SUPERFICIAL LACERATIONS 
OP THK 
P E E I N E U M . 
BY 
FREDERIC D. LENTE, M.D., 
Vice-President New York Neurological Society; Member of American Neurological 
Association ; of American Public Health Association; Hon. Member of 
North Carolina State Medical Society; Corresponding Member 
of New York Medical Legal Society; Member of Board 
of Managers of Hudson Hirer State Hospital, 
<{■<•., Ac.. Ac. 
Read before the New York Obstetrical Society. 
Reprinted from Am. Journal of jOagaETRics, November, 1875. 
NEW YORK: 
JOHN F. TROW & SON, PRINTERS. 
1875. SUPERFICIAL LACERATIONS ' 
OF THE 
PERINEUM. 
BY 
FREDERIC D. LENTE, M.D., 
Vice-President New York Neurological Society; Member of American Neurological 
Association ; of American Public Health Association ; Hon. Member of 
North Carolina State Medical Society; Corresponding Member 
of New York Medical Legal Society; Member of Board 
of Managers of Hudson River State Hospital, 
etc., etc., etc. 
Read, before the New York Obstetrical Society. 
Reprinted from Am. Journal of Obstetrics, November, 1875. 
NEW YORK: 
JOHN F. TROW & SON, PRINTERS. 
1875. SUPERFICIAL 
LACERATIONS OE. THE PERINEUM. 
Die F. D. Lente, of Cold Spring, read the following paper 
on 
Since so little has been said in onr systematic treatises, and 
even onr periodical literature, about lacerations, and especially 
incomplete lacerations of the perineum; and since the attention 
of the profession has been attracted to this subject by Dr. M. 
D. Mann, in the October number of the American Journal of 
Obstetrics, with an implied call for additional information and 
statistics, 1 propose to give briefly the results of my own ob- 
servations in the hope that others, who may have had a larger 
experience in obstetrics, may follow the example, and endeavor 
to set this question at rest, and to establish some principle 
of action. For, as the matter now stands, it is a difficult 
question for a young practitioner to decide when he finds him- 
self at the threshold, perhaps, of his obstetrical practice, con- 
fronted by a considerable laceration of the perineum, probably 
after an instrumental delivery; the matter being still more 
embarrassing if it has occurred in a family of influence. If he 
should call in neighboring consultants of larger experience, his 
dilemma would not likely be resolved, as a disagreement would 
probably be the result, and the notoriety given to the occur- 
rence would only enhance his embarrassment. What then 
shall he do ? lie will turn over the leaves of his authorities, 
if he happen to have a good library, in vain. That is my ex- 
perience in other difficulties besides this; and, until authors 
write more from their case-books, and are less guided by mere 
memory of experiences long past, it will continue to be so. 
If the laceration extend through the sphincter ani, and 
through that triangular space called the perineal body, so ac- 
INCOMPLETE LACERATIONS OF THE PERINEUM. 4 
Superficial Lacerations 
curately described by Dr. Thomas, and thus lay the rectum and 
vagina into one cavity, we may take it for granted that operative 
interference will sooner or later be required. Probably there 
would be no difference of opinion here. But what shall be 
done with the cases of “ superficial ” laceration ? It is only to 
these that Dr. Mann has called attention. 
In the first place, as regards their frequency, my own expe- 
rience accords with that of others quoted by Dr. Mann. It is 
quite common in primijiarce, and after forceps. Moderate 
cases are, as he says, doubtless constantly overlooked, and I 
think fortunately so. Dr. Stokes, long ago remarked, in the 
case of the complication of pneumonia with typhoid fever, it is 
usually fortunate that the practitioner fails to recognize it, as 
he might be tempted to treat it. We have somewhat better 
ideas now of therapeutics, and we know that generally the pneu- 
monia will take care of itself if we can manage the fever. So 
it is, in my opinion, with these lacerations. 
In the next place, how does it occur % For, a knowledge of 
the cause may lead to prevention, and this is better than cure. 
The causes which are generally recognized we need not stop to 
consider. Dr. Mann enumerates three. Then he remarks :— 
“Many perinea are ruptured by a careless delivery of the 
shoulders after the head has passed.” This is so. But many 
are ruptured by the shoulders which are not attributable to 
carelessness. And as too strong an assertion on this point 
might lead to annoying suits for malpractice, especially in 
neighborhoods cursed by a doctor given to fostering such suits, 
it is well that it should be understood that a ruptured perineum, 
even after an instrumental delivery, does not by any means 
imply any want of skill or care on the part of the accoucheur. 
The burden of proof in such cases ought to rest on the prose- 
cution. 
Not long since, in a prominent journal, I read an article by 
a physician of apparently large obstetrical experience, in which 
he contended that rupture was scarcely ever, if ever, attribu- 
table to the passage of the shoulders. Singularly enough, in 
the same number was a table containing a large array of statis- 
tics, showing that this is an exceedingly common cause; and 
so in my experience it is; in my forceps cases especially (and 
it is here that it would be most likely noticed when it occurs), 
it has been the shoulders which have done the damage. I 
have demonsti'ated this more than once to my assistants, that 
the head had passed safely, that the forceps had been removed, 
and that a bad laceration has then been produced by the shoul- 
ders. A good deal of stress is sometimes laid on the importance 
of removing the forceps before the head passes the perineum ; of the Perineum. 
