hernia.

The serious consequences of cutting into such a hernia by mis

take for an abscess, are self-evident.

Varix.—The plexus of veins which forms the erectile tissue of the bulbi vagina has been already referred to (v. Vol. I., p. 9 and Fig. 7). A varicose condition of the veins sometimes occurs in pregnancy and with pelvic tumours. In a case described by Holden,' they formed, when the patient was erect, a tumour of the size of a child's head. When these vessels rupture and the blood is effused into the cellular tissue, a hæmatoma is formed.

Hæmatoma.-This condition is also called "Thrombus" and "Hæmatocele" of the vulva; the former term should be limited to a coagulum within a vessel, and the latter to blood effusion into the peritoneal cavity.

It arises most frequently during labour, from injury produced by the child's head; the effusion may appear rapidly, as a tumour from the size of a walnut to an orange or larger, or may take place gradually. It has also been known to occur independent of labour or pregnancy, as the result of a blow or violent muscular effort.

The treatment consists in the application of ice to the vulva, and regular evacuation of the bladder and rectum without the patient's being allowed to strain. With this treatment, the mass may be absorbed. Should inflammation occur, poultices are applied and pus is evacuated with the knife; if this occurs in the puerperal condition, special care is required to keep the wound aseptic by repeated washing with carbolic solution and dressing with carbolised lint.

External hemorrhage from ruptured veins sometimes occurs. The rupture may be caused by muscular straining, or by a blow or wound of the vulva. The dilated state of the veins makes such an injury serious during pregnancy, and several cases of a fatal result from a blow or kick have been the subject of criminal prosecution (Sir J. Y. Simpson). In a case recorded by Hyde,' hemorrhage from a vein ruptured by a fall proved fatal in forty minutes. Those who suffer from varicose veins should be recumbent for some hours during each day; should a vein rupture, the patient must lie down at once and apply pressure to the bleeding point.

' Immense Vulvar and Vaginal Varix: N. Y. Med. Record, July, 1868.
? Lond. Obst. Trans., Vol. XI.

CHAPTER XLVI.

RUPTURE OF THE PERINEUM AND ITS OPERATIVE TREATMENT.

LITERATURE.

Bantock, G.-On the Treatment of Rupture of the Female Perineum, Immediate and Remote: Lond., 1878. Duncan, Mathews-Papers on the Female Perineum: Churchill, London, 1879. Goodell-Lessons in Gynecology: Phila., 1880. Hart, D. B.— Op. cit. Hildebrandt-Die Krankheiten der äusseren weiblichen Genitalien: Stuttgart, 1877. Schroeder-Op. cit., S. 512. Simpson, Sir J. Y.-Diseases of Women, p. 644. Thomas-Op. cit., p. 165. See Duncan and Hildebrandt for literature. Nomenclature.-It will be most convenient to retain the nomenclature already used in the section on anatomy. The pelvic floor is made up of

Fig. 319.

The sacral or supporting segment of the pelvic floor (Hart). e, symphysis pubis; f, perineum or inferior angle of sacral segment; g, anus.

pubic and sacral segments, as already defined; in labour, each of these behaves characteristically-the pubic segment is drawn up, the sacral one driven down.

In this chapter we are specially concerned with the sacral segment. During parturition it is driven downwards and backwards by the advancing foetus and is more or less torn at its inferior angle. The term

Central rupture of the perineum, the child was born not through the vulva but through the ruptured opening (Sir J. Y. Simpson).

perineum is often vaguely applied; in this chapter, however, the perineum is defined as the inferior angle of the sacral segment (vide Volume I., page 61). Figure 319 shows the perineum. At its lower end, this part of the pelvic floor is made up of the following:

2. Hymen.

3. Fossa Navicularis.

4. Fourchette.

5. Perineal body and skin over its base.

These are mesial structures; laterally, we have the labia majora and

minora.

PATHOLOGY AND VARIETIES.

It should be kept in mind that the vaginal orifice is transverse, the vulvar orifice antero-posterior.

When the foetal head is passing through the vaginal orifice, it distends it all round; while, when passing through the vulvar orifice, it distends 'the lower half of this only, i.e., it does not stretch those parts of the vulva lying above the level of the meatus urinarius.

As the result of normal and abnormal childbirth, we get certain tears of the inferior end of the perineum. In all primiparæ there is at least one laceration of the vaginal orifice, usually mesially and posteriorly-the "inevitable laceration" of Mathews Duncan. There may be also laceration of the following structures: (a) of the vaginal orifice, radiating; (b) of vestibule; (c) of fourchette; (d) of labia minora; (e) of perineal body to a varying depth, the most extensive involving the sphincter ani. Further, there is sometimes central rupture of the perineum. In this lesion, the skin over the base of the perineal body alone may be involved or only the vagina may be torn. Rarely is it a lesion of vaginal wall, connective tissue, and skin, with an unruptured band of tissue between it and the fourchette (Fig. 320); this, therefore, is a perforation through the inferior angle of the thinned-out sacral segment.

ETIOLOGY.

The following causes produce rupture in parturition :

(1) Passage of a large head or of an occipito-posterior rotated into sacrum, passage of the shoulders;

(2) Narrowness of pubic arch;

(3) Straightness of sacrum, as in flat or rickety pelvis ;

(4) Syphilitic ulceration;

(5) Rigidity of parts in elderly primiparæ ;

(6) Careless use of forceps;

(7) Too early passage of hand into vagina to bring down arms in

turning.

Comment on these would lead us too much into Obstetrics.

TREATMENT.

We take this up under the following heads:

a. Prophylactic;

b. Operative, immediate and deferred.

a. Prophylactic.-This properly belongs to midwifery. The obstetrician is too apt to think of the perineum as something that delays the exit of the fœtal head, and to forget the gynecological aspect-that it is the supporting segment of the pelvic floor. Extensive tear of this during labour means not only a larger raw surface for septic absorption, but also is one factor predisposing to prolapsus uteri. The question, therefore, of support of the perineum during parturition comes up here for consideration. To understand this we must keep in mind that the foetal head, in passing through the outlet, drives the sacral segment back and glides forward in a direction parallel to the driven-back posterior vaginal wall. The normal curve of the sacrum favours this latter motion.

The perineum may tear (1) from over-distention of the orifice, or (2) from the too forcible driving of the foetal head against it, i.e., at right angles to the perineum. If, therefore, while the head is crowning and rupture threatening, the palm of the hand covered with a napkin be placed on the skin aspect of the perineum, we can by gentle support keep the head flexed, retard its progress somewhat, and elongate the perineum towards the pubic arch.

In addition the practitioner can materially help in preventing an awkward tear by the preliminary free inunction with medicated vaseline of the head, vagina and skin of perineum, and by tucking in the anterior vaginal wall when projecting too much over the occiput.

Goodell passes two fingers into the rectum and restrains the head with the thumb. The perineum should never be forcibly supported as this damages the vestibule. As regards the use of forceps, the authors have been struck with the fact that with axis-traction forceps the head can be brought over a rigid perineum with a minimum amount of tear.

b. Operative treatment; (1) immediate, (2) deferred. No practitioner should leave a labour case until he is satisfied, by actual inspection or digital examination, as to the amount of perineal tear. When the sphincter ani is involved, the operation is on no account to be deferred but must be performed at the conclusion of the third stage. The practitioner should never run the risk of his patient's having incontinence of fæces.

VOL. II.-15