The Philadelphia practice of midwifery

Front matter

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Chapter I

THE PELVIS consists of the sacrum and coccyx, and two ossa innominata. Ossa innominata, composed of two ossa ilia, two ossa ischia, and two ossa pubis. The division of the innominata. The pehds a basin, 1. The upper and lower basins ; separated by the superior strait, or margin, called also the brim, or linea ileo-pectinea. The excavation, how formed ; deeper behind and on the sides than in front. The outlet or inferior strait, 2. The upper basin described ; its uses. Poupart's ligament a part of the basin. The plane of the superior strait, 3. The importance of adjusting the plane of the superior strait in midwifery practice. The plane of the inferior strait. The axis of the pelvis, 4. The axis of the excavation. The sacrum — its situation — exposure — its curve — its foramina, 5. A knowledge of the foramina of the sacrum useful as a means of diagnosis. The coccyx — not easily forced backwards in labour. The ischium — its pelvic face — a triangle — a plane, 6. The inclination of the plane, 7. The pubis — its rami — ligaments. Its arch. The sacro-sciatic notch and ligaments, 8. The diameters of the pelvis. Four diameters for the superior strait. Two diameters for the inferior strait, 9. Table of pelvic diameters, 10. The sacro-iliac junction strengthened by ligaments behind, but dependent for security in front on the pubic symphysis. The separation of the pubis admits of an opening of the sacro-iliac junction. The symphysis pubis. The triangular ligament, the crown of the pubic arch, 11. The symphyses do not open in labour, except morbidly, 12. 1*

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Chapter II

THE CHILD'S HEAD. The bones not firmly united. The head plastic. Its diameters — as oblique, horizontal, transverse ; and the perpendicular diameter, 13. In labour one of the extremities of the head must present. These are the vertex and chin. Example of face presentation, 14. The fontanels — how distinguished. The anterior or frontal fontanel the largest. Inconvenience arising from firm ossification of the head, 15.

Chapter III

THE DEFORMED PELVIS. Excessive amplitude. In what manner inconvenient, 16. insufficient amplitude of a symmetrical pelvis, 17. Deformity from rickets and malacosteon. The long bones afiected as well as the pelvis. The softened pelvis admits of the sacrum sinking down under pressure, towards the pubis, 18. The new forms of the pelvis very various. The lower strait may be vitiated aione. A straight or very curved sacrum, 19. Deformed by exogtosisj and by convergent spines of the iScbia, 20,

Chapter IV

THE ORGANS OF GENERATION. External, internal, 21. The necessity of studying their anatomical characters. The mens. The vulva. The labia majora. The looseness of their texture and liability to distention, by blood, or water, or inflammation. Their extensibility in labour. Sometimes broken ofi", 23. The labia filled with blood after labour, how treated. When infiltrated with serum, how treated. Abscesses generally suppurate ; why, 24. Cohesion of the labia in children. The scalpel not necessary to destroy the cohesion, 25. The nymphoe. Their structure and uses. They are not eflfaced in the last moments of labour, 26. Subject to painful inflammation. They are enlarged. Excised, 27. The clitoris. Its preputium. Its universal occurrence in mammalia, except the duck-billed animal. Hypertrophia of the clitoris, 28. Salmacis and Hermaphroditus. The vestibulum. The urethra. The female catheter, 20. Sloughing of the urethra; of a large part of the bladder, 30. The hymen, 3L The fossa naviculaiis. The perineum, 32.

CONTENTS. Vll

Resistance of the perineum in labour; and laceration, 33. Necessity of supporting the perineum in labour, 34. The vagina. Its structure. Cicatrices, 34, 35. The uterus; how supported, 36. Its broad ligaments. Its tissue not fully understood by anatomists, 37. Its size in the non-gravid and gravid states, 38. Mode of action of the womb in labour, 39. The Fallopian tubes, 40, The ovaria, 41,

Chapter V

MENSTRUATION. Peculiar to the human female, 42. Regularity of the menstrual office, 43. Importance of the catamenial office, 44. Influence of the ovaria. Comparison of the male and female, 45. Comparison of the menstrual act with the erotic seasons of the mammalia. The proximate cause of the periodicity, 46, 47. Remarks on plethora as an assumed cause, 48. On lunar influence, 49. The menses secreted by the womb. The fluid does not come from the veins, 40. Women who menstruate in pregnancy, 51. Nature of the fluid, 52. Effects of coagula in menstruation, 52. Periods of eruption various in different countries, 53. Period of cessation. Its phenomena, 55. jPangers incident to this crisis, 56,

Chapter VI

AMENORRHCGA. Emansio and suppressio mensium. Causes of amenorrhcea, 57, 58. Necessity of attending to the state of the system, 59. Dependence of menstruation on the state of the circulation. Influence of the liver and portal system. Of the skin. Dress, 60. Emmenagogues, 61. The emmenagogues not worthy of great confidence, 62. Dr Cullen's opinion of them, 63.

