OPEBATIOTT 
FOR THE 
RADICAL CURE OF LACERATED OR RUP 
TURED PERINEUM. 
BY J. H. THOMPSON, M. D. 
Professor of Operative Surgery in the Medical Department of Georgetown College; 
and Surgeon-in-Chief of Columbia Hospital for Women, and Lying-in Asylum, 
Washington, D. C. 
The following is submitted in the hope it may assist in 
directing the attention of the medical profession not only to the 
frequency of the accident of which it treats, but also to the sim- 
plicity of the operation for its cure, and the uniform success 
attending it. 
The author lays claim to little originality in the treatment of 
this lesion, simply modifying in some respects the operation as 
practiced by that illustrious pioneer in gynaecological surgery, 
Baker Brown. 
The tabulated reports from the lying-in hospitals of Europe 
and America furnish no data from which we can judge of the 
relative frequency of this accident to the number of women de- 
livered. Their silence on this subject can only be accounted for 
by a neglect to examine the parts after delivery, or from the 
mistaken notion that a ruptured perineum necessarily reflects 
discredit upon the attending accoucher. It certainly is an acci- 
dent of no uncommon occurrence, both in private practice and 
in public institutions, and under the care of the most accom^—- 
plished obstretricians; its frequency being readily accounted for when we consider the various causes which either singly or in 
combination, may produce the lesion. Churchill gives thirteen 
causes: 
1. Sacrum too perpendicular. 
2. Arch of the pubes too acute. 
3. Thickened state of the urethra and subjacent parts. 
4. The too rapid passage of the head. 
5. Exostosis in any part of the pelvic cavity. 
6. Excessive breadth of the perineum. 
7. Rigidity of the perineum. 
8. Tissues of the perineum weakened by disease. 
9. Occlusion of the lower outlet of the hymen. 
10. Malposition of child’s head. 
11. Malpresentations. 
12. Exercise of too much voluntary force by the patient. 
13. Want of care when instruments are used. 
Tyler Smith only alludes to the seventh division of Churchill, 
“rigidity of the perineum.” 
Gaillard Thomas gives four causes: parturition-, me of for- 
ceps, manual delivery, craniotomy. 
Graily Hewitt simply refers to difficult labor. 
Byford gives as causes: straight sacrum, rigidity of perineum, 
large and unusually ossified head, too narrow arch to the pubes, 
unskillful use of instrument. 
Baker Brown suggests as the principal causes, “the dimen- 
sion of the child’s head being too large absolutely and relatively 
for the capaciousness and expansibility of the maternal outlet ; 
an unnatural rigidity of the perineal tissues, or extreme width 
of the same; unskillful use of instruments; paturition for the 
first time at a very early or late age.” 
Of the twenty-seven eases which have come under my care, 
twenty were of long standing, i. e., varying from one to seven- 
teen years, and their histories having been obtained principally 
from the patient, are not altogether reliable. Six were recent 
cases. In nineteen instances the accident occurred at the birth 
of the first child; the remaining eight were multipara. In two of the multipara instruments were used, as also in four of the 
primipara. In no case could I discover any abnormal acuteness 
of the arch of the pubes, and in only two was the sacrum unusu- 
ally straight. Two had been breech presentations, and eleven 
were extremely rapid labors, accompanied by violent expulsive 
pains ; the patients stating in these cases that they felt the tis- 
sues tear, calling the attention of the attending physician to the 
circumstance. 
From my own experience I consider the principal exciting 
causes to be: 
1. Violent expulsive efforts by the patient, on contact of the 
child’s head with the perineum, in most cases induced by too 
much manipulation. 
2. Unusual width of the child’s shoulders in proportion to 
the size of the head. 
3. Extreme width of the perineum. 
4. Inelasticity of the perineum occasioned by fatty degenera- 
tion of its tissues. 
5. Unskillful use of the forceps. 
The fourth cause occurring most frequently after thirty years 
of age. 
The varieties of lacerated or ruptured perineum arc: com- 
plete but uncomplicated, the sphincter ani remaining intact; 
complete and complicated, attended by rupture of sphincter 
ani; incomplete, when the laceration extends only a part of the 
distance between the fourchette and anus; perforating, this last 
being extremely rare. 
The consequences of this accident arc extremely grave; and 
in many cases of long standing, incapacitate the patient for any 
exertion in the erect posture. 
The principal sequelae are: prolapsus of the posterior wall of 
the vagina and anterior wall of the rectum or “ vaginal recto- 
cele;” prolapsus of the anterior wall of the vagina and the 
posterior wall of the bladder, or “ vaginal vesicocele;” proci- 
dentia of the uterus, with all the complications attending each 
of these conditions. 
These are not supposed results of the accident, but necessary consequences, as we can readily comprehend when we examine 
the anatomy of the female perineum and maternal outlet, and 
the relative anatomy of the “ genito-urinary organs.” From 
some inexplicable cause we find the anatomy of the female per- 
ineum neglected in most works; the male perineum occupying 
the whole attention. 
Fig. 1. 
I. Sphincter ani. z. Tendinous point of Perineum. 3. Sphincter vagina. 
4. Transversus perincei. 5. Erector clitoridis. 6. Aponeurosis. 
7. Levator ani. 8. Gleuteus maximus. 
By reference to fig. 1 we shall tind that the posterior fibres 
of the sphincter vagina and the anterior fibres of the sphincter 
ani, are inserted into the tendinous structure and fascia of the 
perineum: when a complete rupture occurs, the sphincter ani 
contracting from its posterior insertion on either side of the 
coccyx, draws the anterior wall of the rectum backwards; the 
fibres of the sphincter vagina being torn from their posterior 
attachment, loose all power of drawing the posterior wall of the 
vagina forwards and upwards; the transversal is perinei draw 
the lacerated, edges outwards and upwards, widening the gap 
made antero-posteriorly, and the vagina, which normally is a 
closed canal, becomes a mere chasm, and the floor of the pelvis 
is lost. Fig. a. 
FlS- 3- Fig. 2 shows the relative anatomy of the female genito- 
urinary organs in the normal condition of the perineum. Fig. 
3 shows the change produced in the plane of the inferior strait 
by the loss of the perineum, and will readily explain the causes 
of the complications which attend all cases of long standing. 
