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draw the vaginal flaps snugly over the cervical stump like the cover on a ball.

Emmet's operation on the posterior vaginal wall was of. more gradual evolution, but the later operation devised in 1876 does not differ materially from the old trefoil denudation. It must be asserted that Emmet was the first operator to include the rectocele, or indeed any portion of the posterior wall of the vagina, in the operation for laceration of the perineum, so-called. Then, the multifarious operations devised for repairing the pelvic floor or vaginal outlet which include the posterior walls of the vagina are but modifications of his operation. The misconception of the operation for laceration of the perineum, so-called, consists in 1, misconception relative to the exact nature and pathology of the injury; 2, the almost insurmountable difficulty in depicting the operation by diagrams, and 3, the impotence of word description in giving precise directions for its exact performance. The first of these hindrances I consider the gravest, and attributable to popular ideas of the perineal body which Emmet describes as a body that does not exist. The essential lesion in injuries to the pelvic floor is a tear of the pelvic fascia which runs along the lateral sulci of the vagina to which it is attached. The tear occurs where it is reflected upon the front of the perineal muscles, of which it forms the sheath and which it binds together. This condition exists in the tears, indicated by the transverse scar, rectocele and relaxed vaginal outlet commonly seen in the injury incorrectly designated as laceration of the perineum, but more accurately termed laceration. of posterior vaginal wall. Destruction of the integrity of the pelvic fascia is the sole pathology. The sense of bearing down characteristic of this condition is caused by the congestion of the blood vessels consequent upon the lack of support, through the above-mentioned injury to the pelvic fascia, which in its support of the blood vessels has been likened to the trellis supporting the grapevine." The seeming destruction of the perineal body is really only the retraction of the levator ani muscle, which from the loss of support from its sheath, the fascia, is pulled apart by the transversus perinei muscles, like two leaflets of a window curtain separ

ated at the bottom while they remain attached above. The two-fold function of this muscle, to close the vulval cleft during defecation and to assist the dilatation of the sphincter ani, being lost, each stool thus finds an imperfectly dilated sphincter, an unclosed vaginal orifice, a weakened recto-vaginal septum, a convex rectal curve, all of which predispose to rectocele. The constant eversion of this rectocele by defecation, under the circumstances above enumerated, pull down on the cervical attachment of the posterior vaginal wall, predisposing to retro-displacement, which is the first step toward descensus. That the destruction of the pelvic fascia is the essential cause of rectocele, which in turn produces consecutive prolapsus, is proven by the fact that women who have true laceration of the perineum, i. e., complete tear through the sphincter and the recto-vaginal septum, do not have prolapsus. The uterus is not supported by the perineum, as formerly taught, but "is swung from above, like all other organs in the body." These women do not have the bearing down found in the class with transverse tears and the laceration of the pelvic fascia. They do not suffer any discomfort whatever, except from incontinence. The reason of all this is because in the central, complete tears referred to, the fascia is not or cannot be involved. This is the inevitable logical conclusion.

The mechanics and pathology of the results of injuries to the floor of the pelvis may be summarized by the comprehensive reply of a student whom I asked: "Why doesn't a woman with complete laceration of the perineum have prolapsus?" He replied ingeniously: "Because she has no rectocele." Why has she no rectocele?" "Because the pelvic fascia is


not torn."

The converse of these propositions is of course true, and these brief statements comprise much of the unwritten mechanics of many displacements as well as the essential pathology of laceration of the pelvic floor.

The rational correction of this complex condition then would not be not to sew the labia together, which is the popular procedure in one class of operations, nor to denude an arbitrary area of fanciful shape on the rectocele and bring the edges of

the raw patch together, after the fashion of another class. It would rather be in the language of Emmet "to catch up the retracted pelvic fascia at such a point and in such a manner as to take in the slack,' as it were, of the fascia throughout the pelvis. By this procedure the displaced posterior vaginal wall is certainly lifted up and drawn forward in contact with the vesico-vaginal septum. As the steps of the operation advance the displaced anus is lifted upward and forward, the everted tissues at the vaginal outlet gradually rolled in, and the separated levator ani muscles brought together."

I shall not attempt a detailed description of the technique, because I realize the futility of conveying a composite idea of the method, which, to be properly understood, must be seen, preferably at the hands of the venerable Emmet himself. I am not unmindful that this good fortune has been enjoyed by many present. I will simply accentuate a few of the essen

tial features.

