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Tous les autres exemplaires originaux sont film^s en commenpant par la premidre page qui comporte une empreinte d'impression ou d'illustration et en terminant par la dernidre page qui comporte une telle empreinte. Un des symboles suivants apparaitra sur la dernidre image de cheque microfiche, selon le cas: le symbole — ^ signifie "A SUIVRE ", le symbole V signifie "FIN". Lea cartes, planches, tableaux, etc., peuvent dtre filmds d des taux de reduction diffdrents. Lorsque le document est trop grand pour dtre reproduit en un seul clichd, il est filmd d partir de Tangle supdrieur gauche, de gauche d droite, et de haut en bas, en prenant le nombre d'images ndcessaire. Les diagrammes suivants illustrent la mdthode. 1 2 3 1 2 3 4 5 6 J I ^ RESEARCHES IN FEMALE PELVIC ANATOMY \ RESEARCHES IN FEMALE PELVIC ANATOMY nv J. CLARENCE WEBSTER, B.A., M.D., M.R.C.P.Ed. ASSISTANT TO TUP. PROFESSOR OF MIDWIFKRV AND DISKARES OF WOMEN AND CILDBEN IN THE UNIVKRSITV OF F.DINRlTRcilf EDINBURGH AND LONDON: YOUNG J. PENTLAND I 892 EUINDURGH : I'UBLISIIBI) FOR TJIE ROVAI. COLLEGE OK niYSICIANS BY VOUNr, J. rKNTJ,ANl>, II TEvro ■ ilace; and 38 wi-st smitiipield, London, e.c. I I f TO PKOFESSCR A. R. SIMPSON, PRESIDENT, AND THE FELLOWS OF THE KOYAL COLLEGE OF PHYSICIANS OF EDINBURGH, IN IlECOONITION OF TIlKIll EFFORTS TO PUOMOTE SCIENTIFIO UESEAUCH IN MEDICINE, AND IN ACKNOWLEDGMENT OF THE 0ENEH0U8 ENCOORAaEMENT WHICH THE AUTHOR HAS RECEIVED PROM TIIEM, THIS WORK IS DEDICATED. PREFACE IIiTHEUTO, in the text-books, the descriptions of the anatomical changes in the pehis met with during the pucrperium have been of a very imperfect nature, and have been made from the ordinary method of post-mortem examination as well as from 2)hysical examination of the living subject. As the most important changes are those of altered relationships, it is evident that neither of these methods of study can be trusted to furnish exact information. In order to gain the most correct idea of topograpliical relationship, one must make use of the sectional method. As yet only three' cadavera have been fully in- vestigated by means of frozen sections, two of which, the one described by Barbour and the other by Stratz, had deformed pelves. The third is a five-and-a-half days case of Barbour's, in which, unfortunately, the pelvic contents were septic. I am now able, in this volume, to describe in detail the anatomical conditions found in the pelves of women who died of diseases causing no alteration in pelvic relationships, on the 1st, 2nd, 3rd, 4th, 6th, and 15th days of the pucrperium. The details have been obtained both from Sectional and Dissectional study. In each case the whole pelvis, or pelvis and abdomen, was frozen without any disturbance of the parts. Sections were made, drawn, and described, and the slabs, after soaking for a little in spirit, dissected. J Pirogoff and Legendre Imve also published two sections, but without the anatc:!iical details requisite for our in<|uiry. viii rUEFACE My chief aim hns been to observe accurately, and to deseribo witl. (a.tl.ful.K.88, the great n.a.ss of facte which have come under my obser- vation. The work of investigation has been carried out in the Laboratory of the Royal College of Physicians. The majority of the plates have been .Irawn by myself from nrturc, the rest being done by Mr. .1. T. Murray Tho photographs were made with the aid of Mr. J. H. Paterson th," Laboratory-A.ssistant. Plate. XXIII. XXIV. arc copied, with the 'kind pornussion of Dr. Savage, from his work. The Sun,n,j, Su,yicnl Patkolony and Sunjrcal Anatomy of fhc Fema:. Pdnc Organs. To the officials of the Laboratory I nm deeply indebted for the facilities granted me for the prosecution of my work : and I wish especially to acknowledge the unfailin. I CO II 78 )> 80 )i 115 11 117 r\ j SMOBtKnamvasa: KiimuiiiuiiL- mujai iii i i w RESEARCHES IN FEMALE PELVIC ANATOMY ANATOMY OF THE FEMALE PELVIS DURING PUEllPERIUM THE BEGINNING OF THE I'UERrEIUUM. Clinieal .Vote.-Tlio iiaticut cliod of heart disease live miimtus after the e.ul of the tliird ituge of hibour. Vertical Mesial Section (Pluto I.) Bony Pt'few.— The promontory of the sacrum is abnormally high in this case, and owing to che projection of the junction of tlie 1st and 2ml sacral vorteln-se, the condition of " douljle promontory " is i)roduced. Diameters : — Brim (unatomi(!id conjugate;) . . .4''' in „ (ol)stetrical conjugate) . . . 41^ Cavity . . . ' <, Outlet (sacral) „ (coccygeal) The vertical length ..f the Symphysis is 1 i i,,., and its greatest width 'i in. Utcru.i.~'n\ii uterus occupies the greater part of the true pelvis, about one-third of it being above the brim. The lengtji uf the uterus, following its curve from the os externum t(j the fundus, is about 71 in. Its cireurn" ference is 17 in. Its greatest antero-i)()sterior thickness is '61 in.— immediately below the brim. The fundus is I in. i. thickness. The anterior wall, on the whole, is slightly thinner than the posterior; the greatest thickness of the former is 1§ in. opposite the upper part of the symphysis, while that of the latter is It in. opposite the cartilage between the second and third sacral vertebra). The uterine cavity is divided in its whole extent. It measures about B 4a I 2 ANATOMY -^ Till-: FEMALE I'ELVLS «i in. Ju the upper port, for a JiHtanec of 2^ i,,., it measures from before backwards g in. ; below this for iiearly 2 iu. it measures only •<„ n, • near the lower end of this narrow j.art is seen a pouching backwards for ^, in due to a folding of the posterior wall. Below this narrow portion the cavity has a mueh greater antcro-posterior measurement than elsewhere due to the deep curved pouching in front and behind, between the body of the uterus and the cervix ; the anterior porti n is U m. deep, and the posterior ^ ui. Below this the length of the canal between the lips of the •cervix IS ,',, in. The Upper Uteiine Segment is in its upper part moulded ..n the bodies of the sacral vertebra. Its wall is j.ale grey with a pinkish tn.ge over the greater part most marked near the cavity and in the lower part. The periphery is paler than the central mass of the wall. The anterior wall differs in nppearance from the posterior ; it is paler and has fewer vessels visible ; its inner surface is smooth. The posterior wall 18 darker and contains a great many vessels (all closed) especially towards Its inner part; its inner surface is shaggy, marking the area of attachment ol the placenta for a distance of 3[; in. At a distance of about j| in. from the outer surface of the upper part of the anterior wall is seen a, row of closed venous .sinuses. They exten'-low the Hyn.pl.yMiH in lino with the vcrti.al n.rMial axin Ua Perimnm is i„ta..t. thnu-^h llal.I.y. It in 1 i„. from l,of..ro l,,.,-!.- whMs at the haso. It paHsoH upvvanlH, Rrmlimily h.....>,ninK thinnor ly ItiTtnm iH cut in... f.on, th. anun for h ,li„(„n,.., of nhout (i indu.s I-' '<« ..pp.".- part it contains a small quantity of li.p.i.l f,e,,„. ^ is ,.on,- prcBse.1 i,y tho utorus an.l its walls an, pal... Al.ov,, the cavity oxtcn.lin. Hbovc the l.rim is scon th.- ,„,.,so-r.vtun, ....n.p,.css...l 1.,........,, .ho ut..,," and tho bono. The Pentcncm .losoon.ls to forn, .1... ut,-ro-v..,si..al p.„„.h in front tho lowest point hoin.r 2 in. I,..h,w .1,.. I.mn. Tho pouch is .p.ito olosc.l. 'Pho anterior wall ..f ,hc uterus for an in-h al.ovo .1,, l.rin, is in contact with ;,, ,, fjie left of the miildle hue where its greatest antero-posterior in. The great mass of the wall is pale with a pinkish tinge ; around the cavity there is a deep pink tinge. ij I'LATK II. FiKHT Day ok I'ukiii'kiiium. Tnmvem Section. Lfl lMf.~Face of Lower Slab. (Ueiliicod liy .1,.) ". Upper nmi-gii, of Third Suciiil Vortcl.ra. b. Loft do«co,uIing lianuis of Pubor, i„,„.cdiatcly bolow Synmhyds. c. Loft Acctiibuliim. (I. Uterus. e. Utoriiio Cavity. /• Uectiini. !/. IJIiwldor. h. Ureter. i. Fold of posterior layer of Left Broad Ligament. / Broiul Ligament tissues with closed vessels comprcsstd by Ute 3. PLATt II. THE BEGINNING OF THE PVEnmulVM No oi,en vessels are seen at -,11 fl. i • '^ «*c.. half ,,„i„, c..,.a.peri J :, ft f™' "'"' "'"'"»• -'"l"^ -' .!..• «l..«e,I vc«ok ' ""•' '■""""■'■vo ,i»„„ ,o„t„i„i„„ „„„,.|j, Between tl,o„tcr,„,™ui,„i«,,ri„,,,, II ,„,, „ . '■"""" «" ""'l ••' tliili layoi- of „„,,|„ /, . „ ; ,'" "■■ '■"""'»""S "f co,„K,.,ive ^ <-o..ee„ «,e „.... J ;z: ::zr:t zr^ "-■ - ---t:;:t::::i:r;r--''"-^^ «... 1- postonor wall of ti. .ectal.nlun, ■ t Ho , " ''"" '^ '"• ''''^^' '-^""'^ it. At the latter point . ton. n ^"''''''' ^'^>-^^'- « "'■ P^^;-oa,eavit, pointing LllJT:^^ '^ -"" '" ^"^ Po«tcr.or layer of tJ.e h.oad ligan.en tL 'T" ''^'"''' ' ''' ''^ ^^"^ coverea by it. * "^^ ^^'^ '«''t""i >s .se... to 1... p,,^,^. ^'/'c ^roaj /.^>aw;e»< J.as very Jittlo ovf., f t . PC'lvis It extends 21 in. to the left ) V ^"•'"^■'"-'"^'I' Jou.r i„ the '■'•* -' oonncetive ti.ue of t ' ,h ek^'^ '''T' '''"'' ^''^' 1'"'- 'O' 27ie Rectum lies on tho Jnff .> ^i , , clo,c.,. '^^'"'•' - -" --W..! tl.e .„.„„, ,,„,.„^ •«"l Iig,„„™,. ' ™ '""'° ™'« foWings of the „,or„. am ANATOMY OF TIFE FEMALK PELVIS I Vkrtical Obliquk Section (Pliito III.) Tins section passes at right angles to tlic plane of tl.e brim throu^li the . .«m .mme,liately in front of the saero-iliac joint on the right side, and on tlie left side through the ilio-pectineal eminence. The coccyx is divided obliquely at the junction of its second and third verteb^t^ This section It will be observed, passes almost through the plane of the right-oblique diameter of the pelvis. The Uterus ocnipies the greater part of the pelvic cavity. The creat mass of the body is pale with a pinkish tinge-the left half is paler Uian the right; the latter being the site of the placental attachment. In con- trast with the smooth firm mass of the upper part of the body is noticed the spongy nature of the lower part, especially on the left side The lower uterine segment and cervix are of a deep reddish-purple colour The width of the body, at the brim level, is 4 in. ; opposite the middle of the acetabulum 3f in. Its highest point is on the ri^ht of the middle line, If in. above the brim ; in the middle line it Ts 1 o above, n in. to the left it is 1/, in. above, and then slopes sud- denly down, until at the brim it is only J- in. f,om the bone. On th- nglit. 1 ,\, in. from the mid.lle line, it also slopes down, and at the level of the brim it is I in. from the side wall of the pelvis, the space being occupied by the greatly compressed broad ligament and tissues lining the pelvic wall. The greatest vertical height is 4^ in. at a point If in. to the right of the middle line. The thickness of the wall measures at the fundus (the thinnest part) li; u..; at the level of the brim on the left side, 2^ in.; opposite the middle of the acetabulum on the left side, 2,1 in. ; an inch and a quarter belov the brim, ll in. ; at the brim on the right side, l,v j,, . opposite the mid.lle of the acetabulum on the right side, Ij in., and opposite the left extremity of the middle division of the uterine cavity, 1 in. The cervix, a quarter of an inch to the right' of the middle line IS I m. thick ; towards the right it continues of this thickness for a in ' when the wall of the uterus suddenly thins to ,^, in. ; towards its left' side f PLATE III. FiUHT Day of Pukhpeuium. Veiiiail Oblique Section.— Face of Posterior Slab. (Reduced by J.) The Scctiou i. .uade at right a„yle» to the brim, passing almost tlirough th, plane of the Right Oblique Diameter. a. Right Ilium immediately in front of Sacroiliac Synchondrosis. b. Left llio-pcctineal eminence. c. Junction of Second and Thiril Coccygeal Vertebiu". d. Uterus. c. Uterine Cavity. /. Cervi-Y. ])earance, the striio passing from side to side. The vaginal slit is bow-shaped, the concavity at each side being directed upwards. The Rectum is behind the vagina, and is compressed fnjm before back- wards. It lies almost entirely on the left of the middle line, its inner third lying in front of the coccyx. if 8 ANATOMY UF Till'; FIIMALK I'KLVIS The hivad Uijamcnt'i arc greatly coniprcsHcd between the uterus anil the pelvic wall, the vessels bciiij^ closed. The J'erituHcuvi on the right side dcscciicls nearly to the brim, and on the left I in. below it. The Ureter on the right wide is •; in. below the brim, and ,'•',. in. from the bony wall ; on the left side it is 2|- in. below the brim and ^ in. from the bone. Tiiii: Specimen as a Wholk (Plate XVI.) The Left Ovary lies between the left side of the uterus and the pelvic wall. It is not at all visible on looking into the pelvis from above. Its ui)per surface rests against the uterus and looks forwards, inwards and only slightly upwards. The lower surface rests u2)on the rectum, upon the pelvic wall adjacent to it, and also upon a piece of the broad ligament which is folded on itself out.;ide the attachment of the ovary. The posterior free border lies against the left edge of the rectum. The lowest l)art of the ovary is the uterine end. It joins the wall of the uterus directly, just behind the reflection of the posterior layer of the broad ligament at a jtoint 2.| in. to the left of the vertical mesial plane of the body, I ,',; in. behind the jHjstcrior margin of the left acetabulum, and |^,., in. behind a plane passing through the anterior superior iliiic spines at right angles to tin; plane of the brim. The ovarian ligament is .spread out on the uterine ^vall, a little below the brim level. The outer end of the ovary lies jibove, behind ai'd internal to the inner end. The greatest part of the ovary lies above the brim. 'The Lift Fallopian Tube arises from the side of the uterus just above the brim nearly an inch behind the anterior surface. It passes at first backwards and downwards for half-an-ineh, then upwards and outwards for the same distance, and then Ixu^kwards and inwards above the ovary until it reaches the fold between the rectum and sigmoid flexure, where the fimbriated end stops touching both these structures as well as the ovary. The outer part of the tube thus lies in the iliac fossa in a space formed externally by the parietal peritoneum; posteriorly by the junction of the rectum and .sigmoid flexure, and internally by the uterine wall. It thus TIIK I!K(J1NNIN<; (iK TIIK IMfKI.'I'KIMUM q .•..niplftely covers llio uvmy, i.,cvcutin- it ri..,,, hduf. „oou lioiu ahovi.. The finibnated on.l lies 2| in. lumteriur to a i.iai... im«.siMjr tl.rouul, the anterior 8upeii..r iliac Hpincs ut rifrht anglcH to the briia, un.l i;j in. Ih-Iuw tlu; highest ,.H.t <.f the iliHc ercst. It in the highest part cf the tul.e. Tin: Left liroad LUjamnd aii,se.s ,ih a ri.lge of peritoneum in connection with mesentery of the signioi.l IJexure in the left iliac fo.ssa. It runs downwards and forwards towards the l.rini, its outer surface lying against the parietal peritoneum. About i in.^h below the brim the layers separate widely, the posterior passing o syn.pl.yHiH iJ not quite imnillel with the upper part of the sacrum, but diverges from above •lownwards. Tlie sacrum and coccyx measure G^ in. in Icngtii ; thoy form together a well-marked curve forwards. Diameters : — Brim (anatomical). . . . 5 in „ (ol)stctrical) . . . .4^' Cavity • . . . Outlet (sacral) . . . . o „ (coccygeal) . . . • 41 „ The pelvic Hoor projection measures 2{5 in. The umbilicus is opposite the junction of the third and fourth lumbar vertebra). Uterus.— The uterus is divided in its whole length. It occupies the great part of the pelvis. The length of the whole uterus is 7 in. » „ body is about 4| ,, i» » cervix is about 2^ „ » ., uterine cavity is GJ ,, Tlie highest point of the fundus above the brim is 1| in. The greatest width of the body is 3| in. at a point 2^ in. below the fundus, oppc ;te the symphysis and first sacral vertebra. In the upper half of the body tho anterior wall is slightly thinner than the posterior ; in the lower half the *8 »> 5i „ I'LATE IV. Second Day ok I'ukiii'kuium. Verlkul Mesial Section. (Reduced by J.) a. Promontory. b. Sympliysis Pubis. c. Fundus Utori. (I. Cavity of Uterus. e. Os Extorn\un. /. Kectum. ff. Pouch of Douglas. Ii. Utcro-Vcsical Poucii. i. Bladder. j. Urethral Orifice. ! M B> i THE SLCOND DAY OF THE PUEliPERIUM 11 posterior is tliinncr than the anterior. The fundus is | in. thick, being thinner than any other part '^f the liody save the lower part of the posterior wall. The anterior wall in its thickest portion measures if in. ; it scarcely diminishes towards the lower end, so that just above the on internum it measures 1| in. The thickest part of the posterior wall is 2 in., below this point it gradually diminishes until just above the o,s' internum it is 2 in. The body is flexed forwards markedly on the cervix at less than a right angle, the point of flexion being the level of the os internum. There is no well-marked line of division between the body and the cervix. No lower uterine segment can be distinguished. The body of the uterus is of solid consistence and of a pink purplish colour. Next the cavity both walls are for a short distance darkly blood- stained. Numerous vessels are seen nearly closed. Around the fundus, about f in. from the peritoneal covering, is seen a row of nearly closed sinuses, which can be traced for a short distance on both anterior and posterior walls. Outside this layer is seen a longitudinally striated band of muscle, becoming wider as it passes downwards, and gradually disappearing in the coarser, more network-like, structure of the lower part of the body. Tlie Cervix has a somewhat spongy appearance, especially in the anterior wall, being more striated longitudinally. As a whole it is more deeply stained than the body, especially in its lowest part. The anterior wall is thicker than the posterior ; the os externum is 3;|; in. below the brim and 1^ in. above the coccygeal outlet. The Cavity of the uterus from the os externum passes upwards and backwards almost parallel with the brim as far as the os internum ; it then passes forwards almost at right angles to the vertical axis of the abdomen, near the fundus curving downwards and forwards. The wall is rougher over the placental area than in any other part. A thin blood- clot lies in the upper part of the cavity. 'IMic distance of the uterus from the pelvic wall : — 1. Behind the upper part of the sympliysis 2. At the promontory .... 3. At the OS internum .... H in- \ T(y )' II' I 12 ANATOMY OF THE FEMALE PELVIS Tlie Vagina is a closed slit, and is greatly elongated, being almost 5 in. Its walls are congested. The anterior fornix is jj in. deep, the posterior, |J in. The Perineum is intact, rather flaljliy, and congested. The lower part of the pubic segmont is greatly congested. The Bladder lies compressed from above by the uterus. It is empty. The walls average § in. in thickness. The upper surface is slightly sinuous. The anterior wall bulges downwards in front of the urethra. The cavity is >- shaped, the anterior limb being much longer than the posterior, and almost in line with it. Its apex lies at the junction of the upper fourth and lower three-fourths of the symphysis. The junction of the urethra and bladder is !]•? in. below the In-im and just above the sacral outlet. The walls are pinkish brown, the anterior wall being somewhat con- gested. The urethra is If in. long, and curves from al)Ove downwards and forwards as a wavy slit. There is a thin band of extra -peritoneal fat and connective tissue between the bladder and the back of the symphysis ; behind the lower part of the latter it becomes triangular in shape. TJie Eectum is divided from the anus as far as the brim. The cavity is opened in several places. The anus is directed downwards and back- wards, not quite at right angles to the brim conjugate. It was closed. The opening seen in the section was made by a bit of cotton wool used to distend it. The cavity is closed save in tue lower part. Its wallj are of a dark greyish-green colour, the connective tissue outside them being of a pinkish tinge. The Peritoneum descends in front of the uterus to form the utero- vesical pouch, the bottom of tne latter being 2^ in. below the brim. The pouch is empty and closed The anterior surface of the uterus is in contact with the upper surface of the bladder, and above that organ with the peritoneum of the anterior abdominal wall as high as the middle of the fundus, where the utf rine wall comes into relation with intestines — both great and small — is far back as the promontory. The peritoneum descends behind the uterus to form the pouch of I THE SECOND DAY OF THE PUERPEKIUM 13 Doughis, the lowest point of which is 4 in. below the brim. The pouch is closed and empty, the uterus as high as the brim compressing the rectum against the posterior wall of the pelvis. Transverse Section (Plate V.) This section passes through the middle of the symphysis, through tlic 1st sacral vertebra and through the acetabula. The section is at a slightly higher level on the left than on the right side. The litems is rounded, and occupies the greater part of the pelvic cavity, the extra-uterine tissues being compressed between its outer surface and the bony wall of the pelvis. The colour of the uterus is darker than in the spocimo" ct the beginning of the puerperium or in that at the end of third day. The central part of the wall is dark pink-brown. Towards each side it is more deejily coloured red-purple, many partly opened vessels being seen containing blood. Near the broad ligament several large sinuses are seen nearly closed. In the anterior and posterior parts of the wall a few are also seen about f in.