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• 
CASE OF COMPLETE  LACERATION  OF THE PERINEUM.

Successfully operated on  by  Orson  Wood, M. D., and  read by  him
  before the Tolland  County Medical $ociety, at their annual meeting
  in  April, 1858.



  Nov. 12th, 1857, I was called upon to visit Mrs. E., a stout, fleshy,
robust woman, aged  25 years.   She informed me that  six weeks  pre-
viously she gave birth to  a child, (her  first) and that at the time of
its  birth she was "torn open," and ever  since that time she had no
control over her bowels, to retain  either foecal matter or wind;  that
the womb  threatened to  protrude externally if she exerted herself
when in an erect position.  She wished to know if  anything could be
done to relieve her of her miserable condition.  Her attending physi-
cian had left her, telling her, " it would grow up in  time."
  On examination, I found the perineum  completely lacerated to the
i-nus, and the external sphincter ani muscle so nearly torn through as
to be of  little or no use in constricting  the anal  orifice.   I  told  her
that it would never heal up of itself; that nothing  short  of a tedious
operation would relieve her of her miserable condition, and  that  she
must make up her mind either to submit to the operation, or go through
life in her present condition, with the additional trouble of having her
womb come down externally if she used much laborious exercise.
  After  explaining  to her the nature and extent of the operation I
proposed, at the  same time encouraging her with the prospect of a  per-
fect cure, she  was anxious to have it performed.  I advised her to
have the operation postponed until after the third month from the birth
of the child, so that the parts shall have recovered  themselves to be
capable  of undergoing the necessary denudation, and be sufficiently
strong to hold the sutures.
  Dec. 25th, 12 weeks and  five days from the birth of her  child I
was informed that she was ready for the  operation, and accordingly
proceeded to do it.  The bowels having by a laxative and enema been 
78
previously emptied, she was seated  upon a table and put under the
influence of chloroform.  She was  then  placed in the same position
as for lithotomy, and the bladder emptied.   While an assistant seized
one of the labia so as to make it tense, I  made two parallel  incisions
with a scalpel f of an inch  apart, and equal to the fissure in length,
through the skin into the cellular substance, the inner incision passing
along the inner edge of the fissure.   The next step was to dissect up
the  skin  between  these incisions, so as to make a  raw surface of at
least f of an  inch wide.   A  similar operation  was next performed
on the opposite side.  Next, the mucous membrane of the recto-vagi-
nal  septum was carefully pared away.  The denudation was now made
perfect throughout the whole extent of the fissure.  Not  the smallest
remnant  of skin or membrane was left  on the parts intended  to be
united.
  This part of the operation being completed,  the next step was, with
fore-finger of the left hand in the anus for a guide, to introduce a blunt
pointed bistoury into its margin, and then with a firm and quick incis-
ion  I carried the bistoury outward and backward towards  the os coccy-
gis, making the incision about two inches in length,  and deep enough
to divide the skin, subcutaneous areolar  tissue, and the sphincter ani
muscle.  A similar incision was next made on  the opposite side so
that the sphineter ani muscle was completely divided on  both sides of
the anus, which incisions were in the form of the letter V.
  I  next  proceeded to insert the quilled sutures.  With the  thumb
and finger grasping firmly the left denuded surface, a strong  needle
armed with a double thread of stout twine, well  waxed, was plunged
through the skin and  subjacent  tissue, an inch external  to  the pared
surface, and thrust downwards and  inwards beneath it, until its point
reappeared on the inner edge of that surface ;  it was then introduced
at the corresponding margin of the denuded space of the  opposite side,
and made to traverse beneath it in a direction  upwards and  outwards,
until it escaped at a point equidistant from the external  margin with
that at which  it entered on the left side.   Two quilled  sutures were
thus introduced, the first one was passed  as near the rectum as possi-
ble without injuring it.  A quill was then introduced through the loops
of the twine on the left side, and on the right  side the ligatures were
cut from the needles, parted, and tied over the quill on that side, after
having drawn the parts firmly together.  The quills used were pieces
of gum elastic catheter, which answered  the purpose well.   To bring
together the outer margins  along the line of the skin, I inserted inter-
rupted  sutures superficially.  The parts were then well cleansed by 
79
sponging with cold water, and lint soaked in the same was applied over
the wound, and over this a napkin, kept in place by a T bandage.  The
patient was then laid in bed on her side, her knees tied together, and
her limbs flexed.   She now asked me when I was going to begin the
operation.  She had been entirely  unconscious of its performance.
   Two grs. of opium were now given, and gr.  1, to  be taken  every
4 hours.   The parts to be kept constantly wet with cold water.
   Dec. 26th.  Visited her  early this  morning.   She had a restless
night—vomited twice.  Passed catheter and drew off the water.   Diet,
arrow root; allowed to drink cold  water, and to hold ice in the mouth.
Was sent for this afternoon.   She  had  vomited severely, so as to strain
on the stitches.  Morphia, with Plumbi Acetas for the Opium.  Dried
herring and  crackers for food.   Urine  again drawn off.  In doing
this, the greatest caution was used  to prevent any water from dribbling
into the wound or vagina.  Owing to the position she was necessarily
kept in—on her side—the catheter had to be passed from behind.  She
was expressly charged not to let  any  urine be discharged except by
the catheter.  The quantity of water drawn off  in the morning was a
pint; in the  evening about half a  pint.
   27th, morning.   Found she had  a  comfortable night;  no vomiting
 since commencing with the Morphia and herring.   On  passing  the
catheter  this morning,  a little bloody  muco-purulent matter  came
through the instrument,  but no urine.   She had  no desire to pass any.
I syringed a little warm water into the bladder to rinse it out three
times, the last  time the  water returned clear.  I now learned for the
first  time that she had had  several times since her confinement thick
bloody matter pass from her  bladder, and but a short time, too, pre-
vious to the  operation.   The meatus and urethra were very sensitive.
Perineum cedematus;  continue morphia and lead;   cold water  un-
remittingly.   Evening.   Patient  feels comfortable.  No  urine  could
be obtained, but matter came through the catheter similar to that which
 passed in the morning.   Applied  to the meatus  lint soaked in a  solu-
 tion  of Acet. Plumb.
   28th, morning.   Slept well last night.   Expressed a desire to pass
urine ;  passed  catheter;  nothing  obtained but a teaspoonful  of puru-
 lent  matter—not  bloody;  begins to  complain of uneasy sensations
across the hips, back, and  lower  limb of the right  side. Has  been
 turned alternately on each side two or three times daily, though I pre-
 ferred that she should remain quiet in one position  on her side, but
 this she could  not be persuaded to submit to.   Wound  looks well, as
 if the parts  were uniting; has less appetite; does not wish  for any 
                               80