Chapter VII

DYSMENORRHCEA. Various grades of it, 64. Causes of the malady, 65. Caducous secretion. Engorgement and morbid sensibility of the womb, 66. Effects of rest in dysmenorrhoea. Of venesection; aperients; alteratives; diet, 67. The bath. Dress. Dr Mackintosh's mode of treating dysmenorrhoea by the bougie, 68.

VIU CONTENTS.

Chapter VIII

LEUCORRHCEA. All secreting organs liable to morbid alterations of their products, 70. Vigarou's description of leucorrhoea, 71. The leucorrhoeal product formed either in the uterus or vagina, 72. Causes of it, 73. Leucorrhoea affects the health, not on account of the quantity of the discharge, but because the disease is uterine, 74. Danger of attributing it always to weakness, 74. The necessity of the touch in rebellious cases, and of attending to the state of the system, 75. Rest — its influence. Purging. A regulated diet, 76. Cleanliness. Injections. Anodynes, 77, Prescriptions, 78.

Chapter IX

PREGNANCY. Of reproduction, 80, 81. Theories of reproduction, 83. Buffon's theory, 85. Epigenesis, 88. Animalculists, 89. Harvey, Graaff, Spallanzani, 92. Spallanzani's experiments, 94. The cicatricula of the egg, 96. The ovarian vesicle or germ. The decidua, 100. Formation and use of the decidua, 101. The ovule reaches the womb — and its place of attachment becomes the placenta. No part of the placenta derived from the v/omb. The chorion is its source, 102. The amnion and the umbilical vesicle, 103. Probability that the true germ is betwixt the chorion and amnion. Liquor amnii. Its uses, 104. The position of the embryo ; surrounded by the waters. 105. Gradual development of the gravid womb. State of the cervix at different stages. Thickness of the walls of the womb. Its vascularity, 106. Case exemplifying the contractility of the OS uteri. Variety of opinion as to the arrangement of the muscular fibres, 107. Their co-ordinate contraction constitutes labour. Thickening, 108. The womb generally oblique in pregnancy, 109. Effects on the system of very great tone of the abdominal muscles in pregnancy, 110. Headach, vertigo, dyspnoea and cough ; varices and oedema produced by it, 1 11. The after-birth, 112. Its attachment very slight, 113. The secundines of the mammalia, 114. No considerable vessels passing from the placenta to the womb. Explanation of the effusions of blood in detachment of the placenta. Does not always occur, 115. The structure and uses of the placenta; dependence of the foetus upon it, 116. The placenta the medium of the nutrition of the

CONTENTS. IX

foetus, 117. Foeto-placental circulation, 118. Development of the fcEtus more rapid in some women than in others. The duration of pregnancy, 280 days. Dr Merriman's observations on the duration of pregnancy, 120. Experiments of Mr Tessier. The child quickens in the twentieth week, 121. Formation of the septum auricularum, 122. Signs of pregnancy, 122. Touch and ballottement, or tilting, 123. Auscultation. The soulSle, 124. jNecessity of distrusting complaints of amenorrhcea, 125. To procure abortion is a felony. Abortions, 126. Causes of miscarriage, 128. Hemorrhage attendant upon abortion. Management of it. The tampon, 129. Abortion, with the ovum retained, 130, Care required in the use of the plug, 131. Prolapsus produced by abortions, 132. Prolapsions, 133. Singular symptoms produced by prolapsion — with cases, 134, 135. Pessaries, 136. Retroversion, 141. Position of the patient in an attempt to reposit a retroverted womb, 145. Preparation of a patient for labour, 147.

