Perineum

“ These are the cases in which a complete laceration of the perineum is apparently completely healed after operation, but the patient finds that she has incontinence both of flatus and fæces.
On inspection of Fig. 35 this will be well explained. The patient is lying on her back in the lithotomy position: a represents the sphincter which has been torn through; the two cut ends, b and c, are represented by two dark circular, somewhat depressed spots. The rectal orifice gapes; there is no sphincteric power present. The perineum anterior to the anus is firmly healed. ”

“ I always tell my patient why I ask her to do certain things in labor and I have never found any woman who, when able, was not willing to do as I asked. A torn perineum is not desirable, because even when sewn up immediately after labor, it may not unite thoroughly, and thus cause displacements of the womb in the future. A little time and care at the time of labor will save the perineum and every woman is willing to do her share when the conditions are plainly explained to her. ”

“ If the vulva is pricked with a needle, the woman draws herself away; there is no reflex muscular action, closing the vagina and drawing up the anus. The muscles of the perineum have been destroyed.
If the finger is introduced in the vagina and pressed backward and outward in either vaginal sulcus, the tissues are yielding and soft; no supporting sling of muscle and fascia is felt. ”

“ For the purpose of supporting the perineum we sit rather behind the patient, and apply the [Pg 37] palm of the left hand—guarded, for the sake of delicacy, cleanliness, and convenience, with a soft napkin—steadily and firmly against the perineal tumour. I have already mentioned that the thighs must be drawn up towards the abdomen, and the legs bent a little back upon the thighs, and the whole person lying on the left side; and the patient is usually placed so that her feet may rest against the bed-post. ”

“ Treatment.—As prolapse of the uterus is usually caused by injury to the pelvic floor, treatment should be directed in the first place to the restoration of the perineum. 111
In slight cases of prolapse that are seen early, restoration of the perineum by Emmet’s operation is sufficient for cure.
In cases of long duration, however, we have to deal with a variety of secondary conditions. These are as follows: Hypertrophy of the uterus from subinvolution or congestion; elongation of the cervix; hypertrophy of the cervix; elongation of the uterine ligaments; stretching of the vagina ”

“ In the gradual escape of urine by ulceration behind the constricted point—the urethra being neither altogether obstructed, nor nearly so—abscess forms in the cellular tissue, exterior to the ulcerating part. The suppuration is often slow in its progress, and imparts to that part of the perineum a stony hardness. Repeated collections of matter may form, and, if the cause be not removed, numerous openings will form in the scrotum and perineum, and through them fetid matter and urine will constantly and involuntarily distil. The patient is reduced to a miserable state ”

“ The examiner should stand facing the patient, never at the side. The index finger of the left6 hand, lubricated with vaseline or oil, then slowly advances over the perineum into the vagina, noting the condition of the perineum, the presence or absence of cicatrices or of sub-involution of the vagina or perineum, the capacity of the vagina, the condition, size, and direction of the cervix, its distance from the sacrum and vulva, its mobility or fixation. Now, for the first time, the right hand is pressed well down behind the pubes, and the uterus is engaged between it and the examining finger. ”

“ Supporting the perineum is not only absolutely unnecessary, but also apt to be exceedingly injurious. Meddlesome midwifery is always to be deprecated. A natural labor needs no manual local interference. Although many authors and teachers recommend support to the perineum in the last stages, yet more ruptures may be attributed to this practice than to leaving it entirely untouched. A Canadian physician asserts that he has attended 1,700 women in confinement without giving support to the perineum, and yet in no case did rupture occur. ”

“ After labor any injury to the perineum should be promptly repaired. The vagina should be kept clean by irrigations. The urine, if necessary, should be regularly drawn and the bowels moved daily without straining. If conditions be present likely to induce subinvolution—such, for example, as pelvic inflammation or laceration of the cervix—they should receive treatment at the proper time. Undue relaxation of the pelvic floor necessitates a more prolonged rest in bed, the use of astringent douches, and the application of a pessary when the patient resumes the upright position. ”

