[REPRINTED FROM THE NEW YORK JOURNAL OF GYNAECOLOGY 
AND OBSTETRICS FOR SEPTEMBER, 1893] 
PATHOLOGY AND TREATMENT 
OF 
INJURIES OF THE PELVIC FLOOR 
BY ALEXANDER J. C. SKENE, M. D. 
BROOKLYN, N. Y. 
NEW YORK 
ST UYVE S AN T PRESS 
! 54 AND 156 WEST TWENTY-SEVENTH STREET 
1893 [Reprinted from the New York Journal of Gynaecology and Obstetrics 
for September, 1893.] 
PATHOLOGY AND TREATMENT OF INJURIES OF THE, 
PELVIC FLOOR,1 
WITH SPECIAL REFERENCE TO SUBCUTANEOUS LACERATIONS OF THE 
LEVATOR ANI AND TRANSVERSUS PERINaEI MUSCLES AND 
THE FORMATION OF RECTOCELE. 
By Alexander J. C. Skene, M. D., 
Brooklyn, N. Y. 
I intend to add a few items to a subject that has already been 
elaborately treated by many writers. Such minor contributions as I 
have to offer could be soon made, were it not that in order to show 
the effect of the few touches which I propose to add to the original 
portraitures, abundantly presented in medical literature, it is necessary 
to reproduce in brief outline the portions which I desire to treat. 
The few facts which I have to present have been gathered during 
observations made from the standpoint of both physician and surgeon. 
In obstetric practice one has an opportunity to investigate lesions at 
1 Read before the The American Gynecological Society, May 17, 1893. 
This paper has already appeared among the original contributions both of 
the American Gynaecological Journal and The Annals of Gynaecology and Paediatry. 
Its author promised this journal the paper some time ago, and we assume that its 
appearance in the columns of our contemporaries, other than in abstract, is due to 
carelessness of Dr. Skene’s secretary or to the stenographer. We present with the 
paper reproductions of Dr. Dickinson’s excellent illustrations, and believe no further 
explanation is necessary for again publishing this valuable contribution. Alexander J. C. Skene, M. D. 
the time when they occur, while a surgeon has an opportunity to 
study the pathological changes which takes place subsequently. This 
method of investigation should lead to definite and accurate conclu- 
sions, provided the observer has clear views regarding the anatomy and 
function of the pelvic floor, the injuries of which are under con- 
sideration. 
Regarded as a mechanical structure the pelvic floor resembles 
a diaphragm composed of muscles and fascia which close the pelvic 
outlet. Its borders are attached to the bony walls of the pelvis, and 
it is held at its proper elevation by the levator ani muscle. Its mech- 
anism is based upon the principles of the suspension bridge, the 
anchorage being represented by the pelvic bones, the floor represent- 
ing the bridge and the levator ani muscle corresponding to the sus- 
taining cable. (See figure I.) To make sure of being understood, 
the following classification is offered for consideration, and criticism, 
if need be: 
FIG. I. 
All the injuries that are sustained by the pelvic floor are divided 
into two classes; first, those that occur in the median line of the floor 
and in a direction corresponding to the axis of the pelvis; and, second, 
those injuries which occuff'above the floor itself, transverse internal 
lacerations. The laceration in the median line occurs in various forms 
and degrees ; first, a solution of continuity of all the tissues extending 
from the posterior commissure to the sphincter ani; second, the same 
injury as the above plus laceration of the sphincter. These are the 
injuries which have been recognized for ages: to these I have added 
another which I have found during my investigations, viz., subcutaneous 
lacerations of the muscles and fascia in the median line, usually limited to Pathology and Treatment of Injuries of the Pelvic Floor. 
3 
the transversus perinaei muscle and fascia, but in rare cases involving 
the sphincter ani muscle. 
