sacrosciatic ligament. It extends medianward, fan-shaped and becomes inserted by its base in the lateral border of the two distal sacral vertebræ and two proximal coccygeal vertebræ. The coccygeal muscles assist the levator ani and pyriformis in closing the dorsal portion of the pelvic floor or apertura pelvis distal. The relations of the coccygeus are: its ventral border is in contact with the dorsal border of the levator ani, however, separated

cygeus muscle is one of the typical examples of a muscle becoming transformed into a fibrous tendinous band, fascia, from recession or deficient use (as the coccygeus was originally a powerful lateral caudal motor in primitive mammals).

3. Pyriformis (Musculus Pyriformis). -The pyriformis is a flat, pyramidal muscle. Its origin is on the lateral borders of the II, III, IV sacral vertebra

forced expiratory action (controlling contents). It being inserted in the coccyx, it aids to fix the central point of the perineum so that the accelerator urinæ may act. The sphincter ani aids to strengthen the pelvic floor by its action on the anus, as also by its attachment to the centrum perineal on tip of the coccyx. The anal group of muscles-levator ani, coccygeus, pyriformis and sphincter ani-so far as muscular support is concerned, play a major role in the perineum. They do not lend the perineum of pelvic floor its main support nor strength that is performed by fascia. Muscle functionates, fascia supports. Fascia is the corner stone to bear burdens forced on it by muscles.

LEVATOR ANI MUSCLE AS VIEWED THROUGH THE SKIN.

FIG. 11. The pelvic exit is dotted. The direc tions of the levator muscle is evident (illustra tion from Dickinson, 1889).

is through the major sacro-sciatic foramen. It is inserted by a rounded tendon in the proximal border of the trochanter major. It affords a bed on which the sacral nerves can rest and be protected. The pyriformis and coccygeus muscles appear as a continuation of the levator ani and to line the distal as well as the dorsal pelvic wall.

4. Sphincter Ani Muscle Externus.The sphincter ani externus is a thin, flat plane of an elliptical form. It arises from the coccyx, adjacent skin and superficial fascia. In its course it encircles the rectum and becomes inserted into the central tendon of the perineum, the skin ventral to the anus and other muscles. It is supplied by branches from the nervus penendus. The sphincter ani is intimately adherent to the integument surrounding the margin of the anus. The length of the sphincter ani is about four inches and its breadth on the lateral border of the anus is an inch. The sphincter ani maintains the anus continually closed. It can be firmly contracted by will, as in

DISTENDED LEVATOR ANI.

FIG. 12. The elongated and separated bundles of the levator ani are here presented. V, bladder: SP, symphysis; C, clitoris; CV, constrictor of the pudendum; F, fourchette; PA, ventral perineum: AO, anus; PP, dorsal perineum; CR. coccyx; PS, distal point of sacrum; RRR, marks the distended levator ani in separated bundles. The middle R is on the most powerful bundle. The capacity of the levator ani muscle to separate into bundles, fasciculi aids to prevent rupture. Multiple muscular fasciculi separated yield more extensively than if in one solid bundle (Varnier after Dickinson).

in the median tendineous raphe; (c) some fibers may be inserted in the coccyx, rectum, vagina, perineal body, external rectal sphincter.

The

The white line, arcus tendineus. crescentric, curved line, of ligamentous origin of the levator ani is profoundly connected with the pelvic fascia and the muscular fibers of the levator ani begin as tendineous fibers which form the white line. The ligamentous origin of the levator ani muscles is the blended, coalesced, powerful, fibrous fascial planes of the levator ani proximal and distal.

II. PUDENDAL GROUP OF MUSCLES.

In the pudendal group of muscles of the pelvic floor or perineum, I shall include, 5, Sphincter vaginæ (or Bulbo covenosus); 6, erector clitoridis; 7, transversus perinei superficial; 8, transversus perinei profundus. This group of muscles is intimately related to the pudendum in controlling the vaginal caliber, sexual relations and in maintaining the position of the pudendal orifice.

5. Sphincter Vagina.-Constrictor vaginæ, constrictor cunni, bulbo cavernosus. The sphincter vaginæ surrounds the distal end of the vaginæ. It is a double muscle. It arises from the distal border of the ligamentum triangulare or lamina aponeuratica and centrum perineale. In other words, it arises dorsally from the transverse perineal fascia midway between the sphincter ani and ischial tuberosity. A limited number of fibers is connected with the sphincter ani externus. The sphincter vaginæ becomes inserted by two bundles, the lateral of which attaches itself to the curve of the cruva clitoridis, and the medial bundle of which unites itself with that of its fellow distal to the clitoris into a single tendineous plate.

The sphincter vaginæ is a thin, broad, pale, red muscular layer. Through its sheet-like layer the blue bulb of the vagina shimmers. It surrounds the lateral vaginal walls. Its insertion into the bulb of the vagina, on the surface of the corpus cavernosum of the clitoris and in the mucosa between the clitoris and urethra suggests its sexual signification. Its contraction increases the turgidity of the bulb and hence limits the vaginal orifice -it is a sexual muscle, compressing veins and inducing erection of tissue. sphincter vagina-bulbo cavernosumpartially occupies the space between the bi

The

lateral origins of the levator ani from the symphysis pubis. It not only surrounds the vagina but also the vestibule. It aids to strengthen the pelvic floor by means of its sphincter action on the vagina.

6. sus.

