Article IV.- Remarks on Pelvic Peritonitis and Pelvic Cellulitis, with Illustrative Cases. By Lauchlan Aitken, M.D. Rather moie than a year ago there appeared from the pen of a well- known of this a gynecologist city very able monograph on the two forms of pelvic inflammation whose names head this article; and it cannot have escaped the recollection of the reader that Dr M. Dun- can, adopting the nomenclature first proposed by Yirchow, has used on his different terms title-page1 than those older appellations I still to retain. Under these propose ^ circumstances I feel at to compelled least to attempt justify my preference for the original names: and I trust to be able to show that are they preferable to, and less con- others that fusing than, any have as yet been proposed, even though we cannot consider them absolutely perfect. 1 Treatise on A Practical Perimetritis and Parametritis (Edin. 1869). 1870.] DR LAUCI1LAN AITKEN ON PELVIC FERITONITIS, ETC. 889 Passing over, then, such terms as 'periuterine cellulitis or phleg- mons periuterins as bad compounds ; others, as inflammation of the broad ligaments, as too limited in meaning ; and others, again, as engorgement periutdrin, as only indicating one of the stages of the affection,?I shall endeavour as succinctly as possible to state my reasons for preferring the older names to those proposed by Virchow. ls?. The two Greek prepositions, peri and para, are employed somewhat arbitrarily to indicate inflammatory processes which are essentially distinct. I say arbitrarily, because I am not aware that para has been generally employed in the form of a compound to ex- press inflammation of the cellular tissue elsewhere.1 By those who remember that the cellular tissue not only separates the serous membrane from the uterus at that part where the cervix and body of the organ meet, but is even abundant there,2 perimetritis might readily be taken to indicate one of the varieties, though indeed not a in for which very common one, of pelvic cellulitis?a variety, fact, the term perimetric cellulitis has been proposed. It is self-evident how much confusion might arise as to the real nature of a disease simply by the change of one letter of the alphabet. 2d. The term perimetritis, even if employed only to indicate in- flammation in the peritoneum, could not well be used if that inflam- mation were confined to the serous membrane round the tubes or ovaries. For such varieties of pelvic peritonitis we should require to adopt the terms peri-salpingitis and peri-oophoritis; thus, in my opinion, unnecessarily encumbering our nomenclature. The truth to is, that serous inflammation in the pelvis is rarely, if ever, confined . no means the peritoneal covering of one organ ; and, besides, we have of diagnosing it, when it is. In those facts we find other contra- indications to the employment of a term so restricted in its meaning as perimetritis. and to most 3d. The preposition para means, by the side of, too close a Greek scholars a word like parametritis would indicate to the uterus to be used with correctness in a case, for proximity a example, of puerperal cellulitis3 in one or other of the iliac fossas, difficulty which the term pelvic cellulitis to a great extent removes. our best Greek But besides, the preposition para, according to never used to indicate authorities, such as Donaldson and Jelf, is 1 Paranephritis is used by Dunglinson, for instance, to express Inflammation of the 2 Suprarenal Capsules. Lecons sur les Maladies de l'Ut^rus. t 3 Aran, Cliniques of a mere I am well aware that Dr Duncan denies the extension perfectly lms is a cellulitis etiologically parametric, as he would say, to the iliac fossa, point which can only be settled by further inquiry, and especially by autopsic a case oi iliac cellu- demonstration. I can say that I imagine I have seen only matter litis in abscess from an to the uterus without any having ending injury at formed in the true pelvis; and a case adduced by Dr Duncan himself, p. of his work on Perimetritis and Parametritis, seems to confute his theory, (bee trans- also Bernutz and Goupil, Clinical Memoirs on the Diseasesof \\ omen, lated for the New Sydenham Society by Dr Meadows, vol. ii. p- 14b.) ? U VOL. XV.?NO. X. 890 DR LAUCHLAN A1TKEN ON [APRIL proximity to a person or thing, except with the idea of motion towards or by the side of that person or thing. 