NEW OPERA t/ON

FOR

RUPTURE OF THE PERINEUMTHROUGH THE SPHINCTER

BY

J. COLLINS WARREN, M. D.ASSISTANT PROFESSOR IN SURGERY IN HARVARD UNIVERSITY -, SURGEON TO THE

MASSACHUSETTS GENERAL HOSPITAL

REPRINTED FROM VOLUME VII.

(Spnetologicai €ransfactiong1883

A NEW METHOD OF OPERATION FOR THERELIEF OF RUPTURE OF THE PERINEUMTHROUGH THE SPHINCTER AND RECTUM.

J. COLLINS WARREN, M. D.,Boston, Mass.

The operation to be described is intended chiefly for themost serious cases of rupture, where not only the sphinctermuscle, but also a portion of the anterior wall of the rectumhas been torn through. The rent in these cases usually in-volves that portion of the rectal wall which bounds the per-ineal body posteriorly. During the process of cicatrizationthere is little or no union of the sides of the rent, but therecto-vaginal septum is drawndownwards by cicatricial con-traction, and is thus made tocover a considerable portionof the exposed rectum. Theoutlets of the vagina and rec-tum are, however, continuous,and form at the vulva a largecloaca. Fig. I shows the vul-va, with the labia drawn apartso as to display a considerableportion of the posterior wallof the vagina. Below, betweenthe letters A and B, we see alsoa portion of the posterior wallof the rectum bounded above, Fps. i.

in the picture, by the semi-circular margin of the septum,and below by the retractedsphincter muscle.

A NEW OPERATION FOR RUPTURE OF PERINEUM.2

The weak point of every operation hitherto devised liesin the management of the rectal wound. The perinealbody is not situated in front of the rectum, but forms, asit were, the floor of that cavity, which at this point takes asudden curve backward to reach the anal orifice. A freshlyunited linear rectal wound at this point must, therefore,present itself at right angles to the axis of the rectum, andmust sustain the full force of a column of gas or fecescoming down from above. If the wound be a long oneand the perineal body not sufficiently thick, the point ofleast resistance will be in the direction of the vagina, anda recto-vaginal fistula may result. Emmet, who, it mustbe acknowledged, has done more than any other surgeonto place this operation upon its present comparatively firmbasis, has sought to overcome this source of danger bydrawing down the edge of the septum to the sphinctermuscle by means of his bag-string suture, and thus doaway with a rectal wound as completely as possible. Themoment, however, the edge of the septum has been re-leased from its cicatricial bands by the scissors, it begins towithdraw itself to its original position ; a point much fur-ther inside the pelvis than one would imagine who judgedby its position in the cicatrized state. The tension of therecto-vaginal septum when drawn still further down by thebag-string suture is greatly increased, and displays itselffirst when the parts have become swollen by inflammation,the lower stitches being frequently sucked up, as it were,into the rectum ; later, when the tissues are softer, thestitches cut through and the rectal wall retracts, forming anopen wound in the rectum and exposing the lower portionof the perineal body. If we extend the line of the axis ofthe rectum downwards through the perineal body, we shallfind that it emerges usually between the second and thirdstitches externally. It is at this point that the contents ofthe rectum force their way out, so far as the writer’s experi-ence goes, and establish a fistulous opening around whichthe freshly united tissues gradually melt away. The prin-ciple of the method described in this article consists in

y. COLLINS WALLEN. 3shutting out the rectum entirely by a flap operation, so thatit shall no longer enter as an element to be considered inthe healing process. The material of which the flap is com-posed is that usually cut away by the scissors, and consistsof vaginal and vulvar mucous membrane, and also of a cer-tain amount of cicatricial tissue which is to be found at themargin of the rent. The flap is formed by dissecting the“ butterfly ” from within outward, preserving the materialsjust mentioned in one continuous mass, the pedicle beingformed by the entire free margin of the septum (Fig. 1, AB), a hinge on which the flap is swung over so as to ex-clude the rectum from view. The dissection will be per-formed with greater ease and nicety if the knife is used, andshould be made chiefly from the sides in the manner indi-cated in Fig, 2. In reflecting the central portion it is im-portant to avoid “button-hole-ing; ” and for this purpose itis well to keep the septum be-tween the thumb and fore-finger of the left hand, lib-erating the flap by gentlestrokes of the knife to and fro,while the tissues are madetense by traction on the flapwith the forceps in the handsof an assistant. The dissec-tion should stop just short ofthe free margin so as to leaveit intact, otherwise the pedi-cle of the flap would be sev-ered ; on the sides the dissec-tion is carried down sufflcient- Fig. 2.

ly far to expose the ends of the ruptured sphincter muscle.We have now not only the customary butterfly, but, in ad-dition, a twin butterfly hanging from its lower edge andforming a sort of apron (Fig. 3). A portion of the vaginaland vulvar mucous membrane has been folded over as inturning out one side of a hat-lining, and the vaginal mem-

