in those cases where it remains serous. Adhesions there are two distinct regions in which this lesion ocare thrown off between the tubes and coils of the in- curs, and which naturally give rise to two forms of testine, the omentum, the top of the uterus, broad abscess, namely, the cellular tissue of the broad ligaligaments, rectum and pelvic wall. ments and that present in the sheath of the hypogastric artery.

Sometimes the pus extends upwards into the anterior cul-de-sac and adhesions are thrown out between the pubis and the sacrum, in which case the uterus floats, so to speak, in a well of pus.

It is the inflammation of the connective tissue which is found along the vessels irrigating the pelvic organs that gives rise to abscess of the broad ligament. These vessels are the utero-ovarian artery and the lymphatics of the fundus uteri, tube and ovary. The topography of these abscesses is most interesting on account of their treatment. On their inner aspect abscesses of the broad ligament are in relation with the side of the uterus, which organ they push more or less to the op

Now the reason why the pus nearly always collects in the cul-de-sac of Douglas is explained very well by Delbet as follows: "The part of the peritoneum which is first diseased is always that which is situated behind the uterus; it becomes infected nearly always by means of the tube whose pavilion is behind the broad ligaments, nearly above the cul-de-sac of Doug-posite side, and they may even raise up the peritoneum las. When the tubes are healthy the uterus itself always contracts adhesions with the rectum on account of the disposition of the lymphatics."

When once the collection has formed, adhesions wall it off and the pressure within increases and causes Douglas's pouch to bulge into the vagina. This pocket hardly ever extends above the top of the uterus, but there are cases on record where it has extended upwards to the umbilicus, burrowing underneath the omentum, which forms a vault over it.

In the beginning the collection is serous, of a yellowish color, which is more or less tinted red by the admixture of blood, but it is always transparent. It may remain in this condition, but most always it undergoes a purulent transformation. When once pus is formed it may become absorbed when it is not present in any large amount, but in practice we should never count upon such an outcome.

on the anterior and posterior surfaces of the uterus, but only in the neighborhood of its borders. They have a tendency to extend towards the iliac fossa, where they form rounded tumors of varying size and which are perfectly independent of the abdominal wall. When once they have reached the iliac fossa they may extend in two different directions: (1) In some cases they extend upwards under the peritoneum towards the lumbar region, sometimes as far as the diaphragm; (2) in other cases the abscess descends towards the abdominal wall raising up the peritoneum in the vicinity of the ligament of Fallopius and is then in direct relation with the abdominal wall.

A typical abscess of the broad ligament does not come very near the vaginal cul-de-sac, from which it is separated by about two centimetres of tissue, in which is contained numerous vessels of fair size and sometimes the ureter. It is on account of the immediate neighborhood of these vessels that curettement of these abscesses is extremely imprudent, if not to say dangerous.

The

The pus has always a tendency to make its exit through different organs in the neighborhood, which at first ulcerate, and the intestine and more particularly the rectum are its favorite points of exit, but all In the commencement of an inflammatory process abscesses have not the same tendency to open out- there is only an edema, or serous infiltration, but little wards, and there are certain cases where they become by little the meshes of the cellular tissue become disencapsulated by neoformed membranes which line the tended by a serous liquid, which is thick and of a lemon pocket and whose walls become extremely dense; a color, and the pathologic process continuing its progmost important condition for the treatment which we ress transforms this liquid into small foci of pus. recommend, because they are rigid and almost scle-character of this pus has a very great bearing from rotic. The inflammation and induration of the sub- the point of view of treatment, and one can readily peritoneal cellular tissue contributes also to this condi- understand that an incision is more proper in a case tion, and when these cases are examined bimanually, where the pus is whitish in color and of a bland odor they feel like hard cartilaginous masses. In this case than when the collection is greenish in color and prean incision in the posterior cul-de-sac is quite insuffi-sents a fetid odor. cient, because the pocket, if it is single, will be emptied, A hypogastric abscess simply means an inflammabut its rigid and resisting walls will not collapse and tion of the cellular tissue surrounding the internal come together, and sometimes an enormous cavity is iliac artery and the lymphatics of the cervix uteri and thus formed which will prevent healing from taking the upper part of the vagina. There is little to be place. But these cases are infrequent, and what causes said regarding these abscesses excepting that they are the great danger in pelviperitonitis are the adhesions rather frequent in occurrence. The pathological prowhich are thrown off, and these are not only the cess is the same as in the case of abscess of the broad source of persistent pain, but from the malposition ligament, and only differs from the latter by its seat. that they produce in the genital organs will nearly An important fact to be mentioned, and which applies always render the patient sterile. to all purulent collections whether in the tube or the broad ligament, is that their upper wall is formed by the visceral peritoneum, which has become thickened and has lost its normal resistance, so that an irrigation made with any force whatsoever may break through it and enter the general peritoneal cavity.

