NEW METHOD 
-OF- ■* 
PERFORMING THE PRIMARY OPERATION 
-FOR- - 
LACERATION OF THE PERINEUM, 
/ -BY_" 
WILLIAM L. BARRET, M. D., 
PRESIDENT ST. LOUIS MEDICAL SOCIETY; PHYSICIAN TO ST. LUKE'S HOSPITAL; 
LECTURER ON DISEASES OF WOMEN IN THE ST. LOUIS MEDICAL 
COLLEGE; EX-HOUSE SURGE*M TO THE WOMEN'S HOS- 
PITAL OF THE STATE OF NEW YORK. 
READ BEFORE THE TRFSTATE MEDICAL SOCIETY. 
[Reprinted from the St. Louis Courier of Medicine, February, 1883.~\ 
st. louiSTmo: 
COMMERCIAL PRINTING COMPANY, 405 N. Third Street, 
1883» NEW METHOD OF PERFORMING THE PRIMARY 
OPERATION FOR LACERATION OF 
THE PERINEUM. 
I DESIRE to invite the attention of the Society to a meth- 
od of performing the primary operation for laceration 
of the perineum, and to insist on the vital importance of 
never neglecting to resort to the immediate operation. 
The method I propose to describe is one I have practiced 
several years, with entire satisfaction, and so far as my in- 
formation extends it is a method peculiar to myself. 
I have now operated in a considerable number of cases, 
of both complete and incomplete laceration. In all of 
them, without exception, the result was perfect; the peri- 
neal body and the vulval outlet being restored to its virginal 
form. 
This result I was rarely, if ever, able to achieve by obeying 
the rules of the standard authorities. Sometimes the opera- 
tion failed entirely, often it was only partially successful, 
and not unfrequently I was convinced it did harm by forming 
a reservoir that arrested the discharges, and from which 
they percolated into the depths of the wound, retarding 
healthy granulation, and causing septic infection. I will 
not consume time by discussing the frequency of laceration, 
the direful calamities, immediate and remote, that it entails 
on its victims, nor the various means that have been sug- 
gested to prevent the misfortune. These are familiar and 
threadbare themes. Let it suffice to say that perineal lac- 
eration is more frequent, and that its pathological import- 
ance is infinitely greater, than the mass of the profession 
realize; and, I may add, that no skill can anticipate or 
prevent it. Anesthetics, the multitudinous and paradoxical 
methods of support, and even the much vaunted bilateral 
incisions, are unavailing. 
Moreover, when complete laceration has occurred, no 
secondary operation can fully restore to the perineum, its 3 
lost form and function. At least I have never seen a case 
of perfect restoration, although I am familiar with the 
work of the best operators. 
Perinea restored by secondary operations are at best 
but substitutes, and often very indifferent substitutes, for 
the originals. The operation is always a painful, formidable 
undertaking, and death is sometimes its sequel. Several 
deaths from this operation have come to my personal 
knowledge. 
There can be no doubt that the raw, unapproximated 
surfaces of a recent rent form a more favorable site for 
purulent absorption than if its edges are carefully and 
accurately approximated by sutures. I have rarely seen 
cases of neglected laceration escape some degree of septic 
infection, and, per contra, I have observed that the careful 
and prompt closure of these wounds was a noticeable pro- 
tection against sepsis and puerperal inflammatory troubles, 
and that it contributed in an unmistakable manner to the 
prompt and perfect convalescence of the patient. 
The primary or immediate operation is thus described 
by standard authorities : 
" As soon as the placenta is expelled and the uterus re- 
mains firmly contracted, a nurse or an assistant being 
instructed to maintain pressure on the organ to prevent 
any risk of post-partum hemorrhage, the external parts are 
carefully sponged, and if the sanguineous discharge be at 
all free, a cup-shaped sponge may be passed into the 
vagina." 
