Cellulitis not only exists, but it is a rather common occurrence, and used especially to be so before antiseptic midwifery and surgery were so much practised as they are now-a-days. Certain localities are more liable to be affected than others, because they contain a larger amount of connective tissue, and because they are more exposed to injury-viz. the broad ligaments, the surroundings of the lower uterine segment and the fornix of the vagina, the sacro-uterine ligaments, and the space between the cervix and the bladder.

Cellulitis may be acute or chronic.

Acute cellulitis may arise by propagation of the inflammation from a tear or ulcers in the cervix or from corporeal endometritis, the inflammation spreading through the intermuscular connective tissue. It may also begin directly in a tear extending into the parametrium, or it may begin anywhere in the depth of bruised tissue. In most cases it is combined with pelvic peritonitis, lymphangitis, or phlebitis.

That peritonitis and cellulitis go together, whether one or the other is the primary affection, is easy to understand, since the peritoneum and the connective tissue are not only in contact, but the peritoneum is only a modification of connective tissue.

When cellulitis is combined with lymphangitis, the latter is the primary lesion, the lymph-vessels becoming inflamed in the uterus or in the tear of the cervix, and carrying the infection through and into the connective tissue.

Phlebitis may be primary, extending from inflamed uterine sinuses, or secondary, beginning as periphlebitis by contact with inflamed connective tissue, and gradually gaining the deeper coats of the vein. Cellulitis is seldom bilateral.

We may distinguish between a simple traumatic form and a septic form. Both are due to infection with bacteria, but in the first simple bacteria of putrefaction are at work; in the second we have to deal with specific pathogenic bacteria.

Either of these forms may, again, be puerperal or non-puerperal. The traumatic extends in the loose connective tissue, following the interstices between sheets of hard connective tissue; the septic respects no boundaries.

As in other inflammations, we may distinguish different stages, one of infiltration, followed by one of resolution, suppuration, or organization.

During the stage of infiltration the connective tissue is swollen by exudation of serum and formation of small round cells, which change xxx., p. 309; Pelvic Peritonitis-Microscopical Studies," by Mary Dixon Jones, Med. Record, May 28, 1892; "Septic Endometritis and Peritonitis," by W. R. Pryor, Amer. Jour. Obst., vol. xxv. p. 598, May, 1892; "Remarks upon Parametritis," by Geo. T. Harrison, Amer. Jour. Obst., April, 1891, vol. xxiv. p. 460; "How shall we Treat our Cases of Pelvic Inflammation?" by Richard B. Maury, Amer. Jour. Obst., vol. xxiv., Jan., 1891.

the tissue into a gelatinous yellow mass. In most cases the serous fluid and the form-elements disappear again in the course of two or three weeks. In others pus is formed, and of all perimetric inflammations cellulitis is the one which most frequently ends in suppuration. Often the melting into pus takes place at several distinct points, and it is only in the course of time that these separate foci unite into one large abscess-cavity. As to the routes followed by the pus and the point where the abscess breaks, the reader is referred to what has been said above in speaking of pelvic abscess in general (p. 632). Here we shall only add that while a puerperal abscess commonly finds an outlet through the skin;-breaking above Poupart's ligament or, more rarely, below the same; following the vagina down to the labium majus and the anus; going through the obturator foramen or the greater sacro-sciatic foramen; or following the round ligament through the inguinal canal ;-the non-puerperal very rarely perforates the skin, and is usually discharged into one of the hollow organs in the pelvis. The abscess in the connective tissue rarely ruptures into the peritoneal cavity, fatal peritonitis being, as a rule, due to simple extension of the inflammation to the peritoneum.

Cellulitis often leads to uterine displacement, cicatricial retraction of the sacro-uterine ligaments causing anteflexion (p. 426), and that of the broad ligament lateroversion (p. 440).

If the inflammation ends in organization, pus may still form in the indurated tissue after a long time.

