COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD ^^?5 ^v~il HX00063479 ^€rsa^ Columbia (Hnitiers^ftj) intl)fCttpofl^ftngork CoUege of ^fipjiicians anb burgeons Hitirarj* C3l ' v.l Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/theorypracticeo01caze OBSTETKICS. Cazeaux Ais^D Tarxier EIGHTH AMERICAJS^ EDITION. WITH APPENDIX BY PAUL F. MUNDfi, M.D., AND XEAV ILLUSTPvATIONS. IX TWO VOLUMES. Plate T. For Explanation see Page 92. CAZEAUX AND TARN I ER THE THEORY AND PRACTICE OBSTETRICS ; INCLUDING DISEASES OF PEEGNANCY AND PAETUKITION, OBSTETEICAL OPEEATIONS, ETC. By p. CAZEAUX, MKMBKK OF THE IMPERIAL ACADEMY OF MEDICINE, ABJIXCT PKOFESSOR IX THE FACrLTV OF MEDICIN-E,. PARIS, KTC. REMODELLED AND REARRANGED, WITH ADDITIONS AND REVISIONS, By S. TARNIER, PROFESSOR OF OBSTETRICS AXn DISEASES OF ^VOMEX AXB CHILBREX IX THE FACVLTY OF MEBICIXE. OF PARIS. THE EIGHTH AMERICAN EDITION. Edited axd Revised by ROBERT J. HESS, M. D., PHTSICIAS TO THE SORTHERX DISPEXSARV. PHILADELPHIA. WITH AN APPENDIX, By PAUL F. MUNDE, M. D., PROFESSOR OF GVXECOLOGV AT THE XE.V VORK POLYCLIXIC AX-3> AT BARTMOrTH COLLEGE; VICE-PRESIBKXT *^ AMERICAX GYXECOLOGICAL SOCIETY, ETC. WITH CREOMO-LITEOGEAPES, LITHOGRAPHS AND OTHER FULL-PAGE PLATES, AND ONE HUNDRED AND SEVENTY-FIVE WOOD ENGRAVINGS. VOLUME I. PHILADELPHIA: P. BLAKISTON, SON & CO., 1012 Walnut Street. 1886. I \ a 6^1 a 31 V. Copyright, 188G, by P. Blakiston, Son »fe Co. PREFACE TO THE NEW EDITION. In offering this new American edition of the classical work of Cazeaux and Tarnier to the profession, an apology is scarcely necessary. The previous editions have long since been exhausted, and although references to it in the pages of medical literature are frequent, most of the works upon the science and art of obstetrics which since then have been favorably received by the profession have gleaned much of their worth from its valuable teachings. The student of less elaborate text-books is likely, at the present day, to over- look the foundation principles upon which the science has been built, of which these distinguished authors have been for many years the honored teachers. The present, with slight omissions, embraces all that was originally con- tained in previous American editions. A later French edition, and also an Italian, issued during the past year, the latter with notes by Chiara, Morisani, Tibone, and Porro, have been consulted in its preparation, and we trust it will be found to contain the newest observations in obstetrical science made possible by the advance in every department of knowledge relating thereto. We have been careful to avoid any change in the principles of practice as taught by Cazeaux and Tarnier, deeming the acceptance of them by the profession in the past, and the frequent reference to them by authors of the present, as the most certain test of their value, while the latest contributions of the present time in each department of the science have been carefully and freely introduced, due credit being given, so that this edition will reflect the best practice of the best authorities, and be a complete guide to the student and a source from which the profession may continue to draw rich suggestions in this, the highest branch of the science and art of medicine. ROBERT J. HESS, M.D. Philadelphia. PREFACE TO THE FRENCH EDITION. THE sixth edition of this M^ork was almost exhausted, when its author, in the full strength of years and talent, was suddenly struck down by the disease which very soon proved fatal. In departing, Cazeaux left a name beloved of physicians and students, and respected by all. The success of his work on obstetrics had greatly contributed to extend his reputation and scientific authority. Inasmuch, therefore, as the stoppage of its publication would deprive the medical public of a work which, for a long time, has justly been ranked first amongst classical books, both Cazeaux's family and his editor concurred in the opinion that a new edition ought to be published, A classical book soon grows old in these days, and it was found im- possible to bring out a new edition without subjecting it to the altera- tions demanded by the progress of science. I was charged with its pre- paration, and accepted the honor of the task with a full appreciation of its difficulties. I had never been Cazeaux's pupil, but his book was the first from which I had studied obstetrics, and I had been accustomed to see it in the hands of all my fellow-students, and, at a later period, of my pupils also. Independently, therefore, of my personal observa- tion, I was in a position to become acquainted with its character through others. Thus, together with merited praise, I sometimes also listened to criticisms of its details, and profited by all I heard. I was left at liberty to remodel the work according to my judgment, to make the alterations which seemed to be required, to suppress some passages and to introduce new ones. Out of respect to Cazeaux's memory, it was decided that the printing should be done in two kinds of type ; the larger for the old text, and the smaller for what I had myself written. The reader will readily distinguish what belongs to Cazeaux and what to myself, but the work has been resolved into a hoinogeneoua body without contradictory annotations. This last result could not Vlll PREFACE. possibly liave been attained without retouching the old text, by whi(;b a new direction and meaning has been sometimes given to the original ideas. Should it be desired to know certainly what Cazeaux's opinions were, it M'ill, therefore, be necessary to consult an old edition. Especially have I made it a duty not to change the spirit in which tlie work had been conceived ; therefore I can say with Cazeaux, that, " After a work has passed through several editions, a preface is hardly needed, for its object is then sufficiently well known. The present is more particularly intended for the use of students of medicine and mid- wife-students, although general practitioners may also, perhaps, gain something by its perusal, for I have endeavored to make it a condensed summary of the leading principles established by the masters of our art, and for that purpose have drawn from all the works published down to the present day. My position in the lying-in hospitals has enabled me to test the value of the doctrines put forth by former authors; and I have adopted as true all which my daily experience ha.s confirmed, and have rejected unhesitatingly, from whatever source they came, all such as were disproved by the numerous cases brought under my observation, confining myself to quoting, without comment, those whose value I have been unable to determine. "Although this work resembles, in its general arrangement, most of those published on the same subject in France, it differs from them essentially in the main ; for 1 have adopted almost wholly the views of Professors Nsegele, P. Dubois, and Stoltz, which are not found clearly expressed in any of our classical books. I have also extracted freely from the learned treatise of Professor Velpeau, whose vast erudition has greatly facilitated my bibliographical researches; from the course of my former teacher, Professor Moreau ; from the excellent articles of D^sormeaux, of Duges, and of Guillemot; from the classical works of England and America, such as those of Burns, Campbell, Merriman, Ramsbotham, Dewees, Meigs, and Rigby ; and from the treatises of Peu, Delamotte, Levret, Smellie, Baudelocque, Gardien, and Capuron. I have also consulted with advantage the manual recently published by my friend, Dr. Jacquemier ; also, the memoirs of Simj^son, Tyler Smith, Depaul, Devilliers, &c. I may be permitted also to express publicly my thanks to M. Coste, for his great kindness in allowing me to study his beautiful collection. in the College of France, and to borrow several figures from the magnificent work which he is now publishing. Lastly, it will be seen how highly I value the eminently practical writings of Madame Lachapelle. In a word, I have selected from all sources PREFACE. IX Avhaiever bears the impress of truth. In the sciences of observation, a new work is necessarily enriched by the labors of all antecedent writers ; and therefore, its greatest merit consists in collecting its scattered ma- terials, and forming out of them a body of doctrine, which it illustrates in the clearest and simplest manner possible. Such is the end I have endeavored to attain ; and the medical public, and students especially, must judge whether I have succeeded in the attempt. " But few quotations have been made, though their number might have been greatly increased ; but I wished to avoid the charge made by most students against one of our best classical works. However, I have felt bound to refer to living authors whenever I have introduced a new theory, or any particular procedure, which emanated from them ; and besides, as the professorate may be deemed a mode of publicitv, I have respected the right to the original ideas which I have heard emitted by Professor Dubois ; and his name will be found scrupulously associated with all the opinions emanating from him. " jSTotwithstanding a spurious copy published in Belgium, and several translations into foreign languages, the large editions of the work first published were raj^idly exhausted. So favorable a reception made it obligatory upon me to neglect nothing which could render this edition worthy of the reputation of its predecessors. I have, therefore, reviewed and corrected all parts of it with scrupulous care." The plan of the present edition has been so greatly modified that it may be regarded as altogether new, the order followed being that which I long since adopted for my course of lectures, as the most natural and the best. The chapters are grouped into eight principal parts. Part first is devoted to the female organs of generation. The pelvis is first studied by describing separately each of its component parts, afterwards considering them as a Avhole, and pointing out carefully whatever pecu- liarities it may present as to form, direction, and size ; then we pass immediately to the anatomical description of the external and internal organs of generation. It will be seen that I have here profited by M. Sappey's recent researches in regard to the structure of the ovary, and those of Dr. Helie (of Nantes) in regard to the structure of the uterus. The physiology of the genital organs is now so intimately connected with their anatomical arrangement that it is impossible to describe them fully w^ithout speaking at the same time of their functions. The phenomena which they exhibit at certain periods are also very properly regarded as the preludes of generation, making their preliminary study X PREFACE. indispensable to all who would understand the changes which these organs undergo during the puerperal condition. The genital apparatus of the female having been studied in the non- pregnant condition, we examine, in the second part, those very numerous and important changes which they undergo during gestation, and shall often have occasion to quote the many works of Robin on the uterine mucous membrane, the decidua, and the placenta. We afterwards 8tudy the first cause of all of these changes, to wit, the foetus and its appendages, which are traced through the various stages of their devel- opment. From this examination we deduce the signs of pregnancy. Having acquired these preliminary notions, we are in a condition to enter upon the subject of labor in the third part of the work. In the process of parturition we distinguish two orders of phenomena : one purely physiological and expressive of the vital action called into play in order to expel the foetus ; the others, purely mechanical, and consti- tuting the mechanism by which this expulsion takes place. We have given great latitude to the description, and especially to the explanation of the mechanism of natural labor, and think that we have succeeded in explaining certain facts which, hitherto, had