A 
PLEA FOR EPISIOTOMY. 
S BY 
V 
W. P. MANTON, M.D. (Harvard), 
Detroit, Mich. 
/ ) 
Reprinted from The American Journal of Ohstb-tiucs and Diseases of 
Women and Children, Vol. XVIII,, No. 3, 1885. 
NEW YORK; 
STEAM PRESS OF INDUSTRIAL PRINTING COMPANY, 
Stettiner, Lambert & Co., 
Nos. 129 & 131 Crosby Street, near Houston St. 
1885. A 
PI FA FDR RPISIffiTIMY 
. IjJUjl 1 I U11 iJl lUlU I Ul'l 1 1 
BY 
W. P. MANTON, M.D. (H arvard), 
Detroit, Mich. 
Reprinted from Thf. American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XVIII., No. 3, 1885. 
NEW YORK; 
STEAM PRESS OF INDUSTRIAL PRINTING COMPANY, 
Stettiner, Lambert & Co., 
Nos. 129 & 131 Crosby Street, near Houston St. 
1885. A PLEA FOR EPISIOTOMY.' 
BY 
w. P. MANTON, M.D. (Harvard), 
Detroit, Mich. 
In looking over the literature of the expulsive stage cfla- 
bor, one is rather surprised to find the scanty reference made 
to what should be considered one of the most important of sur- 
gical procedures for the prevention of perineal rupture, namely 
episiotomy, or the lateral incision of the perineum. 
Enough is said pro and con. the use of perineal support to 
enable one to form an opinion as to the value of such assist- 
ance ; the inunction of fats and oils—of most doubtful ser- 
vice—in cases of rigid perineum, is fully explained; and 
the proper use of the forceps is clearly demonstrated. Yet of 
the surgical enlargement of the orificium vulvae we find only a 
hint, or at most the method is discussed in a few inadequate 
lines.'1 Thus one author says: 
1 Since this article was begun, a paper from the pen of Prof. Crede, of 
Leipsic, on the same subject has appeared in the Archiv fur Gynako- 
logie, Bd. 24, p. 150. In the revision of my own article I have availed 
myself of this paper and Prof. Crede’s experience. 
2Lusk: “The Science and Art of Midwifery,” London, 1884, p. 210, 
gives the fullest account of this operation of any author I have con- 
sulted. 4 
Manton: A Plea for Episiotomy. 
“ But there are eases in which rigidity is the cause of rup- 
ture ; and when the latter is impending, we may occasionally 
be justified in making a slight incision with a lancet, or tear 
with the finger-nail if possible, on each side of the ostium va- 
ginae.” 1 
Another writes: 
“When the tension is so great that laceration seems 
inevitable, it is generally recommended that a slight incision 
should be made on each side of the central raphe, with 
the view of preventing spontaneous laceration. This may no 
doubt be done with perfect safety, but I question if it is likely 
to be of use. The idea is that an incised wound is likely to 
heal more readily than a lacerated one. When, however, a dis- 
tended perineum ruptures, its structures are so thinned that the 
tear is always linear; and, as a matter of fact, the edges of the 
tear are always as clean, and as closely in apposition, as if the 
cut had been made with a knife. Moreover, the laceration in- 
variably heals perfectly if only the edges be brought into con- 
tact at once with one or two metallic sutures.” * 
When the former author says “ there are cases in which 
rigidity is the cause of rupture,” lie tells but half the story, 
and leads the reader to believe that rigidity alone, if anything, 
calls for the use of the knife. This certainly is a mistake 
which I shall endeavor to explain further on. 
But when so distinguished an accoucheur as Dr. Playfair 
says of episiotomy that he “ questions if it be likely to be of 
use,” we must believe that the operation has not been done 
sufficiently often in the lying-in wards of King’s College Hos- 
pital to prove its efficacy. One hesitates to criticise the opinions 
of men who are known to the world as Nestors in their indi- 
vidual specialties, and yet investigation often tends to overthrow 
such opinions, and place in their stead facts, which in their 
turn must also pass through the fire. 
“ If a laceration is inevitable,” says Matthews Dunjan, “ treat- 
ment to prevent it can be of no avail.” 3 
How then, we ask, are we to know if a laceration is inevitable ? 
Arguing from the above the only answer can be, “wait and 
see; if it tears, it tears; otherwise no harm is done.” 
1 Leishman: “System of Midwifery,” 1879, p. 271. 
2 Playfair : “ The Science and Practice of Midwifery,” vol. I., London, 
1882, p. 339. 