“ But this should never be done till after every means of relaxation has been tried, and the head has been kept back as long as prudent. It is however, always better to open a passage than to let one be torn, because it may be made in the most favorable place. When the perineum is allowed to be torn, the most serious consequences often ensue, and the patient is made a miserable sufferer for life. The Vagina and Rectum may be torn into one, or the power of retaining the contents of the intestine, or bladder, may be for ever lost. ”

“ In the vaginal operation the vagina first should be thoroughly cleansed with a solution of carbolic acid, and the patient placed on her back and not on her side. I am convinced from experience that the usual left-lateral position is a dangerous one, for as soon as the peritoneum is opened the air rushes out and in during every inspiration and expiration—an untoward circumstance which cannot happen in the dorsal position. A duckbill speculum is introduced, and the perineum pulled downward. The cervix uteri is transfixed by a strong thread, by which the womb is drawn downward and forward. ”

“ In first labors there is sometimes unusual rigidity of the soft parts, which are external. Where the perineum is rigid it may require several hours continuance of the pains before it is sufficiently stretched to allow the head of the child to pass. ”

“ The woman should be placed in the knee-chest position. The perineum should be retracted and the cervix exposed with a Sims speculum. It will be observed that the cervix is directed forward toward the symphysis pubis. ”

“ There being four varieties of it, according to Leonides; three of them occur in men and one in women. In men, sometimes about the perineum and sometimes about the middle of the scrotum, there is the appearance of a female pudendum with hair; and in addition to these there is a third variety, in which the discharge of urine takes place at the scrotum as from a female pudendum. In women there is often found above the pudendum and in the situation of the pubes the appearance of a man’s privy parts, there being three bodies projecting there, one like a penis, and two like testicles. ”

“ Causes.—Tear of the perineum allows the bottom of the pelvis to relax. Undue relaxation of the ligaments of the bladder and of the floor of the pelvis, with over distention of the bladder, are responsible for the majority of the cases.
Symptoms.—Weight and dragging feeling. A tumor can be felt in the vagina.
It decreases when the bladder is emptied.
Treatment.—Supports are suitable in some cases (Skene's pessary) . An operation is necessary in many cases. ”

“ We now require to make another examination, because it is possible that the head may have fully entered the cavity, and may be soon expelled. Finding it low in the pelvis, finding the os uteri almost entirely dilated, the membranes broken, and the pains [Pg 36] strong and coming on frequently, it is right not to leave the room; but unless the perineum is somewhat on the stretch, we need not yet take our post exactly by the bed-side. ”

“ The cavity of the pelvis contains the bladder, the rectum, and some of the generative organs peculiar to each sex and some windings of the small intestine; they are partially covered by the peritoneum (lining membrane of the abdominal cavity) .
Anatomy of the Female Genital Organs.—The external genital organs, to which the term vulva is usually given, consist of the mons veneris, labia majora, labia minora, clitoris, vestibule, meatus urinarius, hymen, fossa navicularis, fourchette and perineum. ”

“ But as soon as the head has come to press upon the external parts—particularly when it has made its turn, and is beginning to extend the structures at the outlet of the pelvis, it becomes our duty to take our seat by the bed-side, and never to move from our position till the child has passed. This we do to protect the perineum, in order to prevent laceration. ”

“ Perineal Section is an operation both dangerous and difficult; as Sir Astley Cooper used to say, "the surgeon who performs it requires to have a long summer's day before him."
No director or guide can be passed. A full-sized catheter must be passed as far as possible up to the stricture, and held firmly in the middle line. The patient must be tied up in lithotomy position on a table in the very best light that can be obtained. The perineum being shaved, an incision must be made in the middle line from over the point of the catheter to the verge of the anus, if the stricture extends far back. ”