Chapter X

LABOUR, 149. Baudelocque's theory of the cause of labour, 151. The sinking downwards of the womb at the close of pregnancy, 152. Labour-pains. Their influence on the economy, 153. They excite the blood-vessels and heart, 155. The touch, 156. False pains, how distinguished from true, 157. Injurious effects of over-distension, 158. In the progress of labour the os uteri descends, but rises again when the head has escaped into the vagina, 159. Sketch of the process by which the ovum is expelled, 159, 160. The bag of waters, 160. The chin of the child is brought to its breast. Causes of this flexion, 161. Reason why the head enters obliquely into the pelvis. Positions of a head-presentation, 162. Table of positions from Boivin, 163. Mechanism of labour. The head. The shoulders, 164; 165. Size of the womb after labour, 166,

CHAPTER XL

CONDUCT OF A LABOUR, 167. Table of the duration of 839 labours, 168. Duties of the accoucheur in his intercourse with the patient, 169. Necessity of attending to the circulation — which ought to be excited during labour. A natural degree of excitement not to be prevented, 170. Case where the pulse was sixty-five during a whole labour. Dr Dewees's opinion on copi-

X CONTENTS.

ous bleeding in parturition, 171. Of the use of enemata and aperients in labour, 172. The diet ; effects of on labour, 173. Of the patient's attitude. Obviates obliquity of the womb, 174, 175. The dip, or flexion of the head, to be provided for, and the means of doing it, 175, 176. The rotation of the head— it fails, why. How to remedy it, 177. Delivery of the head sometimes prevented by the grasp of the cervix, which was supposed to be completely dilated, 178. Effects of a very straight sacrum on rotation. The head escapes in a transverse position. How this is effected. Too deep a curve of the sacrum; its effects, 179. A narrow arch. Resistance of the perineum, 180. The danger of rupture of the perineum to be obviated — why and how, 181, 182. The cord twined round the child's neck, 182. The delivery of the shoulders. The body not to be dragged out, 183. How to treat the child. Tying the cord. How to hold it, 184. Management of the placenta, 185. Where the placenta is retained, 186. The placenta sometimes retained. Method of delivery, 187. After-pains, 189. A relaxed uterus bleeds. A contracted one does not admit of a flooding, 190. Concealed bleeding. Case, 191. Effect of position in uterine hemorrhage. Dr James's case of flooding, 192. Use of ergot to prevent flooding. Means of obviating concealed hemorrhage, 194. Women faint from want of mechanical support to abdomen after delivery. Case of Mrs I. A. S., 196. Diet of an accouchee. Treatment of the child, ]97. Sitting up. Of medicines for lying-in women, 199.

CHAPTER Xn.

FACE PRESENTATIONS 201

CHAPTER Xni.

ON THE POSITIONS OF THE HEAD, AND THEIR MECHANISM, IN LABOUR, 216. Of the touch or examination, 218. Presentations and positions — their difference, 221.

CHAPTER XIV.

ON PRESENTATIONS OF THE PELVIC EXTREMI- TY OF THE FCETUS, 228. Causes of breech presentations; not a preternatural labour, 229. Causes of the danger to child, 230. Proportion of cases fatal to child, 231. Mode of diagnosis,

CONTENTS. XI

232, The feet not to be brought down, 233. Positions of a breech presentation. Management of the case, 235. Care re. quired in delivering the head, 239. The author's custom to provide forceps in all cases of pelvic presentation, or other kinds, where the head is last to be born, 238. Delivery in breech cases, where the sacrum is towards the mother's back, 238. Cases, 240, 241. Presentations of knees and feet, 242.

CHAPTER XV.

ON PRETERNATURAL LABOUR, 241. The shoulder presents, 245. Shoulder positions, 247. Diagnosis; it must be turned, 248. The method, 249. The operation, 250. Labour with hemorrhage, 255. Observations on these cases, and the general means of treatment, 256, 258. Louisa Bourgeois's method, 259. Placenta proevia, or unavoidable hemorrhage, 261, 262, Citation from Dr Collins, 263. Delivery in placenta praevia, 264. Concealed hemorrhage, 266. Hemorrhage after the delivery of the child, and before that of placenta, 267. Adherent placenta, 268, Hour-glass contraction, 269. Hemorrhage after delivery of placenta, 270. Case from Mauriceau, 271. Preternatural labour from convulsions, 277, 282. Prolapsion of cord, a cause of preternatural labour, 283, Fainting, a cause of preternatural labour, 284. Hernia, 285.

