PLEASE PiANDLE WITH CARE University of Connecticut Libraries 3 =1153 oiss^ma 7 THEORETICAL AND PEACTICAL TREATISE MIDWIFERY. PI 1 Ml ,%fe A lire; Del i; ivieiw s Ui ' V^4 THEOEETICAL AND PRACTICAL TREATISE MIDWIFERY, INCLUDING THE DISEASES OF PEEGNANCY AND PARTURITION, AND THE ATTENTIONS REQUIRED BY THE CHILD FROM BIRTH TO THE PERIOD OF WEANING. BY P. C A Z E A U X, member op the imperial academy of medicine; adjunct professor in the facult? of medicine of paris; chevalier of the supplementary number of the order of charles iii; member of the surgical society; of tpe biological society; op the medical society of emulation; op the anatomical society; non-resident associate of the medical society of bordeaux; correspondent of the society of ACCOUCHEURS OF BERLIN ; PRESIDENT OF THE MEDICAL SOCIETY OF THE DEPARTMENT OF THE SEINE. APOPTED BY THE SUPERIOR COUXCIL OF PUBLIC IX3TRUCTI0X, AXD PLACED, BY MINISTERIAL DECISION, IN THE RANK OF THE CLASSICAL WORKS DESIGNED FOR THE USE OF MID^\'IFE STUDENTS, IN THE MATERNITY HOSPITAL OF PARIS. SECOND AMERICAN, TRANSLATED FROM THE FIFTH FRENCH EDITION, BY WM. R. BULLOCK, M.D. Mitfcf iiu Juniirc^ an& |0rtg Illustrations. PHILADELPHIA: LINDSAY & BLAKISTON. 1860. Entered, according to Act of Congress, in the year 1857, BY LINDSAY AND BLAKISTON, In the Clerk's Office of the District Court for the Eastern District of Pennsylyania. pniLA delphia: C. SHERMAN & SON, PRINTEn:*, 19 St. James Street. TO DOCTOR HAYER, physician ix ordixary to the empekor ; member of the institute (academy of sciences); of the imperial academy of medicine ; president of the imperial council of hygiene; president and founder of the biological society; physician op the hospital of la charite; commander of the legion of honor. Crstiranninl nf (0ratittih aul Mixihn, p. CAZEAUX. TExlNSLATOR'S PREFACE. The second edition of Cazeaux's Midwifery was translated by Prof. Robert P. Thomas, of Philadelphia, in 1850. A translation of the fifth and last French edition is now offered to the profession in this country. The entire work has undergone a thorough revision by the author, and has received, as will be learned from his preface, alterations and additions which make it, so to speak, a new book. To avoid repetition, the reader is referred to the author's preface and introduction, where are fully detailed the points wherein it differs from other works, and from previous editions of the same work. The translator has only to add, that he has endeavored to perform his task faithfully, and would ask for the work the candid attention to which the experience and position of the author entitle it. WM. R. BULLOCK. W'lLMiXGTox, Delaware, August 17th, 18.57. PREFACE. When a book readies its fifth edition, a preface is hardly needed, for, bj that time, the object of the work is sufficiently well known. The present is more particularly intended for the use of students of medicine and midwife-students, although general practitioners may also, perhaps, gain something by its perusal, for I have endeavored to make it a con- densed summary of the leading principles established by the masters of our art, and for that purpose have drawn from all the works published, down to the present day. My position in the lying-in hospitals has enabled me to test the value of the doctrines put forth by former authors ; and I have adopted as true all which my daily experience has confirmed, and have rejected unhesitatingly, from whatever source they came, all such as were disproved by the numerous cases brought under my observa- tion, confining myself to quoting without comment, those whose value I have been unable to determine. Although this work resembles, in its general arrangement, most of those published on the same subject in France, it differs from them essentially in the main, for I have adopted almost wholly the views of Professors Naegele, P. Dubois, and Stoltz, which are not found clearly expressed in any of our classical books. I have also extracted freely from the learned treatise of Professor Velpeau, whose vast erudition has greatly facilitated my bibliographical researches ; from the course of my former teacher. Professor Moreau ; from the excellent articles of Desor- meaux, of Duges, and of Guillemot ; from the classical works of England and America, such as those of Burns, Campbell, Merriman, Ramsbotham, Dewees, Meigs, and Rigby ; and from the treatises of Peu, Delamotte, Levret, Smellie, Baudelocque, Gardien, and Capuron. I have also con- sulted with advantage, the manual recently published by my friend, Dr. Jacquemier, also, the memoirs of Simpson, Tyler Smith, Depaul, Devilliers, &c. Lastly, it will be seen how highly I value the eminently practical writings of Madame Lachapelle. In a word, I have selected X P 11 E F A C E. from all sources, whatever bears the impress of truth. In the sciences of observation, a new work is necessarily enriched by the labors of all antecedent writers ; and therefore, its greatest merit consists in collect- ing the scattered materials, and forming out of them a body of doctrine, Avhich it illustrates in the clearest and simplest manner possible. Such is the end I have endeavored to attain ; and the medical public, and students especially, must judge whether I have succeeded in the attempt. But few quotations have been made, though their number might have been greatly increased ; but I wished to avoid the charge made by most students against one of our best classical works. However, I have felt bound to refer to living authors whenever I have introduced a new theory, or any particular procedure, which emanated from them ; and besides, as the professorate may be deemed a mode of publicity, I have respected the right to the original ideas which I have heard emitted by Professor Dubois ; and his name will be found scrupulously associated with all the opinions emanating from him. Notwithstanding a spurious copy published in Belgium, and several translations into foreign languages, the four large editions of the work first published, were rapidly exhausted. So favorable a reception made it obligatory upon me to neglect nothing which could render the fifth edition worthy of the reputation of its predecessors. I have reviewed and corrected all parts of it with scrupulous care. The numerous addi- tions made in 1850, have been retained; of these, may be noted the chapters devoted to the study of 1. The secretory apparatus of the genital organs ; 2. Of the structure of the ovaries, and of the human ovum; 3. Of the development of the corpus luteum ; 4. Of the modifi- cations undergone by the mucous membrane of the uterus at the various epochs of the life of the female ; 5. Of the decidua ; 6. Of menstrua- tion. Especially has the pathology of the pregnant female been greatly extended ; in its study I have assumed, as a starting-point, the modifica- tions produced by pregnancy in the composition of the blood. One great fact appears to me to rule the pathology of the puerperal state, namely, the diminution of the solid constituents of the blood. This diminution, which may be regarded as physiological (Researches of Andral and Gavarret), since it is observed in almost all pregnant women, is very frequently so great as to becpme pathological. Different morbid phenomena are then produced, according to the element which is princi- pally involved. I have long since shown, and my views are generally received, that chlorosis, or puerperal hydmemia, is the cause of most of the functional disorders which had previously been attributed to plethora. I hope to show, in like manner, that a series of aifections of a hitherto PREFACE. XI unknown origin, should now be referred to a peculiar alteration of the blood ; an alteration consisting chiefly in a diminution of the albumen, and the ordinary symptom of which is albuminuria. The new views of the physiology of pregnancy, and of the nature of puerperal diseases which I have endeavored to establish, ought, I think, to modify essen- tially the treatment of these affections. To this point I invite the atten- tion of practitioners. The third part has undergone the least change ; I ought, however, to mention as entirely new, the chapters on the effect of labor upon the mother and child, especially that devoted to the apparent death of the new-born infant. In studying the accidents which may complicate labor, I have availed myself of all works published of latter time, and there will, accordingly, be found a number of new considerations in the accounts of hemorrhage and puerperal convulsions, and of the indications to which they give rise. A sixth part has been added, devoted exclusively to the hygiene of children, from birth to the period of weaning. Lastly, at the end of the work, will be found an appreciation of the use of anaesthetics in obstetrical practice. It is impossible to point out all the less important additions scattered through the work ; but they are so numerous that the fifth edition con- tains double the amount of matter in the first. It is, therefore, so to speak, a new book, in which, I trust, will be found collected all our know- ledge in relation to the obstetric art. In conclusion, I may be permitted to express publicly, my thanks to M. Coste, for his great kindness in allowing me to study his beautiful collection in the College of France, and to borrow several figures from the magnificent work which he is now publishing. November, 1855. TABLE OF CONTENTS. Preface to the American Edition, Preface, Introduction, . . . PART I. OF THE FEMALE ORGANS OF GENERATION. CHAPTER I. OF THE PELVIS. ARTICLE I. Of the bones of the pelvis, The sacrum, . Coccyx, Coxal bones or ossa innominata. Articulations of the pelvis. Pubic symphysis, Sacro-iliac symphysis, Sacro-coccygeal symphysis, Sacro-vertebral articulation, ARTICLE IL ARTICLE IIL Of the pelvis in general. External surface, . Internal surface, Superior strait, Inferior strait, . Cavity of the pelvis, Base of the pelvis, Differences of the pelvis, according to Uses of the pelvis. age and sex, PAOE V vii xxxi 18 18 20 20 22 22 23 24 25 26 26 27 29 31 33 35 35 36 XIV CONTENTS. ARTICLE IV. 01 the pelvis covered by the soft parts, 36 CHAPTER II. OF THE ORGANS OF GENERATION. SECTION I. Of the external parts of generation, ARTICLE I. ARTICLE IL The mens veneris, The vulva, Labia majora. Labia minora, . Clitoris, Vestibule, Urethra, Hymen, Carunculte myrtiformes, Fossa navicularis. ARTICLE in. Secretory apparatus of the external genital organs, Class first — Sebaceous and plliferous follicles. Class second — Muciparous organs. Isolated or agminated muciparous follicles, . Vulvo-vaginal gland, .... ARTICLE IV. The perineum. SECTION IL Of the internal parts of generation, The vagina, . The uterus, Of the neck of the uterus, Internal surface of the uterus, Structure of the uterus, Ligaments of the uterus, . Bodies of RosenmuUer, ARTICLE I. ARTICLE II. 39 39 39 40 41 42 43 43 43 45 45 45 45 45 45 46 49 49 49 53 53 68 59 62 63 CONTENTS. XV Of the Fallopian tubes, ARTICLE III. ARTICLE IV. Of the ovaries, . . . . . Structure of the ovaries, .... Of the ovarian vesicles, . . . . Of the unfecundated human ovule, CHAPTER III. ARTICLE I. Modifications undergone by the ovarian vesicles, Concomitant changes of the uterus, The corpus luteum, . . . . . ARTICLE II. ••t? Of menstruation, 65 67 69 69 10 13 74 76 82 PAET 11. OF GENERATION, .... BOOK I. OF CONCEPTION, .... BOOK II. OF GESTATION, .... CHAPTER I. SIMPLE UTERINE PREGNANCY. ARTICLE I. Anatomical changes, ........ Changes in the body of the womb. — Volume, form, situation, direction, thickness of its walls, density, ... .... Alodifications of the neck of the womb, ...... Modifications of the texture and properties of the womb, Texture, ••••...... Properties. — Organic contractility, contractility of the tissue. Relations of the uterus during pregnancy, . . . . . ARTICLE II. 95 95 101 Changes in the neighboring parts, Changes in the breasts, 102 102 108 113 113 121 125 126 129 XVI CONTENTS. ARTICLE III. , enlargement of the abdomen, changes 1,S0 130 . 140 141 . 143 146 . 147 150 . 150 151 . 166 165 Diagnosis of pregnancy, . Rational signs — Suppression of the menses in the breasts, pulse, alterations of the urine, Sensible si^ns. Vaginal touch, Abdominal palpation, Active m>)vements of the child, Passive movements, ballottcment, Anal examination. Auscultation as applied to pregnancy, Sound of the foetal heart, Bruit de soufflet, . Table exhibiting the signs of pregnancy, BOOK III. OF THE HUMAN OVUM, AFTER FECUNDATION, . . 168 CHAPTER I. DEVELOPMENT OP THE HUMAN OVUM. ARTICLE I. Changes of the ovum in the tube, ...... 169 ARTICLE IL Changes of the ovum from its arrival in the womb until after the development of the allantoid, ........ 171 CHAPTER II. OF THE DECIDUA, . . . .177 Old theory, ......... 177 New theory — The decidua is simply the mucous membrane of the uterus, . 180 CHAPTER III. CHANGES OF THE OVUM FKOM THE DEVELOPMENT OF THE ALLANTOID UNTIL FULL TERM. ARTICLE I. Of the fcetal appendages, Allantoid vesicle, Umbilical vesicle. Amnion, Amniotic (luid, Chorion, 189 189 190 191 192 194 CONTENTS. XVll ARTICLE II. Of the organs of connection, ....... 195 Placenta, ......... 195 Umbilical cord, ......... 207 CHAPTER IV. OF THE FCETUS. ARTICLE I. Dimensions and weight of the fostus at the different periods of intra-utevine life, 212 ARTICLE II. Head of the child at term, . . . . . . .218 Diameters of the head, ....... 220 ARTICLE III. Position and attitude of the foetus, ...... 223 ARTICLE IV. Functions of the foetus, ....... 226 Nutrition, ......... 226 Respiration, . • . . . ' . . . . 280 Secretions, ......... 232 Circulation, ......... 233 Changes effected in the circulation after birth, ..... 235 BOOK IV. ABNORMAL PREGNANCIES, . . .238 CHAPTER I. TWIN PREGNANCY, . . . 238 CHAPTER II. EXTRA UTERINE PREGNANCY, . . .244 BOOK V. PATHOLOGY OF GESTATION, . . 261 CHAPTER I. DISEASES OF THE PREGNANT WOMAN — GENERAL CONSIDERATIONS. ARTICLE L Lesions of digestion, ........ 263 XVlll CONTENTS. Anorexia, ......... Pica or nialacia, ......... Vomiting, ......... Discussion in regard to the producing of abortion in grave cases of vomiting during pregnancy, ........ Constipation, ......... Lesions of respiration, ARTICLE IL ARTICLE III. Lesions of the circulation — Alterations of the blood — Plethora and lijdrajmia — Varices and hemorrhoids, ...... ARTICLE IV. Lesions of the secretions and excretions, . Ptyalism, . . Secretion and excretion of urine, . Albuminuria, ...... Leucorrhoea, ..... Dropsy of the cellular tissue, .... Ascites, ...... Dropsy of the amnion, .... Hydrorrhoea, . .... ARTICLE V. Lesions of locomotion, ....... Relaxation of the pelvic articulations, ...... Inflammation of the pelvic articulations, ..... Disposition to falling, .... .... ARTICLE VL Lesions of innervation, ....... Lesions of the sensorial, affective, and intellectual faculties — Vertigo, giddi- ness, syncope, ........ Pruritus of the vulva — Itching of the skin, ..... ARTICLE Vn. Abdominal, lumbar, and inguinal pains, Uterine pains, .... 26.3 264 265 271 274 274 275 286 286 287 288 296 297 299 302 306 308 308 310 310 311 311 313 314 315 CHAPTER II. DISPLACEMENTS OF THE UTEKUS. ARTICLE I. Prolapsus uteri. 317 CONTENTS. XIX Faulty directions of the uterus, Retroversion, . . Anteversion, . Uterine obliquity, Lateral obliquity, Causes, Symptoms, Diagnosis, . Prognosis, Delivery of the after-birth. Treatment, ARTICLE n. ARTICLE IIL CHAPTER IIL OF ABORTION. ARTICLE L ARTICLE II. ARTICLE IIL ARTICLE IV. ARTICLE V. ARTICLE VL CHAPTER IV. OF DISEASES OCCURRING DURING PREGNANCY. Epidemic diseases, . . Sporadic diseases, Chronic diseases, . Surgical affections. Ulceration of the neck of the uterus, PART III. OF LABOR IN GENERAL, BOOK I. 321 321 327 329 329 330 336 340 344 345 349 356 358 360 365 366 Of premature labor, Of retarded labor, 371 371 374 XX CONTENTS. BOOK II. OF NATURAL LABOR AT TERM, 3Y6 CHAPTER I. CAUSES OF LABOR, 3Y6 CHAPTER II. PHYSIOLOGICAL PHENOMENA OF LABOR. Precursory signs, . . . . First stage of labor, Second stage, . . . . The pain, or contraction, Dilatation of the os uteri, . Of the glairy discharges. Bag of waters, .... Of the duration of labor, Effect of labor upon the mother and child, . 385 386 . 387 388 . 392 393 . 394 396 . 399 CHAPTER III. OF THE MECHANICAL PHENOMENA OF LABOR. ARTICLE I. Of the presentations and positions, ...... 402 Table of presentations and positions, ...... 404 Classification of Naegele, Stoltz, and P. Dubois, ..... 409 ARTICLE II. Of the vertex presentation, ........ 412 Causes — Diagnosis — Mechanism — ^Prognosis, .... 413 ARTICLE III. Face presentation, ........ 431 Causes — Diagnosis — Mechanism — Prognosis, .... 432 ARTICLE IV. Presentations of the pelvic extremity, ...... 444 Causes — Diagnosis — Mechanism — Prognosis, .... 445 ARTICLE V. Presentations of the trunk, ....... 456 Causes — Diagnosis — Mechanism — Spontaneous version — Spontaneous evolution — Prognosis, ......... 457 CONTENTS. XXI CHAPTER IV. OF THE NECESSARY ATTENTIONS TO THE WOMAN DURING AND AFTER LABOR. ARTICLE I. Of the attentions to the woman during labor, ..... 467 ARTICLE IL Of the attentions to the child during labor, ..... 477 ARTICLE in. Regimen of women in labor, ....... 482 ARTICLE IV. Of the attentions immediately after labor, . . . . . 484 ARTICLE V. Phenomena of the lying-in state, ....... 485 Changes undergone by the generative organs after labor, . . . 487 Of after-pains, . . . . . . . . .491 Lochia, ......... 493 Milk-fever, 497 ARTICLE VL Attentions to the lying-in woman, ...... 500 CHAPTER V. OF THE ATTENTIONS TO THE CHILD IMMEDIATELY AFTER ITS BIRTH. Debility or disease of the child — Apparent death of the child — Debility of new- born children, ......... 504 PART lY. OF DYSTOCIA, . . . .517 FIRST DIVISION. CAUSESOFDYSTOCIA, . . . 517 BOOK I. OF LABORS RENDERED DIFFICULT, IMPOSSIBLE, OR DANGEROUS, BY DEFICIENT OR EXCESSIVE ACTION OF THE UTERINE FORCES. CHAPTER I. Extreme slowness of the labor, . . . . . . 518 Slowness or feebleness of the contractions, ..... 520 Xxil CONTENTS. Relaxation or suspension of the pains, ..... 523 Irregularity of the pains, ........ 524 Of Ergot, 526 CHAPTER II. OF TOO RAPID LABORS, • • .530 BOOK II. OF LABORS RENDERED DIFFICULT, IMPOSSIBLE, OR DANGEROUS, BY OBSTACLES OPPOSING THE READY EXPULSION OF THE FCETUS. CHAPTER I. DEFORMITIES OF THE PELVIS. Of the pelvis deformed by excess of amplitude, ..... 533 Of the pelvis deformed by excess of retraction, .... 635 ARTICLE I. Pathological anatomy, ........ 536 ARTICLE II. Causes, .......... 546 ARTICLE III. Effect of contractions of the pelvis upon pregnancy and parturition, . . 557 ARTICLE IV. Diagnosis, ......... 564 ARTICLE V. Indications presented by deformities of the pelvis, .... 582 CHAPTER II. MALFORMATIONS OF THE VULVA AND VAGINA. Adhesions of the external and internal labia, ..... 588 Persistence of the hymen, ....... 589 Smallness and rigidity of the vulva, . . . . • • 589 Resistance of the perineum, ....... 591 Malformations of the vagina, . . " . . • • • 592 Inversion of the vagina, ....... 695 CONTENTS. XXIU CHAPTER III. TUMORS IN THE EXCAVATION. ARTICLE I. Tumors developed in the botiy walls, ...... 596 Exostosis, . . . . . . . ■ . . 596 Osteo-sarcoma, . . . . . . . . .597 Deformed callus, .*.... ^. . 597 ARTICLE II. Tumors appertaining to the soft parts, ...... 598 ffidema of the labia externa, ....... 598 Sanguineous tumors, or thrombus of the vulva and vagina, . . . 598 Thrombus of the lips of the cervix uteri, ..... 606 Various other tumors, . . . . . . , .607 Tumors appertaining to the neck or body of the uterus, . . . G07 ARTICLE III. Tumors in the adjacent parts, . . . . . . . 612 Tumors of the ovary, . . . . . . . . (j 1 2 Tumors of the Fallopian tube, ....... 615 Tumors of the rectum, ....... 615 Tumors of the bladder, ........ 616 Tumors developed in the cellular tissues of the pelvis, . . . G17 Hernial tumors, . . . . . . . . .618 CHAPTER IV. OBSTACLES DEPENDENT ON THE NECK OR BODY OP THE WOMB. ARTICLE I. Rigidity of the cervix, ....... 621 Spasmodic contraction of the cervix, ...... 622 Obliquity of the cervix, ....... 624 Agglutination of the external orifice, ...... 626 Tumefaction and elongation of the anterior lip, . . . , 627 Abscess in the lips of the cervix, . . . . . . , 628 Induration with hypertrophy of the cervix, ..... 628 Cancer of the neck, ........ 629 Complete obliteration of the neck, ...... 630 ARTICLE 11. Obstacles dependent on the body of the womb, ..... 631 Anterior obliquity, . . . . . . . . 631 Posterior obliquity, . . . . . , , .632 Lateral obliquity. . , . , , . . , 635 Xxiv CONTENTS. Hernia of the womb, ........ 637 Prolapsus uteri, .......# 638 CHAPTER V. OBSTACLES DEPENDENT ON THE FCETUS OR ITS APPENDAGES. ARTICLE I. 639 642 Diseases of the foetus — Hydrocephalus, ..... Hydrothorax and ascites, ....... Deformities of the foetus — Emphysematous condition of the foetus, . . 643 Tumors of the foetus, ........ 643 Anchylosis of the foetal articulations, ...... 644 ARTICLE II. Excess of volume of the foetus, ...... 