Charles Delucena Meigs Alfred Velpeau.

A complete treatise on midwifery: or, the theory and practice of tokology ... online

. (page 14 of 102)
Online LibraryCharles Delucena Meigs Alfred VelpeauA complete treatise on midwifery: or, the theory and practice of tokology ... → online text (page 14 of 102)
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it is closed ; and he will be able to tell the length which the greatest separation of
each finger measures.

With the finger we have the advantage of appreciating all sorts of deformities
of the pelvis, whatever be their seat, their nature or degree ; the straightness of
the sacrum, as well as excess of its curve ; also, exostoses and tumours of what-
soever nature, the transverse as well as the antero-posterior diameters. By
pressing with a certain degree of force against the point of the coccyx, it is possi-
ble even to learn how much may be gained in the coccy-pubic diameter by the
retreat of the coccyx backwards. Those who have objected that the finger is not
always long enough to reach the angle of the sacrum have forgotten that a pelvis,
in which the forefinger cannot reach to the promontory, is thereby proved to be



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MENSURATION OF THE PELVIS. 87

so spacious that the accoucheur need not trouble himself to examine it any
farther.

Moreover, it cannot be denied that, although it is never very difficult to dis-
criminate between a deformed pelvis and one that is not so, it is nevertheless im-
possible, in certain cases, to determine the exact nature and degree of each
particular deviation ; it is, therefore, no more than right to give the praise they
deserve, to the efforts lately made by Madame Boivin to obtain more precise re-
sults : the instrument which she has invented, and which she has named intro-
pelvimeter, although founded on the same principles as Coutouly's, differs from
it, nevertheless, very considerably. It might be compared rather to what Stein
calls grand pelvimeter. As its branches are separately introduced, one into the
rectum, and the other into the vagina, and as the curve of the rectal branch is
very deep, it may be used in the virgin as well as in the pregnant woman, and at
any stage of labor; it may even be employed in ascertaining the oblique and
transverse diameters, and by altering its vaginal branch it could easily be con-
verted into a calliper. Nevertheless, I doubt that we shall be able to obtain from
this apparatus such exact results as its inventor seems to hope for.

However multiplied the means of measuring the pelvis, it must have been
seen, from the foregoing, that even the most skillful accoucheur will never be able
to attain to the mathematical precision that is desirable. In corroboration of this,
I may mention the following case : A rickety woman, seen by M. Deneuxat the Hos-
pital of the Ecole de M6decine, was examined carefully at the period of delivery.
Once they found three inches, and at another time two inches and a quarter, at the
sacro-pubal diameter. The forceps became necessary at the inferior strait. After
death, it was observed that the smallest diameter was two inches and eleven lines !
But is this a reason for rejecting them entirely, and asserting with Puzos that
the operation itself is of no use ? This author, otherwise so correct, has assuredly
gone too far in saying that a young woman ought to be forbidden to marry, if
she had ever been affected with rickets, or if she has a spinal deviation ; and
humanity and justice both appeal from his judgment. How many ill-shaped
women bring large robust children With the greatest ease into the world!
Another serious inconvenience might attach to such a general proscription : many
women would pay no respect to the prohibition, and not be slow in convincing
themselves that they had been frightened with dangers wholly chimerical.
Hence, what almost always occurs when the effect does not follow the threat,
those who run some risks upon being married, and those who run no risks at
all, would equally turn a deaf ear to advice. On the other hand, it would be
absurd to deny the importance of pelvimetry, in labor, when a decision must be
made between embryotomy and the dangerous operations that may be performed
upon the mother. Finally, by citing, for the purpose of proving the uselessness
of pelvic mensuration, the cases of women who were not afraid to become preg-
nant again after having once undergone the Caesarian operation, Puzos seems to
me to have misunderstood their true position. Is it really the attraction of plea-
sure that always induces them to yield to the brutal husband that the law has
given to them? Is it fair to compare a woman who fears, above all things, to lose
the affections of a man to whom she is united for life, to a young girl, who, free
from all entanglements, ought to think first, and above all, of her own safety ?
(For particulars, see the article Touch in this volume.)



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PART II.
OF THE SEXUAL ORGANS.

In women, as in men, the Organs of Reproduction are partly enclosed within
the pelvis, and partly exposed on the exterior surface of that cavity.



CHAPTER I.