5 
but a little examination will show that, although this may easily 
be done, it is of no consequence, as the blades cannot apprecia- 
bly increase the diameter of the head, as they would do were 
they solid instead of fenestrated. 
Granting that the shoulders are the dangerous portion of the 
foetal body, and it is conceivable that a comparatively sharp 
object should be so, rather than a globular one—what can be 
done to avert the catastrophe. “ Supporting the perineum,” in 
the ordinary acceptation of the term, would only make matters 
worse, as it always does, by stimulating reflex action. The only 
feasible plan would seem to be to retard the advance of the 
presenting part as much as possible, and endeavor to ease it 
through gradually pressing it forward also, perhaps, as it is 
passing. 
Now, as regards what should be done when the laceration has 
occurred. As I have before hinted, if moderate—that is, in 
linear extent—it will, except in instrumental cases, most likely 
be overlooked; and fortunately, as it will save the patient a good 
deal of worry, and the doctor also, if he be inexperienced. If 
it extend nearly to, or quite to the sphincter ani, and perhaps a 
little around one side of the anus, what shall be done % This is 
the point which needs to be better settled than it is. 1 only 
design to give my own experience, and make no reference to 
that of others. Others have indeed said too little about it. My 
flrst case disturbed me very much, and I worried and alarmed 
my patient and her friends not a little by stating pretty posi- 
tively that, although no danger need be apprehended, an opera- 
tion at some future time would be necessary. Weeks after the 
accident, although the patient had had no particular care, and no 
unusual precautions were taken, the wound had healed, and the 
patient appeared to feel no inconvenience. This has been my 
fortunate experience ever since in a good many cases ; for I do 
not agree with Dr. Mann that these Occidents may always be pre- 
vented. Among the poor, I have not even given directions for 
keeping the patient on her side in order to prevent the urine and 
lochia from irritating the wound, because they would probably 
not regard them if 1 did, and they are seldom necessary.1 It is 
astonishing how little suffering such a wound occasions. In one 
case, 1 remember, in which Dr. Murdock of this place assisted 
me, I delivered with the forceps, and showed him that not the 
slightest laceration had occurred from the passage of the head, 
and that, as the shoulders passed, the perineum was rent quite 
to the sphincter ani, extending a little around one side of the 
1 There is one precaution which is important, and which I always enjoin, 
the recumbent posture for at least nine days ; but this is also insisted on in or- 
dinary cases, though not always observed. 6 
Superficial Lacerations 
arms. If was rather a nice patient, a primipara, and as she 
had a competent nurse, I considered it best to acquaint both 
with the occurrence, merely to insure extra cleanliness. I 
might as well have kept it to my seif, as the patient felt not the 
slightest inconvenience from it. Months after, I examined the 
parts carefully, in a good light, and positively could not discover 
a trace of the accident. Even the fourchette appeared perfect. 
This is of course an exceptional case. It is generally easy to see 
the cicatrix, if one looks for it carefully. 1 will briefly refer to 
a more astonishing case than this, though it did not occur in 
my own pz-actice, but it should be put on record, since Prof. 
Thomas does not admit, in the last edition of his now justly 
celebrated treatise on Diseases of Women, that there is any 
well-authenticated history extant of such a case. I have re- 
marked that it must be taken for granted that a laceration 
through the sphincter ani must, be operated on. Put even this 
has its exceptions. Some years ago two of my intimate profes- 
sional acquaintances were interested in such an exceptional 
case. One was the late Prof. Geo. T. Elliot, the other Dr. John 
G. Perry. The vagina of this lady was the smallest and most 
rigid which Dr. E. had ever met with, which led him to caution 
her friends that laceration would probably occur. It became 
necessary to resort to the forceps, and although he used the 
smallest and lightest in his possession, and all the usual skill and 
care for which he was distinguished, an appalling laceration 
did occur, splitting the sphincter ani and the vagina througho ut 
its whole length to the bottom of Douglas* cul-de-sac. lie was 
of course horror-struck at its magnitude, and naturally solici- 
tous to repair damages at once. But Dr. Perry, whom he 
strenuously urged to operate, very properly, in my opinion, al- 
though specially qualified to do so, declined to accede to his re- 
quest. llis own cooler judgment told him subsequently that it 
would not have been prudent, and the unlooked-for result proved 
that it would have been entirely unnecessary. The patient’s 
bowels were not kept confined by opium, as is usually enjoined 
in such cases, but were solicited to act regularly by enemata. Dr. 
Elliot afterwards informed me that this extensive wound 
healed promptly, spontaneously, and thoroughly. lie attribut- 
ed the spontaneous healing of the vaginal portion to the firm 
and rigid condition of its walls, the very circumstance which 
doubtless led to the accident. Dr. Perry has since attended 
this lady in a confinement which presented no unusual difficulty, 
and the perineum has stood the test a second time in Paris. 
Her health has continued good. 
I was writing this paper for occupation, while detained at the 
house of a patient with the most tedious case of labor which it of the Perineum. 