Years ago, when I first called attention to this subject, I was not 
aware that the sphincter ani was ever involved in this form of in- 
jury, but I have seen since then at least three cases in which the 
sphincter ani was lacerated completely while the integument and mu- 
cous membrane of the vagina remained uninjured. The evidences 
that my observations were correct are that there was incontinence, 
the integument on either side was depressed where the lower fibres of 
the retracted muscles had drawn it inwards, and the most careful ex- 
amination proved beyond a question that the integument had never 
been lacerated. I am aware of the fact that a complete laceration 
in the median line may unite by first intention leaving the sphincter 
ani ununited, and that the scar may be so faint as to be easily 
overlooked, but in the cases I have referred to I am positive from 
my own examination, and that of my associates, that no such injury 
to the integument ever occurred. Furthermore, I found in operating 
that when the integument was divided some thickening of the cellular 
tissue was apparent, due no doubt to a reparative exude which occurred 
at the time of the injury. I also found the ends of the muscle far 
apart, the lacerated ends being completely healed over by natural pro- 
cesses. In looking back I recall several more cases of this kind, but 
not having studied them with sufficient care, they are not available for 
my present purpose. 
Injuries of the second class, which are transverse, and have been 
described as internal lacerations, consist in laceration of the anterior 
fibres of the levator ani muscle and fascia, and this is usually attended 
with separation of the muscular layer of the vaginal wall from the 
pelvic floor. In some cases the laceration is complete, involving the 
mucous membrane as well as the muscular coat of the vagina, and in 
very rare cases the laceration reaches upwards and outwards as far as 
the laceration of the levator ani muscle extends, but as a rule the lacer- 
ation of the levator ani is subcutaneous, that is to say, not attended 
with laceration of the mucous membrane of the vaginal wall. The 
injury of this muscle I believe was first described in my early writing 
on the subject, but if this is an unjust claim on my part I shall be 
happy to have it corrected at this time. 
In regard to the pathology of complete lacerations in the median 
line, nothing need be said as the subject is familiar to those who have 
interest in the matter, excepting subcutaneous lacerations of the FIG. If. Pathology and Treatment of Injuries of the Pelvic Floor. 
5 
muscle and fascia. These escape notice at the time when they occur 
unless carefully looked for. They are easily detected however, by 
grasping the pelvic floor in the median line between the thumb and 
finger. By this manipulation it will be found that all the structures, 
except the mucous membrane of the vagina and integument, have been 
divided and retracted, and there is nothing left of the fascia and mus- 
cular structure in the median line excepting the sphincter ani muscle. 
The transverse internal laceration, when entirely confined to the 
muscular structures of the vagina and levator ani muscle, is not an 
easy lesion to detect owing to the fact that a similar condition is pro- 
duced by sagging of the pelvic floor, following delivery and temporary 
paralysis. 
The pathological changes which ultimately take place in the trans- 
verse lacerations are : A marked sagging of the pelvic floor, which in 
itself may be perfectly normal in structure. This sagging is apparent 
upon inspection, and as I have elsewhere pointed out, the diagnosis of 
this laceration is made from the fact that under stimulation the levator 
ani muscle fails to perform its function. The action of this muscle is 
to a large extent voluntary, and this voluntary power is lost and stimu- 
lation fails to call it into action. Of course the continuation of this 
sagging gives rise to or permits prolapsus of the vaginal walls, uterus 
and bladder. Rectocele is also said to follow in this injury, and pos- 
sibly it may in rare cases, but I am fully assured from careful observa- 
tion that the so-called rectocele is not a rectocele at all, but a prolapsus 
of the vaginal wall and a varicose condition of the veins lying between 
the vagina and the rectum just within or above the pelvic floor. This 
I have been able to demonstrate, in a vast majority of cases, by an 
examination which proved that there was no rectal diverticulum point- 
ing towards the vulva, and that pressure upon the so-called rectocele 
caused it to disappear as soon as the blood was pressed out of the 
enlarged veins. This is shown in figure 11. An argument which 
has been made against this by one of my friends, to whom I 
have explained my views on the subject, is that he has noticed 
in faecal accumulations the rectocele protruded through the vulva, 
especially on voluntary efforts being made to evacuate the rec- 
tum. This is offset by the fact that in most of such cases I have 
found that when the rectum is emptied its muscular walls contract and 
there is no diverticulum left. Of course the rectum loses its support 
when the levator ani muscle is lacerated, and is easily overdistended, 
and the distension must be towards the vagina and vulva, but is tem- FIG. 111. Pathology and Treatment of Injuries of the Pelvic Floor. 