When the inflammatory process has extended to the subperitoneal tissue, the damage done is so important that a vaginal incision is more than insufficient, as well as in the case of multiple collections which are composed of secondary pockets independent of the first in which the infectious organism has had its starting point.

We would now like to say a few words on the pathology of suppurative processes in the cellular tissue of the pelvis, and we would here point out that

The following five figures represent diagrammatically what could be felt by palpation in some of our cases, all of which were operated on by posterior colpotomy and made eventful recoveries. I have selected these five drawings from many others that I

In the second class of cases the lesions are exactly dition of affairs may be obtained. In cases of catarrhal the same as in the first, but they undergo their evolu- salpingitis the tubes feel like little hard, irregular tion silently. The various symptoms which later on cords, pointed at their uterine end, swollen at the will form the picture of salpingitis appear one after other. The anatomical relationship of the tubes has the other; they may be only slightly marked or they become changed and on account of the thickening may give rise to considerable trouble, but they always they have undergone they become heavy and fall appear separately. We thus get in the first place pain, down behind the uterus into Douglas's cul-de-sac. which is sometimes complained of on one side, in Cystic salpingitis feels like an oval, hard and irregular other cases it is bilateral; then disturbances in the mass which gives rise to the sensation of fluctuation menstruation arise and so the disease continues its in certain points. In all these tumors we can find a progress. Of course the division into acute cases distinct separation from the uterus and they are united and insidious cases is entirely artificial, and between to the cornua by a kind of pedicle. The uterus is the two extremes there are very numerous intermedi- pushed to the opposite side if the lesion is on one side ary conditions. only, but when the latter is bilateral the uterus is more frequently pushed forwards towards the pubis.

The first symptom is pain in the region of the adnexa, usually on both sides, but perhaps more especially on the left. It sometimes reaches a very extreme acuteness and never is present in any constant type, excepting that it is increased when the patient gets tired and usually becomes better when the patient remains quiet in the horizontal position. The pain increases sometimes a few days before menstruation occurs and diminishes after the blood makes its appearance, but in other instances I have found that it began during the flow and in infrequent cases it did not appear until after menstruation was finished.

Acute secondary pelviperitonitis is practically only a complication of acute purulent salpingitis, and is consequently preceded by the latter affection. It disappears in a few days if the patient is kept quietly in bed, but it usually leaves the adnexa more or less bound down in a mass of exudate. In the beginning there is a sharp pain in the hypogastric region, chills and temperature reaching 39° C. to 40° C., nausea and vomiting, in fact, all the signs of an ordinary acute peritonitis, but what should be remembered is that the secretion coming from the genital organs is always increased in amount. At this time fluctuation is difficult to make out, but in some cases the serum infiltrates the vaginal walls, which become thick and to which the French authorities have given the very apt term of "cardboard vagina."

