COMPLIMENTS OF THE AUTHOR. 
THE 
OBSTETRIC TREATMENT 
OF 
THE PERINEUM. 
BY 
HENRY J. GAK1UGUES, A.M., M ])., 
Physician to the Gynecological Department of the German Dispensary, Fellow of the 
American Gynecological Society, etc. 
(WITH NINE WOODCUTS.) 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XIII., No. II., April, 1880. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1880. THE 
OBSTETRIC TREATMENT 
OF 
THE PERINEUM. 
BY 
HENRY J. GARRIGUES, A.M., M.D., 
Physician to the Gynecological Department of the German Dispensary, Fellow of the 
American Gynecological Society, etc. 
(WITH NINE WOODCUTS.) 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XIII., No. II., April, 1880. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1880. THE 
OBSTETRIC TREATMENT 
OF 
THE PERINEUM. 
BY 
HENRY J. GARRIGUES, M.D., 
(With nine woodcuts.) 
NEW YORK. 
It is a strange fact that the anatomy of an organ which 
is daily subject to the eye and touch of gynecologists and obstet- 
ricians, as the vulva, yet seems rather obscure to many of 
them. Even in recent authors, palpable errors are found. 
A very common mistake is to confound the entrance of the 
vulva, rima pudendi, with that of the vagina, introitus vagi- 
nae. These two openings are entirely different from one 
another as to site, size, shape, and composition of surrounding 
parts. The vulvar orifice is situated on the surface of the 
body; forms, if not dilated, a straight line running in an antero- 
posterior direction, and is limited by the labia majora. The 
vaginal orifice, on the other hand, is situated at the bottom of 
the vulva, is circular, and surrounded by a striped muscle, the 
constrictor vaginae. This point is not without practical impor- 
tance when we come to speak of incisions into the outlet of the 
obstetric canal. Some authors recommend incisions into the 
vaginal orifice, while from other expressions it is clear that 
they mean incisions into the labia majora. Incisions into the 4 
Ctarrigues: The Obstetric Treatment 
vaginal orifice are quite a different thing. Both procedures 
are used, and it is important not to designate them in such a 
way that the reader is led to take one for the other. In olden 
times, the expressions vulva, matrix, and uterus were all used 
to designate the whole genital canal, as proved by Dr. Wm. 
Goodell in his learned history of the treatment of the per- 
ineum.1 This has led to many misunderstandings, and still 
does so. It is, therefore, a decided improvement, when now- 
adays we divide the canal by which the fetus passes into 
three distinct parts with well defined names: the vulva, the 
Vagina, and the uterus; the limit between the first two being 
the hymen, or its remnants, and between the latter two, the 
external orifice of the uterus, commonly called os uteri. Obstet- 
rical authors ought strictly to conform to these divisions estab- 
lished by modern anatomy. 
Another point which is often not clearly understood, neither 
by authors nor practitioners, is what the fourchette or frenu- 
lum is. Those who are opposed to immediate and energetic 
treatment of a laceration of the perineum, are very apt to say 
that only the fourchette was torn, in all cases in which the 
laceration does not extend through the whole length of the 
perineum. In one of the best recent articles on the peri- 
neum, the author, in speaking of the fourchette, calls it “ that 
mucous fold.” The fourchette is not formed of mucous 
membrane, but of skin. It is indeed nothing else than the 
commissura posterior, i. e., the posterior junction of the labia 
majora. These labia grow thinner toward their posterior end, 
and finally a mere fold or duplicature of skin stretches from 
one side to the other. If we separate the labia majora and 
watch the posterior commissure, we see how it gradually 
advances farther and farther up until it reaches the level of 
the posterior border of the introitus vaginae. Thus a fold and 
a hollow are formed; the fold is the fourchette, the hollow is 
the fossa navicularis. The lower surface of this fold has the 
common character of the skin; the upper one is red, moist, and 
forms a transition to the true mucous .membrane, which first 
begins on the labia minora. Although the inner surface of 
the labia majora looks much like a mucous membrane, it is 
1 Goodell: A Critical Inquiry into the Management of tlxe Perineum 
during Labor, in American Journal of Medical Sciences, 1871, pp. 55-58. of the Perineum. 
5 
still counted as belonging to the skin, because it is covered 
with minute hairs. The fourchette, then, is nothing but part 
of the skin of the perineum, and part of the inner surface of 
the labia majora. 
The fossa navicularis does not exist when the labia 
majora are in apposition. It is first formed, and gets its boat- 
shape, when the labia majora are separated. Its lower wall is 
formed by the fourchette, its upper wall by the perineal body; 
its lower end by the sharp edge of the vulvar orifice ; its upper 
end by the posterior circumference of the vaginal orifice. On 
Fig. 1. Vulva (from nature). A, anterior commissure. B, clitoris. 
C, meatus urinarius. D, small recesses. E, hymen (of married woman). 
F, vaginal orifice. G, frenulum or fourcliette stretched by separating 
labia majora. H, labia majora. I, labia minora. K, anus. M, poste- 
rior commissure. 
Fig. 2. Supposed sagittal section of vulva (woman lying on her back). 
A, anterior commissure. B, clitoris. C, urethra. E, hymen (married 
woman). F, vagina. G, frenulum or fourchette stretched. H, labium 
majus. I, labium minus. K, anus. L, fossa navicularis. M, posterior 
commissure. N, perineal body. 
Fig. 1. 
Fig. 2. 6 
Garrigues: The Obstetric Treatment 
both sides it mefts into the inner surface of the labia majora. 
In virgins, the posterior commissure projects a few lines, so 
that the point M*, in tig. 2, lies more anteriorly, and that con- 
sequently the line running from it to the vaginal orifice is 
more curved. In women who have had frequent sexual inter- 
course, it becomes so lax that the projection is lost, as shown 
in fig. 2, or, at least, much diminished. The hollow is large 
enough in the unimpregnated condition, and when the labia 
are well separated, to admit about one-half of the third phalanx 
of the index (see figs. 1 and 2). When, therefore, a recent author 
advises to perform episiotoinv by making an incision midway 
between the fossa navicularis and the fourchette, his advice is 
as difficult to follow as to make an incision between the lower 
lip and the mouth. The fourchette contributes indeed to the 
formation of the fossa navicularis exactly as the lower lip 
helps forming the mouth. /’ 
Let us finally glance at the anatomy of the perineum. Most 
anatomical works have only had their attention directed to this 
part of the body as found in man, in whom the thorough knowl- 
edge of its structure is of paramount importance for the per- 
formance of that grandest of operations in the male, lithotomy. 
As found in the female, it is well described by Henry Savage, 
of London. The excellent term perineal body, which almost 
amounts to a definition, was, as he himself states, suggested to 
him by Henle’s description, in which occurs the word, Korper 
(body).1 In the upper two-thirds of the vagina, the vaginal and 
the rectal walls lie close together, only separated from one 
another by some loose areolar tissue and a fascia, the destina- 
tion of which is to allow the rectum and the vagina to slide on 
each other according to their respective degree of expansion.2 
In the lower third, the vagina keeps the same direction, while 
the rectum turns so much backward that, in the upright posi- 
tion, the anus is turned as much backward as downward. The 
space left between the two is Occupied by what is called the 
1 Savage : The Surgery, Surgical Pathology, and Surgical Anatomy of 
the Female Pelvic Organs, 2d edition, London, 1870. Plate I., fig. 3, text. 
Henle: Handbuch der Anatomie des Menschen, 2te Auflage, Braun- 
schweig, 1873, vol. ii., p. 536. 
2 Wilhelm Braune: Topograpisch-Anatomisclier Atlas, 2te Auflage, 
Leipzig, 1875. Plate IT. and p. 7. of the Perineum. 
7 
perineal body. This body is much longer than the perineum 
described in anatomical text-books. According to this descrip- 
tion, it is only the space between the anus and the commissura 
posterior, while the perineal body extends to the vaginal orifice. 
The perineum proper is much shorter than in the male; it 
measures only fifteen to twenty millimetres, or about one-half to 
three-quarters of an inch.1 On Braune’s beautiful drawing, 
taken from a frozen body, it measures fifteen millimetres, while 
Fig. 8 (Henle2). Perineal muscles. CL, clitoris (turned over to the left 
side). CCC, corpus cavernosum clitoridis. CCU, corpus cavernosum 
urethrae (vaginal bulb). CVA, eolumna vaginae anterior. CW, glandula 
Cowperi. CW1, duct of Cowpers gland. BC1, 2, 3, bulbo-cavernosus 
muscle. JC 1, 2, ischio-cavernosus muscle. TPS, transversus perinaei 
superficialis muscle. TPP, transversus perinaei profundus muscle. SI, 
2, 3, sphincter ani externus muscle. XXX, layer of smooth muscles 
between vagina and rectum. -(-, limit of pubis and ischium. 
the perineal body on the same plate is four and a half centimetres, 
or one and three-quarter inches long, and four centimetres, or 
1 This is the distance indicated by Sappey in his Traite d’Anatomie 
Descriptive. Paris, 1857-1864, Yol. III., p. 224. It seems to be a little 
longer in the living body. Dr. F. P. Foster, whose valuable contribution 
to the anatomy of these parts did not reach me before this paper had gone 
to press (see January number of this Journal), found an average of 2.7 
cm. in nulliparae, and 2.5 in women who have borne children. 