only been pointed out. New views have also led us to describe six principal stages in the mechanism of all the presentations. After the labor, properly so called, comes the study of the delivery of the after-birth, and of the puerperal state; this part including afterward the subject of the attentions to be given to the woman during and after labor, as also an article devoted to apparent death of new-born children. I have also greatly extended the pathology of pregnancy, to which the entire fourth part is devoted. Chapters entirely new will be found in it on the diseases of pregnancy, the alterations to which the placenta is. subject, and the death of the child during intra-uterine life. Thus, I hope that I have supplied an omission that was to be regretted. In the fifth part, which is devoted to difficult labor, we treat in detail of deformities of the pelvis and all other causes of dystocia, the way in which each operates, their situation in the mother, the child or its appendages, the signs whereby their presence may be detected, the indications which they present, and the means of remedying them. In the study of the accidents which are liable to complicate labor, I have profited by all the works published of late years, and in the account of hemorrhage, puerperal convulsions, and the indications which they preseiit, will be found some new considerations. To fill up properly PKEFACB. Xi tlie outline which we had traced, it became necessary to treat carefully of artificial delivery of the after-birth, and the accidents to which it is liable. I have introduced a sixth part, devoted to obstetrical therapeutics, which includes two chapters only : the first being devoted to ergot, and the second to the eifect of a debilitating regimen and a certain course of medication upon the development of the child during intra-uterine life. The seventh part comprises a discussion of the use of anaesthetics in labor, an account of the use of the tampon and of all the obstetrical operations, rendered in a degree of detail proportioned to the interest which attaches to them. The eighth and last part, is exclusively devoted to the hygiene of the child from birth to the period of weaning. It would be impossible to point out all the additions which are scattered through the work, but they are very many. Everywhere have I accorded to the views of Professors Depaul and Pajot, as also to the views of all contemporaneous authors, the prominence which they deserve. I hope therefore that this book, which is, so to speak, a new one, will be found to represent all the most important knowledge which we possess pertaining to the obstetric art. TARNIER. CONTENTS OF VOLUME 1. PA^RT I. OF THE FEMALE ORGANS OF GENERATION. PAGE CHAPTER I. — Or tue Pelvis, 33 - Article I. — Of the Bones of the Pelvis, 34 § 1, The Sacrum, 34 ^ 2. Coccyx, 36 I 3. Coxal Bones, or Ossa Innominata, ...... 37 Article II. — Articulations of the Pelvis, ...... 39 § 1. Articulation of the Pubis, 40 § 2. Sacro-Iliac Articulations, 41 I 3. Sacro-Coccygeal Articulation, 42 § 4. Sacro-Vertebral Symphysis, . . . . . . . 43 1 5. Sub-Pubic Membrane, 44 Article III. — Of the Pelvis in general, 44 § 1. External Surface, 44 2 2. Internal Surface, 44 § 3. Superior Strait, 47 § 4. Inferior Strait, 49 § 5. Cavity of the Pelvis, 51 § 6. Base of the Pelvis, 53 § 7. Differences of the Pelvis, 53 ^ 8. Uses of the Pelvis, 54 Article IV. — Of the Pelvis covered by the Soft Parts, ... 54 CHAPTER II. — Of THE External Organs of Generation, ... 57 Article I. — The Mons Veneris, .58 Article II. — The Vulva, .58 Labia Majora, ......... 58 Labia Minora, 59 Clitoris . 60 Vestibule, 61 xiii XIV CONTEXTS. PAGE Urethra, 51 Hymen, 62 Carunculae Myrtiformes, 63 Fossa Navicularis, . . , 63 ARTiOLr III. — Secretory Apparatus of the External Genital Organs, . 64 Sudoriparous Glands, 64 Sebaceous Glands, . 64 Mucous Glands, 61 Vulvo- Vaginal Gland, 65 Article IV. — The Perineum 67 Perineal Floor, 67 Perineal Body, 67 CHAPTER III. — Internal Organs of Generation, .... 68 Article I. — The Vagina, 68 Article II. — The Uterus, 71 § 1. External Surface of the Uterus, 73 Body of the Uterus 73 Neck of the Uterus, 74 § 2, Internal Surface of the Uterus, 76 Cavity of the Body, 76 Cavity of the Neck, 77 I 3. Structure of the Uterus, 78 Peculiar Tissue, 78 Peritoneal Membrane, 78 Mucous Membrane, . 79 § 4. Ligaments of the Uterus, 82 Broad Ligaments, . . ..... 82 Bodies of RosenmuUer, 82 Round Ligaments, ........ 84 Article III. — The Fallopian Tubes, 85 Article IV. — The Ovaries, 86 ^ 1. Structure of the Ovaries, 88 ^ 2. Ovarian Vesicles, 90 § 3. Human Ovule, 90 CHAPTER IV. — Ovulation and Menstruation 93 Article I. — Modifications of the OvariaM Vesicles, .... 93 The Corpus Luteum, ........ 96 Article II. — Menstruation, 103 CHAPTER v.— TiiE Breasts 115 Human Milk, 117 CONTENTS. XV T^i^HT II. OF PREGNANCY. C 1 1 AFTER T. — CoiJCEPTioN, CHAPTER II. — Changes in the Matekxal Organism, Article I. — Changes in the Uterus, .... I I. Changes in the Body of the Uterus, i 2. Changes in the Neck, ..... § 3. Changes of Structure, 1. Serous Layer, ..... 2. Mucous Layer, ..... 3. Middle Layer, . . • . • A. Mad. Boivin's Structure, . B. Deville's Structure, c. M. H61ie's Structure, 4. Vascular Appai'atus, .... Article XL — Properties of the Uterus (Changes of), . Sensibility of the Uterus, .... Irritability, ....-•• Contractility, ....•• Retractility, Article IIL — Changes in the Parts adjacent to the Uterus, Article IV. — Changes in the Breasts, .... Article V. — Anatomical and Functional Changes in some Par concerned in Generation, § 1. Digestion, § 2. Circulation, I 3. Urine, Kyesteine, . ^ 4. Osteophytes of the Cranial Bones, . . . • § 5. Pigmentary Deposits, ts not PAGE 119 CHAPTER III. — Of the Decidua, Old Theory, Present Theory, CHAPTER IV. Of the Hitman Oyum after Fecundation, . Article I. — Changes which the Ovule undergoes in the Fallopian Tube. Disappearance of the Germinal Vesicle, 125 125 125 130 136 136 137 137 138 139 142 145 148 148 148 149 151 152 155 156 157 157 160 161 166 166 167 167 171 17fl 180 ISO XVI CONTENTS, PAfiE Condensation of the Vitellus, ISO Polar Globules, .180 Vitelline Nucleus and Segmentation of the Vitellus, . . 181 Article II. — Changes undergone by the Ovule from the time of its Arrival in the "Womb to the Formation of the AUantoid, . . 182 Article III. — Of the Foetal Appendages, 187 I 1. The AUantoid Vesicle, 187 I 2. Umbilical Vesicle, 188 § 3. The Amnion 190 § 4. Waters of the Amnion. (Liquor Amnii), .... 191 ?5. Chorion, 192 Arti'.'.e IV. — Organs of Connection, ....... 194 ^ 1. Placenta 194 § r. Umbilical Cord, 207 CHAPTER r. — Of the Foitus, 210 Article T. — The Foetus during Intra-Uterine Life, .... 211 Article II. — Head of the Foetus at Term 217 Article III. — Position and Attitude of the Foetus, .... 222 Artici<£ IV. — Functions of the Foetus, 225 I 1. Nutrition, 225 g 2. Respiration, 229 ? 3. Circulation 231 I 1. Innervation, 236 1 5. Secretions, .......... 230 CHAPTER VI. — Diagnosis of Pregnancy, 237 Article I. — Rational Signs, 237 Article II. — Sensible Signs, 242 § 1. The Touch, 242 Vaginal Touch, 243 Anal Touch, 245 Ballottement, 245 g 2. Abdominal Palpation 247 § 3. Active Motions of the Foetus, 250 2 4. Auscultation. 252 1. Sounds of the Heart, 253 2. Souffle of the Cord 257 3. Uterine Souffle, ....... 258 CHAPTER VIL— Twin Pregxanct 269 CONTENTS. XVI 1 P^RT III. OF LABOR. PAGE CHAPTER L — Causes OF Natdeal Labor, 2Y6 § 1. Efficient Causes, 276 § 2. Determining Causes, ........ 280 CHAPTER II. — Physiological Phenomena of Labor, . . . 284 I 1. Pain and Contraction, . . . . . , . . 288 ^ 2. Dilatation of the Neck, 292 § 3. Glairy Discharges, ......... 293 § 4. Bag of Waters, 294 § 5. Duration of Labor, 297 ^ 6. Effect of Labor upon the Mother and Child, ... 300 CHAPTER III. — Mechanical Phenomena op Labor, .... 304 Article I. — Presentations and Positions, 304 Article II. — Presentation of the Vertex, . . * . . . 314 § 1. Causes, . ' . 314 § 2. Diagnosis, 315 1 3. Mechanism, . . . . . . . . . . 317 § 4. Inclined or Irregular Presentation of the Vertex, . . . 331 ^ 5. Prognosis, 331 Article III. — Face Presentation, ....... 335 § 1. Causes, 335 1 2. Diagnosis, .......... 33G § 3. Mechanism, ......... 338 § 4. Inclined or Irregular Presentations, . . . . . 345 § 5. Prognosis, 345 Article IV. — Presentation of the Pelvic Extremity, .... 347 § 1. Causes, . • . . 349 § 2. Diagnosis, .......... 349 § 3. Mechanism, 351 I 4. Prognosis, 357 Article V. — Presentation of the Trunk, 361 § 1. Causes 302 1 2. Diagnosis, 363 g 3. Mechanism 366 Spontaneous Version, ....... 366 Spontaneous Evolution, ....... 368 § 4. Prognosis, .......... 371 2 XVlll . CONTENTS. PAGB Article VI. — Recapitulation of the Mechanism of Liibor in general, . 371 CHAPTER lY. — Twin Labor, 375 CHAPTER Y. — Premature a\d Retarded Lahor, ..... 377 Article I. — Premature Labor, ........ 377 Article II. — Retarded Labor, 379 CHAPTER VL — Natural Delivery of the Placenta, .' . . 381 CHAPTER VIL — Attentions to toe Woman and Child during Labor, 388 Article I. — Attention? to the Woman during Labor, .... 388 Article IL — Attentions to the Child during Labor, .... 399 CHAPTER VIII. — Attentions to the Woman and Child immediately after Labor, ........... 405 Article I. — Attentions to the Woman immediately after Labor, . Article II. — Attentions to the Child immediatply after Birth, § 1. When the Child is healthy § 2. When the Child is weak or diseased, .... CHAPTER IX. — Phenomena of the Lying-in State, § 1. After-pains, I 2. Lochia, § 3. Secretion of Milk, CHAPTER X. — Attentions to the Woman during her Lving-in, 405 406 406 409 421 429 431 435 439 PATHOLOGY OF PREGNANCY. CHAPTER I. — Diseases which may exist during Pregnancy. , . 443 § 1. Epidemic Diseases, 443 Grippe or Influenza. ........ 443 Cholera .444 § 2. Endemic Diseases, ........ 445 Intermittent Fever, ........ 445 § 3. Eruptive Fevers ... 446 Variola 146 CONTENTS. XIX Scarlatina, Roseola, § 4. A'arious Sporadic Diseases, Typhoid Fever, . Pneumonia, . Various Inflaiuiuations, Icterus,. Syphilis, . Saturnine Intoxication, Phthisis, .... Hysteria, Epilepsy, Chlorosis, § 5. Surgical Affections, § 6. Hypertrophy of the Thyroid Gland, § 7. Ulceration of the Neck of the Uterus, PAGE 4^47 448 448 448 448 449 449 451 453 453 455 455 457 -457 CH4.PTER II. — Diseases of Pregnancy, Article I. — Lesions of Digestion, § 1. Anorexia, .... § 2. Pica, Pyrosis, .... § 3. Vomiting, .... 1. Simple Vomiting, 2. Intractable Vomiting, . 3. Treatment of Vomiting, . A. Medical Treatment, B. Surgical Treatment, 2 4. Constipation ; Diarrhoea, Article II. — Lesions of Respiration, . Article III. — Lesions of Circulation, § 1. Plethora ; Ilydrsemia, § 2. Hemorrhage, ^ 3. Varicose Veins ; Hemorrhoids, Article IV. — Lesions of the Secretions and Excretiona, ^ 1. Ptyalism, ....... I 2. Excretion of Urine, .... ^ 3. Albuminuria; Uraemia, § 4. Dropsy of the Cellular Tissue, . . . § 5. Ascites, ....... Article V. — Lesions of Innervation, . . . . ^ 1. Eclampsia, § 2. Vertigo ; Syncope, ..... 1 3. Various Forms of Neuralgia; Odontalgia, § 4. Paralysis, 2 5. Intellectual Disorders. Mania. 461 463 463 464 464 465 467 470 470 474 477 478 479 479 486 487 488 488 489 490 500 502 505 505 505 507 507 51C CONTEXTS. Article u. 2 2. Article |1. §2. Article U. §2. Article n. §2. §3. Article §1. §2. §3. VI. — Diseases of the Skin, . Itching, ...... Pigmentary Spots VII. — Lesions of the Pelvic Articulations, Relaxation of the Symphysis, Inflammation of the Symphysis, VIII. — Diseases of the Vulva and Vagina, Pruritus of the Vulva Leucorrhcca, ...... Vegetations, ...... IX. — Abdominal and Uterine Pains, Abdominal, Lumbar, and Inguinal Pains, Uterine Pains, Rheumatism of the Uterus, X. — Displacements of the Uterus, . Prolapsus, Retroversion, Anteversion, Lateral Obliquity, CHAPTER IIL — Diseases of the Ovum, Article I. — Dropsy, § 1. Dropsy of the Amnion, I 2. Ilydrorrhoea § 3. Dropsy of the Villi of the Chorion, (Hydatiform Article II. — Lesions of the Placental Villi, Fibrous Obliteration, .... Article III. — Effusions of Blood in the Placenta, Placental Apoplexy CHAPTER IV. — Diseases and Death of thb F(etcs, § 1. Diseases of the Foetus, g 2. Death of the Foetus, CHAPTER v. — Abortion, Article I. — Causes, .... I 1. Causes of Spontaneous Abortion, 1 2. Causes of Accidental Abortion, 2 3. Causes of Induced Abortion, Ahticle it. — Symptoms of Abortion, AinicLE III. — Diagnosis, Mol e.) PACE 512 512 513 CONTEXTS. XXI PAGE Article IV. — Delivery of the Placenta iu Abortion, . . 