Menstruation itself is nearly always disturbed, the most marked derangement being frequent and repeated periods of flowing, with the loss of considerable blood. On the other hand, amenorrhea is infrequent in these cases. The blood appears every fifteen or twenty days and the flow may last a week The serous fluid next transforms into pus and this or more, which is the cause of the anemia almost always pus becomes encysted and then all the local symptoms noted in these cases. The concomitant metritis gives become more marked, but the general symptoms unrise to a more or less purulent discharge during the dergo a decided improvement. The pelvic abscess interval between the metrorrhagias, and this leucor- is thus composed, as I have already pointed out in rhea is sometimes accompanied by pains of a colicky speaking of the pathology, and then its next move nature. It has been thought that these colics have is to make its exit. When the abscess discharges their starting point and their maximum of violence in through the rectum we have all the symptoms of an the adnexa, and that they coincide with the evacua- acute proctitis, namely, a recurrence of the fever, tion of pus, but as the internal orifice in the tube has tenesmus and a very acute dysuria. When the abin these advanced cases become obliterated by the in- scess bursts through the vagina, the fact is simply flammatory process, it is very probable that the pus known by the presence of pus coming from the genicannot make its exit, and that the uterus, which is tal canal. If the abscess pocket should burst into the always very greatly diseased, is the source of the general peritoneal cavity, a condition that my perpurulent discharge. For that matter we all have had sonal experience would lead me to believe as being cases where a severe mucopurulent discharge was extremely infrequent, it would naturally give rise to present due to an infectious metritis, but where the all the symptoms of an acute septic generalized peritubes were perfectly healthy. tonitis.

Disturbances in the digestion nearly always complicate these purulent lesions, and have a very notable influence for the worse on the patient's general condi

tion.

If the patient recovers from her first acute attack she is apt to think that she is well, because the pains have disappeared and have only left behind them a feeling of weight in the pelvis, but suddenly the acute symptoms will return, usually at about the time of menstruation, after the patient has taken cold or has become fatigued. In one or two instances in which a pain was complained of in the region of McBurney's point I was able to demonstrate at the operation that it was due to an adhesive inflammation which had arisen between the appendix and the diseased adnexa. Inspection of the abdomen usually does not show anything in particular. Vaginal examination gives a very incomplete idea of the condition present, but by bimanual palpation a very good idea of the exact con

Evacuation of pus may recur several times when the abscess has been left alone because it cannot thoroughly empty itself, and finally most rebellious fistulæ form, which may cause the patient's death by general hectic.

As regards the diagnosis of the abscess of the broad ligament, it has been pointed out that the con dition presents alternatives of increase and decrease in the size of the tumor, and it is a well-known fact that the cellular tissue of the broad ligament may be the seat of an inflammatory process which is very long in its course and difficult to cure, but which has little tendency to undergo suppuration.

All pelvic inflammatory processes have generally a chronic evolution, and the acute or subacute cases are in most instances simply a lighting up of a latent focus. A pyosalpinx, after having produced very acute symptoms, may continue its evolution insidiously, only giving rise to pain and disturbances of

menstruation up to the time when a perimetritis develops and then a pelvic collection is formed. If it undergoes an intraperitoneal rupture the prognosis is always bad, but the pocket may open into no matter what organ situated in the neighborhood, and one or more fistulæ are formed. An abscess of the broad ligament may undergo resolution, but usually the suppurative process continues and the pocket may open into the vagina, the rectum, rarely through the abdominal wall and still more infrequently into the uterus or bladder. After the pus has been voided the symptoms improve, but the collection will surely reform sooner or later and, as in the case of pyosalpinx, fistula formation will result.

After its sudden commencement and high elevation of the temperature a pelviperitonitis will either pass on to the chronic state, or the liquid collection will become absorbed or be evacuated into another organ. In the puerperal form of pelvic suppuration the prognosis is extremely serious.

ing table, one in which an exaggerated Trendelenburg position can be obtained when the patient is in the lithotomy position, and a table that fulfils this to perfection and which is remarkable by its great strength and perfect simplicity is the one invented by Pryor, of New York. This table has given me entire satisfaction, and it is particularly useful in house-to-house operating, as it can be folded up into very fairly small dimensions.