2 L. c., II., page 456. 8 
Garriguks: The Obstetric Treatment 
one and nine-sixteenths inches high. But during pregnancy the 
genital parts are so developed that, toward its end, the distance 
from the anus to the commissura posterior measures four or five 
centimetres (about one and a half to two inches).1 On a sagit- 
tal section in the medial line, the perineal body has much the 
shape of the cucurbit of an alembic, the head of which is repre- 
sented by the loose tissue between the upper part of the vagina 
and the rectum. This body is by no means an inert mass, only 
serving to fill out a vacant space. It consists, on the contrary, 
to a great extent of muscles, partly striped, partly smooth. In 
treating of the lacerations of the perineum, books generally 
Fig. 4. Muscular floor of pelvis denuded of fascial coverings. Hori- 
zontal section passing through the body of the pubis, acetabulum, and 
sacro-iliac joint, just above the upper margin of the large sacro-sciatic 
notch. (Savage, PL IX., fig. 2). B, neck of bladder. V, vagina R. 
rectum. P, pubic symphysis. C, coccyx. S, sacrum. A, acetabulum. 
1, anterior vesical ligaments. 2, pubo-coccygeal muscle (anterior part of 
levator ani muscle). 3, obturatorio-coccygeal muscle (posterior part of 
levator ani muscle). 4, ilio-pubic line of origin of latter (arcus tendineus). 
5, ischio-coccygeal muscle (m. coccygeus). 6, ligamentum spinoso-sacrum. 
7, pyriformis muscle. 8, m. obturator internus. 
only refer to the sphincter ani, dividing them into two, three, 
or even four classes, according as the laceration does not reach 
the said muscle, or just reaches its outer limit, or extends more 
Braune’s Supplement, plates A and B. of the Perineum. 
9 
or less through it, or finally extends into the gut. This does 
not give a correct idea of what is really going on during a 
laceration. As soon as we consider the perineal body as a 
whole, and from an obstetric stand-point this is absolutely 
necessary, things appear somewhat different. The sphincter 
ani externus is, by its innermost bundles, inserted on the skin, 
but some bundles are immediately continued as bundles of the 
constrictor vaginae (see fig. 3). Besides, the levator ani muscle 
enters into the composition of the perineal body (see fig. 4). 
On the other hand, the superficial transversus perinsei muscle, 
in many female individuals, does not correspond to its name, 
for it does not lie in the perineum but is attached to the 
constrictor vaginae,1 and the deep muscle of the same name 
goes always in that direction. A laceration through the mid- 
dle of the perineal body severs first the bands of organic muscles 
connecting the two bulbo-cavernosi muscles, which together 
are called the constrictor vaginae,2 next the sphincter ani externus, 
and finally, the sphincter ani internus, and the two parts are 
drawn apart by the action of the transversi and the levator ani. 
This arrangement is one of the reasons why these lacerations 
so seldom heal, in that sense of the word, that the two raw sur- 
faces coalesce. In the comparatively rare cases in which the 
laceration takes place, not in the median line, but on one side 
of it, the transversi muscles of that side are also torn. 
Causes of Laceration.—Before we speak of the treatment 
of the perineum during and immediately after labor, it is well 
to know whence the danger threatens. The obstetric canal 
forms a curve (see fig. 5). The propelling force acts from 
above, almost under right angles to the plane of the brim of 
the pelvis, as we can tolerably well observe during delivery, 
and which is admirably demonstrated on Braune’s Plate C,3 
taken from the frozen cadaver of a woman who drowned herself 
just at the end of the first period, and actually died during 
a pain, so that we see the firmly contracted uterus compress- 
ing the child and squeezing its head through the pelvis. As 
1 See Savage’s first edition, plate I., and second edition, plate IV. Bour- 
gery et Jacob, Anatomie descriptive, vol. ii., plate 105, and p. 62. 
2 Henle, 1. c., ii., 537. 
3 The same plate is found, reduced to a small scale, in the second volume 
of Playfair's Midwifery, London, 1876. 10 
Garrigues: The Obstetric Treatment 
long as the fetus ir). this way is pushed against the sacrum, it 
glides otf, as it were, from this hard bone. When the os coccy- 
gis is reached, this movable organ is bent backward and 
straightened out. Finally the whole stress comes to bear on 
the soft perineal body. No wonder, then, that this weak part 
gives way under the formidable pressure exercised upon it 
from above. Besides this general danger, to which every peri- 
neal body is exposed during delivery, many abnormal circum- 
stances jeopardize its integrity. 
The causes of lacerations of the perineum are treated 
Fig. 5. The obstetric canal.1 AB, superior strait. CD, inferior strait 
before the coccyx is bent backwards. X, axis of pelvis. 
of more or less elaborately in most of the special works 
on this subject. I have no new ones to add. I rather doubt 
some of those indicated by others. I shall, therefore, limit my- 
self to a brief enumeration of the causes alleged by the 
authors. 
With regard to the pelvis, the following faults are accused: 
too small and, curiously enough, too great inclination of the 
pelvis ; too great a height of the symphysis (the barrure of the 
French) which can scarcel}7 have any influence at all; too 
straight, or what seems less rational, too curved a sacrum ; and 
too perpendicular a direction of the bones forming the pubic 
arch, so that this arch, instead of forming a wide curve, as in 
1 Spiegelberg: Lehrbuch der Geburtshlilfe, Lahr, 1878, p. 28, stated to 
be taken from Hodge. I have in vain endeavored to find the original. of the Perineum. 
11 
the well-built woman, approaches the angle, as found in men. 
This latter circumstance appears to me the most important of 
all causes, and endangers the perineum greatly, both by itself, 
and by the measures we often are forced to have recourse to in 
order to overcome the obstruction it opposes to labor. 
Other causes are situated in the soft parts: narrowness or 
want of elasticity of the vagina and the vulva ; a too long per- 
ineum ; too great thinness of the perineal body. The lack of 
room, tissue, or elasticity are often attributable to tender or 
advanced age in primiparse, or to edema, varices, condylomas, 
vegetations, ulcerations, or scars. 
A third series of causes come from the child, whose body 
may be generally or partially too large; or the presentation, 
the position, or the attitude may be unfavorable, e. y., cross or 
brow presentation, occipito posterior position, prolapse of arm 
beside the head. 
Finally the character of the delivery must be taken into con- 
sideration. A precipitated delivery, in which the parts do not 
get time to expand gradually, is a frequent cause of a lacera- 
tion of the perineum. The same holds good in forceps deliv- 
eries, or cases of manual extraction. Besides, the forceps are 
apt to injure the perineal body directly, the shanks being 
pressed or rubbed against it. 
Thv frequency with which the perineum is lacerated is very 
differently stated by authors. While some pretend that a 
laceration occurs only once in a hundred confinements, Snow 
Beck found 75 large lacerations in 112 priiniparse.1 The cause 
of this great discrepancy is twofold. In the first place, obste- 
tricians differ very much in their views as to the inevitableness 
and the importance of a laceration of the perineum, so that, 
while one counts every, even the slightest breach of continuity, 
the other only considers cases where the whole perineal body 
is severed from end to end. In the second place, many, espe- 
cially in private practice, do not examine the genitals at all 
after confinement, nay, some teachers instruct even their pupils, 
out of respect for propriety, not to inspect the parts. It has 
happened to myself that one of my patients, on account of a 
precipitated labor, had to call in a neighboring physician. 
