possible, the sac should be stitched to the abdominal wall, and drainage established in that way; but often it is impossible because there is no separate wall. Then we can only wash the cavity out with an antiseptic solution, and drain with iodoform gauze through the wound in the abdominal wall.

C. Hematoma.

Pelvic hematoma, or hematoma of the broad ligament, is an effusion of blood in the pelvic connective tissue above the levator ani muscle, most frequently between the layers of the broad ligament, whence it may extend under the pelvic peritoneum, up under the abdominal peritoneum, and down on the side of the vagina.1

Pathological Anatomy.-The blood is situated in the loose connective tissue between the two layers of the broad ligament and between the peritoneum and the underlying fascia. In most cases it is not a very large collection, but the sac may contain several pints of blood, and form a tumor that nearly mounts to the umbilicus. As a rule, it is unilateral, but both sides may be affected, and then the two lateral tumors are united by an isthmus in front of and behind the uterus, and the rectum is narrowed by a ring-shaped stricture. The flow is arrested by the resistance offered by the surrounding sac, and the blood does not coagulate so rapidly as in hematocele. There may develop some peritonitis, but less than in hematocele. The sac may rupture, with the formation of a secondary hematocele, or it may suppurate, so as to become a pelvic abscess. (See Cellulitis.)

Etiology. Since the connective tissue of the pelvis becomes laxer by pregnancy, multiparous and pregnant women, as well as puerperæ, are more apt to be affected. A varicocele or the fetal sac in tubal pregnancy may rupture in such a place that the blood escapes between the layers of the broad ligament, and not into the peritoneal cavity. Excessive coition may be the exciting cause. The accident happens most frequently during menorrhagia or the pseudo-menstruation following oophorectomy and ovariotomy. The patient may be in perfect health.

Symptoms. Suddenly the patient feels pain in the pelvis, with faintness and rapid, small pulse, but the attack is less alarming than in hematocele.

The vagina, and even the skin, may have a bluish color. A doughy tumor is felt on one side of the uterus, which it pushes over to the opposite side and upward. If the affection is bilateral, the uterus is lifted up. The tumor is in close connection with the uterus,

1 According to W. A. Freund (Gynäkologische Klinik, Strasburg, 1885, vol. i. p. 219) the pelvic hematoma may in non-puerperal cases form between the rectum and the vagina, and in puerperal cases extend from the sides of the vagina to the anterior abdominal wall, the kidneys, and into the mesentery, without entering the broad ligament.

which is rendered immobile. As a rule, the tumor does not rise beyond the pelvic brim, but it may, as stated above, ascend to the neighborhood of the umbilicus and be distinctly fluctuating,

Diagnosis.-The effusion is less rapid, causes less pain and shock, and forms a distinct tumor sooner than in hematocele. In large bilateral collections in the connective tissue the upper surface is convex, the lower more or less irregularly concave, so that the whole reminds one of a jellyfish, while hematocele bulges into the vagina with a convex end like a dilated bag. The ring-shaped stricture of the rectum is characteristic. The tumor is found just within the vulva, while in most cases of hematocele its base is situated higher up. It is found on one or both sides of the vagina-in hematocele, behind. It remains longer fluid. The uterus is sooner rendered immobile. Fever sets in later. In cellulitis the fever precedes the formation of the tumor, the uterus is not immobilized so soon, and the inflammation is referable to childbirth, abortion, or operative interference.

Prognosis. Nearly all patients recover in from ten to fourteen days. Only when occurring in pregnancy, childbirth, or the puerperium is it dangerous. As a rule, the blood, and even the fetus in extra-uterine pregnancy, is absorbed. Suppuration is rare. But the sac may rupture into the peritoneal cavity, and in extra-uterine pregnancy the fetus may continue to grow.

Treatment. As a rule, no operation should be performed, but the same measures be adopted as for hematocele. If the bleeding is severe or the tumor very large, and does not become absorbed or is changed into an abscess, one of the operations described under Hematocele should be performed.