-J in. from the peritoneal surface; internal to these, however, in the rest of the wall no large sinuses arc seen. The cavity is a sigmoid slit running transversely ; its right extremity contains a bit of clot. It is situated nearer the posterior than the anterior surface of the uterus, and nearer the right than the left side. (This wall is cut slightly obliquely, however.) From its right end to the side of the uterus the thickness is 1 {'^^ in. Do. left do. do. 13 Extra-Utenne Measurements : — 1. From the uterus to the bony wall of the pelvis in its middle line in front, the thickness measures 1 in. 2. From the uterus to the bony wall of the pelvis in the middle line behind, its thickness measures § in. 3. From the uterus to the bony wall of the pelvis opposite both acetabula, its thickness measui-es ]; in. 1 J 14 ANATOMY OF THE FEMALE PELVIS 4. From the uterus to the bony wall of the pelvis opposite the right sacro-iliac joint its thickness measures ^'',y in. 5. From the uterus to the bony wall of the pelvis opposite the left sacro-iliac joint its thickness measures f in. The Rectum lies compressed between the posterior surface of the uterus and the sacrum. Its cavity, a mere slit, is l^V ii^- i" width, almost the whole of which is on the right of the middle line. Passing to the left is seen the mesentery of the rectum continuous with the extra-peritoneal tissues. The Broad Ligaments at this level are practically obliterated. Their peritoneal layers are widely separated, their tissue being compressed between the uterus and the wall of the pelvis. The mass of the contracted uterus appears to extend on each side as far as the side wall of the pelvis, thereby separating the peritoneal layers of the ligaments, so that they can scarcely be said to have any lateral extent whatever, being reflected from the uterus to the side walls directly. On the right side of the pelvis the antero- posterior measurement between the layers is 1^ in., and on the loft side 1 in. The layers on the right side are reflected in a plane a little anterior to the reflection of those on the left side. The extra-uterine tissues are considerably blood- stained, several vessels being seen partly distended with blood. Tlie Ureters are cut across, lying behind the parietal peritoneum. The right one is immediately in front of, and in line with, the right sacro-iliac joint ; the left one is further back, being \ in. nearer the middle of the sacrum than the right ureter. The Specimen as a Whole (Plate VI.) The intestines and great omentum are in relation to the upper surface of the uterus. The caput ca3cum rests upon the outer part of the fundus on the right side, reaching inwards to within \ in. of the middle line ; it also rests upon the ovary and Fallopian tube of the same side, both the uterus and appendages being moulded by it, though it is only distended with flatus. PLATE V. Second Day of Pueui'Eiuum. Tmmversc Section. — Ftice of Lower Slab. (Reduced by J.) a. P'irst Sacral Vertebra. b. Symphysis Pubis. c. Uterus. (I. Uterine Cavity. e. Compressed Broad Ligament. /. Kectum. g. Ureter. h. Peritoneum. i. Bladder. m m' PLATE V T ( 4 h f I n H THK SKCONI) DAV OF TlIK I'UKKI'KlilUM ijj The vern.ii;,n.i appeiulix licH uguiimt ti.e ij{,,k ,• part of the rif-ht l.n.a.l U^aumM (iiifiUKlihulo-pelvic) and iutornul to it; its tip tou.l.cs the [)ostcnor extremity of the ovuiy. The raiclcUe purt of the fu.ulus is covered l,y the tmnsverse coh„, and omentum, while on the left i« found a fohl of the si^nnoid (levure The «mall mtestinos only touch a small portion of the posterior wall of the uterus above the hri.u helnnd the j^reat omentum and transverse colon. ' At the i.romontory the return curves to the left for two inchc completely fillin. up the space hetween the left ovary, nterus. and posterior pelvic wall, and then i.asses upwards. I.eeoming the sigmoid (lexun- The flight Ovary lies packed in a space between the sloping .Ld.t BKle of the uterus and the side wall of the pelvis above the b.im Us ong axis IS directed from before backwards, inwards, and slightly upwards Its most anterior point is }, i„. in front of n plane passing throu-di the anterior superior iliac spines at right angles to the brim, and is 1 1, in from the vertical mesial plane of the pelvis; it is attached to the' side of the uterus at a point 1/, in. behind the attachment of the ri.dit Salopian tube. The posterior end is 2 in. from the vertical mesial pkne 01 the pelvis. The surfaces of the ovary look inwards and outwards, the normal under surface being inwards. The inner surface lies ngninst the uterus just below the junction of the fundus with its posterior and lateral walls Ihe outer surface is more irregular, being moulded by the structures lyi„. ag|iinst It ; these structures are from above downwards the caput ca)cum coll, the vermiform appendix, the right infundibulo -pelvic ligament the right Fallopian tube, and the right broad ligament. The highest point of the ovary is ^ in. above the brim; the lowest IS just above the brim. The Eight Fallopian Tube arises from the side of the uterus close to the anterior wall, slightly below the brim and 2 in. below the highest point of the fundus. It bends sharply upwards, and curves backwards, upwards and then outwards for half-an-inch. It then turns sharply inwards and is directed backwards, lying partly in front of and partly outside the ovary ^^ '\ is ■ fi i IG ANATOMY OF TIIK Vm\Ll] PKLVIS Kxt...nully it i. in rolatiun to tho pelvic wall, wl.ilo ahovo it i« Hattouecl l.y the c(4mt cifcum coli. •' ™». w. „ tl,„ „„. f„« „^ „ ,,„„„ , , . , ,.„,„ ,„„ ^^^^. ^,^, __P^.^, ^ f ,c pclv,. ,t ,« f„,„„,,, „„, »|i,,,,uy ,,„„,„„,„,. ,„, ,(i„'„^,, ".l«o i ,„ ,g|,, „,Kl .:,„„ ,.„„„,;„,, ,,„ ,„„„ ,,„^„,, «yc.rp„»e» orwanl,, „l„,„,t parnllel „itl, tl,„ Win,, archo. over the rou,,,! l.gHracnt ami tl,c„ p,»,™ t„ .!,„ U„.M«. „„,1 anterior pelvic wall. The™ .. t n, for,n„., W,in.I tho roun.I liga,„ent a «,uee.-»hapecl ,,o„„h in whieh .<^ the orumpleJ upper looae portion of the ligament. The posterior layer helow the ovary p„.,,e, ,Iownw„r,k an.l .lightly backward, to enter into the formation of the pouch of Doughs. The distance between the diver.i„„ aj-er, ha, been well ,how„ in the transverse section. The part of'tl,: l.gamout above the attachn.ent of the ovary is of much the same thickness as a. tho non-pregnant woman, and is freely movable. It is crun.pled up d he. paeked between the uterus and pelvic wall. Several narrow iold.ng, of the pentoncum are seen below the level of the ovary where the redeefon takes place from the uterus to the wall of the pelvis /y.« Ihala Jlo,,ud Li.j„„,ml starts from the uterus at the junction of its » Wr an lateral walls. It passes outwards in line with thj anterior w ;r, -z :':,."""• -^ "™ '- ^-^-^ - -- -«.» the ncJii!,/u lru.-o.S„c,ul Ligament arises from the uterus about l i„ external to the vertical mesial plane of the pelvis, and opposite the uppe^ part of the . ,rd sacral vertebra. It passes upwards aui outwards to h s.de wall, .^length being not .ore than J in., and it is folded betwe the uterus and the jjelvic wall. The Left Ovary has not the same relations to the left half of the pelvis tliat the right ovary had to the right half. The most posterior part of the right ovary was the free ed^e. The most posterior part of the left ovary is its junetion with the broad ligament; its free edge is turned forwards against the left Fallopian tube PLATE VI. Second Day of tiik Puerpkiuum. Flu. 1.— Left half of Pelvis from nbovo. (Uoihiccd.) o. LivBt Lumbar Vertebra. h. Symphysis Pubis. c. Fundus Uteri. (/. Appondiigos. e. Sigmoid Flexure. Fig. 2.~Kight half of Pelvis seen from above. (Ucduccd.) ,(. Liist Lumbar Vertebra. h. Fundub Uteri. c. Appendages. I !■ eh PLATE VI. I p p i x m if ri ^i jk i w a aiirtw^^ - THE SKCOND DAY OF THE PUEUPERIURI 17 Tho guueial direction of the long axis, us viewed from above, i.s in a line passing from before backwards, outwards, and upwards. The normal upper surface is turned downward and lies against the posterior layer of the left broad ligament, between the Fallopian tube and ovary. It looks downwards, outwards, and forwards. The normal upper surface looks ujjwards as a whole. Its anterior third resting against the uterus looks upwards; the posterior two-thirds looks upwards, inwards, and backwards, and is in relation to a fold of the sigmoid flexure, being, together with an adjacent part of the uterus, covered by it and moulded by the (ippendices ejnjdoica: The whole ovary is somewhat lower than that of the right side, and also a little posterior to it. The inner end is attached to the uterus iJ- in. behind tho left Fallopian tube, as was the case with the right ovary. The Left Fallopian Tube arises from the junction of the anterior and left lateral walls of the uterus at a point in the pelvis ^ in. behind the origin of the right tube. It passes backwards for J in. lying against the uterus, then curves upwards, backwards, and outwards against the free border of the forward-turned ovary, and finally pi^sses outwards, lying on the peritoneum of the iliac fossa external to the mesentery of the sigmoid flexure. On the right side the fimbriated end of the tube lay in front of the ovary against the upper surface of the uterus. The Left Broad Ligament arises in the iliac fossa under the sigmoid flexure, being continuous with the mesentery of the sigmoid flexure. It passes downwards, forwards, and inwards towards the uterus. The free part above the attachment of the ovary is not crumpled as on the other side. Its anterior surface lies against the pelvic wall, its posterior against the ovary and sigmoid flexure. Below the ovary the posterior layer passes directly downwards to enter into the formation of the pouch of Douglas. The anterior layer descends a little lower than on the right side before turning forwards to curve over the round ligament, and then to pass forwards over the bladder and to the wall of the pelvis. The Left Round Ligament arises from the uterus close to the anterior D 18 ANATOMY OF THE FEMALE PELVIS surface under the inner end of the tube, on a iiluue in the pelvis posterior to the origin of the right round ligament, and a little lower. It passes directly upwards, being packed between the uterus and the pelvic wall. The Left Utero-Sacral Liijament arises from the uterus nearly opposite the lower edge of the third sacral vertebra about 1^ in. external to the vertical mesial plane of the pelvis. It passes upwards and outwards for about an inch. It is somewhat on the stretch and is packed between the uterus and pelvic wall. The Peritoneum covering the uterus near the reflection of the broad ligament of both sides is thrown into a great number of folds running in a vertical direction. The Bladder lies slightly more in the left than in the right half of the pelvis. It THE THIRD DAY OF THE PUERPERIUM Clinical Note. — Tlie patient died early on the third day after dilivery, of Ac\ite Yellow Atrophy. She was near full time. r,L 4_3 in. 4A 4f „ Vertical Mesial Section (Plate VII.) Bony Pelvis. — The pelvis is above the normal size, the conjugate of the brim being espscially increased. Diameters : — Brim (anatomical conjugate) „ (obstetrical conjugate) . Cavity (antero-posterior diameter) . Outlet (sacral conjugate) ,, (coccygeal conjugate) There is a slight projection of the junction of the upper two sacral vertebrae. The vertical length of the symphysis is If in. and its greatest thickness f in. The length of the sacro-coccygeal curve is 6|- in. Uterus. — The uterus is divided in its whole length. It is somewhat pear-shaped, anteflexed, and occupying a large part of the pelvic cavity. llie Body is about at right angles to the inlet, the fundus being the highest part — 1^^^. above the anatomical conjugate of the brim. The lowest part is the posterior cervical wall which is 4g in. below the brim. The length of the whole uterus (Fundus to 0. E.) = 6i| in. » ,. body =4f „ „ „ cervix =2 „ „ ,, uterine cavity = 5f ,, The greatest antero-posterior thickness is 3^^^ in. about an inch below the brim. The fundus measures nearly an inch in thickness, being the thinnest part of the body-wall. The anterior wall is thicker than the \ I i Ir- 20 ANATOMY OF TIIK FEMALE PELVIS 99' ^ ! posterior, the thickest part of the former is 1| in. and of the latter 1^ in. The anterior wall passes more abruptly into the cervix ; the posterior thins out {Tradually into it. There ir. no appearance of a retraction-ring nor of a lower uterine segment. The posterior wall of the cervix is thinner than the anterior (? partly due to pressure). The body has a solid appearance, and is of a dark pinkish yellowish grey in greater part. The periphery is of a darker shade. Around the upper part of the cavity the body wall is blood-stained. In the walls several closed vessels can be distinguished. There is a row around the periphery f in. from the peritoneal surface. Around the fundus, however, the blood-stained area and wall adjacent to it has a spongy appearance due to the numerous vessels in it (placental area). The Cervix is more deeply congested than the body. It is of coarser texture also. The arrangement of the muscular fibres cannot be made out with the naked eye. Around the periphery is seen a longitudinally striated appearance. This is seen also somewhat in the cervix. The OS extermim is 3. J in. below the brim and just above the outlet. The cavity is a closed slit save near the fundus, where there is a small space containing blood-clot. Its direction from the os externum is upwards and backwards, aud then upwards and forwards, the concavity looking to the front. Relations.— Behind the uterus are the rectum, meso-rectum, and sigmoid flexure ; in front, the bladder and abdominal wall ; above, the intestines. The part nearest the sacrum is that opposite the junction of the upper two sacral vcrtebrjB, the distance being ^s in. Its point nearest to the symphysis is just behind the upper part, the distance being f in. Bladder.— The bladder is in a partly contracted condition, and lies pressed on by the body of the uterus. The wall averages ^V in. in thickness. It is of a greyish-pink colou; the inner aspect being irregular in outline. Its upper limit is ^\ in. below brim conjugate; its lower is a little above the outlet. The cavity is nearly empty ; it does not form a >- with the urethra, but is oblong, the length being l| in., and tlic width ■- I i, in. i PLATE VII. Third Day of Puerperium. , Vertical Mesial Sectim. (Reduced by J.) a. Promontory. b. Symphysis Pubis. c. Uterus. d. Cavity of Uterus. e. Bladder. /. Os Externum. g. Utero- Vesical Pouch. h. Rectum. i. Vagina. \ w w 1 PLATE VII \ eS^-J*^— .i../-ffV' Il in 1 > If I ( THE THIIil) DAY OF TIIK I'UEIU'KUIUM 21 » The upper surfiice ia stmiglit iind at riglit angles to the brim, being in close rchvtion to the uterus ; anteriorly there is a thin layer of fat under the peritoneum. The anterior wall is curved and in relation to the retro -pubic fat. The posterior surface is attached to the cervix by rather loose connective tissue which appears compact from the pressure of the uterus. The Urethra joins the bladder at a point 24 in. below the brim. It runs downwards and forwards, being slightly sigmoid-sliapcd, ending \ in. in front of the vertical axis of the symphysiH, f in. below the conjugate of the outlet. Its length is \,\ in. It is about parallel with the brim conjugate. Faf/ma.— The vagina is a closed slit in its upper part, but is gaping below. Its anterior wall is about 2L in. in length, and its posterior 2% in. The latter wall below the anterior margin of the cervix bends backwards on itself. Ihe Perineal Body measures 1| in. vertically, and % in. across the basf . The 7?ec- sliapcd, the posterior limb being greatly obliterated by pressure from alwve. The upper surface is flat, being in close relation to the lower part of the anterior wall of the body of the uterus ; an inch and a quarter from the anterior extremity there is a sharp folding inwards of the upper wall. The apex of the organ is immediately below the middle of the J i TIIK FOUUTII DAY OF THK I'UERrEUlUM 90 syniphysiH pubiH. Its junction with tho urethra is | in. l)clow the outlet. (About onc-hnlf tho whole body lies behind it.) The wull has n yellowish -Ijrown simngy iippcarancc and is somewhat blood-stained at the base. The Urethra is markedly sif^nuyid-Hha[)od, being 1 \ in. in lenfrth. There is a thin band of (lonncctive tissue and fat Iteliind the upper part of the symphysis, continuous above with the extra-peritoneal con- nective tissue of the abdominal wall and, below, witli the bladder behind the lower part of the symphysis. That part above the bladder is bloodless, that below is deeply congested, as is the adjoining part of the base of the bladder. The thickness of tissue from the lower margin of the sub-pubic ligament to the vagina in line with the vertical axis of the pidtes is l,^ in. The Rectum is divided for f>\ in. Its cavity, which is empty, is exposed in four places, the highest part seen being opposite the junction of the 2nd and 3rd sacral vertebra); above this point is seen its mesentery. The walls arc greenish-brown, all the vessels in connection with the tissue surrounding them being closed. The anus is directed downwards and backwards, not quite at a right angle to the conjugate of the brim. It was quite closed. (The openino' seen in the section was due to a small piece of cotton -wool being placed in it before freezing.) The Peritoneum descends in front of the uterus for 2| in. below tlie brim. The utero-vesical pouch is closed, and above the bladder the anterior wall of the uterus is in contact with the peritoneum covcrino- the back of the symphysis and the anterior abdominal wall, no intestines lying between. Behind, the peritoneum descends to form the pouch of Douo-las, the lowest point of which is 4 in, below the brim, nearly as low as the outlet. The pouch is closed, the posterior wall of the uterus being in relation to the posterior wall of the pelvis and to the rectum. The fundus is in relation to the intestine. n n I' W I 30 ANAT'^MY OF THE FEMALE PELVIS TRANSViiRSE Section (Plate X.) This section passes through tlic middle of the symphysis in front, and through the junction of the 1st and 2nd sacral vertebra) behind, and through the acetabula on the sides. The Uterus occupies the great part of the cavity of the pelvis. Its greatest transverse measurement is 4;[ in., its greatest antoro-posteriv-ir being 3^ in., immediiitely to the right of the middle line. In structure it appears firm and compact, tlio surface having a smooth appearance. It is around the cavity deeply blood-stained, elsewhere of a pale yellowish-grey colour with a pinkish tinge here and there. The periphery is darker than the rest of the pale area. Several sinuses are seen firmly closed and containing no blood. The cavity is a transverse slit lj| in. wide, situated rather nearer the anterior than the posterior surface of the uterus and slightly sinuous from side to side. Its walls are smooth and there is a small quantity of blood- clot lying between them. The general direction of the cavity from side to side is almost in line with the transverse diameter of the pelvis, so that the uterus can scarcely be said to have any rotation ; if anything, the left side is slightly turned towards the back. The thickness of the wall is about the same on each side, beinjr 11 in. The extra-uterine tissues are compressed between the uterus and the pelvic wall, and are thus rendered nearly bloodless. The distance between the uterus and pelvic wall varies in different places : — a. In the middle line in front h. „ „ behind c. Opposite the right sacro-iliac joint d. „ left ,, e. II middle of the right acetab. / .. ,, left , The Rectum lies entirely on the right of the middle lipe. compressi, ' from Ixfore backwards so that its cavity is a mere transverse it is fc in. I i) " 1(5 ., A .. -i die lipe. Its walls J PLATE X. Fourth Day oi' I'ukiu'Kiiium. Transverse Svclion. — Face of Lower Slid). (Reduced l)y \.) a. TTpper part of Second Sacral Vertebra. h. Middle of Symphysis jHibis. c. Siicro-Iliac Synchondrosis. (/. Uterus. ('. I'eritoneuni. /. Uretci'. , IMAGE EVALUATION TEST TARGET (MT-S) ^ A // «• .,j! A < V, ^< f/. 1.0 j.l ^m iiM 1^ 1^ 1 2.2 1.8 ml 1.25 1.4 1.6 ^ 6" - ► "cr-l > > y^ ^ >y PhotDgrapliic Sciences Corporation 33 WEST MAIN STREET WEBSTER, N.Y. 14SB0 (716) 872-4503 [:- shape, the anterior limb being 2« in. and the posterior 1^ in. in length. Urethm.-Tho Urethra is H in. in length and is signioid-shaped Its junction with the bladder takes place at a point 2^ in. below the conjugate of the brim. The external orifice is situated 1 in. below the symphysis. 1- in. anterior to its vertical mesial axis. Jiectum. ~Tho rectum is cut in three parts. The lower extends from- the anus up^'ard3 and backwards as far as the sacro-coccygeal junction ; it is 31 in. in Lngth and is filled with greenish-yellow faeces. The middle poMion is oval shaped and lies opposite the lower two sacral vertebiv^ bcinc. partly distended with ft^ces. Between it and the lower portion is seen a = thin bridge of the wall tissue. In the upper portion the walls are nearly 111 apposition ; it lies opposite the 2nd and 3rd sacral vertebra3 and is continuous above with its mesentery. The Anus is nearly closed. It looks downwards and backwards. It is at right angles to a line joining .h ) top of the .symphysis with the junction of the uppox two sacral vertebno. and also to the vagina. Pent07ieum.-Tho lowest part of the utero-vesical pouch as regards the conjugate of the brim is the point of refiection of the peritoneum from the J THE SIXTH DAY OF THE I'UEUl'EIilUM 37 Uterus to the l.huMcr ; it is 2^ below. As rcgiirds the erc(!t posture, how- ever, tlie lowest part is the upper surface of the bladder, a short distance behind the lower part of the symphysis. The lower part of the pou( h of Douglas is 3^ in. below the brim conjugate. Hotli pouches are conii.letdy closed. The rcHection of the i)€ritoncuni on to the anterior abdominal wall takes place at the level of the co/ijugate of tlie brim, though, as regards the erect posture, at a point 'I in. al)ove the 8ymphy,sis. Cotmective tissiw, etc.— Jhhmd the lower end of the symi)hy.sis pubis is a well-marked triangular pad of fat, loose in texture and containing several partly fdled venous sinuses. A thin layer of fascia and fat passes from it behind the .symphysis to join a large mass of retro -peritoneal fat and connective tissue above. The anteiior wall of the bladder is intimately connected with this tissue. Behind the bladder are what appear to be solid tissues connecting that organ with the cervi.x. This appearance is due to its compression by the body of the uterus ; in reality it is loose in texture. The urethra and the lower bladder wall behind it are finnly joined to the anterior vaginal wall. The perineum and rectal wall are firndy united to the posterior wall as far up as a point | in. below the pouc^h of Douglas ; above this the connection is somewhat looser. The rectum appears in close union with the fiit and connective tissue behind it. The ano-coccygeal body is a well- marked mass measuring 2j in. from before backwards and IjJ in. in its greatest vortical thickness. f Coronal Section A (I'late XIII.) T'lis section is made immediately behind the symj.hysis, just sh.-.ving the lower part of the posterior surface. (The drawing is that of the anterior face of the posterior slab.> ) The rami of the pubic bones are cut anterior to the obturator foramen. Uterus.— A. portion of the right half of the fundus is seen as it bulges forwards igainst the bladder. Bladder.