7 
has been ray fortune to encounter, with one exception, and was 
interrupted just at this point by the necessity for employing 
the forceps, and a means was thus offered me on the spot of 
exemplifying some of the ideas previously expressed in this 
paper. Dr. Murdock, my assistant in practice, had been sum- 
moned a few hours before to assist me in the use of first 
Molesworth’s and then Barnes’ dilator for facilitating the dila- 
tation of an unusually rebellious os, and had been allowed to 
depart, so I had to operate alone. The head was unusually 
large (the child weighed 10J lbs.), and with all my care in imi- 
tating, as far as possible, the natural process, there being a good 
light on the parts, I saw the perineum tear slowly to the extent 
of an inch or more in the median line. I was almost certain 
that the shoulders of so large a fcetus would extend this to 
the spineter ani at least, but pursued the plan, the description 
of which, singularly enough, had been written scarcely an hour 
before—that is, to press the shoulders forward towards the arch of 
the pubes, and upward in the axis of the vagina. This was per- 
fectly successful, as I was gratified to see, while closely observ- 
ing the part, that there was no further injury inflicted. Indeed, 
this manoeuvre seemed to take almost all the strain off the peri- 
neum. 
Of course every one of any considerable experience knows 
that it is not uncommon to see a short perineum resulting from 
these rather extensive lacerations, and causing a good deal of 
trouble, a want of support to the vagina, prolapsus of rectum 
and uterus, and retroversion, congestion, etc., and that perineor- 
rhaphy is the only radical cure when these annoyances are of 
sufficient importance to render a resort to operation advisable. 
It is, however, under these circumstances one of the simplest, 
safest, and most successful of surgical procedures. But the case 
would be far different were it done immediately after labor, 
which, in such cases, is apt to have been a protracted, an instru- 
mental, and perhaps a complicated one. Drs. Joulin and Mann 
give unanswerable reasons, I think, for not resorting to primary 
operation. One recommendation of the latter we may adopt 
with benefit, perhaps, and without attracting the patient’s atten- 
tion to her condition : to have the ordinary binder broad, and 
let it extend well down below the trochanters, as indeed it al- 
ways should do. This, if tightened daily, will restrict the move- 
ments of the lower limbs sufficiently, and thus, to some extent, 
prevent motion of the edges of the wound. Ilis suggestion of 
what he terms the “ Vienna method” in such cases as extend to, 
or nearly to the sphincter, is also probably a good one, viz., to ap- 
ply strong serrefines to the edges of the laceration. It would 
appear from Dr. Mann’s cases at the Vienna Hospital that 8 
Superficial Lacerations 
union is more apt to occur, whether they are used or not, in 
private practice than in hospital, as might be anticipated. 
Dr. T. G. Thomas said that he was opposed to operating at 
once in such cases as the one observed by Drs. Perry and El- 
liot, and quoted by Dr. Lente, because the patient is too much 
exhausted, and the union of the laceration too extensive an 
operation for her already enfeebled system. Smaller lacera- 
tions to or merely through the sphincter ani should be closed at 
once; still smaller ruptures than these last require no treatment. 
A general rule whether to operate immediately or follow the plan 
of non-intervention, can scarcely be made. The only general 
rule he knows of in this connection is this: There are four 
varieties of laceration of the perineum. 1. A slight distance 
into the perineum; 2. To the sphincter ani; 3. Through the 
sphincter ani; the last two require immediate operation ; 4. 
Some distance up the rectum ; these should not be touched, as 
there is little prospect of success to be expected from an im- 
mediate operation. 
Dr. Lusk said that in his experience the proportion of cases 
of success after the immediate operation in hospital practice 
was about one-lialf. 
Dr. Lee said that there was some difficulty in determining 
the exact extent of the laceration when the parts were swollen 
and turgid, as they usually are, immediately after labor; that 
he had seen an apparently small laceration appear a very large 
one when the swelling subsided. 
Dr. Munde said that in his experience, which had been quite 
large in this respect, he had found that, on the contrary, lacera- 
tions usually appeared larger immediately after delivery, when 
the perineum was distended and the vulva swollen, and that 
they diminished in size after a day or two when the parts had 
regained their normal relations. lie had repeatedly seen 
lacerations of % to 1" in length unite by merely tying the legs to- 
gether, passing no catheter, but letting the patient urinate over 
the perineum, and then pouring warm water over the external 
genital organs, lie had also seen ruptures, which did not unite 
after immediate suture, heal by second intention during the re- 
mainder of the lying-in period. In the Lying-in Hospital at 
Wurzburg, Bavaria, under Frof. Scanzoni, all perineal lacerations 
were immediately closed by thread or silk sutures, and with 
very good results. Dr. Munde thought that of the cases 
operated on by him from to § recovered ; one, he remembers, 
so perfectly as to show no trace whatever of the line of union. 
The method of immediate operation is so universal in Germany, of the Perineum. 
9 
that Dr. Munde was surprised on hearing that the question was 
still an open one in this country. 
On motion of Dr. Noeggerath, it was moved to continue the 
discussion at the next meeting. 
Stated Meeting, March 23, 1875. The President, Dr. Byrne, in 
the Chair. 
Dr. Hoeggeratii opened the discussion on the 
TREATMENT OF LACERATION OF THE PERINEUM 
by reading the following paper: 
After the discussion on ruptured perineum at the last meet- 
ing of this Society, it appeared that the statement made by Dr. 
Lente as an introduction to his paper on the lesion in question, 
had remained almost in statu quo. lie remarked: 
“ As the matter now stands, it is a difficult question for a 
young practitioner to decide, when he finds himself at the 
threshold, perhaps, of his obstetric practice, confronted by a 
considerable laceration of the perineum.” 
