PROGRESSIVE RESISTANCE EXERCISE IN THE FUNCTIONAL RESTORATION OF THE PERINEAL MUSCLES Anxow H. Knom., MD., FACS, Los Anerues, Cau Moliywoud Preshyterion Hospital, Otmatead Memoria) Grom, NTENSIVE investigations and experiences of World War II, the necent studies of physiologists, and reseavel in infantile paralysis have greatly changed the methods of conserving and restoring skeletal masele Zunetion, This knowledge ltas not been applied to genital relaxation to appreciable extent, A. restudly of the problems of the Lax perineum in relation to modem eon- cepts of musclecell regeneration and function veveals that birth-eanal m eulature is especially responsive to an improved method of conserving and restoring funetion, ‘The process of childbearing, although ovdinarily eonsidered 2 normal phys- iologie function, is invariably attended by certain amount of injury to the tismes of the uterus, cexvis, vagina, and perineum, In the majority of women, healing takes place rapidly aud the structures ave quiekly restored to a state Which makes a repetition of the process possible. Never, however, do the organs original integrity of form and funetion, Modern advances in obstetries have led to a great reduetion in the loss of life associated with childbearing. Infection, hemorrhage, and toxemia, the three principal eauses of death in the partusient woman, claim fewer lives every year, and toward the accomplishment of this end obstetrie xeseareh has been, largely directed. It is not enough, however, merely to keep a woman alive; it is important to preserve for her the funetion of her reproductive system and to prevent injury 80 far as possille, in order that the involved organs may again eppre normal state. Althongh some in,juay is inevitable, the manney in whieh labor and delivery are eondueted and the way in which the patient is eared for in the postpartum state will in large measure de the extent and permaneney of that injury ‘Mechanism of Injury ‘The Aelivery of a child is possibile hecause the uterine and abdominal rauseles ean éxert a. Toree great euongh tu overcome the resistance of the birth eanol. An object approximately 10 exo, in diameter is gradually pushed through the cervis, which has an initial opening of only a few millimeters, and through the vagina, with its lumen of only a fow eeutimeters. Changes take place during tho cotirse of prognaiiey whielt propare these struetures for the dilatation whieh is necessary hefore the elild ean he delivered, ‘The tissues heeome progressively softer and more olastie, and, by the end of prognaney, the cervis i usually 0 altered that it becomes completely effaced and dilated ‘and permits the passaye Of the infin withont undue strain, ‘The muscles of the porngum aro Joss adequately prepared, and when the presenting part of iho infant is oreed into the vagina and against the perineal 28 mngel in din Tie near lateral ane ote Wh ing, the are aah} pening heum d peripher AS the Fixe the vay expandi inal pla apart a Tongitna To diameter placed } rubber } inner he peninit the rabh atlached the conte outward injury b often’ pe prevent Var munseles vaginal sending of one | ‘opposite omni of the p of the i and lis for supp museulat the peri levatars to Hill a ana agenv. and phys: o the state rgans rss of threo every Deen tant ayia ate 2 sbor n the aseles canal he the ath wing whiel sively lly $0 issue oes | I eg ge EXDROISE IN RESTORATION OF PERINEUIE 238 nningeles, Jess dilatation aceurs, Instead, as the humen of the vagina jnexeases in diameter, the eells in those portions of the radially inserted! museles whiel: lie nearest. the vaginal orifiee Decome separated from each other as 9 yesult, of lateral stzetehing, while the interdigitating museles whieh survound the vagina ave offen tom as a result of everslongation. ‘When any large abject jn foreed awainst a diayphraem with a sn ing, the greatest stress is at the margin of the orifice, ‘The more peripheral wrens fire subject to much less strain, and it is the aren immediately adjacent to the opening which becomes exeesively alvetehed or tort. This ix true of the perk eum during ehildbitth,. Te 8 in elese presimity 10 the vagina that Ue most Aevere injuries occur, Only after the medial tissues have