Pubic symphysis

“ Owing to the inclination of the pelvis, the base of the sacrum is nearly 4 in higher than the upper border of the pubic symphysis. The female pelvis is distinguished from the male by certain sexual characters. The bones are more slender, the ridges and processes for muscular attachment more feeble, the breadth and capacity greater, the depth less, giving the greater breadth to the hips of a woman ; the inlet more nearly circular, the pubic arch wider, the distance between the tuberosities greater, and the aceta- bulum smaller in the female than in the male. ”

“ That economical adaptation of a portion of a vesicular organ, originally formed for purposes of communication between the embryo and the mother, appears to entail sometimes a defect in the wall of the abdomen just above the pubes, and a defect in the anterior wall of the bladder itself. This is the distressing congenital condition of fissure of the urinary bladder, in which its interior is exposed through an opening in the skin; the pubic bones are separated by an interval, and the reproductive organs are ill-formed ”

“ Eldridge gives an instance of separation of the symphysis pubis during labor,—a natural symphysiotomy. A separation of 3/4 inch could be discerned at the symphysis, and in addition the sacroiliac synchondrosis was also quite movable. The woman had not been able to walk in the latter part of her pregnancy. The child weighed 10 1/2 pounds and had a large head in a remarkably advanced stage of ossification, with the fontanelles nearly closed. Delivery was effected, though during the passage of the head the pubes separated to such an extent that Eldridge placed two fingers between them. ”

“ More or less completely septate bladder, atresia ani, or more rarely double anus, double urethra, increased breadth of the bony pelvis with defect of the symphysis pubis, and possibly duplication of the lower end of the spine, and hernia of some of the abdominal contents into a perineal pouch. Much more rarely, duplication of the heart, lungs, stomach, and kidneys has been noted, and the lower limbs may be shorter than normal. ”

“ Craniotomy, i.e. crushing the head of the foetus to reduce its size, is now very rarely performed on the living child, but symphysiotomy, i.e. the division of the symphysis pubis to produce a temporary enlargement of the pelvis, or caesarean section, is advocated in its place. ”

“ The penis can then be shelled out, the prepuce being first cut through around the corona glandis. If lateral flaps can be formed of sound skin they are then dissected up. The perineal and pubic incisions are now deepened and, assistants holding the testes and penis well out of the way, the neck of the tumour is cut through close to the perineum and pubes. Gaping vessels are all carefully ligatured, redundant tunica vaginalis—if hydroceles be present—being excised. ”

“ At times there is surprise at finding some rare lesion treated with modern technique, and a hint at least of our modern apparatus. Fracture of the pubic arch, for instance, is described in Abulcasis quite as if he had had definite experience with it. When this occurs in a woman, the reposition of the bone is often greatly facilitated by a cotton tampon in the vagina. This tampon must be removed at every urination. There is another way, however, of better securing the same purpose of counterpressure. One may take a sheep's bladder into the orifice of which a tube is fastened. ”

“ If there is no obstruction to the flow of urine, the retention being due to atony or paralysis, a soft catheter is passed and the water drawn off. But when there is an obstruction which cannot be overcome, aspiration has to be resorted to, the needle of the aspirator being pushed through the abdominal wall into the bladder. The point of puncture in the abdominal wall is in the middle line a few inches above the symphysis pubis. The bladder may be emptied in this way very many times in the same person with only good result.
Diseases of Prostate Gland. ”

“ In another, No. 194, a transient inflammatory thickening pointed to a local inflammation of a non-infective character, since no suppuration ensued, and this may have been a case of extra-peritoneal wound; on the other hand, the bladder may have entirely escaped injury. In wounds of the portions of the viscus not clad in peritoneum, as a rule, a very different prognosis obtains. Two typical cases are related, which I believe fairly represent the general results which follow when the bladder is either wounded behind the symphysis or at the base. ”

“ Operation.—A large curved staff with a central groove is to be held firmly hooked up against the symphysis pubis, and then steadied by the left forefinger in the rectum. The operator pierces the raphe of the perineum with a long straight bistoury about half an inch above the verge of the anus, enters the groove of the staff, and cuts inwards, almost, but not quite, into the bladder. In withdrawing the knife the wound in the urethra is enlarged upwards towards the scrotum. ”

“ And if the penis is pressed between the finger and thumb, matter or pus exudes. As the inflammatory stage commences, the formation of pus is increased, which changes from a thin to a thick yellow color, accompanied by a severe scalding on making water. The inflammation increases up to the fifth day, often causing such pain, on urinating, that the patient is tortured severely. When the disease reaches its height, the erections become somewhat painful, when the discharge may be streaked with blood. ”

“ The physiological purpose of the pubic hair is to prevent irritation of the genital organs by the sweat that would otherwise run down upon them, and to protect the skin from direct friction during the act of copulation.
The labia majora in women during the menacme are usually strongly developed, their outer surface is hairy; in parous women we almost invariably observe small or even large lacerations of the frænulum pudendi or fourchette, in front of the posterior commissure of the vulva. ”

