passed first into the tissue lying at the highest part of the side wall of the true pelvis. It then passed into the tissue of the iliac fossa lifting up the peritoneum, and followed the course of the psoas, passing only slightly into the hollow of the iliac bone. Lastly, it separated the peritoneum from the anterior abdominal wall for some little distance above Poupart's ligament, and from the true pelvis below it.

(2.) On injection beneath the base of the broad ligament to the side and in front of the isthmus, the deep lateral tissue became filled first; then the peritoneum became lifted up from the anterior part of the cervix uteri. The separation passed thence first to the tissue near the bladder, and ultimately the fluid passed along the round ligament to the inguinal ring. There it separated the peritoneum along the line of Poupart's ligament and passed into the iliac fossa.

(3.) An injection at the posterior part of the base of the broad ligament filled the corresponding tissue round Douglas' space, and then passed on as described at (1).

Schlesinger has followed out these results in more elaborate researches, which, we regret, space prevents us quoting.

The significance of these investigations will be referred to under Pelvic Peritonitis and Pelvic Cellulitis.

CHAPTER II.

THE POSITION OF THE UTERUS AND ITS ANNEXA, AND THE RELATION OF THE SUPERJACENT VISCERA.

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LITERATURE.

Braune-Op. cit. Claudius-On the Position of the Uterus: Med. Times and Gazette, 1865, p. 5. Crede-Beiträge zur Bestimmung der normalen Lage der gesunden Gebärmutter Archiv. f. Gynäkologie, Bd. I., S. 84. Foster-A contribution to the Topographical Anatomy of the Uterus and its surroundings: Am. J. of Obst. XIII. p. 30. Hasse--Beobachtungen über die Lage der Eingeweide im weiblichen Beckencingange Archiv. f. Gynäk. Band, viij., S. 402. Pirogoff-Op. cit. Sappey— Op. cit. Schrader-Op. cit. Schultze-Zur Kenntniss von der Lage der Eingeweide im weiblichen Becken: Archiv. für Gynäk., Bd. IX., S. 262. An admirable account of the subject will be found in Dr Van de Warker's articles on a study of the Normal Movements of the Unimpregnated Uterus: N. Y. Medical Journal, XXI., p. 337; and on the Normal Position and Movements of the Unimpregnated Uterus: Am. J. of Obst., Vol. XI., p. 314. The literature is also well given there and in Foster's paper.

This is partly due

THE amount of literature, chiefly French and German, on this subject is much too extensive even to be mentioned here. to the inherent difficulty of accurate clinical observations, to the erroneous opinions advanced by many eminent anatomists, and to arbitrary demands as to the normal uterine position made by gynecologists with strong opinions on anteversion.

Thus, in the well-known works of Braune, Luschka, Cruveilhier, and Henle, the uterus is figured from actual sections as normal with the fundus in the hollow of the sacrum, i.e., retroposed. Claudius of Marburg, also an anatomist, is uncompromising on this point. He states, indeed, that the uterus is normal only when, with its broad ligaments, its posterior surface touches the sacrum as closely as the lungs do the ribs (Fig. 49). Now, all gynecologists agree, from clinical observation, that the body of the uterus lies over on the bladder, with the os uteri looking more or less back. This divergence of opinion is extraordinary; and it leads to this interesting practical observation, that what the anatomist considers a uterus normal in position, the gynecologist believes to be abnormal. That is, the retroverted uterus

considered normal in cadavera by the anatomist-is, when found in the living woman, replaced by the gynecologist so that it lies with its body

Transverse section of pelvis in line of pyriform muscles (Luschka). The peritoneum has been removed on the right side. a 3d sacral vertebra; b bladder; c ureter; d levator ani; e rectum; f anterior layer of broad ligament; g uterus: pyriform muscle. Note that here the uterus is retroverted, and the pouch of Douglas without intestine.

There can be no doubt that the uterus lies normally to the front, with its anterior surface resting on the bladder. Great refinement is exercised, quite unnecessarily, by many gynecologists in settling what they believe to be the exact angle which the long axis of the uterus should make with the horizon, when a woman is in the erect posture; and this refinement has been greatly stimulated by the mechanical treatment of what is known by many as anteversion of the uterus. In treating of this vexed question we shall consider

1. The normal form and position of the uterus.

2. The local divisions of the pelvic floor peritoneum as viewed. through the pelvic brim, and the position of the uterus and its annexa. 3. The physiological changes in the position of the uterus.

4. The relation of the small intestine to the pelvic floor and to the uterus and its annexa.

THE NORMAL FORM AND POSITION OF THE UTERUS.

The question of form of the uterus we consider only in the limited aspect of the angular relation of the long axis of the uterus to the long axis of the cervix. These are not in the same straight line but, when the bladder and rectum are empty, lie at an obtuse angle of varying value. This angle is much less in multiparous women (fig. 27), and more marked in nulliparae (fig. 50). The position of the uterus, with

Fig. 50.

Diagram to show normal form and position of Virgin Uterus (Schultze).

empty bladder and rectum, is such that it lies with its anterior surface touching the posterior aspect of the bladder, no intestine intervening: the os externum uteri looks downwards and backwards; and the uterus is slightly twisted as a whole on its long axis, so that the uterine end of the right Fallopian tube is nearer the symphysis than that of the left. We have expressly said with bladder and rectum empty. According to Schultze, the long axis of the uterus is nearly parallel to the horizon. This is probably exaggerated as Schultze's researches were conducted in a way that certainly anteverted the uterus unduly (figs. 27 and 50). Many authors figure the uterus nearly vertical to the horizon, for this purpose distending the bladder until the uterus is

elevated to what they consider the proper angle (fig. 51). It is needless to say how absurd this is. Kohlrausch's diagram so often quoted in

Section of Pelvis, shewing Uterus driven back by distended Bladder and Peritoneum disturbed (Kohlrausch). This is not a normal condition of parts by any means.

support of this allegation really shows, if it show anything, the position of the uterus when the bladder is well distended. The student should note this point, as Kohlrausch's section is the favourite diagram of those who treat as pathological what is really a normal uterus. Fig. 52, from Pirogoff, shows a frozen section supporting Schultze's contention.

It is important to know how results as to the uterine position have been obtained. The chief methods are as follows:

(1.) By frozen, spirit-hardened, or chromic acid sections.-Results ob

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