pelvis follow the arteries, and are particularly abundant between the layers of the broad ligament external to the arteries, and in the posterior wall of the vagina. They are unprovided with valves and apt to bleed excessively when cut or ruptured.

Nerves.

The spinal nervous supply of the pelvis is derived chiefly from the sacral plexus, the fourth and fifth sacral, and the coccygeal nerves. The sacral plexus lies upon the anterior surface of the pyriformis muscle. The pudic is given off from the sacral plexus, and with its hemorrhoidal and three perineal branches affords the chief nervous supply to the perineum, vulva and vagina. The small sciatic supplies the integument of the perineum. The fourth and fifth sacral, coccygeal and hemorrhoidal branches supply the pelvic floor. The hypogastric plexuses and lower ganglia of the sympathetic nervous system supply the internal pelvic organs, and are particularly liberal in their allowance to the uterus and its appendages. The uterus itself depends for its spinal nervous supply upon the filaments that accompany the sympathetic nerves, and is, therefore, in the unimpregnated state, almost devoid of ordinary sensation, and can be subjected to great irritation and even affected with organic disease without giving apparent inconvenience to the system. It seems to require a participation of the peritoneal or fibro-cellular surroundings of the uterus, or a sufficient change in its submucous and muscular substance to decidedly interfere with the functions of these nerves, or else an abnormally debilitated state of the nervous tissue, for the production of any appreciable resentment on the part of the general nervous system. However, let this vast accumulation of nervous elements finally become involved in pathological changes, and the lack of sensibility will not prevent the most profound, far-reaching, mysterious and often disastrous reflex effects. The abundance of the spinal nerve supply to the perineum, pelvic floor and vulva, explains how uterine and ovarian irritation, congestion and inflammation, instead of being felt at their seats, may be symptomatized by a reflected irritability of the sphincters, by pruritis vulvæ et vaginæ, vaginismus, coxalgia, etc.

Lymphatics.

Lymphatic glands are chiefly found about the cervix uteri, in the upper portion of the pelvic connective tissue chamber, behind the broad ligaments and on the sacrum at either side of the rectum, between the large blood vessels, and along the obturator artery. Lymphatic vessels are abundant everywhere in the pelvis. Those about the cervix communicate directly with the connective tissue chamber and lower portion of the broad ligament. Hence infection from the

cervix is apt to lead to pelvic abscess, while infection from the uterine body may give rise to extensive peritoneal inflammation without suppuration.

For the structural anatomy of the pelvic viscera and external genitals, the student is referred to the text books upon anatomy and histology. Space does not here permit a repetition of these things, which are, or should be, a part of the mental equipment of every graduate in medicine.

CHAPTER II.

EXAMINATION OF THE. FEMALE PELVIC ORGANS.

FORTUNATELY for suffering woman, we may arrive at demonstrative knowledge of the locality of her several pelvic organs and of the nature and extent of the diseases which affect them, and consequently treat them with the certainty which a positive diagnosis always insures. The evident advantages of a physical diagnosis will render it quite unnecessary for me to use any argument in favor of it, or to induce medical men to resort to it. A physical examination, however, of the genital apparatus of females, is quite a different matter from a physical examination of the chest, eye, or ear, or any other organ of the body; and hence the necessity of approaching and conducting it under conditions rendered imperative on account of the circumstances connected with it. The education and natural sense of modesty, so appropriate to female character, and which always commands the respect of gentlemen, make such examinations disgusting and disagreeable above almost all others demanded by the necessities of woman's circumstances. With a view to this fact, it is our duty, by our conduct toward our patient, and the management of the examination, to divest it as nearly as possible of every disagreeable feature. Medical men generally, I think, are, as they should be, actuated by the above considerations, and I fear that they are often so influenced by their own sense of delicacy as too frequently to abstain from the enforcement of essential investigations. This is an error we should always bear in mind, and, I think, we shall less frequently regret a thorough, although somewhat indelicate examination when dictated by an honest and intelligent conviction of its necessity, than a neglect of such examination from too great a deference to a sense of shame. We should not, in important cases, take things for granted.

Our bearing to a female patient should be deferential, candid, and modest. She should be convinced by our demeanor that everything we do and say is strictly necessary and relevant to her case, and has its foundation in our solicitude for her welfare. Nothing, therefore, should be said or done but what is called for and obviously proper. This sort of treatment from her medical adviser will always command. the confidence and earnest co-operation of an intelligent female patient. There should be a full and explicit understanding, when possible, between the physician and the patient, as to the necessity of a physical examination, in what it consists, and how it is to be conducted. The good sense of the practitioner will enable him to judge whether

he should commit the detail of explanation to the husband, or some other appropriate second party, or whether he impart it directly to the patient; all the circumstances of the case will enable him to determine this matter without much difficulty. After the preliminaries are disposed of I would insist upon conducting the examination without exposure. It is needless in ordinary.uterine examinations, and should be permitted only when the disease is upon the external parts. One position and kind of preparation, so far as the patient is concerned, will suffice for most cases, whether we wish to make a manual or an instrumental examination. There is no necessity for the patient to unclothe herself.

Position of Patient for Examination.

In the ordinary work of an office I think there is nothing more convenient than Wilson's chair. It can be made to assume so many forms

that it can be used as a chair or table either, and is easily moved into any position in relation to the light.

For many purposes, however, a table will afford us more satisfaction. It is very much to be preferred in surgical operations.

While the gynecological table represented in Fig. 39 is very convenient for an office, an ordinary table such as can be found in any dwelling can be made to answer every purpose.

There are three positions of which we may avail ourselves in making examinations or performing operations: the dorsal, the latero-abdominal, or Sims's position, and the knee-chest position.

In the ordinary dorsal position the patient is placed on her back with the breech very near the end of the table or chair, the knees

flexed and the thighs drawn up close to the abdomen, the feet resting by the side of the nates or in the stirrups, and the shoulders elevated upon pillows. In this position the abdominal walls are relaxed and

brought near the pelvic organs (Fig. 44), and both hands may be used with great freedom in exploring them.

It is, in fact, indispensable to a perfect bimanual examination, and is very convenient for the use of the sound, and almost every form of

FIG. 40.

Position for Sims's Speculum.

speculum. Even Sims's speculum can be made to do effectual service in this position.

For many minor operations and uterine applications it is a very convenient position. This was a favorite position with the late Professor Simon. When the hips and shoulders are greatly elevated, the knees extended, and thighs forcibly flexed upon the abdomen, this is called Simon's position, and is not inferior to any other for examination or surgical operations on the vagina and uterus.