The posterior wall of the vagina becomes straightened, and 
the tissues being relaxed, permit of the formation of a pouch at 
the lower portion, immediately above the internal sphincter, in 
which the faeces accumulate, and vaginal rectocelc soon follows, 
drawing on the posterior cul-de-sac of the vagina, and changing 
the axis of the uterus, which now hangs perpendicularly over 
the external outlet. All support being lost, it descends, draw- 
ing with it the anterior wall of the vagina and the bladder. A 
cul-de-sac of the bladder is soon formed, in which the urine is 
retained, and the bladder can only be completely emptied by the 
patient introducing her finger into the vagina and temporarily 
replacing the uterus. In addition to all her physical sufferings, 
a woman in such a condition is totally unfitted for the marital 
relation. 
It is unnecessary to use any argument to convince an unpre- 
judiced mind of the advisability of an operation, however severe, 
which affords a reasonable prospect of restoring the parts to a 
normal condition and the woman to a life of usefulness. 
The difficulties attending the operation have been greatly 
overrated. In the hands of a skillful surgeon, it is one of the 
simplest and certainly most successful operations in obstetric 
surgery. The profession is indebted to Mr. Baker Brown for 
the best method of operating yet devised for the radical cure of 
ruptured perineum, as demonstrated by his eighty-one reported 
cases. 
As this paper is submitted with the hope that it may be use- 
ful to some of the younger members of the profession, I may be 
excused for entering more fully into the details of the operation 
and the after treatment than would be otherwise necessary. 
In some of the important stages of the operation, I follow the 
plan laid down by Baker Brown, differing from him, however, 
in my treatment of the sphincter-ani and also in some points of 7 
the after treatment. It may be as well to point out the differ- 
ence here : Baker Brown divides the sphincter-ani on either 
side of its cocygeal attachments, and considers it a sine qua non 
to success; I never divide it unless it has been torn through 
anteriorly, believing that it increases the risk of the operation 
by exposing so much the more surface to the process of inflamma- 
tion and suppuration, and at the same time the irritation set up 
necessarily interferes with the chances of union by first inten- 
tion in the wound immediately in front. It is, however, abso- 
lutely necessary that the sphincter remain quiescent during the 
process of union, and until the new tissue has become thoroughly 
organized. To secure this, I adopt the plan first suggested by 
Prof. Van Buren, of New York, i. e., “paralyze the sphincter.” 
This is done perfectly, by introducing the thumbs into the anus, 
seizing the nates on either side, and making gradual traction 
until the thumbs touch the tuber ischii. The paralysis follow- 
ing this remains for two or three weeks, but is never followed 
by permanent loss of power, which is sometimes the result of 
division. 
Instead of the bougie, I have had made some light silver 
tubes, the size of an ordinary catheter, perforated at intervals 
of one-fourth of an inch, and closed at each end with a round 
cap. The advantages I claim for these over the bougie, are 
first, a uniform support on either side not yielding at the parts 
between the sutures, as is the case with the bougie; secondly, 
they are more cleanly; hence less irritating. 
In place of waxed thread I use silver wire. I need say noth- 
ing as to its superiority. The mode of fastening it will be 
explained when I detail the steps of the operation. 
In the after treatment, instead of keeping the bowels con- 
stipated, as recommended by Baker Brown, I keep them in a 
soft condition, securing a passage every day. The discharges are 
painless, no resistance being offered by the sphincter. The 
vagina should be washed out twice a day with the following: 
ff. Aqiia Pura ss. 
Glycerine, ,fss. 
Acid Carbolic, gr. viij. 8 
The urine must be drawn every six hours. For this purpose 
I educate my nurses, and never consent to operate without one 
of them being in attendance from the commencement until the 
patient is perfectly recovered, as the least indiscretion or the 
clumsy manipulation of an ignorant person would jeopardize 
the success of the case, and thus injure both patient and surgeon. 
In about twelve to eighteen hours after the operation, the parts 
may become oedematous. This is to be treated by making sev- 
eral punctures with the lancet, which will liberate the serum 
and relieve the tension. 
Operation.—The patient, being fully setherized, should belaid 
upon a firm table of convenient height for the operator when 
sitting; the buttocks brought to the edge; the thighs flexed upon 
the abdomen; the knees turned out, and held in position by 
assistants. Remove all hair from the parts, and with a small, 
sharp-pointed scalpel, mark the outline of the part you intend 
to remove, taking care to allow for the contraction which will 
necessarily follow cicatrization. The width of the part to be 
removed must not be less than three-fourths of an inch antero- 
posteriorly, and extend the same width upwards on either side 
to the point where the perineum started before the accident. 
It is very important that the dissection be carefully made, 
and hence it is better to remove the membrane in one piece. 
For this purpose, the knife is better than scissors. 
The next step is to insert the sutures. I use a strong curved 
needle, about three inches long, with a cutting point only. This 
is armed with silk doubled, so that, when drawn through, a 
loop remains at the point of entry. Insert the needle an inch, 
or one and one-fourth inches, from the external edge of the 
wound, and press it directly backwards for about half an inch 
before you turn the point towards the inner edge of the wound, 
at which part it is to be brought out; enter it again on the 
opposite side on the inner edge, and make it traverse the same 
direction to the point of final exit. Select a piece of silver 
wire of medium size, about ten inches long, bend the end over 
and hook it into the loop of silk, draw the silk out and the 
wires will follow without kinking. Three to four sutures are generally necessary. The first must be entered at the bottom 
of the wound so as to control the parts around the anus. The 
wires being in position, are to be passed through the tubes and 
secured on the patient’s left side first, by means of perforated 
duck shot, the shot being strongly compressed on the wire, the 
terminal end of which should be bent sharply over, as seen in 
the illustration fig. 4. Bleeding having ceased, the cut surfaces 
are to be carefully cleansed and the parts coaptated by drawing 
first on the central wire, an assistant gently pressing the soft 
parts together. The right tension being obtained, slip the shot 
down to the tube and securely clamp it. Proceed next with 
the lowest suture, and finish at the top—the superficial edges 
arc to be brought together with the interrupted suture. 
Fig. 4. 
The patient, being removed to her bed, should be plaeed on 
her side, her knees tied together and cold-water dressings ap- 
plied for the first twenty-four hours. 
