ani fascia superior and inferior, a strong 
 double fibrous protective muscular sheath, and also 
 the triangular ligament, a powerful layer of fibrous 
 tissue. The coccygeus with its fascia, the levator ani 
 with its double fascia and the triangular ligament 
 practically constitute the pelvic floor and seem to 
 separate the pelvic cavity from the perineum. These 
 are essential structures in oolpoperineorrhaphy. The 
 
 Fig. 20. — Method of denudation of vaginal strips, with curved scissors, 
 from one side of the vagina to the other, as suggested by Dr. Skene. 
 
 levator ani fascia (both layers)* pass from the side of 
 the pelvis to the viscera, firmly attaching themselves 
 to every pelvic organ, forming the strong, fibrous 
 expansions known as ligaments, which serve to hold 
 the pelvic viscera in definite fixed relations. In peri- 
 neorrhaphy, success depends on the restoration of 
 these vital supports; a significant anatomic fact in 
 pelvic pathology is that the blo*od- vessels lie superior 
 to the pelvic fascia and the nerves inferior to it. The 
 
HOW TO MEND THEM. 69 
 
 blood-vessels which arrive in the i perineal region 
 pierce the pelvic fascia and pass chiefly out of the 
 great sacrosciatic notch. 
 
 I'^he levator ani fascia, superior and inferior, is an 
 important structure to limit infection. It separates 
 the ischiorectal fossa from the pelvio cavity proper 
 where so much loose tissue exists. The levator ani 
 fascia is pierced by vessels and nerves, and these ves- 
 sels and nerves are surrounded by lymphatic sheaths 
 which are a source or path by which the infection 
 may travel from the pelvis to the ischiorectal fossa, 
 and vice versa. In perineorrhaphy the levator ani 
 fascia, superior and inferior, is incised. The opera- 
 tion which is performed for the restoration of the 
 perineum exists under different names. It may be 
 termed perineorrhaphy, perineo-vaginal restoration, 
 perineal extension, perineauxesis, or the flap method. 
 However, I think the best name is colpoperineorrha- 
 phy, Colpoperineorrhaphy is an operation to restore 
 the integrity of the supports of the sexual organs. 
 These supports include those of the peritoneum and 
 vaginal sphincter apparatus. 
 
 The perineal body is situated between the lower 
 end of the vagina and the rectum. Difference of 
 opinion still prevails as to the utility of the perineal 
 body in the economy of the female genitals, but, from 
 many dissections and considerable work on the sub- 
 ject, I claim the following functions for the perineal 
 body : 
 
 1. It sustains the lower ends of the anterior rectal 
 wall and posterior vaginal wall. 
 
 2. It supports and directs the discharging end of 
 the vagina forward, aided by the triangular ligaments 
 and levator ani. 
 
 3. It supports and directs the discharging end of 
 the rectum backward; the rectum is directed back- 
 ward by the levator ani muscle. 
 
70 
 
 THE VAGINA AND PERINEUM; 
 
 4. It not only keeps the discharging ends of the 
 rectum and vagina widely apart, but it gives both a 
 support in a curved direction at their termination, 
 thus affording mechanical advantages for maintaining 
 closure of both apertures and preventing the easy escape 
 of the contents of either canal. The wide divergence 
 of the two canals avoids mingling of the secretions 
 and consequent irritation from decomposition. The 
 backward hook of the rectum and the forward hook 
 of the vagina are an important factor in support, and 
 
 Fig. 21.— (After Pozzi.) LeFort's (1889) method, which is similar to 
 Demarquay's (1864-1875) and Eichert's. An incision is made in the vagina 
 at the point C, in the median line down to the rectum ; then an incision is 
 made along the line C, D, E: another line, C, G, is carried along the rectal 
 wall, but not into the rectal mucosa ; another line joins it by means of 
 E, I, G; this makes a distinct triangle, H (seen in No. 3) ; the cicatricial 
 tissue is removed from the triangle, H, and also the portion of the vaginal 
 wall, marked D, is seized and dissected from the rectal ; the space denuded 
 is D and H (No. 3) ; the sutures are introduced as shown in Nos. 2 and 3. 
 The disposition of the sutures is noted in No. 4. The operation is a par- 
 tial flap method, but too complicated for ordinary practice. 
 
HOW TO MEND THEM. 71 
 
 prevents gaping. The perineum is the skin between 
 anus and vagina. The perineal body consists of skin, 
 fat, muscles, fascia, elastic and connective tissue. The 
 perineal body as a support in itself for the genital 
 organs has been much overestimated. 
 
 5. It serves as the point of union of four muscles : 
 the levator ani, the sphincter ani, the bulbo-caverno- 
 sus, and the transversus perinei. ^ It serves also as a 
 point of union of the various fasciae. 
 
 6. It acts as a partial support of the pelvio floor. 
 
 7. It strengthens a tried point in labor. 
 
 8. Laceration of the perineum to any considerable 
 extent destroys the nice balance between anatomic 
 structure and physiologic function in the female 
 
 genitals. 
 
 The object of perineorrhaphy is: To restore partial 
 ruptures; to restore rectal functions after complete 
 ruptures; to prevent prolapse of the pubio segment 
 of the pelvic floor. 
 
 The methods of performing perineorrhaphy are 
 denudation with fixed coaptation, and the flap method. 
 The etiologio factors of lacerations are labor, coitus 
 and trauma. -Partial laceration of the perineum may 
 be accompanied by vulvar patency; increased vaginal 
 secretion; irritability of parts; pathologic condition 
 of nerve structure; neuralgic or neurotic conditions 
 induced by long-continued local lesions; descent (dis- 
 tention) of anterior rectal wall, posterior vaginal wall, 
 and uterus. Complete laceration of the perineum 
 may be accompanied by vulvar and anal patency; 
 increased vaginal and rectal secretion; incontinence of 
 bowel contents and occasionally of bladder contents; 
 irritability and disease of the surrounding parts from 
 the abnormal secretions; neuralgic and neurosal con- 
 ditions from changes in nerve structure; melancholia 
 (neurasthenia) ; relaxation of the displaceable segment 
 of the pelvic floor and consequent prolapse or hernia 
 
72 THE VAGINA AND PEKINEUM; 
 
 of the pubio segment. The result may be severe con-- 
 gestiou from a disturbance of the fascia which holds the 
 blood-vessels in relation. If the blood-vessels become 
 distorted in their bed, disturbed circulation results. | 
 
 In discussing the operation for colpopefineorrhaphy 
 by Emmet and Tait I shall consider these both founded | 
 on anatomic principles, both practical and successful 
 operations, and both arriving at the same end by dif- 
 ferent methods. However, since I can accomplish by 
 a flap method exactly what Dr. Emmet accomplishes 
 by denudation I have preferred to follow the flap pro- 
 cedure. I have employed the flap method for over six 
 years, comprising over one hundred operations per- 
 formed for almost all kinds of perineal laceration and 
 uterine prolapse. In one case the uterus was com- 
 pletely prolapsed for fourteen years. Another case 
 of thirty-four years' standing, with laceration extending 
 up the rectum the length of the index finger, was oper- 
 ated successfully after three previous denuding oper- 
 ations. A third case of twenty-eight years' standing, 
 was lacerated up the rectum for four inches and had 
 passed through three unsuccessful operations. One of 
 twenty-seven years' standing, with three-inch rectal 
 laceration, and one very difficult case of seven years' 
 standing, with several unsuccessful operations by well- 
 known gynecologists, were operated on with perfect 
 success. In these cases of long standing, atrophy was 
 so far advanced from limited blood-supply andjnon-use 
 that it required extensive flaps in order to secure tissue 
 for a perineal body. To show that the perineal body 
 is not significant in uterine support, several of those 
 patients continued for over twenty-seven years with 
 laceration several inches up the rectum, with scarcely 
 a symptom of uterine prolapse. 
 
 It will be observed from even a superficial experi- 
 ence that the patient should be properly prepared 
 for colpoperineorrhaphy. If the patient have a 
 
HOW TO MEND THEM. 
 
 73 
 
 long, pointed cervix, which acts like a conic wedge 
 being driven downward at every breath or increase 
 of intra-abdominal pressure, it will constantly dilate 
 the vaginal sphincter apparatus and should be ampu- 
 tated. The amputation may produce involution of 
 
 Fig. 22 a and b.—Dr. Skene's naethod of denudation' and suturine the 
 rectum. I'^x^-s fuo 
 
74 THE VAGINA AND PERINEUM; 
 
 the uterus. A long, pointed, conical cervix gener- 
 ally has behind it a retroverted uterus which precedes 
 prolapse. 
 
 Again, if there is a cystocele the patient should be 
 prepared by an anterior colporrhaphy. It may be that 
 amputation of the cervix and anterior colporrhaphy 
 can be done at the same sitting and anesthesia as the 
 flap-splitting colpoperineorrhaphy. We frequently 
 perform colporrhaphy and colpoperineorrhaphy at the 
 same time. To require cervical amputation is rather 
 rare, but if there be a retroverted uterus with pointed 
 cervix it should be amputated and turned backward 
 against the sacrum. In short we must imitate nature 
 as much as possible to secure success. All hernia is 
 the same; it is due to the destruction of normal valves 
 and the straightening out of oblique canals. Hence 
 in sacropubio hernia the normal obliquity of the 
 vaginal canal must be restored. Colpoperineorrhaphy 
 restores the posterior vaginal wall and anterior col- 
 porrhaphy restores the anterior vaginal wall. This 
 is not often needed if the colpoperineorraphy be 
 thoroughly performed. Prolapse is prevented by peri- 
 neorrhaphy, elytrorrhaphy, episiorrhaphy (or some 
 abdominal operation). Prolapse may be considered 
 as a downward displacement of the pubic segment of 
 the pelvic floor; the sacral segment of the pelvic floor 
 shares in it by a yielding of some of its parts. There 
 are so many varied opinions as to the etiology of pro- 
 lapse that one can safely say the subject is not fully 
 settled. In my opinion much credit 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 
 many previous views must be changed, but it is hope- 
 ful when the closest and most continued students of 
 the pelvic floor come nearly to the same conclusion. 
 The subject of prolapse, I think, should be studied out 
 
HOW TO MEND THEM. 
 
