THE UTERUS. 2007 



sides of the rectum. Between the layers of these folds robust bundles of fibrous and 

 smooth muscular tissue extend from the uterus to be inserted partly in the rectum, 

 there constituting the iitero-rectal muscle, and partly into the front of the sacrum as 

 the utero-sacral ligament. The latter structure contributes efficient aid in supporting 

 the cervical segment of the uterus, which is thus enabled to maintain its position 

 independently, to a certain degree, of that of the body. 



Position and Relations. — The attachment of the cervix to the vaginal walls and 

 utero-sacral ligaments give to the lower uterine segment a more definite position than 

 that enjoyed by the body, which, being little restrained by its lateral attachments, is 

 especially affected by the condition of the bladder and rectum. When these organs 

 are but slightly distended, the uterus normally, in the erect posture, lies tilted for- 

 ward (anteverted), with the body resting upon the upper vesical surface. Since, 

 under these conditions, the cervix is comparatively fixed and directed backward and 

 the body more or less bent forward (antiflexed), the uterine axis exhibits a marked 

 flexure at the beginning of the cervical segment. This angle varies continually with 

 the position of the fundus, which, receiving little support from its peritoneal and 

 other attachments, is influenced by the changing condition of the bladder. When 

 the latter is contracted and the uterus strongly anteflexed, the angle is more pro- 

 nounced than when the upper vesical wall, and consequently the fundus, lies higher. 

 With increasing distention of the bladder the angle gradually disappears and the 

 uterine axis becomes straight ; in e.xcessive vesical expansion, associated with an 

 empty rectum, the entire uterus may be tilted backward (retroverted), its axis then 

 corresponding with that of the vagina. When both bladder and rectum are dis- 

 tended, the entire uterus may be pushed up above the level of the symphysis. 

 Usually the fundus does not lie strictly in the mid-line but to one side, probably 

 more frequently to the left (Waldeyer, Merkel). This deflection may also affect 

 the axis of the ovary of the opposite side, which, in consequence of the pull thus 

 exerted, then lies more obliquely than on the side on which the utero-ovarian liga- 

 ment is relaxed. The anterior surface of the uterus following the changes of the 

 upper vesical wall upon which it lies, the utero-vesical fossa very seldom contains in- 

 testinal coils, which, on the contrary, frequently occupy the pouch of Douglas. 

 The posterior (upper) surface of the uterus is overlaid by coils of the small intestine, 

 and may also be in contact with the pelvic and sigmoid colon. Anteriorly, below 

 the reflection of the utero-vesical fold, the lower segment of the uterus is connected 

 with the posterior bladder-wall by loose connective tissue ; posteriorly, it is sepa- 

 rated from the rectum by the intervening peritoneal pouch of Douglas ; laterally, it is 

 crossed by the ureters, which, opposite the middle of the cervix, lie about 2 cm. from 

 the uterine wall. In the erect position, the level of the external os corresponds ap- 

 proximately with that of the upper margin of the symphysis, and in the antero- 

 posterior axis lies slightly behind a frontal plane passing through the ischial spines 

 (Waldeyer). 



Structure. — The uterine walls, thickest in the fundus and posterior wall of the 

 body, where they measure from 1-1.5 cm., and somewhat thinner (from 8-9 mm.) 

 at the entrance of the tubes and in the cervix, comprise three coats, the mucous, 

 muscular, and serous. The mucous coat, or endometrium, of a light reddish color, 

 soft, and friable, and from .5-1 mm. thick, consists of a connective-tissue stroma, 

 loose in texture but rich in cells and resembling the tunica propria of the intestinal 

 mucous, and the surface epithelium. The latter is a single layer of columnar cells, 

 about .028 mm. high, that in their typical condition possess cilia by which a down- 

 ward current is established towards the external os. It is probable, however, that 

 the cilia are neither always present, nor uniformly distributed, since they are lost 

 during the disturbances incident to menstruation, and are often present only in 

 patches (Gage). The uterine glands are simple tubular, or slightly bifurcated, 

 wavy invaginations of the mucosa, usually lined with a single layer of ciliated col- 

 umnar cells resembling those covering the interior of the uterus. They are dis- 

 tributed at fairly regular intervals and extend the entire thickness of the mucosa, 

 their tortuous, blind extremities in many cases being lodged between the adjacent 

 muscular bundles, since a distinct submucosa is wanting. In the vicinity of the orifices 

 of the Fallopian tubes, the uterine mucosa becomes thinner, the epithelium lower, 



