THE UTERUS. 1033 



The form, .size, and situation of the uterus vary at different periods of life and under dif- 

 ferent circumstances. 



In the ffft its the uterus is contained in the abdominal cavity, projecting beyond the brim of 

 the pelvis. The cervix is considerably larger than the body. 



At iil'ii}j the uterus is pyriforin in shape, and weighs from eight to ten drachms. It has 

 descended into the pelvis, the fundus being just below the level of the brim of this cavity. The 

 arbor vitae is distinct, and extends to the upper part of the cavity of the organ. 



The position of the uterus in the adult is liable to considerable variation, depending chiefly 

 on the condition of the bladder and rectum. When the bladder is empty the entire uterus is 

 directed forward, and is at the same time bent on itself at the junction of the body and cervix, 

 so that the body lies upon the bladder. As the latter fills the uterus gradually becomes more 

 and more erect, until with a fully distended bladder the fundus may be directed backward toward 

 the sacrum. 



During menstruation the organ is enlarged and more vascular, its surfaces rounder; the 

 os externum is rounded, its labia swollen, and the lining membrane of the body thickened, softer, 

 and of a darker color. According to Sir J. Williams, at each recurrence of menstruation a 

 molecular disintegration of the mucous membrane takes place, which leads to its complete 

 removal, only the bases of the glands imbedded in the muscle being left. At the cessation 

 of menstruation by a proliferation of the remaining structures a fresh mucous membrane is 

 formed. 



Din- ing pregnancy the uterus becomes enormously enlarged, and in the ninth month reaches 

 the epigastric region. The increase in size is partly due to growth of pre-existing muscle and 

 partly to development of new fibres. 



After parturition the uterus nearly regains its usual size, weighing about an ounce and a 

 half; but its cavity is larger than in the virgin state, the external orifice is more marked, its 

 edges present a fissured surface, its vessels are tortuous, and its muscular layers are more 

 defined. 



7/i old age the uterus becomes atrophied, and paler and denser in texture ; a more distinct 

 constriction separates the body and cervix. The ostium internum and, occasionally, the vaginal 

 orifice often become obliterated, and its labia almost entirely disappear. 



Surgical Anatomy. The uterus may require removal in cases of malignant disease or for 

 fibroid tumors. Carcinoma is the most common form of malignant disease of the uterus, 

 though cases of sarcoma do occur. It may show itself either as a columnar carcinoma or as 

 a squamous carcinoma ; the former commencing either in the cervix or body of the uterus, 

 the latter always commencing in the epithelial cells of the mucous covering of the vaginal 

 surface of the cervix. The columnar form may be treated in the early stage, before fixation 

 has taken place, by removal of the uterus, either through the vagina or by means of abdom- 

 inal section. The former operation is the better of the two, and is attended by a much 

 smaller death-rate. Vaginal hysterectomy is performed by placing the patient in the lithotomy 

 position and introducing a large duckbill speculum. The cervix is then seized with a volsel- 

 lum and pulled down as far as possible and the mucous membrane of the vagina incised 

 around the cervix and as near to it as the disease will allow, especially in front, where the 

 ureters are in danger of being wounded. A pair of dressing forceps are then pushed through 

 into Douglas's pouch and opened sufficiently to allow of the introduction of the two fore- 

 fingers, by means of which the opening is dilated laterally as far as the sacro-uterine ligaments. 

 A somewhat similar proceeding is adopted in front, but here the bladder has to be separated 

 from the anterior wall of the uterus for about an inch before the vesico-uterine Ibid of 

 peritoneum can be reached. This is done by carefully burrowing upward with a director and 

 stripping the tissues off the anterior uterine wall. When the vesico-uterine pouch has been 

 opened and the opening dilated laterally, the uterus remains attached only by the broad liga- 

 ments, in which are contained the vessels that supply the uterus. Before division of the 

 ligaments, these vessels have to be dealt with. The forefinger of the left hand is introduced 

 into Douglas's pouch and an aneurism needle, armed with a long silk ligature, is inserted 

 into the vesico-uterine pouch, and is pushed through the broad ligament about an inch above 

 iis lower level and at some distance from the uterus. One end of the ligature is now pulled 

 through the anterior opening, and in this way we have the lowest inch of the broad ligament, 

 in which is contained the uterine artery (Fig. 573), enclosed in a ligature. This is tied tightly, 

 and the operation is repeated on the other side. The broad ligament is then divided on 

 either side, between the ligature and the uterus, to the extent to which it has been con- 

 stricted. By traction on the volsellum which grasps the cervix, the uterus can be pulled 

 considerably further down in the vagina, and a second inch of the broad ligament is treated 

 in a similar way. This second ligature will embrace the pampiniform plexus of veins, and, 

 when the broad ligament has been divided on either side, it will be found that a third liga- 

 ture can be made to pass over the Fallopian tube and top of the broad ligament, after the 

 uterus has been dragged down as far as possible. After the third ligature has been tied and 

 the structures between it and the uterus divided, this organ will be freed from all its connec- 

 tions and can be removed from the vasrina. This canal is then sponged out and lightly dressed 

 with gauze ; no sutures being used. The gauze may be removed at the end of the second day. 

 In squamous epithelioma, amputation of the cervix is all that is necessary in those cases where 

 the disease is recognized before it has invaded the walls of the vagina or the neighboring broad 

 ligaments. The operation consists in removing a wedge-shaped piece of the uterus, including 