It was therefore resolved to continue the discussion on that 
important topic, and I will take this occasion to contribute my 
share in the matter as far as I am able to do so. I will first 
briefly touch upon the proceedings which have been mentioned 
during the discussion—proceedings for which it is claimed that 
they were apt to prevent rupture of the perineum. 
The first, which was incidentally mentioned, has been usually 
designated as Ritgen’s Manoeuvre. It consists in the expulsion 
of the head by means of two fingers placed in the rectum. It 
was, however, recommended already in 1781, by Drs. C. L. 
Ilofman and Hagen, and by Smellie as far back as 1754. It 
seems, however, not to have received the attention due to it, 
perhaps, from its reliable efficacy. Dr. Ahlfeld has lately 
again pointed out the great value of this manipulation in the 
Archiv fur Gynaecol., vol. vi., Ho. 2, 1874. Its principal object 
is to force the head into a space near the symphysis pubis, 
which is usually not occupied in the ordinary process of partu- 
rition. In this manner the head is lifted to a considerable ex- 
tent away from the perineum. Another advantage of this pro- 
ceeding consists in the fact that the perineum is kept succulent 
in the interval as it is during a labor-pain, in consequence of 
which the tissues become relaxed. With Ahlfeld quite a num- 
ber of prominent obstetricians employ it with success at the 
present day. 
The value of the second proceeding, scarifications and inci- 10 
Superficial Lacerations 
sions of the perineum, although spoken of in the highest terms 
by some authors, has not been so successful in the hands of 
others. Dr. (I. F. Abegg, Chief of the Royal School for Mid- 
wives at Danzig, speaks of it in the following manner: “ The 
lateral incisions of the perineum I consider entirely useless. 1 
used to employ them frequently in former times, but I have 
become convinced that in those cases where the perineum was 
not ruptured, it would not have suffered even without the inci- 
sions. On the other hand I have seen, after very large lateral 
incisions, such extensive lacerations of the perineum, that they 
could not have been larger without the use of the bistouri.” 
The able article of Dr. M. D. Mann, in the American Journal 
of Obstetrics, has been the primary incitement to Dr. Rente’s 
paper, as well as to our discussion, and it would seem that the 
very fact of its calling forth a discussion on this subject is 
proof sufficient that the proposition laid down in his paper has 
not had the influence with our specialists which it was expected 
to exercise, from its scientific value as well as from the confi- 
dence placed by the author in the recommendations resulting 
from its contents. This reasoning is strengthened by the tenor 
of the discussion at our last meeting. The members of this 
Society were evidently not convinced of the value of the serres- 
fines in the treatment of ruptured perineum. They have been 
weighing the arguments pro and con of all other proceedings 
to the exclusion of this apparently simple method of treatment. 
The a priori reason of this fact seems to me to be founded in 
the conviction that such a grave and serious lesion as a deep 
rupture of the perineum would not find means of repair in the 
application of a few serres-fines. 
1 will here remark that the term “superficial” rupture of 
the perineum in the heading of Dr. Mann’s article is a misno- 
mer for the lesion which he describes, inasmuch as he desig- 
nates by that name those ruptures which reach up to the sphinc- 
ter ani muscle. Now, when all of the tissues of the perineum 
are involved, we can no longer call it a superficial rupture. 
What then is the value of serres-fines in complete rupture of 
the perineum % 
Let us first see what Prof. C. Braun, the head of the Vienna 
School, which seems to have monopolized their use in our days, 
has to say about their application. In his well-known Klinik 
der Geburtslnilfe und Gymecologie he says : We also have seen 
their use followed by the desired result in many cases. In 
other instances, however, this method of closing the rupture 
has no good effect at all. After describing the conditions 
under which they must be applied, he goes on to say: A cor- 
roding discharge or restlessness of the mother more frequently of the Perineum. 
11 
prevents the success of the method. Patients of irritable con- 
stitution do not support them at all, since the application as 
well as the changing of the clamps is pretty painful. 
Serres-fines have been employed pretty extensively all over 
Germany, but apparently abandoned at the present time. 
Hoogeweg, of Berlin, cured 27 out of 38 cases. At the Mater- 
nity, in St. Petersburg, 12 were cured out of 82 cases, while 
Grenser had no success at all with them. Prof. Winckel em- 
ployed them in 36 ruptures occurring in the Clinic at Rostock, 
17 of which were healed more or less completely. According 
to his experience, they produce pain for a longer time than 
sutures, while they cut through just as readily as the latter, 
and where their ends are attached they are apt to cause ul- 
ceration. 
Prof. B. Schultze, the successor of Hoogeweg, tried them 
faithfully at first, but abandoned them finally for the suture, 
because the results from the latter proceeding far exceeded 
those of the former. 
AVlth the knowledge of these facts and opinions before us, it 
is proper to say, that the value of serres-fines is far from being 
established sufficiently to recommend them as the measure to 
be adopted in the treatment of deep rupture of the perineum. 
