must be relieved and sleep procured by the judicious use of anodynes, such as Dover's powder, the subcutaneous injection of morphia, or chloral. Generally no form answers so well as the hypodermic injection of morphia.

When the acute symptoms have abated and the temperature has fallen, the poultices and stupes may be discontinued and the limbs swathed in a flannel roller from the toes upward. The equable pressure and support thus afforded materially aid the absorption of the effusion and tend to diminish the size of the limb. At a still later stage very gentle inunctions of weak iodine ointment may be used with advantage once a day before the roller is applied. Shampooing and friction of the limb, generally recommended for the purpose of hastening absorption, should be carefully avoided, on account of the possible risk of detaching a portion of the coagulum and producing embolism. This is no merely imaginary danger, as the following fact narrated by Trousseau proves: "A phlegmasia alba dolens had appeared on the left side in a young woman suffering from peri-uterine phlegmon. The pain having ceased, a thickened venous trunk was felt on the upper and internal part of the thigh. Rather strong pressure was being made, when M. Demarquay felt something yield under his fingers. A few minutes afterward the patient was attacked with dreadful palpitation, tumultuous cardiac action, and extreme pallor, and death was believed to be imminent. After some hours, however, the oppression ceased and the patient eventually recovered. A slightly attached coagulum must have become separated and conveyed to the heart or pulmonary artery." Warm douches of waterof salt water, if it can be obtained-may be advantageously used in the later stages of the disease, and they may be applied night and morning, the limb being bandaged in the interval. The occasional use of the continuous current is said to promote absorption, and would seem likely to be a serviceable remedy.

When the patient is well enough to be moved, a change of air to the seaside will be of value. Great caution, however, should be recommended in using the limb, and it is far better not to run the risk of a relapse by any undue haste in this respect. It is well to warn the patient and her friends that a considerable time must of necessity elapse before the local signs of the disease have completely disappeared.

1 Trousseau: Clinique de l'Hôtel-Dieu, in Gaz. des Hôp., 1860, p. 577.

CHAPTER X.

PELVIC CELLULITIS AND PELVIC PERITONITIS.

Recognized from the Earliest Times. From the earliest times the occurrence after parturition of severe forms of inflammatory disease in and about the pelvis, frequently ending in suppuration, has been well known. It is only of late years, however, that these diseases have been made the subject of accurate clinical and pathological investigation, and that their true nature has begun to be understood. Nor is our knowledge of them as yet by any means complete. They merit careful study on the part of the accoucheur, for they give rise to some of the most severe and protracted illnesses from which puerperal patients suffer. They are often obscure in their origin and apt to be overlooked, and they not rarely leave behind them lasting mischief.

These diseases are not limited to the puerperal state. On the contrary, many of the severest cases arise from causes altogether unconnected with childbearing. These will not be now considered, and this chapter deals solely with such forms as may be directly traced to childbirth.

Modern researches have demonstrated that there are two distinct varieties of inflammatory disease met with after labor which differ materially from each other in many respects. In one of these the inflammation affects chiefly the connective tissue surrounding the generative organs contained within the pelvis, or extends up from beneath the peritoneum and into the iliac fossæ. In the other it attacks that portion of the peritoneum which covers the pelvic viscera, and is limited to it.

Variety of Nomenclature.-So much is admitted by all writers; but great obscurity in description, and consequent difficulty in understanding satisfactorily the nature of these affections, have resulted from the variety of nomenclature which different authors have adopted. Thus the former disease has been variously described as pelvic cellulitis, peri-uterine phlegmon, para-metritis, or pelvic abscess; while the latter is not unfrequently called peri-metritis, as contradistinguished from para-metritis. The use of the prefix para or peri, to distinguish the cellular or peritoneal variety of inflammation, originally suggested by Virchow, has been pretty generally adopted in Germany, and has been strongly advocated in Great Britain by Matthews Duncan. It has never, however, found much favor with English writers, and the similarity of the two names is so great as to lead to confusion. I have, therefore, selected the terms pelvic peritonitis and pelvic cellulitis, as conveying in themselves a fairly accurate notion of the tissues mainly involved.

