Before we proceed to describe the data as obtained by the other methods, it seems useful to direct attention to the mode of connection be tween the peritoneum and the uterus. This will make clear why some tumors that appear in the sub-peritoneal cavity assume certain forms. The peritoneum is only in firm connection with muscular tissue at the body of the uterus. This connection is to a certain extent downwards, so intimate that it can only be separated piecemeal and with great care from the underlying structures. The line where the peritoneum is firmly attached to the uterus, is toward the front, on the fully developed virgin uterus, nearly in the middle of the organ, and corresponds to the point designated as the internal os. From this point downwards it is attached by very loose connective tissue to the supra-vaginal portion of the cervix, and to that portion of the bladder over it. Posteriorly the firm attach ment of the peritoneum is a few lines somewhat higher up, and it is loosely connected below with the uterus, cervix and vagina. Somewhat different is the connection at that portion where the peritoneum, becoming reflected on the rectum, forms Douglas's cul-de-sac, and it usually lies a little above the middle of the vagina. At both sides of Douglas's cul-de-sac the loose cellular tissue is more abundant, and numerous muscular fasciculi are found, named by Luschka the retractors of the uterus. The lines of firm attachment of the peritoneum anteriorly and posteriorly, arch over the lateral parts of the uterus, in such a way as to form a triangle, the apex of which reaches to the tubal openings. In this triangular space there is a large amount of loose cellular tissue, which connects the broad ligaments, extends to the uterus, and covers its base, and contains the uterine vessels and nerves, cervical ganglia, and the whole portion of the ureter which extends through the parametrium.
Among others Savage gave a clear description of the sub-peritoneal cellular tissue. He writes: "A plane extending from the middle of the posterior surface of the symphysis pubis to the point of articulation of the third with the fourth sacral vertebra, which intersects the uterus at the junction of the body with the neck, will, with rare exceptions, divide the pelvic cavity into two spaces, a peritoneal and a sub-peritoneal. The parts lying below this plane are imbedded in the cellular tissue, which oc cupies that portion of the pelvis which contains no intestine. The struct ure consists of fibro-elastic, muscular and connective-tissue elements, and is so arranged that its meshes or cells communicate freely with each other." The second method was carefully elaborated by W. A. Freund, who by means of systematic sections through the pelvic cavity made clear the architectural anatomy of the pelvic connective tissue, from which the pathological changes it may undergo are easily recognized.
Freund considers it desirable to make further subdivisions of the pelvic connective tissue immediately surrounding the pelvic organs, and thinks that we could as well speak of paracystium, paracolpium and para.
proctium as of parametrium.
The third method, the injection of air or liquid into the sub-peritoneal space, has been also successfully utilized to distinguish the relations exist ing between peritoneum and pelvic cellular tissue.
The first to use this method for the purpose of studying the cellular tissue in general, was Bichat. He injected air and water into cellular tis sue, and pointed out that the spaces within it must become the channels for pathological exudations. He was followed in this direction by Henke, Bonig, and W. Schlesinger.
Henke proved by injecting the whole arterial system of a cadaver with water the direct communication existing between this system and the interstices of the connective tissue. In this way he demonstrated the distribution of the connective tissue in the neck and the cellular tissue in the pelvic and abdominal cavities.
In this connection the researches of Konig and Schlesinger are most important, as they treat specially of the cellular tissue of the female pel vis. Since by these researches the manner of distribution of pus and of blood is shown, and light is thrown on the manner after which inflam matory processes invade the sub-peritoneal space, we consider it useful to give an account of the results obtained by them.
Konig utilized the bodies of women who died of non-puerperal affec tions shortly after delivery, and injected water or air under the abdominal walls. The results of his observations he states as follows: 1. An exudation in the connective tissue of the broad ligaments in • the neighborhood of the tubes and ovaries primarily extends in the course of the psoas and iliacus, and later gravitates into the true pelvis.
2. An exudation which has for its seat primarily the deeper connec tive tissue in the antero-lateral region of the junction of the body with the neck of the uterus, fills first the cellular tissue of the true pelvis laterally from the deeper portions of the uterus and bladder, and later usually extends along the round ligaments to Poupart's ligament. From thence it extends into the fosse iliaca outwards and backwards.
3. Abscesses formed in the posterior surface of the broad ligament first fill the posterior lateral parts of the pelvis (Douglas's and afterwards follow the track described under 1.
4. Later they become similar, since the same portions of the perito neum are equally displaced.
5. When the pus gravitates to Poupart's ligament, even a small quan tity separates the peritoneum so far from the ligament that a puncture finger-breadths above the same will pierce the abdominal wall without touching the peritoneum.
W. Schlesinger experimented on cadavers of women who did not die shortly after childbirth, and also on such that had never been pregnant. He used boiled and filtrated glue, mixed with a granular coloring matter, and injected it by measurable pressure. These experiments were com pleted by injecting glue under the mucous membrane of the vagina, de termining by this the mode of diffusion of extra-peritoneal exudations originating from the cervix uteri.