What then is the proper treatment for these cases ? It has 
been suggested in the paper by Dr. Lente, that it might be the 
best plan for the physician to ignore the existence of a rupture, 
partly on account of the possible injury done to the reputation 
of the attending physician, partly on account of the fact that 
a great many cases heal spontaneously. With regard to the 
former point, it is my firm conviction, that in framing therapeu- 
tical indications the welfare of the doctor should never be 
taken into consideration. Moreover, I believe that the damage 
done to the profession at large would be greater, if physicians 
were to ignore the existence of the lesion, and leave it to the 
patients to find out their condition afterwards—than if the 
accoucheur would deal fairly with every one of those that have 
confided their welfare into his hands. Let the physician pre- 
pare the friends and relatives of the patient for the possibility 
of such an occurrence, and quiet them with the assurance that 
he will put forth his best endeavors to avoid the accident. 
Should it then take place after all, he will not be blamed for 
ignorance or want of proper care. 
True, a large number of ruptures do heal up without any in- 
terference. But all authors agree at the present time that the 
parts, although healed over, are not reinstated to their natural 
condition ; that they are unfit to perform the physiological func- 
tions allotted to them. The drawbacks for the future welfare 12 
Superficial Lacerations 
of the patient have been sufficiently pointed out again and 
again by writers on gynecology, that I refrain from repeating 
them on this occasion. 
What, then, is to be done in the presence of a rupture of the 
perineum ? Nowadays there is not a dissenting voice among 
the leading obstetricians. To prove this I quote the words of 
Prof, von IIecker, of Munich. lie says: 
“ In no department of the obstetric science have the views 
been advanced and corrected so much during the last twenty 
years as in the prophylactic and curative treatment of rupture of 
the perineum ; almost all over Germany the same principles are 
represented, and it is fair to say that the questions on which 
there exist different opinions are of decidedly minor importance. 
In my opinion,” he goes on to state, “ the right way to manage 
every rupture, is the application of the suture as soon as pos- 
sible after delivery.” 
The reason why the early operation had been abandoned for 
some time, as a most unreliable proceeding, is explained by the 
want of knowledge of those conditions that are requisite to 
insure success ; and in the same measure as operations for other 
lesions of the female genital organs —that for vesico-vaginal 
fistula, for instance—have received an incredible impetus in 
consequence of our improved means of operating, in the same 
measure the opinion bas been generally adopted, that the 
immediate suture in all cases of rupture of the perineum is 
the only rational method of treatment. Prof. IIecker gives a 
report of the success of the immediate operation of forty-two 
ruptures, which took place among 1,5S4 deliveries, nine of which 
involved all the parts up to the anus, without injuring the 
sphincter ; twenty-eight were cured entirely, four partially, ten 
did not heal up. 
From the reports of the Lying-in Hospital of Dresden, pub- 
lished by Prof. F. Winckel in 1874, it appears that thirty-two 
ruptures, three of which reached to the sphincter, occurred in 
1868 after 775 deliveries. The operation was followed by 
complete success in twenty-two cases, by partial success in three, 
while seven remained open. In 1869, among 739 confinements, 
forty-five ruptures took place, one of which passed com- 
pletely through the sphincter ani; thirty-eight of these healed 
entirely by first intention, two only partially, no success in four 
cases, one wras operated later. In 1873, 1011 women were 
delivered ; the perineum was ruptured 115 times. In fourteen 
cases the lesion was not severe enough to call for interference. 
In 101 cases the immediate operation was performed, and ap- 
parently with full success. The report does not mention the 
contrary, nor does another report on the condition of the patients, of the Perineum. 
13 
when they left the hospital, from the 10th op to the 20th day 
after delivery, mention the existence of a single ruptured peri- 
neum. 
I)r. G. F. Abegg, of Danzig, performed the operation in all 
of the ruptures to the number of sixty-eight among 908 births; 
forty-two healed up completely, twenty-two only partially, four 
were not cured on account of puerperal ulcerations of the va- 
gina. Prof. Schroeder reports the success of the operation 
in eighty cases. Of these, twenty-seven healed up entirely by 
first intention, seventeen others were perfectly united, but 
granulated on the surface, fifteen were united in the deeper 
layers of the perineum, in fifteen the operation was unsuccess- 
ful, the result in six cases not known. lie ascribes these not 
very favorable results to the fact that the operations were all 
performed by students, who did them neither with sufficient 
experience nor accuracy. 
From the report of the Lying-in Hospital at St. Petersburg, 
published by Dr. E. Bidder and Dr. W. Sutigin, it appears that 
126 ruptures were united by sutures, which occurred after 1998 
deliveries. Among these sixty healed by first intention, thirty- 
four partially, twenty-nine were not cured, the result in three 
remained unknown. The unsatisfactory result is also attributed 
to the fact, that the operations were performed mostly by 
inexperienced young physicians. 
The best success was obtained by Prof, von IIolst, of Dor- 
pat, Russia, who claims to have (dosed up by first intention 
every single case in which he performed the operation. The 
same good results are claimed by Prof. B. Sciiultze, who suc- 
ceeded in uniting all of the thirty deep ruptures, upon which he 
operated immediately after confinement, with the exception of 
two, where the process of healing was interfered with by puer- 
peral ulcerations in the vagina. 
From a calculation of the results of these various statistics 
it would appear that complete success is obtained in about 
seventy-five out of every 100 cases. 