1 Olshausen: Ueber Dammverletzung und Dammschutz. Yolkmann’s 
klinische Vortrage, No. 44, p. 875. 12 
Garrigues: The Obstetric Treatment 
When I arrived, he told me that everything was all right, and 
the binder had already been fastened. When iny confrere had 
taken his leave, I separated the labia majora, and what should 
I find but a deep laceration, for which I applied no less than 
five stitches. This practice seems to have prevailed until quite 
recently in this country. At least, Dr. M. D. Mann says in 
1874: “As a rule with us, the perineum is never exposed 
during labor, nor is it examined afterwards to see if it has sus- 
tained any injury.”1 If this be true, all prophylaxis and all 
immediate treatment, which form the very subject of this 
paper, are rendered impossible. But I trust that Dr. Mann’s 
own paper has cleared the way for a better understanding of 
the duties of the accoucheur in this respect, and since then, 
many American authors, such as Drs. T. G. Thomas, Noegge- 
rath, Munde, Fallen, T. A. Emmet, of New York ; Goodell. 
and Albert H. Smith, of Philadelphia; H. F. Campbell, of 
Augusta, Ga.; W. T. Howard and H. P. C. Wilson, of Baltimore; 
Skene, of Brooklyn; E. AY. Jenks, of Chicago; Lyman, 
Reynolds, and Richardson, of Boston; have expressed themselves 
in favor of immediate suture of the lacerated perineum,2 which at 
least supposes an ocular examination after the birth of the child. 
In order to give an idea of the frequency of laceration of 
the perineum, when a careful examination is made, I will only 
quote Olshausen (1. c., p. 362), who found 21.1 per cent among 
primiparse, and 4.7 per cent in multiparse in his own clinic, and 
56 lacerations in 119 primiparae, i. e. 47 per cent, in two other 
clinics taken together. At all events, lacerations are very com- 
mon, and we have, therefore, every reason to try our best to 
avoid them, or, if we do not succeed in that, to remedy them. 
It ought to be distinctly understood that, if the accoucheur can 
do a great deal to avoid them, a certain number of lacerations 
are unavoidable, so that the occurrence of this untoward acci- 
dent is by no means in itself a proof of want of skill or care 
on his part. He has no occasion to feel ashamed of it, or to 
try to conceal it. 
1 M. D. Mann: The Immediate Treatment of Superficial Ruptures of the 
Perineum, in Amer. Journ. of Obst., November, 1874, Yol. vii., p. 466. 
2 Ajier. Journ. Obstet., November, 1875, Vol. viii., p. 527, seq.; New 
York Med. Journ., May, 1876, p. 466, seq.; Transactions of the Ameri- 
can Gynecological Society, 1876, Yol. i., p. 306, seq.; Boston Med. and 
Surg. Journ., 18th Dec., 1879, vol. ci., pp. 881-882. of the Perineum. 
13 
Prophylaxis.—Much may be done in order to prevent or 
limit a laceration of the perineum. As it is a chief point that 
the lower part of the obstetric canal should have time to 
become fully dilated, ergot ought never to be given during labor. 
I use this drug in every confinement, but not before the pla- 
centa has been expelled. I give it even for four or five days, 
because I think that, by causing contraction of the muscular 
coat of the blood-vessels, it counteracts the absorption of 
septic matter, and by increasing uterine contraction insures 
good involution. If it augment after-pains, opiates may be 
given conjointly. Given during labor it is a dangerous remedy, 
both for the mother and especially for the child. It is a fre- 
quent cause of laceration of the perineum. 1 do not even like 
to give it in post-partum hemorrhage, unless I am perfectly 
sure that the uterus is empty, for I have found it very difficult, 
after I had given it, to dilate the os internum enough to get a 
single finger .through, which procedure was necessary in order 
to remove a small piece of the egg-membranes that adhered to 
the fundus and kept up the hemorrhage. The great danger 
for the child arises from tetanic contraction of the uterus being 
brought on, by which the oxygenation of the blood in the pla- 
centa is interfered with, resulting in asphyxia. Even without 
tetanus, a too quick succession of uterine contractions may en- 
danger the life of the child. 
In the second place, a thorough evacuation of the rectum 
is very important. In every confinement, I make, therefore, 
an injection of as much lukewarm suds as the woman can 
take in, which sometimes is as much as a basinful. I do not 
pay any attention to the patient’s saying that her bowels have 
moved abundantly. It is surprising what quantities of feces 
sometimes are expelled even under such circumstances. Thus 
not only room is gained for the safe passage of the fetus, but 
we avoid also the repulsive evacuation of feces during the 
birth of the child. 
Next, it is very useful to let the woman be in the left lateral 
position during the passage of the child through the vulvar 
orifice. During the first period, reason and humanity command 
us to let her lie in the position in which she feels most com- 
fortable. During the earlier part of the second stage, the 
dorsal decubitus is preferable, because by proper adjustment 14 
Garrigues: The Obstetric Treatment 
of the feet against some suitable object placed at the end of 
the bed, and by taking bold of a sheet or rope fastened at the 
end of the bedstead, the patient may use her muscular force 
to more advantage, and thereby shorten this period. But as 
soon as the head begins to pass through the vulva, I let her 
turn over on her left side. This position has great advan- 
tages. The parturient parts become easy of access, and can be 
made visible, whilst the whole rest of the body is covered up, 
whereby exposure to cold is avoided, and due regard is taken 
to propriety. The pudicity of the parturient woman is also 
consulted by the mere fact that she does not see the accoucheur, 
and, as it were, hides herself. On the other hand, this renders 
it possible to perform certain minor operations, such as episio- 
tomy, or the application of serres-fines, without frightening 
her, which often is worse than the real pain to be endured. 
The voluntary or often involuntary use pf the abdominal mus- 
cles which precipitates labor is limited. But, most of all, the 
left-side decubitus is useful, because in this position the fundus- 
uteri sinks down on the bed, so that gravitation works in an 
almost opposite direction to the uterine contractions. Thus 
the perineum has not to carry the weight of the fetus added 
to the pressure caused by the fetus being pushed against it. 
Besides being thus in itself a safeguard for the perineum, the 
left side-position facilitates other measures intended for this 
purpose, of which we shall speak presently. 
The left side-position is an old English invention, the so- 
called London method, and English accoucheurs use it also 
during the third stage of labor. This seems to me not only 
inconvenient for the accoucheur, who is obliged to bend sharply 
forward in order to be able to grasp the uterus, but less safe 
for the woman, since the placenta is less readily expelled by 
the method bearing Crede’s name, and hemorrhage less easily 
prevented or controlled. 
In most confinements, such an amount of glairy mucus is 
secreted, and all the parturient parts are so thoroughly bathed 
with the warm liquor amnii, that it is superfluous to use arti- 
ficial emollients and lubricants. But when the waters have 
broken a long time before the child is born, and if the vagina 
is hot and dry, it is entirely rational to bring about by artifi- 
cial means conditions similar to those under which Nature 
# of the Perineum. 
15 
generally works. In snch cases, sponging of the perineum 
with warm water, injection of oatmeal gruel or linseed tea 
into the vagina, inunction with vaseline, or pouring warm olive 
oil on the head during its alternate advance and retreat, may 
become truly useful and conducive to the safety of the peri- 
neum. According to Dr. Goodell (L c., p. 79), inhalation 
of ether, and especially of chloroform, has the property of 
re-establishing the natural mucous secretion. Not having had 
my attention directed toward this point before, I cannot speak 
of it from personal experience. 
In other respects, chloroform is certainly of high value as a 
protection against laceration. Fain being abolished and the 
abdominal muscles paralyzed, the child is pushed forward by 
the mere uterine contractions, and even these are weakened by 
the effect of the drug. 
Next we have to consider a class of manipulations performed 
either with the hands alone or with the forceps, and directed 
either against the maternal organism or against the fetal body, 
in order to preserve the integrity of the perineum. In this 
regard, very different opinions have been put forth, and the 
question, if any such direct protection ought to be used or not, 
is not as yet settled, and, of course, there is still less unanimity 
as to the particular way of affording protection. Dr. Goodell, 
who has made a thorough study of the history of perineal 
protection, sums up by the following resume (1. c., p. 69): 
“There are those who make pressure upon the perineum to 
retard the head; those who make pressure to accelerate its 
advance ;■ those who deny that any such effect can be thus 
produced ; and those who conscientiously use support because 
something must be done. Again, there are those who direct 
all the pressure at the fourchette; others who reprehend this, 
and carefully guard the posterior perineum ; and yet others who 
will not touch the perineum-on any account. Further, there are 
those who push the perineum forwards, and those who, for 
equally plausible reasons, push it backwards. Some dilate the 
sphincter vaginae, some the sphincter ani, and some plug it up. 
Some place their hands transversely across the perineum; 
some longitudinally, with the fingers looking upwards; some 
longitudinally, with the fingers looking downwards; some 
attack it with the knuckles; some scoop out the head with 16 
Garrigues: The Obstetric Treatment 
the vectis, others drag it out by the ears; and yet others rely 
on the forceps. Finally, there are those who use the right 
hand, and those who swear by the left hand ; some who advo- 
cate a folded napkin; some an unfolded napkin; and others 
again who frown down upon all napkins, folded or unfolded.” 