given way dy the periplieral zones become involved vAs the perimeter of the hivt canal expands daring delivery and approuches the fixed 1in of the pelvis, the musculofaseial tissues situated radially between the vagina. and the 3m of the pelvis would hoeome shorteuerd and velaxed if the expaiiding movement were entively linoar, T7 the tissues remained! in. the ori: nal plane, the medial hers of the radially inserted muscles would he pulled apart and separated, Int the muscles would never be subjected to exeessive longitudinal tension, ‘To illustrate this process, ane may picture the pelvis ay a hoop 12: em. in diameters attached to it hy means of rubber hands 5 em, long is a small centrally paged hoop 2 em, im diameter, whieh represents the undilated vogina. |The rubber bands hold the two hoons in one pane, If, now, the diameter of the inner hoop is increased to. 10 em, to carrespand to the dilatation necessary to permit passage of the ebild's head and the two are still held on the same plane, the rubber lands are each 4 em. Jonger than necessary to Keep the two hoops attached. Tt is thus evident that the inner hoop may move trom the plane o| the outer hoop 4.89 em. without sension, Only when the perineum is foreed. ‘ontward more than the amount permitted by the elasticity of the tigsnes will ingury be inficted, aiid it is ab approximately this pobri that an episiotomy is often. pezformed in order to inerease the diameter o7 the vaginol outlet and prevent Zorther downward pull on the museulofaseial tissves Variations in anatomic zelations way he responsible for differences im the tension to which the muscles in any qnadeayt are exposed. Short anterior nngeles may he subjected to excessive tension, Jeading to mjury of the anteriur inal wall, Pasievioy miiseles are move coutmonly averextended by the de- sending head ond axe more commonly injured. Excessive tension in o yuadvant ‘of one diameter will cause relaxation of muscles in both quadrants of the ‘opposite diameter. For this reason Intexal museles are rarely injured Other museles and fascias which ave intimately eoneerned with the support of the pelvie struetares and which must become dilated io permit the passige fof the infant are the sphincters whieh surround the ams aud vagina. | Curtis fd his assoeiatest have showa that strands of umsrles whieh are predominantly for support blend with end insert themselves hy interdigilation into the intvinsie mmiseulatare of the Jower thitd of the vagina sw well as that of the urethra amd ants. Gorseh* hay emphiagized that “the deep muscular strata, whieh eonsist of the Tevator ani together with its fascia, re oF Jess elosely interrelated witit the perineal sphineters. By supporting and fising the pelvie dinpnragm the evators synterize oud cooretinate the etivity of the sphincters.” | According to Hill end yon Del “the k i aupelo aels as a powerful sphineter, since 4 surtornds the vagina like a Joop," amd Bureh* has made the statement that ‘laxation o? the vaginal oulet is caused hy lack of tone of the levator ant muse,” Th muscle tisse in the iumediate proximity of the vaginal canal is in the igtentest (ension stress during labor, ‘This sphineterie zone is most clastio240 KER and resilient anid is capable of undermoing a greater cha other part fof the perineum, Muscles in this area are injured ty yome extent in every pregnaney Init in most instamiees shave amazing: reeperative pa When museles and fascias are subjected to excessive t duuvinge chile birth, twa typos of injuy may result: (1) actunl Inceration and separation of fhe sieles and Faseian and (2) sepuation of individual mele cells frum the motor nerves hy whiel they are innervated, The latter injury i proebly wnt versal, awing to the grunt clasticity of amwele cells and the relatively lesser tensions whieh nerve flhens ean withstand, With the hivth of the hey, the forve whieh has hen applied fo the yerineurn suddenly ecases. ‘The museles and faseias of the peripheral ame, whiel have jeeted to proportionately’ Joss tension stress than these of the medi zane, contract, t0 cause reduetion in; the eirewnference, shape, and form of the vauina. In tlie position they serve ay snp pwrtive aplinis for the medial muscles and faseias, whieh