How, if we recommend the immediate operation, this does 
not exclude the admission of contra-indications. In my opinion 
the only one that ought to be considered as such is a low degree 
of vitality of the patient. If she be reduced by hemor- 
rhage, by a very protracted confinement, or other conditions 
complicating the act of labor, it would be unreasonable to 
insist upon immediate interference. The extent of the rupture 
itself should never be counted as an indication for delaying 
the operation. The reasons that call for an operation in a peri- 
neum ruptured up to the sphincter ani, gain in value in propor- 
tion to the extent of the rupture. It is a well-known fact that 14 
Superficial Lacerations 
the causes of rupture must be sought more in the condition of 
the tissues forming the perineum, than in the duration of labor; 
by which I mean to indicate that a very extensive rupture far 
up into the vagina by no means coincides in the majority of 
cases with a very low amount of vitality. 
Another contra-indication, which has been urged by several 
obstetricians, is the danger of puerperal fever spreading from 
the canal of the sutures, especially at the time of their removal. 
If this were really the case, we ought to be especially careful in 
New York, where we see so much of the fever almost every year. 
I have looked over the several works at my disposal to find an 
answer to this question, and I found it in the above-named re- 
port of the St. Petersburg Lying-in Hospital of Dr. Sutigin. 
Of sixteen cases of rupture, where no operation was per- 
formed, 6 per cent, remained free from puerperal fever, while 
among twenty-six cases which were operated 14 per cent, re- 
mained healthy—and while 12 per cent, died from it among the 
former, only 7 per cent, had a fatal issue among the latter. 
Thus patients in whom a perineal rupture is united immedi- 
ately after the accident, stand the best chance in an epidemic 
of childbed fever. And it is reasonable to expect that the 
closing up of the torn edges should diminish the surface from 
which septic deposits may be absorbed or even developed. 
Hence the prevalence of puerperal fever would rather establish 
an indication for immediate operation than otherwise 
Now after all these considerations I think I will not be ex- 
pected to dilate on other minor objections that have been urged 
against immediate interference; the fact, for instance, that 
the accoucheur was usually on such an occasion not provided 
with the necessary surgical apparatus, or that he was not skilled 
enough to perform the operation. In the first instance he has 
to send for his pocket-case, and in the second, for a more com- 
petent surgeon. 
AVith regard to my own experience I must say that when I 
began to practice in this city I was imbued with the doctrines 
which were taught seventy years ago, that it was useless to 
attempt union by an operation immediately after the accident. 
Of late years, however, I have operated upon every case where 
the general condition of the patient was such as to present no 
contra-indication against the use, or rather continuance of 
chloroform. I have made it a rule to give chloroform when 
the head is impinging upon the perineum in every case where 
I expect a rupture to take place, in order to have the operation 
performed before the patient is allowed to become conscious, or 
to spare her the pain of the lateral incisions, in case I should 
decide to employ them. Since I have no statistics to offer, I of the Perineum. 
15 
will state from memory, that in most instances the result was 
satisfactory, and that in those cases where union did not take 
place, this was owing, in one set of cases, to a want of reaction 
in the tissues involved, and on the other hand, the result of an 
insufficient number of sutures. 
I will briefly state that, except the paring of the edges, the 
method of operating is the same as that employed in ruptures 
of old standing. 
The last operation which I performed is an example of the 
faultiness of the recommendation to keep the bowels confined 
as long as possible. The patient was delivered on the 20th of 
September, 1874, after an easy labor of six hours. A rupture, 
which had existed from the last confinement, and involved even 
part of the sphincter ani muscle, wTas enlarged by this second 
labor so as to tear through the sphincter, and to some extent 
into the vagina. She was put at once under the influence of 
chloroform, and the operation performed in the ordinary man- 
ner, six sutures having been applied. I kept the bowels con- 
fined, because the patient had been subject to chronic diarrhoea 
for many months after the last labor. On the 26tli I removed 
a few of the vaginal and perineal sutures; the parts had united 
completely. In the night of the 28th the patient had a spon- 
taneous evacuation of the size of a large fist, and when I arrived 
to examine the parts, I found that the rupture was as bad as 
on the first day of the accident. By great care and the use of 
irrigations, repeated every three hours, the wound in the rec- 
tum healed by granulation sufficiently to keep the patient per- 
fectly comfortable ; and up to the present time she has had very 
little inconvenience from the almost complete absence of the 
perineum. 
Du. Paul F. Munde read a 
REPORT OF THE NUMBER OF CASES OF PERINEAL RUPTURE WHICH 
OCCURRED IN THE WURZBURG LYING-IN HOSPITAL FROM 1863 TO 
1870, THE MANNER AND RESULT OF THEIR TREATMENT, AND 
THE MEANS USED FOR THEIR PREVENTION. 