Much has been said against supporting the perineum both in 
this country and abroad, and as I am in favor of it, 1 must 
briefly review the arguments directed against it. In the first 
place, it is claimed that it is unnatural to support the peri- 
neum ; it was not made to be torn. This appeal to teleology 
leaves out of consideration the fact that man, for nobody 
knows how many thousand years, has not lived in the prime- 
val natural state. It is not at all unlikely that, with increasing 
intelligence of mankind, the size of the brain even in the fetus 
has increased, while, on the other hand, the muscular system 
of women, and consequently also the perineal body, has 
become weaker than originally.1 However this may be, the 
fact remains that nowadays the perineum is apt to tear, and 
the question is merely, if we can do anything to avoid this 
accident ? In the second place, the adversaries of support say 
that a laceration does not necessarily occur; that we may find 
the perineum entire in women who have borne their children 
without any assistance at all. Granting the possibility of such 
an occurrence, it does not prove that we cannot contribute to 
the attainment of this desirable result by active interference. 
Next it is argued that those very men who support the peri- 
neum have bad statistics with regard to lacerations. This is 
a specious argument apt to impress itself on the reader’s mind 
at the first glance. It is a fact that the same accoucheurs who 
advocate perineal support confess to a great number of lacera- 
tions, but this fact does by no means prove that the laceration 
is due to the support. On the contrary, it is likely that the same 
accoucheurs, if they did not use any support, would have to 
register a still greater number of lacerations. Madden2 says that 
in one-lialf of the cases in which he performed perineorrhaphy, 
1 It has been found by actual measurement that the brain and the sur- 
rounding hones are more developed, and that, on the other hand, the jaws 
undergo a retrogradejnetamorphosis under the influence of civilization. 
(Klein : Deutsche Vierteljahrsschrift fur Zahnheilkunde, xvii., Hospitals 
Tidende, 1879, p. 1000). 
2 Madden: Lacerations of Perineum. Am. Journ. Obst., May, 1872, p. 55. of the Perineum. 
17 
the cause was neglected support, and that rigidity came only in 
the second line. Olshausen (1. c., p. 361) thinks that, in fifteen 
per cent of primiparse, lacerations of the perineum are unavoid- 
able if episiotomy is not performed, in which computation cases 
in which the frenulum alone is burst or torn off are not comprised. 
As we have seen above, the views of different accoucheurs as to 
the presence or 11011-presence of a laceration of the perineum 
differ so widely that a comparison between the results of dif- 
ferent men cannot have any value at all as evidence. It might 
have some weight if the same man, working in an asylum in 
which a great many confinements take place, during one year 
would support the perineum in a certain way, and the next 
year would not use any support at all. But such experiments 
have not been published so far, and consequently all arguments 
based on statistics lack the proper foundation. Further- 
more, the support of the perineum is taxed with impeding a 
slow and equable dilatation, with lowering the vitality of the 
parts, with preventing them from responding in a natural way 
to the demands of the occasion in pushing the head forward 
or pressing it backwards, according to circumstances, and with 
increasing labor pains by reflex action. All these animadver- 
sions apply only to a support exercised too early or too forcibly. 
If we do not support before the presenting part commences to 
dilate the vulvar orifice ; if we are particularly careful during 
the passage of the greatest circumference of the head ; and if 
we limit our support to a moderate pressure, with the flat hand 
placed so that the fold between the thumb and the index comes 
to rest on the posterior commissure, this manipulation is not 
only innocuous, but very useful. Indeed, by so doing we only 
fortify the thin, elastic vulvar ring, which is being stretched to 
its utmost capacity, by applying on it, as it were, a second elastic 
layer, composed of the skin, the subcutaneous cellular tissue, 
and the muscles of the palmar surface of the hand. Evidently 
a thick elastic ring does not burst as easily as a thin one. 
It is another question, if it be advisable also to displace the 
perineum. Some recommend to shove it backward, others for- 
ward. I think that, in most instances, neither the one nor the 
other is good. We must keep the mechanical relations in mind. 
The fetus forms a kind of bent cylindrical body, the vulvar 
orifice an elastic ring. It is evident that the ring will be the least 18 
Garrigues : The Obstetric Treatment 
stretched when its diameter intersects the longitudinal axis of 
the cylinder at right angles. Only if this relation between 
them does not exist, can it be of use to displace the posterior 
part of the ring forwards or backwards, according to circum- 
stances. If the vulvar ring encircles the fetal body in the said 
favorable way, every displacement will only have the effect of 
subjecting the ring to an unnecessary surplus of stretching, 
and thereby expose it to break. A glance at fig. 5 will render 
this point perfectly clear. 
An author in this very Journal1 pretends that the “ present 
German school cautions us against any interference at all.” 
These words contain a double mistake. There is no such thing 
as a German school. Germany owes its scientific greatness to the 
fact that the country is studded with universities, each entirely 
independent of the other. Each of these places is a laboratory 
in which men work with the earnest purpose of investigating 
the secrets of nature, and furthering human knowledge. At 
most, we may speak of a Vienna school, a Berlin school, etc. 
A German school does not exist. On every subject, the most 
opposed views will have their spokesmen in different universi- 
ties. Consequently, modern German obstetricians differ also 
much in their opinions about the advisability of supporting the 
perineum. Olshausen, who has written the most elaborately 
on the subject in recent years in Germany, states that the per- 
ineum is supported almost everywhere in Germany, and holds 
himself that, in cases of membranous perineum, the support of 
the floor of the pelvis is indispensable (1. c., p. 368). 
Until within a few years, I have myself exclusively practised 
and seen practised the above-described kind of perineal sup- 
port, and feel perfectly convinced of its usefulness. I have 
ascertained by direct questioning that, so far from being pain- 
ful, as some pretend, it is a comfort and a relief to the partu- 
rient woman in the most trying moment of child-birth. 
Another kind of protection is afforded to the perineum by 
acting on the body of the fetus. Among the causes of lacer- 
ation we have mentioned a too speedy expulsion of the child. 
This is counteracted by direct pressure on the presenting part, 
especially the cranium. Commonly this pressure is only exer- 
cised so as to keep back the protruding head. Dr. Goodell (1. c., 
1 April, 1876, p. 60. of the Perineum. 
19 
. p. 77) even pushes it back into the vagina if it does not recede in 
the intervals of pains, so that the next pain may expend a portion 
of its force in recovering lost ground. In cases of manual 
extraction, the head ought to be drawn as slowly as possible 
through the vulvar orifice. In forceps deliveries it is advisable, 
if the condition of the mother or the child does not so imper- 
atively call for the utmost speed as to supersede all other con- 
siderations, to take off the forceps when the head has been 
brought into the vulvar orifice. 
It has also been recommended to rectify the position and the 
attitude of the child. If the head is propelled in an oblique 
direction, some try to turn it with their fingers in such a way 
that its sagittal section coincides as nearly as possible with the 
antero-posterior diameter of the vulvar orifice. Some have 
even recourse to the forceps in order to effectuate this change 
of position. I cannot speak from personal experience about 
these manipulations, but, upon the whole, I think that Nature 
herself performs the best turnings of this kind, and that by en- 
forcing a rectification in one place, we run the risk of doing harm 
in another place hidden from view. On the other hand, I hold 
it to be entirely rational to promote the normal extension by 
pressingthe presenting part towards the symphysis pubis. Often 
we find under the ligamentum arcuatum a free space which may 
be utilized to lessen the pressure on the perineal body. The 
pressure against the presenting part may be exercised either 
from the perineum, or, what is preferable, through the rectum. 
The woman lying on her left side, the index and middle finger 
of the left hand are introduced deeply into the rectum, and 
stemmed against the forehead of the child. We may even 
take another step, and, during an interval of pains, slowly press 
the head out through the vulva by a kind of enucleation. I 
have tried this several times, and am so far well satisfied with 
the result. Like so many other good things, it is an old method 
which had fallen into oblivion. Ritgen used it, Olshausen 
(1. c., 369) and Ahlfeld 1 speak highly of it, and it is much used 
in Halle and Leipzig. Certain precautions must not be neg- 
lected in carrying it out. Above all, we must be careful not 
to injure the eyes of the child ; but all parts are so distinctly felt 
through the recto-vaginal wall that this grave mistake is easily 
1 Archiv fur Gynaekologie, 1874, vol. vi., p. 279 seq. 20 
Garrigues: The Obstetric Treatment 
avoided. Another point of great importance is not to press 
with so much force as to cause lacerations in the region of the 
clitoris. This part is much more abundantly supplied witli 
blood-vessels than the perineum, and lesions there may even 
give rise to a fatal hemorrhage. A bad laceration of this kind 
occurred in the practice of Dr. Munde, of this city, and Peter 
Muller, of Germany, has had five cases, three of which ended 
fatally.1 The proper time for resorting to enucleation is when 
the anus is pushed forwards and distended, and the vertex dur- 
ing labor-pains is propelled into the vulvar orifice. 