 75 
 
 anatomically and clinically. The field of investiga- 
 tion is still large. As time goes on the uterus itself 
 will get less attention and the pelvic floor more. The 
 subject of relaxation and submucous laceration will 
 be more studied. Relaxation of the whole pelvic 
 floor, due to repeated labors, infectious processes and 
 anatomic lesions will be found to be a large factor in 
 prolapse. Insufficiency of perineal support should 
 not be lost sight of, and the sphincter apparatus of 
 the pelvic floor will be more studied. From dissec- 
 
 Fig. 23 a and 6.— Fritsch-Walzberg method. The figure is according to 
 Pozzi. The laceration extends into the rectum. S, rectovaginal septum; 
 F, rectovaginal septum lacerated; P, perineum. In b the rectovaginal 
 septum is split. 
 
 tion one would at once conclude that the levator ani 
 fascia and the triangular ligament were the main sup- 
 ports in the pelvic floor, and the relations of other 
 supports must be considered. Dissection is the only 
 intelligible way to understand the subject. For 
 example, dissection of quite a number of bodies has 
 thoroughly explained, in my mind, the conflicting 
 views of anatomists and gynecologists as to the posi- 
 
76 
 
 THE VAGINA AND PERINEUM; 
 
 tion of the uterus. As a gynecologist I have exam- 
 ined several thousand women, and I am sure that the 
 uterus leans forward in the normal condition. Re- 
 peated examination on the back and while standing 
 will prove that slight ante version is the normal posi- 
 tion of the uterus. Now, the anatomist has often 
 insisted that normally the position of the uterus is in 
 the hollow of the sacrum. I have repeatedly found 
 in the dead subject that the uterus is in the hollow of 
 
 Pig. 24.— (After Hegar and Kaltenbach.) BischofE's method of colpo- 
 perineorrhaphy. He denudes high up on each side of the posterior median 
 vaginal column, B, B,A, A. This method partially foreshadowed Emmet's 
 operation. Note the butterfly wings, 1, 2, 3, d, d. Bischoff saved the 
 posterior vaginal. 
 
 the sacrum, precisely as the anatomist has described. 
 Both gynecologist and anatomist are correct. In the 
 living woman the normal position of the uterus is 
 that of anteversion. In the dead woman in dorsal 
 decubitis the uterus generally lies in the hollow of the 
 sacrum. In just such a manner arise the differences 
 of opinion relative to prolapse, which can only be 
 
HOW TO MEND THEM. 77 
 
 cleared up by careful personal anatomic and clinical 
 investigation. A comparison of different causes will 
 soon let in the light. 
 
 Though the peritoneal supports of the uterus be 
 deficient they can be put at rest and finally cured by 
 carefully planned operations on the vaginal sphincter 
 apparatus. All primary uterus supports are attached 
 to the neck of the uterus and before the uterus shows 
 such signs of hernia the supports attached to the neck 
 must be definitely elongated. Doubtless the uterine 
 supports are frequently elongated by Infective pro- 
 cesses and hence a rest by repairing and fortifying 
 the sphincter vaginal apparatus will result in restora- 
 tion. Especially is this true in certain forms of 
 retroversion. If the uterus remains in its normal 
 position (i. e., perfectly movable) no retroversion and 
 consequent prolapse will arise. In chronic infective 
 processes the pelvic organs at times swell, soften, 
 become edematous, ending in a form of hypertrophy 
 from static congestion. I have frequently observed 
 this slow repeated process in the clinics. 
 
 ETIOLOGY OF PROLAPSE. 
 
 1. Insufficiency of sphincter apparatus: a, levator 
 ani muscle; h, triangular ligament (anterior posterior 
 layers and fascia of Colles) ; c, levator ani fascia, supe- 
 rior and inferior; d, perineum (composed of levator ani, 
 bulbo-cavernosus, transversusperinei and sphincter ani 
 ischio-perineal ligaments) ; e, vaginal walls;/, urethro- 
 vaginal septum; g, recto-vaginal septum; A,. muscular 
 and elastic tissue on lower third of vagina. 
 
 2. Insufficiency of peritoneal supports: a, utero- 
 sacral ligaments; 6, round ligaments; c, broad liga- 
 ments; d, vesico-uterine ligaments; e, perineum;/, 
 elongated cervix. 
 
 3. Intra-abdominal pressure increased or applied in 
 abnormal directions. 
 
78 THE VAGINA AND PERINEUM; 
 
 4. Relaxation of anterior segment of pelvio floor: 
 a, repeated labor; 6, submucous, concealed facial lacer- 
 ations; c, subinvolution of pelvio floor and organs. 
 
 5. Weight of uterus, which affords surface for intra- 
 abdominal pressure. 
 
 OPERATIONS FOR PROLAPSE. 
 
 1. Tait's flap operation (and extension) of perineum. 
 
 2. Perineo-episiorrhaphy. 
 
 3. Elytro-perineorrhaphy. 
 
 4. Elytrorrhaphy. 
 
 5. 'Amputation of cervix. 
 
 6. Shortening of round ligaments (Alexander- 
 Adams). 
 
 7 Shortening of broad ligaments. 
 
 8. Fixation of the uterus to the abdominal "wall 
 (hysteropexy). 
 
 9. Schucking's operation. 
 
 10. Herrick's operation. 
 
 11. Mackenroat's operation. 
 
 The operations for prolapse hav0*been as varied as 
 the views of its causes. Operators have attacked the 
 uterus, vagina, vulva and uterine ligaments to accom- 
 plish their purpose. The pioneer idea in prolapse 
 was to close up the vulva so that the uterus could not 
 escape. Thus we have the early episiorrhaphy of 
 Fricke and Kuchler. But surgeons soon saw that 
 simply closing up the vulva was like attempting to 
 board up Mount Vesuvius. The forces at work were 
 not at the vulva but deep in the interior. Then came 
 the operations on the perineum with all their variety, 
 from Guillenneau's successful case through Dieffen- 
 bach, Langenbeck, Simon and Sims, to the modern flap 
 operation. Finally to episiorrhaphy and perineor- 
 rhaphy were added operations on the wall of the 
 vagina (colporrhaphy and elytrorrhaphy). Elytror- 
 rhaphy has been quite a successful addition to gyne- 
 
HOW TO MEND THEM. 
 
 79 
 
 cology, but it is a denudation operation and hence 
 destroys valuable tissue. I have observed that the 
 European operators attempt to save anterior and pos- 
 terior columns of the vagina. Men see in the column 
 a valuable piece of supporting tissue, and some of 
 them, like Martin, try to save it. Dr. Emmet has 
 worked along the same line, and his operation is one 
 of the most useful of its kind, and if mastered and 
 done thoroughly is successful. In it he has combined 
 the best principles of the denudation method. It 
 
 Fig. 25.— (A. Martin.) Colpoperineorrhaphy posterior accordina- to 
 Hegar; a, IS the newly-built perineum. ^ 
 
 saves the columns and denudes the areas of least 
 resistance. His idea of supporting the pelvic floor' is 
 certainly correct. If the flap-splitting method could 
 be made use of in this operation it would be a marked 
 step in advance. The vulvar and vaginal operation 
 of denudation should be superseded by theflap-exten- 
 sion method, which might be called perineo-episior- 
 rhaphy. It is done with no loss of tissue and can be 
 carried right up to the urethra. The amount of flap 
 and consequent barrier of tissue built up at the vulva 
 
80 
 
 THE VAGINA AND* PERINEUM; 
 
 will depend on the depth of the scissors' clip and the 
 amount of exposed tissue, and also much on the man- 
 ner of suturing the surfaces to be coapted. The flap- 
 extension method will form one of the best supports 
 for prolapse. The objections against the Alexander- 
 Adams operation are: 1. Unsatisfactory reports and 
 
 Fig. 26.— Colpoperineorrhaphy after A. Martin, He styles it elytror- 
 rhaphia duplex lateralis. The first step is to resect or denude the two 
 vaginal flaps; the left side is freshened and sutured; the right side fresh- 
 ened with the sutures, but not tied, a, a, the denuded vaginal flaps. 
 
 the bias in selecting cases for the operation. 2. In 
 quite a number of bodies the round ligaments can 
 not be found. In many cases which I investigated 
 no muscular ligaments could be discovered until one 
 got inside the internal abdominal ring. 3. No oper- 
 
HOW TO MEND THEM. 81 
 
 f%u^^}^^^ ^^ ^^^^^ ^^®®^ *^® difficulty will occur 
 4, 1 he danger of opening the peritoneum 5 The 
 round ligaments are insufficient for a main uterine 
 support. 6. Hernia may follow the operation 7 In 
 case of uterine adhesions the ligaments will not 
 raise and support the uterus. Results will not be 
 permanent. The round ligaments will gradually yield 
 to uterine weight, especially if there be an enlarged 
 uterus, as is often the case in prolapse. 
 
 Some of the above objections may be modified The 
 Alexander-Adams operation is an excellent one in 
 selected cases; in retroversion without adhesions it 
 will frequently be of great utility. But it is here 
 mentioned as an accessory operation to colpoperine- 
 orrhaphy. Shortening the broad ligaments is of 
 questionable value. Hysteropexy, or the fixation of 
 a movable organ, is against all physiologic principles, 
 bchuckmg s operation for prolapse is not yet estab- 
 lished, and it seems the bladder would be in great 
 danger ot being wounded during the operation. Her- 
 riok s operation of attaching the cervix to the pos- 
 terior vaginal wall has made little definite progress 
 we have not yet learned how to utilize the sacro^ 
 ;uterine ligaments in prolapse. Such operations are 
 but accessories to colpoperineorrhaphy. The advan- 
 tages of the flap operation are: 
 1. The ease and simplicity of its performance 
 ^. it wastes no tissue; if it fails the patient is no 
 T\rorse off than before the operation, whereas the fail- 
 ure ot a denudation operation leaves serious defects 
 /t. V®.i °^^y operation that restores in a natural 
 method the perineal body. The linear cicatrix is 
 split and sutured in the opposite direction. Dr 
 l^mmet s operation unites the perineal wound artifi- 
 <5ialiy by uniting tissues not previously connected 
 
 4. It withstands subsequent labors; several of our 
 operations have withstood perfectly subsequent labors 
 
82 
 
 THE VAGINA AND PERINEUM; 
 
 Mr. Tait informed me of the same fact in many of 
 his operations. 
 
 5. The sutures are not passed through skin or mu- 
 cous membrane, and therefore are not so liable to sup- 
 purate or produce pain. 
 
 6. The certainty of healing. 
 
 Fig. 27.— Second step in A. Martin's colpoperineorrhaphy. He calls it 
 perineauxesis ; a and b show the lines of the vaginal denudations sutured 
 (elytrorrhaphy). The diamond-shaped space, 1, 2, 3, is the perineorrhaphy 
 following the colporrhaphy posterior. The letters indicate the sutures. 
 
 7. The flap operation secures in the easiest and 
 most convenient manner the widest possible surface 
 for coaptation and healing of the fasciae and adjacent 
 tissues in the median line for support. 
 
HOW TO MEND THEM. 83 
 
 8. The pain after the operation, in my experience, 
 is less than after the denudation operation. 
 
 9. Tait's flap operation can be practised successfully 
 where the repeated denudation operation can not be per- 
 formed because of loss of tissue and excess of tension. 
 
 Fig. 28.— Martin's operation with a continuous catgrut suture (etagr- 
 enaht). It is a continuous buried suture. 
 