were the site of The most eyneentrated Cension xfrews. Come drvetion occurs gray, fov.n sate of fami fs nover eanlueve to rapid healing, amd only after some time does the vagina approximate ite former si and the perineum anproaeh its original eompreteney. ‘The forces what Wad to the dilatation of the birth cana and the consequent stretching amd fearing of muscle and nee Shey vary in their noruve avd in their effect on the pevines! structures, The relotive size of te fetal head and the bong pelvis, the pasition the head assumes in the pelvis, tle character of the nterine contractions, the length of tine during whieh foree is exertod and ihe state of the perineal inuseles, all phiy a part in determining the extent to whiel the perinenm will ho injured. Tan young woman with resilient, elastic muscles if the head is in an accipstoanterior position, the mtorine contractions are normal, and an episiotomy: hais een dono lo prevent overdistention of the perineum, permanent injury is minimized. In any region where tisiues ecome averstretehed, even, though lacerations: of mnselus o fascias are nob visible, nerve ingury is inovitable, Every muscle cell ig supplied with a motor end-plate, attached to one of the many Alaments making up the terminal portion af a motor nave. Sineo musele eells are capable of greater extension than nerve Abory, they may stretel to steht on extent that the motor end-piates are torn fram the newer oF which ther were a part. Never ave all such eomections sevored, Sou muscle eells will netuin tholy innervation and be eapeble of acting as splints or evitelios for Their injaved neighbors. The amount of permanent musele relaxation will depend in large measure on the proportionate nusibers of intuet and diseupted novwemuscle unity and the umber which are reconstructed ‘Mechanism of Reconstruction Tr iq nit enongh, there/are, 10 approximate the margins of laeerated mn and fasrias and suruve then in place, Stel a procedure will ordinarily lead to fh restoration of the gress form of te perineal structures hut will not in ftsel! Then about a veturn io normal function, Ti some way, re-innervation of maxele cells mast he aceonplished smd the injured muscle celle rmusi sain be educated to fimetion, The si Pisehox* stated thy nation most favorable fur n xeturn af fanetion is a demand for use jit gener] an inactive injured muscle Will lose almost 80 per cent of is weight, while sn aetive injured musele will lose only 20 yer cent Injured perinen) nnustle eclls are iit an ideal sitmation for niaintenaner of size through activity, ‘The inferspeisod intaet mnsele cells are andinarily sitfieienthy exercised incentivs tion of th mn cain th with aan lost ite 3 Van Har striated ov vests anda fh xrenter ithe hq applica The developed and salve Titeratung have felt indicated their oft histor on all the. uter ahdonnina nd fori Th restoratia hase beer Wyek" of Foees | cians ind in the per Onc firm peti the duty thst the hy: eontr alter hiv est Past tion af 2 seh req Prive ta nd pass expert Ce paila inthe jeme sauont nd in Tend ter oF Vand ations imsele rents able {that Ney vation Th mn the a the aiseles rad (0 itself nue rented ost 80 Peon sxe jently plo BNEMOIN IN HERTORATION OF PEIN on aomerons fo permit some contraction, and when dese muyeles aue netively exereised, the injured usele cells are put to work at the sune tine, The ineontive foy veirinervation, regeneration, and re-edueation is the need for fune= tion of the nnasele as w whote Th the cause of embryologie develupment, contractile muscle tissue is formed eavlicn tian the nerves which supply it, and consequently nine cells heeone seondavily Synexvated.? This ability of a nerve fher to establish a eonneetion With a nele eell 18 earvied over into adlult life, amd a muselo cell whieh has Tost its innervation way heeome yeinnervated under favorable cirenmstances. Yan Harveveld? Billig anit yim Tiarveveld Arey" and others have shown that striated nmele fibers afrophy wien they Inge hele nezve soppy but are expalle fof esturation when reitnervated, A xingle nerve filer is eapable of growing tnd of multiplying fis bnmelies way tines so thot it way eventually supply fer neither of musele cells tham id originally. Tu no grogp of muscles