In laparotomy the sac, if possible, should be stitched to the abdominal incision, but it may be so brittle that it cannot be lifted so far even when pressure is made against the vaginal roof. In such cases the uterus may sometimes be used to fill the gap. A suture is carried through the abdominal wall, the edge of the sac, the peritoneal cover of the uterus, the other edge of the sac, and the other side of the abdominal wall. If it appears desirable, a second suture may be inserted in a similar way. When these sutures are drawn taut, the sac is closed by the uterus, and the latter brought in contact with the abdominal wall.1

Galvanopuncture through the vagina, with a fine platinum-pointed needle connected with the positive pole, and with a current of 50 milliampères, used from five to ten minutes, has been recommended. In a small hematoma one application suffices; in larger it may be repeated in from three to six days.2

1 Marcus Rosenwasser of Cleveland, O., Annals of Gynecology, March, 1891, vol. iv. p. 325.

2 A. H. Goelet, N. Y. Med. Record, March 8, 1890, vol. xxxvii. p. 279.

CHAPTER VII.

PERIMETRIC INFLAMMATION.

By "perimetric inflammation" is understood the inflammation of the pelvic peritoneum, the pelvic connective tissue, the veins, and the lymphatic vessels and glands in the pelvis. On account of the intimate connection between these different structures and with the neighboring organs, it is quite common that more than one of them is affected at a time, and it is evident that there must be a certain similarity between all pelvic inflammations; but according to the tissue from which the inflammation starts or the one that is most affected we distinguish perimetric inflammations by different names, and these different diseases present also sometimes peculiarities as to frequency, physical signs, prognosis, and indications for treatment. Our old knowledge, based only on clinical observations and post-mortem examinations, has been greatly extended and corrected by the numerous laparotomies that have been performed of late years in these conditions. Thus we describe separately pelvic peritonitis, pelvic cellulitis, pelvic lymphangitis, and pelvic phlebitis.

A. Pelvic Peritonitis.

Pelvic peritonitis is the inflammation of that part of the peritoneum which covers more or less of the uterus, the tubes, the bladder, the rectum, the vagina, and the walls of the pelvis, and which forms the broad ligaments.

Pelvic peritonitis is sometimes called perimetritis as a companion name to parametritis, which is used to designate inflammation of the connective tissue; but since these names are not very characteristic in regard to their derivation,-peri meaning "around," and para, "at the side of,"-since their sound, especially in English, is so much alike that there is little for the memory to take hold of, and since most excellent treatises have been written about them under their old names, we take it to be more practical to preserve the words "peritonitis" and "cellulitis," although the latter leaves much to be desired from an etymological standpoint, being a combination of a Latin root and a Greek suffix, and the root itself being a remnant from the time when what we now call connective tissue was designated as cellular tissue.

Of all the perimetric inflammations, peritonitis is by far the most

common.

Pathological Anatomy.-Different forms of pelvic peritonitis have been distinguished-namely, the serous, the adhesive, and the suppurative—which are sometimes only different stages of the same disease. The inflammation may be acute or chronic.

In nearly all these cases are found diseased tubes, and usually the ovary is implicated. Often the inflammation of the tubes can be traced back to the corresponding condition in the uterus. First the peritoneum becomes injected, its endothelium is lost, and serum is secreted from the denuded surface. The neighboring organs are agglutinated by a yellow fibrinous mass that becomes organized, and forms a false membrane which encapsulates the serous exudation. Serum may also be enclosed in the meshes of the adjacent connective tissue, forming an inflammatory edema. The serum may gravitate down into Douglas's pouch or be found in one of the para-uterine fossæ, or the quantity may be large enough to fill the whole pelvis, and even surmount the iliopectineal line. As a rule, the fluid is found behind the uterus and pushes it forward, sometimes also to one side, but in exceptional cases the uterus being already bound down with adhesions, the fluid is found above and in front of it.

Later this serum in the peritoneal cavity becomes inspissated, forming a yellow mass like orange-jelly,' the more watery part being reabsorbed and connective tissue being formed. Finally, the whole may be absorbed, or, as it is called, the disease ends in resolution.