After having seized the cervix with the two strong tenaculum forceps, one retractor is placed on the posterior vaginal wall, and the cervix is drawn upwards towards the pubis until it cannot be drawn any farther by a gentle traction. With the stout curved scissors a transverse incision varying from four to six centimetres in length is made in the vaginal mucous membrane at the point where it joins the cervix. The mucosa should be boldly cut through with one cut of the scissors, and then introducing the finger through the incision the adhesions are rapidly broken down, the peritoneum is felt, and then guiding the scissors along the finger introduced into the wound the surgeon incises the peritoneum, keeping close to the posterior aspect of the uterus. In very pronounced cases the purulent collection may project so distinctly into the cul-de-sac that the abscess pocket is opened at the same time that the incision into the mucous membrane able hemorrhage may arise from the vaginal incision, and if it is very considerable I think it is better to immediately ligate the vessel or vessels giving rise to the blood before proceeding, because in one case recently operated on quite a serious post-operative hemorrhage ensued, which was only arrested after considerable difficulty. I will say, however, that this case was simply the removal of the adnexa through the vagina, and not a pus case, and that the clamps placed upon the ovarian artery held well and the pedicle was carefully inspected and no oozing came from it, and after considerable trouble the bleeding point was located in the right-hand angle of the vaginal incision. This is, however, the only case where the vaginal arteries have ever given me any trouble. After the sac has been incised the pus flows out freely,. and then the cavity should be explored with the finger in order to ascertain if other pockets exist, and if so they should be broken down and emptied. On several occasions I have found large pus tubes on both

An experience of more than six years in vaginal work has demonstrated to me the fact that posterior colpotomy is a very innocent operation and in the highest degree conservative. It may be performed not only in cases of acute purulent lesions in the pelvis where it would be imprudent, not to say dangerous, to perform laparotomy or vaginal hysterectomy, and also in cases of chronic purulent pelvic lesions. Pos- is made. I would here say that occasionally considerterior colpotomy should, in my opinion, be preferred to laparotomy or vaginal hysterectomy in every case where the patient is a young woman, when it is the duty of the surgeon to preserve the adnexa at any cost, and I know of patients who have had their pelves full of pus which was removed by vaginal incision and who afterwards became mothers. This conservative operation in no way compromises the result if any more radical operation should be deemed necessary later on, and I have never seen a fistula follow in any of my patients, whose number is already fairly considerable. To sum up, I may say before describing the technique and indications and contraindications of the operation, that every suppurating pelvic collection that is accessible by Douglas's cul-de-sac is suited for posterior colpotomy and drainage, the technique of which I will now describe.

In practice the operation may be considered in most cases one of emergency, and consequently no very elaborate preparations can be made, but if one has a day or two at his disposal the ordinary prep-sides present, and in these cases, having made sure by aration as used in any abdominal operation should be employed, and particular care should be given to completely empty the intestines.

digital examination that the general peritoneal cavity was protected by the formation of adhesions, I have opened these pockets with the scissors and inserted a large drainage tube in each tube with very happy results.

The instruments necessary are few and simple. Two ordinary hysterectomy valves, a few artery forceps, two stout tenaculum forceps, a long and stout After the pocket or pockets have been thoroughly pair of curved scissors, two large glass or rubber evacuated the cavity is carefully irrigated with a drainage tubes and an irrigator are all that are neces-1-2,000 solution of cyanide of mercury or a 1-3,000 sary. To operate easily in the vagina depends solution of citrate of silver. entirely upon the valves used and none have given If the pocket is very small, a wick of iqdoform me such perfect satisfaction both in simplicity and effectiveness as those devised by Segond, of Paris. We believe that the operators who speak of the vaginal route as a blind method do so because their vaginal retractors are improperly constructed and are insufficient, and it is for this reason that I have insisted on this point.