"Placing the patient in the dorsal position, with the 
knees drawn up and the hips close to the edge of the bed, 
opposite a window so as to secure a good light, if daylight, 
or, if it be night, a lamp placed on a table behind, the 
seated on a low chair or stool, first approximates 
the torn surfaces to see where to insert the sutures." 
"Any ragged surface may be snipped off, and if the 
surface bleed freely, the part should be sponged with cold 
water to check the bleeding." 4 
"With a curved, long-handled perineum needle, or a 
sharply curved needle held in a needle forceps, and armed 
with a stout silver wire, the operator then inserts the point 
about half an inch or so from the margin, a little below the 
lower angle or fork of the wound, carrying the needle in 
the recto-vaginal septum, so that the wire remains buried 
within this, and bringing out the point on a corresponding 
level with the insertion." 
"Three or more sutures are passed, according to the ex- 
tent of the laceration, each one, except the lower one or two, 
being made to emerge on the mucous membrane of the va- 
gina, very near the edge of the raw surface." 
" Having passed as many as requisite, the sponge which 
was previously passed into the vagina is now withdrawn, 
the raw surfaces approximated and the sutures twisted, 
beginning with the lowest one first." 
" The ends of the sutures should be left two inches long, 
twisted together and the ends secured by gutta percha or a 
piece of India rubber tubing." 
" The urine should be drawn with a catheter every six 
hours, a pad placed between the knees, the limbs bound 
together and the patient directed to lie on her side." 
This description is taken from the latest gynecologi d 
work published, that of Arthur W. Edis, issued in 1882. 
It is in all essential particulars similar to that given in 
all other works, from the time of I. Baker Brown, down to 
the present date. 
The principle involved in this method of operating is 
wrong and the practice has been a failure. It is n'ot possi- 
ble to pass deep sutures from the cutaneous surface through 
the recto-vaginal septum, in such manner as to approxi- 
mate the lacerated surface accurately and at the same time 
preserve the natural shape of the perineum. When sutures 
are passed in this manner the perineum is necessarily 
shortened, and the tissues puckered by the tension of the 
sutures, the tension being from before backwards. 
The tissues are held together in an abnormal position 5 
and by main force, consequently when the natural physi- 
ological changes take place in the tissues themselves, and 
contraction and involution of the perineum is set up, the 
lochia and urine seap into the wound, now relaxed and 
gaping open, and prevent union. 
The above diagram is designed to show the puckering produced in the 
perineum by the tension of deep sutures, as they are ordinarily used. The 
parallel lines are the sutures, and show that the tension is from before back- 
wards. If drawn too tight, as they usua'ly are, puckering must be caused. 
If just exactly the right tension to effect apposition is secured, the subse- 
quent shrinkage that occurs in the process of involution necessarily renders 
the sutures too lax, and permits the wound to gap. 
The operation has failed and failed again, until the 
pro; "jety even of its performance has been denied by the 
highest authorities. Popular professional judgment has 
overwhelmingly condemned it, the vast majority of phy- 
sicians preferring to tie the legs together and trust to 
nature, rather than to the needle and the suture. 
The advocates of the operation seek to palliate the force 
of repeated failures, by the excuse that the operation is 
often performed by inexperienced operators, that it is done 
in the night without proper instruments or assistance, and 
in the midst of anxious friends, with the dread of post- 
partum hemorrhage ever present in the mind of the opera- 
tor, and last but by no means least that the lochial dis- 
charge and the urine get into the wound and prevent union. 
I think I may safely affirm that the results of no surgeon 
in this operation, howsoever skillful and experienced he 
may be, have been entirely satisfactory to himself. This 6 
disappointment is not explained by the inexperience, the 
haste, the fear and the defective instruments of the operator, 
nor is it because puerperal women urinate and have post- 
partum discharges. Failure comes simply because the 
laceration is not closed in the proper direction, and with 
sufficient accuracy to protect the wound from contact with 
the discharges; nor can this protection be effected in the 
manner in which it has hitherto been sought to do it. The 
fault is in the operation, not in the operator. I believe 
that if the operation be performed in the manner I shall 
suggest, failure in the hands of any intelligent physician 
will be as rare as success has heretofore been in the hands 
of the best operators. 