in the. homsr. bady are the yencral prineiples of wuxelecell rexeneration more fo than ta those injured in ehildbirth, weil for some method by whieh perinen! muscles way be preserved and a. Hipniacrates tried il Injections, hut douches fant salves, and Simmntty (a,b. 110) attempted styiport with the hand. Medical Titeratave of the past centway reveals that many obstettielsns ond gynecologists ave fel! that exervise or xonie other conservative meas of reeonstetction ix findieated and should he of value during the ehildhearing age, hut. reeords of their efforts have beer mone ar less relegated to the footnotes of gynecolouie Listny. "Exercises sel as the assamption of the knee-chost yosition, walling on all fous, lew maising and early postpartum getivity are valuable in aiding the uteris fo resume its normal postion and in fauproving the tone of the ahdaninal maseles, Phey do little, however, tw affect the state of the perineum, ‘and Zor its museles spectal exercises mre neeesiary Specific Exercise In the eurrent literiture there ji little mention pf exereises to promote the vostoration of perineal function, end would seem that no satisfactory exercise has heent found. One of the {evr velevenees to exercise és that of Seoti and Van Wye who deseribed a procedure in whieh the patient eontraeiy the gluteal neta, at the same time drawing in the reetim as though ro cheels the passage ff fees Through the lower bowel, Personal cansmunieations frum many’ phys iis indicate that it is 9 fairly common practice to instruct the patient so draw §n the perineal region repeatedly One repnrt of interest is thet, oF an Skolleviki:* who ofwerved upnsnally firm perinen among a the of natives in Soil Africa, He found that if wax tho duty of the midivife, who was usually the mother oe iotlier-iustang, to sve thae the young muther reeaverrd perineal strength after childbirth, Hsereise by eontirdetion of vayival muscles on distended Buxgors way begun several dag alter birth aud seas emitinned periodieally for several werkss, woitil the desived result wa olifaines) Past olxorvations of abstetvicians and gynecolagists in relation ton fon of mnsely Fonction are inv acegril with te earielusiing Fearhed concerning suelt regeneration thvopedh investigations conducted during World War TL Prior to the war, the accepted treatment af injuned muscles was prolonged rest and passive exereise, “Tt has heen forbid, however, that lent, whisling w expert mizassyce, cleetvien! stination and -[litgard general aetivity. Dave Their phiee, shot Cliey have rele rnacle an fatten ta 1 on preventedBry KEGEL fm Jog 8 oy , atrophy, or loss of fimetion, With exeessively long periods of passive shabibine jan, mmvsele reflexes become sa impaived that actual paralysis is often immobiliza siurulated, ing the recent war, according to a wer summany,” it was found that Fomination is ensiey fo prevents than th restore.”” “In the preservation ov restoration of musewlar function, nothing is more fundamental than the Frequent repetition of correctly quided exercises” instituted by the patients own offoris, “*Fxereise must he carried out against progressively inereasing hrin direet proportion to the demands, rrosistamen, ginee museles inerease in stren placed upon then.” Tt would seein rom the aeenmulated evidence that perineal exercises are capeeinlly important for two purposes: (1) to promote a retam of normal muscle Sunetion jn the immediate yortpartuia period a mmugele fanetion in wornen will in the ebildhearing age who, heeause of musele-cell injury ineurred fat a more distant time, suffer relaxation of the pelvie musenlatare. For the past fifteen years I have experimented with various means of oxcr ising the perineal museles, Any active exereise must he ditected primarily foward drawing in the periueam, Only the exceptional woman, however, will continue the oxereise long enough 10 prodaee results on mere instruction to da this. Many wonten, in addition, have no “awareness of Sunetion” and, unless provided with some way. of knowing whether or not they are being suceessfu foo hoeome dizeomaged or are unwilling to make even an initial attempt Tt seemed advisable, eonsermently, ta dovixe some method by whieh the pationt might soe the results