In considering the anatomy of the pelvic organs, only certain points will be mentioned that are particularly related to intra-pelvic technic.

First we must visualize a pelvic cavity entirely filled with viscera. There is no unfilled space. (Fig. 4.) Everywhere each viscus touches and is touched by others. It is only by this vision that we get a true understanding of the etiology and pathology of the conditions which we expect to correct. Nor must we consider only the internal generative organs. Besides these there are the bladder, the urethra, the ureters, the pelvic colon, the rectum, the coils of small intestines, peritoneum and connective tissue. These with their positional relationship to each other as well as their relationship through blood, nerve and lymph supply must be understood.

The uterus (Fig. 1) will be disposed of without a discussion of its ultimate structure as this is capably dealt with in the usual textbooks on gynecology. For our purposes its normal size, position and mobility are of more immediate importance. In fact the physician who has not by experience become familiar with these cannot hope to attain to the fullest success in practice.

Fig. 1. The Uterus in Normal Position. (Findley, Diseases of Women.)

The virgin adult uterus is slightly less than three inches long, slightly less than two inches wide and about one inch thick. After childbirth it remains somewhat larger than before and after the menopause it again shrinks. When palpated through the abdominal walls it seems larger than the dimensions given, owing to the thickness of the tissues through which it is felt. Only by familiarity with its normal size can the small infantile or the atropic, or the enlarged, congested or subinvoluted uterus be recognized.

The fundus of the uterus, when the bladder and rectum are both empty, rises to or slightly above the brim of the pelvis. It is directed forward and slightly upward. It is approximately in the median line, (slightly to the left according to some authorities) and rests forward upon the bladder. The long axis of the body of the uterus is nearly horizontal in the erect position, almost perpendicular in the dorsal position and forms a slight angle with the cervical canal. This position may be considerably modified by the distension of the bladder or rectum. As the bladder fills the uterus becomes more and more perpendicular, (in the erect posture) and with the bladder fully distended the fundus may point upward or even slightly backward toward the sacrum.

Distension of the rectum affects the position of the uterus less markedly, but to some extent. It may press the uterus forward and may render more acute the angle between the body and cervix.

The cervix is normally found about midway the ischial spines, and should point backward and slightly downward. Its direction is also affected, to some degree, by the distension of the bladder and rectum. As the former fills, the cervix points more and more downward, and the same is true as the latter fills. This is because the uterus tilts about a transverse axis running approximately through the cervico-corporeal junction. Pressure applied to the anterior surface of the fundus has the same effect on the position of the cervix as pressure applied to the posterior surface of the cervix.

The uterus has four pairs of ligaments. (Fig. 2). These limit extreme motion of the uterus but do not contribute, directly, a great deal to its support. The chief means of its support is the pelvic floor. There are two vesico-uterine ligaments anteriorly, two sacro-uterine ligaments posteriorly, and a broad and a round ligament laterally.

Fig. 2. Uterine Ligaments, Showing Them All on Same Plane. (Gilliam, A Text Book of Practical Gynecology.)

The vesico-uterine ligaments are formed of two folds of peritoneum that are reflected over the pelvic-connective tissue lying between the bladder and the uterus.

The sacro-uterine ligaments are formed of unstriped muscular fibers continuous with those of the uterus, with fibrous and loose connective tissue, all of which are covered by peritoneum. They are attached to the anterior surface of the second and third bones of the sacrum. From here they run downward and forward to the uterus, one on either side, and are attached at the level of the internal os. Occasionally similar secondary bonds pass downward from the fifth lumbar vertebra. These ligaments with the anterior vaginal walls are said to form an elastic beam by which the uterus is suspended. These ligaments in their normal condition prevent the uterus from being dragged beyond the vaginal entrance.

The broad ligaments are composed of loose connective tissue and unstriped muscle fibers, covering which is peritoneum. They are attached by their inner margins to the sides of the uterus and at their outer margins to the sides of the pelvic wall, following a line beginning midway between the ilio-pectineal eminence and the sacro-iliac articulation, and running downward and backward to the level of the spine of the ischium between the great sacro-sciatic notch and the obturator foramen. At their outer margins these ligaments are nearly vertical (in the erect position), while at their inner margins they are nearly horizontal forming a shelf upon which rest the intestines. These ligaments in a small degree, limit the lateral motion of the uterus, and if the sacro-uterine ligaments have for any reason lost their tone, they assist in preventing total prolapse.

Between the peritoneal layers of the broad ligaments, and transversing the connective tissue of which they are largely composed, are the ovarian and uterine blood vessels, lymphatics and nerves. There are also the uterine tubes, the parovarium, the round ligament and in its lower part near the cervix, the ureter. The ovary is rather on the posterior or upper layer of the broad ligament.