4th. The terms pelvic cellulitis and pelvic peritonitis show to any one, at a glance, the nature of the affection, whether it is in- flammation in the cellular tissue or serous membrane of the pelvis, and do not limit the seat of the disease to the immediate neigh- bourhood of the uterus, as I maintain the words perimetritis and parametritis must do. If we keep in remembrance that the terms pelvic cellulitis and peritonitis are almost invariably employed by gyngekologists when the inflammation in the pelvis arises from some kind of disease of, or injury to, the uterus and its appendages, I hold that, at least in the present phase of our knowledge of the affections, those names can produce no confusion whatever in the mind of any one who adopts them, but must necessarily assist him in rapidly forming a conclusion as to the seat and pathology of the disease. Up to a very few years ago the pathology of pelvic inflammation was only partially elucidated, or had been in many cases erroneously interpreted. Some facts apparently well established, and, at any rate, supported by the weight of great names,1 pointed to the cellular tissue as the seat of those inflammatory processes which were so frequently known to follow the act of parturition, and even to occur in the non-puerperal female from many and varying causes. But as our knowledge of pathology advanced, it came to be recognised that many of those cases which had been regarded as purely extra-peritoneal were in reality affections of the serous and the membrane itself consequences arising therefrom, and that, . in fact, we had to deal with two perfectly separate and distinct diseases, which, indeed, might complicate each other, but of which, strange to say, the one first carefully described2 was by far the most rare, and by much the least important. It would be unjust to one of the most careful and conscientious of clinical observers, M. Bernutz, not to mention that it was princi- pally to his researches that we are indebted for our increased knowledge of the true nature of those inflammatory processes, although I am by no means prepared to go so far as he does, and almost absolutely deny the occurrence of cases of perimetric cellu- litis at all. The fact seems to be, that while the theory of inflam- mation of the cellular tissue in the pelvis?a theory almost univer- sally accepted in our own country?was carried too far by the enthusiasm of Nonat in France, M. Bernutz committed an equally grave error by rushing much too blindly in the opposite direction. The truth, as it usually does, appears to lie within the extremes; and though we can easily believe that M. Bernutz has verified his 1 Sir J. Y. Simpson, Dr Churchill, Dr West, Nonat, etc. 2 Grisolle mentions cases of circumscribed pelvic peritonitis simulating phlegmons as early as 1839, but there was really no accurate information until the work of Bernutz appeared. 1870.] PELVIC PERITONITIS AND PELVIC CELLULITIS. 891 diagnosis more frequently by autopsies in cases of pelvic peritonitis, it must not be imagined, on account of the rarity of such post-mor- tem verification, that cases of perimetric cellulitis are uncommon. On the contrary, it may be pointed out, that the very fact of the lesion being so frequently extra-peritoneal is the reason why we so seldom have an opportunity of completing the diagnosis in the way mentioned. No one can for a moment doubt that pelvic peritonitis is a much more serious and grave lesion, and one much more likely to produce a fatal issue, than inflammation of the cellular tissue of the we pelvis, and of that alone ; and while, on this account, have seldom any opportunity of confirming the presence of a perimetric cellulitis by post-mortem inspection, such a case as that reported by M. Simon1 goes far to prove, not only the possibility of its existence, but even the probability of its frequent occurrence. From this short resume of the present state of our knowledge of those essentially distinct pelvic inflammations, I now turn to one or two cases which will partially serve to illustrate the symp- toms to which they give rise, the treatment we ought to adopt, and as terminate the post-mortem appearances in such fatally. Margaret H., eet. 39, married, and has had four children, was admitted into Ward XII.,2 Royal Infirmary, on 6th March 1869, on account of haemorrhage after an abortion, which had occuned four os and cervix weeks previously. For purposes of diagnosis the were dilated by sponge-tents, and after examination the ergot of rye was given in drachm doses of the liquid extract, thrice daily. The bleeding ceased, and she was about to leave the hospital on 25th with March, when she was seized with a rigor after lying in her bed the rose adjacent; window open. The pulse and temperature very considerably. She perspired profusely after the shivering, and became delirious. She also complained of pain above the pubes. ten- The next day, on vaginal examination, there was fulness and derness in the retro-uterine cul-de-sac, but nothing more.