~Thc anterior limb has been divided. The anterior wall > In all tlie Coronal Sections the face of the posterior slab lia.s Ijeen drawn and described. i LJI 38 ANATOMY OF THE FEMALE PELVIS is cut through obliquely behind the lower part of the 8yni[)hy8is. It ia closely joined to the pubic bonea aa high as the brim. Above the brim it passes into the posterior wall which runs transversely for 2.1 in. The inner surface of the latter wall is seen on the left of the uterus, while Lelow the uterus it is cut across as it lies .igainst the anterior bladder wall. In the right half of the section, therefore, the bladder cavity is a mere slit, while in the left half it appears somewhat pear-shaped, a small quantity of urine being in the left corner. Above the i)ladder wall is seen the suprapubic retro -peritoneal fat with which it is continuous. Urethra. — It is seen f in. below the lowermost portion of the bladder cavity. It.'i wall is transversely oval-shaped, being of a pale Hesh colour. Above it is attached to the retro -pubic connective tissue and fat, and below to the v ginal wall. Vagina. — The vagiuti is divided near its lower end. Its vertical measurement is greater than the transverse. The walls are seen to be greatly folded. Surrounding it on each side is erectile tissue from which the sphincter vaginte cannot be distinguished. Extending in frtmi the rami is seen, on each aide, a thin fleshy mass. These arc the erectores clitoridis. Connective tissue, etc. — The retro-pubic tissue is seen above the urethra. It is of consideraljle extent and contains several filled venous sinuses. In the upper part two denser portions can be made out, viz. tht anterior true ligaments of ohe bladder. The retro-pubic tissue is closely united with the bones at the sides; the junction of the bladder with the bones being less firm. Coronal Section B (Plate XIII.) Thi.'' section passes through a plane posterior to section A, not quite parallel to it. It is | in. behind the latter at the brim, but f in. behind it at the perineum. It passes through the obturator foramen on each side in front of the acetabulum. Width of both inlet and outlet cut across is about 3^ in. Uterus. — The uterus lies partly above but mainly below the brim. l'-) PLATE XIII. Six'iJi Day uv I'ukui'kuium. Flo. 1. Coronal Sedkm A. — Fiice of Posterior Slab. (RediKed by .',.) a. Ramus of I'wljos iniinodiatoly liuliiiid Sympliysis. b. Kight half of l-'imdus Utcii. c. Bladder cavity. iHMruii(;c of tin; hotly riHcmlihs tlmt hccii in tho other (Mdftiiiil HcctioJiH, except thiit the anterior wall is dividt'tl near the lower end of tilt! phit-eiital area antl hIiowh very few vesselH. Ttiwanls the ri^dit hroail ligament several veHnelH r.re .seen, partly lilltMl vith hhnjtl ; t»n the rij;ht witle u few cluHtftl ones are Heeii. Tlie Ci-i'vix w cut olilitiuely. it i« tlarker in coluur antl coarser in texture than the body. I • somewhat conipresHed from helow anu the left Ity the rectum, so thi't \\, a^/jcars rather asymmetrical. It thus seems to take part in the general rotation of the uterus, its ca 'ity being on the right t»f the niitltUe lino. Its canal is cut into near the o.s extentuin and appears as a transverse slit ^ in. wide with a tlf|)re.ssitjn in the mitltUe of the anterior wall. The width between the lateral fornices is 1| in. Vwjina. — The vagina appears as a closed slit running transversiily and i)eiiig curved, the concavity looking upwards. Its tlirection is not tjuite transverse, but st)mewliat slanting from the left fornix downwards towartls the right, owing to thts pressure of the rectum. Following the curve it measures 2 in. The left fornix is /jj in. higher in the pelvis thau the right. Peritoncmn. — This is seen oil the posterior uterine wall and reflected from it to the pelvic wall. Rectum. — The rectum lies chielly on the left of the middle line. Its lower part has been tlivitled. It is considerably distentled with fiuces especially in its left half. Its width is 3g in. It seems undoubtedly to be pushing the uterus towards the right side. Its walls arc in intimate connection with the surrounding tissues of the sacral segment. Tin; junction with the vagina is rather loose. Under it is seen riuscular tissue — the levator ani of each side. Connective Tissue, Lifjaments, etc. — The section piisses below the level of the reflection of the a iterior layer of the broatl ligaments. It shows tLc continuity of the parametric tissue with that adjacent to the lateral fornices and with that on the pelvic wall. On the left side this tissue is wider and looser than on the other side. Its vessels are more distended. On the right side the corresponding tissue is somewhat compressed, apparently through the pressure exerted by the rectum. '1 - - 44 ANATOMY OF THE FEMALE PEEVIS i 5 I Ui'etcrti. — The right is seen under the peritoiieiun external to the uterus, half internal to the pelvic wall and slightly below the brim. The left is seen cut more obliquely f in. internal to pelvic wall and ^ in. below the brim. Gknkral Description (Plate XVI.) Uterus. — The uterus is somewhat pear-shaped, the body being markedly anteflexed on the cervix. It lies nearer the right than the left side of the pelvis, this condition Ijciug more marked at the cervix and lower part of the body than at the fundus. (This is probably chiefly due to the presence of fiuces in the rectum.) It is also rotated so that the right border is higher than the left. Though in tlie Vertical Mesial Section it lies below the conjugate of the brim, the Coronal Sections show that it is above the upper limit of the true pelvis as regards the transverse diameter of the brim. (It is very probable that the uterus would be entirely below the inlet of the pelvis were the rectum empty. ) The vertical mesial section does not give the entire length of the uterus, because the lowermost portion of the cervix lies to the right of the middle line. The whole length really is 5 Jr in., of which the body measures 3^ in. The length of the whole cavity is 4| in. Bladder. — Tiiis organ lies perfectly flaccid and nearly empty. The thinness of the walls is to be associated with the paralysis from which the patient suftcred. Its great size is to be noted. Rectum. — The manner in which the lower part of the rectum, when containing fajccs, can displace the uterus is well brought out. L(^t Broad Lujament. — This ligament arises from the side of the uterus, its highest point of attachment being near the fundus just behind the level of Coronal Section B. For 1 in. its free margin runs downwards ou the side of the uterus as a mere ridge ^ in. in height. Thence it runs outwards and backwards and u}> wards crossing the brim 1^ in. behind the middle of the ilio-pectiueal eminence. The posterior layer is greatly wrinkled as it passes downwards to the pouch of Douglas. The Hound Ligament arises from the side of the fundus, runs down the side of the uterus for 1 in., and then passes outwards and upwards, crossing THE SIXTH DAY OF THK I'UERPKKIUM 46 the brim just beliiiul the middle of the ilio-pcotincal eminence. It is to be noted that, save at its uterine end, this ligament, as it passes from the uterus to the pelvic wall, forms in reality the upper free margin of the broad ligament, that part of the broad liganiuut which normally is above the round ligament and which contains the Fallopian tube, being practically non-developed and represented as a mere ridge behind and below the level of the round ligament. No infmuUhulo- pelvic ligament exists whatever on the left side, Lejl Ovary. — No trace of this body can be found in the pelvis after the most careful dissection. Whether it is in the abdomen, i.e. undescended, it is impossible to say, the upper part of the abdomen not having been removed from the cadaver. All that we can say with certainty is that the left ovary does not lie below the level of the last lumbar vertebra. Left Fallopian Tube. — No part of this exists whatever outside the uterus. That part of the broad ligament normally occupied by it is a mere narrow ridge. In the uterine wall, extending from the left upper angle of the uterine cavity, it can be traced for about /,. in., ending blindly in the uterine muscle. It admits only a fine probe. (For the further considera- | tion of these malformations, vide p. 4G.) The Left Utevo-Saeral ligament arises from the back of the uterus about opposite the middle of the 3rd sacral vertebra. It runs as a peri- toneal fold outwards, upwards, and slightly backwards to the pelvic wall I for 1^ in., being pressed a little forwards by the distended left part of the 1 rectum. J Right Broad Ligament. — This ligament stands out in striking contrast . to that of the left side, being well formed. It crosses the brim about I 1^ in. behind the middle of the ilio-pectineal eminence. The upper I portion, containing the Fallopian tube, is turned inwards with the tube and ovary. The round ligament arises from the uterus op[»osite the origin of the left ligament and crosses the brim a little behind the plane in which the left one crosses it. It lies below the upper free margin of the broad ligament which contains the Fallopian tube of this side. « \ 46 ANATOMY OF THP: FEMALE PELVIS liif/ht Ovary. — Thi,v> body lies behind the broad ligair.eiit, being turned with the upper part of the hitter inwards. Its normal ' uder surface re^t.^ on the inner end of the broad ligament and outer part of the posterior wall of the uterus. Its line of attachment to the broad ligament measures Ig in. ; from the hilum to its free m",rgin it measures 1^ in., and from side to side it also measures 1^ in. Its greatest thickness is at its central part, where it measures | in. ; it thins out towards the periphery. llujlit Fallopian Tube. — This tulje passes from the uterus opposite the highest point on the uterus of the broad ligament of the opposite side. It runs backwards and outwards, curving up above the brim, and then passing inwai'ds and a little forwards, resting upon the ovary. The Right Utero-Sacral Liyament is a little higher at its uterine end than on the other side, and is shorter. The condition of the iuterr^al genitals here met with is extremely rare. In this case there can be no douljt that we have to do with a well-formed uterus. It is impossible to say, on examining it with the eye, wherein it difters from an ordinary uterus in the corresponding stage of pucrperium. Tiie round ligaments are attached just as in a normal pelvis. The uterus differs from a normal one in that the left Fallopian tube is only represented by a short tube in its wall running outwards from the left upper angle of the body cavity. Outside the uterus the tube is only represented by a narrow ridge, the upper edge of the broad ligament. There is not even a solid string to represent it as may be found in some malformed conditions of the tubes. Absence of an o^ary, according to Olshausen, is usually associated with a mal-development of the corresponding half of the uterus, though in some cases it is not. If not, there is usually found some defect in the Fallopian tube, e.g. its inner end is alone developed, the outer being rudimentary or obliterated. In this case it is evident that the lower ends of the Miillerian ducts have united as far as they normally do. The upper half of the left one has not developed into the left Fallopian tube. From the entii'c absence of even a solid string of tissue in the upper edge of the broad ligament, it is probable that from the first there was either a non-develop- ment of the upper parts of the original solid rod which afterwards should PLATE XVI FiciS. 1 and 2. Sixth Day of ruEuvKitiuM. Fui. 1.— Posterior piirt of loft liiilf of Pulvis witli left half of Uterus, seen fvoni above. (Koduced.) .. Fundus Uteri. I). Mal-doveloped loft iiroad Ligament without Tube or Ovary. c. Sigmoid Flexure. - slia|)0, the anterior limb being If in., tlie posterior ^ in. The urethra is slightly sigmoid in shape and passes downwards and forwards parallel to the lower part of the anterior vaginal wall ; its length is 1| in. Its orifice is 2| in. below the brim and ^ in. behind the vertical mesial axis of the pubes. Above, the bladder is in relation to the intestines which fill the utero- vesical pouch. Behind it is connected to the cervix by connective tissue of loose structure. The distance from the bottom of the utero-vesical pouch to the anterior fornix is 1 j^^'^ in. In front is a well-marked triangular portion of fat and connective tissue separating it from the pubes. llie Pentoneum descends in front of the uterus to a point 1| in. below the brim. The utero-vesical pouch is of considerable size because of the retroflexcd condition of the uterus, and is filled with intes- tines. Behind it descends to form the pouch of Douglas, the Test point of which is 3| in. below the brim. The tongue-like projection of the uterus below the sulcus is partly formed by the lower end of the right utero-sacral ligament. Tlie Rectum in almost its whole extent is closed. The lower end together with the anus was opened up a little by means of cotton wool placed in it before freezing. The lower end is directed down- wards and backwards almost at right angles to the brim. One inch from the anus the direction changes, the bowel j)assing upwards and backwards, following the curve of the coccyx and sacrum. The highest point of the cavity seen is opposite the junction of the fourth and fifth sacral vertebra). Below this point it is cut in two places; above it is seen the mcso- rectum continuous with the connective tissue lining the wall of the pelvis; the average thickness being as iiiar up as the junction of the second and third sacral vertebra) | in. ; above this it widens out until opposite the middle of the first sacral vertebra it suddenly a2)pears thinner. In this tissue several partly closed vessels are seen. \m sum THE FIFTEENTH DAY OF THE PUERPERIUM 61 Transversk Skction (Plate XVIII.) This section passes in front, just below the symphysis pubis, bcliind through the junction of the second and third sacral vertebno, and latevally through the aceta1)ula. The [Items on section appears rounded. It is dark-red around the cavity, but paler towards the periphery, especially on the sides. The trans- verse diameter is 2| in. The portion of cavity opened up is somewhat triangular in shape. The thinnest part of the wall is towards the back (fundus). The thickness between the uterus and the pelvic wall is as follows : — 1. At the mi(hlle of the sacrum it is rj, in. and consists of extra-peri- toneal fot and connective tissue. 2. Oj^posite the right sacro-iliac joint | in., of which half is pyriforrais muscle and the rest extra-peritoneal fat and connective tissue. 3. Opposite the posterior edge of the right acetabulum 1| in., of which I in. is obturator internus muscle and the rest connective tissue, etc., con- tinuous with the base of the broad liirament. 4. Opposite the anterior edge of the right acetabulum 1 J in., of which f in. is also parametric tissue. 5. Opposite left sacro-iliac joint 1 in., of which | in. is ovary and extra- peritoneal connective tissue and the rest pyriformis muscle. 6. Opposite the posterior edge of the left acetabulum If in., of which consists of obturator internus muscle and the rest parametric tissue. 7. Opposite the anterior edge of the left acetLOulum If in., of whi .. Tff in. I in. is obturator internus. In the parametric and paravesical tissue on the left side is seen a con- siderable amount of blood-stained tissue due to the oozing of blood from the thawing blood in the partly filled vessels. On the right and left sides in the outer part of the uterine wall and its adjacent parametric tissue in front of the peritoneum of the pouch of Douglas are seen several closed vessels. The anterior third of the uterus is in relation to the base of the broad II IW^' 62 ANATOMY OF THE FEMALE PELVIS ligaments (parametric tissue) and to tlic bladder. The connective tissue joniing it to the latter is of loose structure and is continuous with the tissue lining the pelvic wall at the side of both viscera. The peritoneal surface of the uterus (the posterior two-thirds) is on the left side in close contact with the ovary for a distance of l^V. in-, behind this for an inch with the rectum, and to the right of this with the tissues lining the pelvic wall, continuous in front with the parametric tissue. The Blmhler is cut obliquely through its bocy so that the walls ajipcar thicker than they are. The section passes through the junction of the urethra and cavity. Its transverse width is 2 in. The cavity is curved from side to side, the concavity looking backwards. The distance of the urethra from the pubes at this level is \'^ in. Tim Vcujina is cut into on each side of the middle line in front of the bladder. It is of a greenish colour (due to post-mortem changes). The Peritoneum is only seen forming the pouch of Douglas. It covers the posterior two-thirds of the uterus. Its reflection from the uterus on the left side is a little in front of the corresponding point on the right side. On the latter side it is about 1 in. behind a line passing through the centre of the ilio-pectineal eminences, and on the left | in. posterior to the same line. Lying in the anterior part of the poucli on left side is tlie prolapsed and enlarged left ovary. V':\ |l M \\ E: 4 The Specimen as a Whole (Plate XIX.) The Ritjht Ovary lies with its long axis vertical. Its surfaces look inwards and outwards. Its length is li in. and its width [f; in. The inner surface in its lower fourth rests against the uterus ; above this it is in contact with the intestines. The outer surface rests against the parietal peritoneum as well as against the right infundil)ulo-pclvic ligament, which is folded forwards against the pelvic wall. As a whole the ovary lies ^ in. behind the posterior margin of the right acetabulum. The lower (inner) end is \ in. above the ])rim, the uisjier about f in. above the brim. The Right Fallopian Tube passes from the side of the uterus close to K PLATE XVIII. Fin'KKNTii Day of Pueui-kuium. Transverse Sedion.—Face of Lmver Slab. (Reduced by J.) a. Junction of Second and Third Siiciiil Vertcbrie. h. Descending Rami of Pubcs immediately below Symphysis. c. Uterus. (/. Uterine Cavity. e. Parametrium. /. Rectum. g. Diseased Ovary. h. Ureter. i. Bladder. j. Vagina. k. Peritoneum. II ' r.«..v It i; PLATfT XVIII V^imi^f \\ m li; 4 f i^ PLATE XIX. Fll-TEKNTH Day ok I'UEIll'KltlUM. Fi(i. 1.— Ui)i)or part of riglit half of Tulvis with intestines removed. (Koduccd.) a. Promontory. b. Sympliysis Pubis. c. Fundus Utci'i. (/. FalIoi)ian Tube turned forwards. e. Ovary. Fjc. 2.— Upper part of left half of Pelvis with intestines removed. (Reduced.) u. Promontory. b. Symphysis Pubis. c. Fundus Uteri. (/. Fallopian Tube. e. liectum. /. Ovary. r |R^, /) ;;;) PLATE XIX Fig. Fig. 2 L^V! *i m I'll )1, : I i *%dl THE FIFTEENTH DAY OF THE PUEKrEIUUM ftS its nnterior surface, and extends upwards, outwards, and tlien sli^litly down- wards for 1 in. lyinn; a<,'ainHt tlio ovary. It then l)cnds suddenly forwards and inwards, tlic finil)riatcd end lying in the outer part of the utero-vesical poneli and eovcred hy intestines. The Right Broad Lujnmcnt arises as a mere ridge about 2 in. altovo tlic brim in the right iliac fossa at a point about 2^^ iji. behind a phuie perpendicular to the brim passing through the anterior superior iliac s[»ines, and about 2 in. IjcIow the level (jf the highest part of tins iliac crest. It runs downwards and forwards, gradually increasing in size, crossing the brim behind the acetabuhmi about opposite the right anterior superior iliac spine. It then passes downwards and forwards, the anterior layer going to form the bottom of the utero-vesical pouch, and to be reflei^ted to the anterior abdominal wall, the posterior passing gradually downwards and backwards to enter into the formation of the pouch of Dotigbis. The WkjIU Utavo-Sacval Liyamcnt is a well-marked l)and \'^ in. in length which forms a distinct shelf in the pou(!h of Douglas. Its up})er end is | in. to the right of the vertical mesial line of the sacrum, j in. aliove the junction of the fourth and fifth .sacral vertebra). It runs down- wards and inwards and is attached to the back of the uterus from the lio-ht edge as far in as the middle line (in V. M. S. it was seen). Its under surface rests against the posterior parietal peritoneum, its upper is in contact with the retrotlcxed body of the uterus. 77

low. There exists a well-marked '-etraction ring. This is not the ^.■'rae as the retraction ring of labour. It is relatively nearer the cervix, i.e. the • " Physiology of the Utonis," LabonUorij Reporti R.C.P.E., vol. iii. [i ' f L 1 iji RfiSUMft upper uterine segment of labour lias been added to infcriorly by the amount of tlic lower uterine segment taken up into it. Cervix.— The cervix, though (juite thick, i,s not restored to the prc- parturient condition. It is considerably Hattcned fioni above downwards, though this is probably partly due to the pressure of the ui)per uterine segment. Its cavity is partly also everted. It is congested, and thus stanc:.. out in sharp contrast witli the bo. 118. 'i Lusk, op. cit., jt. 2-15. CO ANATOMY OP THE FKMALE PELVIS recognised. It is i'ound in pei'l'cctly nunnul cti.se.'^, and usually returns to a state of anteflexion. In all these cases, i.e. after the first day, the uterine wall eannot, from its naked-eye appearance, be divided into the three portions noticed at the beginning of the puerpcrium, viz. Upper and Lower Segments and Cervix. Owing to the retraction of the uterine muscle continuing after the end of the third stage, the lower segment is more and more taken up into the thick portion above it, so that, in my sections, by the thirty-sixth hour after delivery it is completely obliterated, the body of the uterus and the cervix being a continuous whole gradually diminishing in thickness from above downwards.* It is inipossil)le to define with accuracy the os internum. We can place it fairly correctly by noting the point of flexion, the level of attachment of the utcro-sacral ligaments, and the point of reflection of the peritoneum from the uterus to the bladder. (In my early puerpcrium cases the utero-vesical pouch is abnormally high.) One can therefore say that the following table is approximately correct : Cass. Cervix. Boily. in. Whole Ulcnis. Cavity. in. in. in. B('(,'iiiiiiiig (if riRT. 7^ «ri passu. This diminution is scarcely l)erceptil)lc for the first three or four days, but has become quite marked by the sixth day, and well pronounced by the fifteenth day. Statements are made in the books regarding the decrease in the size of the uterus, based ' 'Pile " firni attaclinieiit of the peiitoncum " upper limit of the lower segment, is not available which IJofmeier and others give as marking the in the frozen condition. lifiSUAlE 61 upon clinical observationa and instrumental measurements on the living sulijcct. Owing, however, to the fallacies associated with these methods (already ^jointed out), we cannot depend upon them. Lusk ' says that a diminution in the size of the uterus is api)arent in the course of the first twenty-four hours ; Winckcl,^ that the decrease commences as early as twelve hours afterwards, and that there is a daily decrease in length of 2-G cm. Frozen sections do not in any way tend to support these ^'icw8, but are more in agreement with Ileschl ^ who says that the change does not begin until at least the fourth day. What now is to be said regarding the naked-eye ai)[)earances of the uterus ? (a.) On Section. — For four days at least the sections have the ap- pearance of contracted and auicmic non-striped muscle. The vessels are closed and can scarcely be distiiiguislied save under tlie placental site. On the sixth day the uterus has a darker red a])pearance, the vessels beino- more filled with blood and more easily distinguished. On the fifteenth day it is of a dark reddish colour. Of my cases the third day uterus is paler than any of the others. There is no sign of the extremely fatty appearance which Spiegelberg^ says becomes so well marked by the fifth to the eighth day, nor could any fat globules be removed. Neither after thawing took place did 1 find that the texture was extremely soft and friable. It was compact and rather to be described as of a spongy nature, fairly easily indented with tlie finger, the indentation, however, disa2)pearing. It was ccrtaiidy more easily torn than either the non-pregnant or the pregnant uterus. The cervix is softer than the body and is somewhat congested. {b.) Outer Surface.- — Tlie peritoneum is wrinkled over a considerable l)art of the uterus. The wrinkling is especially marked near the broad ligaments and in the pouch of Douglas. It results of course from the diminution in the size of the uterine musculature as a result of contraction and retraction taking place to a relatively greater degree than the shrinking of its peritoneal covering. There is, in other woi Is, a disproportion in their * Op. cit, p. 244. * Text-book of Mid., Eng. Trans., p. 198. ' ZciUch. (I. K.K. (!es. d. Ante ;:h Jfien, 1852, p. 228. * Op. fit., p. 202. 62 ANATOMY OF TUK FEMALE I'ELVLS retracti powers, th. superahundunt pcritonoun. vvl^en the uterus has changed from its pregnant to its post-partum condition, being arranged over he uterus rn a series of folds. By the sixth day the wrinkling has hu-^ely disappeared save near the junction of the broad ligaments The shape of the uterus viewed either from the front, the baek, or he side. IS somewhat pyriform, diminishing in thickness from above downwards In some cases the posterior wall is well rounded, the anterior being more Hattened, but in other cases these conditions are reversed Ihe puerperal uterus differs in this respect from the normal non- pregnant uterus in which the posterior wall is always more rounded than Jic anterior. It usually returns to the normal condition durin. the puer])erium. " (..) W. Surface (Plate XX.) -The specimen from which this description was taken was removed from a patient who died of lung disease ou the first day of the puerperiuin. Cut longitudinally throu-di the anterior wall and laid open, it presented the following appearance :- Three areas can be distinguished : 1. The Placental Site-^rin. occupies the posterior, the left lateral, and part of the anterior wall. It is somewhat lemon-shaped, the length being 4, in. and the greatest breadth 2f in. The area would be neo'?:s:^f*^!flet5S', II )l j i j i i M \ ' ■ t ■ <> rm ■^*'***«-^, li ^ \ PLATE XXI ./ ■ 7 I r, 1 ij RfiSUMli 63 In this arc.i arc seen the openings of the Fallopian tubes. Around each of these is an area, al)out g in. square and perfectly smooth, to which no decidual shreds arc adherent ; this seems to indicate that tl-.e mend)ranes were not attached to the wall in the immediate vicinity of the tubal openings. 