The above cut shows the patient, and speculum in position, and indicates 
the method of introducing the sutures. The highest suture, viz., that at the 
superior extremity of the rent, is inserted first, and the lowest last. It also 
conveys an idea of the amount of tissue embraced by each suture. 
The plan I have pursued is to place the patient in the 
usual position on the back, with the legs flexed on the 7 
abdomen. A satisfactory light is indispensable, and if an 
artificial light is employed, a reflector will be of signal 
service. 
The parts are sponged off, and a sponge inserted into 
the vagina to prevent the uterine hemorrhage from obstruct- 
ing the view. The vaginal sponge having been introduced, 
a Sims' speculum is inserted into the anterior commissure 
of the vulva. This exposes the posterior surface of the 
vagina to the view of the operator, and he can plainly see 
the whole extent of the rent. Then with a very fine, short, 
straight needle with a trocar point, armed with very fine 
silk, and held with a needle forceps, the operator begins at 
the superior or vaginal extremity of the rent, and stitches 
the mucous membrane together, from above downwards. 
The sutures are simple interrupted sutures, cut off short on 
the vaginal surface and left to ulcerate out. Five or six 
sutures are used to the inch. The needle is entered and 
brought out only a line or two from the torn edges, so 
that the suture embraces very little tissue. 
No matter how serpentine and ragged the rent may be, 
it is accurately followed with the needle from its com- 
mencement on the vaginal surface to the edge of the four- 
chette. No trimming of sefrated or irregular edges 
should be resorted to; but, on the contrary, every tongue 
of tissue should be fitted into and stitched down to its 
proper place so accurately that the mucous surface can- 
not gap and discharges cannot enter. The point on which 
the success of the operation turns, and the only point worthy 
of consideration in the proceeding, is the exact approxima- 
tion of the edges of the mucous surface. It is not neces- 
sary either to effect apposition or to maintain apposition of 
the lacerated parts that the sutures should be strong, or 
that they should embrace much tissue in their grasp. 
The perineum, normally only 1| to inches in length, is 
during labor stretched to four or five inches in length. 
Immediately after labor the parts are flaccid and elon- 
gated ; and if the torn surfaces are placed in apposition, in 8 
the same relationship that they occupied before the injury, 
they fit together as naturally and as accurately as an 
oyster fits into its shell. 
There will be no tension on the sutures, and no disposi- 
tion to a separation of the lacerated surfaces; but, on the 
contrary, the contraction that takes place in the perineal 
tissues, as involution progresses and the parts resume their 
ante partum condition, tends to draw the severed surfaces 
into closer apposition, and thus contributes to the success 
of the operation. 
If the parts have been drawn by deep perineal sutures 
into artificial relationship, the normal change referred to, 
disturbs the apposition that is forced and unnatural, and 
opens sinuses, into which irritating discharges percolate 
and prevent union. 
When the mucous membrane has been closed in the 
manner described, the tear in the perineum will also be 
closed, and I believe that the passage of sutures through 
the cutaneous surface might be entirely dispensed with; 
but it has been my habit to introduce one or two super- 
ficial stitches, because it approximates the parts more per- 
fectly and insures a neater appearance. I do not believe 
the external sutures are absolutely essential. 
I do not bind the limbs together, draw off the urine, nor 
constipate the but treat the patient in all respects 
as if no operation had been performed. 
On the fourth or fifth day the external sutures are 
removed. Those in the vagina are left to ulcerate and 
come away spontaneously. The operation, performed in 
this way, is simpler, less painful, more rational, and, I 
believe, more certain in its results than when the usual 
method is adopted. 
Other advantages are observed in the fact that the line 
of union is not traversed by foreign bodies in the form 
of sutures, and that drainage is permitted, if union by 
first intention should fail.