Based upon the conception of the injury outlined in the foregoing, the first and important step is to determine that point on the rectocele, which, when drawn down by a tenaculum, will present a triangular, trowel-shaped area, marked laterally by two folds which lead up to fixed points in the lateral sulci, which mark the limit of retraction of the fascia. If this is not determined with precision it is obvious that any attempt at reuniting the sundered and retracted fascia, thereby restoring the equilibrium of the circulation in the pelvis and drawing together the separated levator muscles, will fail, and the whole object of the operation be defeated.

This tongue-shaped portion of the posterior wall of the vagina, when drawn down, will constitute the new posterior vaginal wall, because the denudation will include that part of the rectocele marked laterally by the lowest caruncle and below by the junction of mucous membrane and skin, extending above into each lateral sulci to the triangular fixed points. before referred to as indicating the extent of retraction of the fascia. The denuded area, diagrammatically speaking, would correspond to the space between the straight lateral and oblique middle legs of the letter M, the ends of the lateral legs being connected by an exaggerated semicircle. The space above

and between the two oblique middle bars of the letter M would correspond to the undenuded tongue-shaped portion of the rectocele; the angle formed by the junction of the outer and middle legs would correspond with the fixed point, and the outer bars to the limit of retraction of the pelvic fascia, as previously determined. The semicircle connecting the lower ends of the letter would designate the junction of skin and mucous membrane.

The sutures that unite the two lateral triangles, and thus catch up the retracted fascia, are introduced in the shape of an inverted triangle, the basic points corresponding to the points of insertion and final exit at the edges of the denudation, and the apical point being in the center of the denuded triangle, at the point of first exit and reëntrance of the suture, where it changes direction. The sutures underneath the semicircular denudation pass transversely across the area, the first or "crown stitch" transversing the tip of the undenuded triangle. When the two sets of lateral sulci sutures are shouldered and twisted, they not only approximate the edges of the lateral triangles, but at the same time draw up and in the underlying tissues previously everted and displaced. The transverse sutures which draw together the levators when tightened, draw the circular edges of the denudation into a linear line of approximation. It will be noticed that this entire operation is on the posterior vaginal wall, and hence Emmet's name for it. It has not involved the skin or labia, and the sutures are all inside. So perfect and secure is this approximation that I have frequently seen Emmet turn the patient on her side, and for the purpose of demonstration, introduce a Sims speculum and retract the perineum without the slightest disturbance to the newly-constructed vaginal wall, and in no wise marring the perfection of the result.

The operation for complete laceration through the sphincter, is more amenable to pictorial description, and I think is more generally understood. It is the simplest and most beautiful of all the operations for this injury. In its simplicity consists its beauty, and as it is solely instituted for the restoration of the sundered ends and broken circumference of that muscle, no mutilating and arbitrary flap-splitting is done, but the ends,

infallibly lying under the two dimples, are lifted up, laid bare with scissors and united by a suture going behind the sphincter end, and drawing the straightened and retracted sphincter into a circle again. The margins of the recto-vaginal septum are freshened and approximated. It has always been the custom of Dr. Emmet to introduce the cleft sutures before the ones to bring the sphincter together. To show the remarkable versatility of this master plastic mechanic: On a certain occasion, when some of the most distinguished men of two continents were at his clinic, he deliberately reversed the plan of a lifetime and introduced the sphincter suture first. He advised those of us who were assisting him to adopt that practice. I do not know that he has ever publicly recommended that modification, but I take the liberty of repeating his suggestion.

Of the operation on the anterior wall I will not speak at this time, nor of his inimitable work in making an artificial urethra. This is an acme of adroitness that we cannot hope to duplicate, and fortunately the occasion for its employment is exceedingly infrequent.

I cannot refrain from decrying the too general practice of substituting other suture material for silver wire in the cervix and vaginal walls. This innovation in plastic work is due to the invasion of gynecological territory by general surgeons, who are just emerging from the use of silk as a universal suture material, and adopting silkwormgut for use in all localities where it can be removed. The general practitioner also essays plastic work, bringing to bear the results of his restricted experience in sewing up skin and scalp wounds.

The newer school of gynecologists, who are unacquainted with some of the older and good methods, are applying catgut sutures to the cervix to avoid the trouble of removing them, and also trusting them in the most awkwardly situated region of the body to protect from infection, the perineum. The non-use of silver wire is perhaps as much responsible for failure in plastic work as nearly any other factor. It is the only suture that can be precisely controlled in the degree of tightness, and indeed it can, if accurately bent or "shouldered" where it crosses the line of proposed approximation, be made

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