Erector Clitoridis (ischio-cavernoThe erector clitoridis or ischiocavernosus muscle is located along the lateral wall of the vagina. It arises from the internal surface of the tuberosity and ramus of the ischium. In its course it embraces each crus clitoridis and becomes inserted in the fascia which envelopes the dorsal portion of the corpus clitoridis adjacent to the point of attachment of the ligamentum suspensorium. The erector clitoridis during contraction obstructs the return flow of venous blood inducing erection of tissue-it is a sexual muscle. 7.

Transversus Perinei Superficialis. The superficial transverse perineal muscles is practically a subcutaneous muscle or a subfacial muscle. It may originate from bone or fascia. In general it arises from the internal surface of the ischial tuberosity and varies in conjunction with the erector clitoridis and coursing medianward and proximalward becomes inserted in the centrum perineale. Some fibers may join the sphincter ani externus. Some of the fibers of the transversus perinei superficialis may be branched bundles from the levator ani. This muscle is intimately connected with the distal border of the trigonum urogenitale or triangular ligament.

It

8. Transversus Perinei Profundus Compressor (constrictor urethra).-Transversus perinei profundus (Hanle) arises from the internal surface of the junction of the rami of the ischium and pubes. courses ventral to the urethræ and dorsal to the vagina. It is attached to the urethral and vaginal walls, blending with the opposite fellow. Unlike the male, the vagina divides the transverse perinei profunda. This muscle is intimately connected with the triangular ligament or trigonum urogenitale. On account of distribution adjacent to the membraneous urethra, this segment of the muscle is termed the compresor urethræ. Dr. H. O. Marcy states that at the central point of union the muscular fibres interdigitate or blend with the fiber of the levator ani.

of the levator ani, i. e., parts of Holl's pubo-rectalis. When the transversus perinei muscles are distinctly developed, it may present a quill or little finger dimension, spheroid or flat band, intimately associated with the dorsal border of the trigonum urogenitale. It originates ad

and transversus perinei arises from rami perinei of the nervus pudendus, and the vascular supply arises from the rami perenei of the arteria pudenda interna.

The topography of the transversus perinel presents points of interest in perineorrhaphy. The transversus perinei is a

landmark between trigonum urogenitale and anal region. The distal surface of the muscle is covered by fascia perinei, the dorsal free border of which surrounds the anal region. The proximal surface of the muscle rests on the aponeurosis of the trigonum urogenitale. It is intimately related with numerous perineal nerves, arteries and veins.

The pudendal group of muscles-sphincter vaginæ, erector clitoridis and transversus perinei-are of limited dimensions, and hence in contractile power. The erector clitoridis is a sexual muscle-aiding by its contraction to obstruct venous blood, and consequently inducing swelling, turgidity and erection of cavernous or erectile tissue. The sphincter vaginæ, though it constricts the distal vaginal orifice, is practically a sexual muscle, aiding by its constriction to obstruct the venous flow from the bulbus vaginæ, inducing swelling, turgidity and erection of this giant spheroid of collected veins. The transverse perinei maintain the tension of perineal fascia and the peritoneal relations of vaginal and anal orifices. It may be stated that the pudendal group of muscles become limited in dimensions, are also limited in their power to strengthen the pelvic floor or perineum; however, being intimately associated and interwoven with perineal fascia, they aid to consolidate and strengthen the pelvic floor in a minor degree. The anal group play the major role as muscular support of the pelvic floor.

[Written for the MEDICAL BRIEF.] The Value of Faith.

BY R. C. CAVE,

St. Louis, Mo.

He who said, "We walk by faith and not by sight," stated a law of life which is true of all men, from the most ignorant peasant to the most learned philosopher. Faith is simply the conviction of the truth of something we do not know to be true-the assurance of the reality of something which lies outside the range of our knowledge. But the range of our knowledge is so limited that, if we did not base our action on the truth of something that lies beyond it, we would not act at all.

We can not know what a day or an hour may bring forth. Hence, every step we take out of the present into the future is taken by faith; every move we make toward the attainment of any end is made by faith. We do not know that we can attain the desired end; we only believe that we can, and are influenced by that faith to move toward it. The farmer sows his seed, believing that it will yield a desirable harvest. The merchant buys his goods, believing that he can sell them at a profit. The physician gives medicine to his patient, believing that it will prove beneficial. So, in all the affairs of everyday life, we walk by faith.

The same law holds in the realm of scientific research and discovery. The scientist observes, classifies, and compares facts, theorizes and experiments, reasons and deduces conclusions, but, his faculties being limited, he can not know that his information is complete or his reasoning free from fallacy, and, hence can not know that his conclusions are true. And when he has ascertained the order of nature with seeming certainty he can not know that this order will remain constant. "Obviously," says Mr. Huxley, "no amount of past experience can warrant us in anything more than a correspondingly strong expectation for the present and future. We find, practically, that expectations, based upon careful observations of past events, are, as a rule, trustworthy. But, for all that, our highest and surest generalizations remain on the level of justifiable expectations; that is, very high probabilities." Hence, he who follows the light that science gives, walks by faith.

* * *

And it is even more manifest that we must walk by faith in our spiritual life. Our religion-whether it be blind obedience to an authority outside of ourselves or fidelity to the divine spirit within us; whether it be abject slavery to the doctrines and forms of the past, or an eager search for and progress toward better things-is but a reaching out after the unknown, prompted and directed by faith.

And faith not only prompts and directs the conduct, but it also moulds character. The civilization of an age or country is determined by its prevailing belief. When