3 “ Papers on the Female Perineum,” London, 1879, p. 16. Manton : A Plea for Episiotomy. 
5 
But Dr. Duncan is more progressive than the last writer 
quoted; lie does not stop with the inevitable, but goes on to 
say that, “ all the lacerations of the orifice of the vagina are 
not inevitable; and that one which is so may be treated 
with a view to prevent its extension beyond the inevitable 
degree.” 
I am of the opinion that the statements that a perineal tear is 
“ always linear,” and “ that it invariably heals perfectly,” even 
when the edges are brought into contact at once with one or 
two metallic sutures, are fallacious. 
In answer to the first let us turn to the obstetrician of St. 
Bartholomew’s, than whom no one has done more to give us a 
clear understanding of the functions of the perineum. Speaking 
of certain cases, he says : 
“The injuries are called lacerations and tears, because these 
words express their mode of production. Most were like 
clean cuts, some more or less ragged on the edges. Others 
might be called deep abrasions and have been designated as 
ulcers.” 1 
The majority of perineal tears are linear but are not always 
such; a number which I have seen have been “ragged.” As 
to “invariably healing,” even when sutured, Dr. Thomas says: 
“There are three circumstances which tend to defeat the sue 
cess of immediate operation. First, it is often performed by 
one not habituated to its performance; and, being practised 
upon a woman who, having just been delivered, is exposed to the 
danger of post-partum hemorrhage, and surrounded by anxious 
friends, it is likely to be finished too hastily. 
“ Second, the lochial discharge, constantly passing over the 
lips of the wound, is very likely to enter and prevent union. 
“ Third, the operator, having been taught to regard the peri- 
neum as the superficial layer of tissues intervening between the 
fourchette and anus, closes this by correspondingly superficial 
sutures, leaves the upper portion of the perineal body open, 
creates a pouch for the accumulation of putrefying materials, 
and leaves the anterior vaginal wall and bladder without support 
in the future.” 2 
Winckel says : 
“ If the perineum was healthy before the rupture, and the 
1 L. c., p. 23, the italics are mine. 
* “ Diseases of Women,” 5th edition, 1880, p. 189. 6 
Manton : A Plea for Episiotomy. 
operation carefully done, about 65 per cent heal entirely by 
first intention.” 1 
But a large number of perinea which rupture are not 
healthy before the tear takes place ; this being a frequent 
cause of the lesion. Hence, a much smaller percentage of 
cures than Winckel gives must be taken as nearer correct. 
Ahlfeld, writing of this laceration in elderly primiparae, says 
that: 
“ The wounded surfaces often have in such cases a mangled 
appearance. To this circumstance it is due that healing in the 
entity by first intention seldom takes place.” 2 
Of eighty perineal ruptures reported by Schroeder : 
“ Twenty-seven healed completely, seventeen were united, but 
granulated along the wound where the skin gaped a little in 
places, or where a small granulating spot was found above on 
the frenulum; fifteen were healed at the bottom in the vicinity 
of the lowest sutures, while the upper part gaped ; and in fif- 
teen no union whatever took place. In six the result was not 
noted. 59.46 per cent are therefore to be regarded as com- 
pletely healed; 20.27 per cent as incompletely, and 20.27 per 
cent as not at all.” 3 
In a number of cases which have come to my notice, the 
patients have absolutely refused to have the parts “ sewed up,” 
immediately after labor, and have been obliged either to submit 
to a later operation, or endure, perhaps, the discomforts which 
so often supervene on lacerations of this part. 
The secondary or remote sufferings to which the subject of a 
lacerated perineum is liable—the reflex nervous, as well as 
from anatomical changes and displacements—are too well known 
to need mentioning here. It will, however, be* of interest, as 
hearing upon the value of episiotomy, to glance for a moment 
at that class of cases which is pre eminently predisposed to this 
misfortune, and afterwards at the percentage of lacerations 
which take place respectively in primiparae and multiparae. 
“ It would appear,” writes Duncan, “ that in the Darwinian 
progress of the species the head of the fetus has increased in 
1 Die Pathologie und Therapie des Wochenbettes,” 3d edition, 1878, 
p. 61. 
* Arch, fur Gynaekologie, Bd. iv., p. 510. 
3 “ Schwangerschaft, Geburt, und 'YV’ochenbett,” 1867, p. 164. Manton : A Plea for Episiotomy. 