OF THE EXTERNAL ORGANS OF GENERATION.

Under the title of external genital organs are generally comprehended the
Mons Veneris, the Vulva, and the Perineum.

Mere appendages of the internal organs, these parts perform only a secondary
office in the great generative function ; but during the expulsion of the ovum,
they undergo changes, and are exposed to dangers, which render the exact know-
ledge of them very useful to the physician-acooucheur.

SECT. I. — NORMAL STATE.
ART. I.— THE MONS VENERIS.

The Mount of Venus (the tur-pvbal eminence, pubes) is a sort of relief formed
by the soft parts that cover the front of the pubis; it is principally composed of
fat, fibrous filaments, and cellular tissue. In fat women, it is sometimes separated
from the belly by a transverse groove of considerable depth ) the degree of its
projection also varies on the same account, but much more on account of the pro-
jection of the bones which support it being different in different subjects.

The skin that covers it is very thick, elastic, not very extensible, and covered
with hair in the adult ; it contains a great number of sebaceous follicles, and the
whole represents a sort of cushion, the uses of which are, according to many au-
thors, connected with the business of copulation. The composition of the mons
Veneris very fully explains the violent pain which accompanies phlegmonous
inflammation of the part, and enables us to comprehend why abscesses formed
within it should be promptly opened.

ART. n. — THE GREATER LABIA.

A sort of cutaneous folds which seem to result out of the bifurcation of the
lower part of the mons Veneris, the two labia separate farther and farther from
each other, for about half their length, and then approach to be united again
about an inch in front of the anus, exhibiting two commissures, one superior or
pubic, the other inferior or perineal. The external surface, formed by the skin



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NORMAL 0TAT9. 69

of the thighs, in, like the pubes, covered with hair at puberty. Their internal
surface is smooth; glabrous, and of a rose color; a considerable number of seba-
ceous or mucous follicles are observed upon it. The accoucheur ought to be
aware that the matter furnished by these follicles may become acrid, and irri-
tating to such a degree as to give rise to a discharge that has often been mistaken
far blennorrhagia, particularly in uncleanly women.

In young girls, the thickness of the labia is greater above than below. In
women who have borne children the contrary commonly obtains. Moreover, be-
fore the age of puberty, they are very close together, and pretty firm. After
marriage they separate from each other, become flaccid, bluish, and lose the regu-
larity of their form.

Composed, like the mons Veneris, of filamentous cellular tissue and fat, they
are also, like it, subject to phlegmonous inflammation, attended with violent pain,
and which ought to be opened early, taking care to plunge the instrument to a
considerable depth if it is desired to avoid relapses and sinuses.

As the tissue of which they are composed is much looser than that of the
mons, and they are exposed to more friction, they are subject not only to purulent
collections, but also to bloody extravasations, serous effusions, &a, which may
acquire a considerable size.

The great labia may also become the seats of hernia, and other tumours, which
should not be confounded with those above mentioned. The slit which they cir-
cumscribe, and which is placed in the direction of the ooccy-pubio diameter, is
called the vulva, while the whole of the external genitals is specially designated
by the word pudendum. This slit contains several parts, situated in a direction
from above downwards : these are the lesser labia and the clitoris, the vestibule,
the meatus urinarius, the vulvar orifice of the vagina, the hymen, the fossa navi-
cularis, and the fourchette.

ART. III. — THE LESSER LABIA.

Thus denominated because they are, in fact, mueh smaller than the preceding,
known also as the nymphw ; the lesser labia have been compared to a young
cock's comb. They arise, superiorly, by two branches, which are continuous
with the prepuce of the clitoris : they then descend, divergingly, on the inner
face of the greater labia, and terminate insensibly about the middle of these lat-
ter, opposite to the orifice of the vagina. They are of a firm consistence, and a
reddish color; they are formed of a tegumentary fold of a mucous character,
very delicate, and very sensitive, and also of an erectile or spongy tissue, very
closely resembling that of the corpus cavemosum in men.

At birth the nymphae generally protrude beyond the level of the greater labia;
in young virgins, on the contrary, the labia almost entirely conceal the nymphae ;
and in adult women who have had children, the lesser labia again become very
salient, while they lose their firmness and their rosy hue.