more herring;  pulse good;  complains of head feeling  bad.    She
drank some new cider last night, which threatened to move her bowete,
and she immediately took 1 gr. of opium, left  her to take  in  case lie
bowels threatened to move.   It quieted them; continued  to take tne
morphia and lead every 4 hours.                          #
  Ordered the Pipsissewa and Pumpkin  Seeds in decoction, to be
drRtik freely
  29th.  Did not see her last evening;  had left the catheter with the
nurse ; instructed her in  the use of  it, with directions for her  to  pass
it should the patient express a desire to  void her urine.  She  had
tried two or three times without obtaining any.   There appeared  now
to be an accumulation of water in the bladder, considerable distention
above the pubis, and a strong desire expressed by the patient to  pass
it;  she was uneasy, restless—pulse 100.  Both metallic and flexible
catheters were passed, warm  water syringed into the bladder, which
returned through the instrument in a full stream, at first bloody, with
mucus.   This  was  repeated until the water  returned clear.   She
thought if I would allow her to do so, she could pass her water by her
own efforts.   As no urine had been obtained  for more than  62 hours,
I consented to  let her  try.   Rolling her over partly upon  her  face,
so that the urine could not dribble into the wound, she was allowed  to
make as much effort  as she pleased.   After trying awhile without  suc-
cess, she thought she could, if left alone.   I left her with the nurse,
when she continued  further fruitless efforts, until she voluntarily re-
linquished any further efforts to pass it.  I left her about % past 11
A. M. with a flexible catheter remaining  in  the bladder.   Returned
at 4 P. M., and was glad to find  that a large quantity of water  had
come away, and the  bladder  appeared to be  emptied, and  she  was
much relieved.
  " 30th.  On  my way to visit the  patient this  morning, I met her
husband who requested me to hasten to see his wife as she was in dis-
tress.  I found her complaining of pain through her hips,  extending
down her thighs to her knees, and  feeling a strong desire to  urinate.
She said she had passed quarts of  water  during the night,  which she
allowed to be passed in a kind of half prone position, to prevent it  from
coming in contact with the wound.  It was received on napkins, which
were stained bloody.   I questioned her if the catamenia  had not re-
turned.  She was sure not, for she said there was no bloody discharge
except with the water.   I passed the catheter and drew off  a full pint
of water tolerably clear,—rinsed the  bladder with water,  and also the
vagina.  Immediately she became easy—pain in hips and limbs gone, 
81
and felt that she could now go  to  sleep—pulse  100.   Removed one
of the interrupted sutures.  The  quilled suture near the  anus had,
during her restless state, been accidentally pulled upon  by her hand
so as to stretch and disturb the parts which it held together.
   Discontinue the diuretic decoction.   Continue morphia and  lead—
To take 3 or 4 ounces of wine daily.
   31st.  Found  her lying  upon her  back with her  knees bent up.
She had been requested to keep on her side, which she had done up to
this time, though frequently changing  sides  by being  carefully rolled
over in bed, her knees being still kept tied together.  Has not  passed
urine since I drew it off yesterday morning.  Nurse had made  several
attempts to draw it off but  failed, and she could not  pass it  by any
effort of her own.  I turned her upon her side and drew off a half pint,
high colored, but not bloody.  A little purulent matter was lodged be-
tween the  vulva before the meatus.  Removed the remaining inter-
rupted sutures.   Continue  morphia without the lead.   Spts. Nitre to
be taken.
   Continued to do well till discharged on the 25th.
   25th.   The hole through  the perinseum is nearly closed.   She would
not submit to have  the  caustic applied again.   Applied the  acetum
cantharis again.  Direct  her  to use it every  third day until it closed
up, which  it did in a few days after this.
   She  expressed herself highly pleased with the cure, and says her
recovery is perfect in every respect.