 10. The short time required to do Tait's flap oper- 
 ation minimizes shock. 
 
 11. The resulting cicatrix is in its natural location 
 and linear, and will thus cause less peripheral nervous 
 disturbance. 
 
84 
 
 THE VAGINA AND PERINEUM; 
 
 12. The stitches leave no cicatrices and therefore 
 will cause no irritation. One can observe the most 
 practical and best observers trying to save the column 
 and trying to perform denudations in the vaginal 
 sulci. The superiority of Tait's flap operation is that 
 it saves all tissue and builds a natural perineum in a 
 natural location, and thus subserves natural forces 
 
 Fig. 29.— Martin's operation with buried catgut, The upper part 
 (elytrorrhaphy) posterior colporrhaphy ; the lower part (perineauxesis) 
 perineorrhaphy; 6, the upper end of thread; c, lower end of the catgut. 
 
 according to nature's original law, and anatomic struc- 
 tures are not much violated by cicatrices and cicatricial 
 contraction. 
 
 A fact not generally appreciated is the neurosis, the 
 neurasthenic condition produced by perineal lacera- 
 
HOW TO MEND THEM. 
 
 85 
 
 tions. The visible wound is not always commensurate 
 with the suflPering. There may be a visible wound, 
 an infection atrium, or simply an over-stretching of 
 muscle and fascia, which stretches and traumatizes 
 the peripheral nerves, producing nervous irritation. 
 The fascial planes which hold the blood-vessels in dis- 
 tinct relation, are so damaged that congestion and de- 
 congestion of the pelvis frequently arise. Healthy 
 veins should be spiral and uniform in caliber. The 
 
 Fig. 30.— Profile view of A. Martin's colpoperineorrhaphy posterior. 
 A, B, elytrorrhaphy ; D, E, C, perineauxesis. 
 
 laceration of the pelvic fascia allows the veins to 
 straighten out and become irregularly dilated. This 
 straightening out and dilatation produces not only 
 blood and lymph congestion, but peripheral nerve 
 pressure. The frequent pelvic congestion and de- 
 congestion from deficient blood-vessels' support, pro- 
 duce conditions which favor the development of 
 pathogenic microbes in the genital mucosa. The gyn- 
 
86 
 
 THE VAGINA AND PERINEUM; 
 
 ecologist sees many patients with neurotic phenomena 
 which can only be attributed to perineal lacerations 
 and defects. 
 
 When the sutures are tied the newly formed per- 
 ineum will look enormously longer, but it will soon 
 shrink to the natural condition. After some experi- 
 ence one can do the flap operation so that on healing 
 the linear cicatrix will resemble the old raphe so 
 
 V 
 
 Fig. 31.— Hildebrandt's method of denudation and suturing. The 
 dotted Knes show the sutures under the tissues. The denuded area is that 
 of a trefoil. Hepner's method of suture is that of a figure 8. Cleveland's 
 method is simply a peculiar method of suturing. 
 
 closely that one can scarcely tell after six months that 
 an operation has been performed. 
 
 For cystocele the flap operation can also be performed. 
 The flap method is alike applicable to partial and 
 complete perineal laceration. The operation is best 
 idemonstrated on complete lacerations. 
 
HOW TO MEND THEM. 
 
 87 
 
 GENERAL CONCLUSIONS. 
 
 1. To cure saoropubio hernia (uterine prolapse), 
 perform amputation of the (sharp) cervix; anterior 
 oolporrhaphy; Tait's flap perineorrhaphy. 
 
 2. The amputation of the cervix is for the purpose 
 of removing the sharp cervical point; directing the 
 cervix backward; restoring the uterus to normal 
 position. 
 
 Pig. 32.— (After Pozzi.) i^autenbach's method in incomplete rupture 
 of tHe perineum. 1, suture of the superior angle; 2, submucous suture of 
 the vaginal wall ; 3,-buried sutures deep in the wound. 
 
 3. The anterior colporrhaphy is for the purpose of 
 narrowing the vagina; elevating the bladder, directing 
 the cervix backward and the fundus forward. 
 
 4. The Tait flap perineorrhaphy is for the purpose 
 of restoring the perineum; restoring the obliquity of 
 the genital canal; restoring such a central floor as 
 
88 
 
 THE VAGINA AND PERINEUM; 
 
 will efficiently support the rectum, bladder, and 
 genitals. 
 
 5. If the cervix be not pointed and retroversion 
 does not exist amputation of the cervix may be omit- 
 ted in the above procedure. 
 
 6. If the uterus and bladder be in normal position 
 and the vagina not prolapsed, anterior colporrhaphy 
 may be omitted. 
 
 7. The permanent success of Tait's perineal flap 
 operation consists in extensive flaps (by means of 
 front and back cuts) and the drawing into the median 
 
 Fig. 33. — Lauen stein's suture in complete laceration. 1, introduction 
 of sutures which coapt the vagina and rectal mucosa ; 2, introduction of 
 the perineal sutures after the vaginal and rectal have been fastened. 
 
 line of large masses of lateral tissue for a pelvic floor. 
 These lateral masses are drawn in and secured for 
 weeks by deep sutures of silkworm gut. These deep 
 sutures, six to eight in number, act like splints for 
 four to eight weeks, and though part of the wound 
 suppurates, the sutures maintain it in coaptation while 
 it granulates and heals. 
 
 8. Our operations have proved definitely that the 
 rectal sphincters may be practically restored to normal, 
 even after long periods of rupture. One case of thirty- 
 four years' standing, with two previous unsuccessful 
 
HOW TO MEND THEM, 
 
 89 
 
 denuding perineorrhaphies and a complete laceration 
 of three inches up the rectum was restored to perfect 
 function. 
 
 9.^ The three surgical procedures described will 
 obviate hysterectomy in many cases. 
 
 10. The flattening out of the operation, or the yield- 
 ing of the union, or the stretching of the parts allow- 
 ing prolapse, will depend especially on the flaps and 
 the amount of tissue permanently drawn into the 
 middle line. 
 
 Figure 34 A. 
 
 12. We especially insist that better results are ob- 
 tained by allowing the silkworm gut sutures to remain 
 in position for from four to six weeks. Should any 
 suppurate they may be removed at any time. Wounds 
 do not heal very firmly under three weeks. 
 
 13. We feel decided in stating from our own experi- 
 ence that the flap operation should not be disturbed 
 by dressings. The patient should be kept quiet for 
 three days, and then a vaginal douche may be given 
 
90 THE VAGINA AND PERINEUM; 
 
 daily. After the first half day the wound is hermet- 
 ically sealed by its own oozing. The limbs should be 
 tied together at the knees. The bladder will generally 
 require the use of the catheter for two to four days. 
 Morphin injections of 1/1 6 of a grain may be given 
 to quiet the pain and induce rest. 
 
 14. The dissection of the rectum from the vagina 
 
 Figure 34 B. 
 
 for one to three inches, was added from my own ex- 
 perience, as I never saw Mr. Tait do this. This addi- 
 tional procedure lengthens the operation to fifteen 
 to thirty minutes; Mr. Tait performs his operation in 
 five to ten minutes. 
 
 15. The result of the foregoing surgical procedure 
 has been gratifyingly successful. 
 
 16. The flap operation fits any and every case, for 
 
HOW TO MEND THEM. 
 
 91 
 
 it resplits the old cicatrix and restores and adds what 
 is required. 
 
 17. In no single case, in over 150 which I have 
 observed, was the flap operation not applicable. 
 
 18. The flap method makes little scar tissue, as the 
 operative procedure is performed in connective tissue 
 
 Figure 34 C. 
 
 while cicatrices form in skin and mucosa. In the flap 
 oolpoperineorrhaphy the posterior vaginal wall is 
 made to sustain the anterior. 
 
 19. In the flap operation the vaginal walls are made 
 to give their full support to the uterus — the posterior 
 
92 THt VAGINA AND PERINEUM; 
 
 wall sustains the anterior vaginal wall and bladder — 
 and also to support and direct backward the rectal 
 wall. 
 
 The flap perineorrhaphy has been chiefly revised 
 and introduced to the profession by Mr. Lawson Tait 
 of Birmingham, England. It is true the flap peri- 
 neal operation was performed in various ways by oth- 
 ers, as Duncan, Colles, Jenks, Marcy and Langen- 
 
 Fig. 34 A, B, C, D.— (After Pozzi.) Freund's method. Freund insists 
 that we should make the denudation exactly as the perineum appeared 
 ■when originally torn. For example, the cicatrix, O, O, originally appeared 
 as large as B, B, X, in A, and should be denuded to that size ; the line X, Y, 
 in B represents the rectal suturing ; the line of sutures, B, A, B, in C shows 
 the vaginal part sewed up; X, Y, corresponds to the rectum suturing; 
 A. C, Y, D, in C, the denuded perineal area, which is still unsutured; 
 D, the final disposition of the sutures in Freund's method. It is an excel- 
 lent one, but complicated, and is wrought with much sacrifice of tissue 
 if the operation fails. 
 
 beck. But Mr. Tait gave it a new impetus, and also 
 performed it with new phases. He performed it with 
 elbow scissors and introduced sutures which neither 
 
HOW TO MEND THEM. 93 
 
 penetrated skin nor mucous membrane. As a pupil 
 of Mr. Tait, for six months, I had ample opportunity 
 to observe his methods of operation. The principle 
 of operation consists in resplitting the old perineal 
 cicatrix without loss of tissue, with fixed coaptation 
 of the flaps. After observing Mr. Tait's methods I 
 naturally practised the operation as performed by 
 him and his assistants. About a year later I began 
 to modify the operation by dissecting the rectum and 
 vagina from each other for a variable but long dis- 
 tance (1 to 2J inches) above the vulva or anus. This 
 modification enabled me to apply it to almost all forms 
 of prolapse, relaxed vaginal wall or perineal lacera- 
 tion; in short, in all conditions requiring perineor- 
 rhaphy and colporrhaphy posterior. The objections 
 raised against the flap method we found, after over 
 six years' trial, were not well founded. One objection 
 is that Tait's flap perineorrhaphy is a " skin opera- 
 tion." If performed superficially it may be subject 
 to the above criticism. However, such criticism can 
 only be applied to imperfect execution. The opera- 
 tor must carefully guard against closing the vulva too 
 far. One can easily make an excessive perineum by 
 the flap method. This objection is, as a matter of 
 fact, worthless. Another objection is that the flap 
 method in no way narrows the vagina. This objec- 
 tion will not hold, as the vagina can be narrowed so as 
 to embrace tightly a single index finger. In fact, we 
 can dissect the rectum and vagina from each other 
 for three inches, up to the peritoneum, or as high as 
 desired, and narrow the lower third of the vagina as 
 much as the operator sees fit. The upper two- thirds 
 of the vagina does not require narrowing. Another 
 objection is that it does not approximate the fibers of 
 the levator ani. It is the operation par excellence to 
 unite the deranged or torn levator ani fibers, because 
 the dissection is carried beyond the levator ani fascia 
 