Importance of Distinguishing the Two Classes of Cases.The important fact to remember is that there exist two distinct varieties of inflammatory disease presenting many similarities in their course, symptoms, and results, often occurring simultaneously, but in the main distinct in their pathology and capable of being differentiated. Thomas compares them and, as serving to fix the facts on the memory, the illustration is a good one-to pleurisy and pneumonia. "Like them," he says, "they are separate and distinct, like them affect different kinds of structure, and like them they generally complicate each other." It might, therefore, be advisable, as most writers on the disease occurring in the non-puerperal state have done, to treat of them in two separate chapters. There is, however, more difficulty in distinguishing them as puerperal than as non-puerperal affections, for which reason, as well as for the sake of brevity, I think it better to consider them together, pointing out as I proceed the distinctive peculiarities of each.

Seat of Disease.-When attention was first directed to this class of diseases the pelvic cellular tissue was believed to be the only structure affected. This was the view maintained by Nonat, Simpson, and many modern writers. Attention was first prominently directed to the importance of localized inflammation of the peritoneum, and to the fact that many of the supposed cases of cellulitis were really peritonitic, by Bernutz. There can be no doubt that he here made an enormous step in advance. Like many authors, however, he rode his hobby a little too hard, and he erred in denying the occurrence of cellulitis in many cases in which it undoubtedly exists.

Etiology. The great influence of childbirth in producing these diseases has long been fully recognized. Courty estimates that about twothirds of all the cases met with occur in connection with delivery or abortion, and Duncan found that out of 40 carefully selected cases 25 were associated with the puerperal state.

It is pretty generally admitted by most modern writers that both varieties of the disease are produced by the extension of inflammation from either the uterus, the Fallopian tubes, or the ovaries. This point has been especially insisted on by Duncan, who maintains that the disease is never idiopathic, and is "invariably secondary either to mechanical injury, or to the extension of inflammation of some of the pelvic viscera, or to the irritation of noxious discharges through or from the tubes or ovaries."

Their intimate connection with puerperal septicemia is also a prominent fact in the natural history of the diseases. Barker mentions a curious observation illustrative of this, that when puerperal fever is endemic in the Bellevue Hospital, in New York, cases of pelvic peritonitis and cellulitis are also invariably met with. Olshausen has also remarked that in the Lying-in Hospital at Halle, during the autumn vacation, when the patients are not attended by practitioners, and when, therefore, the chance of septic infection being conveyed to them is less, these inflammations are almost always absent. As inflammation of the lining membrane of the uterus, of the vaginal mucous membrane, and of the pelvic connective tissue are of very constant occurrence as local phenomena of septic absorption, the connection between the two classes

of cases is readily susceptible of explanation. Schroeder, indeed, goes further, and includes his description of these diseases under the head of puerperal fever. They do not, however, necessarily depend upon it; for, although it must be admitted that cases of this kind form a large proportion of those met with, others unquestionably occur which cannot be traced to such sources, but are the direct result of causes altogether unconnected with the inflammation attending on septic absorption, such as undue exertion shortly after delivery, or premature coition. Mechanical causes may beyond doubt excite the disease in a woman predisposed by the puerperal process, but they cannot fairly be included under the head of puerperal fever.