This enucleation may, of course, also be used in forceps 
deliveries after removal of the instrument, when the head has 
been brought to the vulvar orifice. 
Hitherto we have only considered the dangers accruing to 
the perineum from the passage of the head ; but it is threatened 
as much, or even more, by the passage of the shoulders. Exam- 
ining during the interval which usually follows the expulsion 
of the head, I have often convinced myself that the skin 
between the commissura posterior and the anus was intact, 
and nevertheless found a considerable laceration of this part 
after the birth of the child. As, with a normal child, there is no 
more difficulty for delivery when once the shoulders have passed, 
we must attribute the accident to the passage of this part. 
This is also easily understood when we think of the different 
conformation of the parts in question. In consequence of its 
round circumference, its tapering top, and its alternate pro- 
gression and retrocession, the head will, in most cases, open 
the vulvar ring gradually, and extend it uniformly. The chest 
with the shoulders, on the contrary, measure much more from 
side to side than in the antero-posterior direction. The shoul- 
ders contain hard parts projecting from soft surroundings; they 
form a very abrupt transition from the comparatively narrow 
neck, and are commonly expelled all at once by a single labor- 
pain. All these circumstances render them more dangerous than 
the head, and in fact they have only the one advantage, that they 
come after the parts have already been dilated by the latter. 
We must, therefore, not think that we are done with the pro- 
tection of the perineum because the head has been safely 
1 Scanzonrs Beitriige, vol. vii., p. 201, and vol. vi., p. 148, quoted by 
Munde in this Journal, 1875, vol. viii., p. 537. of the Per ineum. 
21 
born. A distinguished gynecologist has given an advice which 
seems rather objectionable. He advises to turn the shoulders 
before they are expelled, in such a way as to give them a more 
or less oblique direction, so that neither of them glides over the 
perineum. He says that this turning succeeds generally by 
merely pushing the shoulders aside, and if it does not, the desired 
effect is attained by hooking the index finger into the axilla.1 This 
doctrine seems altogether to set aside the golden rule that the 
physician is the servant, not the master of Nature. Nature 
always leads the greatest diameter of the child through the 
greatest diameter of the maternal parts, and attains this end 
by those wonderful turnings and adaptations, the particulars of 
which are not even fully understood. If we give the shoulders 
an oblique direction in the vulvar orifice, the walls of this open- 
ing adapt themselves less well to the body of the child, and are 
consequently more exposed to be torn. If there be any reason 
at all to change the position of the child, the shoulders ought, 
on the contrary, to be turned in such a way that their breadth 
corresponds with the length of the vulva, exactly on the same 
principle as that on which the position of the head is corrected. 
More frequently it will be found useful to prevent the si- 
multaneous passage of both shoulders, by pressing back the pos- 
terior, or, by pulling forward the anterior with the index 
hooked into the axilla. 
Sometimes even tliq forceps are used as a means of prevent- 
ing laceration of the perineum. We have already mentioned 
their use for correcting the position of the head. They are also 
used for extracting the child; but I doubt whether regard for 
the safety of the perineum is a good indication for the use of 
this instrument. It is true that the forceps are often used to 
put an end to delivery when the head is arrested on the floor of 
the pelvis; but then deficiency of labor-pains, not regard for 
the safety of the perineum, gives the indication. In general, 
forceps deliveries are much more dangerous for the perineum 
than natural labors. We have, therefore, also seen that it is 
advisable to take off the blades before the head is drawn over 
the perineum. In many cases, where the head is arrested 
immediately behind the vulvar orifice, pressure exercisedhvith 
1 Olshausen, 1. c., p. 376. 22 
Garrigues: The Obstetric Treatment 
a finger or two from the rectum may render the resort to the 
instrument altogether superfluous. * 
If all the means hitherto considered do not seem sufficient 
to save the perineum, we may still try to do so by the opera- 
tion called episiotomy. At the first glance it may appear 
strange that the accoucheur, in order to avoid a wound, should 
make one himself; but when we come to consider the matter 
more carefully, we will find a great difference between the 
two kinds of injury. The natural rent is commonly directed 
backwards, single and deeper than necessary. In making an 
artificial wound, we can choose a more favorable locality, 
and lessen its depth by multiplying the number of incisions. 
This method is of old date. Paul Dubois practised it in France,1 
Blundell in England ;2 Ritgen in Germany.3 Of late years it 
seems to gain in favor. In this country, Dr. Anna E. Broomall, 
of Philadelphia, has written a good article on the subject.4 
The vaginal, not the vulvar orifice, being the narrowest part 
of the whole canal through which the child has to pass, and 
being actually injured in every confinement, as ascertained by 
Matthews Duncan,6 it would seem logical to make the incision 
in this locality. Simpson recommended, indeed, to cut the 
constrictor vaginae subcutaneously, and others have done the 
same without sparing the mucous membrane ; as a rule, how- 
ever, these deeper parts are not inspected during delivery, and 
it is first when the head dilates the vulvar ring, and this organ 
seems too small or too rigid, that recourse is had to cutting 
instruments. I prefer blunt scissors to the bistoury, as it is 
necessary to divide the tough fascia covering the fat of the labia 
majora, and I have found it difficult to do this with proper 
nicety with a knife. The cut is apt to be either too deep or 
too shallow, while the depth is very accurately determined by 
using the scissors; if performed during a labor-pain, the pain 
caused by the incision is little noticed. Dr. Pallen 8 has advised 
! Chailly-Honore: Traite pratique des accouchements, 6me ed, Paris, 
1878, p. 521. 
2 Baker Brown: Diseases of Women, Amer. ed., Philadelphia, 1856, p. 17. 
3 Ritgen: Ueber Scarification der Scheide u. des Scheidenmundes, in 
Neue Zeitschr. f. Geburtskunde, 1835, vol. iii., number 1, p. 68. 
4 Amer. Jour, of Obstetr., 1878, vol. xi., p. 517 seq. 
5 J. M. Duncan: Papers on the Female Perineum, London, 1879, p. 9. 
6 Pallen in New York Medical Journal, May, 1876, p. 469. of the Perineum. 
23 
to make tlie incisions on both sides, above the openings of the 
ducts of Bartholin,1 lest the ducts be cut, which might lead to 
closure, cystic degeneration, and abscess. The ducts open by a 
minute aperture just in front of and outside of the hymen or its 
site, a locality that scarcely ever will be visible at the time epi- 
siotomy is performed. And then, these openings lie so far for- 
ward that the incisions would have to be made almost in the 
middle, between the anterior and posterior end of the vaginal 
orifice, but here we might wound the semibulbus vestibuli, which 
is in close contact with the gland, and would be liable to cause 
an unpleasant hemorrhage (see fig. 3). Finally, I believe there 
is room enough to perform the operation behind the ducts in 
question. If the incisions be made, as usually recommended, 
one centimetre to the left and to the right of the posterior 
commissure, and extended one or one and a half centimetre 
in the direction of the tuberosity of the os ischii, neither the 
gland nor its outlet is wounded. This kind of episiotomy is 
much used, and is without any doubt a good means of prevent- 
ing laceration of the perineum ; but I think its advocates go too 
far when they claim that these wounds heal within a few days, 
that a complete union takes place, and that they are not bathed 
by the lochial secretion.2 It is easy enough to convince one’s 
self by mere inspection of the incorrectness of the last state- 
ment. As to time, my experience is, that it takes a fortnight 
before the wounds heal up. Finally, they did by no means 
heal in this sense that an agglutination and coalescence took 
place between the cut surfaces ; on the contrary, the wounds 
healed exactly in the same way as perineal lacerations gener- 
ally heal, that is to say, with a retracted cicatrix. The result 
is, consequently, that the vulva no more presents a linear cleft, 
the walls of which touch one another, but a more or less gap- 
ing triangle, the posterior angles of which are formed by the 
cicatrices. One of my patients herself made this discovery, 
and said that she was “ more open than before.” This is a 
drawback which merits to be taken into consideration, as from 
an esthetic and moral point of view it is desirable that the 
1 The name of this anatomist is often written as Dr. Pallen does, Bar- 
tholini, but that is a mistake. He was a Dime, and his name Bartholin. 
