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finger into the vagina and making a little pressure upon the posterior wall, in such a way as to excite contraction of these muscle fibers. In addition the anterior fibers of the levator ani perform another important function, by reason of their insertion into the point commonly known as the perineal body, which function is to draw up that portion of the floor of the pelvis in a similar manner and at the same time as the posterior fibers elevate the rectum and the sphincters of this viscus.
The important point, physiologically, in the pelvic floor is the point ordinarily spoken of as the perineal body, which really constitutes the junction of the various muscle structures we have just been mentioning. The function of this point of junction is not only to support the whole pelvic floor, but also to make a point or plane of resistance to peristaltic action. The curve of the rectum following the hollow of the sacrum tends to throw the force of the peristaltic wave directly against the anterior wall of the rectum just within the internal sphincter and tends to roll outwards the anterior wall, when the integrity of the perineal body, i. e., the point of junction of the various muscle structures, has been interfered with by injury. The resistance to this force is furnished normally by the junction of the vaginal sphincter with the external sphincter of the anus and with the transversus perinei muscles and the further union with the fibers of the deep transversus perinei muscles and with the anterior fibers from the levator ani.
Reference to the internal sphincter of the rectum has been omitted to this point, for the reason that the effect of injury to or rupture of this muscle is directly in contrast with that of injury to the other muscles of this region.
The laceration of the perineal body either to or through the external sphincter, without involving the internal sphincter, is followed by the formation of a rectocele and the dragging down of the internal pelvic viscera. While if the internal sphincter is also lacerated, the patient loses control over the evacuations, but the tendency to the formation of the rectocele and to prolapse of the pelvic viscera is not present.
The further important function which is under the control and dependent upon the junction of the group of muscles in the perineal body is the function of defecation. During this act the peristaltic wave from above assisted by the voluntary compression of the abdominal muscles, is further produced by a dragging upward of the rectum and the sphincters, the result of contraction of the fibers of the levator ani, the sphincter muscles being pulled open and peeled back, as it were. When the point of junction of the muscles in the perineal body has been destroyed, the result must be only partial and incomplete action of the levator ani and unsatisfactory emptying of the rectum.
It is considered unnecessary to discuss further the results of these injuries upon the pelvic viscera, such as dragging down of the bladder, interference with micturition, etc., the purpose being to select rather the more important features of disturbance of function with the idea of illustrating the observations which follow upon the methods of repair.
It is impossible to adopt any well defined or fixed rules in regard to the technique of the repair of lacerations of the perineum, other than such general principles as have already been suggested. Each case of injury is a law unto itself and the operation which will accomplish the purpose desired will have to be carefully adapted to the particular case. As illustrating the application of the principles which have been suggested and the technique of the general principles which would be utilized, the three different characters of lacerations will be selected, viz. :
First A laceration of the perineal body involving all of the structures down to the anal sphincters. This technique will apply similarly to lacerations of lesser degree.
Second-Lacerations including the sphincters of the bowel.
Third-A condition which is known as relaxation of the vagina and vulva and consisting not of injuries to mucous membrane or skin, but of the separation of the deeper structures during repeated labors.
In the first class of lacerations the initial incision should be
made as a rule at the anterior margin, that is, the external margin of the cicatrix, marking the extent of the laceration and at a point about the middle of the laceration, in the middle line of what would be the perineum. The incision should extend from this point along the margin of the cicatrix tissue up each labium to and above the last remaining myrtiform carbuncle; in other words, this incision should follow approximately the line of Tait in his initiatory incision, except that more attention should be paid in the usual cases to following the line of the margin of the cicatrix. In the unusual cases such an incision might invade the outer surface of the labium to too great extent; such cases, for instance, as in which there had been sloughing of the perineum and labium with loss of tissue, rather than simple separation of the parts. The incision should extend upwards on each side to the lowest remaining myrtiform carbuncle, or even just a little higher always, and should not be to the outer side of these structures, but end within these structures. This flap should be dissected from the vaginal floor with the scissors and finger, taking only the mucous membrane, which can be easily peeled up and should be separated from the tissues as high up in the vagina as the relaxation of the posterior vaginal wall seems to extend.