The deep sutures should be removed on the third day ; the 
superficial ones on the ninth. 
For the first month great care must be taken to prevent 
undue traction upon the newly cicatricized tissue. Fig. 4 shows 
the outline of incision, with the sutures in position ready for 
the parts to be brought into coaptation. 10 
Case 1. 
Complete Rupture, with Prolapsus Uteri: Cure. 
Mrs. M— C—, aged twenty-seven, admitted to Columbia 
Hospital June 28, 1866. She gave birth to her first child 
twenty months ago, which she still continues to nurse, the child 
being a fine healthy boy. Patient complained of constant pain 
in the sacral region with profuse leucorrhoea and prolapsus of the 
the uterus. To keep the womb within the vaginal canal, she 
was compelled to wear a T bandage and pad. Her general 
condition was very senemic. Vaginal examination, the patient 
being placed on her side, disclosed a complete rupture of the 
perineum, which originally must have measured at least one 
and three-fourth inches. Os-uteri patulous, with granular 
erosion of both lips, which were much hypertrophied. There 
was a general catarrhal condition of the mucous membrane of 
the vagina, the pelvis was very capacious. Her labor had lasted 
but half an hour. 
General treatment: The child was weaned immediately, and 
the mother placed upon extra diet, with six ounces of wine daily, 
and iron administered in full doses; absolute rest in the recum- 
bent position having been enjoined. 
Locally : Chromic acid was applied to the erosions, which 
were the result of friction against the pad, and a pledget of raw 
cotton, soaked with the following preparation, passed up to the 
posterior cul-de-sac, and allowed to remain twenty-four hours, 
when it was removed and a fresh one introduced : 
R. Glycerine, 
Tannin, 
This treatment was continued for three weeks, the patient 
improving rapidly in her general health. The rest and astrin- 
gent application combined had prevented any descent of the 
uterus ; the mucous membrane had gained considerable tone, 
and the patient was considered in a sufficiently good condition 
to bear the operation for a radical cure. 
July 22.—Patient, being fully was placed in the 
position advised, and the operation proceeded with as directed, Twelve P. M.—Ten hours after operation, patient suffering 
considerable pain, very restless, pulse 120, and irritable. Ordered 
R. Aq. ext. opii. gr. ij, to be administered immediately ; ice- 
water dressing to the vulva to be changed every few minutes; 
the pill to be repeated in four hours, unless the patient was 
quiet. 
Eight A. M.—Slept after taking the second pill; much less 
pain ; pulse 100, and softer ; one grain of the opium to be taken 
every four hours until the patient is free from pain. 
Ten P. M.—Pulse 88, and soft; but little pain since noon; 
complains of thirst; suspended the opium, and gave the “effer- 
vescing mixture.” 
From this time onward everything progressed well. The 
deep sutures were removed on the morning of the fourth day, 
and the superficial on the ninth, the result being complete union 
in every part by first intention. 
Patient was retained three weeks longer in the hospital to 
continue the general treatment, being still somewhat amende. 
Discharged cured, August 21. 
On July 24, 1867, eleven months and three days after leav- 
ing the hospital, she was delivered of a well-developed boy at 
full term. The labor was rapid, and the perenium lacerated for 
about a quarter of an inch, but on the side of the cicatrix. 
This was allowed to take care of itself, as there remained intact 
fully one and a quarter inches. She made a good recovery, and 
has since given birth to another child without anv further lace- 
ration. 
Case 2. 
Complete Rupture, complicated with Coccyodynia. 
Mrs. S—, aged forty-one, married in 1854, delivered of her 
first child March, 1866, nine weeks previous to the time I saw 
her; patient complained of severe pain when sitting, or upon 
the passage of fieces or flatus from the bowels. The history, as 
given by her medical attendant, was as follows: The labor had 
been protracted over three days, the patient suffering severely 
most of the time. A consultation was had on the morning of J 2 
the fourth day, when the forceps were applied and the woman 
delivered of a living child. The rupture was noticed at the 
time, and every attempt was made to bring about a union of 
the parts by keeping the limbs tied together and applying local 
stimulants, but without success. 
Upon digital examination, I found a fracture or dislocation of 
the coccyx at about half an inch from the tip—most probably a 
fracture—which accounted for the severe pain. The fractured 
parts were disturbed on every contraction of the levator or 
sphincter-ani muscles. There was also a complete rupture of 
the perineum. 
It was decided to adopt the treatment recommended by Pro- 
fessor Simpson, of Edinburgh, for the injured coccyx, and then 
to proceed with the operation for the restoration of the 
perineum. 
The double operation it was proposed to perform was fully 
explained to the patient, and her consent obtained, but she 
positively refused to take any anaesthetic. 
The patient being placed on her side, a tenotomy knife was 
introduced at the back part of the coccyx, and its muscular and 
tendinous attachments liberated from both sides and from the 
tip, the operation occasioning but little pain. 
After a few minutes rest, she was placed in the position for 
the major operation, which was proceeded with as usual, and 
lasted fifteen minutes. 
The result was very gratifying. The severe pain which she 
had suffered from the injury to the coccyx was immediately re- 
lieved ; her convalescence was rapid and without one untoward 
symptom. The restoration of the perineum was complete, union 
having taken place by the first intention. 
Case 3. 
Complete Rupture, involving the Sphincter Ani and Recto- Vaginal 
Septum : Cure. 
Mrs. T—, aged dl; mother of four children. She was deliv- 
ered of her last child four months since, at which time the acci- 
dent occurred. There was nothing connected with the history of this case 
which could satisfactorily account for the rupture. The woman 
was well proportioned, of tine physique, and her infant had no 
abnormal development of the head or shoulders. Her labor had 
been of an average duration, and not severe, and the same med- 
ical gentleman attended her with the last as with the three pre- 
vious children. No instruments had been used. 
Her convalescence had been slow; she was unable to sit up 
before the seventh week, and it was four months after the birth 
of her child before she could endure the fatigue of journeying 
from her home in Pennsylvania to Washington. 
I saw her the day after her arrival, and found, upon exam- 
ination, a complete rupture of the perineum and sphincter-ani 
muscle; the laceration extending about one and three-fourths of 
an inch up the recto-vaginal septum. 
