structural associations of the uterus and all the other pelvic organs and tissues. The position of the several pelvic organs may be given in a general way as follows: The uterus in the center, Fallopian tubes and ovaries on either side, the bladder in front, rectum behind, and the vagina below. Covering all of these, except the vagina, is the peritoneum, which is the chief bond of union between the upper portions of the pelvic organs, and out of which are formed the ligaments which have much to do in keeping the uterus in place. The peritoneum, while it covers the pelvic organs, is attached to the bony walls of the pelvis through the medium of the periosteum and areolar tissue, so that one end of each ligament may be said to have an attachment to the inner side of the pelvic bones. The round ligaments are anatomically an exception to this rule. They contain muscular tissue in considerable quantity, and are really outgrowths from the uterus in the form of round cords, which start from the uterus near the proximate ends of the Fallopian tubes, and sweeping round the outside of the pelvis, pass out through the inguinal rings into the labia majora. These ligaments, as well as all the others, can be seen by looking down upon the pelvic organs in situ. The uterus is seen in the middle of the pelvis, and extending across on either side of it are the two broad ligaments made up of the two folds of peritoneum, which

unite after covering the uterus. Running backward from the uterus to the sacrum are those peritoneal folds known as the utero-sacral ligaments. Between the uterus and the bladder, on the sides of the latter, the folds of peritonæum form the uterovesical ligaments. These ligaments are so called, not because they are composed of ligamentous tissue, but rather because they perform a function similar to that of ligaments. With the exception of the round ligaments which are composed of muscular tissue covered with peritoneum, the others are made up of double folds of peritonæum containing between these folds areolar tissue and some fibers of the pelvic fascia.

FIG. 132.-Diagram of the uterine ligaments as seen on looking into the brim.

An idea of the position of these ligaments and their relations to the uterus may be obtained from Fig. 132.

I have noticed that, in the dissecting-room, gentlemen are not able at all times to find the utero-sacral and utero-vesical ligaments; the broad and round ligaments they easily note. The others can be

brought into view in the following manner: If the uterus be drawn well forward by a tenaculum, two tense bands will be seen, the uterosacral ligaments, extending from the side of the uterus back to the sacrum, and as they are thus raised up a pouch of peritoneum appears between them. This is the sac of Douglas. By reversing this manipulation, and drawing the uterus backward, the uterovesical ligaments will be seen running forward on either side of the bladder.

The utero-vesical ligaments, in addition to their attachments to the uterus and bony walls of the pelvis, are also connected indirectly to the anterior vaginal wall by intervening areolar tissue. The utero-sacral are connected in the same indirect way with the upper portion of the posterior vaginal wall, and also to the rectum, on the left side at least.

At the junction of the supra-vaginal portion of the cervix and body of the uterus all the ligaments, except the round ones, are attached. Here also the anterior and posterior vaginal wall and a portion of the bladder join these other structures.

The union of these structures at this point is not direct, but is through the intervention of areolar tissue which is found in considerable quantity in this region. From this it will be seen that these ligaments are continuous from side to side, and also from before backward.

The chief function of these ligaments, aided by the anterior vaginal wall, is to keep the uterus and bladder in position. This is clearly evident from the mechanical principle apparent in the anatomical arrangement of the parts in question, and from the fact that the uterus remains in place for a considerable time when the pelvic floor is defective, and the abdominal pressure more marked than normal.

In short, many cases have been seen clinically in which all the other means that could possibly contribute to supporting the uterus were removed by disease and injuries, and yet the uterus was maintained in position under ordinary circumstances. The most rational idea of the means and ways by which the uterus is maintained in the pelvis I obtained from the following statement by Dr. Frank P. Foster. Speaking of the supports of the uterus, he says: "Ordinarily, they consist wholly of the anterior wall of the vagina in front, and the utero-sacral ligaments behind, which together constitute what may be called a beam traversing the pelvis anteroposteriorly on which the uterus rests, being interposed between them, firmly attached to the one anteriorly and to the other poste

riorly, making them, so far as mechanical effect is concerned, one structure." This is a clear and comprehensive statement of the prin ciples upon which the utero-sacral ligaments and the anterior vaginal wall act in supporting the uterus. I would go one step further than Dr. Foster, however, and claim a like function for the other uterine ligaments. The broad ligaments, firmly attached to the bony walls of the pelvis, and holding the uterus in their folds, make a continuous structure extending across the pelvis in its transverse diameter.