Among 2,560 deliveries, about 1,200 of which occurred 
under Dr. Munde’s personal supervision, or while he was resi- 
dent physician to the hospital, there were 44 lacerations of the 
perineum, that is one in 58 cases = 1.72 per cent. Of these 
lacerations 38 occurred in primiparse, 6 in multi parse, 43 in 
vertex, one in a breech presentation. This last case was in a 
primipara with very narrow vulva and long perineum, in whom 
the breech, which had been stationary at the pelvic outlet for 
24 hours, was manually extracted; notwithstanding bilateral 16 
Superficial Lacerations 
incision of the vulvar border (episiotomy) the perineum rup- 
tured in shape down to and on either side of the sphincter, 
without injuring that muscle; five sutures were applied and 
complete union ensued. Two of the 44 lacerations occurred in 
forceps cases. Of these 44 lacerations 34 were treated by im- 
mediate union with the interrupted suture, well-waxed double 
thread or silk being used. In one case one suture was applied, 
nine times, two; seven times, three; six times, four, and three 
times, five sutures; in eight cases the number of sutures is not 
noted. The legs of the patients were kept constantly tied to- 
gether, they were directed to occupy the lateral decubitus as 
much as possible, the bowels were kept confined until the day 
of removal of the stitches, generally the fourth or fifth day, 
and then opened by copious enemata. The urine was for a 
time drawn twice a day, but finding that the operation of ca- 
theterization necessitated more manipulation of the parts than 
seemed advisable, fearing also the danger of causing cystitis by 
the introduction of lochial fluid into the bladder by means of 
the catheter, especially as a sufficient separation of the labia 
was inexpedient on account of the laceration, Dr. Munde pre- 
ferred to allow the patients to urinate freely over the perineum, 
irrigating the parts immediately afterwards with warm water, 
and found this method much more satisfactory. In 10 cases 
no treatment was adopted, either because the lacerations were 
too slight in extent to require it, or because a syphilitic diathe- 
sis and the presence of broad condylomata on the perineum 
rendered a union by first intention improbable. In 11 of these 
34 cases there was complete, in 7 only partial union: 18 out 
of 34 = 55.5 per cent., about the usual average in hospital 
practice. 
Among 448 confinement cases of which Dr. Munde has ac- 
curate notes, there are mentioned only nine instances of episi- 
otomy. lie is confident that this operation was performed 
much more frequently, probably 40 or 50 times, but was con- 
sidered too unimportant to require notice except in special 
cases. It was customary during the time of service of Dr. 
Munde’s predecessor, as well as during his own, to keep the 
scissors close at hand with every primipara in whom the peri- 
neum appeared likely to yield to the strain occurring during 
the passage of the presenting part; as soon as the distention 
and pallor of the perineum indicated that that part had 
reached the point when the slightest increase of distention 
would result in its rupture, the blunt point of the scissors was 
inserted from to under the sharp border of the vulva, about 
l"from the perineal raphe, and the skin and subcutaneous cel- 
lular tissue divided until the white glistening fibrous fascia ap- of the Per ineum. 
17 
peared. This incision, if necessary, was repeated on the other 
side of the raphe. There can be no question that these sli ght 
incisions saved a number of perinea; Dr. Munde had too often 
seen their value to feel any hesitation in expressing this convic- 
tion. The incisions, although occasionally appearing large at 
the moment, diminished so much in size during puerperal invo- 
lution as hardly to be noticeable ; once only was it found neces- 
sary to apply a suture, and once a small branch of the common 
pudic artery was divided, requiring torsion. Notwithstanding 
bilateral episiotomy, four lacerations of the perineum occurred, 
one in cicatricial tissue, the residue of broad condylomata, and 
three in very high perinea. 
Dr. Noeggerath, in his remarks this evening, recommends 
very justly the method of preventing perineal laceration by 
supporting the perineum, and pushing the presenting part to- 
wards the symphysis by means of two lingers in the rectum—a 
method formerly described by Ritgen, and lately revived by Dr. 
Win. Goodell, of Philadelphia, and Dr. Frederick Ahlfekl, of 
Leipzig. Dr. Munde said that lie had no doubt that this was 
the best and, perhaps, only really efficacious mode of support- 
ing the perineum during labor, but he wished to call attention 
to two accidents which lie had seen happen, and which should 
be guarded against: 1. The flexible parietal bones of the foetal 
cranium may be indented by too strong pressure with the two 
fingers in the rectum, a circumstance which happened to him 
in one instance, the slight depression disappearing without sub- 
sequent evil consequences in a few days ; and 2. The laceration 
of the soft spongy cavernous tissue at the anterior commissure 
of the vulva in consequence of the too strong pressure of the 
head against the symphysis, and the over-distention of the soft 
parts by the broad foetal occiput. 
lie had seen this accident happen in a primipara, in whom 
the attending midwife supported the perineum in the usual 
manner by pressing the hand againt the part from the outside; 
notwithstanding this support a laceration of the perineum oc- 
curred, and when Dr. Munde was called to examine and unite 
it, he found a profuse hemorrhage taking place, as he first 
thought, from the lacerated perineum. On carefully sponging 
off the parts, however, the blood was found to proceed from a 
deep fissure, nearly 2" in length, through the cavernous venous 
tissue to the left of the clitoris. Styptics and pressure were ap- 
plied in vain, and the hemorrhage was not arrested until the 
whole bleeding surface was taken up en masse and ligated, by 
which time the patient had lost quite a large amount of blood ; 
she made a good recovery. 
This case is reported by Dr. Peter Muller, in Scanzoni’s 18 
Superficial Lacerations 
Beitrdge, vol. vii., p. 201, together with five cases of his own 
(three described in vol. vi., p. 148), in three of which the pa- 
tient succumbed to the hemorrhage from the ruptures between 
the clitoris and the urethra. 