7 
size more rapidly than the orifices and passages through which 
it lias to come, have increased in size and dilatability.” 1 
Whether or no we accept this theory of a symmetrical devel- 
opment of the two parts, the fact remains that in a pretty large 
number of cases there is an absolute disproportion between the 
periphery of the fetal head and the soft parts of the mother. 
“ If we acknowledge this,” says Olshausen,2 “ then we can 
with propriety assume that in a like proportion of births episi- 
otomy may be of service.” 
Disregarding deformities of the pelvis and the fetus, which 
are not infrequent causes of perineal rupture, we have remain- 
ing causes due to the patient herself, abnormal conditions of 
the vulva and perineum, and manual and instrumental de- 
livery of the child. Tho patient herself may produce a lacer- 
ation by too violent bearing down or straining, especially 
when the uterine contractions are abnormally strong or 
“ stormy.” 
Position during delivery no doubt also plays an active part 
in producing this lesion. ' The soft parts may have undergone 
some previous operation ; or disease, such as syphilitic orscrofu- 
ous ulceration, may have rendered the perineum dense, hard, 
and cicatricial in character. 
Acute and chronic edema of the parts, as in delayed second 
stage, in nephritis, and sometimes in twin pregnancies and 
hydramnios, leave the tissues in a soft, doughy, and non-re- 
sisting condition. 13. Schultze further gives as a cause the 
abnormal rigidity of the ligamentum triangularis, which 
Winckel thinks is probably very often confounded with con- 
tracted pubes, a condition rarely seen, except in osteomalacia. 
I have found two classes of women particularly liable to 
rupture. In the first we find dark skin, and well developed 
muscles, covered by a dense layer of adipose tissue. Here the 
perineum is usually thick, stiff, and unyielding. The second 
class of patients are women almost the opposite of the first, 
having a loose, flabby, soft muscular development. Here the 
perineum may distend like India-rubber, but is liable to tear 
1 L. c., p. 7. 
2 Volkmann’s “ Klinische Vortrage,” No. 44. 
3 See Aveling, “ Position in Gynic and Obstetric Practice,” 1878, p. 138. 
also Hecker, Arcin'v fur Gyncekologie, Bd. xii., p. 97. 8 
Manton: A Plea for Episiotomy. 
without the slightest warning. I have heard old midwives 
designate such as a “ butter ” perineum. 
Incidentally, other conditions of the tissue may lead to rup- 
ture. 
Of instrumental, etc., interference, nothing need be said, as 
rupture from this cause very often depends upon the skill and 
experience of the practitioner. 
Statistics as to the frequency of perineal laceration may he 
of little value per se, yet they direct our attention to the very 
common occurrence of this lesion, and lead us to inquire if 
there be not some remedy or prophylactic for so great an evil. 
It would be very interesting could these figures be drawn 
from the private practice of our leading obstetricians ; but there 
always seems to be so great a reluctance on the part of most 
physicians to discuss perineal ruptures which have occurred in 
their own patients, that it would be next to impossible to bring 
together such a collection. 
The results appearing in the following tables have been 
taken from various German authorities, and, although few in 
number, will give an idea, at least, of the frequency of perineal 
ruptures in the great lying-in hospitals of that country. 
/.—General Percentage of Perineal Ruptures. 
1,105 cases 
22, per cent 
Winckel2 
No. of cases not given. 
20. * “ 
Hildebrandt.3 
<< a n u 
7.2 
Hecker4 
<( H U a i i 
3.66 “ 
7,190 cases 
3.47 
Spiegelberg6 
3,000 “ 
3.5 
II.—Percentage of Ruptures Occurring in Priuiiparce. 
Preiter5 
In 250 cases of rupture. 
“ 120 “ “ 
88.4 per cent. 
82.60 “ 
Winckel2 
Schroeder1 
No. of cases not given. 
it it it it ft 
34.5 
Olshausen8 
21.1 
1 Quoted by Winckel, 1. c., p. 60. 
2L. c., p. 60. 
3 “Krankheiten d. ausseren weiblichen Genitalien,” 1877, p. 71. 
4 Arch, fur Gynakologie, Bd. vii., p. 448. 
6 Winckel, 1. c., p. 60. 
6 “ Lehrbuch der Geburtshiilfe,” 1882, p. 572. 
1 “ Lehrbuch der Geburtshiilfe,” 1880, p. 679. 
8 “ Ueber Dammschutz und Dammverletzung,” Klinische Vortrage, 
No. 444, Manton : A Plea for Episiotomy. 