Comparatively little hemorrhage will be encountered and very little use will be had for either knife or scissors. The tissues exposed will be on each side immediately within the labia, the sphincter vaginæ superficially, with at their lower extremities the divided ends of the transversus perinei; more deep and careful dissection should demonstrate the deep transversus perinei and the anterior fibers of the levator ani. Such minute dissection, however, is not necessary in the ordinary operation. The first sutures, where there is much relaxation of the vagina, should be placed. high up underneath the vaginal flap in such a way as to catch on each side the anterior fibers of the levator ani and fibers of the deep transversus perinei. The needle can be passed into the tissues on the right side (of the operator) within the sphincter vaginæ not including that muscle, passed inwards, then across to
the opposite side, including the same tissues, back again on the right side and down on the opposite side, making a double suture drawn back and tied in such a way as to draw the tissues together. This suture should not include the sphincter vaginæ and would leave the vaginal flap still separated above from these tissues. After this first suture is tied and in position, another suture should be passed beyond the sphincter vagina on the right side, not including it, through the tissues of the right side of the pelvis, superficially then along the under surface of the mucous membrane so as to include the under surface of the vaginal flap, out through the tissues of the left side in a similar position and should be tied in such a way as to destroy dead space that might be created between the vaginal flap and the tissues brought together by the first suture. After these sutures are in place and tied to the satisfaction of the operator, a needle should be passed through the divided ends of the transversus perinei on the right, the needle not necessarily passing deep, only catching sufficient of the muscle to insure a firm hold, and pass the full length of the structures on this side of the vagina which were not included in the first suture, thence across to the other side and back out, including similar structures; the needle should then pass through the sphincter vaginæ of the right side, a little above the end of the transversus perinei and back out through the similar structures of the left side, making a double suture, which should approximate the parts and should be tied. The next suture should pass just within the mucous membrane through the tissues of the right side on a plane a little higher than the last suture through the sphincter vaginæ and should include all of the tissues upon that side of the wound of operation, should cross over to the left side and back out, emerging just beneath the edge of the mucous membrane. If necessary another suture of the same character should be introduced in order to approximate the edges of the incision in each labia. One of these sutures, not the first one, should include the under surface of the mucous membrane so as to draw it in apposition with the tissues beneath and in this way destroy the dead space that might be left.
The high suture should pass under the edge of the mucous membrane in the incision of the labia, underneath the tissues to the edge of the vaginal flap and should follow the margin of the vaginal flap through its whole length to emerge on the left side in a similar position. The effect of this suture will be to draw the edge of the vaginal flap as with a gathering string down close to the junction of the external incision, and if necessary for neater approximation the margin of the vaginal flap should be trimmed, but it should be left sufficiently long to make a covering from the vaginal side against the secretions from the vagina.
In the majority of instances the sutures which have been described will be sufficient to neatly and nicely approximate the margins of the incisions in the external labia, and when the operation is finished to this point there will remain externally only the line of approximation at the point of the new vestibule with the vaginal orifice narrowed until only the urethra is left in view. If the margin of the skin and mucous membranes along the line of approximation do not come together nicely, they should be brought together by a continuous subcutaneous suture of chromacized catgut or silkworm gut, or silver wire, which can be withdrawn after the parts have healed.
In the operation for complete laceration through the sphincter of the anus, it is important to note with great care the points at which the anal sphincter ends, which is usually marked above by cessation of the rugæ around the anal opening and by a slight dimple or pucker. The initial incision should start on each side at a convenient point above this end of the anal sphincter, about the level of the septum between the vagina and the rectum, the point being a matter of selection in each case. From this point the incision should follow the line of the septum separating the vaginal mucosa from the rectal mucosa or dividing the cicatricial tissue which lies between these two structures. From each external end of this incision an incision should be carried downwards and just to the inner side of the pucker produced by the end of the anal sphincter. The rectal portion of the flap should then