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MAY11 1896

[Read before the Montana State Medical Association, April, 1894.]

Since the introduction of antisepsis in surgical work, operations upon the human body have been wonderfully advanced in kind and number, because of the comparative immunity from fatal results, due to the perfection of a splendid technique based on scientific principles, and the mechanical ingenuity displayed by surgeons of the present day.

Although the methods of antisepsis announced by Lister have since been discarded by him and other surgeons, to him must be awarded the distinction of being the father of antiseptic surgery, on account of the discovery of which it has been possible to so widen the field of operations and perfect their mechanical execution that at the present day there is scarcely an ailment of the human body, susceptible of relief through surgical interference, that is not undertaken by the surgeon with a confidence in success that is displayed in no other field of medicine. Within the professional memory of many of you, such operations upon the brain as are now successfully made, resection and anastomosis of intestines, hysterectomy, operations for appendicitis, for hydro- and pyo-salpinx, and many others, were either unknown or only dreamed of as among the possibilities, while scores of other operations that had been practiced for many years yielded results that justified their performance, probably, but were quite inferior to those of the present time. Among the latter operations is one that has exercised the ingenuity of professional men for the past 250 years with indifferent results until within the past decade, when it has reached a stage of perfection that appears to leave not much, if anything, further to be desired. I refer to perineorrhaphy.

The first recorded operation for repair of the female perineum was done in 1649, by Dr. Guillemeau, a French surgeon. In the eighteenth century, La Motte, Smellie, Sancerotte and others advanced the operation. About fifty years ago Dieffen

bach, in Germany, published a method, the characteristic of which was a large denudation of the surfaces to be united, and in liberating incisions, to whic Roux, in France, added the quill suture. Langenbeck follows with a method called perineosynthesis, a combination of denudation and auto-plastic division, which gave rise to over a dozen slightly differing methods by Demarquay, Simon, Marc See, Hegar, Freund, Baker Brown, and others.

In 1855 Marion Sims added to the methods then in use the silver wire suture, and discarded the liberating incisions, which was an advanced step, by reason of the fact that stitch abscesses occurred less frequently than through the use of other sutures; but ultimate results remained the same as before, viz.: a mucous and cutaneous union, apparently repairing the wound, but in fact leaving a cul-de-sac at the posterior lower portion of the vagina, in which uterine and vaginal secretions lodged, causing vaginal irritation, and in the site of which rectocele developed, followed by a gaping vulva, a lessened depth of the anal orifice, with lax and unusual breadth of the perineum. The improvement following upon the operation speedily disappeared and the patient's condition was soon as bad as though no repair had been attempted.

In 1882 Emmet, in New York, appeared to be the first surgeon to comprehend the full pathology of the trouble, and devised an operation that should meet all the indications presented. In this he admirably succeeded, through what is called the clover-leaf denudation (the highest point reaching the crest of the rectocele in the vagina, and consequently the highest point of separation of fascia and muscular tissue), and the introduction of sutures so as to embrace and bring together the divided ends of muscle and fascia.

Results obtained by Emmet's method were so satisfactory that it was quite generally employed. If fair results were not had by all operators in the practice of Emmet's method, the fault probably rested with the operator, in not carrying out its details, which were somewhat complicated and required to be closely adhered to. Although Emmet's operation appeared to meet all the indications, one fault, that attended all the others, remained, viz.: A division of the mucous membrane within the vagina, through which secretions from the vagina, uterus and bladder might penetrate, causing failure of union either wholly or partially, with a resulting perineal fistula. Notwithstanding this it appeared that simplicity and effectiveness had reached their highest points until, in 1887, what is known as Tait's op

eration became generally known through the published description by Heiberg, of Copenhagen.

This operation, and modifications of it, is simplicity indeed, and can be made in a much shorter time than others, and, I believe, is quite generally used throughout the world.