In this respect, numerous varieties are to be observed; sometimes, indeed, their
appearance undergoes no alteration; at other times, they acquire a considerable
length, either as regards their whole extent, or only near their posterior extremi-
ty. This hypertrophy, which is in some cases natural, but most commonly acci-
dental, is sometimes carried to such an extent as to interfere with coition ; so
that it was formerly not uncommon to amputate the nymphae. In some coun-
tries, they are, naturally, much longer than in our European regions. In Persia
and Turkey, for instance, if we may believe the reports of travelers, it is fre-
quently found necessary to excise them. Haller speaks of it as being common
among the natives of the South, particularly the Moors and Copts.

From the time of Kolbe, all the naturalists have spoken of a peculiar fold
known as the Hottentot apron, and on which Tackard, sparman, Banks, Peron,



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90 OF THE EXTERNAL ORGANS OP GENERATION.

Levaillant, Lesueur, and several others have emitted very different notions.
Evidently depending on the prolongation of the lesser labia, as was seen by Ten-
Rhyne, it is not among the civilized Hottentots that it is met with, but among
the savage tribes of the environs of the Cape, discovered by the Dutch, who called
them Bogismans or Bochismans, that is to say, Bushmen. On this subject no
further doubt can be entertained, since an individual of this species came to be
exhibited at Paris, under the title of the Hottentot Venus : in fact, the drawing
of it furnished by M. Flourens, and the descriptions published by MM. Cuvier
and Virey, show that, instead of being three or four lines, the nymphae of this
woman were several inches in length. It is true, there is a wide difference be-
tween these dimensions and those attributed by certain travelers to the Hottentot
apron ; but it is easy to conceive of an extent of six or eight inches in an organ
which has been seen actually to measure three inches, provided that, by means
resorted to in that country, they are subjected to continual tractions, always
increasing in force, from childhood up to adult age.

The uses of the nymphae are little known. The ancients believed that they
served to direct the course of the urine, whence their name of nymphae. Dionis
and Levret, like all the writers who have followed them, pretend that they unfold
or disappear in labor so as to favor the enlargement of the vulva; but this asser-
tion is wholly false. It is said, lastly, that, being endowed with an exquisite
degree of sensibility, their use is to augment the pleasure of the venereal act

ART. IV.— THE CLITORIS.

The clitoris is a tubercle which authors have compared to the uvula, and which
represents, on a small scale, the penis of the male. In the clitoris are distin-
guishable a loose extremity, round, and of an acorn shape, and a body which is
attached by two roots to the ischio-pubic rami ; but it has not a canal, as is the
case in the male yard. A fold of skin covers it, serves as a prepuce, and then
proceeds to disappear in each of the lesser labia, of which it seems to be the root

During the first months of uterine life, the clitoris is as long and as large as
the penis ; at birth its dimensions are still considerable. But from that time it
ceases to grow, if it does not even diminish, so that at the age of puberty it is in
general not more than four or five lines in length. There are, however, some
women in whom it obtains a much greater development. It has been, on some
occasions, seen to reach the length of from one to five inches; in such cases, it
scarcely differs from its analogue in the other sex.

Such a disposition as the above is further remarkable, inasmuch as it coincides
with certain characteristics which have even led to the belief that individuals of
such conformation belonged to neither sex peculiarly; that is to say, these women
generally have very small breasts, hard features, a beard, and a temper which
leads them to prefer labor and occupations foreign to the pursuits of the seiT
They are stout women, and are fond of procuring illicit enjoyments with per-
sons of their own sex. In a word, such are the individuals who have generally
given rise to the questions relative to hermaphrodism.

Such is the intimate structure of the clitoris that, during coition, the blood
accumulates within, swells it, and occasions its erection ; the delicate membrane
that invests it being of the same nature as that of the nymphae, and very sensi-
tive, it has in consequence been concluded that with the nymphae it is the chief
seat of venereal pleasure. De la Motte has very properly observed that this
organ can in no way interfere with delivery, and justly ridicules the apprehen-
sions, so often manifested by Peu, to the contrary. The clitoris is subject to
certain morbid affections ; its extremity may become transformed into a fibrous
mass, described by Deschamps, and which has been often observed. The clitoris
rarely exhibits any morbid affections; but as its size, when excessive, may incom-



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NORMAL STATE. 91

mode daring copulation, and as its uses are not very essential, it has, in several
instances, been subjected to the operation of amputation. In the case of
Molinette, it weighed nine pounds, and the operation was perfectly successful.
Kramer was no less fortunate in a case where it was three fingers long, and
presented the appearance of a cauliflower. We are indebted to Macfarlane for
another successful case of the kind.

