SECTION 1.

ANATOMY AND PHYSIOLOGY OF THE FEMALE

IN

PELVIC ORGANS.

N order to give a comprehensive idea of the Anatomy and Physiology of the Female Pelvic Organs, it will be advisable to consider it in the following manner :

CHAPTER I. (1.) The External Genitals as observed clinically. (2.) the Pelvic floor and organs resting on it considered as a whole. (3.) the Pelvis considered in detail as follows:-Musculature of Pelvic Floor; Uterus, Fallopian Tubes, and Ovaries; Vagina; Bladder; Rectum and Perineal Body; Peritoneum and Connective Tissue.

CHAPTER II. The position of the Uterus and its annexa, and the Viscera superjacent to the Pelvic Organs.

CHAPTER III. The Structural Anatomy of the Pelvic Floor; Pelvic Floor Projection.

CHAPTER IV. The Bloodvessels, Lymphatics, and Nerves of the Pelvis. Development of Pelvic Organs.

CHAPTER V. Physics of the Abdomen and Pelvis with special reference to the Semiprone and Genupectoral Postures.

CHAPTER VI. Ovulation and Menstruation.

A

CHAPTER I.

LITERATURE.

EXTERNAL GENITALS.

Budin-Recherches sur l'hymen et l'orifice vaginal: Paris, 1881. Matthews Duncan. - Papers on the Female Perineum: Churchill, London, 1880. F. P. Foster-A Contribution to the Topographical Anatomy of the Uterus and its Surroundings: Am. J. of Obst., Vol. XIII., p. 30. Garriguez-The Obstetric Treatment of the Perineum : Am. J. of Obst., Vol. XIII., p. 231. Henle-Handbuch der Eingeweidelehre des Menschen: Braunschweig, 1866. MUSCLES OF PELVIC FLOOR. Cunningham-The Dissector's Guide; Abdomen: Maclachlan & Stewart, Edinburgh, 1880. Henle-op. cit. Luschka-Die Musculatur am Boden des weiblichen Beckens: Wien, 1861. Savage-Female Pelvic Organs, 2d Edition: London, 1870. Turner-An Introduction to Human Anatomy: A. & C. Black. UTERUS, AND ANNEXA; VAGINA. Barnes-The Diseases of Women: London, 1878. Breisky - Die Krankheiten der Vagina: Billroth's Handbuch, Stuttgart, 1879. Cruveilhier-Traité d'Anatomie Descriptive: Paris 1871. Engelmann-The Mucous Membrane of the Uterus: Am. J. of Obstetrics, Vol. VIII., p. 30. Farre-The Uterus and its Appendages: Todd's Cyclopædia, Vol. V. Hart Structural Anatomy of Female Pelvic Floor: Maclachlan & Stewart, 1880. Henle-op. cit. Hennig-Der Katarrh der inneren weiblichen Geschlechtstheile: Leipzig, 1862. Mundé-Prolapse of the Ovaries: American Gynecological Transactions, Vol. IV., 1879. Rainey-On the Structure and Use of the Ligamentum Rotundum Uteri: Lond. Phil. Tr., 1880, p. 515. Ruge and Veit--Zur Pathologie der Vaginal Portion : Stuttgart, 1878. Sappey-Traité d'Anatomie Descriptive: Paris, 1873. Schroeder-Handbuch der Krankheiten der weiblichen Geschlechtsorgane: Leipzig, 1879. TaylorAmerican Journal of Medical Science, Vol. LXXX., p. 126. Turner--op. cit. BLADDER.

H. J. Garriguez-Remarks on Gastro-Elytrotomy: Am. Gynecol. Tr., Vol. III., p. 212. Skene-Diseases of the Bladder and Urethra: New York, 1870. Skene -The Anatomy and Pathology of Two Important Glands in the Female Urethra : Am. J. of Obstetrics, Vol. XIII. Winckel-Die Krankheiten der weiblichen Harnröhre und Blase: Billroth's Handbuch, Stuttgart, 1877. RECTUM. Braune - Topographisch anatomischer Atlas, Zweite Auflage: Leipzig, Veit & Co., 1872. Chadwick-The Function of the Anal Sphincters so-called: Am. Gyn. Tr., Vol. II., p. 43. Pirogoff-Anatome Topographica, sectionibus per corpus humanum congelatum: Petropoli, 1859. Ruedinger-Topographisch-Chirurgische

Anatomie des Menschen: Vierte Abtheilung. PERINEAL BODY. Hart, Henle, Savage, op. cit. T. G. Thomas-The Female Perineum ; its Anatomy, Physiology and Pathology: Am. J. of Obstetrics, Vol. XIII., p. 312. PERITONEUM AND CELLULAR TISSUE. Bandl-Die Krankheiten der Tuben, der Ligamente, und des Beckenperitonäums: Stuttgart, 1879. Barnes-St George's Hospital Reports, Vol. VII., p. 57. Freund-Anatomische Lehrmittel zur Gynäkologie: Beiträge zur Geburtshülfe und Gynäkologie. Herausgegeben von der Gesellschaft für Geburtshülfe in Berlin. IV. Band, 1 Heft. S. 58. Guérin-Sur la Structure des Ligaments larges: Comptes Rendus, 1879, 1364. Le Bec-Contribution a l'étude des ligaments larges (au point de vue de l'anatomie et de la pathologie): Gaz. Hebd.,

15 Avril 1881. De Sinéty-Gynecologie: Paris, 1880. Spiegelberg-Remarks upon Exudations in the Neighbourhood of the Female Genital Canals: German Clinical Lectures (New Syd. Soc. Tr.), p. 169. Braune, Cunningham, Hart, Pirogoff, op. cit.

