Coronal Section of Frozen Body (Rydygier): 1, right lung; 2, right atrium with fovea ovalis; 3, left atrium; 4, right branch of pulmonary artery; 5, arch of aorta; 6, left lung; liver; 8, stomach; 9, ascending colon; 10, bridge of tissue between stomach and duodenum left by removing pylorus; 11, pancreas; 12, duodenum; 13, 13, small intestines; 14, fundus uteri; 15, bladder; 16, obturator internus muscle: 17, descending colon; 18, sigmoid flexure; 19, mesentery; 20, obturator externus muscle; 21, corpus cavernosum clitoridis; 22, meatus urinarius; 23, labia minora; 24, labia majora; 25, femur.

passive counter-pressure exercised by muscles and fascia (pp. 99, 101, 102, 103) turn the child forward around the pubic arch.

The result of parturition is, first, to dilate the vagina and the vulva; second, to tear the perineal body more or less deeply; and third, to elongate and slacken the layer of loose connective tissue between the entire displaceable and the entire fixed portion of the pelvic floor, thus predisposing to prolapsus of the vagina and the uterus.

THE ABDOMINAL REGIONS.

By means of certain imaginary lines the abdomen is divided into regions, the familiarity with which is a great help in gynecological examinations and the recording of cases. One line is supposed to be drawn across from the highest point of the iliac crest on one side to the corresponding point on the other. Another transverse line goes from the lowest point of the wall of the thorax on one side (the cartilage of the tenth rib) to the corresponding point on the other side. Finally, a line is supposed drawn perpendicularly up from the iliopectineal eminence.1

Thus nine regions are formed, the names and relations of which are seen in this table:

The chief contents of each region are best learned by a study of the accompanying figure (Fig. 103).

If we take into consideration the weight of all the organs pressing on the bladder, it is evident that that of a slightly enlarged or simply anteflexed uterus is hardly of any account. The discomfort often complained of in the bladder under such circumstances is either due to an affection of that organ itself or to a nerve reflex. The figure illustrates well the large amount of loose connective tissue found in the pelvis (p. 110).

8

'Different anatomists draw these lines somewhat differently.

PART III.

PHYSIOLOGY.

CHAPTER I.

PUBERTY.

PUBERTY and the climacteric are two important epochs in woman's life, one marking the beginning, the other the end, of the fruitful period. Puberty is the change from childhood to womanhood. It is a gradual development, which generally takes place in the fourteenth or fifteenth year of the girl's life. At that time the breasts become larger, the uterus increases in size (p. 33), the hips become broader, and the contour of the whole body is rounded off. The external genitals get their growth of hair, menstruation begins, and one sex feels attracted to the other.

Normal Development of Mammary Gland simulating Tumor.When at puberty the mammary glands become the seat of greater development, it happens often that one lobule grows faster than other parts, gives rise to some pain, and becomes a little tender. Thus a more or less distinct round or oval swelling is formed, which often inspires fear and brings the young girl to the physician, who might himself be deceived and make a prognosis or even institute a treatment that might hurt his reputation, and, perhaps, harm the patient. It is enough to know of the frequent occurrence of such a condition in order to avoid mistakes. A wet compress covered with guttapercha tissue, or rubbing with an anodyne liniment-e. g. chloroform mixed with twice the quantity of olive oil-relieves the pain, and a good prognosis disperses the anxiety.

Difference between Puberty and Nubility.-Puberty is the period when the possibility of reproduction begins, but by no means the time when it is desirable that the girl should marry and become a mother. Statistics show a very great mortality among married women under twenty years of age. It is evidently against nature's laws that women should become mothers before they are full-grown. Their uteri should have attained their maximum development, the breasts should be fit for nursing, the pelves should have reached a size that

allows the passage of a full-grown child, the muscles should have acquired strength enough to propel it, and the whole system should have been endowed with full power of resistance and endurance. It may, therefore, be stated that most women should not marry before they are twenty years old.

CHAPTER II.

MENSTRUATION AND OVULATION.

MENSTRUATION is the discharge of a bloody fluid from the cavity of the uterus at regular intervals. It is also called the menses, the catamenia, the menstrual period, the monthly sickness, the monthly flow, courses, or turns.

This phenomenon is peculiar to woman and some monkeys.' It is probably due to the erect position, which necessitates a harder tissue of the womb, and excludes the presence of the enormously developed lymphatic system which is found in the horizontal animals, together with a flabby uterus.2

5

The menstrual flow commences in most women in the temperate zone between the fifteenth and seventeenth years of their life. It begins earlier in warm climates than in cold, earlier in cities than in the country, and earlier in the higher walks of society than in the lower. It returns in periods of twenty-eight days,* and lasts on an average four days. The amount varies very much. Four or five ounces are said to be the average. It is increased by exercise, corporeal work, chalybeates, and stimulants. The blood differs from that from other sources by a more or less considerable admixture of mucus and epithelial cells. It has also the peculiar "heavy" odor characteristic of the genitals. It comes from the mucous membrane of the body of the uterus and the tubes, while the cervix has no part in the process of menstruation. Before its appearance the woman feels a certain heaviness in the lumbar region, while pain is always a sign of an abnormal condition. Often the breath has an unpleasant odor during

1 Bland Sutton, Brit. Gyn. Jour., Nov., 1886, Part vii. p. 285.

3

A. W. Johnstone, Amer. Gyn. Trans., 1889, vol. xiv. p. 284.

* Special statistics are found in Hannover's Om Menstruationens Betydning, Copenhagen, 1851, p. 18; and T. A. Emmet, The Principles and Practice of Gynecology, 2d ed., 1880, p. 153 et seq. In a total of 2330 cases, Dr. E. found the average age at the first menstruation to be 14.23 years, but, his patients being from the "better classes," this average is too low.

Most women are entirely unreliable in regard to their statement of the occurrence of menstruation. Very commonly they state that they have it on a certain date of each month. It is, therefore, advisable for the gynecologist to keep book himself of the beginning and the end of the periods of those under his treatment. Thus many an error is proved, many a complaint settled.

5 Funcke, Lehrbuch der Physiologie, 4th ed., 1866, vol. ii. p. 991.

the period. If menstruation has been evolved from the rut in animals, it has changed very materially. While female animals only admit the male during this period of heat, woman not only has an aversion for sexual intercourse during her menstruation, but the act performed during the catamenial period exposes both sexes to disease the woman to retro-uterine hematocele, the man to urethritis and orchitis. As a rule, menstruation ceases during pregnancy and lactation, but exceptions, especially from the latter rule, are by no means infrequent.

The anatomical basis of menstruation is a regularly recurrent development of the endometrium.' About a week before menstruation

Uterus during Menstruation (Courty). Cut open to show the swelling of the whole organ, and particularly the mucous membrane: A, mucous membrane of cervix; B, C, mucous membrane of corpus, much thickened; D, muscular layer; E, uterine opening of tube; F, os internum (the mucous membrane tapers down to these openings).

sets in the mucous membrane of the uterus begins to swell, so that from 2 or 3 millimeters (inch) in thickness it becomes 6 or 7 millimeters (inch) thick. It acquires the greatest thickness on the middle of the surfaces and fundus, and falls gradually off toward the edges (Fig. 104). Its surface becomes wavy in consequence of the

1Leopold, Archiv für Gynük., 1877, vol. xi. p. 110 et seq.