575 Article V. — Prognosis, . . 578 Article YI. — Treatment, = . 579 CHAPTER YI. — ExTRA-rxEEixE Peegxaxct, . . . , . 585 Pathological Anatomy, 591 Symptoms, . . . . . . . . « - 594 Progress, - 596 Causes, 598 Ti-eatment, 601 LIST OF COLORED PLATES AND OTHER FULL PAGE ILLUSTEATIONS. PAGE Plate T. (Colored.) Median perpendicular section of pelvis from front to back, showing both pelvic spaces and the relations of the female pelvic organs to each other ........... Frontispiece. PjjATE II. Figures of Uterus at twentieth or twenty-fifth day of gestation, lialf size 174 Pj.ate III. Figures showing the human ovum, natural size, thirtieth to thirty- fifth day . ' . 210 PijATE IV. (Colored.) Diagram illustrating the foetal circulation (Flint) . . 232 Plate V. (Colored.) Figures showing section of frozen body of a woman during the period of expulsion. The engagement of the head. Commencing expulsion of the head, and the relations of the muscular floor of the pelvis to the presentation at the last stage of parturition ..... 325 Plate VI. Four figures illustrating occi2:)ital, face, brow, and antero-frontal presentation (Olshausen) 347 Pj.ate VIT. Four figures representing the different stages of spontaneous expulsion, and one figure showing labor with the body bent double . . 371 Plate VIII. Six figures showing flexions and retroversions of the uterus . 713 Plate IX. (Colored.) Two figures, an ovarian tumor complicating labor. Longitudinal rupture of the cervix . . ' 743 Plate X. (Colored.) The blood-vessels of the pelvis seen- from the front . . 1025 Plate XI. Vertical and transverse sections of pelvic organs, showing exuda- tion in cellular tissue, Douglas's pouch, right and left broad ligaments, etc. 1145 Plate. XII. External genital organs,' showing difference between those of the virgin, nuUiparous and parous women, and prolapse of anterior wall (cysto- cele), and of posterior wall (rectocele), with laceration of peringeum. (Drawn from life) 1177 LIST OF WOOD-CUT ILLUSTRATIONS. PAGE Anterior surface of sacrum 35 Posterior » « << 35 " " " coccyx 36 Anterior " « " " 36 External surface of the os innominatum 37 Internal ' " " 38 Horizontal section tlirouch tlie articulation of the pu))is 40 Posterior view of the articulation of the pubis . 40 Pelvis with its ligaments; the anterior portion removed 42 Pelvis with its ligaments, posterior view 42 The plane and a.x is of the superior strait and of the inferior strait ... 48 Diameters of the pelvis ............ 48 The plane and axis of the inferior strait 50 Diameters of the pelvis 51 The pelvic excavation . 52 Pelvis Avith soft parts seen from above 55 Position of the pelvis and the direction of its axis during labor . . . .57 External genital parts 58 The hymen in the form of a crescent 62 " " " " " circle 62 Urethral follicles 65 Vulvo-vaginal gland 66 Muscles of the female perineum 67 The internal genital organs 71 Relative position of the pelvic viscera 73 DifTerences in the uterine neclc and external orifice 75 Cavity of the uterus and the Fallopian tubes 76 Tliree sections of the virgin uterus 77 Mucous membrane and tissue of the uterus 80 Bodies of Rosenmiiller 83 Uterus and Fallopian tubes 84 Ovary of female after puberty 87 Section of ovary 89 Ovule or Graafian vesicle 90 Non-fecundated human ovule 91 Ovary and Graafian vesicle at highest degree of development .... 94 Ovary and ruptured vesicle 94 Uterus laid open 96 Ovary laid open longitudinally 97 Corpus luteum (sixtli month of pregnancy) 100 Lobules of a mannnary gland 116 Mammary gland of human female 117 Section of neck of the uterus 132 (A) Gi-adual dilatation of the neck of uterus during jn-egnancy .... 133 (B) " " u u u « ''".... 133 (C) " " " « '< a u .... 133 ^luscular fibres of the uterus 138 Muscular fibres on anterior face of womb 140 Disposition of the muscular fibi-es on posterior face of woml) .... 141 Intercrossing of the uterine fibres 141 xxiv LIST OF ILLUSTRATIONS. Second plane of the anterior muscular layer Internal muscular layer .... The nipple, sebaceous tubercles, and areola Section of womb ..... The decidua after the arrival of the ovum The layer of albumen .... The vitelline membrane Fecundated ovum ..... Ovule shortly after its arrival in the womb The blastoderm .... " '' (in profile) Section of more developed ovum Origin and first traces of the amnios The amniotic hoods ..... Anmios almost completed, and the origin of the allantois Rapid progress of the allantois The allantois spread over the whole internal surface of the ovum Placenta with separate cotyledons . The internal or foetal surface of the placenta The external or uterine surface of the placenta Representing how the villi of the chorion ramify Fragment of the villi of the chorion A case described by Benckiser . Diameters of the foetal skull . Position of child in the womb " twins " " _ _ Form of the bag of waters The head in the occipito-iliac position . The head in the same position but more Hexed The head in various degrees of extension Disengagement of the head Mechanism of face presentations Position of head when forward rotation of chin takes place Three diagrams showing method of converting face into vertex pr Presentation of the breech The same after internal rotation The delivery of the bi-eech Another illustration of the same The same, disengagement of the head . The same, the occiput behind . First position of right shoulder with arm hanging down The same j^osition during the descent Position after rotation ..... The same position, delivery more advanced . Bifurcation of the Fallopian tube . Contraction of the sacro-pubic diameter of the pel The superior strait in the figure eight pelvis . Sinking in of the anteru-lateral walls of the pelvis Pelvis deformed by rachitis " " by osteomalacia The oblique-oval pelvis .... Skeleton deformed by rachitis . " " by flexiue of the vertebral colinnn Baiulelocque's callipers esentations XXV PAGE 143 144 156 168 169 181 181 181 182 183 183 184 184 18o 185 186 187 195 196 196 202 204 209 220 223 270 295 317 319 322 325 338 340 347 352 353 353 354 356 357 369 369 370 370 600 621 621 623 629 629 630 650 650 654 XXVI LIST OF ILLUSTRATIONS. PAGE Huevet's pelvimeter r - . , • 657 Mensuration of the symphysis pubis .... . . 658 Huevet's pelvimeter as a pair of callipers ..... . . 659 A siruple pair of cailipei's ........... 660 Mode of using the finger. ........... 664 Tumor complicating labor ........... 709 Section of a fibrous tumor ........... 722 Vaginal cystocele ............. 729 Kight posterior occipito-iliac position complicated by the cord .... 829 The left occipito-iliac position . .......... 841 " posterior mento-iliac position 852 Oval shaped tumors between the thighs ......... 861 Illustrating Jacquemier's case of twins 865 Hour-glass contraction of womb .......... 87-3 Mode of dilating tiie strictured part of womb 873 " breaking up the adhesions of the placenta ...... 878 Pushing up the head into the left iliac fossa 941 \'ersion by drawing down the feet 942 Delivery of the posterior arm 945 Mode of flexing the head . .951 " rotating the face . 951 Using the blunt hook in breech positions 955 Introduction of the hand in second position of the right shoulder. . . . 956 ^lode of seizing the feet in the same position ........ 956 " " " " second position of left shoulder .... 957 The male branch of the forceps .961 The female branch 961 The forceps locked ........ .... 961 Tarnier's forceps ........ .... 963 Wells' axis-traction attachment applied to Elliot's forceps .... 963 Simpson's forceps ........ .... 964 Hodge's forceps ........ .... 964 Introduction of first branch of forceps .... .... 967 " second branch 968 The forceps applied and locked 969 Forceps applied on the child's head 972 Application of the forceps in right posterior occipito-iliac position . . . 973 Forceps applied and locked in the left transverse occipital-iliac position . . 976 " " '' " " anterior mento-iliac position . . . 981 The same in the mento-posterior position 981 Application of forceps when the head is i-etained, only ...... 984 Using the lever to pull down the occiput 996 Method of dilating the os uteri 1012 (A) Intra-uterine dilator 1017 (B) " " " 1017 (C) " " " 1017 Smellie's scissors closed 1041 The same opened ............. 1041 jSIode of using Smellie's scissors .......... 1041 Cephalotome closed ............. 1042 The same opened ............. 1042 Incising the craniinn with the cephalotome .... ... 1042 The embryotomy or cephalotribe forceps (Baudelocque's) .... 1045 Lusk's cephalotribe 1045 LIST OF ILLUSTRATIONS. XXVU PAGE The'same applied and locked 1046 The cranioclast . 1054 Mode of using the blunt hook 1059 Binder for compression of the mammae ........ 1078 " " u ,1 1078 " " u u _ J078 Position of hands in palpation of the abdomen (i!fMnde) ..... 1101 " " " at the beginning of the examination of the pelvic excavation {Pinard) ..... 1105 The hands exploring the excavation — the right hand arrested by the brow on the right side {Piiiard) ........... HOG Position of the hands and direction of the pressure in external version, when the position is oblique (PinarcZ) .......... 1113 Position of the hands and direction of the pressure in external version, when the position is longitudinal (-Pi?zard) 1114 Munde's placental curette. Length of instrument, 16^^ ; width of loop, %'^ -. 1137 Showing degrees of partial laceration (Jlfwrad^) ....... 1159 " " complete laceration {Mund4) 1159 Wire twister (ilfiif attachment of the right pyramidal muscle. FiO 2. A. Ridge formed by the spinous pi ocesses. B. Posterior sacral foramina. D. Articular processes. The sacrum, although quite thick, is a very light and spongy bone. Besides, it is pierced by a great number of foramina, ,and traversed by n central cavity, which serve to diminish its weight still more. 36 FEMALE OEGANS OF GENERATION. It is formed of five principal pieces (false sacral vertebroe), soraetinies of six, and in one case, seven were observed (Pauw). In Scemmering's cabinet are tliree specimens which present but four pieces. The development of the sacrum is analogous to that of the vertebra, and takes place from thirty-four or thirty-five points of ossification, arranged in the following manner: 1. Five of them, placed one over the other, occupy the anterior and middle parts. 2. In each of the interspaces which separate these, two small osseous laminae are developed some time after birth, which seem to form their articular surfaces. 3. Ten are situated in front and upon each side of the latter, that is, one for each lateral portion of the four or five primitive bones. 4. And behind them six others are developed, between which: 5. There appear three or four that correspond with the spinous processes, or their laminae ; and 6. Lastly, there is one upon each side above the iliac surface, for the articular facet. § 2. The Coccyx. This name is given to an assemblage of three or four, occasionally five little bones, united with each other on the median line of the body, and apparently suspended at the point of the sacrum, of which, indeed, they appear to be only a movable appendage, continuing its line of curvature forwards. Fig. 3. Fig. 4. ^ Posterior surface of the coccyx. Anterior surface of the coccyx. Fig. 3. A. Cornua of the coccyx. B. Apex. Flo. 4. A. Cornua of the coccyx. B. Apex. M. Cruveilhier declares that he has known it, in some cases, to form a right angle or even an acute one with the sacrum. As a whole, the coccyx represents a triangular and symmetrical bone. 1. Its spinal, or posterior face, is convex and irregular, and is only separated from the skin by the posterior sacro-coccygeal ligament. ' 2. It's, pelvic, or anterior face, is smooth and slightly concave, and lies in contact with the termination of the rectum, which rests upon it. Like the preceding bone, it is marked by certain transverse grooves, corresponding with the intervals which had, for a long period, separated its different pieces. 