3. Cervical Area. — Two parts can be distinguished in this area, iz. a lower and an upper portion. The lower, about 1^ in. in vertical extent, is com2)arativcly smooth with ridges here and there, due probably to the remains of the arbor vita). It is deeply congested, and ecchymoscs arc sc. n below the surface. The lower edge is irregular, and on the left side is seen a tear. The upper portion is of a light bluish-grey with ridges seen on it here and there. It becomes g'-adually continuous with the non-placental site of the body cavity, there being no well-marked line of distinction between the two. (It is interesting to compare the placental site with the jdaccnta from the same case (Plate XXI.)). This is rounded in form with an average diameter of about G in. Its area is about 28 sq. in. There has evidently been brought about a great disproportion between the area of the phi. nta and the site of its former attachment to the uterus. The relation of the Uterus to the extra-uterine tissues, and to thej^elvis. — In a pelvis of average size at the beginning of the puerpcrium, the uterus fills the greater part of the pelvic cavity and compresses the extra-uterine tissues. This comi>rcssion is especially marked between the uterus and the bony wall, and to a much less extent infcriorly owing to the softening and relaxation of the fascial and muscular tissues of the pelvic floor. In consequence of this condition of the parts, the intra-pelvic tissues have their blood circulation interfered with to a considerable extent, those parts of the pelvic floor which are least affected, e.g. sub-pubic tLssucs, vaginal walls, and perineum, being congested, the tissues between the uterus and the pelvic wall, however, being ana3mic, having their vessels cloeed or nearly closed. The effect of contraction and retraction of the uterus on its blood circulation has already been referred to. The cff"cct of the compression of the organ as a whole on the tissues outside it is to further interfere with the (low of blood to itself; the ovarian and the uterine arteries a; well as J rar^r- 64 ANATOMY OF TIIK FEMALE PELVIS the uterine branciies of the vaginal a,r*' lies are, owing to tlie rearrangement of tlie broad ligamcntH, twisted, and at the same time compressed against the Ijony wall by the uterus. The only part of the uterus which is not ana3mic is the cervix. It is neitlier retracted nor contracted in the same degree as the body, nor is it subject to much compression ; at the same time it is in close relation to the vascular vaginal walls and para-vaginal tissues which have been so recently engorged with blood, and may therefore become deeply congested. Owing to the very slight diminution in the size of the uterus, this condition of things, as my sections show, is kept up for three or four days. As a result bleeding fnmi tho inner surface of the uterus is greatly inter- fered with, both through the interference of contraction and retraction with the intra-numil circulation, and also through the mechanical pressure of the uterus as a. whole upon the broad ligaments and the tissues lining the pelvic wall containing tlie vessels passing to it. An enormous influence must be exerted by this greatly altered bl'jod supply in the way of initiating or stimulating those retrogressive changes wiiich bring about the involution of the organ, whatever those changes may be. I^'urther, the condition of the cervix helps us to understand why after labour there is so often bleeding as a result of even the small tears which take place in it, and why, if the laceration has extended into the parametric and para-vaginal tissues, so ri(;li in venous sinuses, there may be very serious li:emorrhage. Should this not be checked by the ordinary means, i.e. hot or cohl antiseptic douche, it is evident that pressure of the uterus fr(jm above will tend to diminish the flow of blood to the cervix by compressing it, while the introduction of a firm rectal or vaginal plug might in some cases be used as a resisting structure against which the lacerated part could be more firmly compressed. During the last two years I have made careful observations regarding post-partum hicmorrhage as a result of torn cervix in a considerable number of cases, and I have found it to be most profuse and most difficult to stop in women with abnormally large, e.g. justo-major, kyphotic, or with abnormally contracted pelvis, e.g. rickety. The reason of this is clear if we examine sections made of such ' \ k» PLATE XXII. Fig. 1. Vertioiil Mesial Suction of a Contnictcil Polvis, from a woman who died J, hour after delivery. (Stratz.) (Kuduced.) ((. Undjiliciis. b. Itetraulion King. c. Cervix. (I. Posterior fornix. e. Tip of Coccyx. /. Urethra. g. Urethral orifice. Fiu. 2. Vertical Mesial Section of a Kyphotic Pelvis, from a woman who died 1 ), hour after delivery. (Barbour.) (Iteduced.) ((. Small intestines. b. Last hunbar vertebra. c. Uterus. d. Peritoneum. ('. I'lacentid site. /. Uterine ciivity. g. Rectum. h. Pouch of Douglas. i. Cervix. j. Cervical canal. k. Cellular tissue. /. Jiladder. m. Vein. «. Sym[)hysis [)ubis. o. Urethra. p. Cellular tissue. V. Vagina. w. Anus. i! IF Fig. I. PLATt XXII. RfiSUAlJi 60 pelves. Barbour's section' of a kyphotic pelvis (1^ hour puerperium) shows that the uterus in no way acts as a plug owing to tiio great size of the upper part of the pelvic cavity, and the condition is undoubtedly more favourable to excessive bleeding. (This very case died of post-pa rtum luumorrhage.) In a well-marked rickety pelvis, as Stratz's section shows us (i hour puerperium), the uterus caimot sink down into the pelvis, but remains to a large extent above the brim. The cervix and lower uterine segment as well as the tissues adjacent to them are put on the stretch, and thus these parts tend to become greatly congested. (This case also died of post-partum hajmorrhage. ) (Plate XXII.) Bladder. In all my cases the bladder is empty, or nearly so. They show that after labour it returns to practically the same shape that it had before labour. It varies as to its position in different cases, being depressed more in some than in others. Immediately after labour it may lie at the level occupied by it during pregnancy, or even partly lower ; this depends mainly upon the softening and stretching of its supports, which takes place during pregnancy and labour. As the puerperium progresses a gradual elevation takes jilace. I can find nothing to support the statement of Halliday Croom - that after the labour " the bladder is on a hiyher level than during pregnancy." The conditions which affect the lie of the viscus are : 1. Softening and stretching of its supports. 2. Intra-abdominal pressure. 3. Weight of the uterus. The first of these probably varies considerably in different cases. In none of my cases is it exactly central in the pelvis. It is slightly deflected either to the right or left side. From the relation of the bladder to the uterus it is evident that its distension with urine must cause the uterus to be less anteverted, i.e. must make the fundus take a higher position. Probably, also, the uterus will l)e raised as a whole. ' Atlas of the Amit. of Luhotir, 1889. a q^, ^ j,^ 55 1 GG ANATOMY OF THE FEMALE TELVIS The elevation of the fundus found some hours after delivery is due in most cases to the filling of the bladder. Filling of the lower part of the rectum also raises the uterus, though in a less niariied degree. Tlu'. iiifincnce of this condition of the rectum in changing the position of the uterus is well shown in my Sixth day case. Vagina. The vagina is larger in all its dimensions after labour than before. The vertical mesial sections show that it may return after the third stage to its normal sigmoid shape. In the early puerperium, in its upper part only are the walls in apposition, the lower part gaping considerably, the lower part of the anterior vaginal wall bulging downwards; it returns during the puer- perium to the more normal condition. My Sixth day case shows that on transverse section the vaginal cavity in its upper part is a transversely- curved slit, the cr^cavity looking upwards ; in its middle part it is somewhat H shaped, and in its lower part a vertical slit, the walls not being quite in ai)positiou however. The vaginal cavity, in the earliest case, i.e. immediately after delivery, in its upper part has the usual transverse direction. In the lower part, however, owing to the stretching, the direction seems to be more vertical, the side walls tending to approxi- mate to one another. Perineal Body. — In none of my cases was there any special tearing of the jjcrineum. The sections show that in spite of the great stretching of this part, it may return almost to the pre-parturient shape, though it is soft and, as a whole, lower in position. As the puerperium advances it becomes firmer and more compact. Pelvic Floor Projection. — Its measurement in my cases is given in the following table : — First Day. Second Day. Tliiid Day. Fourth Day. Sixth Day. Fifteenth Day. 2 in. l|in. li in. 2i in. ] I in. 1 in. KtoUMK 67 Alter liiboiir wo thus hco that the projection is greater than in the milliparous condition, when, according to Foster,' it is very little more than 1 in. Compared with the measurements made in cases of pregnancy and labour by Dr. Harbour and myself,- it is found to be less than it was during the second stage, and about the same as, or a little greater than, it was in advanced pregnancy. Broau Ligaments. The upper part, with tube and ovary, has much the same ai)pearance as in the pregnant condition, being freely movable, and having its layers separated only by a small amount of tissue. It is larger than in the non-pregnant woman. The lower part is (^uite different ; it has scarcely any widtli whatever, because the uterus has extended between its layers almost to the side walls of the pelvis. The peritoneal layers arc consider- ably wrinkled, and the tissues between them are compactly pressed between the uterine and pelvic walls. In fact, in sections it is very difficult to say, with the naked eye, where uterine muscle stops and broad ligament tissue begins. At the end of labour the highest part can be traced as a ridge which arises in the iliac fossa passing downwards and forwards, getting larger, and crossing the brim, its layers gradually getting wider until about i in. below the brim the anterior layer passes to the bladder, the posterior descending to form the pouch of Douglas. As the puerperium advances the ligaments gradually return to their normal nulliparous condition. Tubes and Uvaiues. At the commencement of the puerperium they lie almost entirely above the brim on each side, packed in between the uterus and the pelvic wall, and covered with intestines, having descended from the position occupied by them at the beginning of labour.'' * Am. Jour, of (Jbd., vol. xiii. p. 30. 2 Lab. El'}). U.C.l'.E., vol. ii. pp. IG, 43. ^ narboiii', oil. cit. ; Barbour .iiul Webster, op. cit. '",. ! 68 ANATOMY Ol'" TliK KKMALK I'Ki.VlS The uviiry juul tube, tliough in all my early piicriieriuin cawH packed ill between the uterus and pelvic wall, do not always bear the same relation to one another and to the uterus. This variation is duo to the niol)ility of the upper free portion of the broad ligaments. This mobility chiefly affects the tubes, allowing them to lie cither in front of, or behind, their point of attachment to the uterus, and folded in various ways. The ovaries, however, have a much more limited range of movement, less than that possessed by them either in the non -pregnant or pregnant woman. Before labour they arc still separated from the wall of the uterus, the ovarian ligament being well marked.' After labour, however, owing to lateral extension of the retracted and contracted uterus into the broad ligaments, the ovaries get to lie closer to the uterine wall, their inner ends appearing to be attached to it directly, the ovarian ligaments being practically obliterated, having become spread out on the wall of the uterus. The ovary, thus fixed at its uterine cud, is only capable of moving around this fixed point; the outer free end may thus bo found in front, above, behind, or below the attached end. In no case of mine are the relations the same on both sides. The api)cndages, also, may be a little higher on one side than on the other. During the first four days at least they do not become lowered to any marked extent. When they reach their normal position we do not yet know. In my Fifteenth day case on one side, Imth tube and ovary are i)athologically lowered, the ovary having formed adhesions with the parietal peritoneum in the pouch of Douglas ; on the other side, the tube lies partly nljove and partly below the brim, about f of the corresponding ovary being above it In this case, however, the uterus is rotroflexed. The Bearing of these facts upon the Crede method of expelUmj the Placenta and Post-paHimi shock. The Crede method was originally introduced as a means of separatinliy,si,s aud the fingers in front of the promontory, i.e. the hand i.s placed antero- postcriorly qiut the pelvis. Recently Ilaig Ferguson' and Newell" have criticised this method of grasping the uterus, saying that, on account of the rotation of the uterus, the ovaries arc in danger of being compressed between the fingers and the uterine wall, und that, as a result, a condition of shock is apt to be induced in the patient. The former writer has studied clinically three cases of this so-called " post-partum shock," the latter " one or two cases." It seems to me that their explanation of the cause of this condition is open to criticism both on clinical and anatonn 'id grounds. A. Clinical. — (1) So widely employed is the Crede method, it is remarkable that these are the only cases on record of the occurrence of this comlition. (2) In all these cases, the women were neurotic, and there is no reason against supposing that the condition of shock may have been to a large extent produced as a result of the mere Crede manipulation, iqHirt from any compression of the ovaries. While the exact relation of slicjck to psychical and physical causes is not yet clearly defined, we do know that these causes vary greatly in their power of affecting different indi- viduals. Separately or conjointly they may produce shock in all its degrees. There is no doubt, according to Sir \Vm. MacCormac^ aiid others, that in i)ersons of a neurotic temperament the very slightest lesion or pain may lead to shock. It is not too much to suppose, there- fore, that compression of the uterus alone in a neurotic woman mi'dit lead to shock. (3) There is one condition, however, which renders the uterus exqui- sitely sensitive to pressure, viz. inflammation. Merc pressure of a fin ri 70 ANATOMY OF TIIK I'KMAM'; I'KLVIS iinu foiuiire««i()ii of u ulcru.s in tlii.s couditiuii, .sulliciiiit in aniuiiiiL to expel the placenta, uiulouhtedly eausea very <;mvt pain, and nii{,'ht easily lead to shock in ii neurotic patient. (4) There may have been a diseased condition of the tul)e or ovary, or of both, on one side, as a result of which they may have been displaced or eidarjfod and, therefore, sijucozod by the compressing hand. The great pain luiuscd by the compression of an iiiHamed ovary is u well -recognised fact in gynecological examination. At the Cowgate Diapcn.sary 1 have seen two cases witii symptoms somewhat resembling these described by Ferguson and Newell residting from the ordinary bi-mauual examination of neurotic women with old-standing ovaritis. There is no doubt that in operations for diseased appendages a con- dition of .shock is sometimes 2>roduccd, apart from loss of blood. This is attributed by Ferguson to rough handling of the ovary. If he be right, we should find this a very common comi)lication in laparotomies, since, in the majority of operations for removal of the a{)pendages, especially where there is much matting-down of them from inflammatory adhesions, the ovaries arc pretty roughly handled. Moreover, one would expect to find shock common in those cases where part of the ovary is left behind embraced by a ligature ; yet, as far as I know, it has not been particularly noticed in these cases. After any abdominal oj)cration that has been severe and protracted and accompanied with much loss of blood, shock is liable to occur. B. Anatomical. — The relations of the pelvic organs during the third stage have not yet been studied in the cadaver. Thiede,' Stratz,- and Benckiser,^ have studied the uterus of that period, but removed from the body ; topographical descriptions of the pelvis, however, are as yet wanting. We do not know the position of the ovaries exactly duriii" that period, nor whether the rotation of the uterus is increased or diminished. We must de2)end upon cdinical examination and upon certain facts known regarding the condition of the parts before and after the third stage. Ferguson bases his hypothesis largely upon the rotation ' Op. cit. 2 i„ Scliroeder's Ikr Sfhimiig. u. Krcis-s. Ut., Bonn, 1886. ■' Znr AiMt. d. Cer. u. unt. Utennsrij. lleiiclciscr u. llof, 1887. ' urwuMi-: 71 wliicli Ih found ill the ntcnis osition. In the case '' where labour was just commencing, where also there was right rotation, it was the left ovary and not the right whicli was most posterior ; it lay, in fact, in a vertical plane passing through the left oblique diameter of the pelvis. In our Second Stage case,' where the uterus was also rotated to the left, the right ovary lay a little anterior to the left one, because of the disposition of the upper parts of the broad ligaments, the right being turned forwards so that its anterior surface lay against the uterus, the left being turned back. In Barbour's First Stage case,'' in which his transverse sections show scarcely any rotation whatever, the right ov.uy lies anterior to the plane occupied by the left. These facts, acquired by the sure method of frozen sections, certainly tench us that, practically, the ovaries do not take vp dcjhute j^ositions corresjwiiding to the rotation of the prerjnant uterus on its long axis. As these cases demonstrate, the ovary in pregnancy is not attached directly to the uterus but through the ovariaji ligament. It, like the tube, owing to the mobility of the upper free part of the Irroad ligament, can thus move, independent of the uterus, through a considerable range. > Op.cit., i>. 71. 2 Op. cil., p. 1.1. 3 np. Hi., i>. 30 ; iiliUo VII. fig. 2. ■* Op. cil., platu V. fig. 2. '' 0^1. cit., pliite IV. 72 ANATOMY OF THE FEMALE PELVIS After the third stage, as my cases s'low, wliile the pre-partiuient mobility of the ovary is diminished because of the practical "bliteration of the ovarian ligament, it is still sufficient to allow the organ to be arranged in various position... It is found packed between the side of the pelvis and the uterus, and, while one may lie somewhat anterior to the other, in no case do they lie in an oblique diameter of the pr .vis. It is different with the tubes, however ; they have a wider - aige of movement and may be found lying chiefly with the ovary, or they may be stretched out considerably in front or behind it. As has already been said, the uterus is not rotated or only to a slight extent in the lUiijority of early pucrperium cases ; this rotation scarcely affects the lie of the ovaries to a greater extent than in pregnancy and labour. Being as yet in want of facts derived from anatomical study regarding the position of the uterus and appendages during the third stage, and not being able clinically to determine these with accuracy, we are compelled to judge of the probable relation of the parts from what we know of the conditions during pregnancy, labour, and the puerperiura. AVe have no reason to believe thf . rotation of the uterus is any more marked during the third stage or that the ovaries have any more a fixed position, than during these other periods. As far as we Lnow, then, there can be no safer grasp of the uterus than an antero-jwstenv one qud the pelvis, as Credo first pointed out. The safest grasD is that in which the hands are pli;ced with their radial edges together, their thumbs being in front of the vertebrae, and the fingers opposite the middle line of the body in front. So far as my cases show, the ovaries could not be compressed, in normal conditions, by this method of manipulating the uterus. THE FEMALE PELVIC FLOOR Introduction DuuiNG the last clccado in Obstetrical and Gynecological science the views which have been most prominent, in the Edinburgh School at least, regarding the structure of the Pelvic Fluor and its relation to pregnancy, parturition, and certain pathological conditions, e.cj. j^volapms uteri, arc those which have been gained from the study of the pelvis by means of frozen sections. While the praises of the Sectional Method have been heard on all sides during these years, scarcely a note of warning has been raised as to the limitations of tii'' method and the fallacies that may arise from its eni2:»loyment. 'J'hat the non-observance of these limitations has Ictl to tlie establish- ment of erroneous conclusions as to the nature of the jielvic Hoor I hope to be a])le to show in the following pages. During the hist three and a half years I have examined, both by sectional and dissectional methods, twenty-one pelves in the following condition, viz. (a) Ten from the fifth month of fcotal life up to puberty. {h) One in a non-pregnai'.t adult. ((•) One in tiie fiftli month of picgnancy. ('/) One in tlie eighth montli of pregnancy, n ((') One in the first stage of labour. f- I'ubliwheii with 13; rbour.' (/) One in the second staj. of labour. ig) Six in the puerperium. )■ ' Li-h. /,',, jrU IW.l'.v,., -.•..:. ii. 74 THE PELVIC FLOOll The conclusion to which I have come regarding the relative value of the sectional and disscctioual methods is, that for tojwy niphical relations alone is sectional anatomy of chief value ; whereas, for all other purposes, for learning the exact structure of a part of the body, the attachments and complex arrangements of the tissues of which it is composed, the older method of dissection is of prime importance. The advantages of the sectional method may be stated in the words of Barbour, whose experience in this department is extensive. He says' that sections render the body "practically transparent. We thus come to learn the exact relations of the parts to each other and to the surface laudmarks. We see them ; nothing is left to conjecture. It is not too much to say that Ijcfore the days of sectional anatomy the representa- tions of these relations were more or less successful products of tlie imagination ; witness the fact that not a single drawing of the pelvic contents previously given was true to nature." It is evident, therefore, that the best results will l)c obtained from the combined employment of both methods. The large stock of facts whi(;h 1 have accumulated in the course of my investigations will, 1 hope, lead to a truer understanding of the pelvic floor than at present exists. 