9 
III.—Percentage of Ruptures Occurring in Multipart. 
Winckel1 
In 120 cases of rupture. 
“ 250 “ “ “ 
16.66 +per cent. 
11.6 “ 
Preiter5 
Litzmann 
“ 496 “ “ “ 
11.49+ “ 
9. “ 
Schroeder3 
No. of cases not given. 
<< n a a a 
Olshausen3 
4.7 
Some interesting figures have been published in regard to 
the occurrence of rupture in elderly primiparse. 
IV.—Percentage of Ruptures in Elderly Primiparce. 
Grenser4 
In 42 cases 
Ahlfeld6 
“ 102 “ 
30. “ 
Hecker6 
“ 422 “ 
14. “ 
Cohnstein1 
“ 394 “ 
3.56 “ 
In the face of these figures, which at least express the 
relative frequency of perineal rupture, it would appear that 
something ought to be done to bring about a diminution in the 
number of cases. In episiotomy, I claim, we have an efficient 
and—compared with spontaneous rupture—a safe and sure 
means. 
In saying this I do not advocate a new and untried pro- 
cedure, but one which has stood the test of years. 
This operation was first suggested by Miehaelis during or 
about the year 1799.8 
It consists in making an incision with a probe-pointed bistoury, 
or scissors, on one or both sides of the frenulum, about two to 
three cm. above its middle. The knife—which I prefer to the 
scissors, although the latter are used in many of the Continental 
schools—is laid flat against the fetal head, and slid between 
it and the tense ring at the vulvo-vaginal orifice. If the 
knife is now turned on its back, so that the cutting edge 
1 L. c., p. 58. 
3 Winckel, p. 58. 3L. c. 
4 “ Ueber Geburt bei alteren Erstgebarenden in der Privatpraxis.” 
Reprint 1882. These cases from private practice should hardly be placed 
by the side of the others, which are from hospital records. 
6 Arch, fur Gynukologie, Bd. iv., p. 510. 
6 The same, Bd. vii., p. 448. 
1 The same, Bd. iv., p. 499. 
8 According to Prof. Parvin—“ American Gynecological Society’s Trans- 
actions,” Vol. 7, 1882—Quid advocated the operation as early as 1742. 10 
M anton : A Plea for Episiotomy. 
comes to the constricting ring, and is gently raised in the di- 
rection of the ischial tuberosity, an incision will be made, the 
length of which can be regulated by the operator. 
As a rule, from one to three cm. is all that is necessary; audit 
is just as well not to include the external skin in the incision, 
although no harm is done should this take place. The opera- 
tion should be performed on the opposite side if required ; 
but very often unilateral incision is sufficient. The incision 
should be made just at the close of a pain, while the tissues 
are still tense, but the acme of the uterine contraction has 
passed. 
There is little or no pain produced by the cutting; indeed, 
I have done it several times without the patient’s knowledge. 
Care must of course be exercised not to include a fold of 
the fetal scalp, or a bunch of hair between the edge of the 
knife and the frenulum. If the operation has been quickly 
and skilfully done, the head may be delivered during the pause 
succeeding the incision ; but it should not be allowed to escape 
during a contraction, lest the incision be torn down, or a pos- 
terior rupture also take place. 
Rarely these both will occur in spite of our best efforts. 
The after-treatment consists either in uniting the incisions 
by one or two sutures—a performance which I confess I have 
never found necessary—or in cleansing the wound with a bit 
of antiseptic cotton, and then dusting the surfaces liberally with 
iodoform. 
The cuts heal perfectly in the course of a week. 
As to the altered appearance of the vagina which some 
claim, it must be remembered that an incision which appears 
long in the distended tissues may seem only a crack when those 
tissues have contracted. If left to heal by granulation, the in 
cisions appear later as mere nicks which can hardly be said 
to deserve the name of deformity. 
Even this may be avoided by uniting the edges of the wound 
by sutures, the result being a tine cicatrix, which appears quite 
yielding at subsequent labors. 
The indication for episiotomy as given in the books is a 
threatening laceration. This prescribes its usefulness too 
closely. 
There are very many instances where there is no apparent dan- Manton : A Plea for Episiotomy. 
11 
ger of rapture, but, on account of the smallness of the maternal 
parts, it is impossible for the head to get through. Here 
incision, instead of the forceps (in certain instances both), is 
certainly indicated. (Jrede also mentions that it should be 
thought of in prolonged and painful labors, to shorten the 
sufferings of the mother. 