CHAPTER XVL

OF THE FORCEPS, 286. Ancient resources, 287. Doctor Chamberlayne, 288. His case with Mauriceau, 289. The old curve and the new. Smellie and Levret, 290. Pean, or Baudelocque's forceps, 291. Dr D.Davis's forceps, 293. Action of the forceps, 294. It is designed for the head alone, 297. Rules, 298. Application of the forceps, and its use, 299, 305. Application where no rotation takes place, 305. In the second position, 306, With vertex to sacrum, 307. In the fourth or fifth, 308. Transverse head, 309, 310, Forceps in face cases, 311, Locked head, 312. Impaction, 315, Forceps applied to the head in the last stage of footling cases, 315^ Craniotomy, 317. Observations on embryulcia, 317 to 322. Case of Mrs R., 322—334. Remarks on the crotchet, 335. Instruments for delivery in deformed pelvis, 336,

Xll CONTENTS.

CHAPTER XVII.

INVERSION OF THE WOMB 340

CHAPTER XVni.

PUERPERAL FEVER 345

CHAPTER XIX.

ATRESIA VAGlNiE c 360

Chapter I The Pelvis

The Pelvis consists of an irregular canal, composed of four bones, that are firmly united, in the adult, by what are called the symphyses. These bones are, 1st, the sacrum; 2d, the coccyx, which is attached to the lower end of the sacrum; 3d, the two ossa innominata or hip bones, which are united to each other, in front, by the pubic symphysis, and behind, to the right and left sides of the sacrum, by what are denominated the sacro-iliac symphyses. When bound together by their natural ligaments, they might, by a careless observer, be mistaken for a single bone, but, a slight inspection will suffice to show the points of their union which have been just^ mentioned.

The ossa innominata are, further, divided, for the convenience of reference, into portions ; namely, three portions for each os innominatum. They are the os ilium, OS ischium, and os pubis ; the several limits or boundaries of which may be discovered by examining the pelvis of a young subject, in which the ossific growth is not completed. The division lines of the three portions meet nearly in the centre of the acetabulum, giving the upper and outer two-fifths to the ilium, one-fifth anteriorly to the pubis, and the remaining two-fifths to the ischium.

The bony pelvis may be compared to a basin with part of its edge or side broken out ; for the crista of the ilium advances scarcely beyond the transverse diameter of the bowl, leaving a vacant space in front, which in the living subject is occupied by the abdominal muscles. See the figures of the pelvis. The sides of the basin are composed of the costse of the ilia, and the back part is filled up by the lumbar vertebrse : thus representing, as I have said, a bowl with its side broken out. The pelvis is commonly divided into the upper and lower basin — the division betwixt the two being clearly marked by a line, margin, or brim, running right and left, round the sides and back of the pelvis, from the top of the pubis to the front of the articular surface by which the sacrum is joined to the last lumbar vertebra. This line is denominated the linea ileo-pectinea, or ileo-pubic line. It defines the superior strait.

Upon looking downwards into the pelvis, below the linea ileo-pectinea or superior strait, a cavity is perceived, which is called the lesser basin, or, more properly and "echnically, the excavation. The excavation is bounded above, by the linea ileo-pectinea, behind, by the sacrum and coccyx, on the sides by the ischia, and in front by the pubis. As the sacrum, with its appendage, is more than five inches long, the ischia three and a half inches, and the pubis only one inch and a half in length, it is evident that the excavation is much deeper behind and on the sides, than in front. The finger can reach above the strait in front, whereas the hand must be introduced, to reach up to the top of it behind.

The outlet of the pelvis, called the perineal or inferior strait, is bounded by the under and inner edges or lips of the pubes, ischia and coccyx, In the dried pelvis it is of a most irregular shape, furnishing, in front, a large notch called the arch of the pubis, and two very deep indentations or notches in the sides, which have received the appellation of sacro-ischiatic notches, because they occur between the sacrum and ossa ischia.

From the foregoing it appears, that we assign to the pelvis an inferior strait, an excavation, and a superior strait, all of which are comprehended in the term lesser or lower basin ; while on all that portion of the organ which is found above the ileo-pubic line, is conferred the title of superior basin or upper pelvis.

The upper basin of the pelvis is bounded above, by the cristae of the ossa ilia. The anterior extremity of this crista or rim, is called the anterior-superior spinous process, while a little below it, is observed the anterior-inferior spinous process. The ilium terminates, behind, in a posterior-superior spinous process, and has, a little lower down, a posterior-inferior spinous process. The bone exhibits an articular surface, placed in an oblique direction, near its hinder extremity; this surface is tipped with cartilage, that is in contact, in the recent subject, with a similar plate of cartilage upon the sacrum, at the point of their junction, the sacro-iliac symphysis.