of her nelivity and be encouraged to eontinne her offurts—io give her an actual inecntive to, inerease the eontraetile power a” her perineal museles snd vaginel sphinciers. The prineiple of restoring the fumetion of a segregated group of rnscles with a sheeife. aid, method, ar jroxzam of ve-cditeation is well established Tnyough constant use in the fields of orthopedies, nenromuserdar and plastic ety, phywiea! medicine and zohabilitation. Lnsportant speeifieations eommon to aceented methads of restoring Zametion of injured skeiotal museles are means of segrezation, gaidmee, and progression, ‘An eavly theta wfuedied was Friinkel's'* (1805) re-education program for Jocomatar ataxia, Methods recently dexcloped for rehabilitation of the war injured and for eatablishment of awareness of fimetion in patients with infantile paralysis gave valuable help iu this study. The most veeent developments in this highly impovtant field are by Tuddelston and Colseth’* and by Billig,” who re devised & method of registering nusele aetion patentials on a, Toxdspeaker ao that the patient hexs inezeased sound when, he is pulling move acearately with the musele heing, trainer! For Improved Sanetion, The special sense which ordinarily activates the genital museles is the inetilo ‘whielt obviously eannot he utilized in tyainiug, em neeount of its iypersensitivity and eshaustibility, Sight is the most highs developed special serse for the wiidanee of skeletal inagele artion, sad in the restoration of pexineal tmisele, ftmetion the respnise to siglt sense’ guidance ig instantaneous, with immediate anderstanding of the modus operand hy the patient, ‘The Perincometer A. ymeumatic anparatas (Pig. 1) has heen devised specifically for the e vise at birth canal muscles, with measurement of each tmuseular contraction Wisille to the patient. A earl. (Fig. 2) is provided to kecp a recortl of the “ilishisent-of cach exercise pevind and #erve ag & progress quide Zor both ‘sivian. ‘The apparagis eansists of « simple, halaniecd-resistaniee patient and aw Dy mea mereurs cot of | flange 2 with th and pen of the v with me pert patient | 50 that 1 to conte Pasi especial even afvtien that: ation + the ent’s vands rasele tion axred exer vavily 5 will todo mules ss nt ab h the of hee aseles lished plastic means atile alg In "who realeer, rately is the at its special evineal a sith of the an Doth dstanee ginal chamber gperating at atmuspberie prosure and conreeted hy means af Fabher tubing with a nemoueter ealilnated from 0 to 100 mm, of nievemy. In construetion, tle vaginal ebanher is an, asiode-progessed rubber cot of Specified consistency, lightly strotehod over a rigid slender eore wit Aange at cach end. An ait vent, tn the eove conncets the emmatie ela} with the tubing and wmanometer. The hese of the ehambor is fitted with a x rar, tad nae ems ec aera Me Bios PR SR, of PSM tee Seat, nas aie gy ee and yermits pivoting into position. ‘Dhe length (8 em.) and diamoter (2 er.) of the vaginal chamber are in conformity with anatomnie structures, especially with regard to the anterior and posterior musculature of the vaginal wall. Th operation, any prossure from 0 to 100 min, of mereitry exerted on the pueainatie vaginal chamber is immediniely registered hy the dial of the manametor, Tho patient i¢ instructed to insert the pneumatie chamber into the vaginal eavity 0 that the rubber disk resis auainst tho perineum. Sho is then told ta attempt to contunct the muscles of the vagina while watelsmag the dial on the gage. Pationts vary greatly in their ability fo contract the vaginel muyeles, Many, ‘specially those with marked reloxation of the pelvie floor, are unabie to rewister even a few millimeters of pressure on their initiel attempts. (Gradually, after¥ dun withROUSH IN RESVORTION OF PRRINEUM rnd as the museles Decome stronger throvzh exercise, the pressure prneli¢ Wehieh ean tie exerted inervasee amd Sveqptenily reaches 61 to 80 ov more milli- meters of mererry Since the instrument measmres the degree of contraction of the perinenl mavelos, it hax been called’ the “Perineoreter.”” Tt iv a simple pmeumatie apparatny waieh Tanetions auly to show that museular contraction is taking place snd th uicasure the eontreetion, Tis only