THREE is, probably, no branch of surgery that requires more thought, ingenuity, and operative dexterity, than do the plastic operations for the restoration of the pelvic structures in women. A study of the anatomy, physiology, natural and acquired relation of parts, immediate and remote effects of injury and their reflex influences, is essential to a correct understanding of the subject. When the pelvic floor is weakened by a repute of its supporting structures, the functions of all the pelvic organs are, more or less, disturbed, and, ultimately, the entire human organism may become affected.
The levator and muscles form the floor of the pelvis. They are two broad, thin muscles, which have their origin, principally from the posterior aspect of the and ramus of the pubes; posteriorly, from the inner surface of the spine of the ischium. They pass downward and unite in the middle line. The most posterior fibres are inserted into the sides of the coccygeal apex. The middle fibres, which form the bulk of the muscle, are inserted into the side of the rectum, blending with the sphincters.
The transverse perinaei arises from the inner side of the tuberosity of the ischium and is inserted into the sides of the sphincter vaginae and levator ani. These, in conjunction with other less important muscles, and the faciae, make up the perineal body. The levator ani, which constitutes the bulk of the perinaeum, supports the lower end of the rectum, the vagina, and the bladder. A rupture of these parts, such as often occurs during labor, disturbs the muscular equipoise of the region. The torn fibres separate, the transversus perinaei muscles, instead of holding the central raphe in a state of tension, pull open the vaginal orifice. The anus is drawn upwards and backwards, towards the coccyx. The fascia, having lost its attachments, allows the anterior rectal wall to pouch forward, forming a rectocele, which drags the vaginal wall downward.
The vaginal muscle which has its principal attachment to the rectovaginal fascia, loses its tonicity, permits the cervix to fall forward, changing the position of the uterus, which becomes more or less prolapsed, dragging down the bladder, preventing its entire evacuation, which causes increased relaxation and stretching of tissue, cystocele. The blood vessels having lost their support, a general venous stagnation, with its consequent engorgement of the pelvic viscera and discomfort, ensues.
The variety and complexity of vaginal and perineal tears is, indeed, surprising. It has always been my habit to make a careful inspection of the parts after every confinement, and, I believe that I have seen almost every form that could be produced. The orthodox central lesion is the most frequent, but not, by any means, the most injurious. Lateral internal vaginal ruptures, that are often made with the tip of the blade of the forcep when removing it, before the head is born, are among the most mischievous. I have seen these extend from near the cervix uteri to the vaginal orifice, the outside structures being intact, and so deep that the cellular fat protruded through the gap. A infrequent tear, of which I have seen three, is where the vaginal outlet is torn away from its attachments being pushed forward by the head; the mucous membrane gives way just within the orifice.
The most extensive one, extended upward on either side, almost to the urethra, and downward to the sphincter ani muscle, making a pocket-like chasm, in which the four fingers of the hand could be inserted. A small central laceration, though which the child’s shoulder emerged, existed, yet the sphincter was not torn. Another most significant lesion that is often overlooked, is where the muscular structures of the perinaeum are torn in two and the skin remains uninjured; these tears are often deep, from pockets for the retention of septic matter, do not unite but granulate, and form large cicatrices, and yield disastrous results to the pelvic viscera.
A rare condition that I once repaired, was an oblique laceration, one and one-half inches long, that existed well forward near the urethra. It bled furiously, and was difficult to close. I have repeatedly seen a submucous separation of the perineal structure where the mucous membrane of the vagina and the skin on the outside remained intact.
The power to prevent many of the severe disasters to the general health follow ruptures of the perinaeum and vagina, lies with the accoucheur. It is his imperative duty to make a critical examination of the genitalia after every labor, and if he finds any form of rupture, it matters not how insignificant it may seem to him, it may in some remote way produce trouble; therefore, it should be repaired before be leaves his patient. This should be done in the most systematic and painstaking way.
If necessary, an anaesthetic should be given. The genital tract and adjacent parts should be most carefully cleansed, and douched with an antiseptic lotion; the torn surfaces trimmed of all ragged and contused tissue, rendering the parts even and clean cut. The wound should then be closed with two sets of catgut sutures deep and superficial, coaptating like structure. Two much care cannot be exercised in doing the operation. It properly executed, the results are most satisfactory,and failure will rarely follow.
When a laceration has been sustained, and the evil consequences manifest themselves, the case then becomes one for the surgeon’s consideration, and the question that confronts him is, how can a restoration be accomplished; how can the over- distended and everted vaginal tissue be replaced, and the proper support given to the pelvic viscera and blood vessels? The relaxed tissue in front, that forms a cystocele, must be removed; the separated levator ani muscles must be brought together, the retracted pelvic fascia united so as to lift the posterior vaginal wall in contact with the anterior, obliterating the rectocele and closing the gaping vulva. When all this is successfully done, the normal support capillary circulation is relieved, the hyperplasiac deposits absorbed, the hypertrophied organs reduced and a healthy function restored.
The operator who does not fully appreciate the requirements of each case, and deal with it according to its individual demands, but simply endeavors to restore an imaginary perinaeum-a dam-like obstruction to the prolapsing structures-will meet with disappointment in almost every instance.
The time allotted to read a paper does not admit of my taking up the entire list of plastic operations upon the vulva and vagina; therefore I shall only attempt to deal with three, viz., Removal of scars, cystocele and perineal injuries.
It is an established truth with all close observers who treat diseases of women, that cicatrices of the vagina produce both local and reflex irritation, disorder the nervous system, and thereby, more or less, impair the entire bodily nutrition; and I will say here, for the benefit of those who oppose in immediate repair of vaginal and perineal lacerations, that it is bad surgery to leave any wound of those parts, whether it occurs during parturition or from other causes, to heal by granulation.
For aside from the ultimate injury that the pelvic viscera sustains, these reflex troubles may arise, and will yield to no treatment excepting the removal of the scar. Considering the above facts, amputation of the uterine cervix or operations about the vagina ought not to be performed with either the ecraseur or the galvano-cautery. The knife or the scissors should be used, and the demanded surfaces covered with mucous membrane.
These scars of the vagina demand serious attention at the hands of the surgeon; they should be managed with the same care accorded laceration of the cervix. All other or contracting cicatrices should or contracting cicatrices should be dissected away and the resulting wound closed with sutures. Remnants of a lacerated hymen and thickened and sensitive nymphae should be excised, excrescences about the meatus clipped away, adhesions of the clitoris broken up, and, if necessary, a V-shaped piece cut from its hood.
CYSTOCELE.-A cystocele is a pouching deformity of the anterior vaginal wall, caused by a laceration or an over- distension of the structures. It contains the base of the bladder, and is gradually increased by the frequent straining at micturition-an ineffectual effort to evacuate the urine that constantly remains therein. The constant irritation increases the vascularity and causes a thickening of the walls. The condition is one that entails great suffering and is often overlooked by operators. Like other conditions about the vagina that demand repair, many devices-some of them extremely complicated-have been instituted for its correction. Its successful management is simple enough if the requirements are fully understood. The object sought is to change the convex to a plain surface; take all the shack out of the anterior vaginal wall, but not shorten it to any great degree. No stereotyped or set rules can be laid down to govern beforehand the amount of tissue to be removed or to designate the shape of the denuded surface.