ART. V.— THE VESTIBULE.

Circumscribed by the clitoris, the inner face of the nymphaa, and the meatus
urinarius, the vestibule is a small triangular space, depressed, corresponding to
the upper part of the arch of the pubis, through which Celsus and M. Lisfrano
have recommended that the bladder should be opened, for the purpose of
extracting the stone in females, and which performs no special function relative
to generation.

ART. VI.— THE URETHRA.

Beneath the "vestibule is perceived the orifice of the urethra ; this opening is
separated from the vagina only by a kind of tubercle, which projects more or
less in different persons, and which terminates its anterior middle column. On
account of this tubercle, nothing is so easy as to sound a woman's bladder
without uncovering her, for, after a very little practice, the finger suffices for
distinguishing it and guiding the sound. In women the urethra is large, conical,
about twelve or fifteen lines long, scarcely curved ; it has neither prostate gland
nor bulb; its lower wall may be said to be confounded with the anterior
wall of the vagina, and would be rubbed, contused, and laoerated much more fre-
quently than it is, were it not that it is situated at the very top of the pubic arch,
in a free space, which is so narrow that neither the occiput nor forehead of the
child can reach it to lodge in it. Its natural direction, shortness, extensibility,
and width, readily explain the ease with which the catheter is introduced, the
rare occurrence of urinary calculi in women, and the fact that even fecundation
has sometimes taken place where the womb opened only into the bladder. In
a case reported by Flamant, the finger was easily introduced, the vagina was
closed by the hymen, and the woman was pregnant. In a woman who had no
womb, and whom Meyer dissected, copulation was performed through the urethra.
Gruner mentions a case of the same kind, and Morgagni tells us that the husband
of another imperforate woman endeavored unsuccessfully to perform the vene-
real act

ART. VTI.— THE HYMEN.

The orifice of ike vagina, irregular, and of greater or less size in women who
have borne children, more rounded, but of equally variable dimensions in mar-
ried women who have never yet become mothers, is in virgins contracted by the
hymen.

§ 1. DESCRIPTION.

Admitted by some and rejected by others during the seventeenth and eigh-
teenth centuries, the hymen, and not the membrane of the hymen, as it is denomi-
nated in several French works, is a fold which always exists, provided it have
not been destroyed, in young girls. It would even appear that it exists in seve-
ral animals. In a work presented to the institute in 1805, M. Duverney
endeavors to prove that it is met with in many apes, bears, hyenas, hares, etc.,
and I think I may say it is also met with in the giraffe. Cuvier accords it
to the daman; Steller to the sea cow of the north. I do not see why we should
deny it to the ass and the mare.



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92 OF THB EXTERNAL ORGANS OF GENERATION.



PLATE III.

THE GENITAL ORGANS.

Fig. 1.

a, a. The greater labia.

b. The clitoris covered with the prepuce.

c. The perineum.
d, d. The leaser labia.

«. The vestibule.
/. The meatus urinarius.
g. The vagina.
X. The hymen,
i The fourohette.
j. The fossa navicularis.
k. The posterior commissure of the vulva.
I The bladder.

m. The womb slightly elevated.
o,o. The ovaries
p, p. The Fallopian tubes.

q. The commencement of the rectum,
r, r, r. The intestines collected in the left iliac fossa.

Fib. 2

Represents the utenu in ait&, at full term, distended with the product of con-
ception, inclined to the right, and twisted on its own axis from behind forward,
and from left to right. (Taken from nature.)

a, a, a. The anterior walls of the uterus.
6, b. The Fallopian tubes,
c, c. The ovaries.
dyd^dyd. The round ligaments.

#,«,«. The intestines pushed back by the uterus.
/,/. Flaps of the abdominal walls turned back.