Even solid adhesions can probably disappear without leaving any trace; at least a uterus that at one time is immovably moored to the surroundings may regain entire mobility. This absorption is doubtless favored by the constant movement in which the pelvic organs are kept by respiration, the different degrees of fullness of the bladder and intestine, their evacuation, sneezing, coughing, muscular exertion, and sometimes an intervening pregnancy in which the adhesions are softened and stretched. But, as a rule, adhesions remain indefinitely. The serous cyst may remain unchanged for many months. Sometimes the contents become bloody in consequence of rupture of vessels in the adhesions, and in rare cases they become purulent. In the adhesive form we find on one or both sides of the uterus a tumor composed of the tube, the ovary, and, perhaps, a knuckle of intestine or a part of the omentum, all matted together with plastic lymph or organized adhesions. As a rule, this mass is bound in the same way to the posterior surface of the broad ligament, or, more rarely, to the posterior surface of the uterus, the anterior surface of the rectum, the superior surface of the bladder, or the pelvic wall. Serum may extravasate into such a mass. The ovary is covered with a false membrane. The tube is contorted, and its sinuosities bound together; the abdominal ostium is often closed; the fimbriae may have grown together; bands of adhesions form constrictions which cause adhesive salpingitis and strictures or total partitions in the interior of the tube. The uterus may be retroflexed or retroverted, and bound to the rectum, or, more rarely, anteflexed or anteverted, and bound to the bladder. The condition

1John Williams, Obst. Trans. of London, June 3, 1885, vol. xxvii.

we here describe, as it presents itself in laparotomies, is in most cases probably a late stage of the preceding form, but in some cases there is little serous effusion from the beginning, and the exuded fibrinous lymph is soon transformed into connective tissue by a process similar to that causing dry pleurisy. This dry chronic form is particularly frequent in connection with tuberculosis, while the common acute form is ordinarily accompanied by more or less serous exudation.

Pelvic peritonitis may be suppurative from the beginning, as when gonorrhea extends through the uterus and tubes, or a serous exudate may in the course of time, instead of being absorbed, become purulent. Fortunately, this is a comparatively rare occurrence.

Pus in the pelvis may be found in the tube (pyosalpinx), in the ovary (ovarian abscess), in the peritoneal cavity, or in the subperitoneal connective tissue. Often it is found in all these localities at the same time. We have described the first two in dealing with the Diseases of the Tube and the Ovary. Here we will only add that the pus-filled tube may become so distended that it occupies the whole pelvis, where it may adhere, so that it cannot be separated from the peritoneum. The pelvic abscess of the connective tissue will be described below. Here we have only to do with the intraperitoneal collection of pus. On account of the preexisting wall formed by adhesions and the new irritation caused by the acrid contents, this abscess, although situate in the peritoneal cavity, is in reality, as a rule, separated from it by a complete partition of varying thickness. This intraperitoneal abscess may open into a hollow organ, most frequently the rectum, less often the vagina, and rarely the bladder. It may rupture into the peritoneal cavity, which, fortunately, is a rare occurrence, and it may find its way out through the peritoneum, the connective tissue, and the skin above or below Poupart's ligament, or burst in the gluteal region, which it reaches through the great sacrosciatic foramen.1

Often the abscess is only partially emptied through a long, narrow, and devious canal surrounded by indurated tissue, or refills again when the outlet becomes blocked up. Such fistulous abscesses may remain indefinitely as a source of fresh attacks of peritonitis or as a drain on the patient's constitution, which makes her an invalid or causes death by exhaustion.

In contact with the purulent collection the muscular fibers of the uterus are apt to undergo fatty degeneration. The inflammation may follow the lymphatics through the infundibulopelvic ligament up to

1 W. M. Polk thinks this is brought about by agglutination of the fimbriated end of the tube to some point of the peritoneum, which yields and allows the migration of the pus ("Peri-uterine Inflammation," N. Y. Med. Record, Sept. 18, 1886, vol. xxx. p. 315).