PRACTICAL CONSIDERATIONS : THE UTERUS. 2015 



opened. It may also burrow into the vagina or rectum. Suppuration takes place, 

 however, in only a small percentage of cases. 



The condition is usually recognized by the rapid swelling and induration at the 

 sides of or behind the uterus, and in closer relation to it than is the swelling of a pyo- 

 salpinx or of an ovarian abscess. Pelvic collections of pus of this nature may be 

 evacuated through the vagina by an incision made close to the cervix, — to avoid the 

 ureters and the uterine arteries ; but it should be remembered that this procedure 

 does not remove the focus of primary infection, such as a diseased Fallopian tube. 



Blood coUedioyis (haematoceles) or tumors (intraligamentous) may also occur 

 between the layers of the broad ligaments. 



The narrow lower border of each ligammt lies on the floor of the pelvis, but is 

 separated from it by a thick layer of subperitoneal tissue, in which the uterine artery 

 with its veins passes nearly transversely inward from the internal iliac artery at the 

 side of the pelvis to the cervix at about the level of the vault of the vagina. 



The ureter, on its way from behind forward to the bladder, passes through this 

 loose cellular tissue just below the base of the broad ligament. It lies close under 

 the uterine artery from one-half to one inch from the side of the cervix. It is within 

 this short distance that the uterine vessels are tied, either from within the abdomen 

 or from the vagina, according to the method of operation, in the removal of the 

 uterus (hysterectomy). The inclusion of the ureter within the ligature is one of the 

 greatest dangers in this operation. This accident is more likely to occur if the 

 artery is crowded closer to the ureter of one side, by a tumor or other mass, in the 

 opposite side of the pelvis. The ureter is also in danger, as it lies along the side and 

 floor of the posterior compartment of the pelvis. It may there be injured in the 

 removal of adherent masses, such as inflamed tubes and ovaries, or of retroperitoneal 

 tumors or cysts. Calculi in the vesical ends of the ureters may be removed through 

 the vaginal wall (page 2020). 



The free upper border of the broad ligament between the fimbriated extremity 

 of the tube and ovary and the side of the pelvis — the suspensory ligament of the 

 ovary or the infundibulo-pelvic ligament — is of practical importance because, in 

 addition to supporting the ovary, it contains the ovarian vessels where they are usu- 

 ally tied in the operations for th"e removal of the uterus or its appendages. Kelly 

 calls attention to a space immediately below the vessels in this region, where the two 

 layers of the peritoneum, forming the broad ligament, come close together. By pass- 

 ing a ligature through this membranous interval and tying over the top of the broad 

 ligament, all the ovarian veins and the artery are included. If the uterine vessels 

 also are tied by a separate ligature, at the cornu of the uterus, there should be no 

 danger of hemorrhage in a salpingo-oophorectomy ; or, if the uterine vessels are 

 secured at the sides of the cervix, in the floor of the pelvis, and the ovarian vessels 

 are ligated, as above, on both sides of the pelvis, the hemorrhage will be controlled 

 for a hysterectomy. 



The round ligaments, passing outward and forward from the sides of the 

 uterus through the internal ring and inguinal canals to the labia majora, tend by their 

 direction to maintain the uterus in its normal anteflexed position. When retrodis- 

 placements of the uterus do occur these ligaments become stretched and lengthened. 

 They have frequently been shortened by operation to correct such displacements. 

 This may be done by the extra-abdominal method in the inguinal canal (Alexander's 

 0}>eration), or within the abdomen (Palmer Dudley operation), the latter method per- 

 mitting a more accurate estimate of the special peculiarities or difficulties of a given 

 case. 



Occasionally in the adult — always in the foetus and in 20 per cent, of cases in 

 children (Zuckerkandl, quoted by Woolsey) — a patulous process of peritoneum, the 

 canal of Nuck, accompanies the round ligament, lying above and in front of it for 

 a variable distance through the inguinal canal. It is analogous to the vaginal process 

 of peritoneum which descends with the testicle, and, like it, predisposes to congenital 

 inguinal hernia (page 1767) and to hydrocele (page 1953). Should its lumen become 

 constricted at some point, the portion beyond the obstruction may secrete fluid and 

 give rise to the so-called "cyst of the canal of Nuck," which is analogous to an 

 encysted hydrocele of the cord in the male (page 1953). 



