Anatomical cal Relations. —In order to understand the varieties of diseases which may affect the pelvic peritoneum and cellular tissue, especially the mode of extension of inflammatory processes in the pelvic connective tis sue, and the distribution of pus and extravasated blood, it is necessary to have a full knowledge of the peritoneal lining and connective tissue of the pelvis.
To obtain a clear idea how the peritoneum lines the pelvis, and its relation to the uterus and its appendages, we may imagine the pelvic cavity lined by peritoneum, and the uterus with its appendages pushed up from below between the rectum and bladder, whereby a large por tion of these organs is covered by peritoneum. The organs are more or less covered by peritoneum, the cervix and parts of the round liga ments being free from peritoneum, towards the so-called sub-peritoneal cavity. By means of this upheaval of the uterus, the strong broad liga ments are formed on either side by duplication of the peritoneum. Re garding the form and situation of the spaces so formed between the uterus and bladder on the one hand, and the uterus and rectum on the other, and concerning the folds of the peritoneum thus produced, the text-books on anatomy afford sufficient information. • Special attention is to be called to the fact that from the superficial muscular layer of the side of the uterus, numerous muscular structures arise, which become partly adherent to the abdominal wall, partly to the pelvic wall, and partly radiate into the perimetric tissue. The round ligaments, hence, are true prolongations of the superficial muscular layer of the uterus; they pass out covered by loose cellular tissue, through the inguinal canal, join there the muscles of the abdominal wall, and iu the same way, the muscular fasciculi coming from Douglas's pouch, and de scribed as retractors of the uterus, blend with the wall of the rectum and the sacrum as partly muscular bundles Laterally the ovarian ligaments form prolongations of the uterine muscular fibres, and likewise there radiates into the anterior and posterior layers of the broad ligaments, a fairly strong muscular structure blending with the vessels, nerves and connective tissue which surround the uterus, and further the vesico uterine ligaments contain muscular fibres derived from the uterus. The bladder and rectum are also attached to the pelvic wall by delicate mus cular fibres. The muscular fibres radiating from the uterus usually par ticipate in all inflammatory processes of the uterus, in this way carrying the inflammation to peri-uterine tissues.
Until recently little attention was paid to the connection between the peritoneum and pelvic organs, and to the distribution of the loose cellu lar tissue. Only since the intimate relation between the connective tissue and the lymphatics was determined, and their importance as a channel for inflammatory products was recognized, have investigations in this di rection been reassumed. There are three methods of successfully study ing the same. The first method is the anatomical preparation; the second is to study the topographical extension and anatomical relation of the pelvic connective tissue by making systematic sections of specimens hard ened by alcohol or freezing; the third method is to inject air or fluid into the sub-peritoneal space.
By the first method the existence of the pelvic cellular tissue and its extensive distribution was recognized, but the difference in firmness with which it adheres to the underlying tissues in the different localities of the pelvis, and with which it connects the different layers of peritoneum to one another, can not be ascertained with knife and finger, and yet a full knowledge of this is necessary for the determination of the distribution of blood extravasations and collections of By this first method es pecially, Luschka, in his work on the position of the abdominal organs, demonstrated the relations in question, and illustrated them clearly.
Luschka's statement regarding the pelvic cellular tissue in the above mentioned work, is as follows: Under the peritoneal sac a layer of cellular tissue more or less per vaded by fat invests the parts that are uncovered by peritoneum, and ex tends uninterruptedly, so as to fill the spaces left between the lower mar gin of the peritoneum and the levator ani. If we consider that the latter presents to a certain degree a pelvic diaphragm in the median plane by extending from the walls of the pelvis and descending gradually, we will readily understand that the pelvic cavity is divided by it into an upper and lower space. Now as the peritoneum does not reach down to the levator ani muscle, there must necessarily be left a space between the two, and by this the cavity above the levator ani is divided into a peritoneal and sub-peritoneal cavity. But between the under surface of the levator ani and the pelvic wall, especially laterally, a very deep space is also left filled with fat, which being limited by the skin may properly be called the subcutaneous pelvic cavity. Of these three divisions of the true pel vis, the sub-peritoneal pelvic cavity is of great practical interest, as its contents surrounding the organs uncovered by peritoneum often become the seat of abscesses, which find their way in different directions, for in stance through the great sacro-sciatic foramen under the muscles of the buttock. Its contents do not only consist of loose fatty cellular tissue, allowing the expansion of the hollow organs, and the adaptation of the loose peritoneum to the increase in volume of these organs without being stretched, but the sub-peritoneal cavity also contains numerous arteries, veins, absorbents and lymphatic glands. Especially do the largely .de veloped venous plexuses form a considerable part, which certainly serves the purpose of a compressible surrounding for the pelvic organs, always ready to fill up the space left by a decrease in volume of the same. This cellular tissue also surrounds a portion of the rectum and bladder, as well as the portions of the uterus we have mentioned, and it is hence necessary to define the natural limits of what is spoken of in gynecology as the pars metrium." Frankenhauser, in demonstrating the nerves of the uterus, also revealed the pelvic cellular tissue (vide plate IV. and VI. in his treatise on " The Nerves of the Uterus," Jena, 1867).