7 
porary, not permanent, and hence not a rectocele. I may say further 
in reference to this form of injury that it is followed by pathological 
changes which give rise to more distressing symptoms than any other. 
It is in this form of injury that prolapsus more frequently occurs, not 
only of the uterus and vaginal walls, but also of the bladder; and there 
is greater liability than in any other injury to the formation of varicose 
veins around the lower portion of the vagina and rectum, which give 
rise to no small degree of suffering. In this injury, too, subinvolution 
of the vagina and uterus most frequently occurs. All this has been 
clearly pointed out by Dr. Emmet, and by him alone as far as I have 
been able to discover. More than that, I believe that there is in addi- 
tion to the subinvolution of the vagina a certain degree of areolar 
hyperlapsia, which accounts for the extraordinary thickening of the 
vaginal walls seen in this class; still more, if relief is not obtained there 
comes a time when atrophic changes of the vaginal walls take place 
which cause further changes in the venous circulation, and if the injury 
goes many years without repair, atrophy of the levator ani muscle 
occurs, and such changed structures become absolutely incurable by 
any method of operating. It is quite a number of years (sixteen or 
eighteen) since I called attention to the atrophic changes in the muscles 
which take place in cases of long standing, and though a certain 
amount of temporary relief is obtained by operating, prolapsus of all 
the pelvic organs recurs. 
I formerly believed that in connection with transverse lacerations 
a subcutaneous laceration very often occurred, but I am satisfied now, 
after more extended observation, that in place of a laceration there is a 
thinning out and absorption of the tissues in the median line which 
produces a condition similar to that of subcutaneous laceration. This 
absorption is brought about by the sagging of the pelvic floor which 
makes undue traction upon the transversus perinsei muscles and fascia 
and as the posterior wall becomes prolapsed additional pressure is 
made at that point, and hence the absorption or atrophy which takes 
place in the median line. This change of structure resembles in every 
particular the lesion of subcutaneous laceration, but it is only found in 
cases that have existed for a long time, in which there is marked pro- 
lapsus of the vaginal walls and, of course, great sagging of the entire 
pelvic floor. These facts in regard to pathology have a very important 
bearing upon the question of treatment, as will be noted further on. 
In laceration of all the tissues from the posterior commissure down 
to the sphincter ani muscle the scar tissue is the only pathological con- FIG. IV. Pathology and Treatment of Injuries of the Pelvic Floor. 
9 
dition which is found and that rarely gives rise, at least for a number 
of years, to any suffering, because if the levator ani and the bulbo-caver- 
nosus muscles are uninjured the remaining portion ,of the pelvic floor 
is brought forward and sufficiently closes the vulva to prevent pro- 
lapsus of the pelvic organs. 
In regard to complete laceration involving the sphincter ani, I 
accept in full the pathology and treatment as described by Emmet, 
especially the treatment. A word, however, may be said with refer- 
ence to certain changes which take place in subcutaneous laceration 
mentioned above. Immediately after it occurs it is easily detected, 
but after convalescence from confinement an examination will show an 
apparently sufficient pelvic floor, because the space between the 
divided ends of the muscles and fascia is filled in with an exudate 
which restores for the time-being the appearance of that ring or band 
which closes the vulva, and which has been called the perineal body, 
without any very good reason for the name. In a few months this 
exudate becomes absorbed and the pelvic floor at this point becomes 
thinned out and presents the physical signs to the touch that are 
present in the recent injury. See figure 111. There is in this form of 
injury a little more sagging in the middle portion of the pelvic floor 
than is found in complete laceration. 
Treatment. 
While one can easily understand that during the experimental 
stage of plastic surgery of the pelvic floor many different operations 
were practiced and commended by numerous surgeons, there is no 
reason for so many different ways of surgically treating injuries of the 
pelvic floor at this time. As there are certain definite lesions, and the 
object of surgery is to restore the injured structures to their original 
condition, or as near as art and science can do so, there should be, by 
this time, more definite agreement among operators regarding this 
branch of plastic surgery. Perhaps the diversity of opinion arises from 
the fact that the exact nature of the injuries and the changes of 
structure which subsequently occur are not clearly understood. It 
may be for some such reason that in this department of gynaecology 
there is such an extraordinary diversity in both theory and practice. 
