peritonitis. The occurring of suppuration is indicated by rigors and should be hastened by the hot douche and poultices. We may have only part or parts of the exudation suppurating, so that in a cellulitic swelling we may have inflammatory exudation containing separate abscess cavities. In these, tapping with Matthieu's aspirator is very good, and may be often repeated. Care should be taken that the aspiratory needle has been purified in carbolic lotion (1-20), and prior to introduction dipped in carbolic oil (1-20).

When pus is present in large quantity, the treatment varies according to the part at which it points.

(1.) If it point below Poupart's ligament, in the buttock, or behind the kidney, it is to be opened under Listerism and a drainage tube inserted. Results by this method are admirable.

(2.) If it bulge in the vaginal roof, it should be opened as follows:Pass Sims' speculum, and open into the cavity with Paquelin's cautery at a dull heat; make the opening big enough to admit two good sized drainage tubes. Daily irrigate the cavity with weak carbolic lotion (1-100) or boracic lotion (1-30). If the discharge is profuse it may be received into pads of salicylic cotton wool placed over the vulva; oakum or marine lint may be used among poor people.

The drainage tubes should be double, and with a small piece at the end at right angles which prevents them slipping out. They should not be perforated, as this prevents the washing out. If only straight tubes can be had, a small piece of ivory can be stitched to the upper end.

During suppuration, tonics and nutritious diet should be given.

Aitken, Lauchlan-Case of Pelvic Hæmatocele: Ed. Med. J., 1862, p. 104. Bandl-Op. cit Bernutz and Goupil-Op. cit. Barnes-Op. cit. p. 590. Bourdon-Tumeurs fluctuants du petit bassin: Rev. Med., 1841. Crede-Monatsschrift f. Geburtskunde, Bd. IX. S. 1. Duncan, Matthews-Uterine Hæmatocele: Ed. M. J. 1862, p. 418: Clinical Lectures, Churchhill, Lond., 1879. Fritsch-Die Retro-uterine Hæmatocele: Volkmann's Sammlung No. 56. Kuhn-Ueber Blutergüsse in die breiten Mutterbänder und in das den Uterus umgebenden Gewebe: Zurich, 1874. M'Clintock-Diseases of Women 1853. Nélaton-Gaz. des Hôpitaux, 1851 and 1852. Pelletan-Clinique Chirurgicale, Paris 1810. Priestley, W. O.-Pelvic Hæmatocele: Reynolds' System of Med., Vol. V., p. 783. Simpson, J. Y.-Peri-uterine or Pelvic Hæmatocele, Collected Works, Vol. III., p. 121 : A. & C. Black, Edinburgh. Schroeder-Op. cit. S. 453 Kritische Untersuchungen über die Diagnose der Hæmatocele Retro-uterina : Arch. f. Gyn. Bd. V. Tilt-Pathology and Treatment of Sanguineous Tumours, Lond. 1853. Voisin-De l'hématocèle Rétro-utérine: Thése, Paris 1858. The literature is well given in Bandl's work and Priestley's article.

SYNONYMS-Retro-uterine Hæmatocele: Uterine Hæmatocele. THIS subject will be considered under the same heads as the preceding. Preliminary Considerations.-The abundant venous supply of the pelvic organs, the congestion induced by menstruation, and the hæmorrhage accompanying the monthly rupture of the Graafian follicle, render women peculiarly liable to hæmorrhages into the pelvic cavity. Yet it is astonishing that it is only since 1850 that this subject has really attracted gynecologists' attention. It was in that year that Nélaton gave the subject due prominence; although Voisin (1810), Recamier, Bourdon (1841), Ollivier, and Bernutz had all recorded cases, under such titles as Bloodgush from an aneurism of the ovary," "Blood cysts of the pelvic cavity." Nélaton had diagnosed his case as an abscess, and opened it with a bistoury; the blood and blood clots escaping from the incision showed its real nature unmistakably. Since that time, pelvic hæmatocele has taken its place in gynecology as a serious and important symptom.

NATURE.-An effusion of blood, usually into the pelvic peritoneum, sometimes beneath it; enclosed either by anatomical structures or previously existing inflammatory adhesions.