She had had but little trouble in controlling the bowels, being 
naturally of a very costive habit, but flatus passed involuntarily. 
When the bowels were moved she suffered great pain, occasioned 
bv the ulcerated condition of the edges of the upper part of the 
laceration. 
There had been no prolapsus of the uterus, and the mucous 
membrane of the vagina was in a healthy condition, excepting 
the part at the edges and apex of the laceration. 
It was necessary to perform two distinct operations: first, to 
restore the integrity of the sphincter ani and recto-vaginal sep- 
tum ; and secondly, to restore the perineum. 
July 3.—Patient being aetherized, was placed upon her back, 
with limbs well flexed upon abdomen. The thickened edges of 
the laceration on both sides were removed by the scissors, the 
incisions extending half an inch beyond the apex of the rupture, 
to secure healthy tissue. The sphincter was divided laterally. 
The edges were carefully approximated by the interrupted wire 
suture. The wires were removed on the ninth day, and the 
parts found perfectly united. 
August 11.—The operation for restoration of the perineum 
was performed in the usual manner. The sphincter not having 
recovered from the previous division was not interfered with. 14 
On the second da)' after the operation there was so much 
oedema of the parts engaged within the sutures that I was fear- 
ful it would be necessary to remove them ; but free puncturing 
and the application of ice proved sufficient. The deep wires 
were not removed until the fifth day, when it was found that 
suppuration had formed in the track of the middle suture, the 
pus flowing freely upon its withdrawal. This accident was the 
result of retaining the deep sutures in situ two days longer than 
was necessary, but it in no way interfered with the success of the 
operation, union being perfect in every part. The superficial 
sutures were removed on the ninth day. 
Patient left for her home on September 18th, cured. 
Case 4. 
Complete Rupture, eight gears’ standing : Cured. 
Mrs. H—, admitted into Columbia Hospital September 17, 
1866 ; seamstress by occupation ; mother of two children; com- 
plains of severe pain in the sacro-lumbar region, profuse leu- 
corrhoea and smarting after urinating. 
Examination revealed complete rupture of the perineum, with 
eversion of the lower portion of the vagina, which was intensely 
inflamed. The inflammation was rapidly reduced by the use of 
glycerine and aqueous extract of opium. 
The operation for restoration of the perineum was performed 
September 27, and the patient left the institution, October 24, 
cured. 
Case 5. 
[neoniplete Rupture. 
Mrs. S—, wife of a physician, delivered of her first child 
after a protracted labor, the head having rested upon the peri- 
neum for six hours. The rupture was discovered on the birth 
of the child, and I saw her in company with her husband a few 
hours afterwards. 
The laceration extended to within one-fourth of an inch 
of the anus. The parts being carefully sponged with a 
weak solution of carbolic acid in water, the edges were approx- 
imated and retained in position by the quilled suture. The after treatment differed but little from that pursued in 
eases of long standing. 
The patient made a good recovery, the operation being entirely 
successful. 
Case 6. 
Complete Rupture, 'Recto- Vaginal Fistula and Prolapsus Uteri. 
Mrs. M—, widow, aged thirty-seven; mother of five children, 
youngest child being three years of age. 
Complains of constant pain in the back ; profuse and offen- 
sive discharge from the vagina; loss of appetite and extreme 
debility. 
Examination revealed a complete rupture of the perineum, 
and a fistulous opening into the rectum two-thirds of an inch in 
length immediately below the posterior cul-de-sac. The uterus 
measured four and half inches, and bled freely on the with- 
drawal of the sound, although great care had been used in its 
introduction; cervix hypertrophied and os patulous, but no 
ulceration or abrasion. 
Treatment: The following ointment was introduced into the 
cavity of the uterus every third day with the view of reducing 
the endo-metritis : 
IE Ungt. simplex, giv. 
Argent nit. eryst., gr. x. 
Aq. ext. opii, 
A pledget of raw cotton soaked in glycerine, containing four 
grains carbolic acid to the ounce, was passed up to the cul-de- 
sac morning and evening—the glycerine to reduce the hyper- 
trophy of the cervix and the acid as an antiseptic. 
Tonics were freely administered, and the patient kept in the 
recumbent position. 
On the seventh week, from the commencement of treatment, 
“Sims’ ” operation was performed for the closure of the fistula 
with perfect success. 
Three weeks afterwards, the perineum was restored by the 
usual operation. The patient made a good recovery and left for 
her home, in West Virginia, January 22, 1867, cured. 
I have since learned that this lady was married the following Juno, and in due time gave birtli to a child, but did not learn 
with what result as respects the perineum. 
Case 7. 
Complete Rupture of five years' standing : Cured. 
Mrs. C—, admitted into Columbia Hospital January 12th, 
1867. Mother of one child. Patient complains of prolapsus of 
the uterus whenever she stands or walks ; constant pain in the 
lumbar region ; offensive leurcorrhoeal discharge, so abundant as 
to compel her to wear a napkin. Menstruation occurring fort- 
nightly. 
Upon examination, there was found a complete rupture of the 
perineum; the cervix uteri protruding between the labia, os 
patulous, cervix hypertrophied. Patient was placed under con- 
stitutional and local treatment, with the view of restoring the 
uterus and its functions to a healthy condition, before attempt- 
ing the restoration of the perineum. 
Her recovery was very slow, it being nearly three months be- 
fore she was in a condition to endure surgical interference. 
April 8.—Operation for radical cure performed in the pres- 
ence of the clinical class. There was considerable difficulty in 
arresting the hemorrhage, owing to the unusual size of the arte- 
rial branches, which were wounded in the dissection. A liga- 
ture being inadmissible, we were compelled to rely on torsion 
which in this instance failed to accomplish the object. 
The deep sutures were removed on the third day, the super- 
ficial on the eleventh. Union perfect. 
Case 8. 
Complete Rupture: Cure. 
Mrs. B—, admitted into Columbia Hospital March 19, 1867. 
Pregnant with her first child. Upon making an examination, 
in order to ascertain the probable time of labor, it was found 
that the vaginal orifice was extremely small, as also the lower 
part of the vaginal canal. The perineum was thick and inelas- 
tic, feeling like cartilage. This condition of the parts made it probable that during delivery there would be a rupture of‘ the 
perineum and lower part of recto-vaginal septum. 