aetion iy to provide » medina Retween mitisele action and silt, ‘There is no ymovision to stimubste muscle ceontraction, no dacs it provide Zor passive exereise in any way, ‘The apparutus Aris constmeted with the view tint any juibitting or wasging action wut feat its puepose and would prove detrimental, huomful, and wseless, wd that, in the preservation or mestoration if perineal! mnseular function, nothing is hore fanlamental shan exeresae instituted by the patient's awn efforts, Clinical Application 1e initial test with the) apparatus requires Fess than five minates and i nade in the eowse of physieal eSnmination, The watient iy instructed to exercise twenty minutes tinve dimes daily amd fe. record Toth tie periady and the omise sions oF exercike on her chart. ‘The perio over w is my to eaery tut this procelure varies Wheipally in yelation fo the state of the perineum ni the finte exereises are commented and to the diligence of the patient. Initial presence aie ahyenee af awraveniess of fanetion and euordinatiun also is.on. inapor Lint factor, An vceasional pintient may experience reat diffeclty hn gaining awareness of funetion Restoration of tone and Souetion to lax or atrophied perinenl muscles re- quives fram twenty to forty houes of proueessive resistance exeveise, spread over twenty ta sisty days, AS a Teale, yong patients promess move ta colder antes, Init ane Wonian of 5S biezvawd her eontractile strength from 10 to $00 inn. of meremy without undue effort in thirty days, ‘The period reawized for masini results varies als according. to the purpose fax which Perineome exercise is preseribed, whether to rstore tone and tanetion in the immediate posipattan periud, to imprave early exstocele or veclucele during: tie. child: hearing yours, to iiipruve fhe vaginal wgseles xo that a contraceptive diaphragm nay: he setained" oF fo relieve winary sizes incontinence, When satisfactory Tsults are not nebieved in a reasonable period, the patient may he exereisine ahdottinal aiuteal, or other extuaneous muscles fo affeet dial readings, Backache Or ahdominal distvess also suggest that the Weoag nnuseles axe heing used. ‘The Patient who complains of fatigme prohwhly is exexting greater effort than is For these reasons the patient shonld he seen. at least ones 2 week, yy be property direeted. arly, she iy enemraged to atternpt to nevease the pvsware T to 2 mm, of mercury daily and to Keep a veeund oF the nnsinuis eontraetiin af whieh she is eapable at eel esereise period, For this Prose the graphie chart jas heen prepared, ty enable her to record the pres Rares register Oi the dial, ‘The aettal reeord kent dy one patient is shown in gD With minor variations any woman with reasonable diligence may duplivate the record shown, ‘The types of ewatenctions of whieh this patient was eapable x While the patie with her exereies and evideneed progressive restoration of tnetion In Pigg fed, Brand 6. While Ike period neeessane Tar masiinum restoration of finetion by exereise may vary, i is posible te diseerm shires or fae phases of Aecclojment. The reser eliose: for ilust ation shuns four phases rather event Aidtihnted iver four weeks, The fist phase, the period required to establish246 KEGEL Se hOB ore awareness of Zunetion and coordination, may be absent or brief or veqnire as long ag eight days, ‘The sceand phase is a transitional phase, The third phase, ‘evio« of regeneration, is aveoanized grossly by the gradual inovease of resist noice registered, Tt is daring this phage thot a ehange in symptams, such as lief of uniamy fueontinenee, seems, The phawe of restoration is recognized by a leveling ont of the resistzmee whieh the msenlar contractions are able to over fore, usally hove 60 mm. of mneveury pressure, A leveling out at less than 40 nnn. is sa indiention that the lower vaginal muscles have been aetive and that with eantinnation of exervise the muscles in a. higher plane will show evidenee of regmieration, Tu meet the lutte euntingeney, ane speeifeation of the pneumatic vautinal ehnmnbor is that Tt shall he eompressible but uot expansible, TE eompres. sion of cine segment were to enue ballooning of another segment of te chamber, iL wuld he posible for strung amuseles fo undergo development