Many will consider this definition unsatisfactory; it must be taken, however, in connection with the following remarks. Pelvic hæmatocele is not a disease. It is only a symptom of some previously existing pathological condition of the pelvic organs, just as hæmoptysis is not a disease but usually a symptom of some lung condition. We have limited the term hæmatocele to hæmorrhages into the pelvic cavity.

It is disputed whether the inflammation encysting and limiting the hæmorrhage is antecedent or consequent to it. The former view has much more evidence in its favour, although some cases support the latter. This, however, belongs more especially to pathological anatomy. It may be urged that we have limited the term pelvic hæmatocele to hæmorrhages enclosed by anatomical relations or inflammatory adhesions. We do this, however, for the following reason. The hæmorrhage gives no physical sign until enclosed, and is no more palpable to the finger examining through the fornices than the intestines or ascitic fluid are. Fluid blood in the pelvis can only be diagnosed by abdominal incision or post-mortem.

PATHOLOGICAL ANATOMY.

Post-mortem cases are rare, but enough have been recorded to give us some idea of its pathology.

In almost all the cases, the blood is found enclosed by pelvic inflammatory adhesions, apparently antecedent. Dr Lauchlan Aitken has recorded a case which, during life, presented the usual physical signs of retro-uterine hæmatocele, viz., a retro uterine tumour bulging into the posterior fornix vaginæ and displacing the uterus markedly forward; and in which, on post-mortem, clotted blood, not enclosed by adhesions, was found behind the uterus.

Usually, however, the tumour when retro-uterine has, as its boundaries, the uterus and broad ligaments in front and the sacral peritoneum behind; while, above, it is roofed in, as it were, by adherent intestine or by the retroverted and adherent uterus. The uterus is markedly driven forward by the effusion.

Sometimes the blood is found effused between the layers of the broad ligament, which limits it unless the effusion is so great as to perforate a lamella and escape into the peritoneum. Occasionally the blood is below the peritoneum and dissects it up as it escapes from the vessels ; or it is found in the cellular tissue of the pelvis.

It is of the highest pathological importance to note that in a very large proportion of the cases diseased ovaries have been found; changes

Retro-uterine Hæmatocele, Pouch of Douglas previously obliterated by inflammation.

in the Fallopian tubes (dilatation and filling with blood or pus) being less common.

Retro-uterine Hæmatocele. Pouch of Douglas not previously obliterated (Schroeder). The effused blood undergoes changes in course of time, so that blood crystals, granular corpuscles and oil drops are found as traces of the

previous blood effusion.

When the patient dies soon after the hæmorrhage, the blood is merely clotted. In most cases of recovery it becomes entirely absorbed.

ETIOLOGY: SOURCES OF HÆMORRHAGE AND VARIETIES.

The table quoted below shows that pelvic hæmatocele is most common in women between the ages of 25 and 35, that is, women in their period of full menstrual and sexual vigour. Out of 43 cases, the ages, according to Schroeder, were as follows:—

It is also most common in Multiparæ, and occurs in about 4 or per cent. of specially female diseases.

5

The following are the chief causes of hæmorrhage, and its anatomical

sources.

1. Predisposing causes. Profuse menstruation; violent exercise during menstruation, such as dancing; violent coitus during menstruation; varicose conditions of the subperitoneal veins; purpura; scorbutus; hæmophila.

2. Anatomical sources. (a.) Pelvic Peritoneum. There may be rupture of veins of the pampiniform plexus, or of the veins below the uterine peritoneum. In the former case, we may get the blood pouring directly into the peritoneum; or first passing between the layers of the broad ligament, and either remaining enclosed there or rupturing into the peritoneum. The hæmorrhage, according to Virchow, may arise from vessels developed in the false membranes of pelvic peritonitis. Crede of Leipzig quotes a case where he tapped a tumour and first got serum, then blood-stained serum, and finally blood. In two days, a fresh tapping first gave putrid blood and then fresh blood in abundance. (b.) Connective tissue.-Rupture of veins occurs here also.

(c.) Uterus.-We may have regurgitation in menorrhagia from the uterus along the dilated Fallopian tubes. Rupture of interstitial extrauterine pregnancy is another cause of hæmorrhage.

(d.) Fallopian tube.-Blood may come from its hyperæmic mucous membrane. More usually it arises from rupture of an extra-uterine pregnancy there.