The labor was very rapid, and every effort was made to pre- 
vent the anticipated accident, but, so far as the perineum was 
concerned, without success. 
A severe attack of metro-peritonitis followed delivery, and it 
was some weeks before an attempt could be made to restore the 
integrity of the lacerated parts. 
May 23.—The usual operation was performed in the presence 
of the class. The patient’s recovery was rapid; union perfect 
by first intention. She left for her home in North Carolina 
dune 25th. 
The large amount of white inelastic tissue, and the few mus- 
cular fibres entering into the formation of this woman’s peri- 
neum, would make it liable to rupture at any succeeding labor. 
Case (J. 
Complete Rupture: Cure. 
Mrs. S—, mother of two children, the youngest twenty-eight 
months old. From the history of this case, which was given 
entirely by the patient, the rupture must have occurred at her 
first labor, which was very protracted. She suffered the usual 
discomforts attending the lesion, but her general health was good, 
although she had taken but little exercise, as it always in- 
creased the uneasiness about the pelvis. 
May 26, 1867.—Patient being placed in position, chloroform 
was administered, and the operation commenced. Doctor F. A. 
Ashford, my usual assistant, administering the anaesthetic. When 
the operation was about half completed, there was a sudden ces- 
sation of respiration and irregularity of the heart’s action. The 
tongue was instantly drawn forward, and artificial respiration 
commenced, but at the end of five minutes, there was no ap- 
parent improvement in the patient’s condition. The artificial 
respiration was continued for nearly thirty minutes before we 
were rewarded by a full-drawn inspiration by the patient. Our 
feelings may be better imagined than described. It is hardly 
necessary to state that the operation was completed without the 18 
further use of au anaesthetic. The patient was quite feeble for 
some days, but her recovery was perfect. The same success 
attending the operation in this, as in the previous cases. I have 
since delivered this lady of a well-developed child, weighing 
eleven pounds, the perineum remaining intact. This is the third 
case in my practice where I have nearly lost my patient by the 
use of chloroform. I use it no longer, preferring the slow, but 
safer, anaesthetic, sulphuric aether. 
Case 10. 
Complete Rupture. 
Mrs. B—, aged nineteen, mother of one child four months 
old. 
The rupture in this case had been produced by the unskillful 
or careless use of forceps, the operator being a German midwife, 
who applied them without the consent of the patient or her 
husband. 
The limbs had been kept together, and warm stimulating 
applications made to the vulvar ; but the urine and discharges 
coming in contact with the lacerated edges prevented any union. 
June 7, 1867.—Operation performed at noon. In the even- 
ing the patient complained of great pain, and was very restless; 
ordered a full dose of opium, to be repeated in six hours. The 
following morning the parts were so much swollen that I found 
it necessary to puncture them freely and to remove the middle 
suture, and loosen the upper one; warm applications were kept 
constantly applied. 
This treatment relieved the pain, and no other unpleasant 
symptom presented itself. 
The remaining two sutures were not removed until the fourth 
day, when, contrary to my expectations, there was perfect union. 
This patient was very fat about the genitals, and the error 
which caused the difficulty in the case was drawing too tightly 
on the wires, not making sufficient allowance for the swelling 
which would necessarily follow where there was so much cellu- 
lar tissue included. 
[CONCLUSION IN OUR NEXT.] 19 
Case 11. 
Complete rupture, complicated with Polypus of the Uterus and 
Haemorrhoids. 
Mrs. M—, ret forty-three, mother of nine children ; married 
at fifteen years of age; first child born before she had reached 
her sixteenth year. Patient emaciated and almost exsangui- 
nated. She has haemorrhage from uterus every few days, and 
from the haemorrhoids whenever the bowels are moved. 
A careful examination was made, and, in addition to a com- 
plete rupture of the perineum, there was discovered a group of 
ulcerated haemorrhoids. The uterus was much enlarged, and 
the introduction of the sound followed by a copious discharge 
of blood ; a sponge tent was introduced to determine the diag- 
nosis, so far as the uterus was concerned, and upon its with- 
drawal the next day a large polypus was discovered. The 
treatment was directed first to the removal of the polypus, and 
the arrest of the haemorrhage, which was done by ligation. 
After recovery from this, the haemorrhoids were destroyed by 
the treatment adopted by Prof. Markoe, of New York, i. e. 
the application of fuming nitric acid to their entire surface, 
every three or four days, until removed. The application is 
almost painless. It was deemed advisable to defer the opera- 
tion, for the restoration of the perineum, until the patient’s 
general health might be restored. 
June 28.—Operation performed without the use of any anas- 
thetic, no unpleasant symptoms occurring during the after treat- 
ment, and the patient left for the country July 19th, cured. 
Case 12. 
Rapture complete, nine years duration: Cure. 
Mrs. F—, aet. 31. In her first and only confinement, which 
occurred nine years since, the perineum was torn completely through, the child presenting breech first. For the last seven 
years she has worn a ball pessary to retain the uterus in situ. 
The pessary was removed, rest in the recumbent position en- 
joined, and a strong solution of tannin in glycerine applied to 
the mucous membrane of the vagina daily. This treatment was 
continued for some weeks with success. 
July 11, 1867.—Performed my usual operation which was 
followed by some irritative fever, controlled readily, however, 
by opium. 
The deep sutures were removed on the third, the superficial 
on the eleventh day. The union was perfect. 
I met this lady at the house of a friend of hers eleven months 
after, when she informed me she had suffered no inconvenience 
since the operation, and had enjoyed better health than for sev- 
eral years previous. 
Case 13. 
Complete rupture, and fibrous tumor of left labia. 
Mrs. A—, ret. 38, came under my care September 8, 1867, 
Has had three children, the laceration having occurred with 
the first child. The tumor in the labia was first noticed about 
three years since, and during the last eighteen months has in- 
creased rapidly. 
She had been told that rupture of the perineum was incura- 
ble, and I was therefore consulted only in reference to the 
tumor, which had grown to be a source of great discomfort, 
being very large and blocking up the entrance to the vagina. 
The tumor was removed with some difficulty, its attachments 
being strong and deep, and the operation attended with con- 
siderable venous haemorrhage. After its removal it weighed 
nine and half ounces. 