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PLATS 3




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trORMAL STATE. 93

In shape resembling a half moon, with its concave and sharp edge turned for-
wards, its extremities are sometimes so much prolonged as to unite nnder the
urethra, and thus form a circular valve, whose breadth, however, diminishes as
it approaches the meatus urinarius : being on its convex edge continuous with
the mucous membrane of the vagina and vulva, the hymen may contract the
entrance of the vulvo-uterine canal in very various degrees^ and even close it
entirely. Its circle always contracts from behind forwards. I have sometimes
detected muscular fibres in it, which were arranged in a decussating manner, as
in the womb ; in such cases, it was thick, strong, elastic, and very much deve-
loped. At other times, I have seen it thin, transparent as a pellicle, and very easily
broken. In general, it is thicker at birth than at any other period of life. In
new-born infants it often presents the shape, the rosy tint, and softness of the
lesser labia.

Regarded as the seal of virginity by the vulgar, and for a long time so consid-
ered by medico-jurists and magistrates, the hymen has on more than one occasion
been the cause of an iniquitous decision by the tribunals, either in condemning
an innocent woman, or, on the contrary, in absolving one who was scandalously
guilty. But at present it is universally admitted that a thousand causes foreign
to the act of coition may destroy it, and that copulation itself does not always
occasion its rupture. If this membrane be thin, delicate, and broad, a sudden or
extensive movement of the limbs, excoriations, the appearance of the menses,
Ac., may cause it to disappear. If it be thick, muscular, elastic, but narrow,
the sexual union would not be prevented, and the hymen might remain whole
until labor should take place, as is proved by the cases mentioned by Par6,
Naegele, and others ; but I believe it incapable in any case of furnishing a real
obstacle to the escape of a child.* If the hymen be broad and resisting, while at
the same time it either partially or completely closes the canal of the vagina, it
might form an insurmountable obstacle to the flow of the menses outwards, and
by retaining the blood in the vagina or womb, give rise to symptoms that would
be more or less important, according to circumstances. Smellie, Denman, &c.,
report the cases of women in whom this state of things produced all the general
symptoms of pregnancy, and who recovered their ordinary health as soon as an
incision into the hymen had allowed of the escape of the blood with which the
parts were filled. I have been consulted on account of one young lady, twenty-
two years of age, whose hymen had prevented the consummation of marriage. I
met with another specimen, in the corpse of a woman about forty years of age,
who had cohabited with her husband for a long time, but without having any
children. As a general rule, however, the hymen is ruptured at the first sexual
approach, which, in consequence of this laceration, is accompanied with more or
less pain, and a slight discharge of blood. When once torn, its shreds contract,
and give rise to one or more tubercles, known by the name of myrtiform carun-
cles.

§ 2. VARIETIES.

It appears to me there are six distinct kinds of hymen : —

1st. The semicircular, in which the hymen is formed by a narrow fold strong

• I consider the hymen to be a ibid or duplicatnre of the mucous lining of the orifichm
vagin*. It is in all respects analogous to the valvules conniventes of the bowel. In many
individuals it is ruptured by the sexual congress ; in others it escapes uninjured, and is not
wmfnquenthf met with in the examinations made during the conduct of labors. Like the
other tissues with which it is connected, it is tractile and distensible to such a degree that it
is even possible for a child to be born without destroying it, as I have ascertained in my
attendance on persons confined with a second parturition. I make this statement with con-
fidence, as I am sure it will be confirmed by persons much engaged in obstetric practice,
who will take the trouble to make the inquiry. — M.



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94 OF THB EXTERNAL ORGANS OF GENERATION.

enough to admit of oopulation without being ruptured. This variety, though not
very common, is by no means rare.

2d. The creacentio, in which the concave edge approaches more or less the
urethra, so as to diminish the entrance into the vagina posteriorly. In this case,
it is almost invariably ruptured in coition.

3d. The circular, in which the free edge, very much thinner than the other,
is often fringed, as it were, leaving an opening sometimes slightly round, but
generally closer in contact with the anterior wall of the vagina than die posterior.

4th. It often presents the form of a disk o* perfect diaphragm, usually
pierced by a certain number of small holes like a watering-pot, and sometimes
without the least opening.

5th. In place of a simple valve or a circle, we observe a small bridle, or a
small cord, under the urethra and at the concave edge of the hymen, as in the
cases reported by Smellie and Millot.

6th. Finally, there is sometimes a second a few lines above the first, as Messrs.



Online LibraryCharles Delucena Meigs Alfred VelpeauA complete treatise on midwifery: or, the theory and practice of tokology ... → online text (page 14 of 102)