94 
 
 THE VAGINA AND PERINEUM; 
 
 superior and inferior through the levator ani muscle. 
 In fact, it enables the operator to secure both the 
 levator ani fascia superior and inferior, which em- 
 braces the levator ani muscle. One must secure the 
 levator ani fascia in order to secure the levator ani 
 
 Fig. 35.— (After Pozzi.) A. R. Simpson's method. It is really a flap 
 operation. In the left hand cut, a, b and c represent the lines of incision 
 to make the flaps ; S, vagina ; 1,1, vaginal flap ; 2, 2, rectal flap. The scissors 
 are first entered at b, and the point emerges at n, and then a clip is made ; 
 second, the scissors are entered at 1, and pushed between the vaginal and 
 rectal walls over to 1, and a clip makes the rectal and vaginal flap. Dissect 
 the vaginal flap from the rectal as high as the case requires. To do this, 
 seize the vaginal flap with several small forceps, which the assistant can 
 gently hold; also seize the rectal flaps with several small forceps and allow 
 them to hang, as their weight is sufficient to put the flap on tension ; with 
 the two fingers in the rectum and a pair of blunt-pointed scissors the dis- 
 section of the flaps is conveniently made. The sutures are introduced as 
 shown in the cut. Observe that in this operation four flaps are made and 
 that the rectal and vaginal walls are sutured separately; also note that 
 the sutures 1, 2, 3, are entered by passing through the skin. The suturing 
 and flap making is absolutely different from that of Mr. Tait's flap method, 
 in which only one flap is made and no sutures enter the skin or mucosa,^ 
 and all cutures are in denuded tissue. 
 
HOW TO MEND THEM. 95 
 
 muscle, which is guarded and embraced by a definite 
 fascial sheath. The flap operation reunites the pos- 
 terior vaginal fascial septum without denudation, as 
 Emmet's operation unites it with denudation. Both 
 Emmet's and Tdit's operations are based anatomic- 
 ally on the same principle — one denudes however, 
 and the other does not, but employs a flap to cover 
 the wound. My practice is to dissect the rectum and 
 vagina in the lateral sulci. In the American Text- 
 book of Gynecology the writer on "Flap-splitting 
 Perineorrhaphy'' makes the following absurd state- 
 ments: "Its field of usefulness is very limited indeed. 
 Practically it is applicable to those cases in which 
 only the superficial and most exterior fibers of the 
 perineum are torn." The above views can certainly 
 be based only on imperfect knowledge, execution, or 
 observation of the operation. We can affirm that it 
 is one of the most certain and effective of all opera- 
 tions on the perineum. The flap method of colpo- 
 perineorrhaphy is the one above all others that enables 
 an operator to reunite the levator ani fascia superior 
 and inferior *with the enclosed levator ani muscle 
 without blind searching, to abolish a rectocele, and to 
 repair prolapse of the uterus. The same writer cited 
 above makes a further statement as ridiculou s as the 
 first, that, "In no way possible can this operation 
 (flap-splitting) narrow the vagina, abolish a rectocele, 
 or bring together the separated fibers of the pelvic 
 fascia." It is fortunate that this "American" text-book 
 does not represent the views of all Americans. The 
 flap-splitting perineorrhaphy, in the hands of those who 
 have thoroughly practised it, has proved absolutely 
 that it will narrow the vagina, abolish a rectocele, and 
 bring together the separated fibers of the levator ani 
 fascia superior and inferior with the fibers of the 
 levator ani muscles. Also it securely unites the liga- 
 menta ischeo-perinei. The flap method is alike use- 
 
96 
 
 THE VAGINA AND PERINEUM; 
 
 ful in partial and complete operations, and in high 
 rectovaginal dissections does all that Emmet's does, 
 with no denudations, and with a better chance of 
 healing, by avoiding the infectious atrium. Also, like 
 Emmet's operation, Tait's flap-splitting is founded on 
 anatomic structures and designed to restore physio- 
 logic functions. Both operations have come to stay. 
 
 Fig. 36.— A perineal laceration to the rectum. Two fingers of the left 
 hand are in the rectum ; the recto-vaginal septum is put on lateral tension 
 by the traction fbrceps on each side ; the blade of the scissors is inserted 
 between the rectal and vaginal walls, and the dotted line marks out the 
 flap to be produced. 
 
 The conception of the flap-splitting operation rests on 
 the pathologic conditions of the wound. If one ex- 
 amines a vulva with lacerations, he will see linear cica- 
 trices, narrow white lines which are transverse in dis- 
 section. These white lines are the healed cicatrices 
 of the old perineal lacerations The linear cicatrix is 
 
HOW TO MEND THEM. 97 
 
 healed at right angles to the original wound or rent. 
 Wounds generally heal in the direction of the tear. 
 
 On this peculiar condition of the cicatrix being at 
 right angles to the wouud is based the flap-splitting 
 method of Mr. Tait. The transverse cicatrix is split 
 and sutured at right angles to itself. It simulates the 
 Heinike-Mikulicz pyloroplasty when the wound is 
 sutured exactly in the opposite direction to its inci- 
 sion. It is the same procedure as one may employ 
 in varicocele to shorten the scrotum, i.e., incise the 
 scrotum along the spermatic cord for three inches and 
 then suture the scrotal wound at right angles to the 
 incision as is practised in Dr. Senn's clinic. In su- 
 turing the split cicatricial wound at right angles to 
 itself we restore exactly the original normal structures 
 of the perineum. By this method the perineum and 
 relations are restored to the normal condition, which 
 alone will withstand subsequent labors. The patient 
 should be prepared for three days before the opera- 
 tion by cathartics, so that the digestive tract may be 
 thoroughly evacuated. The cathartics should be so 
 administered that all defecation should cease 8 to 10 
 hours before the operation. There will then be no 
 feces in the rectum during the operation nor for some 
 hours subsequent. The patient is anesthetized, and 
 lies on the back. The instruments useful in this oper- 
 ation are elbow scissors, a handled needle with an eye 
 in its pointed end, and strong silkworm gut. The 
 silk worm gut should be thoroughly washed with 
 soap and water. The index and middle finger are in- 
 troduced into the rectum, and the recto-vaginal sep- 
 tum is divided in the linear cicatrix. The scissors 
 point is then forced under the skin of the labia and 
 carried upward as far as desired and clipped. The 
 opposite side is treated exactly the same. Back cuts 
 are now made on each side of the rectum as long as 
 desired. In slight operations the back cuts are not 
 
98 
 
 THE VAGINA AND PERINEUM; 
 
 required. The anterior vaginal flap is seized with 
 forceps and drawn forward, while the posterior rectal 
 flap is seized and drawn backward. We dissect the 
 rectum from the vagina as high as desired (IJ to 3 
 inches). At the same time the lateral space on each 
 
 Fig. 37.— (Modified from Pozzi.) A very extensive recto-vaginal lacer- 
 ation of old standing, with large radiating cicatricial tissue showing 
 healing lines. The scissor blades on each side introduced between the 
 rectal and vaginal walls at the cicatricial margins illustrate how the flaps 
 are produced. " Back cuts" extend to the scissor handles; the back cuts 
 are made to produce a larger perineal body. A Sims' speculum is inserted 
 into the vagina, anteriorly. 
 
HOW TO MEND THEM. 99 
 
 side of the vagina is dissected as extensively as is 
 required to make the perineal body. (See Fig. 19) 
 The two fingers of the left hand are kept continually 
 in the rectum as a guide. The extent of the dissec- 
 tion is governed by the condition of the parts, the 
 size of the wound, and the object in view; whether it 
 be narrowing the vagina, extension of the perineum, 
 or almost closing the passage for prolapse. With con- 
 siderable dissection, a few arteries may need clamp- 
 ing; however, the hot irrigation will nearly always be 
 sufl&cient to check the hemorrhage. If the bulb be 
 out it will bleed profusely, but sponge-pressure will 
 soon check it. If the scissors cut open a vulvo-vagi- 
 nal abscess the whole gland should be dissected out 
 and disinfected, in order to avoid an abscess in the 
 wound. 
 
 The second step of the operation is to introduce the 
 sutures of silkworm gut. The two fingers are removed 
 from the rectum and well cleaned. The point of the 
 handled needle is introduced at the upper angle of 
 the wound (No. 2 in Fig. 21) without penetrating the 
 skin or vaginal mucous membrane, carried along 
 about one-half inch from the distal edge of the vaginal 
 flap and made to emerge at the median raphe. It is 
 then threaded and drawn out. The point of the 
 needle is again introduced at the upper angle of the 
 wound on the opposite side (No. 4 in Fig. 21), forced 
 along the distal edge of the flap about one-half inch 
 from the edge and made to emerge again on the 
 median line. It is threaded and drawn out. This 
 constitutes the first suture. Generally three anterior 
 sutures are introduced in the above manner. To 
 introduce the posterior sutures (three or four) the 
 index finger should be placed in the rectum as a guide, 
 to avoid passing the needle too close to the rectal 
 mucosa, endangering fistula. The fistula may arise 
 quickly or slowly. If quickly an abscess will arise; 
 
100 
 
 THE VAGINA AND PERINEUM; 
 
 if slowly (two to four weeks) a fistula will arise and 
 remain a longer or shorter time. In one case a fistula 
 persisted for three years. The posterior sutures are 
 introduced similar to the anterior. However, they 
 should be deeper and should thoroughly include the 
 levator ani fascia superior and inferior with the 
 
 Fig. 38. — (Author.) A stage in progress of the flap-forming colpoperi- 
 neorrhaphy. Here the sutures appear as if the process had started at 
 the anus, but the safest and most practical method is to begin to intro- 
 duce sutures and tie from the anterior end. All sutures are threaded in 
 the median line. The needle may be thrust across the entire denuded 
 field, but one can make more perfect and deeper suturing by doing one- 
 half at a time. 
 
HOW TO MEND THEM. 101 
 
 enclosed levator ani muscle. The point of the 
 needle is passed into the edge of the wound, avoiding 
 the skin, and pushed onward to the median line, 
 where the point emerges, is threaded and drawn out. 
 It is again introduced on the opposite side and 
 threaded in the middle. In all cases requiring exten- 
 sive dissection the needle should be passed through 
 half of the wound only. In the less extensive part of 
 the wound the needle may pass through the whole 
 ;^ound at once. Mr. Tait employed three to five 
 sutures. We employ five to seven sutures. 
 