Upon recovery, the patient, by my earnest recommendation, 
submitted to the operation for the restoration of the perineum, 
which was performed December 4, and attended with the usual 
success. Case 14. 
Complete Rupture with prolapsus of the Uterus of seven years 
duration. 
Mrs. P—, set. 40 ; admitted into Columbia Hospital on the 
recommendation of Doctor Van Buren, January 20, 1868. 
Mother of one child seven years of age. Since the birth of 
this child she has been suffering from prolapsus of the uterus, 
and for the last five years the uterus and vagina have been ex- 
ternal to the body, supported by a handkerchief passed round 
the loins. There was complete rupture of the perineum. The 
exposed mucous membrane had lost its characteristic appearance 
and was extensively ulcerated. The accompanying vagino-vesi- 
cocele had not been reduced for some years, and the bladder had 
become so irritable from the decomposition of retained urine 
that only a few drops could be tolerated above the amount ac- 
cumulated in the cul-de-sac. When voided it necessarily passed 
over the ulcerated surface before mentioned, and caused extreme 
pain. 
It is difficult to conceive of a condition more deplorable than 
that from which this poor woman was suffering. 
The enormous capacity of the vagina would render any 
attempt to retain the uterus in situ by a pessary unsuccessful, 
and, after consultation, it was decided to attempt a radical cure 
by a modification of “Sims” operation. This was performed 
in the presence of Doctors N. Young, J. Eliot, T. Morgan, and 
the clinical class. An ellipse six inches in length and four 
inches in width was removed from the anterior portion of the 
vagina, the whole of the thickened tissue, included within the 
limits, being removed, interrupted sutures of silver wire were 
introduced one quarter of an inch apart, and the uterus was 
returned within the pelvic cavity before the parts were brought 
in apposition. 
The patient was placed upon her back and the pelvis elevated, 22 
a pledget of raw cotton, soaked in glycerine and carbolic acid, 
introduced daily, and the urine drawn every six hours. No 
unpleasant symptom followed. The wires were removed on 
the fourteenth day, when it was found that every part had 
united by the first intention. 
On March 2d the operation for the restoration of the peri- 
neum was performed in the presence of the same gentlemen, 
and was attended with complete success. 
For about one year this woman suffered no inconvenience, 
but after that time the uterus began to descend, and made its 
appearance externally eighteen months after the first operation. 
She was admitted into the Howard Hospital, and Dr. Reyburn 
removed a further section from the vagina, which appears to 
have perfected the cure. 
I am satisfied that many of these operations fail from the 
operator being too conservative, not removing a sufficient amount 
of tissue. The perineum remained intact. 
Case 15 
Complete Rupture, two months standing: Cure. 
M. S.—, admitted into Columbia Hospital January 24, 1808, 
upon the recommendation of Dr. N. Young; was confined of 
her first child two months since, her labor having been very 
protracted and finally terminated with forceps. An attempt 
had been made to restore the perineum immediately after her 
labor, by the interrupted suture, but without success. 
The usual operation for complete restoration was performed 
in presence of the clinical class on January 25th. She was 
discharged, cured, February 27th. 
This woman was confined with her second child, eleven 
months after leaving the Hospital, without any injury to the 
perineum. 23 
Care 16. 
Complete Rupture, twenty-one years duration: Cure. 
Mrs. N.—, set 47 ; mother of eight children. Although the 
injury in this case occurred at the birth of her first child, and 
the inconvenience attending it had increased with each succeed- 
ing year, yet nothing beyond mere palliative measures had been 
suggested for her relief. The uterus had been retained in situ 
by the daily introduction of a sponge saturated with a strong 
decoction of white oak bark. Her urine was voided by cathe- 
ter only, which she had learned to introduce herself. 
When placed under my charge, March 8, 1868, she was em- 
aciated to an extreme degree and anaemic, the irritability of her 
nervous system was so great that it was only after repeated at- 
tempts I succeeded in keeping her quiet long enough to make a 
sufficient examination to satisfy myself as to her condition. 
The rupture of the perineum was complete, but uncomplica- 
ted with either prolapsus of the uterus or vaginal walls; this 
usual accompaniment, in cases of long standing, having been 
prevented by the daily use of the medicated sponge pessary. 
It required some weeks of preparation before this patient was 
in a condition to permit of operative interference, but, by the 
free administration of cod liver oil, strychnine, iron and whisky, 
I succeeded in bringing her up to a point that warranted an 
attempt at radical cure. 
June 8.—Assisted by Drs. Ashford and Eliot, I performed 
the usual operation; the deep sutures were removed on the 
third, and the superficial on the twelfth day, every portion hav- 
ing united by first intention. 
The first three days after the operation this lady suffered from 
a continued series of hysterical paroxysms, large doses of the 
bromide of potash, (one drachm every two hours,) failed to con- 
trol her, and they apparently yielded only to exhaustion. 
The generally morbid nervous condition of this patient, ac- 24 
companied by a habit of constant catheterization, and an indis- 
position for the slightest exertion, which continued for some 
time after the operation, made it one of the most difficult cases 
I have had to manage. 
August 13.—She left for the springs, not having been out of 
her house before for five years. 
Case 17. 
Incomplete Rupture, ttro years duration: Cure. 
N. S.—, ret 27 ; has had three children; the two first born 
without any unusual difficulty, the last a protracted labor, the 
breech presenting. Her convalescence was slow. 
The laceration extended to within one third of an inch of the 
sphincter, and the vaginal walls had commenced to yield to the 
pressure of the uterus. An operation was recommended at once, 
not on account of any immediate inconvenience, but to prevent 
the complications which would present in a short time, if the 
perineal support should not be restored. 
The operation was performed on May 8th, no anaesthetic be- 
ing used, the deep and superficial sutures were removed at the 
usual time, and similar success attended this as had marked 
former cases. 
Case 18. 
Complete Rupture, immediate operation: Cure. 
Mrs. F.—, set 30. I was sent for to deliver this lady May 
11th, after she had been in labor for sixty-five hours, but the 
child was born before I reached the house. The head was of 
unusual size, and its passage doubtless the cause of the rupture. 