3. Its tivo lateral borders are quite irregular, and are occupied by the attachments of the anterior sacro-sciatic ligaments, and the ischio-coccygeal muscles. 4. Its slightly concave base presents, above, an oval surface, which articulates with the apex of the sacrum, and behind, two little tubercles called the cormia of the coccyx. 5. The apex is rounded, irregulai', and sometimes bifurcated, affording attachment to the levator ani muscle. The coccyx is developed from four or five centres of ossification, that is, one for each of its parts. of the pelvis. 37 § 3. The Coxal Bone, Haunch Bone, or Os Innominatum. This is a non-symmetrical, quadrilateral bone, curved upon itself, as if twisted in two different directions, contracted in its middle, and of a very irregular figure. The pair occupy the lateral and anterior parts of the j)elvis., It presents an internal and external face, and four borders, for our consideration. 1. The external, ov femoral surface, is turned outwards, backwards, and downwards, at its superior part, while inferiorly, it looks forward. At its superior and posterior portion is seen an unequal, narrow, and convex surface, affording origin to the gluteus maximus muscle, and ter- minated below by a slightly elevated circular ridge, called the superior curved line. Beneath this, there is a larger surface, which is concave behind, narrowed in front for the insertion of the gluteus medius muscle, and bounded by a slight ridge below, called the inferior curved line; still lower, there is a third extensive and convex surface, serving for the attach- ment of the gluteus minimus muscle. All that portion of the femoral face just described forms a large fossa, alternately concave and convex, bearing the name of the external iliac fossa. Towards the front, the external face presents the cotyloid cavity or the acetabulum, at its superior part; and a little more in advance and below, the sub-pubic, or obturator foramen. This opening is triangular, with rounded angles; its long diameter is inclined downwards and outwards, and its circumference is sharp and irregular, presenting above a groove, directed obliquely from behind forwards aud from without inwards, through which the obturator vessels and nerves pass out. A fibrous membrane that subtends the foramen is attached to its periphery, except in the immediate vicinity of the groove. Upon the upper side of the obturator foramen, between it and the median line, there is a concave or nearly plane surface for the origin of several muscles. Extern.al surface of the os innominatum. A. External iliac fossa. B. Crest of tiie ilium. C. Anterior superior spine of the iliUin. 1). Anterior in- ferior spine of the ilium. E. Horizontal branch of the pubis. F. Posterior superior spine of the ilium 0. Posterior inferior spine of the ilium. H. Cotyloid cavity. I. Ischium. K. Sub-pubic or obturator fonimen M. Ischio-pubic rainus. 0. Descending branch of the pubis. 38 FEMALE ORGANS OF GENERATION. 2. The abdominal, or internal face, is directed forwards at its upper part, and backwards at the lower. It may be divided into two portions, the superior of which is characterized by a large excavation, called the ititernal iliac fossa, by a semilunar articular surface found just behind this fossa, and called the auricular facet, and still more posteriorly, by some rugosities, analogous to those found on the articular faces of the sacrum. The superior portion is terminated below by a large, rounded, and con- cave line, which separates it from the other moiety. The latter, or inferior portion, presents behind a nearly triangular plane surface, which corre- sponds to the cotyloid cavity and to the body of the ischium; near its middle, we find the obturator foramen, and in front, the internal face of the pubis and of the ischio-pubic ramus. 3. Borders. These are four in number. ^'*'-^- The posterior one has a very irregular shape, being oblique from above down- wards, and from without inwards. The posterior superior spinous process is found at its junction with the superior border. This prominent, well-marked eminence is separated by a rough margin from another though less voluminous one, called the posterior inferior spinous process. Below this last apophysis, the student will observe a very deep notch, which con- tributes to the formation of the great sciatic foramen, and is terminated below by a triangular, pointed projection, bearing the title of the spine of the ischium. This pro- cess is more or less prominent in different individuals, and is sometimes directed in- wards. A groove is seen just beneath it, in which the tendon of the obturator in- tern us muscle plays; this groove is a part of the lesser sciatic notch ; and lastly, this border terminates at the tuberosity of the ischium. The anterior border is concave, oblique above, and nearly horizontal in front. The anterior superior spinous process is formed by its union with the superior border. A considerable depression exists under this apophysis, which separates it from another one, called the anterior inferior spinous process. Then we find a groove just under this elevation, for the gliding of the conjoint tendon of the psoas magnus and the iliacus internus muscles; which groove is bounded, in front and below, by the ilio-pectineal eminence. And lastly, the border is terminated by a triangular horizontal surface, which is directed downwards and forwards, and is broader externally than internally, and by the spine and angle of the pubis. The superior border or crest of the ilium is thick, convex, and inclined nutwaids, excepting at its posterior part, where it looks slightly inwards — Internal surface of the right os innominntum. A. Internal iliac fossa. B. Anterior superior spinous procesu of the ilium. C. Crest of the ilium. D. Posterior superior spinous process of the ilium. K. Posterior inferior spinous process of the ilium. F. Articular surface. G. Spine of the ischium. H. Tuberosity of the ischium. I. Sub-pubic or obturator foramen. K. Ischio-pubic ramus. M. Ilio-pectineal eminence. N. Spine of the pubis. OF THE PELVIS. 39 being twisted, in its course, somewhat like an italic/. Anatomists have subdivided it into the external and internal lips, and the intervening space. The anterior superior spinous process bounds it in front, and the posterior superior one behind. The inferior border is shorter than either of the others ; it presents, how- ever, three parts for study. There is an oval surface above, for articulating with its fellow of the opposite side, forming the symphysis ; below, it is terminated by the tuberosity of the ischium, and in the middle, we find the ischio-pubic ramus; this is a sharp ridge, formed superiorly by the descend- ing branch of the pubis, and inferiorly by the ascending portion of the ischium. The coxal bone is developed from the priricipal centres of ossification, which appear at the same time in the iliac fossa, the tuberosity of the ischium, and in the pubis. Owing to this mode of growth, it has been customary to divide the os innominatum into three portions : the superior one, styled the ilium, forms, in a great measure, the contour and prominence of the hip; the pubis, being anterior, supports the genital organs; and the inferior one, which sustains the body when seated, is named the ischium. Several years after birth, an osseous lamina resting upon the superior border of the bone, is developed to form the iliac crest, whilst a similar layer embraces the tuberosity of the ischium, and extends to its ramus ; at the same time, a third centre of ossification appears for the anterior inferior spinous process of the ilium, and a fourth forms the angle of the pubis. ARTICLE II. ARTICULATIONS OF THE PELVIS. [The four bones just described are united by four articulations peculiar to the pelvis; one in front for the two pubic bones, two behind for the iliac bones and the sacrum, and that of the coccyx with the sacrum. All these articulations are usually termed symphyses : thus the articulation of the two pubic bones is styled the pubic symphysis, the junction of the iliac bone with the sacrum is called the sacro- iliac symphysis, and the connection of the sacrum and coccyx the sacro-coccygeal symphysis. It should be observed, however, that the symphyses or amphiarthroses are characterized by flat articular surfaces, united by a layer of fibrous tissue which allows a bending motion without any sliding of the bones upon each other. Now this sliding motion exists in the pelvic articulations of the female. It is, there- fore, a mistake to classify them amongst the amphiarthroses, and only by an abuse of language can they continue to be called symphyses. Lenoir's researches prove that some anatomists were near the truth in considering them as arthrodia. In twenty-two female subjects between the ages of eighteen and thirty-five years, Lenoir found that the four pelvic articulations are formed by the contact of sur- faces covered with cartilage and lined with synovial membranes ; they present, therefore, all the characteristics of arthrodia, and have a simple, sliding motion. To the four articulations proper, of the pelvis, it is well to add in this connection, the articulation of the sacrum with the spinal column. Here we have really one of the amphiarthroses or symphyses. The description of the sub-pubic ligament completes the history of the liga- mentous connections of the pelvis. j 40 FE^rALE ORGA>s'S OF GENERATION. § 1. Articulation of the Pubis. This articulation is formed by the approximation of the oval surfaces occupying the upper part of the lower border of the coxal bones. These surfaces are slightly convex and unequal, and are covered with a cartila- ginous lamina which fills up the inequalities. The convex shape and the direction of their faces are such, that they only come into contact for an inconsiderable extent at their internal or posterior part, and hence they leave above, in front, and below, an open space, which is the more con- siderable, in proportion to the distance from the centre of the joint. The articulating surface of the two cartilages is a little facet, about six or eight lines in its vertical diameter, by two or three in its transverse one. This facet is smooth, and furnished with a synovial membrane, which is the more lubricated with synovia as the female approaches the period of labor. A considerable thickness of the interpubic ligament fills up the interval which exists between the other points of these articular surfaces. This interpubic ligament is formed of a very dense fibrous substance. It has the form of a wedge, Avith the point forced down between the bones and the sides adhering to the rough surfaces fronting the articulation. Two planes of fibres are discoverable in it; the deeper ones, which pass from one iliac bone to the other, and are shorter in proportion to their depth, are crossed, and disposed in several layers. They constitute the interpubic liga- ment properly so called. The othei-s, which are more superficial, are parallel, and pass obliquely from within outwards and from above down- wards. Beginning at the upper part of the articulation they spread in descending, until they are finally divided into two bundles, which become lost in front of the branches of the pubic arch by mingling with the peri- osteum of the bones and the tendons of the muscles inserted in the vicinity. These form the anterior pubic ligament. The uppermost portion of the anterior pubic ligament seems to take its origin in the fibrous cord which is inserted on the spine of the pubis, and which cushions, so to speak, the upper edge of that bone, in such a way as to efface its inequalities. It constitutes the superior pubic ligament. Lastly, at its lowest part, the anterior pubic ligament assumes the fcrni of a thick triangular bundle occupying the summit of the pubic arch, and fixed by its lateral edges to the upper and internal part of the two branches thereof. This ligament, called the triangular, or sub-pubic ligament, pre- norizonta.1 section through the articuhition of the pubis. Posterior view of the articulation of the p abis. Ir'lG. 7. A. SjnoTiul uiembnine. B. Articular cartilages. C. Inter-pubic ligament. D. Section of the bones Fig. 8. A. Posterior projecting piwi. B. Sub-pubic ligament. C. Section of horizontal branch of pubis D. Section of iBchio-pub-" ramus. OF THE PELVIS. 