I have practiced it in a number of cases, with uniformly good results. It is often called the flap-splitting operation, and its origin in Tait is questioned. According to Sanger, Tait was preceded by Voss, of Christiania. Dr. E. W. Jenks, of Detroit, Mich., claims to have made this operation many times, several years before it became known as Tait's.

To whomsoever the credit for first perfecting it may be due, is probably not so important as the fact that in it is a method enabling all physicians possessing ordinary surgical skill to afford relief, with a high degree of certainty, to large numbers of women in every locality, who would otherwise drag out a shortened, miserable existence.

It is not my purpose to enter into the etiology of lacerations of the perineum, nor to describe the operations for their repair, as all who may not be fully conversant therewith can get complete descriptions of these in any modern works on gynecology; but it may be of interest to study their pathology, symptomatology and diagnosis.

The perineum is a fibro-muscular body, at the base of which, between the skin and the mucous membrane of the vagina, is contained connective tissue and facia which encloses and gives support to the constrictor vaginæ, transversus perinei, levator ani and sphincter muscles of the anus, while on each side is found the bulbo-cavernosus, which should be avoided in perineorrhaphy, because of its great vascularity.

Perineal tears are generally divided into complete and incomplete, the former extending into and through one or both of the sphincter muscles of the anus, while the latter vary from a simple tear of the fourchette to a division of the perineum back to the sphincter ani. Lacerations dependent on childbirth assume various characteristics, the most common of which is a longitudinal tear through the mucous membrane of the vagina on each side of the median line, joined at their lower end by a transverse or crescentic tear, and connected with the external surface of the perineum by a division of the tissues below the cressent in the median line; nearly as frequent, is one lateral tear with one-half the transverse line of the former completed externally through the median line; often a lateral tear extending through the skin by the side of the anus without passing towards the median line, and sometimes the crescentic tear alone, wholly

within the vagina. At times there may be no solution of continuity of either the vaginal mucous membrane, or the skin, while a tear of underlying tissues, fascia and muscles takes place that involves as serious consequences as those that may be diag nosed by inspection.

It is generally held by gynecologists that the rational signs vary according to the extent of the laceration. This I cannot endorse, except that in complete lacerations there may be incontinuance of gas and faeces, not found in incomplete lacerations. In the latter form, even if the fascia or muscles are not torn, the ultimate results are apt to be as distressing as though a large rent existed. The symptoms may not follow so quickly, but they come as surely.

The perineal body in its integrity closes and protects the vagina from the atmosphere, from friction of the clothing; affords a support to the perineal muscles, and at the same time affords an inclined plane for the easy outlet of urine and vaginal secretions. When a laceration has taken place, even though superficial, a portion of perineal function is impaired; the blood vessels lose their tonicity, become enlarged and tortuous, and congestion occurs; the mucous membrane, because of impaired circulation and exposure to atmospheric air and friction of clothing, becomes œdematous and hypertrophied; the muscles, because of lack of support and consequent greater strain in performing their functions, gradually become relaxed and flabby, through which the rectal and vesical walls gradually protrude, and we have recto- and cysto-cele; prolapse of the vaginal wall gradually takes place from below upward; retroversion and prolapse of the uterus follows, and a cervical metritis results. I have seen these symptoms in a number of cases, and scarcely more could be seen were the perineum torn to the sphincter.

Subjective symptoms attendant upon lacerations are: illy defined pains in the lower portion of trunk, a localized boring or burning pain near lower end of spinal column, occipital headache, a feeling as though "The insides were coming down," incapability of exertion and oftentimes great difficulty in walking.

Much has been said and written in support of the contention that the perineal body is the principal support of the uterus. I believe that the uterus, like all other moveable organs of the body, is swung in position, the sacro-uterine ligaments being the main guy-ropes, and the peritoneum the suspending agent. But while the perineal body is not the principal support of the uterus, in its normal position, it is unquestionably one of its supports, as it is of the rectum, bladder and small intestines,