The perineum was torn through to’ the anus, involving a por- 
tion of the spincter. The parts were brought together by the 25 
quill and interrupted suture, united kindly; the wires were re- 
moved at the usual time, and her convalescence was as rapid as 
it could have been had no accident occurred. 
Case 19. 
('bmplete Rapture of the Perineum, and prolapsus of the Uterus 
and Vagina. 
P. N.—, set 40; admitted into Columbia Hospital June 2, 
1868. This woman stated that she had been for several years 
in the condition in which she presented herself at the hospital, 
unable to work for her support, and dependant upon the chari- 
ties of the public. 
The entire vaginal walls were exterior to the body, and cov- 
ered with scales of dried epithelium, abrasions, and ulcerations, 
there being no spot of healthy mucous membrane. The os uteri 
was patulous, the index finger passing readily into the uterine 
cavity, and the whole organ very much hypertrophied. 
Before any operation for a radical cure could be attempted, 
it was necessary to restore the vaginal mucous membrane to a 
healthy condition. 
The procidentia was reduced with some difficulty, and the 
vagina kept thoroughly anointed by pledgets of raw cotton 
soaked in glycerine and watery extract of opium. This appli- 
cation not only served to restore the mucous membrane, but re- 
tained the uterus in situ. 
The treatment, conjoined with a general tonic course, was con- 
tinued for some weeks before the constitution and local condi- 
tion of the patient was sufficiently improved to permit of surgi- 
cal interference. 
July 3.—Patient being fully by Dr. Ashford, was 
placed in the ordinary position for lithotomy, and Emmett’s 
modification of “Sims’” operation for the radical cure of pro- 
lapsus uteri performed, the section being taken from the ante- 
rior wall of the vagina. The parts united perfectly and were 
considered sufficiently contracted to retain the uterus in position 
when assisted by a restored perineum. 26 
On the seventeenth day of the same month the usual perineal 
operation was performed, and on August 20th she left the hos- 
pital apparently cured. 
Dr. Ashford saw this woman about one year after the opera- 
tion. She had been working steadily most of the time since 
she left the hospital. The perineum was strong and perfect, 
but the uterus was found to be low down and resting upon the 
perineum. 
The same mistake was made in this as in case 14, and it will 
be necessary to remove another section from the posterior wall 
of the vagina to perfect the cure. 
Case 20. 
Complete Rupture of the Perineum and Procidentia Uteri, eleven 
years standing: Cure. 
Mrs. P.—, ret 50; admitted into Columbia Hospital July 11, 
1868. The condition of the patient was similar to “case 14/’ 
but she had taken better care of herself. By frequent bathing 
and anointing the parts with fresh lard, she had succeeded in 
preventing the ulcerations and excoriations of the mucous mem- 
brane. 
July 20.—The patient being fully setherized, the same opera- 
tion was performed as in case 14, but double the quantity of 
tissue removed, the calibre having been reduced more than one 
half. 
No constitutional disturbance followed, the wires were re- 
moved on the fourteenth day, when every part was found 
united. 
August 5.—The usual operation for restoration of the peri- 
neum was performed in the presence of my clinical class. The 
deep wires were removed on the third, and the superficial on 
the eleventh day, union being found perfect. Patient left the 
hospital, September 8th, cured. 
There is no probability of a return of the prolapsus in this case, 
for the contraction of the vagina was so perfect that the uterus 27 
could not descend, and there being fully two and one quarter 
inches of sound perineum, the maintenance of the vagina in its 
integrity was secured. 
Case 21. 
Complete Rupture of the Perineum, with Procidentia Uteri, twelve 
years’’ standing: Cure. 
Mrs. B—, jet GO; admitted to Columbia Hospital July 27th. 
The general condition of this patient good; her constitution 
having suffered little from the local trouble, probably owing to 
the absence of the periodical congestions attending the catame- 
nia, the climacteric period having been reached at her 48th year. 
The uterus was much enlarged from congestion due to its 
malposition, not from any increase of its parenchyma, lied ac- 
tion of the procidentia and rest in the recumbent position for a 
few days, brought the uterus down to nearly its normal dimen- 
sions. 
The size of the vulvo-vaginal opening was enormous, and 
the restoration of a perineum, of ordinary dimensions, would 
have failed in retaining the uterus in situ. I therefore decided, 
with the consent of patient, to close the entire opening, leaving 
only a portion patent, the size of a goose quill, for the escape 
of the secretions. 
August 8.—The operation was performed in the presence of 
Drs. Young and Eliot, Dr. Ashford assisting. The mucous 
membrane was removed on either side to the extent of four 
inches, and of the same width as in the ordinary operation for 
restoration. Six deep sutures were used, and nine superficial. 
The wires were removed at the usual time, and union found 
to be perfect. She left the hospital September 13th, cured. 
Case 22. 
Complete Rupture, Procidentia, and Vesico-vaginal fistula: Cure. 
Mrs. D—, set 38; admitted to Columbia Hospital September 
4, 1868, on the recommendation of Dr. L. Mackal, Jr. She 
was flic mother of three children, but, from her history, I could 28 
not learn in which of her confinements the rupture occurred, but 
that some months elapsed after the birth of her last child before 
she experienced any serious inconvenience. She then com- 
plained of a continuous pain in the lumbar region, and profuse 
lucorrhoea. After standing for a short time, or making any 
extra exertion, the uterus would protrude through the vulva. 
Upon making her condition known to her family physician, 
he recommended the use of astringent injections and adjusted a 
ring pessary to retain the uterus, requesting her to return to his 
office in a few weeks to have the pessary removed. She, how- 
ever, found herself relieved by the measures adopted, and did 
not see him again for more than one year. There had been no 
return of the prolapsus, but she then complained that her urine 
constantly dribbled from her, and of an offensive sanguinco- 
purulent discharge from the vagina. 
The pessary was removed, and ulceration found to have taken 
place through the walls of the vagina and bladder, at the lower 
portion of the neck, producing a vesico-vaginal fistula. 
At the time of her admission to the hospital, she was much 
emaciated and anaemic, and it was several weeks before any 
attempt was made to restore the integrity of the parts. 