1 shall consider the subject under the following heads : — The meaning of the term " Pelvic Floor." The Floor studied by Dissection. The Floor studied by Frozen Section.''. The Floor in relation to Pregnancy. The Floor in relation to Laljour. The Floor in relation to " Prohipsus Uteri." The MiiANiNci of the Term "Pelvic Floor." The term "Floor" is not a good one, since it leads one to think of the floor of a house, e.g. a rigid partition running transversely between walls. Consequently in looking for a floor in the pelvis we >ire apt to seek for ' Tkc Aiiiduiiiy of LiiImhi- and ils CluiiaU Ikiiriiiij, Ediiilnirgli, ji, 7. THE TERM "PELVIC FLOOR" 75 sometliiDg which has the character of a house floor. The pelvic floor lias no such structure. It is not a rigid partition, nor does it run transversely. It is elastic and movable, varying in its thickness, its nature, and its slope at various parts, while it runs across a very irregularly .shaped space — the outlet of the bony pelvis. It is composed of a variety of tissues, diff"cring in their consistence, their strength, and the firmness of their attachment to the bony wall. The fjrcat 2)iti'pose of the peWic floor, as a Jloor, is undoubtedly to sustain the weight of the great mass of abdominal viscera or, in other words, to resist the intra-al)domiual jjressurc. As Hart ^ has shown, an increase in the intra-aljdomiual pressure, a weakening of the floor, or both these conditions combined, may lef.u to a hernial protrusion of the floor just as corresponding conditions in the abdominal wall produce a similar result. In strict anatomical accuracy, therefore, it must be admitted that all those structures in connection with the pelvic outlet which help to I'csist and support this jyressure, and whose removal would I)e a source of weakness, must be considered as forming a pai-t of the floor. While sectional anatomy is of the greatest value in dcmousti'ating the nature of the floor as a whole, there can l)e no doubt that dissectional work is the only method wo possess of analysirig its constituent elements and the part tliejf play in resisting the intra-al)dominal pressure. Neither Hart nor Symington has, it seems to me, given at all sufficient prominence to this method of study in their papers on the pelvic floor, formulating their conclusions almost entirely from the examination o{ sections. According to Hart,- whose views have been mainly followed during the last ten years, the floor is composed of those tissues which close the outlet of the pelvis, being bounded by skin externally and by peritoneum internally, the uterus and appendages being removed. He divides it into an anterior part called the pubic segment, and a posterior part called the sacral segment, the line of division between the two being the vaginal slit. Studied in vertical mesial section, the former is seen to be triangular in shape, loose in texture, loosely attached to the pelvis and to include the structures lying between the symphysis and the vaginal slit, • Tlie Striuiuml Anaiomy oj tlie Female Pelvic Flow, 1880. 2 Op. tit I u 1.!S j; 70 THE TELVIC FI.OOK l)ciiig cliicfly composed of bladder, uretlind uiid interior vaginal walls ; the latter, strong in structure, embraces the tissues between the vaginal slit and posterior bony wall, firmly dovetailed into the sides of the latter. Symington,' on the other hand, considers "that the rectum and the bladder, like the uterus, should not be regarded as parts of the pelvic floor, but as organs resting upon it." He further says, that " the anterior part of the pelvic floor is composed of firm tissue, and is connected as strongly with the antorior part of the pelvic wall as is the sacral segment with the sacrum and coccyx." He also says that only the lower half of the vagina is in the pelvic floor. Both of these authors have formed these different conclusions from their study of the pelvis by frozen sections. The Floor studied by Dissection. (Plates XXHI. XXIV.) Dissection is of prime importance, and should precede all other methods of studying the floor, for by it alone do we gain a true knowledge of the nature of the floor and of tlu; (iomplex arrangement of the structures composing it. T shnll describe these structures singly, and discuss the value of each in regard to the supjMH't and strength given by it to the fl oor. A. Pcloic Fascia. This structure is, undoubtedly, of the very greatest vnlue in resisting the intra-abdominal pressure at the pelvic outlet. 1. Parietal Layer. — In front this layer, a strong aponeurotic memlnane for the most part, is continued across the sub-pubic arch, as the so-called " posterior layer of the triangular ligament." Its lower border blends with the base of the so-called "anterior layer of the trinngular ligament" (triangular ligament proper) ^ which is attached at its apex to the sub-pubic ligament, by its base to the superficial fascia and central point of the perineum, and by its sides to the pubic arch. It is perforated by the urethra and vagina, and is thereby considerably weakened. This layer is never recognised as a distinct membrane in frozen sections because it is so ' "A contribution to the norninl Anatomy of the Feniali' Pdvic Floor," KiVm. MkI. Jour., March 1889. -' Cunningham, Tlic Dmedor's GnMi; Edin. 1880. THE VLOOll STUDIED BV DISSECTION 77 l)k'ii(lc(l with adjiicent structures ; it certainly forms part of the pelvic floor, strengtheniiig its anterior part, helping to support and steady the urethra and vagina as well as the perineum. In the postcrioi- part of the pelvis the parietal layer plays a less important part in helping to bridge across the greater and lesser sacro-sciatic notches. Here the great and small sacro-sciatic ligaments arc the m(jst important supports, though the parietal fascia internal to them and attached to them is an additional source of strength. (I do not think that the importance of the sacro-sciatic ligaments in regard to the mechanism of labour has been sufficiently noticed. From their position and strength they must influence considerably the course of the various parts of the fwtus as they appear successively at the pelvic floor in labour. As the coccyx is driven downwards and back- wards they must also ])e considerably stretched.) 2. Visceral fMi/er.—Thm layer and its divisions are .scarcely noticed by most writers in obstetrics. The pelvic fascia is generally studied in the dissecting-room in the male ; its arrangement in the female is not usually dwelt on to any considerable extent. There can be no doubt that it forms an important resisting structure to the intra-abdominal pressure. What is its disposition ? In the greater part of its extent it springs from the parietal layer along the iohite line. This irhite line passes around the pelvic wall from the ischial spine behind to a point on the posterior surface of the symphysis pubis, a little above its lower end. The visceral layer passes inwards, on each side, upon the upper surface of the levator ani to the lateral walls of the bladder, vagina, and rectum, where it divides into four layers : — (a) Vesical layer.~T\m layer turns upwards upon the lower lateral aspect of the bladder, forming the " lateral true ligament of the hladder." It is in firm union with the bladder-wall, and thins as it passes upwards over the bladder, to be continuous with the corresponding layer of the opposite side. {h) Vesico-var/inal layer.— Thin layer, thin but strong, passes between the bladder and the anterior vaginal wall, being in firm union with both, and being continuous with the corresponding layer of the opposite side. 78 THE TELVIC FLOOR At its posterior part it blends with tlic connective tissue which attaches the posterior part of the l)lad(lcr to the neck of the uterus. (c) Rccto-Vwjinal Uujer.—TXns, layer passes between the vagina and the anterior wall of the lower part of the rectum. Except for a short distance behind the upper part of the vagina, the union between this layer and the vaginal and rectal walls is very firm. Below it is continuous with the strong connective tissue elements of the perineal body. It is con- tinuous with the corresponding layer of the opposite side. {d) liectal lai/ei:— Thin layer passes behind the rectum, attached to its walls, and joins the corrcsjionding layer of the opposite side. It is pro- longed downwards as a thin layer towards the lowest part of the gut, being, of course, internal to the levator ani. These layers in sections are not always made out with ease as distinct fascial structures on account of their intimate ])londing with surrounding parts. They are more readily made out by dissection when traced from their parietal origin inwards in the uncut pelvis. They are of great significance, and are undoubtedly of chief importance in sliiKjing the Madder, the vagina, and the loivcr jxtrt of the rectum in the pelvis. In most obstetrical works I find no mention of them whatever. (e) Anterior visceral %e)-.— Further, the arrangement of the visceral fascia in the anterior part of the pelvis is of considerable importance. Here the visceral layer, arising from the back of the lower part of the pubes on each side of the middle line, almve the point of origin of the anterior fibres of the Icvatores ani as well as the attachment of the parietal fascia, passes backwards as two strong bands above them and on each side of the urethra to become blended with the anterior surface of the bladder. These are the anterior true ligaments of the bladder. Between them is a space filled with loose connective tissue and fat, continuous below with the retropubic fat and above with the suprnpubic or retro-peritoneal fat. (/) Anal fascia. — Lastly, there is a thin aponeurotic inembrane, which arises from the parietal fascia along the white line under the attachment of the levator ani and passes downwards, closely attached to the muscle and blending with the corresponding layer of the other side and with the other connective tissue elements of the perinc;im. In front it is attached to the I'LATE XXIII. {From Saniijf.) Fiii. 1. Pelvic Fiisciii from ahove. (Kudiicud.) 11. Ivcotuin. V. Viigiiia. /;. IJhuldcr. h, e. Purictiil Fii-scia. (I. Kecto-vcsiciil Fiisciii. Fig. 2. Superficiiil Dissection of Peniioiini. (Ucduccd.) /t. Anus. r. Vagiiiii. ' '. Clitoii.s. T. Tiilior Ischii. c. Obturator Coccygeus. d. Deep layer of Perineal Fascia. k Iscliio-Pubic lianius. ■I Fi(!. 3. Deep Dissection of Perineum. (Keduued.) A. Cilutcus Maximus. L. Great Sacro-Sciatic Ligament. S. Deep layer of Petineal Fascia. m. Anterior layer of Triangular Ligament. p. Posterior „ !)• Base of Triangular Ligament. c. Anal Fascia, Fki. 4. Triangidar Ligament fiom the front. (Heduccd.) 1. Clitoris. 2. Suspensoi'y liigament. 3. Crus Clitoridi.s. ■i. Sul)-pubic Ligament. 5. Dorsal Vein of Clitoris. C. Posterior layer of Triangular Ligament. 7. Transversus Perinei. 8. Outer Layer of Triangular Ligament. PLATE XXIII. en il en THE FLOOR STUDIED BY DISSKCTION 79 posterior layer of tlie tiiiuigulur li^iiiueiit ([Kirietiil pelvic; fascia).' Thin layer is ealled by some the wial fascia, uml by others tlic aponeurosis of the levator am, Ji, Supcrjicial Fascia. Under the skin, over all the lowermost part of the pelvic floor, is a well-marked layer of superficial fascia. Towards the skin it coiiHists of fine fibrous trabecuku containin<^ a large quantity of fat which is most abundant behind and on each side of the anus ; over the tuberosities of the ischium, this superficial fascia becomes tough and stringy," the fibrous septa being thicker and stronger, attaching the skin to the Jjone. The deep laijey is of more importance, being dense and aponeurotic, and giving considerable strength to the pelvic Hoor through its attachments. An- teriot'lij it is attached to the lower edge of the pubic and ischial rami, extending back almost to the tuberosities ; posteriorly it blends in the perineum with the base of the triangular ligament. C. Pelvic Muscles entering info the Flour. Levatores Ani. — These muscles together form a muscular diaphragm with the concavity upwards. They are usually described as being of chief value in strengthening the pelvic fioor. Tiiat they are the most important muscles in the fioor is true ; but on account of their thinness it seems to me that they cannot 'per se exercise a very great infiuencc in resisting the intra-abdominal pressure. Savage ^ divides each into two portions, viz. the pnho-coeciigens and the ohturator-eoeeygens. Symington' has well described the arrangement and functions of these. llie puho-coecyfjeus passing on each side, from the back of the 2)ubes to the last two pieces of the coccyx, ;ict as sphincters of the lower part of the vagina and the anal canal, and tend to draw upwards and forwards the perineal body and coccyx. A few fibres blend with the urethral and vaginal walls, others turn inwards in the perineal body in front of the ^ The Amer. Syst. of Gijn. uml Uhsl., vol. i. ^ Tlw Surgery, Surgical Pathology, and Surgi- p. 227. cal Anatomy of the Female Pelvic Onjann, London, - Ounnin^luini, i/^f. cit., \,. 5. 1882. ■* Op. cit, ji. 59. IMAGE EVALUATION TEST TARGET (MT-S) / O ^J z« 1.0 i.l 1.25 If "a 2A 2.2 1.8 i4_ ill 16 Photograpliic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14S8Q (716) 872-4503 I i^ ! 80 THE PJiLVIC ILOOU internal sphvicter of the anus ; belli 'id the anus there is a blending of some fibres of opposite sides. Tlie obturruor coccygens, the ma'.n part of the muscle, arises from the white line between the pubos and the ischial spine. It runs backwards, downwards, and inwards to the sides of the coccyx. With these should be associated the thin coccygci muscles which arise from the ischial spines and small sacx'o-sciatic ligaments and are inserted into the sides of the last sacral and the coccygeal vertebroe. They have no direct accioii upon the pelvic viscera. They heli^ to fill in the sides and posterior part of the pelvic outlet ; they resist somewhat the intra-abdominal pressure, and they can elevate the coccyx after it has been bent downwards. This is quite different from the ordinary impression which the student has regarding the arrangement of these muscles. It is usually understood that the greac mass of the levator ani arising from the white line passes downwards and inwards and, while being attached behind to the coccyx, mainly converges towart's the middle line, where it blends with the muscle of the opposite side in the perineal body and behind the anus. Coronal sections are largely to blame for giving this false impression. For example. Hart and Barbour,' in their description of a coronal section of Barliour's passing through the obturator iuterrius muscle, describe the levator ani as arising from the white lim; and as passing down to be inserted into the perineal body. The truth is that the main part of the muscle arising from the white line passes backwards to be attached to the coccyx and lower part of the sacrum, and meets the corresponding portion of the opposite side in the middle line, only at the tip of the coccyx. It is the a'ltcrior and smaller jjortion, the so-called pubo-coccygcus, which alone, by means of its attachment to the urethral and vaginal walls and by its blending with the corresponding muscles of the opposite side in the perineum and Ivhind the anus, helps to strengthen the pelvic outlet across the middle line. Its outer fibres arc, of course, parallel to and continuous with the obturator coccygeus, and hence the utterly erroneous impression which the coronal sections give of the levator ani arising from the white line and being inserted into the perineum. The presence of the vaginal slit is a great ' AJtin. of (lijn., J). 48. PLATE XXIV. {From Sacaijc.) Fici. 1. Front of Pelvis from within. (Reduced.) 1. Anterior true Ligaments of Piluddcr. 2. Pill loCoccy gens. ."5. OI)turator Coccygcus. 4. Pudic Vein. 0. Venous Plexus. G. Posterior layer of Triangular Ligament. 7. Pubo-Coccygeus. Fiii. 3. Muscular part of Floor fiom above. (Reduced.) A. Acet4il)ulum. B. Neck of Bladder. It. Rectum. /'. Symphysis. C. Coccyx. S. Sacrum. 1. Anterior true Ligaments of Bladder. 2. Pubo-Coccygcus. 3. Obturator Coccygeus. •1. White Line. 5. Coccygeus. 7. Pyriformis. 6. Obturator Internus. Fig. ± Levator Ani from above. (Reduced.) 1. Pubo-Coccygeus. 2. Obturator Coccygeus. 3. Coccygeus. 4. Origin of Levator Ani from Poiie. 5. Coccyx. G. Median Hai)he. /;. Bladder. V. V:igina. U. Rectum. Fi(i. 4. Muscular part of Floor from below. (Reduced.) \. Clitoris. 2. Deep Fascia. 3. Crus Clitoridis. 4. Krector „ 5. Bulbo-Cavcrnosus. 7. Transversus I'crinci Supcrficialis. 8. Sphincter Ani Extermis. 9. Pubo-Coccygeus. 10. Obturator Coccygcu? U. Coccygeus. V. Vagina. G. Gluteus Maximus. _. PI. ATE XKIV. THE FLOOR STUDIED I5Y DISSECTION 81 source of weakness to this muscle. The value of tlie levator ant to the pelvic floor has, indeed, no dou])t, been greatly overstated. Kelly' goes so fur as to describe the muscular part of the floor as its principal strength. If one imagine the visceral portions of the pelvic fascia and the anal fascia removed, it is not difficult to realise the conijiarative weakness of the musculiu- diaphragm in supporting the intra-abdominal pressure. The other muscles of the pelvic floor play a very small part mi strengthening it. The fninsvertois j)crint'i is a very small muscle, very difficult to define - and less developed in the female than in the male. The sphinctev vaf/iim helps, iu a very small degree, to strengthen the floor through its sphincter action on the vagina (though, actcording to Symington," this is very slight, its main action being merely to compress the vestibular bulb) as well as through its attachment to the clitoris in front and to the central point of the perineum behind. The sphincter ant in the same way helps by its sphincter action on the anus as well as through its attachment to the central point of the perineum in front and the tip of the coccyx beliiud. 'The compressor nrethrcv or tramwersus perinei proJnnl^ TIIH I'LiOU STUDIKI) 1!Y 1)ISSI.;CTI()N 83 Symington' and Crocni - iirgo that the !)Ia(l(lcr slmul,! l,o roganlcd iis resting upon tho [.civic iluur. The tiuatomy of the parta shows "that it is embedded in the floor. Further, they say that because the organ fills and empties it cannot be considered as part of the Hoor. Is not this objection of the nature of a ([uibble ? Arc the anatomical connections not the same in all conditions of the bladder? If between two posts we tie a rope forming a kind of suspension bridge, and then cutting the rope in two attach between the ends a strong bag which can be filled and emj.ticd ; is the bag, because it is liollow, and capable of being filled aud emptied, not to be considered as forming part of the brid^-e ? iW The analogy is a fair one. The bladder is simply a bag slung between the walls of the anterior and lower part of the pelvis. Fof/ma.— The wall of this passage is slung in the pelvis by fascial and muscular attachments aud is thereby made to form an intimate portion of the pelvic floor. These attachments arc us follows : Fascial — - Triangular ligament wliidi it pierces. Vesico- vaginal layer of visceral pelvic fascia. Vagino-rectal layer. Muscular — Pubo-coccygeus division of levator ani. Sphincter vaginiu. Trausversus perinei profundus. Ordinary Connective Tissue — That connecting it with the bony wall. Op. cit. Oil. cit., i>. CO. # 84 THE PELVIC ELOOli nil I Secondary — Tlirou;;)i its V(M'y fii'ui junction witli the urcthni, the huMc. of tho bhulilcr iuul the lower part of the rectum, it is supported by the attachments of these structures. Tho analogy made in reference to the bladder will apply here again. Symington ' is unwarranted, I think, in making the greater portion of tho vaginal wall worthy of a place in tho pelvic floor, and at the same time excluding the upjjcr portion of tlic vaginal wall. Ilis coronal section, passing through this portion, has evidently misled him as to the wider relationships of the vagina. That the upper part of the vagina is less strongly united to the bladder and rectum than the lower and larger part is to the structures in front and behind it, cannot bo disputed. These connections are of small importance, hi re. the part they play in the pelvic floor. It is its lateral attachments to the pelvic wall, by means of the fascial structures of the floor, wnich are of chief importance. I quite admit, however, that the vesico-vaginal and recto-vaginal layers are thinner and weaker in their upper part than elsewhere. Rectum. — Most of the authors already quoted are not precise :n their reference to this structure. All are agreed that the lower portion of the wall of the gut fonning the anus is an intimate part of the floor. It is diqjuted as to where the upper limit ends. The so-aaWcA first 2^ci'Vt of the rectum — that part provided with a mesentery — must bo excluded. The second j^rt, which extends from the first part to the tij) of the coccyx and resting against the sacrum, coccyx, obturator-coccygeus part of the levator ani, and tho coccygcus itself, to all of which it is attached, cannot be considered as forming a part of the pelvic floor, since tho intra-abdominal pressure tends to push it, not out of the pelvis, but against the bony posterior wall. From the coccyx downwards the wall is a part of the pelvic floor, its attachments being as follow : Fascial — Recto-vaginal layer of visceral pelvic fascia. Rectal layer ,, ,, 1 Op nt., p. Of). THE FLOOR STUDIKD UY DISSECTION B5 Muscular — Pubo-coccygcuH portion of levator uiii. Sphincter nni. Connective tittsne — That connecting it with sui-rounding ^Jtirts unci wit lu bony wall. Secondary — Through its attiichnicuts to tliu posterior vaginal wail and perineum. The lowest part of the rectum, therefore, is, like the vagina, a tube slung between the sides of the pelvis by the fascial tissues of the floor, supported by certain muscles as well as by the vaginal and perineal attachments. It must bo borne in mind that the gut Is (juite closed unless distended by Hiitus or faices. Uterus. — Has this or.;an no claim to be considered part of the pelvic Hoor? According to Hart it has not. He says' that it merely rests on the f!oor, not being suspended. He compares it to the male bladder, which he regards as resting upon the pelvic floor, its ligaments having nothing to do with its support. This statement is opposed to all the teaching of anatomists. I can find no one who at all agrees with him in this view. It is sufficient to quote liom Sir William Turner^: — "Passing to the bladder are two important membranes which, together with its vessels and ducts, retain it in position. These membranes are the peritoneum and the pelvic fascia." Hart strenuously contends that the female bladder is a portion of the pelvic floor, and it is impossible to understand why he should not place the male organ in the same category, since they are both attached to the bony wall in practically the same manner. His comparison o^ the uterus to bladder is, therefore, from his point of view, a bad one. What, now, arc the connections of the uterus ? 1. In the Fa;tus. — The common origin of the uterus and vagina frjm * Obstetrical Traiuactioiis, Edin., vol. xiv. p. 24. ^ Introduction to Human Anatomy, Edin., 1882, !>. 