Th3 broad thin portion of the ilium, looking upwards and inwards, is the costa, or iliac fossa. It is in this concave part of the bone, that the child's head or other presenting part, is placed temporarily, whenever it becomes necessary to push that part away from the upper strait, in order that the accoucheur's hand may pass upwards into the womb, to seek for the child's feet, in turning. This seems to be one of its chief obstetrical uses ; since the head can not be pushed backwards, because of the vertebrae, nor readily in front, on account of the resistance of the muscles ; so, when the head rests on the strait, or within it, the accoucheur's hand, in order to pass upwards through the strait, must first of necessity remove the head into some other position. Poupart's ligament, which extends from the anterior-superior spinous process of the ilium to the pubis, also in some measure prevents the head from being pushed out of the way towards the left or right front, and is by some persons considered as composing part of the limits of the upper basin.

In order to get a good idea of the plane of the superior strait, let a half sheet of paper be cut in such a manner as to fit within the linea ileo-pectinea, and when placed therein, it will represent that plane. Hold the pelvis in such an attitude as it occupies in an individual standing up or sitting, and it will be found that the plane of the strait dips at about thirty-five degrees, an inclination which is increased or diminished, at will, by extending or flexing the lumbar vertebrae.

In the practice of midwifery, it is often a matter of great importance to attend to the degree of inclination of this plane. Let us suppose a child lying within the uterus, and destined to pass downwards through the pelvis : if the plane of the superior strait be excessively inclined, the presenting part of the child would be propelled upon the top of the pubis, or even over and above it — a case that is not unfrequently met with; whereas, if the inclination be just or natural, the presenting part enters the opening withvout such impediment. To a practitioner unacquainted with the indications derived from the state of inclination of this plane, much embarrassment is likely to accrue, ac long as he remains ignorant of the reason which prevents the engagement, as it is called, of the head from taking place.

If a piece of paper be fitted into the lower strait in like manner with that above mentioned, it will represent the plane of the inferior strait : upon comparing them, they are found to be very much inclined towards each other, being distant from each other one inch and a half in the front of the excavation, and five inches and a half behind.

If a piece of wire be now passed perpendicularly through the centre of the piece of paper that represents the plane of the superior strait, it will represent the axis of that strait. And if another wire be pushed through the centre of the plane of the inferior strait, and perpendicularly to it, it will be the axis of the inferior strait. The upper wire will strike the sacrum pretty low down, or towards its point; and the lower wire will strike the same curve pretty high up towards its base ; all of which shows, conclusively, that the axis of the superior is diff'erent from the axis of the inferior strait, or what comes to the same thing, that the canal of the pelvis is a curved one, and that the child in passing out must proceed through a curved, and not a straight canal. If the upper wire were bent, and pushed through the upper plane, and carried downwards until it passed through the centre of lower plane, it might then represent a curved axis of the curved canal; it would be the axis of the excavation.

If the reader will now take into his hand a sacrum, he will see that it is a triangular bone, with the apex downwards, and the base upwards. At the base is an articular surface, by which it was joined to the last lumbar vertebra ; and on each side is an articular surface, by which it was united to the innominata, as before mentioned: these facettes are so placed that, it will be at once evident, the sacrum could not be driven downwards without riving open the innominata, for it enters them like a wedge ; nor could it be driven outwards without also riving them asunder ; so that it is in a manner dovetailed into the coxalia ; a very wise provision of nature ; for, all the forces t?jat naturally operate on it, tend to drive the sacrum either downwards or outwards ; as, first, the weight of the body, and second, the pressure of the foetus during the parturient throes. These are the only forces to whose displacing action it is much exposed.

The sacrum is about four inches long, and when the coccyx is added, the whole length is at least five inches. If a ruler be placed so that it may touch the top of the sacrum and the point of the coccyx at the same time, it will represent the chord of an arch, the arch being formed by the curve of the sacrum, the deepest part of which curve will be found about midway between, but rather nearer the top than the bottom, and at least half an inch in depth, in an average of cases, notwithstanding that some specimens are found, in which the curve is either much greater or much less. All deviations from the average measurement exert a more or less unfavourable influence upon the progress of a labour.

Upon each side of tlie hollow of the sacrum may be observed a row of holes, which transmit nerves from the lower end of the medulla spinalis. They are generally five in number upon each side. The situation of these nerves exposes them to severe pressure during the transit of the child's head over their foramina; and, as in other cases of pressure upon a nerve, the parts to which they are distributed, become affected with severe cramp or numbness, which generally vanishes as soon as the pressure ceases, but, not unfrequently, continues long after the termination of the labour, in consequence, perhaps, of the nerve having been severely contused and injured.