644 Monstrosities, ......... 645 Multiple and adherent foetuses, ...... 645 Multiple and independent foetuses, ...... 647 ARTICLE IIL Prolapsus or falling of the cord, ...... 652 ARTICLE IV. Shortness of the cord, ........ 657 ARTICLE V. Malpositions of the child, ....... 661 Inclined vertex positions, ........ 662 Anomalies in the mechanism of natural labor, .... 663 Inclined breech positions, ........ 665 Face positions, ........ 665 Trunk positions, ......... 669 Complicated positions, ....... 670 BOOK III. OF THE DISEASES OR ACCIDENTS THAT MAY COMPLICATE LABOR, AND REQUIRE THE INTERVENTION OF ART. CHAPTER I. OF PUERPERAL HEMORRHAGE. ARTICLE I. Of the causes of uterine hemorrhage — Predisposing causes, . . . 676 Determining causes, ....•••• 680 Special causes, ....••••• "°^ Insertion of the placenta upon the lower segment of the uterus, . . 682 Rupture of the cord or of one of its vessels, ..... 685 CONTENTS. XXT Shortness of the cord, ........ 688 Rapid contraction of the uterus, ....... 690 ARTICLE 11. Svmptoms of uterine hemorrhage, . . . . . • 690 External discharge, . . . . . • • .691 Internal discharge, ........ 691 ARTICLE III. Diagnosis, ......... 692 ARTICLE IV. Prognosis, .......... 69Y ARTICLE V. Treatment, ......... 701 A synoptical table of the treatment, ...... 711 CHAPTER II. OF PUERPEKAL CONVULSIONS. Causes, ......... 715 Symptoms, . . . . . . . . .720 Terminations, . ,. . . . . . . . 725 Diagnosis, . . . ' ; . . . . . . 728 Prognosis, ......... 729 Pathological anatomy, ........ 732 Nature of eclampsia, ........ 733 Treatment, ......... 736 CHAPTER III. OF RUPTURES OF THE UTERUS. Causes, ........ 748 Symptoms, ......... 752 Prognosis and termination, ....... 754 Pathological anatomy, ........ 756 Treatment, ......... 758 Ruptures of the vagina, ........ 760 CHAPTER IV. OF RHEUMATISM OF THE UTERUS, . . 762 CHAPTER V. OF CERTAIN DISEASES THAT MAY COMPLICATE LABOR, 766 SECOND DIVISION. OBSTETRICAL OPERATIONS, . . 769 XXvi CONTENTS. ■ CHAPTER I. OF VERSION. ARTICLE I. Cephalic version, ....••••• '72 ARTICLE II. Pelvic version, . . ...... 776 General rules of the operation, ....... 777 Difficulties that may be met with in its performance, . . . 783 Appreciation of version. ........ 789 Version in vertex presentations, .... . . 7i)0 Version in face presentations, . . . • . . .791 Version in breech presentations, ...... 791 Version in trunk presentations, . ...... 792 Trunk presentations with escape of the arm, .... 794 CHAPTER II. OF THE FORCEPS. ARTICLE L Preliminary precautions, ........ 799 ARTICLE 11. General rules for the application of forceps, ..... 801 ARTICLE IIL Special rules for the application of forceps, ..... 807 Application in vertex presentations, ...... 807 Application in face presentations, ....... 815 Application of the forceps on the retained head, after delivery of the body, . 818 General considerations on its employment, ..... 820 CHAPTER III. OF THE LEVER OR VECTIS, . . .829 CHAPTER IV. OF PREMATURE ARTIFICIAL DELIVERY. ARTICLE I. Cases requiring premature artificial delivery, ..... 8.12 ARTICLE IL Operative procedures, ........ 838 CONTENTS. XXVll CHAPTER V. OF THE PRODUCTION OF ABORTION, 846 CHAPTER VI. OF THE EFFECT OF BLEEDING AND A DEBILITATING REGIMEN UPON THE DEVELOPMENT OF THE CHILD, . . 850 CHAPTER VII. OF SYMPHYSEOTOMY, . . . .853 CHAPTER VIII. OF THE CiESAREAN OPERATION, CHAPTER IX. OF EMBRYOTOMY, . 859 866 PART Y. OF THE DELIVERY OF THE AFTER-BIRTH. Of the natural delivery, . ARTICLE I. ARTICLE II. Of the artificial delivery, .... Inertia of the womb, .... Excessive volume of the placenta, Weakness of the cord. Irregular or spasmodic contractions of the uterus, Abnormal adhesions of the placenta, . Of partial or complete retention of the placenta, . Of putrid absorption of the placenta, Tardy expulsion of the placenta, . Complete absorption of the placenta, . ARTICLE III. Of hemorrhage before, during, or after the delivery of the placenta, Causes of hemorrhage, — inertia, .... Symptoms, ....... Diagnosis, ..;.... Prognosis, . . . . . Preventive treatment, ...... 877 883 884 885 885 886 890 894 895 896 897 899 899 900 902 903 903 xxvni CONTENTS. Curative treatment, .... Use of the tampon, ..... Compression of the uterus, Compression of the aorta — Discussion, Ergot, ...... Transfusion, ...... Inertia and secondary hemorrhage. Active and passive hemorrhage, but without inertia of the walls, Hemorrhage from the umbilical cord, Inversion of the womb, .... Rupture of the uterus, .... 905 906 906 907 909 910 912 913 915 916 920 PART YI. OF THE HYGIENE OF CHILDREN, . 922 BOOK I. OF THE ALIMENTATION OF CHILDREN, 922 CHAPTER I. OF LACTATION, CHAPTER II. OF NURSING. ARTICLE I. Of nursing by the mother, .... Precautions to be observed by women who intend nursing, Rules to be observed whilst nursing, Of weaning, ARTICLE II. ARTICLE IIL Of the regimen of mothers, whilst nursing, .... ARTICLE IV. Of obstacles to nursing, .... . . Of erosions and excoriations, of chaps, fissures, and cracks of the nipple, Accidents which may obstruct nursing by the mother, Variations in the quantity of milk — Agalactia — Galactorrhoea, . Health of the mother, ....... Alterations in the quality of the milk, ..... 923 930 931 932 940 943 944 945 950 950 951 952 CONTENTS. XXIX ARTICLE V. Of mixed nursing, ........ 954 ARTICLE VL Of wet nursing, ......... 956 Of the choice of a nurse, . ..... 957 How to regulate nui-sing by wet nurses, . . . . . .961 Of the regimen of wet nurses, ...... 962 ARTICLE VIL Of nursing by a female animal, ....... 963 ARTICLE VIII. Of artificial nursing, ........ 964 CHAPTER III. GENERAL CONSIDERATIONS RESPECTING CERTAIN POINTS RELATING TO THE HYGIENE OF CHILDREN. Clothing, .......... 966 Washing — Bathing — Attention to cleanliness, .... 966 Aeration — Promenades, . . . . . . , .967 Sleep, - . 968 APPENDIX. On the use of anaesthetics in obstetrical practice, .... 969 INTRODUCTION. Labor is that function whicli consists in the natural or artificial expulsion of a viable foetus through the natural parts of generation. The term expulsion evidently comprises three secondary Ideas : namely, that of a body which expels, that of a body which is expelled, and that of an opening or canal through which this expulsion takes place. Hence, we may foresee to what an extent the structure, the position, the dimensions, and the relations of these different parts, must influence the degree of facility with which this func- tion is accomplished; as also, how greatly a knowledge of this structure, and these relations, must facilitate a comprehension of the forces brought into play by nature for the accomplishment of her work, and of the mechanism whereby the expulsion is effected. Consequently, the first part of this book will be devoted to a description of the generative organs of the female; in which, we shall first study the pelvis, and, after having described each of its constituent parts, shall consider it as a whole ; carefully pointing out the peculiarities that its form, direction, or dimensions may offer ; and then passing immediately to an anatomical description of the ex- ternal and internal organs of generation. Most of the leading authors, after describing all these parts in their normal condition, study their vices of confor- mation, position, &c. ; but as this method appears objectionable, we defer the consideration of all those anomalies, that are justly viewed as causes of dystocia, to the division in which we treat of difl&cult labors. For, by thus bringing to- gether the causes and the effects they produce, we hope to avoid unnecessary repetition, to aid the memories of students, and at the same time to demonstrate more fully the importance of a knowledge of these anomalies. The physiology of the organs of generation is so intimately connected with their anatomical arrangement, as to make it impossible to describe them fully without treating at the same time of their functions. The phenomena which they present at certain periods are, beside, very properly considered as the pre- ludes of generation, rendering a previous study of them indispensable to all who would understand the modifications which these organs undergo during the puer- peral state. After having studied the organs of the female in the non-gravid condition, we shall examine the numerous and important modifications they undergo during XXXll INTRODUCTION. gestation ; and from this examination we shall deduce the signs of pregnancy, and the therapeutical measures that may be employed for the particular symp- toms to which they give rise. The second part will be concluded by studying the primary cause of all these modifications ; that is, the fcjetus and its appen- dages, which will be severally considered at the diiferent stages of their develop- ment. These preliminary points having been acquired, we shall then be prepared to describe the parturition, in which two orders of phenomena will be distinguished : the one, being purely physiological, is an expression of the vital actions brought into play for the expulsion of the foetus; while the other is entirely mechanical, and constitutes the mechanism whereby this expulsion is effected. We have devoted much space to the description, and more particularly to an explanation of the mechanism of natural labor; and we hope to have succeeded in explain- ing certain facts connected therewith, that have hitherto only been pointed out. In the fourth part, which is devoted to the management of difficult labors, we shall enumerate in detail the caUses of dystocia, the mode of action of each, the signs by which their existence may be recognized, the indications for treatment they present, and the means of remedying them. In the fifth part, we shall study the delivery of the after-birth. Like the parturition, this is usually simple and natural, but it may be complicated by numerous difficulties and accidents that require the intervention of our art; and hence, in order to fill up properly the design we have traced out, it will be neces- sary to treat in detail of the natural, the artificial, and the complicated delivery of the after-birth. Finally, in the sixth and last part, we have endeavored to give, in as condensed a form as possible, such principles of hygiene as are applicable to the physical education of children from birth to the time of weaning. TREATISE ON MIDWIFERY. PAET I. OF THE FEMALE ORGANS OF GENERATION. The female organs subservient to generation are : the ovaries, the principal function of which is