7!)4. ^ 80 rilK I'KLVIC I'LOOIt the fu.siijii of tlu' lowiu- [m-[» nt tlio Miillciiuii diicts must \h' niiiciiibi'icd. la the third uiid fourth moiitliH there is no diHtiiiclion between the uterua mid vagina.' After this the uterine wall gradually liocomcH thicker, especially in the cervical portion, v;hilo a vaginal portion at the same time developH. The important fact to be noted, liowever, Ih that while the uterus is, in the fcetua, relatively higher than in the adult condition, in other respocts it has relations the reverse of those existing in the adult condition. Thus, in the fcotus, the cervix is both very much longer, as well as wider than the body — exactly the reverse of the adult condition. In the foetus the thickness of the cervix in proportion to the pelvic diameter is relatively greater than in the adult condition In the foetus there is relatively much less of the uterus covered witli peritoneum than in the adult. The broad ligaments are, therefore, in the foetus, relatively very small. The cervix, which forms f, tl; . whole uterus, is, save on its posterior surface where it is covered with peritoneum, firmly embedded ill the fascial and coniiectixe tissue structures, below the peritoneum. In front it is .ittachcd to the bladder which extends across the pelvis from side to side, the vesico- vaginal layer of pelvic fascia passing between them and being connected with both ; laterally it is connected with the pelvic wall. From its large sizo, relative to the width of the pelvic cavity, it is relatively nearer the wall than in the adult condition. In several of my cases, from being somewhat nearer one side than the other, the attachment is very short, and the cervix is practically fixed in position. In the foetus and new-horn child it is evident, theivfoi-e, that the pelvic floor is relatively thicker, and occupies more of the pelvis than in the adult. The greater i^ortioa of the uteims — the cervix — is also, in the early period of life, an intimate part of the floor. 2. In the Adidt. — The change from the fostal to the adult condition is characterised by a marked increase in the length and width of the body in relation to the cervix of the uterus. The greater part of the 1 Qiudn's Anatomy, Tenth Ed., vol. i. pt. i. p. 124. ^ THE I'l. Mi STUDIKI) IIV DISSKCTION 87 orfiriin in now covered with i)eritoneu .1, tlu! hroiul lif^miiieiits lieiiip in relation to nuieh more of tlie uteruH tlian in eiirly life. ()\vinelviH, the eervix rehitive to the pelvie cavity Ih very much smaller than in the fa-tus, and is relatively, therefore, at a farther distiuice from its walls. What, then, ant the adult attachment.s of the litems '? Fascial — Posterior i)art of vesico-^'iginal layer of visceral pelvic fascia. Connectirc tissue — That attaching cervix to Madder. That attaching crvix to si(l(! walls of pelvis (parametric). That attaching liody to pelvis in the fold of the liroail, ntero- sacral and round ligaments. Mii.scnhir — Non-striped muscle in the hroad, round, utero-sacrai aixl ntero- vesical ligaments. Secondary — Through its connection with the bladder and the vagina, which arc, as already seen, slung in the pelvis. What importance is to be attached to these various connections ? The vesico-vagiiud layer of pelvic fascia has not directly much influence in supporting the uterus since it is very thin at its posterior limit, blendiu"' with the tissue joining the bladder and cervix. The tissue between the bladder and cervix, though described as being loose in nature, is yet sufKcient to unite them intimately. It is, indeed, partly through this junction thnt the pubic segment is elevated during labour by the upward tension of uterine retraction, though, of course, the tension tells mainly on the vaginal wall, with which the uterine muscle is directly continuous. Schultzc' points out that this connection is very rarely disturbed. He says that, " not only does the uterus closely follow the posteric vail of the bladder in the movements due to the variations in the quantity ' The PnthoUijy ami Tmilmcnt of Displacements of the Ulrrus, lOii};. Trans., London, ji. 2. 88 THE PELVIC FLOOR of tiriiie contained in it, but the bladder also follows the anterior wall of the uterus so closely, when the latter organ is displaced or cidarged, that tlu! relation of the posterior ])ladder wall to any tumour in or above the pelvis is of great diagnostic importance whenever there is any doubt as to the share the uterus has in the formation of the tumour." Tiie connective tissue between the cervix and pelvic wall on each side is loose in nature. Non-striped muscle is found in it. What, now, is to be said regarding the broad ligaments ? Have they nothing to do with the support of the uterus ? The peritoneal covering is of very little practical im'iortance in serving this purpose. Within this covering, however, is fibro- muscular and clastic tissue' which can be traced as bands in several places running from the uterus to the pelvic wall. The upper part of the ligament, which is freely movable, containing the tube and ovary, can have nothing to do with supporting tlie uterus. If one exercise the slightest downward pressure on the uterus in the cadaver, it is found that a line of resistance is formed in the broad ligament runnin"- from near the cervix upwards and outwards towards its upper parietal attachment. The same thing is found during pregnancy and the puerperium. In pregnancy the suspending action of the ligaments is -very evident. Sir William Turner ^ says that they act as lateral ligaments for the organ. In the non-pregnant woman, in normal conditions, this may scarcely at all be present, and it may serve merely to steady the uterus, but if the other supports of the uterus be removed, or intra-abdominal pressure be increased, then the ligaments are stretched and eiuleavour to support the organ. In the operation of vaginal extirpation of the uterus, after the organ has been separated from its vesical and vaginal connections, although the vagina be distended as widely as possible, the uterus does not tend to fall down, but is kept in position by its ligamentous attachments. If at this stage the uterus be pulled down to the vulva and then let go, it is instantly drawn up again. Indeed, the difficult part of the operati' n is the ligaturing of those structures and the removal of the uterus from them. 1 Cop, 0/). nf., ]i. 210. ^ Op. ril., p. 841. THE FLOOR STUDIED BY DISSECTION 89 The utero-sjicral and the utoro-vesic;il ligumcuts act in much the samo manner as tlic broad ligaments, i.e. tliey are in a condition of somewhat elastic tension. A. R. Simpson' has emphasised the fact that in the normal condition the uterus may be i)ulled down to the vulva with ease. He says that " in general the organ must descend so far as to '-ring the os clear through the vulva before the utero-sacral ligaments arc put on the stretch. It is when these become quite tense that thcj patient has any sensation of special discomfort." This is undoubtedly true regarding parous women, but in uuUipani! one has to exercise more force, and even then can rarely draw the uterus so far down as in parous women. It is the clastic nature of the broad and utero-sacral lig-^ments that allows the uterus to be drawn down, and which helps partly to draw it i;p again. (As already mentioned, this may take place even when the vaginal and bladder attachments are gone.) Inflammation in the iigamcnts renders them less elastic and makes it difficult or impossible to draw down the uterus. Where the tonicity has disappeared, and they have become stretched and thinned, it is always a very easy matter to pull down the uterus. liUschka - has considered the utero-sacral ligaments of such importance that he has given the name of Muscularis retmctor iileri to the muscular tissue within them, and he says that they " determine and secure the normal posi- tion of the lower end of the uterus." It is oljjectcd by some that such thin foids cannot have much strength. The observations of Kiistner ^ ou this point are worthy of special note. He has made a special microscopic study of the utero-sacral folds, and he says that while in the free portion of the fold there is very little muscle, at its lateral attachment there is a dense Hat muscular bundle. He considers this almost equal in strength to the round ligaments. Coe * says that they commonly relax under the influence of an amcsthetic. It is to be noted also that the utero-sacral ligaments run backwards from the uterus in a direction practically parallel with the vagina. Through this > C'ontrib. to Obstet. and Oi/n., Kdiii., -^ Die NormaU uml Path. Lagen u. Bewiy. p. IS'l. ties Uterus, p. 44. - Anal. d. Menschl. lieckens, p, 360. ■• Op. eit., p. 221. N I, 90 THE PELVIC FLOOR tension they undoubtedly also act through the cervix on the vagina, helpiuj^ to keep up its upper end. Foster' indeed, says that the vagin.fj attached to the bone in front through its connections, forms with the utero- sacral ligaments through the medium of the cervix an antcro-posterior ])eam of considerable power. The vaginal attachment is, it seems to me, a very important support of the uterus. The vagina is slung in the pelvis by the fascial layers around it, and l)y its attachment to the bladdei', urethra, etc. The uterus being attached to the upper end of its wall is, in consequence, also supported. Schultze corroborates this view. He says- that the fixation of the vagina and its immediate surroundings is an essential factor in securing the position of the uterus. It is rather remarkable that Hart should place no value whatever on the supporting or even steadying power of these ligaments in the non-pregnant condition, but that he should, when explaining the action of the retracting uterine wall on the pelvic Hoor during labour, say^ that, as a result of the longitudinal muscle-bundles which pass into them from the uterus, they afford external fixed j^wints for uterine action, Avhereby during the pains the uterus is steadied. Surely this steadying and fixing power must be no inconsideral)le one. From an anatomical standpoint it is evident therefore : a. That the uterus does not merely rest upon the pelvic floor as a chair or table rests upon a house floor, as Hart* says it does, but that, through its cervical portion, it is embedded in and forms part of the pelvic floor. h. 'J^hat, Ijeing suspended ])y its vaginal and bladder attachments, by the broad and utero-sacral ligaments, it, thercfo]-e, as part of this suspension bridge arrangement, helps to resist the intra-abdominal pressure in the same manner though not in the same degree as the bladder. This resistance is less than that offered by the fascial layers lower in the pelvic floor. 1 Amer. Gyn. Trans., 1881. 2 Of. cit., i>. 1. 3 Ohalet. Trans., Edin., vol. xiv. p. 05. < lb., vol. V. lit. 2, \>. GC). m THE FLOOR STUDIED BY FROZEN SECTIONS 91 The Floor studied by Frozen Sections. The vertical mesial section shows, undoubtedly, in the non-pregnant woman, with parts intact, the appearance first described by Hart.^ The pelvic floor stretches from puljcs to sacrum broken only by the urethra, vagina, and anus. The vagina is a closed slit running practically parallel with the brim, and may be considered as dividing the floor into two parts — the pubic and sacral segments. Excluding the uterus, the former has a triangular shape and the latter an irregular quadrilateral shape. Hart describes the former as consisting of bladder, urethra, anterior vaginal wall, and bladder-peritoneum. Its attachment to the pubes is a loose one, being separated from it by a pyramidal mass of fat ; the posterior bladder wall is loosely attached to the anterior vaginal wall, while the urethra and anterior wall are closely blended. He describes the sacral segment as consisting of rectum, perineum, posterior vaginal wall, and "strong rcsistent muscular and tendinous tissue " ; the posterior vaginal wall and anterior rectal wall are loosely connected, as far dow;. as the apex of the perineal body. From these data he generalises as follows : "The pubic segment is loose in texture, has only a loose bony attach- ment anteriorly, and will evidently permit of mobility in an up and down direction. The sacral segment is made up of dense tissue, is strong in structure, has a strong dovetailed attachment to the sacrum, and is only movable downwards when it revolves round the sacrum and coccyx as a whole." The weakness in the floor, due to the presence of the vagina, is in the virgin practically of no importance. The pubic segment cannot slii) past the sacral because it is firmly pressed against it, the pressure actinff at right auffles to the vagina. These are the data upon which Hart has chiefly Itased his explanation of the mechanism of parturition, and to a considerable extent that of prolapsus uteri. I Ohtet. Trans., Eclin., vol. v. i>t. 2, p. fir>. I* THE PEL^'IC FLOOIl Where are tlie fallacies in this view of the floor ? A false impression as to the anatomical nature of the floor is given as well as of its mechanics. a. The floor is only divided into these segments liy the width of the vagina. The average width varies between, say 1 in. and Ig in. ; the average width of the pelvic outlet is 5 in. The pelvic floor is, therefore, only divided into a pubic and a sacral segment in \ or 1 of its width. h. Hart's description leaves out of account entirely the strong fascial layers which I have already described, and which are so intimately con- nected to form the fascial framework of the floor. lie describes strong tendinous and muscular tissues in the sacral segment, leaving them entirely out of account in the pubic segment. I have already shown that the visceral layers of the pelvic fascia are most strongly developed in the anterior part of the pelvic floor, while the 2^'uho-cocci/gcus portion of the levator ani and the transverse i)erinei lirofundus have certainly as much influence in the anterior part as in the posterior part of the floor. Fart's description takes no notice either of the triangular lig.ament or ol the important layer of deep superficial fascia under the skin. These omissions are due to the fact that in sections these fascial structures appear so blended with the tissues about them that they are not distinguished. c. Though in the middle line the bladder is separated from the lower part of the symphysis by loose cellular tissue and fat, behind the upper part it is close to the bone and more firmly attached. Certainly on each side, as my section (plate XII 1.) shows, it is more closely united with the bone. My section as well as Symington's ' shows that undoubtedly the pulnc segment is firmly attached to the lower margin of the pubes. The loose cellular tissue surrounding the bladder has not the first part to play in allowing of or limiting the movements of that organ. It is its fascial attachments — its true ligaments. The range of movement of which the bladder is capable is in reality chiefly the range possessed by these ligaments. All changes in position in the pubic segment, likewise, depend primarily * Ohtd. Trans., Ediii., vol. v. pt. 2, \i\\ fil, GO. THE FLOOR IN EELATION TO rREGNANCV 93 upon the range of movement and elasticity of its fascial attachments to the bone, secondarily of its muscular and other attachments. Hart dwelt upon the "loose nature" of the pubic segment and its " loose attachment " to the bone as necessary in explaining the disposition of the segments of the flocr in Braune's Second Stage cise. Such an explanation might be necessary were the pubic segment drawn up to the extent Hart thought it to be. (The nature and mechanism of the changes during parturition I shall discuss under the heading on page 95.) d. The description of the pubic segment as resting upon the sacral segment is a conclusion based entirely upon the fallacious conception of the pelvic floor which the vertical mesial section gives, and is entirely out of keeping with the structure of the floor as determined by dissection. The two segments are intimately connected ; the fiisci.il and muscular suspensory arrangement of the floor is common to both. The arti^cial division of the floor is not at all necessary, and is only of service in aiding us to :ompre- hend moi'c clearly the changes which take place during labour. The Floor in relation to Prkgnancy. During pregnancy there is considerable softening of the tissues of the floor. This is of great importance in facilitating the disturbance and stretching of the parts occasioned by parturition. As regards the disposi- tion of the floor as a whole, the chief change is that attendant upon the increased weight of the pregnant uterus, but partly also upon the softening of the tissues. In order to determine the amount of sinking of the floor thus caused, I have carefully studied two cadavera, the one in the fifth month of pregnancy,' and the other in the eighth month ,^ as well as the other cases previously puldishcd. I have arranged in tabular form the facts acquired by measurements in regard to tlie following points : 1. The pv^lvic floor projection and skin distance between the coccyx and the lower border of the symphysis pubis. 2. The change in the position of the urethral orifice. 1 Lab. Rqu R.C.P.E., vol. iv. - Barbour luul Welistei-, Luh. Reports H.d.P.E., vol. ii. 94 THE PELVIC FLOOR 3. The change in the position of the junction of the urethra with the lladder (base of bl; elder). 4. 'Ihickness of the tissue between the lowci' margin of the symi)hysi.s and the vagina in lii>e with the vertical axis of the former. 5. The depth of the utero- vesical pouch of peritoneum. 6. The position of the anterior and posterior lips of the cervix. The following table shows that during pregnancy the pelvic floor projection is increased as well as the skin distance from coccyx to symphysis ; that the base of the bladder, the urethral orifice, the cervix, the l)ottom of the utero-vesical pouch, are lower than in the nulliparous condition. All these facts show that the pelvic floor is bulged downwards somewhat during pregnancy. Table. Nullipara. Webstor'a 5 ino. Pieg. Barbour anil Webster's 8 mo. Preg. liiaune's 9 mo. Preg. In. In. In. In. Pelvic floor proj 1 '8 2 3:] Skin dis. from Coc. to Sym. . 5tV b\ Gl 10 Dist. of Uretli. Or. below brim 23 n 2S 2^ Dist. of Ureth. Or. below Sym. i 1 u 11 Dist. of junct. of Bktl. and Urethra below brim n 3 2^ n Thick, of Tissue bet. Pub. anil Vag. r. K i;; 12 Depth of Ut. Ves. Pouch below Iwini n '•^A 2! 2^- Dist. of 0. E. lielow brim post. n 4 3iV 31 Dist. of 0. E. below brim ant. 2i 4 3iV 3J Dist. of 0. I. below brim ant. . 2i 3J 2| n Dist. of 0. I. below post. n 3J n 2f For sake of comparison T have added tl le correspond ing measurem ents in the n iiUipara. THL FLOOR IN liELiVTION TO LABOUll 95 The Floor in relation to Labour. The disposition of the itelvie floor duniig the progress of labour luis been the subject of recent discussion. Hurt,' from a study of tlie vertical mesial section of Bruune's Second Stfigo case, arrived at the following conclusions : 1. The pu])i(! segment is hauled up partly above the brim by the upward tension of uterine reiiuotion, 2. The sacral segment is driven downwards. 3. The bladder is lifted up above the symphysis and stripi)ed of its peritoneum. 4. The urethra is clonoatcd. Symington,^ on the other hand, thinks that "the pul)ic segment is pushed downwards and forwards under the pubic arch," and "that the bladder is the only part of Hart's pubic segment that is not depressed." There is thus a very decided difference of opinion between these two authors. From the careful study of two cadavera,'^ the one in the first stage of labour, the other in the second stage, as well as of cases published by Barbour,^ Winter,^ Chiari,'' and Saexinger,* since Hart's work was written, I am in a position to show that Symington's views are entirely erroneous, and that Hart's views as to the drawing-up of the pubic seo'ment are correct as to the method by which this takes place, though not correct as to the extent of elevation which takes place. The method adopted by me in investigating this question was the following : I arranged the vertical mesial sections in order according to the degree to which labour had proceeded, and measured corresponding points in the floor in the various sections in reference to the anatomical brim conjugate and also to the symphysis. In this way one can follow throughout labour the changes in position taken up by these various points. By making a diagram, placing in it the ■I m 11' ' The Stnictural Anatomy of the Female Pelvic Floor, p. 14. ^ Op. di , p. 61. ^ PubliHlictl in conjunction with Dr. Barbour, Lah. Reports R.C.P.E., vol. ii. * Vide Biblioyrayhy. wm 9t> THK vu^'ic rr.ooii I points according to the nieasuicnicntH olttaiuod uml joining the coiivHpond- i r points, one niiglit gnipliicidly represent with considerable exactness the direction and extent <>f movement of each point. The measurements were made in reference to the following : 1. The pelvic floor projection and skin distance between the coccyx and the lower border of the syn^'Nysis. 2. Change in the position " the urethral orifice. 3. Change in the position of the junction of the urethra with the bladder (base of bladder). 4. Thickness of the tissue between the lower margin of the symphysis and the vagina in line with the vertical axis of the former. 5. The depth of the utero-vesical pouch of peritoneum. 6. The position of the os externum and os internum. 7. Chaiiffes in the relation of the junction of urethra and bladder (base of bladder), and the cervix to the pubes and to one another. Table 1. Pelvic Floor Pkojection and Skin Distance fkoji Coccyx to Lowku Margin OF Symphysis. stage. Nullipiu'iv Pregnancy, 5tli nio. 8tli „ 0th „ First Stage Second Stage I) Whoso Section. Averaj^e AVebstc'i's Biirhour and AVclister'« Braune's Barbour luul Webster's Winter's Schrueder's Barbour's Braune's Chiari's Barbour and Webster's Pelvic Floor Projection. In. 1 ' 8 n 2.V Skin Dis. from Coccyx to Syiii. In. lO" H 5.V 'I (In the other published sections the coccyx is not indicated, so that accurate measurements cannot be made.) THE FLOOK IN RKLATION TO LABOUU 97 This liiblo (F.) sliowH that in the early part of the first stage tluno is scirccly iiiiy cliange ; that in tlie first part of the second stage, while the bag of mem])raiie8 j^'T^i^tf', the pelvic floor projection is probably increased ; and that later, while the head is low di»wn it is diminished because of the coccyx being pushed downwards and backwards. The following table (II.) shows that the urethral orifice in the first stage Table II. ClIANOE IN THE POSITION OK rilH UllKTlIRAI. OUIFIC'K. Htaf,'o. Whose Ciiso. Distniicoiii front of llio Vcitleal Axis of I'libos. Oi«taiico below liriin. Distance below Lower Kdgi! of Syni]iliysi.s. III. In. In. Nullipara Average 1 2.1-2 A \ Pii'giiftiicy, 6tli iiif). 8tli „ nth „ Webster's Barbour and Webster's ' Braiine's 1 K 1. n 1 1. 1} First Stage » » Scliroeder's liarbour and Webster's Winter's Barbour's 1 a. n 4 5 H 1 1 Second Stage » If Braune' i Cliiari's Barbonr and Webstc. (i) i 2 (2|) 2\ i of labour is on a somewhat higher level, and that it is not anterior (probably slightly posterior) to the position occupied by it at the end of j^regnancy ; that, during the second stage, it occupies a still higher level ; and that, while an abnormally long persisting bag of membranes may cause it to appear scarcely moved at all backwards, in the more normal condition of the parts it is posterior to the plane occupied by it during the first stage. These fticts arc not in accordance with the theory of the pushing downwards and forwards of the pubic segment. ' Bladder partly distended. mm 98 TlIK I'KFiVIC FLOOR Tahle tit. ClIANOK IN THK POSITION OK THE JUN(;TION OK TIlK UUETllllA WITH TlIK BLAIilUCn. 