                             REMARKS.

   Had I known the unsound condition of the urethra  and  bladder at
the time of the operation, I should have  proposed to delay it, until the
 parts become sound.  It caused much trouble in the  after treatment,
 endangering the union of the wound.  I deemed it essential to  prevent
 any urine  passing to the wound, as it would  if it got between  the cut
 surfaces most  likely have prevented their union.   Brown says "it is
of great importance to draw off the urine every four or six hours  for
three or four, or more, days after the operation."   In this case  it could
 not be attended to so often.   The distance (3 miles) I resided from
 the patient, made it impossible for me to attend to  it so  often,  and  the
 nurse, who was instructed to  do it, did not succeed, owing  in  a great
 measure to the diseased and sensitive  condition of  the urethra, and the
 unfavorable position in which the patient had to lie.
   The constant application of cold water dressing  was very agreeable
 to the sensations of the patient, and she often  called for their renewal.
               11 
82
    It will be perceived from the history of this case, that special atten-
  tion was paid to keep the bowels  constipated until the  parts had be-
  come so firmly united as to prevent their being torn  apart  by the
  passage of foecal matter.  From  inattention  to  this important point,
  and allowing discharges from  the  bowels too soon after the operation,
  disruption of the union of the parts has  been caused, and the  whole
  benefit of the operation frustrated.   In this  case they were not allowed
  to be moved  until the 14th day after the operation;  and even then,
  she felt a sensation of tearing  in  the wound,  on  the passing of some
  hardened feces, but I think it did no essential injury, as the union was
  now pretty firm throughout the whole extent of the wound, except the
  small opening near the rectum.
    Whether the small opening was  caused by the accidental pulling or
  " catching (as the patient expressed it,) with her hand "  upon the lower
  end of one of the quills, or from  the  great difficulty of  making that
  part of the fissure unite  by the  first intention, I am unable to say.
  This accident happened during the restless night that she discharged
 so great a quantity of water in the  bed  upon napkins which, as men-
 tioned  in the history of the case, were much stained with  blood, and
 was the fifth night  after the operation.  It may well be supposed that
 some of the urine  did come in contact with the wound, and was in-
 sinuated between the lips of that  part which she  disturbed so  as to
 prevent or break up  the union  of it.  In examining the parts, next
 morning after the  accident, the end of the quill  near  the onus was
 pulled up from the  bed in which it  had lain, the  deep suture  in that
 place appeared to  have been disturbed, and a little purulent  matter
 appeared  at that part  of the wound.  I am  the more particular in
 stating these facts because  the  manner in which this  operation was
 performed has, according the statement of  Brown, most  generally in
 his hands, (though not  in every instance,) resulted in a perfect union
 of the entire perineum by the first intention.   When there has been a
 failure with  him it always has been at the place it was in  this case.