A NEW OPERATION FOR RUPTURE OF PERINEUM.4brane becomes now a portion of, and continuous with, theanterior rectal mucous membrane.1 The bowel now termi-

nates in a sort of fimbriated ex-tremity. This flap is redundantnot only in length but in breadth,and must, therefore, be throwninto longitudinal folds and bepressed downwards, while thetwisting of the first stitch bringsthe divided ends of the sphinc-ter together over it. After theremaining stitches have beenFIG- 3>

taken we find the end of the flap still projecting at the ante-rior margin of the anus. It is well not to trim this off short,as subsequent retraction will draw a considerable quantity ofit into the rectum; on the other hand, if all is left, the flap isunnecessarily long and the tip of it is liable to slough. Itcan be disposed of by folding in longitudinally, as when wepinch the lower lip together between the thumb and finger,and stitching the apposed raw edges ;

or it can be spread out in a fan shape,and adjusted to a short curved incis-ion through the edges of the skin atthe bottom of the wound, as in Fig, 4.This curved incision might be contin-ued all round the anus and the freemargin of rectum, then readjusted soas to be more evenly distributedaroundthe circle. The anus would then haveexactly the appearance of an artificialanus as after colotomy, but such anadditional dissection is hardly neces-sary. When the flap has been formedand allowed to drop down over therectum, the cavity of the bowel is no Fig. 4.

longer seen and in finishing the operation we have a prob-1 This method was first proposed by the writer in the Boston Medi-

cal and Surgical Journal , January 3, iByB.

J. COLLINS WARREN. 5lem almost as simple to perform as the formation of a peri-neum when the sphincter has not been ruptured. 1 Thegeneral plan of taking stitches is shown in Fig. 3. It willbe noticed that undue constriction is avoided, there beingno necessity for the use of the bag-string suture, and thethickness of the perineal body is preserved. These deepsutures are so arranged as not to touch the flap or septumthat it may have free play to assume its normal position,or that the flap may not be so restricted as to endangerits vitality. The adoption of the flap as a feature of theoperation consequently involves a radical change in themethod of taking stitches as laid down by Emmet. Forthese sutures annealed copper wire, silver-plated, is used ofNo. 29, Brown and Sharp gauge ; the next finer grade usedat the hospital, No. 24, though taking less room, being lia-ble to break. Before they are twisted a few superficial cat-gut sutures are taken in the vaginal mucous membrane forgreater security from vaginal discharges.

The first patient operated upon by this method wasthirty-one years of age, and had sustained a severe lacerationof the perineum involving the sphincter and rectum, duringa long and difficult labor three months before her entranceto the hospital. She was in a poor condition and anemic,but complained of no uterine symptoms, and desired an op-eration for relief from the incontinence of the rectum. Asa preliminary step in the operation, the sphincter was thor-oughly stretched by seizing the free ends and pulling uponthem much as one would pull molasses candy. The opera-tion was then performed in the manner above described.The portion of the flap projecting from the anus beingfound unnecessarily long was trimmed slightly and thenfolded on itself longitudinally, and the raw edges weresewed together, giving it the appearance of a small hemor-

1 As a convenient way of distinguishing the two varieties of rupture,the writer would suggest: that those cases in which the perineal bodyalone has been torn be called “ simple rupture of the perineum; ” andin those cases in which there has been a laceration of the sphincteror rectum, the term “ compound rupture of the perineum ” be used.

6 A NEW OPERATION FOR RUPTURE OF PERINEUM.

rhoid at the anterior margin of the anus. During the oper-ation the exposed surfaces were irrigated by a warm streamof carbolized water (1-200) flowing from a fountain syringe,and a narrow strip of lint soaked in carbolized oil was placedon each side of the sutures after the operation and reneweddaily for almost a week. The wound was thus kept in per-fectly aseptic condition, and instead of the customary smartreaction there was scarcely a perceptible rise in the tem-perature, the thermometer ranging as high as 100.2° F. onone evening only. Vaginal douches were used after thesecond day, and the urine was drawn regularly with thecatheter.

A special feature of the after treatment was the diet; afree use of milk, prescribed generally as a convenient formof liquid diet, has the great disadvantage of being followedby a large accumulation of fecal matter, the fatty portionsbeing rolled together in hard or putty-like masses, whichsubjects the delicate union to a severe strain and may de-stroy it altogether. This peculiarity of milk as an article ofdiet in the sick-room has not been sufficiently recognized.Its extensive employment in diseases of the intestinal canalwill doubtless be somewhat curtailed when this fact is morefully appreciated. The proportion of residual material indifferent forms of food is a point in the regulation of thediet which should receive more attention than it has hith-erto. A liquid diet from which milk was rigidly excludedwas prescribed in this and the other cases. It is well to be-gin this regimen the day before the operation, and for thefirst twenty-four hours after it to give little else thancracked ice and small doses of some fluid beef extract.The discomforts and dangers of flatus are also avoided.The following is the diet list of the case above mentioned :

First day, beef tea fviii., brandy fii.Second day, beef tea fxvi., brandy fiii.Third day, beef tea fxxxii., cup of tea without milk for break-

fast.