41 senls a rounded base, which completes the arch of the pubes by giving it a reguhir curve calculated to facilitate the exit of the foetus. Thus, we have three anterior pubic ligaments, a superior pubic and a 3ub-pubic ligament, all of them representing a spreading out of the inter- osseous ligament. Behind the symphysis, the fibro-cartilaginous substance forms a sort of projecting pad, which occupies the middle part only, and disappears from above downwards. Finally, the ligamentous arrangement of the articulation is completed by the posterior pubic ligament, composed of fibres extending transversely from one pubis to the other, above the projection just noticed. This liga- ment, which is very thin, and of moderate strength, forms the posterior lining of the synovial membrane. § 2. Sacro-iliac Articulations. This articulation is formed by the junction of the semilunar facets, which were pointed out in describing the border of the sacrum and the internal face of the ossa ilia. Both these facets are covered w^ith a diarthrodial cartilage, which is closely adapted to the inequalities they present; that, however, which per- tains to the sacrum, being always much thicker than the layer which belongs to the iliac bones. The latter is so thin, that its existence has been denied. These cartilages are covered with a synovial membrane, which secretes quite abundantly a viscid and transparent synovia. But, when the female has passed the prime of life, this fluid often concretes, and becomes disposed in isolated flakes upon the articular surfaces, — a fact which has caused its true nature to be misunderstood. A very limited sliding motion is all of which this articulation is suscep- tible. The bones are held together by the following ligaments : 1. The posterior, or great sacro-sciatic ligament, is found at the posterior inferior part of the pelvis. It is triangular, thin, flattened, and narrower in the middle than at the extremities. It arises by a large base from the posterior inferior spinous process of the ilium, the sacro-spinous ligament, the last of the posterior tubercles of the sacrum, and from the inferior part of the margin of this bone and border of the coccyx, and running outwards, downwards, and a little forwards, is inserted into the tuberosity of the ischium. Its fibres are arranged in such a way, that the internal ones cross the external about their middle. 2. The lesser sacro-sciatic ligament is smaller than the preceding, though nearly of the same form, and situated more in front. Within, it is broad, being partially confounded with the other, but arising a little more ante- riorly upon the sides of the sacrum and coccyx; thence, it passes forwards and outwards to be inserted into the spine of the ischium. The sacro-sciatic ligaments convert the two sciatic notches into foramina. They not only serve to unite the sacrum to the ilium, but also contribute to the formation of the parietes of the pelvis. 3. The posterior sacro-iliac ligament is a collection of yellow, elastic, fibrous bundles, intermixed with fatty pellets, which fill up the rough 12 FEMALE ORGANS OF GENERATION. Pelvis with its ligaments; the anterior portion remoTed. A. Internal iliac fossa. B. Section if the bones. C. Origin of the great sacro-sciatic l-'gament. D. Great sacro-sciatic ligament. E. Lesser sacro-sciatic ligament. F. Great sacro-sciatic foramen. G. Last lumbar vertebra. H. Ilio-lumbar ligament. L Sacro- veitebral ligament. Fig. 10. Pelvis with it.'* ligaments. Posterior view. A. Great sacro-sciatic foramen, through which is seen the horizontal branch of the pubis. B. Great sacro-sciatic ligament. C. Tuberosity of the ischium. D. Posterior sacro-iliac ligament. E. Posterior superior spinous process of the ilinin. F. Inferior ■acro-iliac ligament. excavation observed beliind the cartilaginous surfaces; very short, numerous, and interlacing in every direc- tion, they become almost in- timately blended ■svith the sacrum and coxal bone^ On account of their strength, they greatly consol idate this articulation. 4. The anterior sacro-iliac ligament is a simple fibroua lamina, extended transverse- ly from the sacrum to the oa innominatum. It is rather an expansion of the perios- teum of the pelvis than a true ligament. 5. The superior sacro-iliac ligament is a very thick fas- ciculus, passing transversely from the base of the sacrum to the coxal bone. 6. The inferior sacro-iliac ligament (vertical sacro-iliac of M. Cruveilhier) arises from the posterior superior spinous process of the ilium, and is inserted just below the third sacral foramen into the tubercle found at the termi- nation of the border of the sacrum; and behind, into the great sacro-sciatic liga- ment. § 3. Sacro-coccygeal Articulation. This articulation, which for a long time was supposed to resemble those between the bodies of the vertebrae, differs from them materially in being a true arthrodia. It is formed by the opposition of the oval surface of the point of the sacrum to that of the base of the coccyx ; the middle of the former Ls projecting, and corresponds to a depression in the centre of the latter. The long diameter of the articular face of the coccyx is directed transversely. The cartilages covering these surfaces aie rather thinner at the centre than at the circumference. They are provided in the adult female with a synovial membrane, which is supposed by M. Lenoir to be only developed by the movements of the coccyx upon the sacrum, since he has failed to meet with it in subjects under eighteen years of age. OF THE PELVIS. 43 1. The anterior sacro-coccygeal ligament consists of a few parallel fibres, which descend from the anterior part of the sacrum to the corresponding face of the coccyx. 2, The posterior sacro-coccygeal ligament is flat, triangular, broader above than below, and of a dark color. Arising from the margin of the inferior orifice of the sacral canal, it descends to, and is lost upon, the whole posterior surface of the coccyx. It also aids in completing the canal behind. In investigating upon the dead body the anatomical arrangement to which the motion of the coccyx on the sacrum is due, it was ascertained by M. Lenoir that the motion takes place almost as frequently in the sacro- coccygeal articulation, as in that of the second piece of the coccyx with the third. Sometimes it happens simultaneously in both, whilst in few cases only does it occur in the connection of the second piece with the third, or of the third with the fourth. These inter-coccygeal articulations are similarly constructed. In all cases, in fact, in which the points of niotion of the coccyx were changed, M. Lenoir discovered a more or less complete anchylosis of the articulation between the sacrum and coccyx, and of those between the bones of the coccyx itself, at points above and below the one which preserved its mobility. Then, also, wherever situated, the movable articulation Avas constructed as follows: 1. Of articular surfaces irregular in form but corresponding exactly, which were incrusted with diarthrodial cartilages and provided with a synovial membrane. 2. Of lax peripheral ligaments formed at the expense of the layers of fibrous substance covering the bones of the coccyx. 3. Lastly, motion was possible in every direction. It is to be observed that ossification is more frequent and rapid in the joint between the sacrum and coccyx than in that between the first piece of the coccyx and the second; the third and fourth become fused very early. It is therefore easy to understand how the great mobility of the sacro-coccygeal articulations rend^ers luxation possible in labor, whilst in cases of anchylosis, either fracture or a sudden separation of the united bones might occur. During pregnancy, the ligaments of the pelvic articulations become so softened and swelled by imbibition of fluid, as to render the mobility of the articular surfaces very evident. This softening is very considerable in some cases, and may make walking, or even standing, impossible. (See Diseases of Pregnancy.) § 4. Sacro-vertebral Symphysis. . This is produced by the junction of the sacrum with the fifth lumbar vertebra. It is a true amphiarthrosis,- as are all the vertebral articulations. It takes place at three difierent points, viz., between the oval facet, seen at the middle of the base of the sacrum, and the inferior surface of the body of the last vertebra; and at the two articular surfaces found near the entrance of the sacral canal. The modes of connection are, a fibro-cartilage (which is much thicker in 44 FEMALE ORGANS OF GENEKATION. front than behind), the termination of the two anterior and posterior verte bral ligaments, the interspinous ligament, and lastly, the sacro-vertebral ligament, a short, very strong, fibrous bundle, which descends obliquely from the anterior inferior part of the transverse process of the last vertebra, downwards and outwards, towards the base of the sacrum, Avhere it is inserted. Further, a svnovia.! membrane is found in the articulation between the oblique process of the sacrum and those of the vertebrae. To these must also bv^ added the ilio-lumbar ligament, which passes from the apex of the transverse process of .the fifth lumbar vertebra to the thickest portion of the iliac crest; and the ilio-vertebral ligament formed of two fibrous bauds, the superior of which arises from the middle and lateral part of the body of the last lumbar vertebra, and the inferior, from the inter-sacro-vertebral space; both are then spread out on the coxal bone. § 5. Obturator Membrane. The obturator membrane still claims a description, in order to finish the history of the ligamentous apparatus of the pelvis. This, as has been remarked by M. Cruveilhier, like the sacro-sciatic ligaments already epoken of, is rather an aponeurosis serving to complete the pelvic walls, than a true ligament. These resisting membranes are probably intended to diminish, in the hour of labor, the compression of the mother's soft parts, included between the infant's head and the osseous parietes of the pelvis, as also to favor, by their elasticity, the passage of the head through the pelvic excavation. Obturator membrane. — This membrane subtends the foramen thyroideum, excepting at its superior part, where an opening exists, which converts the groove, intended for the passage of the obturator vessels and nerves, into a complete canal. Being inserted by its external semi-circumference into the corresponding part of the periphery of the obturator foramen, it is attached by its internal half to the posterior face of the ascending ramus of the ischium. Its surfaces afford origins for the two obturator muscles. This membrane is composed of aponeurotic fasciculi, which cross each other in every direction. ( Cruveilhier.') ARTICLE III. OF THE PELVIS IN GENERAL. Studied in its general asi)ect, the pelvis represents a cone, slightly flat- tened from before backwards ; the base of which, being above, is at the same time inclined forwards, whilst the apex is directed downwards and a little backwards. § 1. External Surface of the Pelvis. Anatomists have divided this surface into four regions: the anterior of which exhibits, \yn the median line, the front part of the symphysis pubis. OF THE PELVIS. 