'it Stago. WlioHO ('ano. DiKtiinco hvUm Urini. Pistmicii l)cliiiid Vertical Axis of Syinpliysis. Niillipnra Pregnancy, 5th mo. 8th „ 0th „ First Stage » II Second Stngo » » Avoroge Wel).Htcr'H Bnrhour and Webster's Brauno's Schnii'dei's Barhoiir and Wtbster'a Winter's IJarhour's Brauno's Ohiari's Barbour and Webster's In. 21 3 -} 2^ 1| In. n H r> H 1 ! I 5 1 .lust about in line with This tabic shows that the lowest part of the bladder, viz. the point of entrance of the urethra, is, during the early part of the first stage, scarcely altered in position (being neither raised nor pushed forwards), but that during the second stage it is considerably elevated. Table IV. TincKNKss OF Tissue between Loweh Margin of Puises and Vaoina in line WITH Vertical Axis ok Puhks. i'tagc. Whose Case. Thickness of Tissue. In. Nullipara Average fi Pregnancy, fith nio. 8th „ Webster's Barbour and Webster's n 9th „ Braune's '1 First Stage Schroeder's Barbour and Webster's It Winter's ;i » Barbour's Second St^e 11 II Braune's Chiari's Barbour and Webster's 1 TIIK FLOOIt IN liKLATlON TO LAIIOUU •J!) Tliis t:il)lo hIiuwh tliiit (Ik; tliickiuiHS of this tissuo, thirinj,' liiliour, is not iiicrotised, us it ccrttiiiily would be wore tliere ii pusliin^f downwiiid.s oC the pubic Hogmeut. Tablk V. Dki'th ok Utkuo-Vkhioal Pouch ok Pkiutonkum iiioi,ow Bium. HtaKo. Whose Sootiiin, Uiittaiico bulow liriiii. Nulliimrii Avomfeo In. 2.1 Progniincy, Blli nu). Webster'^ a.-',, 8tli „ UinlMmr ami Wulwtcr'H 2:,' 'Ml „ liniuiio'H 4 First Stage Winter'H 21 tt Biii'binir ami Welistcr'H It Sclivoeilur's 1 " n Barbour'a Second Stii^'c Brauiie's Above Brim. » Chiai'i'H 11 II Barbour and WubHtcr's II This tabic shows that the utoro-vcsieal pouch is not made to descend when labour commences, but is, on the contrary, elevated, i.e. 8trippe( Average Webster's Barbour and Webster's Braune's Scliroedcr's Barbour and Wobstcr'.s Winter's Braune's ' Cliiari's i Barbour and Web ter's In. 1 1 1 1 •s 1 (Just about in line with it) f tn. 2 H 1 If n a 1 T« Accompanying the uterine traction are two other conditions which help to force the pubic segment forwards against the bone, viz. the stiffening and passing forwards of the uterine wall during the pains and the com- pression by the head after it has descended through the dilated cervix into the pelvic cavity. At this stage, I believe, the head docs push the pubic segment, but pushes it upwards and forwards, and this is due to the strong upward and forward resistance of the sacral segment against the head. The bladder is not at all drawn up into the abdomen to the degree hitherto supposed ; the greatest part of it lies in the pelvis. In Braune's second stage case its highest point is f in. above the brim conjugate, in Chiari's 1 in., and in Barbour and Webster's If in. In the latter, it is to be observed, labour is further advanced than in the other cases ; here the position of the organ was well determined, the great mass of it lay behind the pubes having a transverse breadth of nearly five inches. In both Braune's and Chiari's cases the urethral opening of the bladder 1 Although Braunc and Chiari do not mark length of the canal. Wo now know that the the uitper limit of the urethra, we may almost urethra is not elongated in labour, exactly place it in their plates by measuring the TllK FLOOlt IN liELATION TO LAlJUUU 100 is lower than in Harbour and Webster's case. The explanation of these differences is to be found, most probably, in the unusual duration of the bag of membranes in an unbroken condition in the former two ; the downward and forward pressure exerted by it resists somewhat the upward traction of the uterus by pushing the anterior part of the pubic segment against the pubes. It seems to me, therefore, that from the facts obtained by a careful study of all the cases hitherto published, .vc are justified in concluding beyond doubt — 1. That the pubic segment is not at all pushed downwards during labour. 2. That, on the contrary, it is elevated, and mainly by the upward traction of the uterus, as Hart firsC pointed out. 3. That this traction is at work from the very commencement of labour, but that owing to opposing forces it does not begin to raise the (.""-ment before the first stage has advanced for a certain 2)erioil ; it is not, howevcj-, till the second stage that its effects arc marked. The segment is not made to slide up by reason of its supposed loose attachment to the bone. If the tables be examined it will be seen that the lower and anterior portion of the segment is very little raised ; the main elevation is in the upper and posterior part, e.g. junction of bladder and vagina witli cervix. This part is elevated and moved to the front, i.e. it may be described as moving in the arc of a circle whose centre is the line of attachment to the lower part of the pubes of the anterior visceral layer of the pelvic fascia or anterior true ligaments of the bladder. In the general softening of the tissues these ligaments probably take part, and so may be a little stretched. 4. That, in the second stage, the advancing child helps to compress the pubic segment thus moved forwards, and that when low down in the pelvis, the upward and forward resistance of the sacral segment increases still more the pressure. 5. That the greater part of the bladder is not drawn above the pubes, as Hart thought it to be. but that it really remains behind the pubes, only a small portion being above it ; the walls are then anterior and posterior, the urethral opening being at or near the most dependent part. 6. That the urethra is not elongated during labour. 1 ^' t 'i riS IOC THE PELVIC FLOOR 7. That the pcritoucuiii is stripped from a large part of the bladder. 8. That the elevation of the pubic segment may be somewhat retarded by long persistence of the bag of membranes. 9. That the sacral segment is driven down. 10. That the parametric and para-vaginal connective tissues are greatly stretched during labour. ThK FlOOU in llELATION TO PUOLAPSUS UtERI. Hart's description of the nature and mechanism of this affection is based chieHy upon the view of the pelvic floor obtained by a study of coronal and transverse sections.' Examined in this way, he finds that a ring of loose connective tissue can be traced in the pelvic floor running in the following direction ; beginning behind the pubes as the retropubic fat, it passes back on each side, on the inner aspect of the obturator interims and upper portion of the levator ani, and then l)etween the posterior vaginal and anterior rectal wall. This ring divides the pelvic floor into (a) The entire displaceahle portion, consisting of bladder, urethral and vaginal walls, with the uterus and appendages resting upon it. (6) The entire fixed portion, consisting of all outside the imier aspect of the levator ani and all behind the posterior aspect of the posterior vaginal wall. The loose tissue between these is a line of weakness. Tlie entire displaceable portion is supported by the entire fixed portion. In i)rolapsus uteri the former is driven down past the other, this line of weakness forming the " line of cleavage " between the two. is Hart's division of the pelvic floor in this way in keeping with the anatomical details furnished by dissection ? Does such an important line of weakness exist in the pelvis? Yes, if we leave out of consideration (he j)elvic fascia, as Hart has done. There is no doubt whatever that there is in the pelvis, as I have already pointed out, loose tissue behind the pubes, at the sides of the bladder, vagina, and rectum, and between the upper part of the vagina and the rectum. Hart's description, however, gives one the 1 Pp. cit. Topo(jriqihmd tind iSVf. Amt. nj the Fiiniik I'dvis, Edin., 1885. . THE FLOOR IN RELATION TO PKOLAPSUS UTERI 107 erroneous impression that this tissue is the sole link between the structures internal and those external to it, and that because of its weakness it is possible for the internal to slide down upon the external. The important structures which have been overlooked are the visceral layers of the pelvic fascia, forming ligaments for bladder and urethra, for vagina and rectum, as well as the triangular ligament, the deep superficial fascia and the anal fascia which blend with one another in the perineum, and also with some of the visceral layers, thus binding together inferiorly the structures described as " entire displaceable," and those described as " (sntire fixed." Verily, the pelvic floor described without the pelvic fascia ranks on the same footing as a house described withont foundations, girders, or rafters. It is as if we were to make a transverse section of a barrel between the hoops and then to describe the whole barrel as consisting of a series of cylindrically arranged staves (without reference to the very important though few and small hoops). The truest idea (jf the pelvic floor is gained when we consider it as having a strong fa.scial framework in which are suspended bladder, vagina, uterus, and rectum, and having in connection with it certain muscular structures which give additional strength. The floor thus as a whole resists intra-abdominal pi'cssure, the anterior and posterior parts of the floor being intimately connected by the fascial and muscular tissues. Anatomically, therefore, it can be proved that the so-called " displaceable portion " docs not merely vest on the "fixed portion" in such n, manner as that, when the support of the latter is gone, the former falls down. Clinically also, it seems to jne, the facts are against this view. Many cases of perineum rujitured even into the anus are not followed by prolapse ; whereas, if Hart were |' j correct, in every case, owing to the loss of support, this .snould occur. Prolapse of the bladder, urethra, and vagina with the uterus, in reality, it will l)e found, depend upon the power that the fascial and other tissues suspending them between the bony pelvic walls possess of resisting intra- abdominal pressure. If the former be weakened, or the latter increased, or both these conditions be combined, prolapsus occurs. The nature and mechanism of prolapsus uteri is still a very disputed riii 108 THE PELVIC FLOOR 4 question. There arc certain points, liowevcr, which are granted by every- body. These are as follows : Prolapse may be acute, subacute, or chronic ; the last is by far the most common variety, and is the form ordinarily referred to under this term. It is extremely rare in women who have never been pregnant. It is rare in women who arc in good circumstances and lead a comfortable life, even though they are multipara).' It is common among poor hard-working women. The influence of pregnancy and labour on the floor is as follows : — Its tissues are softened and stretched by the increased intra-abdominal pressure as well as during the birth of the child, when it may also be torn. After labour the floor bulges down more because of this stretching. Among the poor, women usually rise too soon from bed and begin too early to do such work as lifting, carrying, etc. Hence the greater tendency to a prolapse of the floor among them. What part does the perineum play ? There is no doubt that it is usually found to be more or less ruptured. Thomas,^ who described the perineal body as a wedge supporting the anterior part of the floor, said that the destruction of the wedge resulted in the prolapse. This is no longer bi'licvcd in. Hart says that rupture of the perineum is rupture of the "entire fixed segment," and that thus the "entire displaceablc " portion can be driven down more easily. That rupture of the perineum fixvours prolapse when other causes are in operation is undoubtedly true. It does so, howevci', not ])coausc a supporting wedge is removed, according to Thomas, nor because a supporting segment of the floor is weakened. These mechanical explanations arc not in keeping, as I have shown, with the anatomy of the floor. Neither is it, as is so often said, because the junction of the levatores ani is torn through. In an ordinary mesial tear passing even into the anus, only a small i)art of the iniho-coccyfjcus can be torn, viz. those fibres which are deflected inwards to the perineum from the main mass of the muscle which passes back on each side of the middle line to the coccyx. The most important structures torn through are the various fascial 1 Sclmltzc, The.Vathihijij nwl Trftilment nf Din- plaeimctits nf the Uhrii«, Kiig. Trans. 1888, ji. 277. ^ " The Female Pcriiienm ; its ^nat., Phys., ami I'ath.," Am. Jiwr. of Ohsl., A;.iil 1880. THE FLOOR IN RELATION TO TROLAI'SUS UTERI 100 tissues which meet in the perineum — a point vvliich lias l)ccn entirely overlooked. These are the following : 1. Triangular ligament — anterior and posterior layers. 2. Recto-vaginal visceral layer. 3. Anal fascia. 4. Deep superficial fascia. It is evident that such a rupture must lead to a weakening of the suspensory framework of the floor, especially in its anterior half The tearing of the small muscles, e.g. transversns jteHnei jnvfmuJus, transversm perinei, sphincter vagina, and sphincter ani, gives them after- wards but a small share in the support of the floor, though their loss is ot minor importance when compared with that of the fascial structures. In many women, chiefly among the well-to-do, who undergo little physical exertion, these losses may be present for a long time and yet no prolapse occur. This is because the rest of the suspensory framework is sufficient to resist the normal intra-abdominal pressure. If in such, however, chronic bronchitis supervene, the result may be that a prolajise occurs because the intra-abdominal pressure is too strong for the weakened floor. It is well known that there may be congenital deficiency of the perineum without prolapsus. One interesting case is recorded' by Pro- chownik, in which a girl lived in this condition until she was nearly twenty. She then, however, was put to very hard physical exertion for seven months, and the result was a prolapse. Now as to the nature of the prolapse. Hart says that the uterus has nothing to do with it, the condition being really a hernia of which the uterus forms part of its covering. Schultze, on the other hand, in his classical work on the subject, says,^ that the essential part of the affection is a descent of the whole uterus, the direct cause being the relaxation of its essential attachments — the utcro-sacral ligaments, giving rise to the retroversion, which is always, according to him, the preliminary stage of a prolapse. Hart does not mention the utero-sacral ligaments as having any ' ArrhivJ. Gyn., vol. xvii. p. 326. 2 q^, „;f p 273. 110 TIIK PELVIC FLOOR l!f I pai't to play wliatcvcr, and he says tliat tlic rctrovoi'Hioii ocoiu's (luring the progress of the prolapse. Hart says that, first of all, the floor in front of the anterior rectal wall is driven down — the anterior vaginal wall from below upwards, followed by the uterus and then by the posterior vaginal wall from above downwards. Tension on the cervix is caused, and hence retroversion results. Schultzc,' however, says that the displacement backwards which results from relaxa- tion of the utcro-sacral folds loads to the prolapse of the anterior vaginal wall, not the latter to the former ; this displacement diminishes to one-half or one-third the distance which previously sejjarated the uterine and pelvic insertions of the vagina, and so forces the anterior viiginal wall with the bladder to bulge into the lumen of the canal. Tie thinks that the psirt which the anterior vaginal wall plays in dragging down the uterus is over- estimated ; though not proven, he says that it is most probable that the first descent of the uterus is not thus brought about. These differences of opinion are certainly very great. The exact truth is, I believe, to be found midway between them. The mechanism is not the same in all cases. 1. Prolapsus in early life is rare, but Avhen it does occur it is un- doubtedly a condition connected with weakening of the floor. In fact the whole floor may be prolapsed, e.y ii'cciit hii'iiKurlm^'i', icsiiltiiii; fnjiii ft twi.stwl |io(liclc. It was itiiiovkI liy Dr. litiiy II;irt.' The iwiticiit iiiuild jjood iirnHicss for a week, tint on tli(^ iiiiitli -.lay iliod of cardiac fMilnrc. Methml iif Sliubj, — Tliu |p(dvis, iis well m tlic iilidonii'ii, was removed from tlio cadaver intact, and was frozen in tlid usual manner.' A vertical nu'sial section w.is cut, ilrawn, ami descrilied, after wldcli the contentH of the nmniotie cavity were renmved and a cast of tlio cavity lundo in plaster of I'aris. A cast of the fnlus was also taken. The spceiiiicn was then placed in spirit and studied in detail after a few day.s. Vkrtical Mksial Suction (I'lute XXV.) Bony Mcasiircments Brim — Conjugate (anatomical) . „ (obstetrical) Cavity — Conjugate . Outlet — Conjugate (sacral) (coccygeal) 4,i 111. 4 „ 4f „ H ., 4i ., Vertical lengtli of symphysis is one and a half inches, of sacrum and coccyx six inches. Pelvic floor projection is one and five-eighth inches. The umbilicus is opposite the junction of the tliird and fourth lumbar vertebra). Uterus. — Occupies the main part of the pelvic cavity and extends also above the brim. It is in close contact with surrounding structures. Above the brim the anterior wall lies against the abdominal parietes and ' To Dr. Hurt's gre.it kimliu'.'<3 I am indebted for the specimen. 2 Lab. Uqmrls 1W.I'.E., vol. ii. p. .3. IH FEMALE PELVIS IN THE HEGINNING OF THE FIFTH MOxVTII liiglier up against the intestino. Tlic fuiidus and upper part of the posterior wall arc also in relation to the intestine. The liighost point of the uterus is two and three -quarter inches above the brim. Below the brim the anterior wall preHses against the pubes and the upper wall of the I (ladder, the posterior wall touching from above downwards the upper part of the sacrum, the upper part of the rectum and a dermoid tumour of the right ovary which lies in the pout^L of Douglas. The lower part of the cervix is in cIohc contact with the vaginal walls. The OS cxlcrnvm is four inches below the brim, and the os mtcrnimi three and one-eighth Inches. The Vcirtical mesial circumference of tlio whole uterus is sixteen and a half inches. The hocfy is of firm consistence and of a pink-grev colour, that part with the placenta being slightly darker. On close examination the muscle shows a finely striated appearance, cliieHy in a longitiulinal direction. Several closed vessels are seen in the upper portion of the body, being especially numerous opposite the placenta. In the lower jxirtion of the body very few vessels are seen. Though there is no definite point at which the body can be divided into ail iqqjcr and lown' ntcnne mjnwnt, it is very evident Ihat this distinction can be made out — the upper portion of the uterine wall being considerably thicker than the lower portion, the passage from one to the other being gradual. On the anterior wall the difference is best marked, the point of division being about four and three-quarter inches above the cervix, or one and a half above the .symi)hysis ; on the posterior wall the change takes place lower down — about three-quarters of an inch nearer the cervix. The average thickness of the uj^iwr tUerine segment is nearly half an inch ; that of the lower uterine segment be" \g in the anterior wall three- sixteenths, and in the posterior one-quarter inch. Near the cervix both walls thicken slightly as tboy pass into the cervix. The cervix is darker in colour and coarser i texture than the body, being an inch in length. The anterior and posterior walls are in apposition at the lower end of the canal, but in the rest of its extent slightly separated. I'LATM XXV. The Fkmalk I'kiais in tiih 1!k(iinnin(i (U' iiik Fiitii Munth hk I'ltKdNANcv. Verlicid Mesial Scdiuii. II. I,i)vel of lIiiihiliciiH, /'. FiindiiH ulori. c. IMiiuoiiUi. (/. Li(|iior Ainnii. c. VeiiouH Sinus. /. Unil)iliciil Cold. l(icenta is on the anterior wall, being mostly on the uj^jier but partly on the lower uterine segvierd. It is of a dark red-purple colour. It is three-quarters of an inch in its greatest thickness— just above its centre ; it thins more markedly towards the lower end. The membranes arc seen as a thin lining on the wall of the uterus and crossing the os internum. The liquor amnii, the cord, the arms and thorax of the fcetus cut transversely, are well shown. The 2icritoneum in front descends to a point two and three-sixteenth inches below the brim, and behind three and one-quarter inches below it. Over the lower uterine segment anteriorly it is loosely attached, but posteriorly it is closely attached, just as it is to the upper uterine segment. The bhulder is emi)ty. It lies partly above, partly below the conjugate of the outlet. The upper surface is concave and in relation with the anterior uterine wall. It is in front closely attached to the back of the pubes, there being no well-defined retropubic triangular pad of fat between them. A thin layer of fat covers the anterior portion of the upper surface, and is continuous with a well-marked layer passing upwards to the abdominal wall. The upper wall below the utero-vesical pouch is connected to the uterus by very loose cellular tissue. The cavity is a mere slit. The urethra lies entirely h-Aow the outlet ; it is sigmoid-shaped, one and three-eighth inches in length. The junction of urethra and bladder lies three inches below the brim. The vagina has much less of the sigmoid curve than it normally has. The anterior and posterior walls are in apposition, save near the vulva. The rectum is divided from the anus as far as the lower cud of the sacrum. A small section of the upper portion of the gut is also seen near the lower end of the first sacral vertebra. i; ^p 116 FEMALE PELVIS IN THE BEGINNING OF THE FIFTH MONTH On examining the specimen, after it had been a few days in spirit, further information was gained. The lUerus is slightly nearer the right than the left side of the pelvis in its upper part. The bladder slopes from 1"low upwards and to tlie right, the highest point not being seen in vertical mesial section, being one and a half inches to the right of the symphysis and a quarter of an inch above the brim. The left broad liyament cannot be well described, owing to the con- traction of the upper part as a result of the removal of the left dermoid ovarian tumour. The riyht broad ligament in its upper part is somewhat dragged down- wards by the right ovarian tumour. The riyht dermoid ovarian ttmnour is about the size of a turkey's egg and lies in the pouch of Douglas, being compressed from before backwards. It contains the ordinary yellowish, fatty-looking contents, with hair, skin, and a few small bones, and from its plasticity is made to appear somewhat flattened between the uterus and the sacrum. No normal-looking piece of ovary could be detected, neither was any corpus hUeum to be found. Cast of Amniotic Cavity (Plate XXVI.) The cast was taken after the foetus and liquor amnii had been removed, the placenta and membranes being left in tiitti. Viewed from the front and back it has the general shape of a pear flattened from before backw :d, the broad end beinf;; lowermost. Viewed from tlie side it is also pyriform, the sides being compressed from before backwards ; the anterior surface is markedly convex, the posterior slightly convex below and concave in its upper part. The small antero-posterior diameter of the upper part is due to the flattening of the upper part of the uterus from before backwards, and also to the space occupied by the placenta on the upper part of the anterior wall. The left half of the cast is thicker 1 han the right. The posterior surface shows a flattening in its lower part chiefly on the right cide, caused by the dermoid tumour in the pouch of Douglas ; in its upper part is seen a hollow due to the pushing inwards of the uterine wall t.l PLATE XXVI ^ The Female Pelvis in the Beginning of the Fifth Month of Pregnancy. Cast of Amniotic Cavity. (Reduced.) Fig. 1. Anterior Aspect. a. Fundus uteri. h. Placental area. c. Os internum. Fig. 2. Left Lateral Aspect. (/. Fundus uteri. c Promontory mark. /. Os internum. PLATE XXVI. CM UliSUMfi 117 by tlio promontory. On the iiutcrior surface is st'cu the mark of tho phiccuta occupying .somewhat less than half the area of the surface ; it is oval in 8ha])c, the long axis being almost vertical and measuring four and a half inches, the transverse measuring three and a quarter inches, while the circumference measures twelve and a quarter inches. The water displacement of the whole cast is GIO c.c. The surface area of the whole cast is about sixty-five square inches. The jjlacental area measures about eleven and three-quarter inches. Cast ov Fodtus. The parts of the frozen foetus removed from the amniotic cavity were placed together, and cast in plaster. The attitude is one of flexion, though not of extreme degree, the limbs showing a considerable degree of extension at all the joints. The water displacement of the cast is 210 c.c. The 2)<^hiic Jloor j^J'ojection is one and five-eighth inches. If this bo compared with the projection in other ca.ses, we find that it is greater than in the nulliparous condition, and less than in the later months of pregnancy. stage. Whoso (.'use. Pelvic floor .'rejection. Skin distance from Coccyx to .Symjihysi.s. Nnllipiira Five months Prog. Eij,'ht months „ Nine mouths „ Average Webster Harbour and Webster Braune Braune and Zweifcl III. 1 2 In. 6A 10 7i The utei-us has the following characteristics worthy of note. Its longest diameter is the vertical, which measures from os externum to fundus about seven and three-quarter inches ; the greatest width is five inches, and the greatest antero-posterior diameter four inches. In the frozen state there is seen to be a flattening of the uterus from before backwards. In its upper part this is evidently due to the pressure of the anterior abdominal wall, and in the lower to the dermoid tumour in the pouch of Douglas. The 118 FEMALK PELVIS IN THE BEOINNINO 01 .lE FIFTH MONTH inegiilarity of outline of the wall is duo to tho pressure of neighbouriiif,' strueturcs iigtiiust it, eliicHy the ayniphysis and promontory. The cast of the cavity shows these points, and also brings out the fact that the uterus near the. fundus, in both its transverse and antero-postcrior diameters, is smaller than that part situated just above the cervix. When the parts were examined after thawing took place, the pressure of the anterior abdominal wall being removed, it was found that, when viewed from the side, the antero-posterior measurements of the upper and lower p(iles of the uterus were more nearly equal than they -ippcared to be in the frozen state. The fact that the upper portion of the uterus is not of larger bulk than the lower is worthy of note. At the beginning of pregnancy the pyriform shape of the uterus, with 2 a I OUTI.INK OK UlKUlIS SKKN I'KOM IHH FllON 1'. 