the secretion of the ovule or female germ ; the Fallopian tubes, designed to receive the ovule, and conduct it into the cavity of the uterus ; the uterus, a kind of receptacle, whose office it is to contain the fecundated germ during its period of development, and to expel it immediately afterward finally, the vagina, a membranous canal extending from the neck of the uterus to the external genital parts. Most of these organs are situated within a large cavity, the walls of which are composed of bones and soft parts ; the cavity is termed the cavity of the pelvis, ox pelvic cavity. On account of the importance of the pelvis as an organ both of protection and transmission, we shall, with it, begin the study of the organs of generation. CHAPTER I. OF THE PELVIS. The basin, in Latin, pelvis, is a large, irregular, bony cavity, a sort of curved canal, which terminates the trunk inferiorly, and sustains it by its posterior part. It is placed directly upon the lower extremities, which afford it points of sup- port, and to which, in the erect posture, it transmits the weight of the upper portions of the body. Its position in an adult of ordinary stature is, in general, about the central part of the whole trunk. In the infant at term, and more especially during the intra-uterine life, it is much below this point ; and at a cer- tain period of foetal existence, when the lower extremities resemble as yet but 2 18 FEMALE ORGANS OF GENERATION. little nipples, it even occupies the inferior portion of the body. Especially should the accoucheur study the pelvis in its totality and in its relations with the great function which it subserves. Now as the best way of understanding a whole is to decompose it, and study separately its constituent parts, we shall proceed at once to consider individually the bones which enter into the composi- tion of the pelvis. ARTICLE I. The bones which together constitute the pelvis are : the sacrum and the coccyx, both placed behind and on the median line, and the ossa innominata or coxal hones. These last are in pairs, being situated at the sides and articula- ting with each other in front. § 1. Or THE Sacrum. This is a symmetrical, triangular bone, which is curved forward at its lower part, and is placed at the posterior part of the pelvis, where it appears like a wedge, forced in between the two ossa innominata, immediately below the verte- bral column, and directly above the coccyx. It is traversed longitudinally by the sacral canal (a continuation of the vertebral canal), and, relatively to the axis of the body, it is directed from above downwards, and from before backwards ; hence the column represented by it forms an obtuse angle with the lumbar ver- tebrt^, being salient in front, and receding behind. This point is called the pro- montory, or the sacro-vertebral angle. Besides this direction, the sacrum is curved upon itself from behind forwards, so as to present an anterior concavity, the hollow of the sacrum : this curvature is generally much more marked in the female than in the male. Anatomists describe the bone as having two faces, two borders, a base, and an apex. 1. The spinal, or posterior face, is convex, rough, and very irregular, pre- senting on the median line three, four, or five prominences, the longest of which are above, and continuous with the ridge formed by the series of spinous pro- cesses of the vertebra;; lower down, the sacral canal is terminated as a triangular gutter, being bounded laterally by two tubercles, called the cornua of the sacrum ; upon each side of, and close to the median line, a large furrow exists, at the bottom of which the four posterior sacral foramina are seen, communicating with the vertebral canal, and serving to transmit the nerves of the same name. Outside of these foramina we find a series of elevations, apparently analogous to the transverse processes of the vertebrae ; and above them two irregular fossrc, into which the posterior sacro-iliac ligaments are inserted. 2. The pelvic, or anterior face, is smooth and concave, and is traversed by four prominent transverse lines, the remnants of the sutures between the difi'erent pieces that composed the bone in early infancy, and which serve to separate some superficial, transverse, and quadrilateral grooves found there, from each other. Sometimes the first of these prominent lines is so well marked as to be mistaken, when practising the touch, for the sacro-vertebral angle. OFTnEPELVIS. 19 The anterior sacral foramina, four in number, are found nearer the lateral mar- gins; they communicate with the sacral canal, and transmit the anterior branches of the nerves of the same name. Beyond the foramina is an unequal surface for the attachment of the pyramidal muscles. 3. The borders of the sacrum may be divided into two portions. 1. The superior, being very thick, presents, on its anterior half, a semilunar articular facet for joining with the coxal bone, and on its posterior part an excavation, and some rough projections for the attachment of the sacro-iliac ligaments. The other, or inferior portion, is quite thin, and is occupied by the insertion of the sacro-sciatic ligaments. 4. The base is directed upwardly and a little in front, and has its greatest dia- meter transversely. An oval facet, more or less inclined backwards, surmounts it at the middle, whereby the bone is articulated with the last lumbar vertebra. Upon each side is seen a smooth surface, which is concave transversely, and con- vex from before backwards. These surfaces incline forwards and are continuous with the iliac fossje, being covered, in the recent subject, by the anterior sacro- iliac ligaments. They are separated from the anterior face of the sacrum by a rounded border, which forms, as we shall hereafter learn, the posterior part of the superior strait. The two surfaces constitute the ioings of the sacrum. Be- hind, are found the upper orifice of the sacral canal, and the two articular pro- cesses of the first piece of the sacrum. 5. The ajyex of the sacrum is directed downwards, and a little backwards ; presenting an oval facet for the articulation of the coccyx. 6. The sacral canal, hollowed out in the thickness of the bone, is the termi- nation of the vertebral canal; being triangular and broad superiorly, it becomes narrow and flattened at its inferior part, where it degenerates into a gutter, that is converted into a canal by the ligaments. This lodges the sacral nerves, and communicates both with the anterior and the posterior sacral foramina. The sacrum, although quite thick, is a very light and spongy bone. Besides, it is pierced by a great number of foramina, and traversed by a central cavity, which serve to diminish its weight still more. It is formed of five principal pieces (false sacral vertebrae), sometimes of six, and in one case, seven were observed (Pauw). In Soemmerring's cabinet are three specimens which present but four pieces. The development of the sacrum is analogous to that of the vertebrae, and takes place from thirty-four or thirty-five points of ossification, arranged in the follow- ing manner : — 1. Five of them, placed one over the other, occupy the anterior and middle parts. 2. In each of the interspaces which separate these, two small osseous laminae are developed some time after birth, which seem to form their articular surfaces. 3. Ten are situated in front and upon each side of the latter, that is, one for each lateral portion of the four or five primitive bones. 4. And behind them six others are developed, between which : 5. There appear three or four that correspond with the spinous processes, or their laminfe; and 6. Lastly, there is one upon each side above the iliac surface, for the articular facet. 20 FEMALE ORGANS OF GENERATION. § 2. The Coccyx. This name is given to an assemblage of three or four, occasionally five little bones, united with each other on the median line of the body, and apparently suspended at the point of the sacrum, of which, indeed, they appear to be only a movable appendage, continuing its line of curvature forwards. M. Cruveilhier declares that he has known it, in some cases, to form a right angle or even an acute one with the sacrum. As a whole, the coccyx represents a triangular and symmetrical bone. 1. Its spinal, or posterior face, is convex and irregular, and is only separated from the skin by the posterior sacro-coccygeal ligament. 2. Its pelvic, or anterior face, is smooth and slightly concave, and lies in con- tact with the termination of the rectum, which rests upon it. Like the pre- ceding bone, it is marked by certain transverse grooves, corresponding with the intervals which had, for a long period, separated its different pieces. 3. Its tioo lateral borders are quite irregular, and are occupied by the attach- ments of the anterior sacro-sciatic ligaments, and the ischio-coccygeal muscles. 4. Its slightly concave base presents, above, an oval surface, which articulates with the apex of the sacrum, and behind, two little tubercles called the cornua of the coccyx. 5. The ajjex is rounded, irregular, and sometimes bifurcated, affording attach- ment to the levator ani muscle. The coccyx is developed from four or five centres of ossification, that is, one for each of its parts. § 3. The Coxal Bone, Haunch Bone, or Os Innominatum. This is a non-symmetrical, quadrilateral bone, curved upon itself, as if twisted in two different directions, contracted in its middle, and of a very irregular figure. The pair occupy the lateral and anterior parts of the pelvis. It presents an in- ternal and an external foce, and four borders, for our consideration. 1. The external, ov femoral surface, is turned outwards, backwards, and down- wards, at its superior part, whilst inferiorly, it looks forwards. At its superior and posterior portion is seen an unequal, narrow, and convex surface, affording origin to the gluteus maximus muscle, and terminated below by a slightly elevated circular ridge, called the superior curved line. Beneath this, there is a larger sui-face, which is concave behind, narrowed in front for the insertion of the gluteus medius muscle, and bounded by a slight ridge below, called the inferior curved line ; still lower, there is a third extensive and convex surface, serving for the attachment of the gluteus minimus muscle. All that portion of the femoral face just described forms a large fossa, alternately concave and convex, bearing the name of the external iliac fossa. Towards the front, the external face presents the cotyloid cavity or the aceta- bulum, at its superior part; and a little more in advance and below, the sub- pubic, or obturator foramen. This opening is triangular, with rounded angles ; its long diameter is inclined downwards and outwards, and its circumference is sharp and irregular, presenting above a groove, directed obliquely from behind OF THR PEL VIP. 2t forwards and from without inwards, through which the obturator vessels and nerves pass out. A fibrous membrane that subtends the foramen is attached to its periphery, except in the immediate vicinity of the groove. Upon the inner side of the obturator foramen, between it and the median line, there is a concave or nearly plane surface for the origin of several muscles. 