45 which is directed from above downwards and from befcie backwards, at an angle with the perpendicular of some 15° to 20^ ; next (passing outwards) is a smooth surface, from which several muscles of the thigh arise, then the external obturator fossa, occupied in the recent subject by the muscle of the same name, and finally by the anterior half of the edge of the cotyloid cavity. The posterior, bounded by the hinder part of the iliac crest, presents, on the median line, the ridge of the sacral spinous processes, the inferior open- ing of the vertebral canal, the union of the sacrum with the coccyx, and the posterior face of this latter bone. The ten posterior sacral foramina, transmitting the nerves of the same name, are found in two deep gutters, on the sides. These grooves prolong the spinal gutters, and are occupied in the recent state by the commence- ment of the sacro-spinai muscles. The lateral regions may each be divided into two parts : one, the superior, is the external iliac fossa ; the other, or inferior, offers, behind, the posterior aspect of the sacro-sciatic ligaments, and the plane of the notches or foramina bearing the same name; and, in front, the cotyloid cavity and the external face of the tuberosity of the ischium. § 2. Internal Sueface. The internal surface or cavity of the pelvis has been aptly compared to the basin of the ancient barbers. ( Vesalius.) In fact, like those vessels, it has a superior part which spreads out freely, and is called the great, the superior, or the abdominal pelvis; and an inferior one, more contracted, bearing the title of the little pelvis, or pelvic excavation. 1. The great pelvis has a very irregular figure, and forms a species of pavilion to the entrance of the pelvis. Its walls are three in number: the anterior one is deficient in the dried skeleton, but in the living state it is supplied by the anterior abdominal muscles; its posterior parietes exhibit a notch in its middle, that is ordinarily filled up by the projection of the last lumbar vertebrae, which are usually left in connection with the pelvis, although in reality not forming any part of it. Two gutters are found on the sides of this eminence, occupied by the psose muscles; further outwards, the anterior part of the sacro-iliac symphyses appear, which constitute the boundaries between the posterior and lateral regions : these latter are con- stituted by the internal iliac fossse, covered by the iliacus internus muscles. 2. The lesser pelvis, or basin. This forms a curved canal, larger in the middle than at its extremities, and slightly bent forward. If all the parts described as appertaining to the great pelvis be removed by the saw, as recommended by Chaussier, a species of ring will remain, whose circum- ference, being narrow in front and much broader behind, will furnish a correct idea of the shape of the pelvis. Four regions are found in this cavity also : The anterior one is concave transversely, and is inclined upwards, having the posterior part of the pubic articulation near its middle: this is geuerally prominent, assuming the form of a longitudinal pad, which may in some cases project to the extent of from two to three-eighths of an inch. Towards 46 FEM.VLE ORGANS OF GENERATION. the sides a smooth surface appears, and then the internal obturator, or sub- pubic fossa, having, at its upper external part, the inner orifice of the sub- pul)ic canal, through which the external obturator vessels and nerves pass out from the pelvis. It is not at all uncommon for females to complain during labor of eevero cramps in the muscles of the upper internal part of one thigh. These pains result from the pressure made by the child's head upon those nerves, as it glides over this portion of the excavation. The posterior region — constituted by the front face of the sacrum and coccyx — is directed downwards, and is concave from above, downwards. It consequently exhibits those peculiarities already noticed when describing the sacrum. The lateral regions present two quite distinct portions : the anterior one is wholly osseous, corresponding to the back part of the cotyloid cavity, and to the body and tuberosity of the ischium. It is directed from above down- wards, from behind forwards, and from without inwards. The posterior one is formed by the internal face of the greater and lesser sacro-sciatic ligaments, and by the internal aspect of the great and small sciatic notches, converted by them into foramina ; it has an opposite direc- tion to the former. One of these foramina is larger and situated higher up than the other, and is of an oval form. The other is triangular, smaller, and more inferior. The pyramidal muscle, the great sciatic nerve, gluteal artery, and the internal pudic vessels and nerves, escape from the pelvis through the great sciatic foramen. The small sciatic hole is filled up by the obturator internus muscle, and the internal pudic vessels and nerves, which re-enter the pelvis in order to supply the perineum. If two vertical sections be made, the one extending on the median line through the sacrum and the pubis, dividing the pelvis into two lateral halves, and the other at right angles to the first, dividing it into anterior and posterior halves, four equal parts or quarters of the pelvis will be thereby produced, which accoucheurs have designated as the anterior and posterior inclined planes. Desormeaux included only the lateral regions of the excavation, which he divided into two equal parts, in the composition of these planes: according to him, the anterior inclined planes are con- tinuous with the anterior region ; the posterior, with the front face of the sacrum ; and the spine of the ischium is found at the point of union of these two. The direction of the inclined planes is always the same, whatever be the manner in which they are formed. That is, the anterior are directed from without inwards, from above downwards, and from behind forwards; the posterior, from without inwards, from above downwards, and from before backwards — in a word, in such a way as to resemble somewhat the four sides of a lozenge which is slightly curved in its length. By most authors, these inclined planes are supposed to play an important part in the mechanism of labor: for they imagine that their direction has an immediate influence upon the movements which the head of the foetus performs in the excavation. In anticipating that the description of the mechanism of labor hereafter OF THE PELVIS. given will invalidate this assertion, we shall simply observe that the move- ments of rotation executed by the head, take place more frequently whilst the latter is strongly bulging out the perineum, and is so far below the inclined planes as scarcely to feel the influence of their direction, and further, that these motions often occur in an opposite direction. The great and the lesser pelvis are separated from each other by a kind of horizontal circle, which has been designated by accoucheurs as the abdom- inal, or superior strait, the isthmus, or margin of the pelvis. Finally, the apex of the pelvis presents an opening that is limited by a circle, partly osseous, partly ligamentous, to which the name of the inferior strait has been applied. Consequently, these two straits are the extreme limits of the pelvic excavation. § 3. Of the Superior Strait. The superior strait is formed, behind, by the sacro-vertebral angle, and the anterior border of the wings of the sacrum: outwardly, by the rounded margin that bounds the internal iliac fossa below ; and in front, by the ilio- pectineal eminence and the horizontal ramus of the pubis, terminating at the symphysis of this bone. The abdominal strait has been variously com- pared to an ellipse, an oval, and to the heart of a playing-card. We may assert, however, with Chaussier, that its shape is that of a curvilinear triangle, the angles of which have been rounded off, and having its base • behind and the apex in front. It constitutes the entrance to the lesser pelvis, and is therefore the first part of the narrow canal which the foetus has to traverse. Hence, the pains taken by accoucheurs to study this osseous opening can readily be conceived. All the modern authors since the days of Deventer, have endeavored to fix precisely the degree of inclination of its plane and axis, to ascertain the direction the foetus should follow in engaging in the pelvic canal, and to determine carefully the dimensions of the latter, and their accordance with those of the body, which is to pass through it. The plane of the superior strait is inclined obliquely from above down- wards, and from behind forwards; but writers are far from being unanimous in regard to the degree of its inclination; that is, in determining the angle formed by the sacro-pubic line, at the point where it meets a horizontal one, drawn from the superior part of the symphysis pubis towards one of the points on the anterior face of the sacrum. Although originally placed at 45^ by J. J. Miiller (1745), this angle has successively been fixed at 35° by Levret; at 75° by Camper, and at 55° by Saxtorph; and still more recently Professor N^egele, after a great number of researches, has con- cluded to consider it as an angle of 60° (1819). It is now generallyad- mitted that the degree of inclination in the plane of the superior strait is from 55° to 60° in the erect position of the female. The direction of the plane being once understood, it is an easy matter to ascertain that of its axis; for the latter being a line which falls perpen- dicularly upon the centre of this plane, it must evidently form with the vertical the same angle that the plane itself does with the horizontal line, 48 FEMALE ORGANS OF GENERATIOX. and consequently must have just the same degree of inclination. Being thus understood, the axis of the superior strait is a line (a b, Fig. 12) which, commencing near the umbilicus of the female, would pass directly through the centre of this strait, and fall upon the point of union of the upper two- thirds of the coccyx, with its inferior third. Hence, it will be directed from above downwards, and from before backwards. Further, the inclina- tion of this plane varies according to Fig. 11. the woman's position. Thus, it is al- most nothing when recumbent, and sometimes in this position the plane of the superior strait instead of being directed forwards and upwards, even looks upwards and backwards (Du- bois) ; when the trunk is bent strongly forwards, the inclination of the plane is diminished and becomes more nearly horizontal; towards the end of gesta- tion, on the contrary, the inclination increases, especially when, in order to restore equilibrium, the upper part of the body is carried much backwards. As the figure which represents the circumference of the superior strait is not a perfect circle, its dimensions, taken at different points, are, of course, unequal, and, accordingly, writers have admitted several diameters for it, thus : There are three principal ones (Fig. 2), numely, an antero-posterior or sacro-pubic diameter a a, which extends from the sacro-vertebral angle to the upper part of the symphysis pubis ; it is from four and a quarter to four and a half inches in length. 2. A transverse one, b b, passing from the middle of the rounded border ^"'- ^2- that terminates the iliac fossa of one side, to the same point on the opposite side; this is five and a quarter inches long. 3. An oblique diameter, c c, ex- tending from the anterior part of the sacro-iliac symphysis to the ilio-pectineal eminence of the opposite side; this is found on both sides, and is four and three-quarters inches long. - Lastly, M. Velpeaii admits a fourth diameter, called by him the sacro-cotyloidean ; before a a. The iXDtero-posterior, or sacro-pubic diameter. 6 6. described, llOWCVer, bvBurUS, rhe transverse diameter, c c. The two oblique diameters. , . * ,, a c. The sacro-cotyloid interval. Undcr the morC exaCt name 01 /.