I feel sure that even

hospital as cases of acute pelvic cellulitis. when the abdomen has been opened and the suppuration discovered, the true nature of the case has not always been made out. Many instances in which a collection of pus has been opened and the cavity drained, and in which the operator has been unable to satisfy himself as to the precise seat of the suppuration, have, I have little doubt, been cases of suppurating ovarian cyst. The matting together of adjacent parts is, of itself, sufficient to introduce an element of confusion, and to render recognition difficult.

But there is one condition that contributes to increase this difficulty more than any other, and that is, the tendency of an ovarian cyst, when it becomes inflamed while still small enough to lie in the pelvis, to contract adhesions to the broad ligament, and, in the course of its enlargement, to draw the stretched and thickened broad ligament over it until its anterior surface is completely concealed by it as by a hood. Until an operator becomes familiar with this phenomenon the condition that presents itself to his eye and touch is exceedingly puzzling and misleading. What often happens is that, deepseated fluctuation being detected, a trocar is passed through the broad ligament into the suppurating cyst behind it, and the cyst is emptied and drained under the impression that it is a collection of pus either in the broad ligament or behind the parietal peritoneum. Operators who have had frequent occasion to open the abdomen in cases of obscure pelvic suppuration will, I feel sure, recognise the truth of this description. The proper treatment of such cases is not to tap the cyst, but, having obtained access to it by the careful and patient separation of adhesions, to enucleate it, if possible, entire, until there remain only the normal attachments, which can then be treated as a pedicle and the whole cyst removed.

With regard to the cause of the suppuration in these cysts, the evidence is strongly in favour of the view that in the great majority of cases the suppurative change in the ovary is secondary to purulent salpingitis. Of the thirty cases in which.

suppurating ovarian cysts were discovered it will be seen from the next table that active purulent salpingitis was found in thirteen and chronic salpingitis in twelve.



Directly communicating with suppurating Fallopian tube
Adherent to suppurating Fallopian tube

Adherent to inflamed Fallopian tube




Adherent to ulcerated vermiform appendix

Source of infection undetermined



The fire had

In the latter the conditions of the parts around shewed that the tubal inflammation though now chronic and comparatively quiescent had originally been acute and severe. here, as it were, died out, though in the neighbouring structures, to which the flames had extended, it was still raging. Thus 83 per cent. of the cases of suppurating ovarian cyst were associated with salpingitis If it be asked why may not the tubal disease be secondary and the ovarian primary, I reply that if that had been the case one would have expected the mucous lining of the tube to be the last part affected and the least; in other words, one would have expected evidence that the inflammation of the tube had passed from the peritoneal coat inwards rather than from the mucous coat outwards. In eight instances the suppurating tube and the suppurating ovarian cyst were, at the time of operation, in direct communication owing to ulceration of the cyst wall and perforation into the adherent tube. Whether the cystic degeneration in the ovary ever itself begins as an indirect result of inflammatory changes involving the outer coat of the ovary I cannot say; but certainly, in the majority of cases, it is much more likely that there already existed a small cyst, the contents of which became infected from the adjacent tube and underwent suppuration; and that under these circumstances the cyst grew so rapidly as to be easily mistaken for a large abscess in process of formation. Of the five remaining cases of suppurating ovarian cyst, in one the cyst had evidently become infected from a diseased vermiform appendix; whilst

in the remaining four the source of the suppuration was not discovered. It is of course possible that in these the cysts became infected from their propinquity to the rectum.

To the remaining cases of intra-pelvic suppuration enumerated in the table, I propose only to allude very briefly. The subject of tubercular disease of the uterine appendages-of which there are seven cases on the list-is one of extreme interest, but is much too large to be adequately dealt with on the present occasion. I would merely say, in passing, that when the disease is limited to these parts, or when the only other manifestation of the disease is miliary tubercle of the peritoneum, removal of the diseased appendages is not only a justifiable operation, but is frequently attended with the most satisfactory results. The female pelvis is one of the situations where we are happily able, when the condition has been discovered in time, to rid our patients of the disease before it has become a focus of general tubercular infection.