Seat of the Inflammation in Pelvic Cellulitis.-Abundance of areolar tissue exists in connection with the pelvic viscera, which may be the seat of cellulitis. It forms a loose padding between the organs contained in the pelvis proper, surrounds the vagina, the rectum, and the bladder, and is found in considerable quantity between the folds of the broad ligaments. From these parts it extends upward to the iliac fossa and the inner surface of the abdominal parietes. In any of these positions it may be the seat of the kind of inflammation we are discussing. The essential character of the inflammation is similar to that which accompanies areolar inflammation in other parts of the body. There is first an acute inflammatory oedema, followed by the infiltration of the areola of the connective tissue with exudation, and the consequent formation of appreciable swellings. These may form in any part of the pelvis. Thus we may meet with them-and this is a very common situation-between the folds of the broad ligaments, forming distinct hard tumors, connected with the uterus and extending to the pelvic walls, their rounded outlines being readily made out by bimanual examination. If the cellulitis be limited in extent, such a swelling may exist on one side of the uterus only, forming a rounded mass of varying size and apparently attached to it. At other times the exudation is more extensive, and may completely or partially surround the uterus, extending to the cellular tissue between the vagina and rectum or between the uterus and the bladder. In such cases the uterus is imbedded and firmly fixed in dense, hard exudation. At other times the inflammation chiefly affects the cellular tissue covering the muscles lining the iliac fossa. There it forms a mass easily made out by palpation, but on vaginal examination little or no trace of the exudation can be felt, or only a sense of thickness at the roof of the vagina on the same side as the swelling.

Seat of the Inflammation in Pelvic Peritonitis.-In pelvic peritonitis the inflammation is limited to that portion of the peritoneum which invests the pelvic viscera. Its extent necessarily varies with the intensity and duration of the attack. In some cases there may be little more than irritation, while more often it runs on to exudation of plastic material. The result is generally complete fixation of the uterus and hardening and swelling in the roof of the vagina, and the lymph poured out may mat together the surrounding viscera, so as to form swellings, difficult, in some cases, to differentiate from those resulting from cellulitis. On post-mortem examination the pelvic viscera

are found extensively adherent, and the agglutination may involve the coils of the intestine in the vicinity, so as sometimes to form tumors of considerable size.

Relative Frequency of the Two Forms of Disease.-The relative frequency of these two forms of inflammation as puerperal affections is not easy to ascertain. In the non-puerperal state the peritonitic variety is much the more common, but in the puerperal state they very generally complicate each other, and it is rare for cellulitis to exist to any great extent without more or less peritonitis.

Symptomatology.-The earliest symptom is pain in the lower part of the abdomen, which is generally preceded by rigor or chilliness. The amount of pain varies much. Sometimes it is comparatively slight, and it is by no means rare to meet with patients who are the subjects of very considerable exudations who suffer little more than a certain sense of weight and discomfort at the lower part of the abdomen. On the other hand, the suffering may be excessive, and is characterized by paroxysmal exacerbations, the patient being comparatively free from pain for several successive hours, and then having attacks of the most acute agony. Schroeder says that pain is always a symptom of peritonitis, and that it does not exist in uncomplicated cellulitis. The swellings of cellulitis are certainly sometimes remarkably free from tenderness, and I have often seen masses of exudation in the iliac foss which could bear even rough handling. On the other hand, although this is certainly more often met with in non-puerperal cases, the tenderness over the abdomen is sometimes excessive, the patient shrinking from the slightest touch. The pulse is raised, generally from 100 to 120, and the thermometer shows the presence of pyrexia. During the entire course of the disease both these symptoms continue. The temperature is often very high, but more frequently it varies from 100° to 104°, and it generally shows more or less marked remissions. In some cases the temperature is said not to be elevated at all, or even to be subnormal, but this is certainly quite exceptional. Other signs of local and general irritation often exist. Among them, and most distinctly in cases of peritonitis, are nausea and vomiting, and an anxious, pinched expression of the countenance, while the local mischief often causes distressing dysuria and tenesmus. The latter is especially apt to occur when there is exudation between the rectum and vagina which presses on the bowel. The passage of feces, unless in a very liquid form, may then cause intolerable suffering.

Such symptoms may show themselves within a few days after delivery, and then they can barely fail to attract attention. On the other hand, they may not commence for some weeks after labor, and then they are often insidious in their onset and apt to be overlooked. It is far from rare to meet with cases six weeks or more after confinement in which the patient complains of little beyond a feeling of malaise and discomfort, and in which, on investigation, a considerable amount of exudation is detected which had previously entirely escaped observation.

Results of Physical Examination.-On introducing the finger into the vagina it will be found to be hot and swollen, in some cases