2. The abdominal, or internal face, is directed forwards at its upper part, and backwards at the lower. It may be divided into two portions ; the superior of which is characterized by a large excavation, called the infernal iliac fossa, by a semilunar articular surface found just behind this fossa, and called the auricular facet, and still more posteriorly, by some rugosities, analogous to those found on the articular faces of tho sacrum. The superior portion is terminated below by a large, rounded, and concave line, which separates it from the other moiety. The latter, or inferior portion, presents behind a nearly triangular plane surface, which corresponds to the coty- loid cavity and to the body of the ischium ; near its middle, we find the obtu- rator foramen, and in front, the internal face of the pubis and of the ischio-pubic ramus. 3. Borders. These are four in number. The posterior one has a very irregular shape, being oblique from above downwards, and from without inwards. The posterior superior sjyinous process is found at its junction with the superior border. This prominent, well-marked eminence is separated by a rough margin from another though less voluminous one, called the posterior inferior spinous process. Below this last apophysis, the student will observe a very deep notch, which contributes to the formation of the great sciatic foramen, and is terminated below by a triangular, pointed projection, bearing the title of the spine of the ifcJiium. This process is more or less prominent in difi"erent individuals, and is sometimes directed inwards. A groove is seen just beneath it, in which the tendon of the obturator internus muscle plays; this groove is a part of the lesser sciatic notch; and lastly, this border terminates at the tuberosity of the ischium. The anterior border is concave, oblique above, and nearly horizontal in front. The anterior superior spinous proctss is formed by its union with the superior border. A considerable depression exists under this apophysis, which separates it from another one, called the anterior inferior spinous process. Then we find a groove just under this elevation, for the gliding of the conjoint tendon of the psoas magnus and the iliacus internus muscles ; which groove is bounded, in front and below, by the ilio-jyectineal eminence. And lastly, the border is termi- nated by a triangular horizontal surface, which is directed downwards and for- wards, and is broader externally than internally, and by the spine and angle of the pubis. The superior border or crest of the ilium is thick, convex, and inclined out- wards, excepting at its posterior part, where it looks slightly inwards — being twisted, in its course, somewhat like an italic /. Anatomists have subdivided it into the external and internal lips, and the intervening space. The anterior superior spinous process bounds it in front, and the posterior superior one behind. The inferior border is shorter than either of the others ; it presents, however. 22 F K M A L K K G A N S OF GENERATION. three parts for study. There is an oval surface above, for articulating with its fellow of the opposite side, forming the symphysis; below, it is terminated by the tuberosity of the ischium, and in the middle, we find the ischio-puhic ramus; this is a sharp ridge, formed superiorly by the descending branch of the pubis, and inferiorly by the ascending portion of the ischium. The coxal bone is developed from three principal centres of ossification, which appear at the same time in the iliac fossa, the tuberosity of the ischium, and in the pubis. Owing to this mode of growth, it has been customary to divide the OS innominatum into three portions : the superior one, styled the ilium, forms, in a freat measure, the contour and prominence of the hip; the pubis, being ante- rior, supports the genital organs; and the inferior one, which sustains the body when seated, is named the ischium. , Several years after birth, an osseous lamina resting upon the superior border of the bone, is developed to form the iliac crest, whilst a similar layer embraces the tuberosity of the ischium, and extends to its ramus; at the same time, a third centre of ossification appears for the anterior inferior spinous process of the ilium, and a fourth forms the angle of the pubis. ARTICLE II. ARTICULATIONS OF THE PELVIS. These are five in number; namely, one in front for the pubes, two behind for the iliac bones and sacrum, that of the coccyx with the sacrum, and of the latter with the spine. Three of these articulations have also received the name of syviphyses ; for instance, the term symphysis pubis has been applied to the articulation between the two bones of the pubis, and that of sacro-iliac symphyses, to those of the sacrum with the ilium. They have been classed with the amphiarthroses. The researches of M. Le- noir, however, have proved the correctness of those anatomists who regarded them as arthrodia. He has shown, by an examination of the bodies of twenty- two females, between the ages of eighteen and thirty-five years, that the four pelvic articulations are formed by the contact of surfaces covered in great part with cartilage, and lined with synovial membranes. § 1. Symphysis of the Pubis. This articulation is formed by the approximation of the oval surfaces occupy- ing the upper part of the lower border of the coxal bones. These surfaces are slightly convex and unequal, and are covered with a cartilaginous lamina which fills up the inequalities. The convex shape and the direction of their faces are such, that they only come into contact for an inconsiderable extent at their inter- nal or posterior part, and hence they leave above, in front, and below, an open space, which is the more considerable, in proportion to the distance from the centre of the joint. The articulating surface of the two cartilages is a little F T II E P E L V I S. 23 facet, about six to eiuht lines in its vertical diameter, by two to three in its transverse ona. This facet is smooth, and furnished with a synovial membrane, which is the more lubricated with sy^novia as the female approaches the period of labor. A considerable thickness of the interpubic ligament fills up the interval which exists between the other points of these articular surfaces. This interpubic ligament is formed of a very dense fibrous substance. It has the form of a wedge, with the point forced down between the bones and the sides adhering to the rough surfaces fronting the articulation. Two planes of fibres are discoverable in it ; the deeper ones, which pass from one iliac bone to the other, and are shorter in proportion to their depth, are crossed, and disposed in several layers. They constitute the interpuhic ligament properly so called. The others, which are more superficial, are parallel, and pass obliquely from within outwards and from above downwards. Beginning at the upper part of the arti- culation they spread in descending, until they are finally divided into two bundles, which become lost in front of the branches of the pubic arch by min- gling with the periosteum of the bones and the tendons of the muscles inserted in the vicinity. These form the anterior pubic ligament. The uppermost portion of the anterior pubic ligament seems to take its origin in the fibrous cord which is inserted on the spine of the fahis, and which cushions, so to speak, the upper edge of that bone, in such a way as to efface its inequalities. It constitutes the superior pubic ligament. Lastly, at its lowest part, the anterior pubic ligament assumes the form of a thick triangular bundle occupying the summit of the pubic arch, and fixed by its lateral edges to the upper and internal part of the two branches thereof. This ligament, called the triangular, or sub-puhic ligament, presents a rounded base, which completes the arch of the pubes by giving it a regular curve calculated to facilitate the exit of the foetus. Thus, we have three anterior pubic ligaments, a superior pubic and a sub- pubic ligament, all of them represe/iting a spreading out of the interosseous liga- ment. Behind the symphysis, the fibro-cartilaginous substance forms a sort of projecting pad, which occupies the middle part only, and disappears from above downwards. Finally, the ligamentous arrangement of the articulation is completed by the posterior pubic ligament, composed of fibres extending transversely from one pubis to the other, above the projection just noticed. This ligament, which is very thin, and of moderate strength, forms the posterior lining of the synovial membrane. § 2. Sacro-iliac Symphysis. This articulation is formed by the junction of the semilunar facets, which were pointed out in describing the border of the sacrum and the internal face of the ossa ilia. Both these facets are covered with a diarthrodial cartilage, which is closely adapted to the inequalities they present ; that, however, which pertains to the sacrum, being always much thicker than the layer which belongs to the iliac 24 FEMALE ORGANS OF GENERATION. bones. The latter is so thin, that its existence has been denied. These carti- lages are covered with a synovial membrane, which secretes quite • abundantly a viscid and transparent synovia. But, when the female has passed the prime of life, this fluid often concretes, and becomes disposed in isolated flakes upon the articular surfaces, — a fact which has caused its true nature to be misunderstood. A very limited sliding motion, is all of which this articulation is susceptible. The bones are held together by the following ligaments : 1. The jiosterior, or great sacro-sciatic ligament, is found at the posterior in- ferior part of the pelvis. It is triangular, thin, flattened, and narrower in the middle than at the extremities. It arises by a large base from the posterior infe- rior spinous process of the ilium, the sacro-spinous ligament, the last of the pos- terior tubercles of the sacrum, and from the inferior part of the margin of this bone and border of the coccyx, and running outwards, downwards, and a little forwards, is inserted into the tuberosity of the ischium. Its fibres are arranged in such a way, that the internal ones cross the external about their middle. 