at the expense ‘of Weaker ratieles, While progressive resistance exereise with the aid of the Perincometer is useful whenever it Is dlearable to strengthen pevineal museles, work now being dono ny relieving, urinary stress ineontinenee Tnrnishes an exeellent exainple of ‘he effeaey af the method, ‘Ty date (May 20, 1948), the condition has lieen reliever! i 64 cuss, Thatfiefent time lias elapsed to justify a statistical repovt ‘on this sinies, Tint ihe patient longest under observation has remained dry for ‘unsteen months. Same of the women treated had warn pads eoutinuonsly for as Tong as cloven years; thes had underinie one to three plastie operations, without relief, There have heen no failures when the condition was dae pri auvily to relaxation or atrophy of the anteriar vaginal museles and the patient Tradl wh least jartial eoutied at times. The mother has heen used alo to improve tone of muscles and texture of tissues in the presence of anal ineontinenge, and apparently facilitated repaie A patient with mdimentary vagina and eongenital alsonce of the uterus was instructed fo use the “Perincameter"” after plastic procedures to enlarge the vagina, and inereased sphinetey aetfon trom 0 to 40 mm, contractile strength. Summary, ‘The passage of the fetal head through the vagina during delivery is in- Vurially sitended by mmscle injury. Bscossive teusion sever motor end- plutes attached to muscle eclls fvom the terminal nerve ‘laments to which th deter geld ata eter TENS ie ab ce ED PFE Bia en aa Bice ne een a se magn Ba tanga Oe EPED tls BHlienee sf dnevad Retion exis ‘Sourar SP Tineke Peved Bens aadeanic polke aetten 2PNERCISH IN RESTORATION OF PHRINBUM a4 | ee toninde om enpoeite pe)8 Yo he 8 pe fave normally commeeted ‘This partial Joss af iunercation is in Torge measure espousihle. for the relaxation of perineal muscles sv commonly: oliservedd ater ehildbivth “Bxperience has shown thot a dontand for use is Che most important fetor in restoring fle funetional eayeity’ of any skeletal anaseie, Active exercise will aid in the reinnervation of injured nusele cells and will being about a return of nortal eontratility ‘The shorter the time elipsing hetween muselo surgieal proceduve and the hegiuting of exereise, the less wll be the amomt Of tissue afeuphy and the sovier will he the tine necessary to re-establish not smal funetion, Bxereise with the Perineometer is useful In restoring frmetion and tone ity the immediate postpartum pexiod, improving early eystuvele and seetorcle du ing the childbearing yous, impruving the vauinal museles so that a contricey- tive diaphragin may he retained, and relieving wrinary stress incontinence Sunstieal procedures for the correction of vaginal, wrethiral, znd rectal in= competence may be facilitated iy preoperative and postoperative exereise whieh Inyproves tle texture, tone, and fumetion of perineal waxsces. The “Pevineometer,”” im instrament devised to register musele euntraction of great value as a viene! aid 1 guiding the patient duving the eouve of her oxeredxes and in encouraging her to coutinite until the desired result is attained ‘The method of exereise descriled suggests « new approach to the studies of perineal pliysiology as related to physics \jury due to ebildbinth or a References 1 Corila, A. Th, Asn, B,J, and Reway, CB Gordy AL Hy! Ara, 34nd Ash Fe Ta 2, greek, B. Vis, Berfuoupaleve Anata SHE, He, and van Dele Ts Surg Gy Darel, latte Soothe 863,472 318-9, Tischsey a Aon, Nov. Phos Ghneyy Bet, Bassopet, J eorah’3e 131 tat i f. Va Macreveli, At Ass. Physiol, 184s 477, WHS, CB Ee Yer and tan Hatrereldy Az (8 Nav. 21, Toll, 4104, 104 we WoB, oun Cangas, i Finustaltes, Har Newopath, & Paper Te The Dévelopmuntal Asnsutny, Phinney hs, 19 1, 80010 We Ay and Va Wek, HL “pniladelfibig WH, tat & eh Yan Sonkvils, Bors gemnuae BPS Ate Sirgen a Holl 2: veh. binins Mad. 28: WTS, le Baseutials of Obstetrics and Gynecology, iin; Daruthy. At Pema communi TF, Powell, racy O., Peraaal combaneat ion (200 NuIE eww ca than the therapy. harass bo a pelvic 1 ay eatly, sigmoid quently Whe ployed s aystemie seh st degree 0 treated | asingle De main ov a fn tolorated Snitial terminal nd pro complet to surr0 Ii in safe avea, th it is a eneft destroy panied