The first and second operation for the closure of the fistula 
were unsuccessful, owing to the unhealthy condition of the 
tissues, there being no attempt at union. On the third trial I 
determined to remove every portion of suspected tissue around 
the fistula, and by so doing, increased the opening from one quar- 
ter of an inch in its long diameter to one and one-eighth of an 
inch. The wires were removed on the tenth day and union 
found perfect. After some weeks of rest, she had gained 
strength and flesh, and I restored the perineum by the usual 
operation. The deep sutures were removed on third, the super- 
ficial on the twelfth day. 
November, 28, she left the hospital perfectly cured. I have 
frequently heard from this patient since she left. She is enjoy- 
ing good health, and has suffered no inconvenience from her 
former troubles. Case 23. 
Complete Rupture, Vaginal Rectocele, eleven years’ duration : 
Cure. 
Mrs. R—, jet 32; mother of one child, was placed under my 
care October 4, 1868. Her labor was tedious and terminated by 
the forceps. The perineum was entirely gone, and she had a 
large rectocele; had worn a ball pessary for some years. 
A section was removed from the posterior wall of the vagina 
which relieved the rectocele, and after a full recovery from this 
operation, the cure was completed by restoring the perineum in 
the usual mode. 
She left for her home December 20th, cured. 
Case 24. 
Complete Rupture, four years’ standing: Cured. 
Mrs. B—, ret 29; admitted to Columbia Hospital August 8, 
1868. Mother of three children ; the accident occurred at the 
birth of her last child, her labor having been very rapid, and 
the child’s head and shoulders unusually large. She had applied 
for admission in March, but was at that time so extremely anae- 
mic that no operation would have succeeded. I recommended 
her to wait a few months, and placed her upon tonic and 
stimulating course of treatment. She improved rapidly, and at 
the time of her admission was in a good condition. 
August 10.—The ordinary operation was performed in the 
presence of the class; Dr. Ashford, my first assistant, adminis- 
tering the anasthetic. Everything progressed favorably; the 
sutures were removed at the usual time, and union found perfect. 
Patient left the hospital September 11, cured. 
Case 25. 
Complete Rupture, Haemorrhoids, and Prolapsus Uteri: Cure. 
Mrs. S—, jet 35 ; mother of six children, came under my 
care September 2, 1868; has been suffering for several years from haemorrhoids, l lit during the Inst six months they have 
increased so much in size, and are attended with so much pain 
as to disable her from engaging in her household duties. 
It was for this difficulty that she consulted me. Upon exam- 
ination I discovered the ruptured perineum, and detected a horse 
shoe pessary, which she said she had worn since 1862. I re- 
commended first the removal of the haemorrhoids, and then the 
restoration of the perineum; promising her she would be able 
to dispense with the pessary. 
The haemorrhoids were removed with chain ecraseur, with the 
loss of not more than one ounce of blood. Three weeks after- 
wards the perineum was restored by the usual operation. But 
little constitutional disturbance followed either operation ; pati- 
ent made a rapid recovery, and was entirely relieved from pain 
or inconvenience. 
I have seen her frequently since, and the cure appears to be 
permanent; the uterus is in its normal position, and is disposed 
to stay there. 
Case 26. 
Complete Rupture, jive years’ standing, Ulcers of Rectum. 
Mrs. D—, set 37 ; admitted to Columbia Hospital October 
17, 1869. The general condition of the patient was not good, 
but she was urgent for the operation, as she had left her family 
for that purpose and was anxious to return. 
October 19.—Patient, being fully setherized, the ulcers in the 
rectum were freely divided ; the sphincter being included in the 
division—and the usual operation for restoration performed in 
the presence of the Clinical class. There was much more ha3- 
morrhage than usual, and some time elapsed before the parts 
could be brought together. Three deep sutures and six super- 
ficial were used. 
October 21—10 a. m.—Patient has had a severe rigor, lasting . 
over half an hour, followed by heat of skin, thirst, and considera- 
ble pain in the head; pulse 120. There was no unusual inflama- 
tion or pain about the parts to account for these unpleasant symptoms. A full dose of opium was administered, and or- 
dered to be repeated in six hours. At 9 p. m., skin moist, pulse 
120 and small, no marked restlessness; ordered one ounce of 
brandy with each dose of the opium. 
Twenty-second—10 a. m.—Patient bright and cheerful; less 
fever, pulse 118, soft; removed the deep sutures; parts very 
healthy. 
8 p. m.—Has had another chill more severe than the first, 
pulse 130; great restlessness; some cough, but not very trouble- 
some; gave quinia, opium and brandy in full doses. 
23d, 11a.m.—Skin moist, tongue slightly furred, pulse 117. 
A careful examination was made to ascertain if any pus had 
formed in the track of the deep sutures, but none was found. 
She continued in much the same condition until the 28th, 
when the superficial sutures were removed, and contrary to all 
reasonable expectations there was perfect union. 
From this time onward the cough was more troublesome, she 
had occasionally rigors, 'temperature increased, pulse never be- 
low 120, great prostration, and all the well marked symptoms 
of surgical fever. She died December 21st, two months from 
the time of operation. No post-mortem was allowed. 
The error I committed in this case was in operating upon a 
patient decidedly below par. If I had submitted her to a judi- 
cious course of medical treatment for some weeks at least before 
operating, I feel confident she would have been spared to her 
family, and I saved the mortification of reporting a case which, 
in its general results, was a decided failure. 
Cask 27. 
Complete Rupture, Prolapsus of the Rectum, three years' standing: 
Cure. 
Mrs. S—, set 37 ; mother of four children. The rupture oc- 
curred at the birth of her last child, and was complete, extend- 
ing through the sphincter. Whenever the bowels were moved 
or the patient stood for a few minutes, the rectum would be- 
come prolapsed to the size of a large orange, and it was diffi- 
cult to return it. 32 
The treatment was directed to the restoration of the perineum 
and sphincter ani, being satisfied that the protrusion of the 
bowels was a natural consequence of the loss of support. 
March 21, 1869.—I restored the perineum in my usual mode, 
but departed from my general practice in the after treatment by 
keeping the bowels closed for sixteen days, in the meantime 
throwing into the rectum, twice daily, two ounces of a strong 
decoction of white oak bark. 
April 8.—The bowels were moved by one ounce of castor 
oil; there was no extrusion of the rectum, aud the perineum 
was perfectly sound. 
I have seen this lady on two occasions since, and she assures 
me she has had no return of the difficulty.