2 Pallen, 1. c., p. 469; Broomall, 1. c., p. 524; Chailly-Honore, 1. c., 
p. 521. 24 
Garrigues: The Obstetric Treatment 
genitals after delivery be brought back as near as possible to 
their original shape. But it is still more important that these 
little wounds may give rise to infection, which is not the case 
with a well-stitched laceration. Both these evils might be avoided 
by suturing the wounds ; but if sutures have to be applied, it 
will in many cases be better to stitch a perineal laceration made 
by Nature than episiotomy-wounds made by the accoucheur 
himself, and the necessity of which is problematic. Perhaps the 
laceration will prove so moderate as not to necessitate sutures 
at all. Dr. Albert H. Smith,1 of Philadelphia, cauterizes the cut 
surfaces with pure carbolic acid, in order to prevent absorption 
of putrescent materials. In deciding on the propriety of resort- 
ing to episiotomy in a given case, many things have to be taken 
into consideration, besides the probability or non-probability of 
the occurrence of a laceration. If the circumstances be such 
that a rent could not be sutured, this would go far in favor of 
performing episiotomy. On the other hand, this operation 
does not preclude a perineal laceration with absolute certainty. 
Thus, the editor of this Journal saw it happen in four cases, in 
spite of bilateral incisions.2 
As soon as the delivery is completed, the accoucheur ought 
to make an ocular examination of the condition of the peri- 
neum by separating the labia majora. We leave out of con- 
sideration the rare cases of purely central ruptures not extend- 
ing subsequently into the vulva, the still rarer perforation 
limited to the recto-vaginal septum, as well as the lesions situ- 
ated near the meatus urinarius. If, in spite of all precautions, 
a perineal laceration ha£ occurred, we find it either on the 
inner surface of the vulva and vagina only, or at the same 
time on the skin, behind the posterior commissure. Shallow 
tissures in the vaginal orifice, as well as slight injuries to the 
fourchette, need no other treatment than injections with car- 
bolized water (one or two per cent), or an ointment or oil 
containing from live to ten per cent carbolic acid. Deep lacer- 
ations ought to be united immediately. If deep rents occur- 
ring in the perineal body, while the skin between the posterior 
commissure and the anus remain intact, do not heal up, they 
1 St. Louis Med. and Surg. Journal, October, 1879, p. 512. 
2 This Journal, November, 1875, vol. viii., p. 586. 
3 Madden, 1. c.. p. 52. of the Perineum. 
25 
cause that membranous condition of the perineum so often 
found, which does not give sufficient support to the adjacent 
parts. This kind of rent ought, therefore, to be sutured from the 
vagina. More commonly the rent extends more or less through 
the skin, in the direction of the anus ; in this class of cases, I 
use a different treatment, according to the length and Height 
of the rent. It is now an established practice throughout 
Europe to suture deep perineal lacerations immediately, and, 
as we have seen above, weighty voices have of late been heard 
from different parts of this country to the same effect. It is, 
therefore, superfluous to say anything more on this head. Per- 
sonally, I regard the immediate suturing of a deep rent in the 
perineum as such a blessing for the newly confined woman, 
that I do not even admit as a counterindication that she is too 
weak to be profoundly anesthetized. I have applied sutures 
in such cases, either without any anesthetic at all or in an 
incomplete anesthesia only pushed so far as to somewhat blunt 
the sensibility. But I believe there is a large number of 
lacerations, deep enough to indicate artificial union, but not 
considerable enough to necessitate a proceeding that causes so 
much pain, takes so much time, and gives rise to so much 
talk, as the application of sutures. In these cases I make use 
of serres-Jines, and, as I am perfectly satisfied with the results 
obtained, I think it may not be superfluous to enter into some 
details on this subject. 
These small self-holding clamps were invented in 1849 by 
Yidal de Cassis, of Paris, soon introduced into obstetric practice 
in France, and adopted in Germany. I am not aware that they 
ever have been tried in England. In this country they were 
recommended a few years ago by Dr. M. D. Mann, of New 
York, who had seen them used in Vienna (1. c.). But the ques- 
tion thus brought up before the American profession was, as 
it were, drowned in the much larger and more important ques- 
tion if any immediate union ought to be aimed at or not. 
Under such circumstances, the suture of course came into the 
foreground, and the serres-fines were lost sight of. As now 
the pertinency of recourse to immediate union is recognized 
everywhere, the time may be more favorable for speaking of 
the more modest little clamps. I am perfectly aware that they 
have been abandoned in many places in Germany; but Spiegel- 26 
Garrigues: The Obstetric Treatment 
berg1 certainly goes too far when lie calls them obsolete, for Dr. 
Mann saw them in daily use in the Vienna Asylum, the largest 
lying-in institution in German-speaking countries, and I can 
add that they are used throughout Denmark, and give entire 
satisfaction. They were introduced there by Dr. A. D. Muller, 
who in 1866 wrote a treatise on lacerations of the perineum 2 
in which he gave a detailed description of forty-one cases treated 
in this way as compared with thirty left to Nature’s own 
efforts. Of the forty-one cases, two extended through the 
sphincter ani, or up into the rectum, and healed only partially. 
Of the remaining thirty-nine lacerations, twenty-nine were one 
inch or more in length ; ten less than an inch. Twenty-tive 
were completely united by the first intention in from four to 
six days ; seven times the union was complete, except a small 
angle towards the posterior commissure, which subsequently 
healed by granulation, so that the perineum retained its whole 
original length. In two cases, a greater part healed by 
granulation, so that the whole length of the perineum was 
preserved. In three cases, union only took place to the extent 
of one-third to one-half inch; and in two cases no union at 
all was obtained.3 These figures, which already prima facie give 
a favorable impression of the operation, are still more remark- 
able when it is borne in mind that all the observations were 
made in hospital practice. 
The editor of this Journal has reported (1. c.) the results 
obtained by suture in the Wurzburg Lying-in Hospital from 
1863 to 1870. Oat of thirty-four cases, complete union took 
place only in eleven ; partial union in seven ; no union in six- 
teen. Accordingly, in eighteen out of thirty-four or in fifty- 
five and a half per cent, some degree of union took place ; and 
this is, according to the said well-read author, “ about the usual 
average in hospital practice.” If we now group Muller’s 
figures in the same way, we obtain some degree of union in 
thirty-nine out of forty-one cases, or in ninety-five per cent. 
We may also post Muller’s figures thus: Complete union was 
obtained in eighty-three per cent (sixty-one per cent by first, 
1 Spiegelberg: Handbuch der Geburtshi'ilfe, Lahr, 1878, p. 629. 
2 A. D. Muller: Om Bristninger af Mellemkjodet under Fodselen (On 
Lacerations of the Perineum during Labor), Copenhagen, 1866. 
SL. c., pp. 138 and 170-177. of the Perineum. 
27 
and twenty-two per cent by second intention), partial union 
resulted in twelve per cent, none in five per cent. 
Muller’s other table (1. c., pp. 123 and 164-169), showing 
thirty cases of incomplete laceration that were not treated at 
all, is not less interesting. In no case did the laceration heal by 
the first intention, except one, in which the posterior half was 
healed on the eighth day after parturition. In almost all the 
other cases the torn surfaces staid apart, union taking place 
to the extent of a few lines only. In one case only, complete 
union was obtained in the course of a month by granulation. In 
two other cases, the same result was indeed obtained in respec- 
tively two and a half and three weeks ; but as the skin had not 
been torn, they do not illustrate what is generally understood 
by lacerations of the perineum. Serres-fines, then, applied in 
suitable cases, give better results than both expectation and 
suture. 
The adversaries of serres-fines, e. g., Winckel,1 pretend that 
they cause as much pain as sutures, cut as easily, and are 
less reliable. I believe that the reason of the discrepancy in 
the opinions on this method is chiefly to be found in the make 
of the instrument. All those I found here were indeed so bad as 
to be worse than useless. Their chief faults are that they are 
much too short, and much too strong. If such short, strong 
steel clamps are used, it is no wonder that they hurt, and cut 
through, and do not help. Now, I have had some excellent 
ones made by Messrs. Tiemann & Co., 67 Chatham street, 
New York (see Fig. 6), but it has cost quite a number of 
attempts before they succeeded. The 
clamps are one and a quarter inches long, 
one-half inch of which goes to the legs 
beyond the crossing, and end in minute 
claws. They are made of thin brass 
wire, number 19 of Stub’s gauge, nickel- 
plated, and so weak that they just keep the torn surfaces in 
apposition. As a rule, they can, therefore, only be used once, 
but as they are sold for two dollars a dozen, the expense in 
each case is a trifle. 