 The third step is to tie the sutures of silkworm gut. 
 All the "sutures are seized at the distal end by the left 
 hand while^he right hand pushes the tissues of the 
 wound as far toward the loop of the sutures as possi- 
 ble. This is a partial step, as it narrows and puckers 
 the wound very much, so that when each individual 
 suture is tied it assumes its final location. The 
 sutures should not be tied too tight, as they are apt 
 to cut through considerable tissue. After the sutures 
 are tied, a linear gap of considerable width will exist 
 in the niedian line, for the sutures do not penetrate 
 the skin, and hence will not draw it in close coapta- 
 tion. Here some of the inexperienced will be 
 tempted to place a few skin sutures to avoid the 
 gaping of the wound. Be sure not to do it, for they 
 cause pain and may produce an abscess; when the 
 legs are placed together the edges of the wound will 
 coapt. The ends of the sutures should be left long 
 and all tied into a single bundle. The after-treat- 
 ment consists in applying no dressing or chemicals to 
 the wound. If there be considerable pain small hypo- 
 dermic doses of morphin may be used for thirty-six 
 hours. Most patients will require catheterizing, from 
 trauma to the distal ends of the pubic nerves. After 
 forty-eight hours we begin to give two quarts of a 
 vaginal douche, evening and morning. The bowels 
 
102 
 
 THE YAGINA AND PERINEUM; 
 
 should be moved on the third or fourth day by means 
 of calomel given in small doses (1 grain two or three 
 times) and followed by teaspoonful doses of MgSOi. 
 Diet should be regulated and limited for three days 
 before and three days subsequent to the operation. 
 
 Fig. 39.— (Eobinson-Holland.) Method of formation of anterior and 
 posterior flaps in the flap method of executing colpoperineorrhaphy. 
 
 The patient should lie in bed for at least two weeks, 
 and afterward get up as she is able. The sutures 
 should be watched. If one becomes loose it should be 
 removed. If none become ioosa or separate they may 
 remain for three, four or even six weeks. Three 
 
HOW TO MEND THEM. . 103 
 
 weeks is soon enough to remove the sutures. The 
 wound heals more firmly with the sutures in for four 
 weeks or more. The sutures act like splints, holding 
 the surfaces in fixed coaptation, avoiding motion, 
 which interferes with perfect union. The sutures 
 often give pain on removing, and it would perhaps 
 be better in some neurotic cases to anesthetize the 
 patient. However, I never practise it. Amateurs 
 must be warned not to close the vulva unnaturally 
 tight as it might disturb marital relations. The cuts 
 in the article will show the steps in the technique. 
 
 THE EMMET OPERATION. 
 
 This operation is in marked contrast to all previous 
 ones for similar purposes, as union of the denuded 
 labia was the first procedure. The peculiarity of 
 Emmet's operation consists in denudation of the lower 
 median posterior vaginal wall; bilateral denudation 
 of triangular portions of the lateral sulci of the 
 vagina; in the method of introducing the sutures, 
 which are so arranged that on tying they lift the pro- 
 lapsing parts toward the pubic arch, restoring ana- 
 tomic structures, as the H-shape to the vagina and the 
 normal curve of the vagina. The patient should be 
 prepared for several days by cathartics and daily skin 
 baths. The bowels should be evacuated by eight to 
 twelve passages, so that no feces will be in the rectum 
 while operating, nor for 24 to 36 hours after. Thor- 
 ough salt rubbing of the skin not only stimulates the 
 apparatus of the skin to the climax of secretion but 
 reflexly stimulates the bowels and kidneys to active 
 secretion. In short, place all secretory organs — skin, 
 bowel and kidney — at their maximum activity for the 
 operation. Place the anesthetized patient on the 
 back, with an assistant holding each limb, With 
 tenacula fixed to definite points of the vagina, as for 
 example, one at the median crest of the rectocele, one 
 
104 
 
 THE VAGINA AND PERINEUM; 
 
 tenaculum on each side of the vagina at the highest 
 point of the triangle of denudation in the sulci and 
 one on each side of the posterior vaginal wall at the 
 junction with the skin and mucosa, one can mark 
 the outline of the denudation with a scalpel. It is 
 well, before denudation, to test whether the area is 
 too large to insure coaptation of the wound without 
 undue tension. The area defined by the tenacula is 
 
 Fig. 40,— (Robinson-Holland.) Method of introducing the sutures in 
 the flap method of colpoperineorrhaphy. Note that the handled needle 
 is threaded in the median line. This cut was drawn from a photograph 
 taken of a patient during the operation. 
 
 denuded by the operator cutting off long strips of 
 vaginal mucosa with scissors curved on the flat. 
 Others denude with the scalpel, rolling the denuded 
 vaginal flap on a staff or on the fingers. With expe- 
 rience, large areas may be rapidly denuded. The area 
 requiring denudation in the lateral sulci depends on 
 the amount of slack in the posterior vaginal wall, for 
 
HOW TO MEND THEM. 105 
 
 this operation has the special merit of narrowing the 
 vaginal canal. With a typically relaxed vaginal out- 
 let a large area of denudation will be required, and 
 especially high in the right and left vaginal walls. 
 The denudation should consist of the whole thickness 
 of the vaginal wall. Continuous hot water irrigation 
 over the denuded surface will check the hemorrhage. 
 The operation is eminently a posterior colporrhaphy, 
 and the success will depend on denudation in the 
 lateral vaginal sulci, and not on the denudation of the 
 so-called perineum. In case the vaginal wall is very 
 slack and thin it is well to extend the denudation deep 
 into the bilateral subvaginal tissue in the vaginal 
 sulci. Perfect denudation is a requisite; no islands 
 of vaginal mucosa must be left. The second step of 
 the operation, equally important with denudation, is 
 the plan erf introducing the sutures. The object of 
 the special planning of the sutures is to lift the lax 
 vaginal outlet upward toward the pubic arch, restor- 
 ing the vaginal condition. The skill in planning the 
 denudation in the right and left sulci of the vagina is 
 no less than that employed in the introduction of the 
 well-devised plan of sutures, The chief materials for 
 sutures are silver wire, silkworm gut, and catgut. To 
 suture the denuded surface expose one of the triangles 
 in the lateral vaginal wall. Begin to suture at its 
 apex, passing the suture transversely across the angle, 
 after which immediately tie it. The second suture is 
 passed one -quarter of an inch from the first (four 
 sutures to the inch). The needle is passed through 
 the vaginal wall and subvaginal tissue toward the 
 operator (in an anterior posterior direction), whence 
 it emerges, and is re-entered at the same point and 
 passed in an antero-posterior direction under the sub- 
 vaginal tissue through the denuded triangle, emerg- 
 ing on the vaginal mucosa at the edge of the wound. 
 This makQs the suture, before tying, represent a tri- 
 
106 
 
 THE VAGINA AND PERINEUM; 
 
 angle, with its apex (at the emerged points of the 
 suture in the denuded triangle) toward the operator, 
 and characterizes the plan of suturing; i. e., they are 
 introduced in an antero-posterior direction, and by 
 tying, they lift the vaginal outlet toward the pubic 
 arch. The next suture is introduced by passing the 
 needle through the vaginal wall (on the internal side 
 
 Fig. 41.— (Author.) Diagram of the plan of Tait's flap colpoperineor 
 rhaphy : a, S, sacrum ; R, rectum ; P, intact perineal body ; V, vagina, with 
 urethra above it ; &, has had the torn perineal body, P, repaired by the six 
 sutures marked by stars ; c, shows the H-shaped anterior cuts, a, 6 ; c, (/, 
 the posterior cuts ; R, rectum ; V, vagina. 
 
 of the triangle) deep into the subvaginal tissue of the 
 denuded triangle (directly toward the operator), 
 whence it emerges, and is re-entered at the same 
 point and carried upward and outward (away from the 
 operator) very deeply under the denuded area, emerg- 
 
HOW TO MEND THEM. 107 
 
 ing on the vaginal mucosa at the external side of the 
 triangle. The sutures on the external side of the 
 denuded triangle should be especially deep and should 
 include extensive tissue. Generally three or four 
 sutures are sufficient to close the triangle of each sul- 
 cus. The suture at the base of each triangle may be 
 called a tension suture. It can be tied as soon as 
 passed, which will enable more superficial sutures to 
 be applied to the upper part of the triangle. The 
 crown or pursing suture is now passed within the 
 vagina by introducing the needle in the mucosa on 
 the lateral vaginal wall close to the incision, a short 
 distance below the center of the triangle. The needle 
 should emerge in the subvaginal tissue in the sulcus 
 below the point of introduction. The needle is re- 
 entered and carried across the vaginal sulcus just 
 below the vaginal incision, emerging at the opposite 
 side. One or two auxiliary pursing sutures are added 
 and the several sutures tied; superficial sutures are 
 then added, as required, to close the gaps in the 
 wound. The deep sutures should be of silkworm gut 
 and the superficials of catgut. 
 
 In this essay it is not the purpose to discuss imme- 
 diate repair after labor, but the views are directed 
 toward chronic damage of the vulva, vagina and pelvic 
 floor. It will require careful examination of the 
 vulva, vagina and uterus to decide in certain cases 
 what will be the wisest plan to pursue. Some cases 
 show extensive laceration with but .few symptoms, 
 while others show little damage, but complain of 
 severe suffering. Such differences rest on visible 
 and invisible supports. Extensive perineal lacera- 
 tions demand repair whether they create symptoms or 
 not, as such lesions will in all probability lead to ill- 
 ness. One may occasionally meet a patient who has 
 had a perineal operation, and the perineum to all 
 intents and purposes appears normal ; yet an exami- 
 
108 
 
 THE VAGINA AND PERINEUM; 
 
 nation reveals the fact of a reotocele above the restored 
 perineal body, and the patient confirms the results of 
 the examination by still announcing herself as suffer- 
 ing. In operating, the dissection of the so-called 
 perineal body should extend as high on the recto- 
 
 Fig. 42.— The outlines of the anterior "cuts," (A, E,) and posterior 
 '*cuts" (A, B,) in the flap colpoperineorrhaphy. to, Clitoris; /i, urethra; 
 L, P, anterior vaginal wall ; A, N, anus ; N, R, perineum ; E, C, labia. The 
 vaginal orifice is wide open. The laceration is not complete, i.e., it does 
 not reach the rectum, 
 
 vaginal septum as there appears redundancy of the 
 posterior vaginal wall (rectocele). Nothing less will 
 cure the patient. The perineal body, in its broadest 
 sense, is a resistant ligamentous, fibromuscular struo- 
 
HOW TO MEND THEM. 109 
 
 ture which closes the abdominal cavity below. The 
 body begins to be supported from the curved white 
 line located on each side of the pelvis, as one may be 
 impressed by looking into a pelvis from above. It is 
 bowl-shaped, and as soon as this peculiar shape 
 becomes lost, the supports have given away at some 
 point. Observed from below the perineum is nar- 
 rowed to the space between rectum and vagina. The 
 flap operation is capable of repairing any defect in 
 the pelvic floor. In complete laceration the anal and 
 vulvar orifices are in direct communication, like a 
 cloaca. The rectovaginal septum may show a boot- 
 jack angle or an irregular arched outline. The irreg- 
 ularly-torn outline of the rectovaginal septum shows a 
 double-walled layer or curved sides. At the upper 
 angle of the lacerated rectovaginal septum the rectal 
 mucosa pouts, rolls and appears as a red or pink 
 ground which aids in locating the line to split the 
 flaps. 
 