“ The superficial fascia of the hypogastrium, the scrotum, and the perinaeum forming a continuous membrane, and being adherent to the several parts above noticed, may be regarded as a general double sac, which isolates the inguino-perinæal region from the femoral and anal regions, and hence it happens that when the urethra becomes ruptured, the urine which is extravasated in the perinaeum, is allowed to pass over the scrotum and the abdomen, involving these parts in consequent inflammation, whilst the thighs and anal space are exempt. ”

“ After surrounding the small intestine it becomes the posterior layer of the mesentery and so again reaches the posterior abdominal wall, down which it runs until the rectum (R) is reached. The anterior surface of this tube is covered by peritoneum to a point about 3 in. from the anus, where it is reflected on to the uterus and vagina (V) in the female and then on to the bladder (B) ; in the male, on the other hand, the reflection is directly from the rectum to the bladder. ”

“ Bimanual examination made after intraperitoneal rupture 325 reveals an indefinite fulness or a yielding mass in the pelvis behind the uterus. The blood free in the peritoneal cavity coagulates slowly, and the fluid blood or soft unrestrained clots are often very difficult to palpate. For this reason, at first the examiner can feel only an ill-defined fulness in the pelvis. If the woman survives and the mass of blood becomes more solid, it may then be distinctly palpated as a solid mass behind the uterus, bulging into the vagina, and extending up into the abdomen. ”

“ The ulnar edge and the tips of the fingers of the other hand should then be placed upon the abdomen, immediately above the symphysis pubis, and gently pressed backward and downward toward the vaginal finger 24 (Fig. 2) . In this way the various pelvic organs, the uterus, Fallopian tubes, ovaries, and ureters, may be palpated between the two hands, and their position, size, shape, and consistency may be determined. Such an examination is, of course, made much more easily in a thin woman than in a fat one. ”

“ PLATE 39, Fig. 3.—The serous tunica vaginalis is separated from the peritonaeum.—When the testicle, 7, has descended to the scrotum, the serous tube or lining of the inguinal canal and cord, 6 b, 6 c, closes and degenerates into a simple cord, (infantile spermatic cord,) and thereby the peritonaeal sac, 6 a, becomes distinct from the serous tunica vaginalis, 6 d. But the fibrous tube, or outer envelope of the inguinal canal, remains still pervious, and continues in this condition throughout life. ”

“ While the external genitals are forcibly pulled upward in the pelvic cavity toward the head, the encircling incision behind the anus is deepened, cutting the fat-tissue, connective-tissue, and muscle around and behind the rectum, until the whole mass of genital organs and rectum is so loosened that it strips up easily to the brim of the pelvis, where any remaining attachments of peritoneum or blood-vessels are severed and the entire mass removed for examination on the board. ”

“ If the cyst be intra-ligamentous in development, or if it be wedged in the pelvis, the first symptoms of the disease appear at an earlier date. The intra-ligamentous tumors first separate the layers of the broad ligament; they push the uterus to one side, and press upon the bladder, ureters, and rectum. The disposition of the peritoneum may be altered in a variety of ways by these growths. They may grow altogether behind this membrane, becoming retro-peritoneal, coming into immediate relationship with the rectum ”

“ The fold of peritoneum, called the recto-vesical pouch, is about four inches from the anus, therefore it is not within reach of the finger; and we run no risk of wounding it in tapping the bladder if the trochar be introduced near the angle of the trigone.
f. The finger can feel one of the ridges or folds of mucous membrane which are situated at the lower part of the rectum. This fold projects from the side, and sometimes from the upper part of the rectum, near the prostate. When thickened or ulcerated, this fold occasions great pain in defæcation; and great relief is afforded by its division. ”

“ Bimanual examination reveals the condition. The broad ligament will be found filled with a tense mass that bulges into the vagina. The uterus is pushed to one side. The mass may extend behind the uterus and surround the rectum. The upper outlines felt by the abdominal hand are ill defined.
The loss of blood from simple rupture into the broad ligament is not often sufficient to cause death. The fetus may continue to develop, however, and secondary rupture into the peritoneal cavity may occur.
Rupture of the tube or of the gestation-sac into the peritoneal cavity is a very fatal occurrence. ”