A strong and contracting levator is responsible for many cases of detention of the after-coming head. The body having been delivered, the muscle contracts around the neck, retaining the head, to the extreme hazard of the child.
Budin reports a case. The body was delivered, after much delay, by the aid of Ergot, traction and expressio-foetus. Forceps finally delivered the head without lacerating the perinaeum, but the levator was badly torn. No sutures were used, and the result was entire loss of power in the levator muscle.
Cases of most aggravated obstruction have been reported as the result of extreme thickening and shortening of the levator.
Benicke reports a case where such muscular changes had taken place, as the result of long-continued vaginismus and contraction, that forceps, under chloroform, were unavailing, and craniotomy was restored to. Cases of this kind must be rare.
The levator may present abnormalities in the shape of irregular thickening of the muscles, presenting constrictions like tendinous bands.
Revillout speaks of a case where a ring or bridle was found within the vagina which prevented the application of forceps. Believing the obstruction to be a band of cicatricial tissue, it was incised. The autopsy showed that it was the levator. She had suffered from extreme vaginismus.
A case, unique, as far as I can learn, occurred in my practice. Mrs. S-, age 39; primipara. Just within the vagina was one, and a little farther up a second sharply-defined, constricting cord. They were like two puckering strings, firm and unyielding. The vagina seemed gathered in folds upon them, but otherwise normal in texture and yielding. Digital examination was not only painful to the patient, but made her peculiarly nervous. The constriction was not so great as to in the least interfere with the introduction of the finger, but even slight pressure upon those constricting bands was unbearable.
Other than this, labor progressed normally until the head entered the pelvic canal and began to press upon the supper constricting band, when, in the midst of a pain, without warning, she went into a violent convulsion. With the aid of ether and forceps the delivery was speedily accomplished, with no subsequent convulsions. The perinaeum was ruptured to the anus, the irregular tear extending up the vagina past the site of the upper ring. Sutures were used, but how near the repair put the parts in a normal condition I cannot say, never having her under my care since. Some two years afterwards, is a distant city, she was delivered of a still-born child, after a hard labor, but without any convulsions.
Lesions of the levator are of frequent occurrence, and are often overlooked at the time, since they are within the vaginal canal, and the cutaneous perinaeum may show no signs of injury, or the laceration may extend through the perinaeum and up the vaginal canal. A careful examination will show that beyond the perinaeum the laceration is more or less ragged, and irregular and deflects to the right or left of the median line. When we consider how the levator is reinforced by the intervening rectal walls and the peculiar interweaving of the longitudinal rectal muscular fibres with portions of the levator, we see that the most vulnerable part of the levator must be just before it reaches this adjunct of strength.
This fact makes repair less liable to be perfect, as the deep sulci so often found on one or other latero-posterior vaginal wall proves. In fact, except the band of fibres-unusually small and unimportant-that crosses diagonally the larger belly of the levator arising from the pubic ramus, it is anatomically self-evident that the levator will not be torn at the median line. The torn muscle retracts, and if discovered at the time of injury, it is not an easy matter to so close the wound as to bring the ends of the lacerated muscle in perfect adaptation, which certainly should be done. If neglected, we have a pocket for the collecting of septic matter, which even the free use of the vaginal douche may not remove.
If left to heal by slow granulation, it is usually with a partial or complete loss of power in the levator. Sometimes there remains a cicatrix that is specially sensitive, some nerve filament being so incarcerated in it as to be in a constantly sensitive condition. This may be revealed to the patient and physician only by the educated touch of the examining finger, while it may have been a nidus, from whence had radiated neurotic and other troubles for months and other troubles for months and years.
Often, we believe, there is a concealed submucous laceration. There being no break of continuity in the mucous surface, the injury is only discovered by the sulcus caused by the retracted ends of muscles, and by the impaired function.
Not infrequently in suturing a lacerated perinaeum at the time of accident the wound is not brought together evenly and the torn muscle is distorted from its normal line. The circumstances attending the case and the absence of efficient assistants makes this result, while to be deplored, in a degree excusable as far as the medical attendant is concerned, and the wonder only is, that the results are generally so good. The gynaecologist must often come in and undo what has been imperfectly done.
Mrs.-, primipara, as the result of a tedious and difficult delivery, had complete rupture of the perinaeum and a portion of the recto-vaginal septum. Stitches were immediately inserted. For a few months there was a constant sense of pulling in the parts, especially in walking and in sitting down or rising from a chair. This she came to notice less and less. Haemorrhoids developed. Defecation was somewhat difficult and attended by discomfort in the anus. At the end of ten months coitus had become very painful and was soon unbearable. Nervous hysterical symptoms began to show themselves, and at the end of sixteen months from the date of delivery, when she came into my hands, she was physically and mentally in a most miserable condition.
Physical Examination.-Externally the perinaeum seemed fairly well restored with the exception that the vaginal commissure was drawn to the right of the median line. Pressure near the anus and near the os vagina caused a sharp lancinating pain. Within the vagina the perineal wall was a hard uneven cicatricial mass. A line of firm tissue, tensely drawn, extended form the right anterior to the left posterior wall of the vagina, and was there incorporated in the cicatrix.
It was evidently a portion of the levator ani, that in the suturing of the ragged wound had become misadjusted. It caused a partial occlusion of the vagina, and by constant traction upon the left vaginal wall produced a deviation of the commissure to the right. Pressure upon it caused a sharp pain to extend upwards into the pelvis and a sickening feeling in the epigastrium. There was a stricture of the anus, the anterior wall being hard cicatricial tissue. There was subinvolution, but otherwise the uterus was in normal condition.
Operation.-I dissected out the vaginal cicatrix, thoroughly releasing the misadjusted muscle. Removed sufficient mucous membrane so that when the raw surfaces were coaptated the normal wedgeshaped body of the perinaeum would be restored. The mucous membranes of the opposing sides were united with a continuous catgut suture, and the denuded surfaces were held in apposition by two deep catgut sutures within the vagina, and one silver suture introduced from the perineal surface and encompassing the whole field of operation.
The anus was dilated, the cicatrix removed and the healthy mucous membrane dissected up like a crescentic-shaped pocket, the deepest portion being about an inch, and but little at its juncture with the integument on either side of the anus. This flap of mucous membrane was then brought down over the size of the removed cicatrix and sutured to the integument. The result has proved satisfactory to patient and surgeon.