 After the rectovaginal septum has been lacerated 
 for a long time it presents irregular cicatricial bands, 
 some of which are thin, others thick, assuring differ- 
 ent stages of atrophy and contraction. Bridges or 
 bands of tissue may stretch from one point to another 
 showing a penetrated condition. Again, the lower 
 edges of the lacerated rectovaginal septum may be 
 drawn upward by the fibers of the levator ani still 
 embracing the parts by the aid of its double fascial 
 sheets. Besides small, irregular depressions may be 
 felt or observed where the stump of a bundle of the 
 levator muscles has been torn away and retracted. 
 The deep sutures applied after splitting the septum 
 will include these stump ends of the muscles by means 
 of fascia so that they may be again forced to the 
 median raphe and fixed there. The flap operation 
 does not need to observe whether the sphincter, anus 
 or rectovaginal septum be lacerated, for it is alike 
 
110 
 
 THE VAGINA AND PERINEUM; 
 
 applicable to each and all. On examination we may 
 find all kinds of associated conditions with extensive 
 colpoperineal lacerations, as lacerated cervix, subin- 
 volution of the vagina, cystocele, rectocele, and retro- 
 version of the uterus. Now if the uterine appendages 
 
 Fig. 43.— Dissection of the flap and the anterior vaginal wall, N,R, 
 drawn up with forceps. The posterior flap, S, is drawn backward by for- 
 ceps, two sutures, 6, n, are already passed ; three more sutures, one being 
 introduced by passing the curved-handled needle from the lateral edge of 
 the wound to the middle of the denuded surface and threading it from 
 the median line with silkworm gut ; D, I, anus ; V, perineum ; E, clitoris ; 
 X, urethra ; L, P, anterior vaginal wall. 
 
HOW TO MEND THEM. 
 
 Ill 
 
 are freely movable we can generally cure the patient 
 by curettement, repair of the cervix and colpoperineor- 
 rhaphy, for much of the disease observed is du6 to 
 disturbed circulation. The vessels have been torn 
 from their supporting bed by the deranged fascia. 
 The veins have become straightened out, dilated 
 
 Pig. 44.— Sutures tied in the operation for colpoperineorrhaphy with 
 incomplete laceration. A, N, anus; L, M, labia; A, clitoris; V, urethra: 
 E,D, median line of the peripeal raphe; P, posterior point of perineal 
 space. 
 
 locally, and have lost their elegant spiral form, result- 
 ing in blood stasis, congestion. Restore the supports 
 and circulation will resume. 
 
 The diagnosis consists of observation and palpa- 
 
112 THE VAGINA AND PERINEUM; 
 
 tion with the aid of a large Sims speculum. In the 
 diagnosis a notably striking feature is the changed 
 appearance of the vulvar outlet. Normally the peri- 
 neum is widest at its upper end. With lacerated 
 perineum or relaxed vulva the whole external appear- 
 ance is changed. The narrow puckered chink or slit- 
 like aperture of the natural vulvar orifice is trans- 
 formed into a patulous gaping. Again, the normal 
 vagina presents a sigmoid curve with the posterior 
 vaginal wall coapting and embracing the anterior, like 
 a valve. But in deficient vaginal apparatus these 
 two concentric coapted curves have lost their rela- 
 tions, especially the posterior vaginal curve. It should 
 be remembered, in diagnosing this deficiency at the 
 vulva, that the non-closure is not due especially to 
 loss of the perineal body,. but to defect in the levator 
 , ani muscle and its double fascial layers. The levator 
 ani muscle endows the rectum with its anterior curve 
 and drags the lower end of the vagina upward and 
 forward against the pubic arch. This fact can be 
 demonstrated by introducing the finger into the vag- 
 ina and forcing backward and* downward, when by 
 removing the finger, the vagina quickly returns to its 
 normal position. The vaginal orifice has no distinct 
 sphincter like the mouth or anus, but has an indirect 
 sphincter, the horseshoe loop of the levator ani, aided 
 by the pubic arch. The arch acts like a fixed point 
 and the vagina is indirectly closed by shortening, con- 
 tracting of the anterior bundle of the levator ani 
 muscle. The vagina is closed by flattening its walls 
 antero-posteriorly between the rectum and pubic arch. 
 It is H-shaped. There is a slight puckering of the 
 vagina at its external orifice by means of the weak 
 bulbo-cavernosus muscle, but practically this amounts 
 to nothing in physiology and anatomy. On account 
 of the position of the rectum in relation to the leva- 
 tor muscle it produces a sigmoid curve to the rectum, 
 
HOW TO MEND THEM. 
 
 113 
 
 with its convexity forward. This is due to the fact 
 that the strongest bundles of the levator muscle encir- 
 cle the rectum about an inch above its orifice or lower 
 end, whence by contraction it yields at the point of 
 greatest force, i. e., at the sigmoid bend. On account 
 
 Figr. 45,— Flap formation in a case of complete laceration of the recto- 
 vaginal septum into the rectum. The scissor blade is splitting the vaginal 
 from the rectal wall to form the flap, F, whose margin comes from the 
 mucocutaneous line X, P; P, P, is the back cut; A to A, the opposite back 
 cut; A, M, the anterior scissor clip, 
 
 of the position of the vagina, levator ani and pubic 
 arch, the lower end of the vagina is dragged upward, 
 producing its sigmoid curve forward, in the opposite 
 
114 THE VAGINA AND PERINEUM; 
 
 direction to that of the rectum. In other words, the 
 plane of the pubic arch is anterior to the plane of the 
 levator ani muscle, and when it contracts it must nec- 
 essarily drag the lower end of the vagina upward and 
 forward. These considerations may be appreciated 
 by introducing the finger into the vagina and the 
 thumb into the rectum. It is best studied 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 
 arch produces a kind of valve, which acts almost as a 
 certainty against prolapse while intact. This is one 
 of the elements of success in both the Emmet and 
 Tait perineal operations. The vast difference in 
 appearance between the virgin and the relaxed vaginal 
 sphincter apparatus of the multipara is due to the 
 yielding of supports by the process of labor in nearly 
 all cases (visceral ptosis excepted). This does not 
 appear so strange when we consider that the virginal 
 passage of the vagina is about an inch in diameter, 
 while the passing head, shoulders and breech demand 
 ten to twelve inches in diameter. It is not strange 
 that tissues forced to stretch from one to twelve inches 
 should forget to return. The levator ani muscle is 
 arranged in fasciculi or bundles, or it would become 
 defective more frequently. The sphincter and vaginal 
 apparatus may be injured by external accidental 
 trauma, but labor is the chief factor. 
 
 Relaxed vaginal outlet, concealed lacerations or 
 deep musculo-fascial tears of the pelvic floor, can not 
 be too forcibly brought to the notice of the physician 
 as an important diagnostic indication for colpoperine- 
 orrhaphy. Kelly calls such, concealed relaxation. 
 This is a condition of loose, gaping vulva, compared 
 to the mouth of a bag without its puckering-string by 
 Dr. Emmet. If the patient lie on the back the fork 
 of the buttocks looks flattened, the anus appears 
 
HOW TO MEND THEM. 
 
 115 
 
 everted, and one may observe the vaginal mucosa 
 bulging out above or below. The condition is fre- 
 quently described as rectocele or cystocele, or both. 
 Others call it perineal laceration. Some will write 
 that it can not be perineal laceration, because the skin 
 perineum is longer than the normal one. The skin 
 perineum is longer than normal because, when it was 
 stretched at labor, it never returned to normal (sub- 
 
 Fig. 46.— Advanced stage of the flap-splitting operation. L, V, anterior 
 vaginal flap held up by forceps ; the posterior rectal flap is held backward 
 by forceps ; the most posterior suture is placed along the margin of the 
 torn rectum ; other sutures are being introduced by being threaded in the 
 median line and drawn out. Note that the needles do not penetrate the 
 ekin or mucosa. 
 
116 
 
 THE VAGINA AND PERINEUM; 
 
 involution). Occasionally one can introduce the four 
 fingers of the hand and put the long relaxed perineum 
 on a stretch. It is in these long, lax skin perinei .that 
 physicians disagree as to conditions, the one asserting 
 that the perineum is plenty large enough and does 
 not require an operation, while the other rightly asserts 
 that the perineum is but a small part of the support 
 of the sexual organs. The fact is, the whole vagina 
 and sphincter apparatus has become deficient, the 
 
 Fig. 47.— Another stage of flap forming. Observe that the most pos- 
 terior suture is being introduced by the needle passing from one side of 
 the denuded wound to the other, because the space is short, but the 
 denuded surface under the flap is generally so wide that it is most prac- 
 tical to pass the handled needle from the lateral margin of the wound to 
 the median line, where the needle is allowed to emerge and become 
 threaded. Thus the sutures are passed through half of the wound at one 
 time. 
 
HOW TO MEND THEM. 
 
 117 
 
 yulva pouts, the anus everts, and the floor of the pel- 
 vis flattens out. If the patient is requested to bear 
 down, the anterior and posterior vaginal walls will roll 
 outward, often to an astonishing degree. By the act 
 of straining, the cervix can be felt descending. The 
 patient has utero-ptosis. The sacro-pubic hernia is 
 
 ^*iijfe>-' 
 
 Fie 48 —Finished operation in a case of complete .laceration. R, L, 
 anterior end, and A, F, posterior end of newly-built perineal raphe; A, N, 
 ossus ani is a little patent. 
 
 more marked if one examines the patient in the stand- 
 ing position. By careful inspection and palpation 
 while the patient lies on the back, one may feel the 
 retracted cicatricial stump ends of the lacerated levator 
 ani muscle, and by irritating the little cicatricial ele- 
 vated or depressed stumps we can see the contractions 
 
118 
 
 THE VAGINA AND PERINEUM; 
 
 and relaxations in them. Sometimes the perineum 
 or lower posterior vaginal wall is so relaxed that it 
 is large enough to close up the vulva like a valve. 
 The horseshoe loop of the levator ani, which extends 
 from one pubic ramus to the other, presents no more 
 the resisting, broad, elastic loop felt in the virgin, but 
 in the middle one feels an irregular sharp edge of 
 
 Fig. 49.— (Author.) Method of forming the flaps with a non-complete 
 laceration, with anterior and posterior "cuts" and vaginal flap. 
 
 narrow dimensions. Also the loops of the levator are 
 more displaced to the side of the vagina. Though 
 the patient can generally control stool, yet the vigor- 
 ous elasticity of the muscular loop is definitely im- 
 paired. With the patient on the back and the two 
 index fingers in the vagina, one can quickly test the 
 degree of deficiency of the sphincter vaginal appara- 
 tus by pressing downward and backward. The vulva 
 
HOW TO MEND THEM. 119 
 
 may pout with perineal skin intact, and the same may 
 be said of the rectum. The fascia and levator ani 
 may be quite defective on one side and intact on the 
 other side. In very sensitive women, made worse by 
 long-continued irritation, the examination is occasion- 
 ally delusive, because reflex irritation puts parts on a 
 tension. 
 