Chronic Cellulitis.-Chronic cellulitis is found as a remnant of the acute form in the shape of cicatrices, indurated bands, discharging abscesses, and fistulous tracts. It may also be an originally chronic cirrhosis (atrophic chronic cellulitis), which will be described later.

Etiology-Acute cellulitis is not found in childhood, and is rare after the menopause. It is confined to the age of sexual maturity, and especially to the puerperal state.

Puerperal cellulitis may be due to a tear in the cervix in an otherwise normal labor; but is especially caused by obstetric operations, such as forced dilatation of the cervix or the extraction of the child with forceps through a narrow pelvis. It may join inflammation of the uterus, tubes, and ovaries. Sometimes a hematoma-puerperal or non-puerperal-is first formed, which later suppurates.

Non-puerperal cellulitis is due to the use of tents, over-distention and other operations on the cervix, enucleation of tumors, or the presence of a non-puerperal hematoma. But, finally, all these cases are due to infection, and the difference in their course depends on the different kinds of microbes at work, especially the difference between common bacteria of putrefaction and specifically pathogenic micrococci.

Cellulitis may also be brought on by exposure to cold.

Symptoms.-The symptoms are much like those of peritonitis, but with certain differences. The patient may have a chill; there is a rise in temperature; her pulse becomes frequent; her tongue is furred; she feels weak; she has no appetite; she has pain in the lower part of the abdomen, and, perhaps, vesical or rectal tenesmus; but the pain is not so sudden nor so severe as in peritonitis; there is less tendency to vomiting, and no distention of the abdomen. On vaginal examination we find heat, swelling, and considerable tenderness. If the broad ligament is the seat of the disease, we feel a tumor varying in size between a walnut and an apple. If sufficiently large, it pushes the uterus over to the opposite side. If the inflammation is bilateral, the uterus is lifted up, and often the two lateral tumors may be felt connected by a bridge in front and behind the cervix. If the connective tissue around the sacro-uterine ligaments is affected, we feel the semilunar fold forming the upper limit of Douglas's pouch swollen on one or both sides. Occasionally the swelling may be limited to the connective tissue behind or in front of the cervix (posterior or anterior cellulitis). If the inflammation extends to the iliac fossa, the corresponding leg is drawn up.

Transition to pus is marked by the swelling becoming soft, but hardly distinctly fluctuating.

Induration of the tissue may last for many months. Often irritability of the bladder continues after the fever and swelling have subsided-a symptom which is referable to shortening of the sacro-uterine ligaments, which pull on the cervix and indirectly on the base of the bladder, which is bound to it with a thin layer of connective tissue.

As to other sequels, we may find amenorrhea, menorrhagia, or dysmenorrhea.

Diagnosis.-Enough has been said under the Symptomatology and in speaking of pelvic peritonitis (p. 635) about the difference between cellulitis and the latter disease. Hematoma begins suddenly without fever and with great pain. An inflamed ovarian tumor may be very hard to differentiate except by the history and later course of the disease. A common ovarian tumor is movable. A uterine fibroid forms one mass with the uterus and moves with it, whereas in cellulitis it is possible to feel a groove between that organ and the swelling in the broad ligament, and the uterus is more or less immovable. Retroperitoneal sarcoma is a chronic disease, in which the constitution soon suffers.

Prognosis. The prognosis of cellulitis is less grave than that of peritonitis. It may, however, become fatal in a short time through septicemia or develop into the more dangerous peritonitis. As a rule, the prognosis is good as to life, but very uncertain as to time and complete recovery.

Treatment.-All that has been said above about the treatment of peritonitis (p. 636, et seq.) applies to cellulitis, whether an abscess is formed or not. I shall, therefore, limit myself to a few additional remarks bearing especially upon cellulitis.

Prophylaxis consists in avoidance of refrigeration and in antiseptic midwifery and surgery. Slowly dilating tents should, as far as possible, be discarded, and replaced by rapid dilatation with steel dilators.