The objections to this operation seem to consist: 
1st. In the fear that some anatomical element of the vulva, 
as the vulvo vaginal gland duct, etc., may be injured; that the 
cut surfaces may be a point of departure for infection, etc.; 
and that the incisions do not really prevent rupture. 
2d. That, if advocated, it will be unnecessarily often per- 
formed. 
I have myself performed and witnessed the performance of 
episiotomy a large number of times, and up to the present have 
seen none of the evil effects which some attribute to it. I have 
never seen the deformity, painful cicatrices, etc., which Parvin 
saysTarnier has observed, and am inclined to believe that they 
are rare occurrences. That the wounds might prove points 
for the entrance of septic material cannot be denied; buf in 
those cases which I have noted this has not taken place, and 
the slight rise of temperature which has occasionally been 
found can just as well be attributed to fecal accumulation, 
or to injuries higher up in the parturient canal, as to the 
lateral incisions. 
In 2,000 cases examined by Crede, there were records of 
33 deaths. Autopsy showed 19 of these to he due to septic 
infection ; the other 14 cases were caused by eclampsia, uterine 
rupture, and intercurrent diseases. Of the 19 septic cases, 15 were 
found in 1,572 cases where the perineum was intact—a per- 
centage of 0.954; while only 4 died who had perineal lacera- 
tion—a percentage of 0.934, a scarcely appreciable difference. 
This would seem to indicate that the chances for infection are 
about equal, whether episiotomy is done or not. 
It cannot be said that lateral incision saves the perineum in 
all cases, but of 957 primiparse 1 of which I have notes, I find 
but two 2 cases of posterior laceration recorded as occurring 
after episiotomy. The perineal wounds were as follows : 
1 Vienna Clinic. 
2 These were both forceps cases. 12 
Manton : A Plea for Episiotoiny. 
1V.—Pi'imipcirce (957) 
Lateral incisions 38 0.396 per cent. 
Spontaneous ruptures 22 0.229 ‘‘ 
Ruptures in spite of incision »... 2 0.208 “ 
Munde1 reports 448 cases where episiotoiny was done nine 
times. He is, however, “ confident that this operation was 
performed forty or fifty times,- but was considered too unim- 
portant to require notice except in special cases.” Four 
ruptures of the perineum took place in spite of the incisions; 
a percentage so high, if the operation was done only nine times, 
that we are forced to believe the cases must have been very 
exceptional ones ; or else the number of operations really done 
must have far exceeded the number noted. 
Prof. Crede gives the following analysis : 
V.—Primiparce (1,000). 
Lateral incisions 259 25.9 per cent. 
Spontaneous ruptures 104 10.4 “ 
Ruptures in spite of incision 29 2.9 “ 
Perineal injuries.. 392 39.2 per cent. 
VI.—Multipart (1,000). 
Lateral incisions/ 12 1.2 percent. 
Spontaneous rupture 14 2.4 “ 
Perineal in juries 36 3.6 percent. 
From the above we see that with 259 incisions only 29, or 
2.9 per cent, tore after episiotoiny had been performed, thus 
saving 230 perinea from posterior laceration—a result which 
certainly speaks well for the operation. 
Crede further found that lacerations diminished in propor- 
tion to the frequency with which lateral incisions were made. 
Thus, of live assistants, the one who resorted to the operation 
oftenest had the fewest ruptures: 
Incisions in Iparse. Ruptures in Iparsa. 
10.3 per cent. 20.7 per cent. 
20.4 “ 11.8 
26.3 “ 11.0 “ • 
28 “ 7.4 
32 , “ 7.2 
Of all these cases not one of total rupture is recorded. 
1 This Journal, vol. viii., p. 535. Manton: A Plea for Episiotomy. 
13 
Whether or no the advocacy of this operation will lead to its 
abuse remains to be seen. 
In the foregoing pages I have attempted to show : 
1st. That the percentage of perineal ruptures is verylarge. 
2d. That certain conditions of the maternal soft parts, etc., 
predispose to rupture. 
3d. That episiotomy diminishes the frequency of these rup- 
tures to a minimum, and thereby rescues a corresponding num- 
ber of women from a greater or lesser amount of suffering. 
4th. That only in very exceptional cases does rupture take 
place after episiotomy. 
5th. That the danger of infection is no greater where episi- 
otomy is done than where it is not. 
If the above statements are correct, there is no excuse for 
the accoucheur who allows a perineum to rupture without hav- 
ing first done episiotomy for its possible prevention. 
I'm mi fJirrti.