 We may classify the operations for colpoperineor- 
 
 _ Fig. 50.— (Eobinson-Sclaoler,) The flap formation. On the right the 
 scissors are shown forming the anterior "cut ;" on the left the blade of the 
 scissors only is shown, forming the posterior '"cut" beside the rectum. 
 
 rhaphy into three general divisions, viz.: posterior 
 median oolpoperineorrhaphy, posterior bilateral colpo- 
 perineorrhaphy, and the posterior flap oolpoperineor- 
 rhaphy. Some of the principal originators and advo- 
 cates of posterior median oolpoperineorrhaphy were 
 Dieffenbach, Langenbeck, Baker-Brown, Osiander, 
 Simon, Hegar, Hildebrandt, Jobert, DeLam belle, Le 
 Fort, Sohjoeder, Werth and Reamy. 
 
120 
 
 THE VAGINA AND PEKINEUM; 
 
 The chief originators and promoters of bilateral 
 colpoperineorrhaphy are Emmet, Staude, Freund, 
 Martin, Bischoff, Groodell and Kelly. Some of the 
 pioneer originators and advocates of the posterior flap 
 colpoperineorrhaphy were Langenbeck, Duncan, Tait, 
 Jenks, Voss, Simpson, Marcy, Colles, Sanger. 
 
 Whatever the apparent differences of the above 
 three classes of procedure, all the advocates praoti- 
 
 Fig. 51.— (Robinson-Scholer.) Flap formation with the scissors at the 
 bottom of gutter between rectal and vaginal flaps. 1, 1, vaginal flaps held 
 aside by the shepherd's crooks, 6, 6; 2, 2, rectal flaps; 3, 3, "back cuts;" 4, 
 rectal lumen ; 5, outline of cervix. Tnis represents a complete laceration 
 high up into the rectum. 
 
 cally agree that definite denudation (flap or other- 
 wise )5 exact approximation of wound surfaces, and 
 deep sutures (without tension), based on anatomic 
 lesions, are the prerequisites of success. Methods 
 and modifications are not so important as attention to 
 anatomic and surgical principles. The physiology of 
 
HOW TO MEND THEM. 
 
 121 
 
 structure being disturbed by an overstretched peri- 
 neum or elongated supports (enteroptosis), it must 
 be restored by reproducing as near as possible ana- 
 tomic integrity. 
 
 The relaxed tissue must be corrected with deep 
 sutures and dissection; the blood-vessels must have a 
 definite supporting bed in which to functionate; the 
 peripheral nerves must be protected against continued 
 
 Fig. 52.— (Robinson-Scholer.) The sutures in position in a case of 
 laceration high up into the rectum. 1, 1, the vaginal flaps held aside by 
 the shepherd's crooks, 6, 6; 2, 2, rectal flaps held in place by the crooks, 
 7, 7 ; 8, 8, points to the line or angle of junction between the rectal and 
 vaginal flaps. 
 
 repeated trauma, and the organs must assume a nor- 
 mal position, all of which belongs to the domain of 
 colpoperineorrhaphy. The genius of Emmet estab- 
 lished the utility of surgical procedure in the vaginal 
 sulci. The grand operations of Bischoff sparing the 
 posterior vaginal column (or median vaginal surface) 
 foreshadowed and aided Emmet, as well as the schol- 
 
122 
 
 THE VAGINA AND PERINEUM; 
 
 arly labors of Schatz on the pelvic floor. As a pupil 
 of A. Martin in 1884, I saw the contemporaneous and 
 independent development of Emmet's operations in 
 the vaginal sulci, in the hands of the most skilled 
 gynecologic surgeons of Germany. 
 
 It may be remembered that the Emmet and Tait 
 operations are alike valuable in operations for relaxed 
 
 Fig. 53. — (Robinson-Scholer.) A case not ruptured into the rectum, in 
 which the sutures are in position. The sutures are threaded from the 
 median line, as seen in the cut. Observe that the sutures penetrate neither 
 skin or mucosa. 
 
 vaginal outlet, with the advantage in the Tait opera- 
 tion of a flap to protect the wound. The reason Em- 
 met's operation is about of equal value is that healing 
 in the vaginal sulci is almost certain, hence but little 
 danger of loss of valuable tissue by non- healing. 
 Nothing is gained by denuding an area of vagina over 
 
HOW TO MEND THEM. 
 
 123 
 
 retaining that same area intact, for it will contract to 
 its original size shortly after the tension which pro- 
 duced it is removed. 
 
 The rational symptoms resulting from lacerations 
 requiring colpoperineorrhaphy are very numerous and 
 varied, but they follow a logical sequence. In general 
 the chain of symptoms is as follows: A local point 
 of irritation — an infection atrium; reflex irritation 
 which unbalances the other viscera (abdominal and 
 
 Fig. 54.- 
 laceration. 
 
 -(Robinson-Scholer.) Completed operation on an incomplete 
 Five sutures were employed. 
 
 thoracic). The irritation, from a focal point, travels 
 up the hypogastric plexus, the ovarian plexus and the 
 lateral chain of sympathetic ganglia to the abdominal 
 brain and thoracic plexus, which aids in disturbing 
 the visceral rhythm. Anatomic facts must be in- 
 spected. We find on each side of the uterus a large 
 ganglion, a massive collection of nerve- cells which 
 has been termed the cervico- uterine ganglion. We 
 may call it the pelvic brain. An enormous mass of 
 
124 
 
 THE VAGINA AND PERINEUM; 
 
 nerve-cells — the abdominal brain — is found at the root 
 of the celiac axis, just behind the stomach. Three 
 great ganglionic masses of nerve-cells are found in 
 the neck (superior, inferior and middle cervical gan- 
 glia), and a vast, intricate network of nerves in the 
 heart — Wrisberg's plexus. Each of these large gan- 
 glionic nerve masses is in intimate and close commu- 
 
 Fig. 55.— (Robinson-Scholer.) First stage of Dr. Emmet's operation, 
 ■via. : Denudation of the posterior vaginal wall ; denudation of a triangle 
 in each sulci of the vagina, with the noted method of his peculiar suturing. 
 
 nication with the genital organs. Many strands of 
 nerves connect each ganglion with the pelvic viscera. 
 It is the numerous nerve strands which play the 
 important role, because many strands, tracts, will carry 
 many messages, and a few ganglion cells can take 
 care of innumerable peripheral reports. A few gan- 
 glion cells will receive and dispose of many messages 
 from many lines. Now the ganglion cells — the tho- 
 
HOW TO MEND THEM. 
 
 125 
 
 racic, abdomiDal and pelvic brains — assume a certain 
 control over the rhythm of their respective viscera. 
 Hence the viscus which is the most intimately con- 
 nected to those three brains by many nerve strands 
 will exercise significant power over the rhythm of the 
 organs. One of the chief functions of a viscus is 
 rhythm. If this be disturbed the organ becomes 
 defective and fails in its final object. 
 
 Pig. 56. — (Robinson-Scholer.) Another stage, in which the triangle in 
 the right vaginal sulcus is closed with two sutures ; sutures in position. 
 
 Let it be remembered that the irritation from a dis- 
 eased organ is emitted at all times, without regard to 
 physiologic rhythm by which the organ accomplishes 
 its mode of life. The occasion of rhythm is the nat- 
 ural stimulus of an organ, as food for the digestive 
 tract, air for the lungs, blood on the endocardium, 
 urine in the urinary tract, a fetus in the uterus, fluids 
 in the Fallopian tubes, and food material in the liver, 
 
126 
 
 THE VAGINA AND PERINEUM; 
 
 carried to it by the portal vein. If we follow a dis- 
 eased message emitted from the pathologic genitals 
 up to the abdominal brain over the lateral chain — the 
 hypogastric ovarian plexus — where it is reorganized 
 and emitted to the digestive tract, we may observe 
 the following disturbances: Excessive secretion in 
 the digestive traci; deficient secretion; disproportion- 
 ate secretion. Excessive secretion may induce diarrhea; 
 
 Fig. 57.— (Eobinson-Scholer.) The two denuded triangles closed by 
 sutures ; the remaining sutures in situ. 
 
 deficient secretion, constipation; and disproportionate 
 secretion may produce fermentation (bloating); the 
 continuation of such reflex factors institutes indiges- 
 tion. The reflex irritation, passing from the diseased 
 genitals to the abdominal brain, is reorganized and 
 transmitted to the liver over the hepatic plexus. This 
 pathologic irritation produces excessive, dispropor- 
 
HOW TO MEND THEM. 
 
 127 
 
 tionate or deficient secretion in the liver. The liver 
 secretes bile, glycogen and urea. It has a rhythm, just 
 as the heart or lungs. 
 
 The transmission of pathologic irritation — reflex 
 irritation — to the liver unbalances its rhythm and dis- 
 turbs its secretion. If the rhythm of any organ be 
 disturbed its function will soon become defective. 
 For example, the rhythm of the small intestines is 
 
 Fig. 58.— (Robinson-Scholer.) Operation finished. The Y-shaped line 
 shows the line of suturing. 
 
 governed by the superior mesenteric ganglion, which 
 induces a rhythm four to six times daily, according 
 to food indigestion. Improper foods, disturbing the 
 regular rhythm, soon induce indigestion. The de- 
 scending colon, sigmoid and rectum (the fecal reser- 
 voir) is controlled by the inferior mesenteric ganglion, 
 which makes a daily rhythm. The superior mesen- 
 
128 THE VAGINA AND PERINEUM; 
 
 terio ganglion has a four- to six-hour rhythm, while 
 the inferior mesenteric ganglion has a 24-hour rhythm. 
 Any one knows that disturbing the rhythm causes 
 constipation, and eventually many neurotic symptoms 
 arise. Long-continued indigestion produces malnu- 
 trition. Pathologic irritation passes to viscera at all 
 and any times, in season and out of season, day and 
 night, while organs are attempting to rest or to pass 
 through a rhythm, always causing disturbances. Or- 
 gans secure rest and repair between rhythms. 
 
 Malnutrition is followed by anemia — a disproportion 
 between the blood-vessels and plasm. Long continued 
 anemia is followed by neurosis. The numerous gan- 
 glia are bathed in waste-laden and irritating blood. 
 Innumerable local and distant neurasthenic conditions 
 are manifest. We have, then, as a train of evil symp- 
 
 Fig. 59.— Author's perineorrhaphy needle. 
 
 toms following genital defects: 1, local irritation — an 
 infection atrium; 2, reflex irritation to the abdominal 
 brain, where it is reorganized and sent out to the 
 various viscera; 3, indigestion and malnutrition; 4, 
 anemia; and 5, neurosis. 
 
