the cervix uteri, resulting in a fistula in that situation. I published the case in full in a paper in the 17th volume of the St. Thomas's Hospital Reports, and shall here merely give an abstract of it.

Case 3 A married woman, aged 36, was admitted into hospital nineteen weeks after her fourth confinement Her first three labours had been natural the last one had been very difficult, delivery having been accomplished by the use of forceps, and then only after prolonged effort. She became feverish soon afterwards, and had much vomiting. The lochia were arrested. A fortnight after the labour a purulent discharge took place from the vagina. This went on for a few days, when, the flow not being very free, an opening felt on making a vaginal examination was enlarged by the medical attendant. The purulent discharge continued for thirteen weeks, gradually diminishing in quantity. It then suddenly became more profuse and very offensive, and the opening was again enlarged. Not long after this a quantity of horribly offensive pultaceous material passed, together with a quantity of hair three or four inches in length. This offensive discharge went on up to the time of her admission. The patient had endeavoured to occupy herself in the house, but found that she was becoming thinner and weaker, and that she was never safe from a sudden outburst of ill-smelling discharge. An abdominal swelling had been noticed for the first time about six weeks after the confinement.

On admission the patient, who was sent in as a case of pelvic cellulitis, was pale, wasted, and very ill. She had a rounded tumour in the right iliac region, reaching to the level of the umbilicus. The posterior fornix of the vagina was obliterated; the finger on entering the vagina passed directly into the cervix uteri. On the inner and posterior wall of the cervix could be felt a lacerated depression, such as would be caused by the passage of a moderate-sized trocar. No opening was discoverable in the vaginal wall. There was a hard rounded mass in Douglas's pouch, depressing the vaginal roof.

On opening the abdomen the swelling proved, of course, to

be a suppurating dermoid of the ovary. The tumour was carefully and with much difficulty detached all round, a quantity of highly offensive pus flowing from the vagina during the manipulation. Before separating the adhesions in the neighbourhood of the perforation, the pedicle was divided, in order that the tumour might, after separation, be lifted quickly out, and the inevitable soiling of the pelvis from the escape of the cyst contents reduced to a minimum. As the tumour was removed a gush of highly offensive gas escaped with a distinct whiz. The peritoneal cavity was repeatedly douched, and after the abdomen had been closed and the patient had rallied a little the vagina was thoroughly douched with hot boracic lotion.

The convalescence was somewhat delayed by suppuration in the pelvis, but the patient was able to sit up in bed in three weeks, and at the end of six weeks she left the hospital well. Five weeks later she presented herself looking remarkably well.

This case, like the first, is an instance of suppurative inflammation of an unsuspected ovarian cyst, closely following a difficult labour. It is easy to understand how readily the true nature of such a case may be overlooked. The probability is that, in this latter case, some laceration of the posterior wall of the cervix took place during delivery, opening up a channel by which septic infection could easily reach the tumour, which had no doubt been rendered specially susceptible owing to the bruising it had recently undergone.

The next and last case that I shall relate is to my mind the most interesting of all. It was sent into the hospital as a case of pelvic cellulitis following influenza and complicated with abscess which had burst into the bladder.

Case 4. The patient, a woman aged 32, had been married nine years but had never been pregnant. She had had an attack of inflammation in the right side of the lower part of the abdomen three years previously, the attack having been preceded for a few days by a yellow vaginal discharge After this she had remained well until six months before her admission, when she had what was supposed to be an attack of influenza, with

shivering and perspiration but no pain. She kept her bed for a fortnight and then went into the country. Whilst there, she noticed some thick yellow matter in the urine, which had continued to appear ever since, that is, for a period of five months, the daily quantity being estimated by the medical attendant to average about half a fluid ounce. There had been frequency of micturition but no dysuria. The general health had been but little affected. Menstruation had been regular. She had suffered pain from time to time in the right iliac region, but this had never been very severe.

On examination under anesthesia, the uterus was found of normal length, the canal directed to the left. On the right side of the pelvis a large, hard, uneven, roughly globular mass was felt, depressing the vaginal roof and extending upwards to the level of the anterior superior iliac spine, A sound introduced into the bladder was prevented by the swelling from passing beyond a very short distance in the middle line, but passed easily to right and to left of it posteriorly. The urine contained a varying quantity of pus.

