tained in this way are not specially valuable, as there is some post mortem change in the uterine position not yet thoroughly understood.

Section of Female Cadaver (Pirogoff).

a Vagina; b Uterus; c Bladder.

Note Bladder in diastole, Uterus parallel to horizon, and shallow dip of Douglas' Pouch.

(2.) By the bi-manual examination of the Pelvic Contents.-This is probably the best method, although it exaggerates the normal anteversion of the uterus in a way that will be readily understood when the chapter on the bi-manual has been studied.

(3.) By the use of the sound, or by a more elaborate means described by Schultze. Space does not permit of a full description of the latter, but a good account of it is given in Foster's paper.

THE LOCAL DIVISIONS OF THE PELVIC FLOOR PERITONEUM AS VIEWED THROUGH THE PELVIC BRIM, AND THE POSITION OF THE UTERINE ANNEXA.

For valuable papers and sections on this subject, we are indebted to Hasse of Breslau and Ruedinger of Munich (fig. 53 and plate II.). Hasse froze not quite thoroughly a female cadaver in the upright posture, cut through the abdomen transversely, and then lifted out the softened

Female Pelvis and contents viewed through the Pelvic Brim (Hasse).

Bladder: II. Paravesical Pouch; u Uterus; o Ovary; t Fallopian Tube; d Pouch of Douglas:
I Lateral Pouch of Douglas; ip Infundibulo Pelvic Ligament; r Round Ligament; pu
Position of Ureter; o Ovarian Ligament; r Rectum; c Colon.

viscera until the pelvic contents were exposed undisturbed.
bladder was moderately distended.

The

Fig. 53 shows Hasse's drawing. The fundus of the uterus lying on the bladder is well seen. In front of the broad ligament-of which the infundibulo pelvic ligament is the only portion visible in fig. 53we have, on each side, the paravesical pouch of the peritoneum. Behind it lies the lateral pouch of Douglas; while just behind the uterus and bounded on each side by the utero-sacral ligament is the pouch of Douglas proper. The Fallopian tubes lie in the true pelvis, in the paravesical pouch. Each broad ligament sweeps outwards and backwards to near the sacro-iliac synchondrosis of its own side. The position of the ureter is well indicated.

According to Hasse the long axis of both ovaries runs outwards and forwards, forming with the transverse axis of the uterus an angle open to the front. Part of each ovary (the half) projects above the plane of the pelvic brim. Schultze, on the other hand, figures the ovaries as having their long axes almost antero-posterior (fig. 54).

u

Fig. 54.

Position of Fundus Uteri and lie of Ovaries. Bladder distended (Schultze).

THE PHYSIOLOGICAL CHANGES IN THE POSITION OF THE UTERUS.

The mobility of the uterus is one of its most characteristic features. With every movement of respiration, in singing, walking, and in all violent movements, the uterine position is changed. Dr Van de Warker has studied, in a valuable paper, the influences bringing about these changes in position; this may be consulted for details of his method of investigation and results obtained.

Of the greatest importance is the effect of the distended bladder on the uterine position. As the bladder fills, the uterus becomes retroposed

to an extent shown at figs. 51 and 54. The intestines are forced out of the upper part of Douglas' pouch, and the height of the peritoneal reflection from the anterior abdominal wall is considerably increased. All these points are well illustrated by fig. 44 from Pirogoff. As the urine is evacuated, the uterus passes forward to its normal anteverted condition and the intestines pass back into Douglas' pouch. Probably,

undue distention of the bladder leads to permanent retroversion in some cases, especially if the uterus be gravid. Rectal distention displaces the uterus forwards and to the right side.

THE RELATION OF THE SMALL INTESTINE TO THE PELVIC FLOOR

AND TO THE UTERUS WITH ITS ANNEXA.

The small intestine lies resting on the uterus, ovaries, Fallopian tubes, and broad ligaments. There is no small intestine in the vesico-uterine pouch. When the bladder is empty and the unimpregnated uterus to the front, there is small intestine in Douglas' pouch except at its very lowest part. The pouch of Douglas becomes emptied of intestine as the bladder distends, and has no intestine in it when the uterus is retroverted. Many authors assert that there is never small intestine in Douglas' pouch. This opinion is undoubtedly wrong, as any one can satisfy himself by studying sections. Often Douglas' pouch contains serum, and this displaces the intestine. Figures 35, 39, 44 bear out these opinions; fig. 47 and plate II. should be carefully studied as illustrating the position of the superjacent intestines. The paravesical pouch probably contains intestine when the uterus lies to the front, and certainly contains it when the uterus is retroposed. Occasionally the omentum may interpose between the small intestine and the pelvic viscera.

To sum up briefly :

a. The uterus and bladder behave practically as one organ qua position (ie., they move together), when the uterus is to the front.

b. The exact angle which the uterus makes with the horizon cannot be fixed, and knowledge on this point is not necessary.

c. The uterus lies normally to the front, but has a range of mobility indicated in fig. 55. The posterior lip of the cervix is 15 to 3 cm. above the tip of the coccyx. By digital pressure the uterus can be

elevated about 4 cm. (11⁄2 in.).