(1.) EXTERNAL GENITALS AS OBSERVED CLINICALLY. UNDER the term external genitals are comprised the structures known as Labia Majora, Fourchette, Labia Minora, Clitoris with its prepuce, Vestibule, and Fossa Navicularis. For clinical convenience the urethral orifice and hymen also are described with these; although the urethral orifice belongs to the urinary system, and the hymen separates anatomically the external genitals (vulva) from the vagina.

External Genitals of Virgin, with Diaphragmatic Hymen. The Labia Majora and Minora are drawn apart, and the prepuce drawn back.

a Labium majus; Labium minus; c Praeputium clitoridis; d Glans clitoridis; e Vestibule just above urethral orifice; / Mons Veneris. ()

The Labia Majora (fig. 1. a) are two thick folds of hair-clad skin, running parallel to the anteroposterior diameter of the pelvic outlet,

extending from the symphysis pubis backwards between the thighs, and meeting each other posteriorly in the middle line about 2.7 cm. (1 inch) in front of the anus. Each labium has an outer and inner surface, and consists of a thick fold of skin enclosing a quantity of fat, blood-vessels, and dartos. Superiorly, where they are best developed, they form by their junction-anterior commissure-the structure known as the mons veneris (vide lithographic frontispiece); while posteriorly, they are a mere fold of skin known as the Fourchette or posterior commissure. The fat and connective tissue are therefore almost entirely wanting at the fourchette, which is not a distinct structure but is simply the posterior junction of the thinned-out labia majora. Both labia are, in the adult, covered with crisp hair which is most abundant over the mons veneris and outer surface but very much less on the inner.

The Labia Minora (fig. 1. b) are two small oblique folds of skin, one on the inner surface of each labium majus. Posteriorly they blend insensibly with the labium majus at about its middle, while anteriorly they converge and each divides into two small branches, an upper and a lower. The upper branches meet to form the prepuce of the clitoris (fig. 1. c), while the lower in a similar way form its suspensory ligament. As a rule the labia minora do not, in the adult, project beyond the labia majora. Sebaceous glands are present on both labia. The Clitoris, covered by its prepuce, lies in the middle line and at the apex of the smooth piece of mucous membrane known as the vestibule. Only that part analogous to the glans penis is seen (fig. 1. d). The clitoris proper consists of two crura which arise from the rami of the ischium and pubis and unite superiorly to form the body of the clitoris, which lies beneath the mucous membrane. The glans clitoridis is not directly continuous with the body, but joins it through the pars intermedia of the bulb (vide post, p. 10).

The Vestibule (fig. 1. e) is a triangular smooth mucous surface bounded superiorly by the clitoris, laterally by the labia minora, and inferiorly by the upper margin of the vaginal orifice. In the middle line at its base the dimple of the urethral orifice can be distinctly felt 2-2.5 cm. (1 inch) in front of fourchette. Small depressions and mucous glands open on

its surface.

The Vaginal Orifice lies in the middle line between the base of the vestibule and the fossa navicularis. Its orifice is guarded by the hymen, a thin fold of mucous membrane enclosing some connective tissue, blood-vessels, and nerves (?) The hymen may be crescentic in shape, attached to the posterior margin of the vaginal orifice, and with free

edge towards the base of the vestibule (figs. 2 and 5); or diaphragmatic, attached all round the vaginal orifice, but with a small hole (figs. 1 and 4) or vertical slit (fig. 3) in it. Sometimes it is not so perforated, constituting a pathological condition.

Vertical Mesial section of External Genitals (Henle).

a Anus: 6 Perineal body; c Vagina; d Urethra: e Labium Minus; f Prepuce of Clitoris; g Fossa Navicularis, with Hymen in front and Fourchette behind. (†)

Fossa Navicularis.-Normally, the inner aspect of the fourchette is in contact with the outer and lower surface of the hymen. When the fourchette is pulled down by the finger, a boat-shaped cavity is madethe fossa navicularis. Its posterior boundary is, therefore, the inner aspect of the fourchette; its anterior, is the posterior aspect of the hymen. These two are in contact unless artificially separated. The ducts of the Bartholinian glands open into the fossa by small pin-hole apertures (fig. 2).

From behind forwards, in the female ano-vulvar region there lie in the middle line the following structures :

(1.) Anus.

(3.) Fourchette.

(4.) Fossa Navicularis.

(5.) Vaginal orifice, with Hymen or its remains.

(6.) Urethral orifice.

(7.) Vestibule.

(8.) Clitoris with its prepuce.

Laterally we have the labia majora and minora.

The following points should be carefully noted. In the nude erect female only the mons veneris is seen (vide lithog. frontis.). The well developed labia majora have their inner surfaces always in contact and are only slightly separated by the widest divergence of the knees. The