The coccyx is attached to the apex of the sacrum by a joint, which is said to admit of the point of the bone moving back half an inch when pressed by the foetal head. I think, however true it may be that the coccyx moves backwards when hard pressed, that this does not occur as a common or ordinary event. This seems to be established upon a reference to the situation of the sacro-sciatic ligaments, which fasten the coccyx so firmly to the os ischium that it requires a severe strain to move it backwards as far as is pretended. I have had several occasions to observe, that where the coccyx has been violently pressed backwards in labour, great pain and inconvenience have resulted from the accident, the symptoms being not very dissimilar from those which occur after falls upon the point of the bone.

The ossa ischia, whose situation has already been pointed out, merit the attention of the student of this important portion of obstetric anatomy, particularly as regards the appearance and influence of their inclined planes, of which so much is said in books of midwifery. The inner face of the ischium is nearly an equilateral triangle, and is three and a half inches in length ; the surface is smooth and level, so that a ruler, laid upon it, touches it throughout. From the posterior side of the triaugle proceeds a strong process called the spinous process of the ischium, which furnishes a place of attachment for the lesser sacro-ischiatic ligament. The lower portion of the bone is rough and very thick, constituting the tuberosity of the ischium, the part upon which the body rests when in a sitting posture. A process springs upwards, forwards, and inwards from this point,, to meet and unite with a like portion sent down from the pubis ; it is the ramus of the ischium. The planes of the two opposite iscliia incline towards each other forwards and downwards ; in order to get a good idea of this inclination, let the student take a pair of compasses, and measure with them the transverse diameter of the superior strait, the legs resting upon the linea ileo-pectinea respectively. They will be found at least fou and a half inches apart. But if they be now transferred to the transverse diameter of the lower strait, a leg of the compass resting upon the inner lip of each tuber ischii, they will be four inches apart ; proving that the inclination of the planes causes them to approach at least half an inch in the course of their descent of three inches and a half from top to bottom of the sides of the pelvis. The posterior angles of the ischia are also much farther apart than their anterior. If two slender rods, eighteen inches long, be laid along the faces of the ischia, one on each, in a dried pelvis, and the lower ends of the rods be allowed to project below, they will cross each other about thirteen inches below the outlet. The effects produced by this arrangement of the inclined planes will be discussed in a subsequent page.

But while the surface of the ischium is level, that of the sacrum is very much curved, being farther from the pubis, by at least half an inch, at its middle, than at either its base or apex, a circumstance of the utmost importance in what is called the mechanism of labour. It is this curve of the sacrum, that gives to the lesser basin its specific character as " excavation." If the sacrum were straight, as the ischia are, there could be no excavation, the canal would be conical ; a glance at the pelvis, or the figures, shows this conclusively.

asffiii-TTiyri,.—

THE PELVIS.

It should now be observed, that the pubis sends off an horizontal portion to unite with the ilhira and ischium in the acetabulum, and a descending ramus to meet the ascending ramus of the ischium, which it meets half way. These horizontal and descending portions leave an oval opening called the foramen ovale, which, in the recent pelvis, is filled with a membranous ligament called the obturator membrane, giving origin to muscles, and passage to vessels and nerv^es. The descending rami of the ossa pubis are connected together, towards their origin, by a ligamentous matter, which, from its shape, is called the triangular ligament, and is a part of the interpubic ligament, which not only binds the two pubes together, but also serves to render the arch of the pubis broader or lower, as well as stronger. The anterior edges of the rami are turned outwards, as if some hard body had passed through the pelvis, and squeezed them out, while in a soft and plastic state. This conformation admits of their retaining the requisite degree of strength, while it also allows the opening through which the child is to pass, to be sufficiently large and free ; a singular proof of the wonderful adaptation of the organs, in early life, to the functions they are destined to perform at a more advanced period of existence.

The sacro-sciatic notch is partly occupied by two ligaments : one proceeding from the edge of the sacrum to the tuberosity of the ischium ; and the other from the edge of the sacrum, and coccyx, to the spine of the ischium ; the former is the outermost one. Hence it is seen, that the lower strait of the pelvis, in the recent subject, is marked by the point of the coccyx, the inner edges of the tuberosities and rami of the ischia, the inner edges of the arch of the pubis, and the inner edges of the sacro-sciatic ligaments.