2. The hsser sacro-sciatic ligament is smaller than the preceding, though nearly of the same form, and situated more in front. Within, it is broad, being partially confouaded with the other, but arising a little more anteriorly upon the sides of the sacrl||^ and coccyx; thence, it passes forwards and outwards to be inserted into'the spine o£ the ischium. The sacro-sciatic ligaments convert the two sciatic notches into foramina. They not only serve to unite the sacrum to the ilium, but also contribute to the formation of the parietes of the pelvis. 3. The posterior sacro-iliac ligament is a collection of yellow, elastic, fibrous bundles, intermixed with fatty pellets, which fill up the rough excavation ob- served behind the cartilaginous surfaces ; very short, numerous, and interlacing in every direction, they become almost intimately blended with the sacrum and coxal bones. On account of their strength, they greatly consolidate this articu- lation. \ 4. The anterior sacro-iliac ligament is a simple fibrous lamina, extended trans- versely from the sacrum to the os innominatum. It is rather an expansion of the periosteum of the pelvis than a true ligament. 5. The superior sacro-iliac ligament is a very thick fasciculus, passing trans- versely from the base of the sacrum to the coxal bone. 6. The inferior sacro-iliac ligament (vertical sacro-iliac of M. Cruveilhier) arises from the posterior superior spinous process of the ilium, and is inserted just below the third sacral foramen into the tubercle found at the termination of the border of the sacrum ; and behind, into the great sacro-sciatic ligament. § 3. Sacro-coccygeal Symphysis. This articulation, which for a long time was supposed to resemble those be- tween the bodies of the vertebraj, diff'urs from them materially in being a true arthrodia. It is formed by the opposition of the oval surface of the point of the sacrum to that of the base of the coccyx ; the middle of the former is projecting, and corresponds to a depression in the centre of the latter. The long diameter OF THE PELVIS. 25 of the articular face of the coccyx is directed transversely. The cartilages cover- ing these surfaces are rather thinner at the centre than at the circumference. They are provided in the adult female with a synovial membrane, which is sup- posed by M. Lenoir to be only developed by the movements of the coccyx upon the sacrum, since he has failed to meet with it in subjects under eighteen years of age. 1. The anterior sacro-coccygeal ligavient consists of a few parallel fibres, which descend from the anterior part of the sacrum to the corresponding face of the coccyx. 2. The posterior sacro-coccygeal ligament is flat, triangular, broader above than below, and of a dark color. Arising from the margin of the inferior orifice of the sacral canal, it descends to, and is lost upon, the whole posterior surface of the coccyx. It also aids in completing the canal behind. In investigating upon the dead body the anatomical arrangement to which the motion of the coccyx on the sacrum is due, it was ascertained by M. Lenoir that the motion takes place almost as frequently in the sacro-coccygeal articulation, as in that of the second piece of the coccyx with the third. Sometimes it happens simultaneously in both, whilst in few cases only does it occur in the connection of the second piece with the third, or of the third with the fourth. These inter-coccygeal articulations are similarly constructed. In all cases, in fact, in which the points of motion of the coccyx were changed, M. Lenoir dis- covered a more or less complete anchylosis of the articulation between the sacrum and coccyx, and of those between the bones of the coccyx itself, at points above and below the one which preserved its mobility. Then, also wherever situated, the movable articulation was constructed as follows : 1. Of articular surfaces irregular in form but corresponding exactly, which were incrusted with diarthro- dial cartilages and provided with a synovial membrane. 2. Of lax peripheral ligaments formed at the expense of the layers of fibrous substance covering the bones of the coccyx. 3. Lastly, motion was possible in every direction. It is to be observed that ossification is more frequent and rapid in the joint between the sacrum and coccyx than in that between the first piece of the coccyx and the second ; the third and fourth become fused very early. It is therefore easy to understand how the great mobility of the sacro-coccygeal articulations renders luxation possible in labor, whilst in cases of anchylosis, either fracture or a sudden separation of the united bones might occur. During pregnancy, the ligaments of the pelvic articulations become so softened and swelled by imbibition of fluid, as to render the mobility of the articular sur- faces very evident. This softening is very considerable in some cases, and may make walking or even standing, impossible. § 4. Sacro-vertebral Articulation. This is produced by the junction of the sacrum with the fifth lumbar vertebra. It is a true amphiarthrosis, as are all the vertebral articulations. It takes place at three difi'ercnt points, viz., between the oval facet, seen at the middle of the 26 FEMALE ORGANS OF CxENERATION. base of the sacrum, and the inferior surface of the body of the hist vertebra ; and, at the two articuhar surfaces found near the entrance of the sacral canal. The modes of connection are, a fibro-cartilage (which is much thicker in front than behind), the termination of the two anterior and posterior vertebral liga- ments, the interspinous ligament, and lastly, the ancro-vertehral li(jame7it, a short, very strong, fibrous bundle, which descends obliquely from the anterior inferior part of the transverse process of the last vertebra, downwards and out- wards, towards the base of the sacrum, where it is inserted. Further, a synovial membrane is found in the articulation between the oblique processes of the sacrum and those of the vertebra). To these must also be added the ilio-lunibar ligament, which passes from the apex of the transverse process of the fifth lumbar vertebra to the thickest portion of the iliac crest ; and the ilio-vertebral ligament, formed of two fibrous bands, the superior of which arises from the middle and lateral part of the body of the last lumbar vertebra, and the inferior, from the inter-sacro-vertebral space ; both are then spread out on the coxal bone. The obturator membrane still claims a description, in order to finish the his- tory of the ligamentous apparatus of the pelvis. This, as has been remarked by M. Cruveilhier, like the sacro-sciatic ligaments already spoken of, is rather an aponeurosis serving to complete the pelvic walls, than a true ligament. These resisting membranes are probably intended to diminish, in the hour of labor, the compression of the mother's soft parts, included between the infant's head and the osseous parietes of the pelvis, as also to favor, by their elasticity, the passage of the head through the pelvic excavation. Ohturator membrane. — This membrane subtends the foramen thyroideum, ex- cepting at its superior part, where an opening exists, which converts the groove, intended for the passage of the obturator vessels and nerves, into a complete canal. Being inserted by its external semi-circumference into the corresponding part of the periphery of the obturator foramen, it is attached by its internal half to the posterior face of the ascending ramus of the ischium. Its surfaces afford origins for the two obturator muscles. This membrane is composed of aponeu- rotic fasciculi, which cross each other in every direction. (^Cruveilhier.') ARTICLE III. OF THE PELVIS IN GENERAL. Studied in its general aspect, the pelvis represents a cone, slightly flattened from before backwards; the base of which, being above, is at the same time in- clined forwards, whilst the apex is directed downwards and a little backwards. § 1. External Surface of the Pelvis. Anatomists have divided this surface into four regions : the anterior of which exhibits, on the median line, the front part of the symphysis pubis, which is directed from above downwards and from before backwards, at an angle with the OF THE PELVIS. 27 perpendicular of some 15° to 20° ; next (passing outwards) is a smooth surface, from whicli several muscles of the thigh arise, then the external obturator fossa, occupied in the recent subject by the muscle of the same name, and finally by the anterior half of the edge of the cotyloid cavity. The posterior, bounded by the hinder part of the iliac crest, presents, on the median line, the ridge of the sacral spinous processes, the inferior opening of the vertebral canal, the union of the sacrum with the coccyx, and the posterior face of this latter bone. The ten posterior sacral foramina, transmitting the nerves of the same name, are found in two deep gutters, on the sides. These grooves prolong the spinal gutters, and are occupied in the recent state by the commencement of the sacro- spinal muscles. The lateral regions may each be divided into two parts : one, the superior, is the external iliac fossa ; the other, or inferior, offers, behind, the posterior aspect of the sacro-sciatic ligaments, and the plane of the notches or foramina bearing the same name ; and in front, the cotyloid cavity and the ex- ternal face of the tuberosity of the ischium. § 2. Internal Surface. The internal surface or cavity of the pelvis has been aptly compared to the basin of the ancient barbers. ( Vesalius.) In fact, like those vessels, it has a .superior part, which spreads out freely, and is called the great, the superior, or the abdominal pelvis; and an inferior one, more contracted, bearing the title of the little jjelvis, or j)ehic excavation. 