In reply to an objection made by Dr. M. D. Mann to the 
operation of episiotomy, that the incision, besides being very 
painful, might become the seat of septic infection and diph- 
theritic deposit, Dr. Munde said that he had performed the 
operation very often, never with bad results ; that small abra- 
sions and lacerations of the vaginal entrance occur almost in 
every labor, from which septic infection might readily take 
place if there were any disposition to such an accident, and 
that one or two small incised episiotomy wounds would not in- 
crease that disposition ; the pain of the incision is so momen- 
tary that it is scarcely felt by the patient during the greater 
agony of the termination of the second stage of labor. Of 
course the operation should be performed only when there ap- 
pears no other chance of saving the perineum ; that it is much 
to be preferred to a perineal rupture scarcely needs mention. 
He had seen one case of superficial rupture of the peri- 
neum in a woman, the skin of whose perineum had been con- 
verted into cicatricial tissue by broad condylomata; in this 
instance he distinctly saw the cicatricial integument crack in a 
longitudinal direction as the head distended the perineum, and 
this superficial rupture extended to double the extent of the 
moderate actual complete rupture. He would ask whether it 
is justifiable not to treat by immediate suture a perineal lacera- 
tion in a syphilitic person, or whether it should be united and 
the chance given it to heal. He thought the latter, for he had 
in Germany treated several bad sabre wounds of students, who 
were notoriously syphilitic, by the immediate suture, and had 
seen them heal by first intention. 
Dr. Noeggeratii said that it was a common surgical rule not 
to operate in syphilitic cases, until the syphilitic taint had been 
at least apparently removed. This applies to secondary opera- 
tions. A certain diseased condition of the arterial coats in 
syphilis (which has thus far, however, been observed only in 
the cerebral arteries), would appear to prevent union of the 
wound. In a fresh woundf such as laceration of the perineum, 
he does not think that we would be justified in refusing the 
operation merely on account of syphilis, although there is less 
chance of success. Sigmund, of Vienna, however, asserts that 
wounds in syphilitic persons heal quite as readily as in healthy 
people. 
Dr. Byrne related a case of laceration 2" up the recto- 
vaginal septum, which occurred some three months ago during of the Perineum. 
19 
labor. The patient was too much exhausted to permit an im- 
mediate operation. The laceration has gradually united spon- 
taneously, and the woman has now almost recovered the use of 
her sphincter ani. 
CONTINUATION OF THE DISCUSSION ON THE TREATMENT OF PERI- 
NEAL LACERATION. 
Dr. Mann said that, as the subject of immediate treatment 
of rupture of the perineum had excited some attention of late 
in the Society, he would like to present one of the serre-fines, 
the employment of which he had recommended in his article 
in the American Journal of Obstetrics for A o vein tier, 1874. 
This one came from Vienna. It would be seen that it was not, 
as Dr. Leute had said in his paper, a very strong serre-fine, the 
spring of this one being quite weak. 
Dr. Mann did not think that Dr. Noeggerath’s figures in his 
paper as read at the last meeting, w’ere quite fair. lie had cer- 
tainly shown that the result obtained by some form of opera- 
tion were much better than could be expected where we were 
merely content with tying the knees together and enjoining rest. 
But he did not think that the superiority of the suture over the 
serre-fines was so clearly .established as Dr. hfoeggerath would 
lead us to believe. Dr. Noeggerath had counted 115 cases 
reported by Winckel as being all cured, because nothing was 
said to the contrary. This was hardly fair, however, as the 
reports of previous years from the same institution had not 
shown any such results. It could hardly be expected that they 
would jump from 38 cures in 45 cases to 101 cures in 101 cases 
(14 were so slight as not to require suture). Leaving out then 
these cases, the percentage of cure is reduced to 56 per cent.,, 
while by serre-fines the cures had been about 38 per cent, 
lloogeweg, however, reported 27 cures in 35 cases, or 77 per 
cent, by the serre-fines. It was hardly fair to conclude because 
one man obtained no success, and another very poor results 
from the use of the clamps, that it was the fault of the instru- 
ment. The fault lay rather in the operator, or how could one 
get so much better results than another? Perhaps, also, the 
springs were too stiff, or they were not properly applied. At 
any rate, the fact remained that 77 per cent, had been cured, 
and what one man had done, another could do. Dr. Mann; 
hoped that the clamps would be tried by the profession in this 
country, and that the subject would be discussed until some 
definite plan was decided on. 
Dr. ]M oeggerath said that he had had some hesitation in ad- 
mitting the 115 cases into his statistics, but had been led to do 20 
Superficial Lacerations of the Perineum. 
so from the fact that a very careful report of the condition of 
the genital organs of each patient was given before she left the 
hospital, and'nothing was said about rupture. He therefore 
thought they could be safely counted as cured. As to serre- 
fines he thought they occupied the same position in the treat- 
ment of rupture of the perineum as they did in general sur- 
gery ; twenty years ago they were in general use, but were now 
abandoned, because it was found that they did not unite the 
deeper tissues, only the skin being held in apposition, while 
the muscles were allowed to retract and consequently did not 
unite. 
Dk. Mann said that he did not think the cases were parallel. 
In the perineum after labor the tissues were all relaxed, and if 
the patient were placed on her side or the knees kept together 
the entire surface of the wound was brought in contact. That 
was why we had so many cases of spontaneous union. The 
only danger was that they would slide or slip one on the other, 
and that they would gape, and this was prevented by the serres- 
fines.