              DIVISION OF THE SPHINCTER  MUSCLE.

  It may, perhaps,  be asked, why I divided the sphincter ani muscle,
on either side from the anus toward the coccyx?  I will not  here
go into a lengthy discussion on this  point.   A  few facts stated will I
 hope  make  the  reason obvious.   From  the uncertain, and most fre-
quently, xmsuccessful results of  the  operations heretofore  devised  the
opimon of surgeons  in England  has, until quite recently, been to aban 
83
don these cases to the operations of nature, to narrow the parts as best
it might, which has generally left the unfortunate subjects of it to pass
through  life, in  cases where the  laceration was  complete, in a very
miserable condition, which can well be imagined, but which I will not
now take time to describe.
  Dr. Robert Barnes says, " I believe that no amount of skill and pre-
caution will  justify the  surgeon  in the  majority of cases, in looking
for perfect union by means of any of the  sutures in common use.   He
claims to have succeeded in one case by means of the  lead  suture in-
vented by Mr.  Brooke.   Mr. Ferguson succeeded (in 1850) in one
case  with the interrupted sutures, and by adopting Dieffenbach's plan
in making parallel incisions in the long diameter of the perineum, and
filling them with dry lint.  In his second case, he succeeded  but par-
tially.
  To say nothing of Hilton's operation, which he seems to have  aban-
doned, Mr. Lungenbeck, in three cases reported, succeeded in making
complete union in one case by the first intention, and in two cases the
central portion of one was open four or five lines in length with sup-
puration; and the other, the wound about half an inch posteriorly.
These were eventually closed by granulations.  In his  operations,
flaps were dissected up, and Dieffenbach's incisions made.
  In the case which I have reported, the operation was  performed in
the manner recommended by Brown  in his recent work on Surgical
Diseases of Women.   He  there  strongly advises the  division  of the
sphincter muscle; and  his  cases,  of which he has had  many, have
mostly resulted in complete  union  by the first  intention.   Some few
cases have partially failed, by a small opening near the rectum, as mine
did.   In one case where he divided the  sphincter only on one side, it
partly failed.  He afterward divided it on the other side and it suc-
ceeded.
  By freely dividing this muscle, the parts are relaxed, which allows
the sides of the fissure in front of the  anus to be more easily approx-
imated, and prevents them from being drawn apart by its traction.
  I am  aware  that Horner * failed entirely to secure a union of the
parts in which he operated on in 1848, although he divided the sphinc-
ter ani muscle.   But he used only the interrupted  sutures.  He says
" the operation was a failure, though the  bowels had been kept  unop-
ened for many days."   He says nothing  about the urine.   If that was

          * Am. Journ. Med. Sciences, No. XL., page 329, New Series, 
84
 permitted to  come in contact with the wound, it would, most likely,
 have prevented a union of the parts.
   If the operation is well performed  in  every respect according to
 Brown's  method, and strict  attention paid to the after treatment as
 recommended by  him, a perfect union of the  parts may be effected, I
 believe, in every case, even of the longest standing, provided no un-
 toward accident happens to  the patient,  to prevent  it.    Cases are
 reported by Brown of ten, fifteen, and more years  standing, in which
 he made perfect cures.  Any small opening that may be left after the
 union of the greater  part of the fissures, can be  healed  by granula-
 tion, as it was in the case I have related, and the unfortunate subjects
 of this  accident be thus relieved  from an  otherwise miserable exist-
 ence.
   1*. S.   It may  not  be  improper  to  state that  the  laceration was
 caused  by the neglect, or rather mismanagement, of the  attending
 physician.  All that he did in the last expulsive pains, (as I was in-
 formed by the mother,) was to use pressure on the abdomen with his
hands.