It was evident that there was chronic suppuration of the uterine appendages (probably, from the size of the swelling, of both tube and ovary), and that there was a sinus communicating with the bladder. I had not yet had occasion to operate upon a case of this kind, and although I saw no other satisfactory way of dealing with it, I undertook the operation with considerable misgiving.

However, on the 8th of December of last year I opened the abdoinen. After separating and drawing aside the omentum, which completely concealed the contents of the pelvis, the mass was easily seen occupying the right and central portions of the pelvis, deep down. It was covered by peritoneum, and there did not for some time seem to be any possibility of finding a break in the apparent continuity of the covering of the mass with the peritoneum of the pelvic walls. At length it was found possible to insinuate a finger behind and to the right of the uterus, and so to commence the work of separation. The

thickened right broad ligament had been drawn over the anterior surface of the diseased parts, and dipped down superiorly where it was adherent to omentum and pelvic wall. These adhesions having been separated, access was obtained to the mass beneath, and, with the fingers of an assistant in the rectum to serve as guide, separation was slowly and carefully effected. The mass, when removed, proved to consist of the inflamed right Fallopian tube and a suppurating cystic ovary three inches in diameter. The firmest adhesion was in the neighbourhood of the fimbriated end of the tube. When this was separated, a quantity of soft inflammatory débris was set free. The tube was dilated, and its mucous membrane congested and œdematous. No pus was present in its canal. The ovary was removed without rupture. Its surface was convoluted like that of a tomato, On its under surface was a small opening, from which blood-stained purulent fluid oozed on pressure, and which probably represented the aperture of communication with the bladder. On section, it was shewn to contain two separate cysts, each of them filled with purulent fluid of a brick-red colour, and without ill-odour. One of the cysts was surrounded by indurated tissue in. thick. The bladder was deep down, quite out of sight and out of reach, so that any attempt to close the opening in its wall was entirely out of the question. No urine escaped, and very little pus appeared to have exuded into the pelvis during the operation. It was thought prudent, however, to wash out the pelvis well with hot boracic solution. The uterus had by this time moved to its normal position in the middle line, and perched on the fundus was the normal and adherent left ovary. The left tube was adherent but apparently free from disease. On passing a catheter, a drachm or two of blood-stained purulent fluid escaped from the bladder. A drainage-tube having been inserted, the incision was now closed.

The urine drawn off up to midnight contained pus and blood. The bladder was at first emptied by catheter every two hours to prevent distension. Next day the interval was prolonged to

three hours, and on the fourth day to four hours. The discharge through the drainage tube at the first dressing was turbid, and contained leucocytes. It then became chiefly serous; but later it again became purulent, though never urinous. There was some cystitis, with alkaline urine, from the fourth to the tenth day, when the urine became natural. The patient was able to sit up on the sixteenth day, and left the hospital looking stout and well at the end of two months. Notwithstanding that the general condition was excellent, there continued to be a little suppuration from the lower angle of the wound for six months, when the sinus finally closed. The patient has presented herself since from time to time, and when I last saw her, a month ago, she was in perfect health, and menstruating regularly.

I have narrated these cases with two objects specially in view. The first was to shew that when pelvic suppuration is complicated by internal fistulæ, the suppuration is not cellulitic however much it may simulate it, but is due to intra-pelvic disease that can only be properly dealt with by abdominal section. The second object I had in my mind was to shew the feasibility, even in the most unpromising cases, of complete removal of the disease, and to urge the superiority of that method of treatment over the mere emptying and draining of the suppurating cavity and the stitching of the edges of the sac to the abdominal incision.

I am painfully conscious that in offering the foregoing remarks to my professional brethren in Birmingham and the Midlands, I am addressing many who have had a far larger experience than I in the treatment of the diseases to which they refer, and before whom it would be much more fitting that I should appear in the capacity of learner than of teacher. Nevertheless I trust they will appreciate my effort to prove to them that the example they have set, in endeavouring in spite of much opposition to advance the department of medicine with which I am more especially identified, has not been altogether lost even upon the benighted Londoner.

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