Instead of the hot douche, some recommend a continuous current of ice-water, beginning at a pleasantly warm temperature and diminishing the heat gradually; and, to judge by the superiority of the ice-bag over the poultice in other inflammations, the advice seems worthy of trial. This injection can easily be administered through

FIG. 310.

GTIEMANN &CO...

Frost's Vaginal Syringe.

Frost's vaginal syringe (Fig. 310), which plugs the vagina and has an efferent tube leading down to a vessel under the bed.

If pus begins to form, the maturation of the abscess should be furthered by the use of warm abdominal poultices and warm vaginal injections.

Some recommend early aspiration in several places through the vaginal roof, by which a small amount of bloody serum is withdrawn, but the discomfort unavoidably connected with the operation and the danger of infection make other means of promoting absorption preferable. If pus is formed, aspiration is hardly radical enough to produce a cure.

When pus begins to form in several foci, it is best to give them time to unite before opening the abscess.

If pus follows the round ligament, the operator may succeed in introducing a glass drainage-tube through the inguinal canal.

If an abscess forms between the uterus and the bladder, it must be opened very cautiously by a T-shaped incision in the vagina.

An abscess in the broad ligament may be reached by partial excision of the uterus. First the cervix is removed, and then so much of the body cut away that the finger can be introduced into the

1

1 Landau, Centralblatt für Gynäkologie, 1892, No. 35, vol. xvi. p. 689.

abscess-cavity. Hemorrhage is exclusively controlled by hemostatic forceps, which are left in place for forty-eight hours. This method. would only be available in women with a large vagina.

Some go even so far as to perform total vaginal hysterectomy in order to reach a purulent collection in the pelvis, whether situated in the connective tissue or elsewhere.1

Chronic Atrophic Cellulitis.-It consists in a cirrhotic contraction and hardening of the pelvic connective tissue, like that taking place in the kidneys, liver, spleen, lungs, and other organs. It appears in a circumscribed and diffuse form. The circumscribed is due to ulcers in the bladder and the rectum, laceration of the cervix, or chronic metritis. The induration is situated on a level with the so-called superior sphincter. On the anterior wall of the vagina, corresponding to the base of the bladder, is found a stellate cicatrice, from which the induration can be followed more or less far into the surrounding parts. This condition is combined with congestion of the hemorrhoidal veins. The diffuse form starts from the base of the broad ligament, and may extend through the whole pelvis. The arteries are diminished in size; the veins are either narrowed or dilated, and contain often thrombi or phleboliths. It leads to venous congestion and varicosities, atrophy and sclerosis of the uterus, and synechiæ between the walls of the cervix. The vagina is shortened, and often funnel-shaped. The cervical ganglion (p. 62) is covered and interspersed with cicatricial tissue.

The causes of the diffuse form are the same as those of the circumscribed or too great or too frequent sexual excitement, especially masturbation, and losses through hemorrhage and leucorrhea. Chlorotic women with hypoplasia of the genitals and the circulatory system are particularly predisposed to it.

Symptoms. Patients affected with chronic atrophic cellulitis have a decided propensity to masturbation, with indifference, or even aversion, for coition. They suffer often from erotic dreams, with emissions of mucus. They complain of pain in the iliac fossa, dyschezia, dysuria, dysmenorrhea, often intermenstrual pain (p. 404), and the disease is always accompanied by hysterical symptoms, among others copiopia hysterica (p. 238).

Prognosis.-The circumscribed form may be cured when the cause is removed, and especially if pregnancy supervenes. The diffuse is incurable, but may remain stationary for long periods.

Treatment. The causes must be removed, the vagina treated with

1 Péan, Bulletin de l'Académie de Médecine, No. 27, 1890; Segond, "De l'Hystérectomie vaginale dans le Traitement des Suppurations pelviennes," Revue de Chirurgie, 1891, No. 4.

This disease has been described by Wilhelm A. Freund in Gynäk. Klinik, vol. i. pp. 239-326.