What recommends this method more than anything else, is 
the great simplicity of the proceeding ; no assistance, neither 
1 Winckel: Krankheiten des Wochenbettes, Berlin, 1869, n. 47. 
Fio. 6. 28 
Gar rig ties: The Obstetric Treatment 
skilled nor unskilled, is required. I do not even say a word 
to the patient, or her friends, about the occurrence of a lacera- 
tion. When I have done washing her, and whilst she is still 
on her left side, I lift up the lips of the wound with the thumb 
and the index of the left hand, and apply the serres-fines with 
the same fingers of the right hand, one to three in number, 
according to the length of the rent. The one that comes near- 
est to the anus, is first applied, about one-third to one-half of an 
inch in front of the posterior angle. The following are put 
on, progressing towards the posterior commissure, leaving the 
same distance between each two. The foremost shall be put at 
the commissure itself. They are put on at right angles, and 
pushed in as deeply as the length of the legs will allow. 
Before putting them on, the wound is carefully cleaned with 
carbolized water. Very seldom does it become necessary to 
twist an artery, or cut off some loose shreds of tissue. The 
pain is quite insignificant and momentary. The serres-fines are 
left in place four days. Their removal again causes very slight 
pain. When they have been removed, the sides of the rent 
appear lifted up in a ridge, which subsides within a fortnight. In 
the places where the claws have sat are found minute ulcera- 
tions which heal readily. The instrument I recommend 
never cuts through in the time indicated. With the serres- 
fines I use exactly the same treatment as with the suture, 
which will presently be discussed, i. e., a towel around the 
knees, a daily mild aperient, and vaginal injections with carbol- 
ized water. The catheter is only used if the patient cannot 
make water herself, and she is permitted to lie alternately on 
her back and on her sides. 
It is impossible to indicate, in a theoretical way, precisely 
what cases are fit for the treatment with serres-fines. First of 
all, I would exclude all those in which the rent extends into 
the anus; and even if the anal ring has not burst, I do not 
think those are proper cases where the rent is high, for it is 
evident that the clamps can exercise their power but little 
beyond the surface included within their grasp. I have 
also met with cases in which it was impossible to fix them. 
This is the case in fat women with hard, unyielding tissues. 
It becomes impossible to raise the necessary fold, or the deeper 
layers are withdrawn from the grasp of the clamps, so that they of the Perineum. 
29 
only hold the skin. But, even after all these subtractions, 
there remain a large number of cases in which they work 
admirably, nay, even a larger number than those requiring 
suture. 
On account of its great simplicity, and the trifling pain it 
causes, this proceeding can be resorted to in all suitable cases. 
The consequence is, that many smaller rents, which else would 
be left unheeded, because the accoucheur does not want to 
make noise about a small thing, or because the woman refuses 
to consent to have her rent stitched up, are so perfectly united 
as if she never had borne a child. We have seen above that 
they very rarely heal, in the true sense of the word, by them- 
selves ; and we find the cicatrices left by them every day in 
gynecological practice. The importance of these minor rents 
has been strongly emphasized by Dr. Thaddeus A. Beamy, of 
Cincinnati,1 and recently again by Dr. Geo. Lyman, of Boston.3 
A new method has been recommended for their treatment, 
when of old standing, by Dr. Edw. W. Jenks, of Chicago.3 I 
would also call attention to the excellent paper on the Pelvic 
Floor, by Dr. David B. Hart, in Edinburgh Medical Journal, 
April, 1879. Nobody interested in obstetrics and gynecology 
should neglect to read it. It is based on the above-mentioned 
plates of Braune. Thus, one good work engenders another. 
Best of all is, not to allow the minor rents to become old, and 
that is done in an easy, almost painless, and effective way by 
serres-fines. I therefore engage every practitioner to try 
them; but what I have said applies only to the instrument 
when made as I have described it. Everybody can convince 
himself of the insignificance of the pain they cause, when well 
made, by applying them on the fold of skin extended between 
the thumb and the index of his own hand. 
In cases that are not fit for serres-fines, sutures are to be 
used. This operation is constantly being simplified. Baker 
Brown (1. c., p. 40) insisted on cutting the tendon of the 
sphincter ani muscle loose from both sides of the os coccygis, 
and on applying alternating quilled and interrupted sutures. 
1 Transactions of the American Gynecological Society, vol. ii., p. 576 
seq. 
2 Boston Medical and Surgical Journal, 18th December, 1879, vol. ci., p. 
881. 
3 This Journal, April, 1879, vol. xii., p. 252 seq. 30 
Garrigues: The Obstetric Treatment 
Madden (1. c., p. 66) thinks it is necessary to use large pads 
or compresses, so adjusted under a binder as to force the but- 
tocks closely together, and take the strain off the suture wires. 
Most operators believe artificial constipation and the use of the 
catheter to be indispensable. Experience has taught otherwise. 
Dr. Noeggerath1 uses chloroform in every case where a 
laceration threatens to occur, and sews the rent up before the 
patient awakes. As often some time passes before the expul- 
sion of the placenta, and as, at least in my experience, hemor- 
rhage is apt to occur after it has come away, when chloroform 
has been used, I cease the use of the anesthetic in the mean 
time. When all hemorrhage has been checked, and the patient 
washed, I again put her under the influence of chloroform, 
unless she be so weak that the risk would be too great. 
Bantock 2 and Winckel3 operate in the left lateral position. 
This seems to be more difficult, as the buttocks come too close 
together, and the direction in which the needle has to be car- 
ried is rather awkward. It is most convenient to have the 
patient lying on a table, in lithotomy position. One can also 
operate on her in her bed, by turning her so as to bring the 
buttocks towards the edge of the bed, and placing her feet on 
two chairs. The latter way is preferable when she is much 
exhausted; but it is much more fatiguing for the operator, 
who is obliged to kneel down during the whole procedure. 
Skilled assistance is, of course, very desirable, but by no means 
indispensable; two persons of common intellect, generally the 
husband and the nurse, will do. The accoucheur himself puts 
the patient under influence of chloroform, but afterwards the 
assistant, standing on the right side of the patient, keeps up the 
narcosis, under the direction of the doctor. Each assistant 
holds one knee, bent and carried outwards with his arm, and 
the one placed on the left side of the patient separates the lips 
of the wound, while the operator inserts the index of the left 
hand into the rectum. He places his instruments on a small table 
at his right hand, or, if the operation is performed in the bed, 
on the chair at his right hand. As this article is not destined 
for specialists, but for general practitioners, it may perhaps 
1 This Journal, November, 1875, vol. viii., p. 584. 
2Bantock: Treatment of Ruptured Perineum, London, 1878, p. 22. 
3Winckel, 1. c., p. 46. of the Perineum. 
31 
not be superfluous to enter into such details. The wound is 
carefully cleaned by removing clots with a pair of forceps, cut- 
ting off loose shreds with curved scissors, and douching the 
vagina with hot carbolized water (one per cent). A sponge or 
cotton tampon with a string attached to it, iu order to be able 
to remove it easily after the operation, is introduced above the 
rent. Thus, the blood is prevented from trickling down over 
the wound from the uterus. 
Baker Brown’s needles, as recommended by Dr. Albert H. 
Smith (1. c.), that is to say, long curved needles with an eye near 
the point, and fastened in a wooden handle, are indeed conve- 
nient, but they make an unnecessarily large hole ; they cannot 
be used when the laceration extends high up into the vagina, or 
implicates the rectum to any considerable extent; and finally 
it is an instrument more to carry about, which has only a limited 
applicability, while common needles may be used in most parts 
of the body, and for the most different purposes. Dr. T. A. 
Emmet1 and his school use round, straight needles. I have 
no personal experience with them; but I have convinced myself, 
by seeing them used by the master himself and others, that 
they are introduced with much more difficulty than the old- 
fashioned curved ones, with cutting edges. Admitting that 
they may be preferable in other operations, I do not think they 
are necessary in the one just now under discussion. 
The material used for sewing is not of great account. The 
great German gynecologist, Gustav Simon, always used silk. 
Many use carbolized catgut. Bantock (1. c., p. 28) recom- 
mends silk-worm gut. Most operators prefer silver wire, and 
I do so myself. If sutures have to be introduced from the rec- 
tum, soft materials are preferable, because they do not irritate 
the intestine, and need not be removed. But if only vaginal 
and perineal sutures are used, consequently always in incom- 
plete lacerations, silver has great advantages. It is easier to 
twist it than to tie the other materials, it gives support to the 
lax tissues, keeps the torn surfaces well adjusted, and does not 
absorb fluids. The silver wires, about eight inches long, are 
bent under a sharp angle at one end so as to form a kind of 
hook by which they are fastened to the silk or thread, threaded 
1 Emmet: Principles and Practice of Gynecology, Philadelphia, 1879, 
p. 44 and 391. 32 
(xarmgues : The Obstetric Treatment, 
into the needle. Both ends of the thread are passed through 
the eye of the needle and tied with the remaining part of 
the thread in a half knot, just behind the head. Dr. 