1, At tlio beginning of iircRnanry. 2, During the third and fointh niontlis. 3, At the beginning of tlio fifth niontli. 4, At the end of pregnancy. its wide ujtper and narrow lower portion, is well recognised. A similar shape is again found late in pregnancy, as frozen sections and casts made by l)r. Barbour and myself show." It is also usually taught that, after the very early months, the uterus becomes spherical in shape. In this five months case the uterus is neither spherical, nor pyriform as in the later months. It seems, indeed, to be in an intermediate position. The longest diameter is the vertical one. The antero-posterior diameter is greatest just below the middle of the body. Of special interest, however, is the shape of the body as seen from the front. It differs from the pyriform and spheroidal shapes of the early months, as well as from the pyriform of the late mouths ; it has indeed a pyriform appearance, with, however, the tvidest part lowermost 1 Lab. Reports 11.U.P.E., vol. ii. p. 1. KESUMR 119 and not uppermost, ns is the case in the late montliH. The forcgoinjr diiirrrams reprosent the uterus as seen from the front at various stages of pregnancy. Wiicther this is the normal shape at tho iR'gimiing of the fifth month can only be demonstrated l>y frozen Rcctions and casts of other cases. In this case it is possible that the presence of the tumours may have somewhat modified the growth of the uterus, though one cannot definitely settle this point. Even, however, allowing for the pressure on the lower uterine segment by the small tumour in the pouch of Douglas, it i« '- ident tliat the transverse diameter of tho upper part of the uterus . least not greater than that of the lower part (thus ditVering greatly from the condition in early and late pregnancy) ; there seems, indeiul, to be no doubt that in this (rase the lower diameter is widiu- than the upper. If the uterus be compared with that of an eight months piegnancy case,' it is evident that there is a marked i)rei)onderancc in size, in the latter, of the upper portion of the uterus over the lower ; in fact, the casts seem to show that, from the l)cginning of the fifth month onwards, the increase in size of the uterus takes place almost entirely in its upper portion. The differentiation of the wall into lower and uj)i)er segments is well marked. It is, indeed, much better defined than in the other frozen 8cctio]is of pregnant women already published. In the latter (which are in the late stages of pregnancy), the upper uterine segment is much thinner than in the present case. Here the thickness of this part is aJjout the same as the wall of the non-pregnant uterus. As regards the lower uterine segment, this case agrees with the others in having that of the anterior wall thinner than the posterior, but differs from them in the great extent to which it is developed. Anteriorly, the apparent junction of the upper and lower .segments is more than four inches above the cervix (at this point there is a sinus in the wall — ? circular sinus) ; below this level the peri- toneum is loosely attached, while above it, it is very firmly attached. Posteriorly, the lower uterine segment is not so well marked off" from the upper ; the peritoneum covering it is firmly attached save in the lowermost portion. ' Lnh. IteporU IIV.P.E., vol. ii. p. 7. 120 FKMALK PKLVIS IN THE BKaiNNINQ OF THE FIFTH MONTH In none of the other published cases is the h)wer uterine segment of sucli a length as in this case. In n uterus at full time, described by Bayer,' it measured three and one-eighth inches (8 cm.) ; in another it measured three and one-sixteenth inches (7'5 cm.) Ilofmeicr^ has also found it to m(uisure two and three-quarter inches (7 cm.) in two full-time cases. Is the extreme degree of development of the lower uterine segment in this case abnormal or oidy unusual ? In Harbour's table,' describing all the uteri in which the segment has been described, the greatest variations are found to exist. For example, in Renckiser's four months case tlie firm attachment of the peritoneum is one and three-eighth inclu's (3'5 i .i.) above the cervix, whereas in Mayer's it is opiwsitc the upper end of the cervix. There is no reason to doubt that the present condition is but one of many variations found. Possibly the firm attachment of the peritoneum may not mark the up\)('r limit of the segment, though, indeed, it is exactly opposite the junction of the thick upper and ihin lower uterine segments. In some cases described l)y Bandl, it was a little above the upper end of the lower .segment. It is possible, also, that the uterine wall to which the lowest bit of the placenta is attached is not lower but upper segment, and it may be only the commencement of the thinning of that part of the wall becau.se of the placental attachment. In the other frozen sections the placental part of the wall is much thinner than in the present case. Allowing for this po.ssible explanation of part of the thinning, there would still remain a lower segment of exceptional length — the longest of any recorded case. It is very evident that the cervix does not enter into the formation of the lower segment ; it is of much the same size as in the nulliparous condition. A careful study of all the vertical mesial frozen sections in published cases shows that in the later months the cervix is as large as in the early period, being only somewhat compressed from above downwards, so that it appears slightly shorter and thicker. This condition is chiefly due to the pressure of the softened uterus against the sacral segment of the pelvic floor ; the softening becomes even more marked as pregnancy ' Moi-]>h. d. Clebiinnutter, 1885. Daswiterc Utednsegmmtes, etc., 1886. ■' The Anat. nf Lahnur, etc., 1 880. UfiSUME 121 n(lviincr>8. Owing t<. the continued Iiypernjmia tlioro may even lie some inercivsed growth, Mucii of the (liscuHHion iis to tlu« relation of the cervix to the lower segniont hiiH arisen from the study of uteri removed from the hody ; in tliis way Hatteuing of the cervix occurs, so that its normal Hha|.e is eom|.l.tely altered. Moreover, a micromiopic study of the mucous m.Muhrane cannot decide the question ; the passage of the cervical mucous niembrane into the decidua of Liie lower segment is not al)rui)t l)iit gradual, and no well- defined OS internum can be made out. Of much greater value is the examination of the muscular tissue, that of the lower segment being arranged in a series of plates, mostly longitudinally arranged, that of the cervix being a felted network of bundles. The peritoneum has a somewhat unusual arrangement. In front, dn bott(mi of the utcro-vesical pouch is not as low in relation to the cervix and bladder as is generally the case ; behind, also, the bottom of the pouch of Douglas is above the level of the posterior fornix, not leaching down between the rectum and upper part of the posterinr vaginal wall as it does in tiie great majority of cases. The dip of the utero-vcsical pouch below the l)rim is two and three-sixteenth inches, and that of the pouch of Douglas three and a quarter inches. If these measurements be compared with corresponding ones in the nullipara, there is found to be very little ('iffcrcncc. The peculiarity in this case is not that the pouches arc inusually high, but that the uterus is exceptionally low in the pelvis. It is probable that the peritoneum has not descended with the uterus as the latter has sunk down, and has been consequently separated from its lowest attachments. The tissue below the utcro-vesical pouch, between the bladder and lower uterine segment, is very delicate and loose, and would easily allow of this separation. The reflection of the peritoneum, from the anterior abdominal wall to the bladder, is exceptional. In most nulliparous cases, the highest point of the bladder is in the middle line, either above or below the upper margin of the symphysis, the outer edge sloping downwards and outwards on each side behind the pubic bones. I 122 FEMALE TELVlS IN THE BEGINNING OF THE FIFTH MONTH In this case, however; tlic l)la(Ulcr is inclined obliquely from below upwards and to the right, the highest point being a quarter of an inch a])ove the ])rim, and one and a half inches to the right of the symphysis. The disposition of tl, j pelvic peritoneum during pregnancy has not yet been definitely scttlctl. Regarding its lateral arrangement it is der- J.iat, during the progress of gee* -tion, as the uterus increases in its transverse and vertical diameters, the peritoneum on each si^e of the pelvis is con- siderably elevated. This has been well demonstrated by Barbour and Polk. Rcfrardincr the arrangement in front and behind there is considerable uncertainty. Polk ' declares that the peritoneum is lifted up so that (while in the non-pregnant condition a line drawn from the centre of the symphysis to the junction of the third and fourth SiKU'al bones corresponds to its lowest portion in front of the uterus and behind, except the pouch of Douglas), at the end of pregnancy, and before the uterus has fallen, its lowest level (excepting the pouch of Douglas) is at a line from the centre of the symphysis to the promontory. This statement is not in accord with the evidence furni.^hcd by frozen sections. Polk formed his conclusions from dissectional work — an unreli- able method in determining topographical relationships especially in investi- gating pregnancy, because, owing to the increased softening of the pelvic tissues in that condition, they are very readily stretched and compressed, the normal position of parts l)eing easily altered. Most of the fro.'cen sections of nullipara) show that the peritoneum reaches a lower level than that indicated by Polk. In regard to the changes during pregnancy, though we cannot speak with absolute certainty, owing to the lack of a sufficient number of frozen sections, yet wc have sufficient facts at our disposal to disprove the state- ments made by Polk and others. Variations are doubtless found, just as in the nuUiparous condition. If we measure the dip of the peritoneal pouches below the brim of the present five months case, in Barbour and Webster's eifht months case, and in Braunc's full-time case, we find that the pouches are as low as in the nullipara, or even lower. In a ^Ax months case of Barbour's (unpublished) it is three-quarters of an inch lower (I leave out of 1 Ncv> \ork Med, Jniini., vol. xxxv. j). "00. lifiSUiMJi 123 cousidenitiou tlic full-time ca,ses of Waldcyer, and Hraimo and Zwcifcl, the first liavinj^ a fractured pelvis and the other au unusual arraugeineut of the bladder). The changes in the anterior attachments of the peritoneum during pregnancy have always been described in relation to the uterus and the bladder. The growing uterus elevates the peritoneum, it is usually said, stripping it from the bladder ; the pouch of Retzius, therefore, at; well as that of Douglas, must reach a higher level as pregnancy advances. This conclusion is contradicted, we find, by frozen sections. As regards the stripping of the bladder, we find, certainly, that this does take place in pregnancy, though, as the sections show, the amount varies in ditferent ciises. From a study of the frozen sections, it seems to me that the hitherto attributed cause, viz. the elevation of the peritoneum by the growing uterus, is not the main cause. The growth-changes in the uterus in the latter half of pregnancy, as I have already indicated, affect chiefly its upper and not its lower part. " is difficult to see how these changes can disturb the peritoneal relations of the pouches of Douglas and Retzius. The explanation is rather that the bladder is stripped away from the peritoneum by th-^ sinking of the pelvic floor; owing to the very delicate loose connective tissue joining the bladder and peritoneum, the latter does not follow the posterior part of the former in its downward descent. Usually the bulging of the floor is most marked near the end of the pregnancy, and Waldeyer's and Brauiie's sections show a great part of the bladder uncovered. In Barbour and Webster's eight months case, where the bladder is not so pushed down, there is scarcely any stripping of the peritoneum. In tiiis five months case, where the bladder is very low, a considerable portion has lost its peritoneum. The variations that are found in the diflerent cases may have normally existed in the non-jjregnant condition, ])ut they are, no doubt, partly due to the fact that the peritoneum of the utero-vesical pouch is more or less folded in diflerent cases. Whatever be the cause of the stripping of the bladder, the extent of the stripping must de})end upon the num])er and size of these folds to be unfolded. 124 FEMALE PELVIS IN THE BEGINNING OF THE FIFTH MONTH 1 As regards the pouch of Douglas, there is no elevation in its central portion throughout the whole of pregnancy. The explanation of the low position of the uterus is not evident. The frozen sections of full-time cases show as much sinking, while in the eisrht months case it is nearly as low. It is usually taught that this extreme degree is only normally met with at the end of gestation. It may be that the sinking is progressive from about the middle of pregnancy, being, in some cases, very marked long before term. In this case, it must not be forgotten, the presence of the tumours may have something to do with the low position. The coexistence of pregnancy and double ovarian tumour, though rare, has been noticed in several cases. Sometimes, as here, it is impossible to find ovarian tissue, while no corpus luteum may be found. , BIBLIOGRAniY AOTEPAOE, These, Lyon, 1880. Burner, Ueber <1. puerp. Uterus, 187r). Benckiser, Ziir Aiiat. J. Cer. ii. iiulcruterin scg., 1882. Breisky, Cyclop, of Obstet. and Gyn., vol. x. 1889. Barbour, The Anat. of Lab. and its Clin. Bear., 1889 ; Atlas of Anat. of Lab., 1889. Braune, Die Lage d. Uterus und Foetus am Ende d. Scliwang., 1872. Braunb u. Zweifel, Oefi'ierdurclisch. durch d. Korp. e. lloohscliwang. gefuhrt, 1890. Barrour and WED.STER, Anat. of Advanced Prog, and of Lab.; Lab. Reports R.C.P.E., vol. ii. Bandl, Ueber d. Verhalten d. Uterus u. Cervi.x in d. Schwangerschaft u. walirund d. Geburt, 1876. Bayer, Morphologic d. Gebiirnuitter, etc., 1885. Charpentier, Traite d. Accouch., 1883. Croom, Tiie Bladder, 1884; Okstet. Trans., Edin., vol. xiv. CoE, Amer. Syst. of Gyn. and Obstet., 1887. Chiari, Ueb. d. topogr. Verhalt. d. Gen., etc., 1885. Cunningham, The Dissector's Guide, 1880. Duncan, Mechanism of Nut. and Morbid Part., 1875. Foster, Am. Jour, of Obst., vol. xiii. ; Am. Gyn. Trans., 1881. Ferguson, Obstet. Trans., Edin,, v(il. .\iv. Hart, Obstet. Trans., Edin., vol. v. ; Obstet. Tran,s., Edin., vol. xiv. ; Tlic Struct. Anat. of Feni. Pel v. Floor, 1880; Topog. and Sect. Anat. of the Fern. Pelv., 1885. Hart and Barbour, Man. of Gyn., 1890. IIki,M[:, Lab. Uep. B.C.P.E., vol. iii. IlESCili^, Zeitsch. d. K. K. Ges. d. Aertze m Wien, 1852. Hoi'MEiER, Das unl, Uterinseg. in Anal. n. Physiolog. Beziehung, 1880. Kehukr, Midler's Mandbuch d. Gyn., 1888. KiJsTNKR, Das Unt. Ut. Scg., 1882 ; Die Normal u. Path. Lag. w. Bewcg. d. Uterus. Kelly, Am. Syst. of Gyn. and Ohst, 1887. LU.SCIIKA, Die Muse, am Boden d. AVeib. Beck., 18G1. LusK, The Science and Art of Mid., 1892. Martin, E., Die Neig. u. lieug. d. tiebiirmut., 186(i. MiLsoM, Tiic.se, l.iyoii, 1880. Maccormac;, Qualii's Did. of Med., 1883. Newell, Leonard's lllus. Med. Jour., Detroit, 1890. Oi.SHAUSEN, Die Krankb. d. Ovarieii, 188G. Polk, Observations upon the Anat. of the FemaL Pelvis ; N.Y. Med. Journ., vol. xxxvi. Pkochownik, Arch. f. Gyn., vol. xvii. Uanney AND FoOTKR, Am. Gyii. Trans., 1881. 126 BIBLIOGRAPHY ScHllOKDEU, Dor Schwang. u. kreis. Ut., 188G. Saexinqeu, Oefricrdui'chscb. eiuer Kruis., 1888. ScHULTZE, The Path, and Treat, of Displac. of the Ut., Eiig. Trans., 1888. SiJU'soN, A. R., Contrib. to Obstet. and Qyn., 1880. Savage, The Female Pelvic Organ.s, 1882. Stratz, Scliroeder's "Der Schwang. u. kreis. Ut., 188C." Symington, Edin. Med. Jour., March 1889. Si'iEGELUERQ, Toxt Book of Mid., Eng. Trans., 1888. TillEDE, Zeitschr. f. Oyn., bd. iv. TuKNEll, Introd. to Hum. Anat., 1882. Thomas, Am. Jour, of Obstet., 1880. WiNCKEi,, Text Book of Mid., Eng. Trans., 1890. Waldeyeu, Medianschnitt einer Hochsch. etc,, 188C. Winter, Zwci Medianschnitt durch Qebiirende, etc., 1889. INDEX I. THR ANATOMY OF THE FEMALE PELVIS DURING THE PUERPERIUM. Bfgiuniwj of Puerpcrimn — Bkililer, 3, 6. liioad li<;nmciita, 5, 8, 9. Disscctional, 8. Extra-uterine nicasmi'nients, 3, 5. Falloiiiiiii tubes, 8, 0. Ovaries, 8, 9. Peritoneum, 4, 5, 8, 9. Rectum, 4, K, 7. Transverse section, 4. Ureters, f), 8. Ut.-sac. and round ligaments, 9. Uterus, 1, 4, 0. Vagina, 3, 7. Vertical mesial section, 1. ,, obli(iue section, 0. Fourth Day— HIadder, 28, 33, 35. liroad ligaments, 31, 33. nissectional, 31. Extra-utcriiic measurements, 28, 30. Fallopian tubes, 31, 33. Ovaries, 31, 33. Peritoneum, 29, 32. Rectum, 29, 30. Transverse section, 30. Urotcra, 31. Ut.-sac. and round ligaments, 32, 33. Uterus, 26, 30. Vagina, 28. Vertical mesial section, 26. Fifteenth Day — Bladder, 49, 52. Broad ligaments, 53, 64. Dissectlonal, 52. Extra-uterine measurements, 49, 51. Extra-peritoneal tissues, 51. Fallopian tubes, 52, 54. Ovaries, 52, 53. I'lritoneum, 50, 52, 53. Rectum, 50. Transverse .section, 51. Ureters, 52. Ut.-sac. and round ligaments, 63, 54. Uterus, 48, 51. Vagina, 49, 52. Vertical mesial section, 48. Bladder, 65. liroad ligaments, 67. Fallopian tubes, 67. Ovaries, 67. Pelvic floor projection, 66. Perineum, 66. I'ost-partum sbock, 69. Relation of anatomical facts to Crcdi; manipula- tion, 70. V.igina, 66. Uterus, 55, 59. Cavity, 60, 62. Cervix, 57, 64. Diminution in size, 59. Inner wall, 62. In contracted pelves, 66. In enlarged pelves, 65. Lower uterine segment, 56, 62. Outer surface, 61. Relation to extra-uterine tissues, 63. „ pelvic wall, 63. Rotation, 58. Upper iitorine segment, 56, 60. 128 Sccoml Day — niadilor, 12, 18. IJioad ligaments, 14, 10, 17. Disscotion, 14. Kxtra-iioritoiipal tiaaiio.'i, 14. Extra-iitciiiu! niciisurcmeiit.s, 11, 13. Fallopian tubes, 15, 17. Ovaiifs, 15, 16. I'eritoncnni, 12, 18. Rectum, 12, 14. Tiansvei'80 soi'tion, l.'t. Ureters, 14. Ut.-sae. and round ligament, l(i, 17, 18. Uterus, 10, 13. Vagina, 12. Vertical mesial section, 10. Sixth Day— Bladder, 3(i, 37, 39, 41, 44. Hroad ligaments, 42, 43, 44, 45. Coronal section, 37, 38, 40, 42. Pis.section, 44. Extra-utorinc nic.isnrements, 34. Kxtra-iioritoneal tissues, 37, 38, 40, 43. Fallopian tubes, 42, 4.5, 46. Malformed int. genitals, 46. INDEX Ovaries, 42, 45, 46. Peritoneum, 36, 40, 43. Rectum, 30, 41, 43, 44. Ureters, 44. Ut.-sai\ and rnninl ligaments, 42, 44, 45. Uterus, 34, 37, 38, 40, 42, 44. Vagina, 35, 33, 39, 41, 43. Vertical mesi.al section, 34. Third Day— I'.laddcr, 20, 25. liro.id ligiiments, 2u. Coronal section, 22. Dissection, 24. Extra-iwritoneal tissues, 20, 21, 23. Extrauterine measurements, 20. Falbipiiin tubes, 24. Ovaries, 24, 2,5. IVritonenm, 21, 23, 2,5. Rectum, 21, 22, 25. Ureters, 24. Uterus, 19, 22. Ut.-s.ac. and round ligaments, 25. Vagina, 21. Vortical mesial section, 10. II. THE FEMALE PELVIC FLOOR. Anal fascia, 78. Broad ligaments, relation of, 88. Dissectioual view, 76. Etiology of prolapsus uteri, IDS. Fallacies in sectional study, 92, 107. Floor in relation to parturition, 94 „ „ pregnancy, 93. ,, ,, prolapsus uteri, 106. Meaning nf Icrni " I'loor," 74. Musdrs of F!om; 79. OlutOHS max., 81. Levator ani, 79. .Sphincter ani, 81. ,, vagune, 81. Tran.qversns perinei, 81. ,, ,, profund., 81. Nature of prolapsus uteri, 109. Parietal pelvic; fascia, 76. Sacro-sciatic ligaments, 77. Sectional study of floor, 91. Superficial fascia, 79. Triangular lig.amcnts, 76. Ht.-siie. ligaments, 89, 90. Varieties of prolapsus uteri, 111 Vi.iccrnl pe hncfuseia. 76. Anterior layer. 76. Rectal i» 78. Recto-vaginal ayei , 78. Vesical )I 77. Vosieo-Vf ginal 11 77. Viscera ami Piismgrs connected with Floor, f Bladder, 82, 92. Rectum, 84. Uleriis, 85. In adult 86. In fietus 85. Wbite line 77. '■i ^ INDEX 129 Til. THE FEMALE PELVIS IN THE BEGINNING OF THE FIFTH MONTH OF PREGNANCY. niaddcr, 115, 116. Bioad liganicnts, 116. Cast of amniotic cavity, 116. ,, f(CtU8, 117. Coivi.t uteri, 114, 120. Double ovarian tumour with pregnancy, 121. Lower uterine segment, 114, 119. Pelvic floor |)rojection, 117. Peritoneum, 115, 121. Placenta, 115, 117. Shape of Uterus, 118. Umliiliou.'), 113. Upper uterine segment, 114, 119. Uterus, 113, 116, 118. Vertical mcsiaF section, 113. J YOUNG J. PENTLAND'S RECENT PUBLICATIONS. Tliiid, Kiiliirged, ami tlioiouglily Kivinia Kiliti »v«, Chitli, i.|i. xx. «f>2, Illustmtwl with lOft Colounil "I'IntrH fidiii OriKiiml l)ra»iii);td, 8v4i( iaii lor Di.sia.si'a orilK' Skin, Kilinh\irHh Itoyal Inliiniary ; Consulting I'liysiciivn, Edinburgh City Hosiiital ; Lectunr on iJiscasus of thu Skin, School of Medicine, Edinhuigh. [/'cnlliiiitl'ii Mi/ioil So'iis—rul. J. In Press, Second Edition, 8vo. To lie Illustrated with many additional Coloured Tlatcs from (Irigiual Drawings. 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