R

FIG. 183.—Section of pelvis with the slings of the uterus; behind, the utero-sacral ligaments; in front, the anterior vaginal wall (after a section by Hart).

anterior vaginal wall, utero-sacral, vesico-uterine, and broad liga

ments.

Fig. 133 shows a section of the pelvis with these ligaments and the anterior vaginal wall with the uterus resting upon them.

Fig. 134 shows a transverse

section of the pelvis just in front of the uterus and broad ligaments, and represents these structures and the manner in which they support the uterus.

A similar function may be claimed for the round ligaments, at least so far as their effect in preventing the backward displacement of the uterus. Some have claimed that the round ligaments have but little supporting power to sustain the uterus in place, while others give it much credit in this direction. Those who believe in

FIG. 134.-Diagram of the uterus şlung between the broad ligaments.

Alexander's operation of shortening the round ligaments for the relief of retroversion of the uterus certainly claim great supporting power for these ligaments, and with good reason, I think.

Finally, I may add, that I believe that the ligaments, the vagina, and the other pelvic organs all aid in keeping the uterus in position, and are sufficient to do so under ordinary circumstances. Still, when extraordinary strain is brought to bear upon the pelvic organs, the pelvic floor supplements these supporting structures. Moreover, the relation of the trunk to the pelvis has much to do, if not in keeping the pelvic organs in place, certainly in freeing them from pressure from above.

The pelvis is so placed that, in the erect posture, its cavity is behind rather than beneath the abdomen, and the abdominal muscles partially divide the greater cavity

from the lesser. This is shown in the accompanying diagram, where the arrow indicates the direction of the force transmitted to the pelvis through pressure from above (Fig. 135).

There is very little direct abdominal pressure upon the pelvic organs in the erect posture. The axis of the pelvis is backward and downward, while that of the abdomen is perpendicular, so that the pressure is indirect from above.

FIG. 135.-The normal inclination of the pelvis and the transmission of force from above.

Some claim that a suction power is exerted upon the pelvic contents by the diaphragm. It is said to act like a piston in the cylinder of a pump. There is reason to believe there is something in this, from the fact that, on examination through a Sims's speculum, the uterus is seen to rise and fall with respiration. This motion is to a large extent arrested when the patient is in the erect posture.

If it is a fact, as it appears to be, that the abdominal organs are fixed by suspension in their normal position, and that in their descent during this limited motion the pressure upon the pelvic organs is indirect, then this relationship contributes to maintain the position of the pelvic organs as surely as if there were some traction or suc

tion action of the diaphragm tending to draw these organs upward.

In regard to the pelvic floor and its relations to the displacements of the uterus, that subject has been fully discussed under the head of injuries of the pelvic floor. It is only necessary to repeat my belief already expressed to the effect that, while the pelvic floor does not directly support the uterus, it indirectly aids in doing so, and if it is lost from injury prolapsus of the pelvic organs follows as a rule.

DISPLACEMENTS OF THE UTERUS.

There are a great many forms of displacement of the uterus, if every change of position of that organ be taken into account, but of those that occur as primary affections there are only two that are often seen, and one that is very rare. These are downward, backward, and forward—that is, prolapsus, retroversion, and anteversion.

Prolapsus and retroversion are really the only forms of displacement which practically claim attention in this connection. These the gynecologist is called upon to treat daily as primary affections. Occasionally, a case of anteversion may be seen which apparently is not caused by some other affection more important than the consequent displacement, but this is exceedingly rare. Again the uterus may be anteverted to a considerable extent without causing the slightest trouble. This form of displacement (quite a rare one) is generally produced as a consequence of some other disease, either of the uterus itself or the organs and tissues around it, or else when it does occur it gives no trouble; and, as a rule, very little can be done to relieve it by the ordinary methods of treating uncomplicated displacements. Taking all this into account, it is evident that the downward and backward displacements alone demand special attention, either in practice or in the discussion of the subject.

The other forms of displacement of the uterus, described in textbooks, are the right and left lateral anteversions and retroversions. These displacements are always due either to some lesion of development or to some previous affection, the products of which either push or pull the uterus out of place. There is also a retrocession of the uterus and an antecession, which are not described in books. Perhaps better names for these would be transposition backward or forward. In these dislocations the uterus is found either behind or in front of the axis of the pelvic cavity, or superior strait. These, like the lateral dislocations, are secondary to some abnormal state