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dragging away of the uterus. If the supports of the latter are weak and cannot resist the continued traction and downward action of the vagina, the body descends before the cervix is elongated.

Is the vagina a supporting column to the uterus? Foster, as has been said, shows a diagram (Fig. 10) to represent the anterior wall of the vagina as having this action, assisting the utero-sacral ligament in its work above by forming a support from below. Van de Warker also believes in this columnar action of the vagina. Other writers state that the action of sup

FIG. 22.-Showing condition of perineum of case Fig. 21.

port is due to the angle which the uterus maintains with the vagina. From diagrams and reasoning this sounds plausible. but clinical experience reveals any number of congenital cases in which this diagrammatic relationship is not maintained and no trouble in the way of descent of the organ ensues. The backward displacements are a more striking demonstration of this.' This, together with the action of the vagina upon the cervix, causing its enormous elongation and descent without bringing about the descent of the body itself, are proofs, it would seem, that while the vagina may act as a columnar support to the uterus 1 See notes accompanying Figs. 29, 30, 31, and 32.

and maintain it in place, both in this manner and by means of its position toward it, this is not always the case.

3. What have the ligaments to do with the mechanism of descent? This is the most difficult question of all. It is natural to suppose, from the very name "ligaments," that they have something to do with uterine support and that their rôle is active rather than passive. Yet it should be borne in mind that, because of the great changes which must take place at the time of pregnancy, these ligaments must necessarily be in such a condition as to permit of the greatest mobility of the organ, which

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FIG. 23.-Section showing the relation of uterus and vaginal walls, as well as rectum and bladder, in complete descent. (Barnes.)

in nine months can enlarge to such an enormous extent, and after confinement return in less than two weeks to very nearly the original three inches of its normal size. The experiments which have been made to show the action of the various ligaments have already been considered. True, many of these were performed upon the cadaver, in which the contractility and elasticity of life were not present; nevertheless I cannot think them worthless as showing the action of the ligaments on their normal plane. The evidence in regard to their action as keeping the uterus from falling is conflicting. There is a consensus of opinion, however, that the utero-sacral ligament is the main

uterine supporter, and opposer of its descent. Its main action would be to maintain the uterus in its relation to the vagina, and this must be suspended in those cases, to which I have already referred, where the uterus is congenitally retroverted, and in many of those cases in which, as I have already said, no downward descent takes place.

The action of pregnancy on all these ligaments is to relax and extend them, so that after childbirth they must be entirely

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FIG. 21.-Vertical section showing relation of uterus and vagina to bladder and rectum. (Savage.)

reconstructed. If left in a state of subinvolution they surely would not oppose descent. The question is, would they facilitate it because of the lack of their sustaining action?

The traction of the uterus in its downward descent must pull upon the ligaments. In some cases I believe that individual ligaments yield to the traction. Signoret says that the uterosacral ligament is stretched and sometimes broken. I believe the ligaments are among the chief, if not the chief, factors in opposing uterine descent when the traction is from below, and

that in such cases one ligament may yield more than another; and, as the utero-sacral ligament is the shortest, it will show a greater effect than the others from traction. When the uterus sinks from its own weight or from pressure above, I believe the whole pelvic vault yields, as is shown in the plate of Savage, where forcible traction accomplished the complete prolapsus (Figs. 19 and 20).

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FIG. 25.-Vesical relations to uterus and perineum. (Savage.)

4. Various other factors to be considered in relation to uterine descent. Aside from the structures which we have considered, and which from their intimate relations with the uterus are more or less actively or passively concerned in its procidentia, several other important facts should be reviewed. Foremost among these the subtle phenomena of intra-abdominal pressure should

be considered. This force is constantly acting. It is more powerfully exerted in coughing, lifting, and in defecation and urination. The extent of this pressure at the time of the expulsive effort of the last stages of labor is exceedingly great. It varies also in different individuals, acting without the volition of the individual. It is often demonstrated on the gynecological table by the expulsion, more or less forcible, of pessaries or speculi. It is this force which returns the replaced procident uterus to its former position outside the vulva while the patient is still in a recumbent position. In normal conditions there is a balance between this force and outside forces, so that it does not

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act to cause the downward displacement of the uterus, even with the force of gravity to aid it and a downward stress of the vagina. If the lacerated perineum has any connection whatever with the prolapsus of the uterus, it must act by opening the vaginal canal and disturbing the balance between the internal and external relations of pressure. The whole forms a question most delicate and intricate, in pelvic physical dynamics, which has not yet been solved.

Reuter speaks of the variations in the pelvic angle which make the pelvic inclination greater in some than in others. Nature having given this tendency in some to prolapsus uteri,

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