The case in which an intra-pelvic suppuration was found to be due to a diseased appendix vermiformis is, of course, one that does not properly come within my province as a gynæcologist. It happened, however, that the acute attack of peritonitis for which the patient was admitted occurred a few days after parturition, and was naturally thought to be connected with that process. As it is only under exceptional circumstances that such cases come under my care, it is obvious that my individual experience affords no guide to a correct estimate of their relative frequency.

The six cases in which the seat of the suppuration was not definitely made out occurred in the earlier part of my work, when, having not yet attained the boldness that comes of experience, I was content to empty and drain any deep-seated collection of pus in the pelvis without attempting to separate and remove the suppurating organ.


I propose to devote the remainder of the time at my disposal to a consideration of those cases in which collections of pus

within the pelvis have burst into the rectum, the genital canal, or the bladder, and in which, the opening being insufficient and the evacuation of the pus consequently incomplete, a sinus remains, through which there is a constant or intermittent purulent discharge. From amongst a number of such cases that have come under my observation I have selected for mention a single example of each of the main varieties of this form of fistula, beginning with the most common one-that, namely, which occurs as the result of the bursting of a collection of pus into the rectum.

Case 1. A woman, aged 35, who had been in good health all her life, and was entirely unaware that she had a tumour of any kind, was attended in the Maternity Department of St. Thomas's Hospital in her eighth confinement. The presentation was an occipito-posterior, and, the head was arrested above the brim. After failure with the forceps, delivery was easily effected by version. On the sixth day the temperature, which had hitherto not exceeded 99 2° F., rose to 100 2° F. The patient had no pain of any moment until the seventeenth day, when she complained of a dull aching pain in the lower part of the back and the outer part of the left thigh. There had been no rigor, or sickness, or headache, or constipation, but the patient was losing flesh; her appetite was poor; and she complained of much thirst. On the nineteenth day there was noticed for the first time some swelling in the abdomen. The temperature, which had been gradually rising for a fortnight, was now 103°. Accordingly, on the following-i.e., on the twentieth-day the patient was admitted into the hospital.

The note on admission describes her as thin, pale, and sallow. The chest sounds were normal. The abdomen was irregularly distended. The uterus reached to within three inches of the umbilicus, and was pushed forwards so as to form an obvious projection of the anterior abdominal wall. Both uterus and bladder were drawn upwards so as to lie entirely above the pubes. On deep palpation, behind and above the rounded upper margin of the uterus could be felt a swelling, imparting to the hand the sensation of a tense cyst.

On vaginal examination, a centrally-situated swelling, continuous with that felt behind the uterus in the abdomen, was found to occupy the hollow of the sacrum, distending the pouch of Douglas. The swelling was of unequal consistence, and in one part gave a sense of fluctuation. The temperature ranged from 99° F. in the morning to 101° F. in the evening. The urine was healthy.

It was thought at first that the swelling might be a hæmatocele, but when the patient had been nearly three weeks under observation, a large quantity of very foetid pus was passed by the rectum.

The temperature at once fell to normal, and next day there was a marked diminution in the size of the swelling. Pus continued to be passed with each evacuation for four days. After an interval of six days the temperature again rose and the size of the abdominal swelling became evidently increased. Next day there was a further escape of pus from the rectum, and this continued, without diminishing the temperature, for four days, when abdominal section was performed. The swelling proved to be a suppurating dermoid cyst of the right ovary. The cyst was everywhere adherent, and the process of separating and removing it was one of extreme difficulty, occupying two hours and a half. Notwithstanding the utmost care some of the fœtid contents of the cyst escaped into the abdominal cavity. The peritoneum was subsequently flushed with hot boracic acid solution and a drainage-tube was inserted at the lower angle of the incision.

The cyst contained a compact mass of hair 4 ins. by 3 ins., some pieces of bone, and, in a separate loculus, 28 fluid ounces of thick yellow fluid which solidified on cooling. A direct communication existed between the cyst and the right Fallopian tube, which was nine inches in length and greatly thickened, and was in a state of acute suppurative inflammation. The cyst had also opened by ulceration into the rectum.

Convalescence was somewhat protracted, but no pus was again seen in the evacuations, and none of the contents of the bowel

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