-....CV- c /(. The plane of the snperior strait prolonged beyond tlie pubis, c e. The plane of the inferior strait prolonged bej-ond tlie pubis, c d. Shows the departure of this plane from the horizontal line. a b. The axis of the superior strait, g/. Th« axis of the inferior strait. OF THE PELVIS. 49 the sacro-cotyloid interval a c, existing between the prmontory and the posterior part of the cot}loid cavity. This interval, according to the examinations of the French surgeon, is from four to four and one-eighth inches in extent; but from the results of Nsegule and Stoltz's researches it is much less, being scarcely three and a half inches (the mean obtained from ninety pelves). The circumference of this strait varies from thirteei? to seventeen inches; Levret taught, that it equalled one-fourth of the female's height ; but to establish such an approximation, the development of the pelvis should always be iu direct proportion to the stature of the individual, which is certainly not the fact. § 4. Of the Inferior Strait. The inferior strait — the perineal strait — or apex of the pelvis (as it is variously called), is more irregular in shape than the superior one., Its outline presents, in fact, three tuberosities or osseous projections, separated by as many deep notches. If, however, the advice of Chaussier be followed, and a sheet of paper be placed over this opening, so as to trace its outline with a crayon, it will be found to have an oval figure, the smaller extremity of which is in front and the larger one, looking backwards, is broken in upon by the prominence of the coccyx. This point, disappearing at the moment of the head's pas- sage, offers no obstacle to the delivery ; and, therefore, the strait may be considered as nearly an oval. The periphery of the pelvis at its apex is formed by the inferior part of the symphysis pubis, the descending branch of this bone, the ascending branch and tuberosity of the ischium, the inferior margin of the great sacro- sciatic ligament, and by the border and point of the coccyx. Hence, three triangular projections are found in it: the two ischia upon the sides, and the coccyx behind. The first two are immovable, but the last, on the con- trary, is effaced at the period of delivery, as just mentioned ; for the mobility of the sacro-coccygeal articulation allows the coccyx to be pushed downwards and backwards by the foetal head, as it traverses the inferior strait. The two lateral prominences, made by the tuberosities of the ischia, are placed on a plane somewhat lower than the point of the coccyx ; and consequently, in the sitting posture, the weight of the body rests solely on those tuberosities, and not at all upon the coccygeal extremity. This cir- cumstance furnishes us a reason why transverse contractions of the pelvis are far more frequent at the inferior strait than the antero-posterior ones. The three notches also require a passing notice ; thus, the two postero- lateral ones are very deep, but when the sciatic ligaments have been pre- served, they are comparatively superficial ; the third is found anteriorly ; its apex corresponds to the inferior part of the symphysis pubis, its base to a line drawn between the anterior parts of the tuberosities of the ischia, and its sides are formed by the ischio-pubal rami. The term arch of the pubis has been applied to this notch. The columns of the arch are distorted outwardly, as if a rounded body had been forcibly expelled from the peh-is. whilst the bones were soft, and had pushed them before it ; and this arrange- 4 50 FEMALE ORGANS OF GENERATION". ment, which is more marked in the female than the male, favors the descent of the head. The arch is three and a half to three and three-quarter inches broad at the base ; but only one and a quarter to one and a half inches at its apex ; in height, it is about two, to two and a half inches. Hence the area of the inferior strait will not present a uniform plane (should it be desirable to ascertain the irregularities it exhibits), because all parts of its margin are not upon the same level. However, to obviate the difficulty met with, in determining the direction of this plane, Duges has divided the strait into two nearly equal portions, the one anterior, and the other pos- terior, meeting at the tuberosities of the ischium, and each presenting a distinct plane and axis ; but as this method of proceeding uselessly com- plicates the question, we prefer considering the terminal plane of the pelvis, as represented by the coccy-pubal line, thus leaving out the lateral projec- tions altogether. The question is then reduced to these terms: What is the direction of the line that extends from the point of the coccyx to the inferior part of the symphysis pubis? Writers, likewise, variously describe this ; for instance, according to the majority of the French accoucheurs, the plane of the inferior strait is slightly oblique, from below upwards, and from behind forwards, so that it would unite with that of the superior strait (if prolonged) in front of the symphysis pubis. On the other hand, M. Noegele concludes, from his numerous researches, that the inclination of the antero-posterior diameter of this strait is from 10° to 11° from the horizon, and that the point of the coccyx is found, as a mean, from a half to three-quarters of an inch higher than the summit of the pubic arch ; and, therefore, the coccy-pubal line is a little "oblique from above downwards, and from behind forwards. The lower extremity of the axis of this plane of the inferior strait would cut the coccy- pubic diameter at right angles, and terminate above at the sacro-vertebral ansrle. As a further result of his labors, he has found that, in five hundred well-formed persons, of different stat- Fio- 13. ures, four hundred and fifty-four have the point of the coccyx more elevated than the inferior portion of the sym- physis; in twenty-six it was lower, and in twenty individuals both points were on the same level. M. Velpeau remarks, as we think with some reason, that, at the moment of delivery, — the only time, after all, when it is requisite to form an idea of the direction of this plane, — the point of the coccyx, being pushed downwards and back- rL u_lVi I { y^ (^ wards by the passage of the head, is at least on a level with, if not lower than c d. Ti.e horizontal line, c e. Tiie plane of the in- ^^ inferior part of the Symphysis. ferior strait (during lab r). a 6. The axis of the in- ■'. /.-»«■ -\-^ ^i i tenor Btrait ihe assertion of M. JNtegele, there- OF THE PELVIS. 51 ^i^.-^ Fore, although true as applied to the female not in labor, fails during parturition ; and it must be admitted that th'j plane of the inferior strait is then oblique from below upwards, and from behind forwards. The axis of this strait is represented by a line (a b, Fig. 13) directed from above downwards, and from behind forwards, which, starting from the first piece of the sacrum, falls at a right angle upon the middle of the bis- ischiatic space. The remarks made upon the variations in the direction of the plane, apply with equal force to its axis. The latter crosses the axis of the superior strait in the excavation, forming with it an obtuse angle, the sine of Avhich is in front. It is also very important to know the dimensions of the perineal strait, and hence' obstetricians describe three principal diameters at that point, namely — 1. The antero-posterior or coccy-pubal diameter (a a. Fig. 14), . fio. u. running from the point of the coccyx to the summit of the pubic arch ; it is usually four and a quarter inches long, but may increase to four and three-quarter inches during labor, by the retrocession of the coccyx. 2. The bis-ischiatic, or transverse diameter, h h, is four and a quarter inches in ength, and goes from one tuberosity .f the ischium to the other. 3. The oblique diameter, c e, commences at the middle of the great sacro-sciatic ligament, and crosses to the point of union of the ascending branch of the ischium, with the descending ramus of the pubis, and is four and a quarter inches long, but may become one- quarter of an inch more during labor, from the elasticity of these ligaments. All the diameters of the inferior strait are, therefore, in the dried pelvis, about four and a quarter inches in length, though their dimensions are susceptible of great variation during labor. § 5. Of the Excavation. The excavation is that space comprised between the superior and the inferior straits, and it is in this cavity that the foetal head executes its prin- cipal movements ; and it is somewhat surprising, that, until quite recently, this canal was scarcely mentioned in the majority of the classic works, not- withstanding the importance of a knowledge of its dimensions, as also of the direction of its plane and axis. Its dimensions comprise both the height and width at the different points: thus the height in front, is one and a half inches ; upon the sides, three and three-quarter inches ; whilst it is four and a qua-rter inches behind, if a straight line be drawn from the sacro-vertebral angle to the point of the coccyx, and five inches and a quarter, following the curve of the sacrum. a a. The antero-posterior or cocoy-pnbal diameter. 6 6. The transverse or bis-ischiiitic diameter, c c. Tha two oblique diameters. 52 FEMALE ORGANS OF GENERATION". Three diameters are also described for this cavity (like the straits), so as to appreciate its extent in the different directions. All of them are taken at the centre of the excavation, and they consist of an antero-posterior one, of four and three-quarters to five and one-eighth inches in length, a trans verse diameter four and three-quarter inches long, and an oblique one, of the same length ; consequently, all the diameters of this cavity are very nearly four and three-quarter inches each. If the canal forming the excavation were a cylinder, it Avould only be necessary to divide it by a plane, perpendicular to its walls, in order to represent the opening of this cavity; but a simple division, thus made, would not give a just conception of the excavation, for two reasons. First, the canal is not cylindrical, because its sides are not parallel, and the anterior face of the sacrum presents a ^10- 15. well-marked curvature ; the pubic wall being nearly straight, and the lateral parietes very oblique from without inwards, and from above downwards. Consequently, to furnish an exact idea of the general arrangement of the pelvic excavation, it seems necessary to divide the canal (see Fig. 15) by a series of planes, all passing from the point c (the point of intersection of the planes of the superior and inferior straits) to any point whatever, p q r s t, on the anterior face of the sacrum. Each of these planes will show the opening of the pelvic cavity at the level W'here it is found. Now, to determine, wdth cer- tainty, the direction of the gen- eral axis of this excavation, it is requisite to raise a perpendicular line from the geometrical centre of each of these sections, and to draw a line g k through the base of each. This line g k (which, as the student will observe, is not straight) is called the general axis of the pelvis. It is now readily understood that this line is nearly parallel to the anterior face of the sacrum, and its extremities correspond with the axes of the superior and the inferior straits ; hence, this curve exactly represents the whole axis of the pelvis, or, in other words, the line which the foetus must follow' in traversing the pelvic excavation. It would be wrong to consider the line, representing the entire axis of the excavation, as a simple curve ; for M. Nsegele has well observed, that it cannot be composed of two straight lines, as often taught, nor is it a simple arc of a circle. In fact, the anterior face of the bodies of the first two bone>- a b. The plane of the superinr strait, i d. The plane of the inferior strait, c. The point where these two planes would meet, if prolonged, m n. The horizontal line. tf. The axis of the superior strait, g k. The axis of the excavation, p q r s I. Varioiis points taken on the sacrum to show the plane of the excavation at each point. OF THE PELVIS. 