Emmet’s suture-twister, Dr. Sims’ shield and Dr. Thomas’ 
stretcher will he appreciated by everybody who tries them, 
but they are not indispensable. The wires may simply be 
crossed and twisted with the fingers. All the wires are passed 
before the twisting is begun, but it is convenient to twist 
the two ends of each wire slightly together immediately after 
it has been passed, in order to find, without delay, which ends 
belong to one another. Beginners are always apt to make their 
sutures too tight, the result of which is that they cut through 
in a few days. The two raw surfaces ought just to be brought 
into contact, and very slightly pressed together. Applied 
in this way, the sutures will indeed also cut somewhat, hut not 
cut through. I have adopted Dr. Emmet’s excellent way of 
leaving the twisted wires long 
enough to unite them all in one 
bundle, in front of the vulva, and 
hold it together by a small piece 
of rubber tubing, one of the 
wires being bent back around 
the rubber band, so as to pre- 
vent it from slipping off (fig. 7).1 
I leave the sutures in place one week; when they are to be 
withdrawn, the wire is cut as near as possible to the mucous 
membrane on one side, with sharp-pointed scissors, and the 
twisted part drawn toward the same side. Thus the newly 
united surfaces are strained the least. 
A recent author recommends to insert the wires fully an inch 
from the central line or raphe. This seems to me to be too4 
far. The adaptation of the edges of the wound will be less 
accurate. I pass the sutures only a centimetre, less than half 
an inch, from the edges. The needle has, as a rule, to be car- 
ried behind the whole torn surface, so that the wire becomes 
entirely imbedded in the tissue. The only exception from this 
rule is Simon’s triangular suture, of which we shall speak 
presently. 
The number of sutures should not be too restricted. This 
Fig. 7. 
1 Emmet, 1. c., p. 395, fig. 71. of the Perineum. 
33 
has a great influence on the result. Since I use serres-fines 
for smaller rents, I rarely apply less than five sutures, and 
when the laceration extends high up in the vagina, even if 
the rectum is not implicated, eight may be necessary. If 
only the perineal body has been torn, all the sutures may be 
passed from the perineum, beginning at the anus and going 
up to the posterior commissure. If the rent extends some 
way up in the vagina, separate vaginal sutures have first to be 
passed, beginning at the upper end and going down to the 
perineal body, which then is treated in the usual way. It 
would be waste of time td give clinical histories illustrating 
Fig. 8. 
so common a tiling as a lacerated perineum, but I will give a 
few diagrams in order to show how the sutures are passed. 
Fig. 8 is from a primipara, twenty-one years old, narrow 
pubic arch, forceps delivery. Long rent through the whole 
thickness of the recto-vaginal septum, except the gut. I applied 
a Sims’ speculum under the pubic arch, directed an assist- 
ant to hold it, and drew the posterior wall of the vagina down 
with the left index, in order to get at the upper part of the rent. 
I could neither see nor feel how deep my sutures came, but I 
tried to embrace the whole thickness without entering into 
the intestine. The numbers mark the order in which the 
sutures were put in. Fig. 9 is from a primipara, thirty-one 
years old, vagina so narrow that a week before her confine- 34 
Garrigues: The Obstetric Treatment 
ment it was difficult to introduce a finger; narrow pubic 
arch, forceps delivery. Rent through perineal body to the 
transparent rectum, and through vaginal wall one inch more 
upwards, with a smaller side-branch. The first seven sutures 
were of silver wire, numbers eight and nine of silk. In both 
cases the bowels were kept open, and the sutures were taken 
off on the eighth day, when the wounds were found perfectly 
united. 
When the rent goes right through into the rectum, and 
extends high up, a row of sutures are first passed into the 
rectum, from the upper end of the rent down to the anus. 
Fig. 9. 
Here silk or catgut is preferable, and the sutures ought not to 
be very deep. Next, silver sutures are passed into the vagina 
in a row reaching down to the skin. Finally, a few superficial 
silver sutures are passed into the perineum. This disposition is 
Simon’s so-called triangular suture, an improvement on Dieffen- 
bach’s original method.1 Dieffenbach sewed also the three 
sides of the torn surface, but used deep perineal sutures. 
The advantage of Simon’s method is, that all the traction goes 
in the direction of the vagina, and thus there is less likelihood 
of the formation of a recto-vaginal fistula just above the 
perineal body, where it is often found, and probably due 
1 Simon : Chirurgische Mittheilungen, 2te Abtheilung. Prague, 1868, 
p. 259. of the Perineu m. 
35 
to the traction exercised by the thick perineal body with its 
deep sutures. 
The chief thing to bear in mind in perineorrhaphy is, that it 
is a plastic operation, that we want the surfaces and edges to 
grow together by the first intention, and that to this end they 
must be brought into proper contact with one another. The 
sutures must, therefore, be passed symmetrically, and if the 
regular deep wire sutures described do not entirely adjust the 
edges, a superficial silk one may be added between two of the 
others. 
When the sewing is finished, the knees are firmly tied 
together with a towel. It is not necessary to keep the patient 
all the time on her side. If the knees are bandaged, the 
parts are not stretched when she lies on her back, and with 
regard to the proper involution of the uterus, it is preferable 
that she should lie alternately on either side and on her back. 
In the latter position, she feels more comfortable when a 
round pillow is introduced under her knees. All movements 
ought to be executed very slowly and with the help of a 
nurse. Morning and evening the vagina is injected with luke- 
warm carbolized water (1 per cent), until it returns perfectly 
pure, and the external parts are cleansed with the same fluid. 
Most women who have sustained a laceration of the peri- 
neum are unable to urinate. Commonly it is enough to empty 
the bladder with the catheter twice a day. But it is much 
more convenient for all parties if the patient can make water 
herself, and there is no reason why she should not be per- 
mitted to do so. Fresh urine has not the least bad influence 
on wounds, as demonstrated by Simon. The only precaution 
I use is, to let her make water immediately before the injec- 
tions, and to give an extra one if she urinates at other times 
in the twenty-four hours. Thus all stagnation and decom- 
position which would interfere with the healing of the wound 
are prevented. 
The idea of keeping the bowels loose is by no means a new 
one. It was, on the contrary, the method used by the earlier 
operators,1 until Dieffenbach, and after him Baker Brown, 
introduced the constipating method. It is Simon’s2 merit to 
’See Bantock, 1. c., p. 9; Baker Brown, 1. c., p. 48; Dieffenbach: 
Operative Chirurgie, Bd. i., p. 626. 2 Simon, 1. c., p. 268. 36 
Garrigues: Obstetric Treatment of the Perineum. 
have revived the old method, which has special advantages in 
case of the primary operation. It is much better for the 
general health that the patient should have her bowels moved 
every day, than to be kept constipated during the first fort- 
night of her puerperal state. This aperient method allows 
her to take abundant nourishing food, while most of those who 
favor the constipating method keep her on very low diet. 
The generous food is not only desirable to counteract the 
general debility incident to child-bearing, but has a direct 
influence on the healing of the wound. Finally, the danger 
ot‘ the agglutination giving way when at last the bowels are 
permitted to move, is avoided. I have myself seen the 
sphincter torn under such circumstances, and others have 
reported cases in which the whole rent was re-established, for 
even if emollient enemas are used, it may happen that scybala as 
large as a fist are expelled. I prefer castor oil to any other 
aperient after perineorrhaphy. Two fluid drachms every morn- 
ing are generally enough. If the oil cannot be borne, I pre- 
scribe | ij.—iv. Hunyadi Janos water in the morning, or a 
heaping teaspoonful of the compound licorice powder of the 
German Pharmacopea in the evening. Laxatives seem to me 
preferable to enemas as recommended by others, especially if 
there are rectal sutures, as the nozzle of the syringe may 
interfere with the sutures. 
If, from some cause or other, the wound has not been 
united immediately, it is still possible to make it heal by 
the application of sutures or serres-fines. Nelaton even 
advised always to wait six or eight days.1 Holst has obtained 
union by applying sutures the ninth day, and A. D. Muller 
has reached the same result with serres-fines put on as late as 
the twelfth day after confinement.2 But in this kind of cases 
the granulations must first be made to bleed by scraping or 
scarifying the granulating surface, or by pressing a sponge 
against it. 
If the period of granulation has also passed, the case no 
longer belongs to obstetrics, and consequently lies beyond the 
scope of this paper. 
104 West Forty-fifth Street, 
New York, January, 1880. 
1 Eustace: Archives de Tocologie, 1878, p. 556. 
9 A. D. Muller, 1. c., pp. 146-147.