PRACTICAL CONSIDERATIONS: THE UTERUS. 2013 



appendages, their blood-vessels, together with their nerves and their enveloping 

 connective tissue. This transverse fold of peritoneum is analogous to the mesentery 

 of the small intestine, serving the same purpose for the uterus and its appendages — 

 i.e., to hold them in position and to transmit their blood-vessels and nerves. 



The posterior eompartment of the pelvis, the r e do -titer ine, is the larger and 

 deeper of the two. The lower portion of it, included between the two recto-uterine 

 folds of the peritoneum, is the pouch of Douglas, or recto-vaginal pouch, because it 

 lies between the rectum and the upper fourth of the vagina, from which it is separated 

 only by subperitoneal connective tissue. The rectum, bulging forward the posterior 

 wall, and the ovaries, hanging from the anterior wall, tend to fill this compartment, 

 the remaining space being occupied by small intestine and a portion of the sigmoid 

 flexure. 



Abnormally it may be encroached upon by a retroposed uterus, which tends to 

 drag downward and backward its appendages, the tubes and ovaries, towards 

 Douglas's pouch, where they may be palpated by the finger through the vagina. 

 Because of the greater depth of the posterior compartment and because of the fact 

 that abscess and other pelvic operative conditions are usually situated in it, it must 

 almost always be drained, if drainage is necessary after operation in this region. 



The anterior or vesico-uterine compartment of the pelvis extends below only 

 to the isthmus of the uterus. The remaining supravaginal portion of the cervix 

 is in close relation to the bladder, but the loose interx^ening layer of subperitoneal 

 tissue permits a ready separation of the two in the operation for the removal of 

 the uterus (hysterectomy). Since the body of the uterus inclines forward, nor- 

 mally, touching the bladder, the space in this compartment is slight. It excep- 

 tionally contains a few coils of small intestine, and may lodge also a part of the 

 sigmoid flexure. 



A tumor or pregnant titerus filling the pelvis may press upon the iliac veins, 

 producing oedema and varicose veins of the lower extremities, of the vulva, and of 

 the rectum (hemorrhoids) ; upon the lumbar and sacral nerves, causing cramps, 

 neuralgia, or paralysis ; upon the bladder, with resulting vesical irritability and pain ; 

 upon the rectum, inducing constipation and hemorrhoids ; upon the ureters, giving 

 rise to hydronephrosis ; or upon the renal veins and kidney, producing albuminuria 

 and possibly uraemia. 



The uterus is held in position between the bladder and the rectum by its liga- 

 ments, and is kept from dropping to a lower level (prolapse) mainly by the support 

 received from atmospheric pressure acting through the floor of the pelvis. The broad 

 or lateral ligaments attach it and its appendages — the Fallopian tubes and ovaries 

 — to the sides of the pelvis. The round ligaments act chiefly in tending to prevent 

 retro-displacements. The musculo-fibrous utero-sacral ligaments and the anterior and 

 posterior reflections of peritoneum materially steady the cervix, which is also fixed by 

 its attachments to the bladder and vagina. Moreover, the intra-abdominal pressure 

 applied through the intestinal convolutions that are normally in contact with its 

 posterior surface aids in holding it in position. The body of the uterus is more 

 freely movable than the cervix, and in spite of its supports the uterus, as a whole, is 

 one of the most mobile of the viscera. The cervix, for example, may easily be made, 

 through traction by means of a tenaculum, to present at the orifice of the vagina, in 

 such operations as amputation of the cervix, repair of lacerations, or dilatation and 

 curettement. _ On account of its mobility, its intrapelvic situation, and the elastic 

 support received from the bladder, and indirectly from the levator ani muscles, the 

 uterus is very rarely injured by blows on the abdomen. If upon' examination it is 

 found to be fixed, or not easily movable, some abnormal cause should be sought for, 

 such as pelvic inflammations or tumors. 



The essential conditions in the production of a prolapsed uterus obtain when the 

 uterus is the seat of subinvolution from any cause, especially a puerperal infection, 

 and the pelvic floor is relaxed or torn. The stretching of the pelvic ligaments has 

 then not been fully overcome by later contraction, and the atmospheric support 

 (dependent upon a tightly closed vaginal oudet) is lacking because of the weak- 

 ened perineal floor. As the uterus reaches a lower level its ligaments become truly 

 ' ' suspensory' ' and resist its further downward progress as soon as their uterine attach- 