53 of the sacrum forms a straight line ; the sacral cui've embracing only the last three bones. Consequently, the central line, which is evidently parallel to this, will consist of a straight and a curved portion — straight, for that part of the excavation corresponding to the two superior vertebrae, and curved in the space, which is bounded behind by the last three sacral vertebra, and in front by the anterior pelvic walls. § 6. Base of the Pelvis. The base of the cone, represented by the pelvis, has its circumference directed upwards and in front ; it exhibits, behind, a notch, into the bottom of which the base of the sacrum projects, and which is further filled up by the last lumbar vertebrae (generally left in situ to complete the posterior wall of the greater pelvis), by the ilio-lumbar ligaments, and by the qua- dratus lumborum muscles ; 2, outwardly, the anterior two-thirds of the iliac crest furnishing attachments to the external and the internal oblique and transversalis abdominis muscles ; and 3, in front, the anterior superior and inferior spinous processes of the ilium, the groove for the passage of the con- joint muscles — the psoas magnus and iliacus internus, the ilio-pectineal eminence, the superior border of the horizontal branch of the pubis, the spine, and lastly, the upper margin of the symphysis of this bone. § 7. Differences of the Pelvis. 1. According to the sex. Considered as a whole, the pelvis in the male is smaller but deeper, the bones are thicker, and the muscular impressions more marked, than in the female. The superior strait being more retracted, resembles the figure of a heart on a playing-card. The excavation is not so wide, though it is deeper, especially in front, owing to the greater length of the symphysis pubis ; the ar*h of the pubis is straight, nearly triangular in shape, and is not widened in front. The coccyx is early joined to the sacrum, and the articulations of the pelvis are much sooner anchylosed than in the female. In the latter, we may add, that the iliac fossae are lai'ger and more warped outwardly (whence the prominence of the haunch bones), and the iliac crest less twisted in the form of an italic /; the interval separating the angle of the pubis from the cotyloid cavity is more consider- able, causing, in part, the projection of the great trochanters, and a wider separation of the femurs ; the superior strait is larger and more elliptical ; the curve of the sacrum deeper and more regular ; the tuberosities of the ischium are farther apart; the pubic symphysis shorter; the foramen thyroi- deum more triangular ; the arch of the pubis broader, more rounded, and more curved, and the lateral borders, formed by the ischio-pubic ramus, more contorted outwardly. 2. According to the age. At birth, the pelvis is extremely narrow and elongated, and of such inconsiderable dimensions, that its cavity will not contain several of the organs afterwards found in it ; from which circum- stance, the protuberance of the belly, observed in the foetus and in children at term, in great measure results ; the excavation has the form of a cone, the abdominal strait being strongly inclined downwards: the sacrum is 54 FEMALE ORGANS OF GENERATlOI^, nearly flat, and so much elevated that a horizontal line diawn fvow the superior part of the pubis would pass beneath the coccyx ; the coxal bones are narrow, elongated, and nearly straight at their superior part, an^^ the cartilaginous iliac crests are not twisted. From this disposition it necessarily happens that the greatest diameter of the pelvis extends from the sacrum to the pubis. Burns declares that this form changes by degrees as the little girl advances in age: thus, the — Aiitero-posterior diameter mi'asiiies . TraiisversB diameter lae.isuiv^, . . . At 9 years. At 10 years. At 13 years. At 14 years. At IS y&ar»; 2^ inches. 2% iuclies. 314 inclies. 3 ill. 5 liues. 314 inclies. 3^ iucUos. 3% inches. 4 inches. 3% inclies. 41^ inches. [3. According to Races. ' This subject, studied by Vi-olick and Dubois, has been recently taken up by Joulin, who published an important memoir on it, in which he proves that there is nothing characteristic in the differences to be observed in the pelves of the three races, Aryan, Negro, and Mongol ; in the two latter espe- cially, the resemblance is so strong that it is impossible to distinguish them. The same author states that, contrary to what has been said, in all human races the transverse diameter of the superior strait is greater than the antero-posterior ; but that the oblique diameter of the superior strait of the pelvis of the Negress and Mongol female differs from the transverse by a few millimeters only, whilst in the Aryan female the difference amounts to a centimetre and a half. The pelves of the Negro and Mongol are, besides, less capacious than those of the white race; they have less depth, and the pubic arch is wider by several degrees.] § 8. Uses of the Pelvis. The pelvis constitutes the base of the trunk, and, according to Desor- meaux, it forms a complete ring, that may be reduced to two arches; the posterior and superior of which receives ^le whole weight of the trunk, whilst the anterior and inferior one serves as a buttress to it. The two lower extremities are attached to the lateral parts of this circle, and support, in the erect posture, all the weight of the superior part of the body. This use of the pelvis satisfactorily explains to the accoucheur the vicious forms the cavity often assumes when ossification is retarded, or when- ever any disease alters and softens the bones. Another function of the pelvis is to inclose and protect the bladder, rectum, and seminal vesicles of the male; the uterus, Fallopian tubes, and ovaries in the female. During gestation, it sustains and gives a proper direction to the womb ; and in labor, it affords a passage to the child. ARTICLE IV. OF THi; PELVIS, COVERED BY THE SOFT PARTS. It will not suffice to study the pelvis as found in the skeleton alone, for the changes produced in its form and dimensijns in the living fem^ale, by the arrangement of the soft parts, also require our special attention. OF THE PELVIS. Fig. 16. ii 11 Being continaous above with the abdomen, the great pelvis incloscs and supports the mass of the intestines, and affords points of attachment by its walls to two orders of muscles. The one destined to form the inclosure of the belly fills the large opening exhibited in front, and thus constitutes the anterior abdominal wall ; the extensibility of which, in comparison with the resistance of the posterior plane, accounts readily for the tendency of the uterus to incline forward in the advanced stage of gestation. The others, two in number, are placed in the iliac fossaj ; they are the iliacus internus, and the psoas magnus muscles, which, from being situated on the late- ral parts of the abdominal strait, change both its form and di- mensions. The first of these has radiated fibres, and occu- pies the iliac fossse ; the second descends from the sides of the lumbar vertebrse, and after hav- ing been joined to the preced- ing, is inserted into the lesser trochanter of the thigh bone. These two muscles, surrounded and confined by an aponeurosis {fascia iliaca), may be regarded as a sort of cushion, forming a convenient support to the de- veloped uterus, and destined to protect it by the elasticity of the soft parts against the shocks and concussions continually produced by locomotion. Notwithstandiag the presence of these muscles, the strait still resembles a curvilinear triangle in shape, the base, however, of the triangle being in front instead of behind, as it was in the dried pelvis ; the transverse diam- eter is diminished half an inch by their presence ; the antero-posterior one is, perhaps, a little abridged by the thickness of the vesical walls, uterus and soft parts that line the posterior face of the symphysis and anterior sur- face of the sacrum, the oblique diameters alone remaining unchanged ; the location of the rectum, however, on the left, shortens slightly the corre- sponding diameter. The modification of the transverse diameter, produced by the psoas mus- cles, is always much less when these are in a state of relaxation from the flexure of the thighs. Finally, as Baudelocque has remarked, the bis-iliac diameter is diminished in length, in proportion to the thickness of these muscles, and the antero-posterior one being more contracted, the strait be- comes more elliptic or rounded. Two muscles are also found on each side of the excavation, covering the obturator and ischiatic foramina ; namely, the obturator internus, and the pyramidales. Flamand attributes the move- Pelvis, with the soft parts seen from above. A. A section of the aorta. B. The vena cava inferior. C. The internal iliac artery, arising together with D, the ex- ternal iliac, from the primitive iliac trunk, e. External iliac vein. F. The iliacus internus. and G, the psoas magnus mus- cles. H. The rectum. I. The uterus with its appendagas. K. The bladder, the fundus of which is depressed so as to bring the womb into view. 56 FEMALE ORGANS OF GENERATION". ments of rotation, executed by the head in the pelvis, to the action of these muscles ; but the same reasons that caused us to reject the influence of the inclined planes on this process, equally deter us from entertaining the opinion of the Strasburg Professor. The pelvic cavity is still further diminished by the rectum, bladder, and cellular tissue ; more especially when the latter is loaded with fat. Consequently, the foetal head descends with more difficulty in very corpulent women than in others. The perineal strait, although open in the dried skeleton, is here occupied by a sort of contractile concave partition, which sustains the viscera of the pelvic and abdominal cavities. This floor, so to speak, is composed of two muscular planes ; the interior of which, formed by the levator ani and coccy- geal muscles, is concave above ; and the other, having its concavity below, is constituted by the sphincter ani, the transversus perinei, the ischio-cavern- ous, and the constrictor vaginre muscles. The internal pudic vessels and nerves, a large amount of cellular tissue, the skin, the pelvic aponeurosis, and an inter-muscular aponeurosis complete this floor, which, in the hour of labor, ought to become thin and distended, but which occasionally ofiers such an obstacle to the spontaneous delivery of the foetus as to require the intervention of art. The extent of the perineum, in its ordinary condition, is three inches, namely : from the point of the coccyx to the anus, there are one and three- quarter inches, and from the anus to the vulva, one and one-quax'ter inches ; but at the instant of the passage of the head through the genital fissure it becomes so distended, that the interval separating the anterior commissure from the coccyx, is increased from four to four and three-quarter inches. It must now be evident that the terminal outlet of the pelvic canal, in the pelvis, covered with its soft parts, is not at the point of the coccyx, but rather at the anterior commissure of the perineum ; in fact, the latter is so greatly distended in the last moments of labor, that its anterior border goes beyond the inferior part of the symphysis pubis, thereby prolonging very considerably the posterior wall of the pelvic excavation, and, as a conse- quence, the canal to be traversed by the fcetus. Wherefore, the direction in which the head is ultimately disengaged is not represented by the axis of the inferior strait, but by that of a plane vhich may be drawn from the lower part of the symphysis to the anterior commissure of the distended perineum. Hence, in order to form an exact idea of the line traversed by the foetus, from its entrance into the superior strait until its final exit from the vulva, it will be necessary to continue the op