1. The great pelvis has a very irregular figure, and forms a species of pavilion to the entrance of the pelvis. Its walls are three in number : the anterior one is deficient in the dried skeleton, but in the living state it is supplied by the ante- rior abdominal muscles ; its posterior parietes exhibit a notch in its middle, that is ordinarily filled up by the projection of the last lumbar vertebrae, which are usually left in connection with the pelvis, although in reality not forming any part of it. Two gutters are found on the sides of this eminence, occupied by the psoae muscles ; further outwards, the anterior part of the sacro-iliac symphyses appear, which constitute the boundaries between the posterior and lateral regions : these latter are constituted by the internal iliac fossae, covered by the iliacus in- ternus muscles. 2. The lesser pelvis, or hasin. This forms a curved canal, larger in the middle than at its extremities, and slightly bent forward. If all the parts described as appertaining to the great pelvis be removed by the saw, as recommended by Chaussier, a species of ring will remain, whose circumference, being narrow in front and much broader behind, will furnish a correct idea of the shape of the pelvis. Four regions are found in this cavity also : The anterior one, is concave transversely, and is inclined upwards, having the posterior part of the pubic articulation near its middle : this is generally promi- nent, assuming the form of a longitudinal pad, which may in some cases project to the extent of from two to three-eighths of an inch. Towards the sides, a smooth surface appears, and then the internal obturator, or sub-pubic fossa, hav- 1 i 28 FEMALE ORGANS OF GENERATION. ing, at its upper external part the inner orifice of the sub-pubic canal, through which the external obturator vessels and nerves pass out from the pelvis. It is not at all uncommon for females to complain during labor of severe cramps in the muscles of the upper internal part of one thigh. These pains re- sult from the pressure made by the child's head upon those nerves, as it glides over this portion of the excavation. The posterior region — constituted by the front face of the sacrum and coccyx — is directed downwards, and is concave from above, downwards. It consequently exhibits those peculiarities already noticed when describing the sacrum. The lateral regions present two quite distinct portions : the anterior one is wholly osseous, corresponding to the back part of the cotyloid cavity, and to the body and tuberosity of the ischium. It is directed from above downwards, from behind forwards, and from without inwards. The posterior one is formed by the internal face of the greater and lesser sacro- sciatic ligaments, and by the internal aspect of the great and small sciatic notches, converted by them into foramina ; it has an opposite direction to the former. One of these foramina is larger and situated higher up than the other, and is of an oval form. The other is triangular, smaller, and more inferior. The pyramidal muscle, the great sciatic nerve, gluteal artery, and the internal pudic vessels and nerves, escape from the pelvis through the great sciatic foramen. The small sciatic hole is filled up by the obturator internus muscle, and the internal pudic vessels and nerves, which re-enter the pelvis in order to supply the perineum. If two vertical sections be made, the one extending on the median line through the sacrum and the pubis, dividing the pelvis into two lateral halves, and the other at right angles to the first, dividing it into anterior and posterior halves, four equal parts or quarters of the pelvis will be thereby produced, which ac- coucheurs have designated as the anterior and posterior inclined planes. Desor- meaux included only the lateral regions of the excavation, which he divided into two equal parts, in the composition of these planes : according to him, the ante- rior inclined planes are continuous with the anterior region ; the posterior, with the front face of the sacrum ; and the spine of the ischium is found at the point of union of these two. The direction of the inclined planes is always the same, whatever may be the manner in which they are formed. That is, the anterior are directed from without inwards, from above downwards, and from behind for- wards; the posterior, from without inwards, from above downwards, and from before backwards — in a word, in such a way as to resemble somewhat the four sides of a lozenge which is slightly curved in its length. By most authors, these inclined planes are supposed to play an important part in the mechanism of labor; for they imagine that their direction has an immediate influence upon the move- ments which the head of the foetus performs in the excavation. In anticipating that the description of the mechanism of labor hereafter given will invalidate this assertion, we shall simply observe that the movements of rota- tion executed by the head, take place more frequently whilst the latter is strongly bulging out the perineum, and is so far below the inclined planes as scarcely to F T H E P E L V I S. 29 feel the influence of their direction, and further, that these motions often occur in an opposite direction. The great and the lesser pelvis are separated from each other by a kind of horizontal circle, which has been designated by accoucheurs as the abdominal, or superior strait, the isthmus, or margin of the pelvis. Finally, the apex of the pelvis presents an opening that is limited by a circle, partly osseous, partly liga- mentous, to which the name of the inferior strait has been applied. Conse- quently, these two straits are the extreme limits of the pelvic excavation. § 3. Of the Superior Strait. The superior strait is formed, behind, by the sacro-vertebral angle, and the anterior border of the wings of the sacrum : outwardly, by the rounded margin that bounds the internal iliac fossa below; and in front, by the ilio-pectineal eminence and the horizontal ramus of the pubis, terminating at the symphysis of this bone. The abdominal strait has been variously compared to an ellipse, an oval, and to the heart of a playing card. We may assert, however, with Chaus- sier, that its shape is that of a curvilinear triangle, the angles of which have been rounded oflF, and having its base behind and the apex in front. It constitutes the entrance to the lesser pelvis, and is therefore the first part of the narrow canal which the foetus has to traverse. Hence, the pains taken by accoucheurs to study this osseous opening can readily be conceived. All the modern authors since the days of Deventer, have endeavored to fix precisely the degree of inclination of its plane and axis, to ascertain the direction the foetus should follow in engaging in the pelvic canal, and to determine care- fully the dimensions of the latter, and their accordance with those of the body, which is to pass through it. The plane of the superior strait is inclined obliquely from above downwards, and from behind forwards ; but writers are far from being unanimous in regard to the degree of its inclination ; that is, in determining the angle formed by the sacro-pubic line, at the point where it meets a horizontal one, drawn from the superior part of the symphysis pubis towards one of the points on the anterior face of the sacrum. Although originally placed at 45° by J. J. Muller (1745), this angle has successively been fixed at 35° by Levret; at 75° by Camper, and at 55° by Saxtorph ; and still more recently, Professor Na^gele, after a great number of researches, has concluded to consider it as an angle of 60° (1819). It is now generally admitted that the degree of inclination in the plane of the superior strait is from 55° to 60° in the erect position of the female. The direction of the plane being once understood, it is an easy matter to as- certain that of its axis ; for the latter being a line which falls perpendicularly upon the centre of this plane, it must evidently form with the vertical the same angle that the plane itself does with the horizontal line, and consequently must have just the same degree of inclination. Being thus understood, the axis of the superior strait is a line (a b, Fig. 1) which, commencing near the umbilicus of the female, would pass directly through the centre of this strait, and fall upon the point of union of the upper two-thirds of the coccyx, with its inferior third. 30 FEMALE ORGANS OF GENERATEON. Fig. 1. Hence, it will be directed from above downwards, and from before backwards. Further, the inclination of this plane varies according to the woman's posi- tion. Thus, it is almost nothing when recumbent, and sometimes in this posi- tion the plane of the superior strait in- stead of being directed forwards and upwards, even looks upwards and back- wards (Dubois) ; when the trunk is bent strongly forward the inclination of the plane is diminished and becomes more nearly horizontal; towards the end of gestation, on the contrary, the inclina- tion increases, especially when, in order to restore equilibrium, the upper part of the body is carried much backward. As the figure which represents the circumference of the superior strait is not a perfect circle, its dimensions, taken at different points, are, of course, un- equal, and, accordingly, writers have admitted several diameters for it, thus : There are three principal ones (Fig. 2), namely, an antero-posterior, or sacro- pubic diameter a a, which extends from the sacro-vertebral angle to the upper part of the symphysis pubis ; it is from four and a quar- ter to four and a half inches in length. 2. A transverse one, h h, passing from the middle of the rounded border that terminates the iliac fossa of one side, to the same point on the opposite side ; this is five and a quarter inches long. 3. An oblique diameter, c c, extending from the anterior a a. The antero-posterior, or sacro-pubic diameter. 6 6. part of the Sacro-iliac Symphysis The transverse diameter, c c. The two oblique diameters. Iq the ilio-pCCtinCal eminence of a c. The sacro-cotyloid interval. . . the opposite side ; this is found on both sides, and is four and three-quarter inches long. Lastly, M. Velpeau admits a fourth diameter, called by him the sacro-coty- loidean ; before described, however, by Burns, under the more exact name of the sacro-cotyloid interval, a c, existing between the promontory and the posterior part of the cotyloid cavity. This interval, according to the examinations of the French surgeon, is from four to four and one-eighth inches in extent; but from the results of Naegdle and Stoltz's researches it is much less, being scarcely three ..cv. c h. The plane of the superior strait prolonged beyond the pubis, c e. The plane of the inferior strait prolonged beyond the pubis, c d. Shows the departure of this plane from the horizontal line. ab. The axis of the superior strait, g f. The axis of the inferior strait. Fig. 2. OF THE PELVIS. 