 In the incomplete cases of laceration the disturbance 
 is attributed to gaping of the vulva and the consequent 
 favoring of rectocele and cystocele. This condition 
 is followed by uterine prolapse, endometritis and met- 
 ritis. The patient suffers from ill-defined pains while 
 standing and walking. These patients complain in a 
 manner similar to that of those who are afflicted with 
 enteroptosis. When the lacerations become complete, 
 not only a physical defect of control of feces and gas 
 exists, but a train of mental symptoms follow com- 
 plete lacerations or serious lesions and gravely affect 
 
HOW TO MEND THEM. 129 
 
 life, both physically and mentally. The patient is 
 easily fatigued, neurotic constantly, liable to exacer- 
 bation of infectious processes. 
 
 One of the most unfortunate results of extensive 
 laceration of the rectovaginal septum is diarrhea. 
 When the sphincter muscles have been so far drawn 
 apart at the ends that they are almost a straight line, 
 the rectum has lost all control of feces. A straight 
 sphincter is a symptom of complete laceration; the 
 diarrhea accompanying the straight sphincter is very 
 exhausting. The amount of separation in the sphinc- 
 ter muscle tells the story of the degree of laceration. 
 When one can find the deep dimples in the skin, on 
 each side of the gaping vulva, due to the cicatricial 
 ends of the muscular bundles contracting, it may be 
 estimated that the vaginal sphincter is extremely de- 
 fective and that over half of its arc is wide open. 
 Only a carefully planned operation can relieve this 
 condition. The widely gaping vulva is exposed to 
 much trauma and consequent infectious processes. 
 The congested genitals and rectum produce excessive 
 glandular secretion, which furnishes a culture medium 
 not only to the pathogenic bacteria, but tends to mul- 
 tiply the regular residents of this locality into exces- 
 sive number, and in all probability dangerous kinds, 
 for doubtless bacteria rapidly change from one kind 
 to another by change of food and temperature. It 
 would be strange indeed 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 
 toxins, which become absorbed and carried away by 
 the veins and lymphatics. The rectal veins are known 
 to stand in direct communication with the liver by 
 way of the valveless portal system. Hence may be 
 observed the vicious circle established by the defec- 
 tive sphincter apparatus of the vagina. Again, con- 
 
130 THE VAGINA AND PERINEUM 
 
 sider the innumerable reflexes which must necessarily 
 arise from the infected, frequently congested, occa- 
 sionally acute, inflammatory invasions of the genito- 
 rectal organs. These reflexes arise in all degrees and 
 conditions, and the patient almost imperceptibly 
 passes through the stages of indigestion, malnutri- 
 tion, anemia and neurosis. Again, many of these 
 patients are operated on by inexperienced surgeons, 
 with consequent imperfect results. Then a conflict 
 of opinion arises as to the perineal defect being the 
 cause of the trouble or whether the etiology is to be 
 located in the nervous system, for one of the evils of 
 today is the confounding of nervous and genital dis- 
 eases. After an imperfect operation on the genitals, 
 with a consequent imperfect result, the operator is 
 liable to throw the whole defect on the nervous sys- 
 tem. As the nervous system and the liver are the 
 chief scapegoats of ignorance (and knavery) it is 
 difficult to demonstrate the error. It requires wisdom, 
 knowledge and experience to discriminate between 
 genital diseases and their consequent train of neurotic 
 effects, and the diseases which definitely belong to the 
 nervous system itself or to other causes than the gen- 
 itals. I must insist, however, that this requires more 
 time and skill than any general surgeon or physician 
 is able to give. 
 
 Until one comprehends the practical anatomy, it is 
 almost impossible to interpret the rational symptoms 
 of the deficiency of the supports of the sexual organs. 
 The popular view of general physicians that the peri- 
 neal body is the chief support is one illusion which 
 I find, after considerable experience in teaching, diffi- 
 cult to eradicate. It is the indefensible mechanical 
 theory that the perineal body is the keystone, the cork 
 which stops the bottle, or the wedge which plugs up 
 the pelvic outlet. Unfortunately, a prominent Ameri- 
 can gjrnecologist at one time abetted this false theory. 
 
HOW TO MEND THEM/ . 131 
 
 One of the very common diseases accompanying 
 perineal lacerations is endometritis. Little need be 
 said to defend or explain this condition, for it is evi- 
 dent to all observers how the endometrium may be 
 insulted by trauma, congestion and bacterial invasion, 
 when unduly exposed from deficient support. Exces- 
 sive glandular secretion arises; leucorrhea, which may 
 be non-infective, then pathogenic infection soon fol- 
 lows with its consequent train of evils. 
 
 This leads me to a subject of vast importance. It 
 is the metritis (subinvolution) which so frequently 
 accompanies laceration of the perineum. The general 
 practitioner calls it subinvolution. But we will call 
 it metritis, because we believe it to be of microbic 
 origin. Be it remembered, the uterus above all organs 
 is liable to infection, because its glands pass directly 
 into its muscular walls. It has no submucous layer 
 or barrier to protect the muscle. The intestine has a 
 submucous muscular layer which acts like a barrier 
 against microbe invasion. But the uterus has no 
 muscularis mucosae. It has no barrier between its 
 glandular apparatus and its muscular apparatus, so 
 that microbes or their products which gain the uterine 
 glands soon gain the muscular walls of the uterus 
 and produce metritis. Hence metritis is one of the 
 frequent accompaniments of perineal laceration, and 
 as metritis is a very chronic disease, it is apt to con- 
 tinue even beyond the repair of the perineal injury. 
 
 From this short view it may be observed that the 
 rational symptoms of injuries to the pelvic floor are 
 generally a train of evils which increase with time, and 
 the final brunt is most apparent in the nervous sys- 
 tem. Many of the symptoms can only be accounted 
 for by carefully noting the many cases of invisible 
 lacerations — the relaxed pelvic floors, perineal supports 
 and sphincter vagina apparatus — which disturbes cir- 
 culation by the vessels being torn from their proper 
 
132 THE VAGINA AND PERINEUM; 
 
 fascial beds, the veins becoming elongated, dilated, 
 straight, and losing their normal spiral form, and the 
 nerves being put on the stretch or traumatized. 
 
 We thus have disturbed vascularization; conges- 
 tions and decongestions of blood and lymph have also 
 disturbed innervation from traumatized nerves. En- 
 teroptosis exists and the avenues of infection are 
 widely exposed. The supports of the pelvic floor have 
 been overstretched by one or more labors and have 
 not resumed their normal integrity. On examining 
 such patients, as Schatz points out, the normal anal 
 cleft is flattened out, the dent and furrow becomes 
 broad and shallow and the anus, instead of being 
 drawn up under the pubic arch, appears flat, exposed, 
 and fallen back toward the coccyx. The skin peri- 
 neum may be much larger than normal, being over- 
 stretched. The finger introduced into the vagina no 
 more feels the rigid levator ani muscle loop, but in its 
 stead the relaxed, overstretched, flabby tissues lying 
 between the gap made by the separation of the leva- 
 tor ani fascia 'superior and inferior with its contained 
 muscle in various degrees. Perhaps there is no lesion 
 more overlooked in the pelvic floor by the general 
 practitioner than the relaxed, overstretched outlet. In 
 1883 Emmet and Schatz first" clearly announced their 
 views in regard to relaxed pelvic outlet. The very 
 deep perineum is deficient, while the shallow, short 
 one is the vigorous one. The patient with relaxed 
 pelvic outlet generally begins to complain of bearing- 
 down symptoms on rising from bed some two or three 
 weeks after labor. She feels weak, unable to work or 
 exert herself, pain in the back, general lassitude and 
 prostration. 
 
 The relaxed pelvic floor is most impressive to the 
 operator, by examination before and after the anes- 
 thetic, when he is about to operate. Before the anes- 
 thetic the pelvic outlet is held in partial tension by 
 
HOW TO MEND THEM. 133 
 
 the remnants of the muscular and fascial supports; 
 the loops of the levator ani muscle being irritated by 
 the non-balance of parts being torn, the patient is 
 constantly losing nerve force by the attempts of the 
 reflex irritation in keeping up the tension. When the 
 patient is fully anesthetized 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- 
 nificant defect exists, beyond his expectation, in the 
 sexual apparatus. The perineum falls back, the anus 
 flattens and everts, the vaginal walls roll outward, and 
 the deep anal furrow assumes a plane approximating 
 that of the buttocks. Vast changes in subcutaneous 
 and submucous supports have occurred, capable of 
 being repaired only by an operation which restores 
 vessels to a stable bed, nerves to a protected sheath, 
 and organs to a position which will insure normal 
 circulation and innervation — in short, proper nour- 
 ishment. With such patients in the erect posture the 
 intra-abdominal pressure is continually displacing the 
 viscera by forcing them into and through the weak- 
 ened pelvic outlet. The pelvic outlet, beyond the 
 normal floor is full of prolapsing organs which often 
 deceive the practitioner by closing up the gap. 
 
 The length of time allowed to relapse between the 
 injury and the operation on the perineum should not 
 be less than three months. The parts do not heal 
 well shortly after labor. Old gynecologists, as Byf ord, 
 recommended at least six months to elapse before the 
 operation should be performed. Perhaps four months 
 after injury it would be fairly safe to operate. The 
 old cicatrix can not always readily be found, but by 
 pulling on the vagina in various directions the puck- 
 ering tissue about the scar will be discovered. The 
 palpating finger may also find it. 
 
 The cicatrix produces new points for the attach- 
 ment of the torn fibers of the levator ani muscles 
 
134 THE VAGINA AND PERINEUM; 
 
 which may give the outlet a peculiar, irregular, puck- 
 ered appearance when the muscular bundles contract 
 from their new points of attachments. The flap for- 
 mation should extend beyond the cicatrices so that 
 the ends of the muscular bundles may be included in 
 the sutures. The time for operation should be mid- 
 way between the menstrual periods. 
 
 In regard to the perineal body : The posterior curve 
 of the vagina must be reproduced by restoring the 
 rectovaginal septum. 
 
 A new perineal body should be restored, so that the 
 natural backward curve of the vagina should persist, 
 i.e., normal relations should be established between 
 the perineal center of body on the one hand and fas- 
 cia on the other. The perineal body, the punotum 
 fixum of vulvar surface relations, should be restored. 
 
 In writing this essay I have derived aids and sug- 
 gestions from all accessible authors and have at- 
 tempted to duly credit the labors. 
 
 Some suggestions were acquired in regard to draw- 
 ings from the book of W. J. Stewart McKay. 
 
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