“ We find, therefore, that although the pelvis constitutes a rigid, bony, ringlike structure, there are four joints: the symphysis pubis, the sacro-coccygeal, and the two sacro-iliac articulations. As the cartilages in these joints become somewhat softened and thickened during pregnancy, because of the increased blood supply, they all permit of a certain, though limited amount of motion at the time of labor. ”

“ The finger will enter a quantity of brick-dust coloured pus in the cellular substance around the bladder, and if considerable force has been used in the extraction of the stone, will readily find its way towards the wound in the perineum; the barrier between the adipose structure of the perineum and the reticular texture of the pelvis being broken down, the suppurative inflammation spreads rapidly along the latter, and may be traced in some cases, between the peritoneum and abdominal muscles, as high as the umbilicus ”

“ Barkesdale relates the history of the case of a Confederate soldier who was shot at Fredericksburg in the median line of the body, 1 1/2 inches above the symphysis, the wound of exit being in the median line at the back, 1/2 inch lower down. Urine escaped from both wounds and through the urethra. There were no bad symptoms, and the wounds healed in four weeks.
The bladder is not always injured by penetration of the abdominal wall, but may be wounded by penetration through the anus or vagina, or even by an instrument entering the buttocks and passing through the smaller sacrosciatic notch. ”

“ The strain required to induce a prolapsus of the bowel or a rupture into the inguinal canal is exerted as much on the bladder, ureter, and kidney as on the other localities. Physicians who have taken the pains to observe must have noticed, more than once, how the child afflicted with a phimosis has not only at times to wait for the stream of urine to appear, there seemingly being some obstruction to its starting, but how often such a case is afflicted with a stammering, halting urination. ”

“ Of a violent inflammation of the penis, which had originated in unclean intercourse with a beast, with a coruncle, or knot, constricting the urethra, cured in a manner to the last degree empirical and cruel. The penis being laid on a rough stone, the Physician suddenly when the patient was not expecting it, struck it as heavily as ever he could with his doubled fist, so that the stoppage and ulcer might burst. This case has a smack of the Venereal disease about it; and might serve as an argument for those who hold that this disease was known to the Ancients as well. ”

“ Pressure of the seat of the chair upon the perineum also causes distress, so the man sits sideways and on the edge of the seat. If abscess forms, it should be incised from the perineum; if allowed to run its course it may burst into the bladder, the urethra or the rectum, and set up serious complication. The treatment of prostatitis (inflammation of the prostate) consists in rest in bed, sitz-baths and fomentations. If retention of urine takes place a soft catheter must be passed. In the early stage of an acute attack a dozen leeches upon the perineum may do good. ”

“ Lastly, cystitis occurs, and the urine contains fetid pus. A stone in the bladder gives rise to pain at the end of the penis, and it is apt suddenly to stop the flow of urine during micturition.
The association of any of these symptoms leads the surgeon to suspect the presence of a stone in the bladder, and he confirms his suspicions by introducing a slender steel rod, a “sound,” by which he strikes and feels the stone. Further confirmation may be obtained by the help of the X-rays, or, in the adult, by using a cystoscope. ”

“ Also in the breast and in the prostate, with the waning of sexual life there may occur a formation of fibrous tissue--chronic _interstitial mastitis_, _chronic prostatitis_, having analogies with the chronic interstitial inflammations of internal organs like the kidney--_chronic interstitial nephritis_; and in the breast and prostate, as in the kidney, the formation of fibrous tissue leads to changes in the secreting epithelium resulting in the formation of cysts. ”

“ The sphincter ani, or the muscles of the anus, are relaxed, from the excessive action of the abdominal muscles; and the fæces pass in small quantities involuntarily. There is a protrusion of the bowel, which adds to the distress, and, by its irritation, brings on a looseness or diarrhœa.
The prostate gland, which is seated near the neck of the bladder, suffers inflammation and enlarges, beginning at the orifice of the ducts, which open into the urethra.
The emission of semen, which often happens involuntarily, is attended with agonizing pain, producing cold shiverings, followed by heat ”

“ 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. ”

“ In like manner, if the sore become spreading, or otherwise malignant, we must suit the applications to the state of it. When the ulcer is freed from inflammation we may loose the dressings, and use diachylon plaster to the groins and bottom of the belly. During the whole time of the treatment, the thighs must be bound together, which contributes to the cure with the other remedies. If the stone, being small, fall into the penis, and cannot be voided with the urine, we may draw the prepuce strongly forwards, and bind it at the extremity of the glans. ”

“ With people that have been circumcized, the skin must be detached behind the crown of the gland. This operation is not very painful as the prepuce being loosened, you can draw it with the hand back to the pubis without any loss of blood.
Then the loosened integument is drawn once more over and beyond the gland. This done the verge is dipped frequently into cold water, and then covered with a plaster, which has a strong tendency to minimize inflammation. As soon as it is quite free from inflammation, the verge is to be bandaged from the pubis to the annular incision ”