31 and a half inches (the mean obtained from ninety pelves). The circumference of this strait varies from thirteen to seventeen inches ; Levret taught, that it equalled one-fourth of the female's height j but to establish such an approxima- tion, the development of the pelvis should always be in direct proportion to the stature of the individual, which is certainly not the fact. § 4. Of the Inferior Strait. The inferior strait — the perineal strait — or apex of the pelvis (as it is vari- ously called), is more irregular in shape than the superior one. Its outline pre- sents, in fact, three tuberosities or osseous projections, separated by as many deep notches. If, however, the advice of Chaussier be followed, and a sheet of paper be placed over this opening, so as to trace its outUne with a crayon, it will be found to have an oval figure, the smaller extremity of which is in front, and the larger one, looking backwards, is broken in upon by the prominence of the coccyx. This point, disappearing at the moment of the head's passage, offers no obstacle to the delivery ; and, therefore, the strait may be considered as nearly an oval. The periphery of the pelvis at its apes is formed by the inferior part of the symphysis pubis, the descending branch of this bone, the ascending branch and tuberosity of the ischium, the inferior margin of the great sacro-sciatie liga- ment, and by the border and point of the coccyx. Hence, three triangular pro- jections are found in it : the two ischia upon the sides, and the coccyx behind. The first two are immovable, but the last, on the contrary, is effaced at the period of delivery, as just mentioned ; for the mobility of the sacro-coccygeal articulation allows the coccyx to be pushed downwards and backwards by the foetal head, as it traverses the inferior strait. The two lateral prominences, made by the tube- rosities of the ischia, are placed on a plane somewhat lower than the point of the coccyx ; and, consequently, in the sitting posture, the weight of the body rests solely on those tuberosities, and not at all upon the coccygeal extremity. This circumstance furnishes us a reason why transverse contractions of the pelvis are far more frequent at the inferior strait than the antero-posterior ones. The three notches also require a passing notice ; thus, the two postero-lateral ones are very deep, but when the sciatic ligaments have been preserved, they are comparatively superficial ; the third is found anteriorly ; its apex corresponds to the inferior part of the symphysis pubis, its base to a line drawn between the anterior parts of the tuberosities of the ischia, and its sides are formed by the ischio-pubal rami. The term arch of the pubis has been applied to this notch. The columns of the arch are distorted outwardly, as if a rounded body had been forcibly expelled from the pelvis, whilst the bones were soft, and had pushed them before it ; and this arrangement, which is more marked in the female than the male, favors the descent of the head. The arch is three and a half to three and three-quarter inches broad at the base ; but only one and a quarter to one and a half inches at its apex ; in height, it is about two, to two and a half inches. Hence the area of the inferior strait will not present a uniform plane (should it be desirable to ascertain the irregularities it exhibits), because all parts of its 32 FEMALE ORGANS OF GENERATION. margin are not upon the same level. However, to obviate the difficulty met with, in determining the direction of this plane, Duges has divided the strait into two nearly equal portions, the one anterior, and the other posterior, meeting at the tuberosities of the ischium, and each presenting a distinct plane and axis ; but as this method of proceeding uselessly complicates the question, we prefer considering the terminal plane of the pelvis, as represented by the coccy-pubal line, thus leaving out the lateral projections altogether. The question is then reduced to these terms : What is the direction of the line that extends from the point of the coccyx to the inferior part of the symphysis pubis ? Writers, likewise, variously describe this; for instance, according to the majo- rity of the French accoucheurs, the plane of the inferior strait is slightly oblique, from below upwards, and from behind forwards, so that it would unite with that of the superior strait (if prolonged) in front of the symphysis pubis. On the other hand, M. Naeg^le concludes, from his numerous researches, that the incli- nation of the antero-posterior diameter of this strait is from 10° to 11° from the horizon, and that the point of the coccyx is found, as a mean, from a half to three-quarters of an inch higher than the summit of the pubic arch ; and, there- fore, the cocey-pubal line is a little oblique from above downwards, and from be- hind forwards. The lower extremity of the axis of this plane of the inferior strait would cut the coccy-pubic diameter at right angles, and terminate above at the sacro-vertebral angle. As a further result of his labors, he has found that, in five hundred well-formed persons, of different statures, four hundred and fifty- four have the point of the coccyx more elevated than the inferior portion of the symphysis ; in twenty-six it was lower, and in twenty individuals both points were on the same level. M. Velpeau remarks, as we think with some reason, that, at the moment of delivery, — the only time, after all, when it is requisite to form an idea of the direction of this plane — the point of the coccyx, being pushed downwards and backwards by the pas- Fig. 3. sage of the head, is at least on a level with, if not lower than the inferior part of the symphysis. The assertion of M. Nseg^le, there- fore, although true as applied to the female not in labor, fails during partu- rition ; and it must be admitted that the plane of the inferior strait is then ob- lique from below upwards, and from be- hind forwards. The axis of this strait is represented by a line (a b, Fig. 3) directed from above downwards, and from behind for- wards, which, starting from the first piece of the sacrum, falls at a right angle upon the middle of the bis-ischi- atic space. The remarks made upon the variations in the direction of the plane. c d. The horizontal line. ferior strait (during labor) ferior strait. c €. The plane of the in- a b. The axis of the in- OF THE PELVIS. 33 apply with equal force to its axis. The latter crosses the axis of the superior strait in the excavation, forming with it an obtuse angle, the sine of which is in front. It is also very important to know the dimensions of the perineal strait, and hence obstetricians describe three principal diameters at that point, namely — 1. The antero-posterior or coccy-pubal diameter (a a, Fig. 4), running from the ^'S- ^• point of the coccyx to the summit of the pubic arch ; it is usually four and a quarter inches long, but may increase to four and three-quarter inches during labor, by the retrocession of the coccyx. 2. The bis-ischiatic, or transverse dia- meter, h h, is four and a quarter inches in length, and goes from one tuberosity of the ischium to the other. 3. The oblique diameter, c c, commences at the middle of the great sacro-seiatic liga- ment, and crosses to the point of union of the ascending branch of the ischium, with the descending ramus of the pubis, and is four and a quarter inches long, but may become one quarter of an inch more during labor, from the elasticity of these ligaments. All the diameters of the inferior strait are, therefore, in the dried pelvis, about four and a quarter inches in length, though their dimensions are susceptible of great variation during labor. a a. The antero-posterior or coccy-pubal diame- ter. 6 6. Tlie transverse or bis-ischiatic diameter, c c. The two oblique diameters. § 5. Of the Excavation. The excavation is that space comprised between the superior and the inferior .straits, and it is in this cavity that the foetal head executes its principal move- ments; and it is somewhat surprising that, until quite recently, this canal was scarcely mentioned in the majority of the classic works, notwithstanding the im- portance of a knowledge of its dimensions, as also of the direction of its plane and axis. Its dimensions comprise both the height and width at the different points : thus the height in front, is one and a half inches; upon the sides, three and three-quarter inches ; whilst it is four and a quarter inches behind, if a straight line be drawn from the sacro-vertebral angle to the point of the coccyx, and five inches and a quarter, following the curve of the sacrum. Three diameters are also described for this cavity (like the straits), so as to appreciate its extent in the different directions. All of them are taken at the centre of the excavation, and they consist of an antero-posterior one, of four and three-quarters to five and one-eighth inches in length, a transverse diameter four and three-quarter inches long, and an oblique one, of the same length ; conse- 3 34 FEMALE ORGANS OF GENERATION. quently, all the diameters of this cavity are very nearly four and three-quarter inches each. "^ If the canal forming the excavation were a cylinder, it would only be neces- sary to divide it by a plane, perpendicular to its walls, in order to represent the opening of this cavity, but a simple division, thus made, would not give a just conception of the excavation, for two reasons : First, the canal is not cylindrical, because its sides are not parallel, and the anterior face of the sacrum presents a well-marked curvature; the pubic wall being nearly straight, and the lateral parietes very oblique from without inwards, and from above downwards. Con- sequently, to furnish an exact idea of the general arrangement of the pelvic ex- cavation, it seems necessary to divide the canal (vide Fig. 5) by a series of planes, all passing from the point c (the point of intersection of the planes of the superior and inferior straits) to any point whatever, p q r s tyOn the anterior face of the sacrum. Each of these planes Fig. 5. will show the opening of the pelvic cavity at the level where it is found. Now, to determine, with certainty, the direction of the general axis of this excavation, it is requisite to raise a perpendicular line from the geometrical centre of each of these sections, and to draw a line