A few days later beefsteak was given, at first in small

J. COLLINS WARREN.

quantities, and broths were substituted, 1 The stitches wereremoved on the fourteenth day, and the perineum wasfound to be firmly united throughout. The projection atthe anterior margin of the anus had retracted so as to beimperceptible. As an experiment the bowels were notmoved until the twenty-first day, and then, following a smalldose of oil, an abundance of soft, slippery, and well formedscybala, in other words normal feces, was discharged.

In the second case the patient, thirty-five years of age,had a rupture of three and a half years’ standing, whichhad been operated upon twice without benefit, the incon-tinence of the rectum being still complete; the rupturedid not, however, extend beyond the sphincter. The en-tire flap made in the operation in this case was allowed toremain, and subsequently a portion of the tip about the sizeof a pea sloughed and was removed. Union of the perinealbody was complete and there was absolutely no febrile dis-turbance. The same antiseptic precautions were observedduring the operation and after treatment as in the firstcase. The stitches were removed on the twelfth day, andthe bowels were moved by a small dose of oil on the twen-tieth day, the evacuations being normal in character.

The third case was one of the most aggravated forms ofrupture one has an opportunity to see. It had existed butthree months and involved the anterior wall of the rectumfor a considerable distance from the anus. On separatingthe labia a large cloaca was disclosed, lined, particularlyposteriorly, by a membrane in a state of irritation, a gran-ular condition existing at some points. The patient waskept under preparatory treatment for two weeks to restorethe parts to a healthy condition. The method of operatingwas precisely the same as in the other cases. The flap pro-jecting at the anus, after the wound was closed, was foldedon itself and held together by two fine silver sutures. Thediet consisted chiefly of beef tea and chicken broth. Thecharacter of the bill of fare can be varied considerably, and

A similar diet is also prescribed by the writer after operations onthe rectum and uterus.

8 A NEW OPERATION FOE RUPTURE OF PERINEUM.

even solid food be taken at an early day, provided milk inevery form is rigidly excluded. As illustrative of the ten-dency of the septum to retract, it may be mentioned thatthe flap was gradually sucked up into the rectum during thehealing process, and was subsequently found nearly an inchfrom the outer margin of the sphincter. It could be felt inthe rectum for some time as a little polypoid tumor, buteventually disappeared. If the tip of the flap was at thispoint, its base must have been situated from two to threeinches from the sphincter muscle, showing how far the edgeof the recto-vaginal septum withdraws into the pelvis whenit has been liberated from its cicatrized position. The ther-mometer registered ioo° F. on the second evening only.The stitches were removed on the thirteenth day, and thebowels were moved by an enema on the twenty-first day,when an abundant and natural evacuation occurred. Nocathartic was given and no opiate was necessary, except onesub-cutaneous injection of one sixth of a grain of morphinethe day following the operation. The body was not com-pletely restored, but the union of the rectum and sphincterand a considerable portion of the body took place.

The points which the experience of the writer has shownto be of value in the treatment of this injury are; first, therestoration of the recto-vaginal septum by a flap, which doesaway with a rectal wound and with tension of the septumalso ; and secondly, the selection of an appropriate diet bywhich the character of the fecal discharges can be con-trolled. The plan, adopted by some operators, of havingfrequent and early movements of the bowel during the pro-cess of union does not seem to be in accord with good sur-gical principles, which recognize rest as a most importantfactor in the healing of a wound. It was designed to avoida danger which with appropriate diet will not occur. Thediet here recommended would doubtless be well adapted tosuch a method if it were thought desirable. The antisepticdouche, although it favors hemorrhage, keeps the parts wellcleaned during the operation, and prevents inflammatory re-action, which, however, may be partially accounted for by

y. COLLINS WARREN. 9the lack of tension in the tissues. The stitches were keptin somewhat longer, as is the habit of the writer, than iscustomary. Experience shows that they do no injury, andserve a useful purpose in preserving the shape of the peri-neal body. The patients were all seen six months after theoperation, and each one expressed herself highly pleasedwith the result.

Note. Since this paper was written, further experience in sev-eral cases shows the method of handling the flap as given in Fig-ure 4, to be quite satisfactory. It is not necessary to dissectdown the entire butterfly, but the dissection may be begun highenough on the vaginal wall to secure a sufficiently long flap. Thedenudation can then be continued with the scissors.

Emmet’s plan of drawing down the vaginal mucous membraneby the upper stitch so as to cover the vaginal portion of theperinea] body has been tried in two cases, with satisfactory re-sults.