I operate simply by removing the scar tissue, and in so doing vivify 
the ends of the muscles and fascia that have been divided, when, in the 
median line, injuries extend from the posterior commissure to, and 
include all the tissues of the pelvic floor at this point. The vaginal FIG. V. Pathology and Treatment of Injuries of the Pelvic Floor. 
wall which has been attached to the lower angle of the laceration is 
liberated and raised up so as to form the inner surface of the pelvic 
floor. The lateral surfaces are united with sutures, the upper two or 
three taking in the posterior surface of the vaginal wall, and uniting it 
to the inner surface of the pelvic floor. 
In complete laceration involving the sphincter ani, I follow closely 
the principles involved in the operation as laid down by Dr. Emmet. 
If in any way I differ from him in some of the minor details, such as 
using silk in place of silver sutures, it is simply because it is con- 
venient for me personally to do so, not with any disposition to try to 
improve upon what I conceive to be a perfect operation. This much 
of the treatment might be summed up in a sentence as follows, viz.: 
That in this class of injuries I follow the methods which appear to me 
to have resulted from the contributions of all the best operators from 
Baker Brown to Thomas Addis Emmet. 
I especially desire to call attention to subcutaneous laceration in 
the median line when it involves the fascia and transversus perinaei 
muscle alone. Laceration of the sphincter ani subcutaneously is so rare 
that it may be ommitted from the present consideration. The first 
stage in this operation is to make the incomplete laceration complete 
by dividing the integument from the posterior commissure down to the 
upper border of the sphincter ani, and any loose cellular tissue which 
may exist between the integument and the vaginal wall. If the termi- 
nation of the vaginal wall is drawn downwards towards the sphincter and 
there is prolapsus of the posterior vaginal wall, giving the conditions 
seen in figure 111, the vaginal wall is liberated below and separated from 
the cellular so that it can be raised up to the posterior commissure. 
Any thickened cellular tissue or exudate that is found in the wound is 
carefully trimmed out until the fascia and muscle on either side are 
reached. Quite often it is necessary to trim off some of the super- 
fluous integument which has been produced by stretching. The wound 
is then closed in the same way as a recent laceration is sutured, except- 
ing that the vaginal wall is caught in the upper sutures and united 
thereby to the pelvic floor as heretofore mentioned. This injury is the 
only one in which any kind of “flap-splitting” seems to be indicated or 
could possibly be of the slightest use in overcoming the injury. 
Treatment of the Tra?isverse or Internal Lacerations. 
Dr. Emmet was the first surgeon to devise an operation for the 
relief of this injury. I had for long observed and comprehended the FIG. VI. Pathology and Treatment of Injuries of the Pelvic Floor. 
transverse or internal injury but never conceived of any method of 
remedying it until I heard from Emmet. It is true that by supporting 
the pelvic floor during convalescence from confinement, in cases in 
which this injury had occurred, some effort to repair the injury by 
natural healing processes was made, and quite successfully in some, 
but when the injury persisted and the usual pathological changes 
developed in consequence of this injury, no operation that 1 had ever 
tried was really of any service in restoring the structures. As soon as 
Dr. Emmet gave to the profession his discoveries in this department 
I saw the great importance of his valuable contribution to this branch 
of pelvic surgery, and I began at once to practice the operation as best 
I could. I have found that it meets every indication most fully in cases 
of transverse internal laceration in which the pelvic floor itself is in per- 
fect condition. The operation is not adequate when the pelvic floor has 
sustained a subcutaneous laceration, or when atrophy has occurred in 
the median line from stretching, a common complication of the trans- 
verse laceration if permitted to exist for any great length of time. In 
these conditions I found it necessary to modify Dr. Emmet’s method 
of operating in order to obtain the results required. Moreover, I have 
obtained better results by treating the so-called rectocele somewhat 
differently from the. way in which it is treated by Dr. Emmet. 
