b. The peritoneum passes from abdominal wall to symphysis, at a point 11⁄2 inches above the latter;

c. The retropubic fat is partly above and partly below the top of the symphysis. We may now once more contrast these postures.

Upright posture (Plate I.).

1. Pubic and sacral segments in apposition and vagina a slit.

2. Retropubic fat behind pubis. 3. Empty bladder behind pubis.

4. Peritoneum passes from anterior abdominal wall to fundus of

empty bladder, immediately

above symphysis.

5. Urethra and bladder meet at a 5. Urethra and bladder almost in

The reason why the pubic segment passes downwards when the vaginal orifice is opened, is that atmospheric pressure now acts on the vaginal aspect of the pubic segment (with its weak mesial attachment to the pubis) and drives it further down. As the result of this posture, changes take place in the length and direction of the vaginal walls and in the position of the uterus. These are briefly :—

1. Vagina.-(a.) Both walls elongate.

(b.) The anterior follows the direction of the posterior aspect of the symphysis; the posterior, the

curve of the sacrum.

2. Uterus.-(a.) The normally placed uterus passes nearer the sacrum and nearer the thoracic diaphragm.

(b.) The retroverted uterus, fixed or unfixed, becomes

more retroverted.

(c.) The retroverted unfixed uterus does not become replaced so as to lie anteverted.

The results given have been obtained as follows:

a. By observation on living patients, aided by silhouettes of the outlines of the nude body in the upright and genupectoral postures;

b. By study of frozen sections of the female pelvis, and especially by

study of a frozen section of a cadaver placed in the genupectoral posture.

For further details on this subject Simpson and Hart's atlas may be consulted.

An important practical result follows from these observations.

The

Pelvis in frozen section of cadaver in genupectoral posture. A anus; P perineum; R rectum; V vagina; u urethra; B bladder; S symphysis; f retropubic fat; U retroverted uterus; pp peritoneum. Between the small intestine and peritoneum is fatty omentum (Simpson and Hart).

vagina dilates or, more properly, the segments of the pelvic floor separate exposing their free margins-the vaginal walls-when a patient assumes the genupectoral posture and the hymeneal orifice is opened so as to admit air. If a patient be so placed opposite a good light and the sacral segment be hooked up, a complete view of the vaginal walls and cervix is obtained. The same results can be got by placing the patient in the

posture known as the semiprone. On this last fact is based the use of the vaginal speculum known as Sim's Duckbill speculum (v. Chap. X.).

THE EFFECT ON UTERINE POSITION OF DIGITAL PRESSURE IN THE VAGINAL FORNICES.

This is a subject of great practical importance.

If, when a patient is lying on her left side, the index finger of the examiner's right hand is passed into the vagina as far as the posterior fornix, and pressure made there in the direction of the antero posterior axis of the fornix, the following results may be noted :

(1.) The posterior vaginal wall is elongated, the cervix drawn back, and the uterus, if anteverted, becomes more so (fig. 66).

Fig 66.

Anteversion being produced by digital pressure in posterior fornix.

(2.) If the uterus is retroflexed, the flexion is not remedied. Should the fundus be fixed, the retroflexion is increased as the cervix is drawn back while the fundus remains.

Similarly, if pressure be made in the anterior fornix :

(1.) The uterus becomes elevated and slightly rotated backwards, because the cervix is pulled forwards (fig. 67).

(2.) If the uterus is anteflexed, the flexion is not diminished.

By pressure in these fornices, therefore, we only act on the cervix,

unless the uterus is very much retroverted or anteverted. The body of the uterus is acted on only indirectly, through its union with the cervix.

Fig. 67.

Retroversion of uterus produced by digital pressure in anterior fornix.

Consequently, no vaginal pessary can undo the flexion of a retroflexed or anteflexed uterus.

RELATION OF POSTURE TO EXAMINATION AND TREATMENT.

We have already mentioned several postures as being the proper ones for certain manipulations; and we here sum up briefly what it is of use to know in regard to these.

The side-lateral, where the patient lies on her side in the ordinary way, is convenient for vaginal examination; passage of Fergusson's, Neugebauer's, or Cusco's speculum; passage of the sound and catheter. The dorsal posture is imperative for abdominal examination and the bimanual.

The semiprone is the best posture for passage of Sims' speculum ; vesico-vaginal fistula operation.

The lithotomy posture is specially valuable for operations on the perineum, vaginal walls, cervix and uterus.

The genupectoral posture is useful for replacement of the retroverted

uterus.

CHAPTER VI.

MENSTRUATION AND OVULATION.

LITERATURE.

Beigel-Die Krankheiten des weiblichen Geschlechtes F. Enke, Stuttgart, 1875. Dalton-Report on the Corpus Luteum: Am. Gyn. Tr., Vol. II., p. 11 : Physiology, 6th edition, J. and A. Churchill, 1876. Engelmann-The Mucous Membrane of the Uterus, with especial reference to the Development and Structure of the Decidua : Am. J. of Obst., Vol. VIII., p. 30. Frey's Histology-Barker's Tr., 1874. Kinkead -Med. Press, September 14, 1881. Kundrat-Untersuchungen über die Uterusschleimhaut: Strickers Jahrbuch, 1873. (Kundrat and Engelmann were co-workers.) Leopold-Studien über die Uterusschleimhaut während Menstruation, Schwangerschaft und Wochenbett: Archiv. für Gynäk., Bd. XI., S. 1091. Loewenhardt-Die Berechnung und die Dauer der Schwangerschaft: Archiv. für Gynäk., Bd. III., S. 456. Möricke-Die Uterusschleimhaut in den verschiedenen Altersperioden und zur Zeit der Menstruation: Ztschr. für Geburtshülfe und Gynäk., VII. Band, 1 Heft, 1881. Underhill-Note on the Uterine Mucous Membrane of a Woman who died immediately after Menstruation: Ed. Med. J., 1875. Simpson, A. Russell-Emmenologia; Contribution to Obstetrics and Gynecology: Edinburgh, A. and C. Black. Larson Tait-Br. Med. Journ., June 4, 1881. Williams-On the Structure

of the Mucous Membrane of the Uterus, and its Periodical Changes: London Obst. Jour., Vol. II., p. 681.

So far as

THE subject of Menstruation is not as yet well known, and on many points eminent and trustworthy observers are at variance. our present knowledge goes, the following is a brief resumé.

PRELIMINARY CONSIDERATIONS.

Definition. A periodical flow of blood from the uterine cavity, with shedding of the superficial layers of its mucous membrane, accompanying the discharge of an ovum from the ovary, occurring in properly developed women between the ages of 14 and 44, and interrupted by uterogestation and lactation.

Period of its Onset.-Menstruation begins, in this country, usually at the age of 13 to 15 (puberty). It may be delayed to 16, 17, or 20; but this is unusual. Its onset is earlier in warm countries, later in cold ones; earlier in delicately nurtured girls.

Period of its Cessation.- With the interruptions of pregnancy and lactation, it continues in healthy women until the age of 44 to 50. The period of its final cessation is known as the menopause. As a general rule the menopause is early when menstruation has begun early, and

vice versa.