Taking it for granted that all are familiar with Dr. Emmet’s opera- 
tion I need only state wherein I have presumed to deviate in some 
particulars from his methods. In Emmet’s operation we are directed 
to vivify the tissues up to the most prominent part of the rectocele, 
and then continue the vivifying upwards in the vagina on either side 
beyond the uppermost portion of the rectocele. No tissue is removed 
in the median line from the posterior commissure down towards the 
anus. So far as the lateral denudation in the vagina and suturing are 
concerned I follow the classical method. In the median line I remove 
only tissue enough to liberate the vaginal wall from the pelvic floor and 
then reflect it upwards and backwards. I then divide the tissues in 
the median line down to the sphincter ani muscle, or down to where I 
find muscular tissue and fascia; in other words, produce by incision a 
complete median laceration. The angles in the vagina are then 
brought together by the sutures down to the muscular tissue of the 
pelvic floor, that is, down to the bulbo-cavernosus and the ends of the 
transversus muscle on either side. The muscle, fascia and integument 
are then closed by sutures from below upwards ; the enlarged vessels 
and cellular tissue are then crowded backwards towards the rectum Alexander J. C. Skene, M. D. 
and the vaginal wall united to the floor of the pelvis with the sutures, 
which bring together the lateral edges of the pelvic floor. 
Figure IV shows the conditions before denudation. 
By this procedure the muscles and fascia in the median line are 
restored; the muscular wall of the vagina is attached to the pelvic 
floor as far back as the rectum and upwards to the posterior commis- 
sure. By this method the so-called rectocele is completely disposed 
of and the posterior wall is held downwards and backwards in its 
normal position ; in other words, made to resume its normal relations 
to the pelvic floor. (See figure V). 
Figure V after denudation. 
In this way the essential requisites are obtained : first, the central 
part of the floor is restored; the so-called rectocele is disposed ot 
without loss of vaginal tissue ; the normal relations of the vagina and 
pelvic floor are established, and the overdistended veins receive more 
support than can be offered by any other operation known to me. 
The veins should not be wounded if this can possibly be avoided, 
either while vivifying the tissues or introducing sutures. If by chance 
a vein is wounded it should be exsected, or the opening closed with a 
ligature. This guards the patient from phlebitis and extravasation. 
The veins can usually be avoided while suturing by separating them 
from the vaginal wall and pressing them downwards and backwards 
while passing the needle. In regard to the arteries which usually lie 
just beneath the vaginal wall, no harm comes from dividing them if 
they are ligated; in fact the closure of the arteries may be beneficial 
in lessening the blood supply during convalescence, thereby allowing 
the veins to regain their original calibre. 
In regard to the treatment of prolapsus of the bladder and vaginal 
walls caused by injuries of the pelvic floor, especially in cases of long 
standing, it appears that colporrhaphy on the vagina for the purpose of 
correcting such lesion is as a rule unsatisfactory, as it favors the pro- 
gress of atrophy and recurrence of the prolapsus. My attention was 
first called to this at a time when I did a large number of those opera- 
tions, adopting in order the operations of Sims, Emmet, Martin of 
London, and Noeggerath. In watching the after-results in many of 
those cases I have found that atrophy of the vagina progressed with 
unusual rapidity and the prolapsus returned. 
I believe that colporrhaphy is seldom resorted to at the present 
time, though it was quite in vogue a few years ago. Such treatment is 
unsatisfactory, excepting occasionally where in addition to the colpor- Pathology and Treatment of Injuries of the Pelvic Floor. 
rhaphy the injuries of the pelvic floor have been cured. In such cases 
the restoration of the perinseum would have accomplished the same 
object as well without as with the operation upon the vagina. This 
statement is not wholly based upon my own experience. Imperfect 
operating might be assigned as the cause of failure in my practice, but 
I have had an opportunity of examining a large number of patients 
operated upon by the highest surgical authorities of the age, and have 
found some failures among them also. At first, or immediately after 
operation, the success appears to be perfect, but as the atrophic changes 
go on in the vagina the scar tissue almost invariably gives way and the 
cystocele and prolapsus of the vaginal walls recur. 
It is now several years that I have endeavored to relieve prolapsus of 
the bladder and urethra by operating to reunite the severed muscle 
fibres and fascia to the subpubic ligament. This principle upon which 
the operation is based is the same as in Dr. Emmet’s operation for in- 
ternal lacerations, especially related to the posterior vaginal wall, and I 
find that the same principle can be applied in operating for the relief 
of prolapsus of the anterior vaginal wall and cystocele.