Another thing that is essential in vaginal work, in order to do it properly, is the right kind of an operat

gauze may be sufficient, but it is better practice to obtain a free drainage and for this purpose two glass. drainage tubes or two red rubber drains should be introduced well up into the cavity. The vagina is next carefully packed with gauze, and an ordinary aseptic dressing is placed over the vulva and held in place by a T bandage. The next day the pocket is carefully cleaned out with peroxide injected into one drainage tube, and after a couple of days the vaginal packing

is removed and renewed. As the pocket retracts it forces the tubes downward and after a few days usually they may be changed for ones of smaller calibre. Posterior colpotomy has been more particularly advised in cases of pelvic suppuration and the so-called retro-uterine hematocele. This latter condition does not come into the province of this paper, but I would like to say one or two things regarding its treatment by the vaginal incision. As we all know, hematocele is due to the rupture of an ectopic gestation in a large majority of cases, and when it results in a large collection of blood and all evidences of hemorrhage have ceased, posterior colpotomy is, in our opinion, by far the better method to adopt under these circumstances. Laparotomy is always a very serious operation when dealing with a hematocele, and is always attended by many difficulties, and posterior colpotomy should be preferred to the abdominal route because it is a more simple operation, far less dangerous, and just as efficacious if not more so than the abdominal incision. In cases of hematocele the adnexa can be explored with as much ease through the vaginal incision as through the abdomen and they can be removed with just as much ease through the vagina if it is deemed necessary to do so. We believe that there is less liability of infecting the cavity after the blood has been removed when posterior colpotomy is done, because we get a natural and easy drainage and it can be treated more directly than through the abdomen.

in the vagina, posterior colpotomy is contraindicated and abdominal section should be resorted to. When the purulent collection is very large and surrounds the uterus, so that it floats, so to speak, in pus, vaginal incision is proper, but on account of the multiplicity of the pockets vaginal hysterectomy will have to be resorted to, because in most instances drainage would not be sufficient.

In this latter class of case it is practically useless to endeavor to preserve the tubes and ovaries, because the pus and false membranes which completely surround these organs will progressively give rise to their destruction.

When we are dealing with an acute suppurating salpingitis or a puerperal pelviperitonitis, the serious general condition of the patient demands the evacuation of the pus by posterior colpotomy, because laparotomy and hysterectomy are particularly grave under these conditions.

In cases of acute gonorrheal salpingitis or pelviperitonitis the general condition of the patient will be the guide which will dictate to the surgeon how he should act, but generally speaking, a large number of these cases will recover perfectly after the pus has been evacuated through the vagina unless the pocket has become secondarily invaded by the streptococcus or the staphylococcus. Abscess of the broad ligament is subject to the same treatment.

In closing this paper I would say that posterior Posterior colpotomy may also be used as a prepara- colpotomy is, in my opinion, a justifiable procedure in tory step towards vaginal or abdominal hysterectomy, a large majority of cases, and, like everything else in and after the purulent pockets have been emptied surgery, if we can cure a patient by a simple opand drained they diminish in size, the patient's generation, that is the one to be selected. I have endeaveral septic condition can be improved, and then if total ored to point out that the operation in question will hysterectomy is deemed necessary, it can be done not cure every case any more than will any other under far more advantageous conditions. one operation, but it certainly has a vast field of use

In principle, all cases of pelvic suppuration should fulness and in many cases a patient will be left with be treated by incision and drainage, and this having all her organs of generation in a very fair state of been said we should examine more closely what should health, and we should always endeavor not to sacribe our conduct in the presence of primary or second-fice these organs whenever the condition justifies. ary pelvic suppuration, be it either acute or chronic. In those cases where the purulent collection is localized within the pelvis and when it is not composed of a large number of pockets, posterior colpotomy is proper. On the other hand, when dealing with those cases where the purulent collection is so divided into minute cavities that the mass forms a sponge full of pus, so to speak, colpotomy is insufficient and vaginal hysterectomy is, in our way of thinking, the proper operation to select.

PARTURITION COMPLICATED WITH SUPPU

RATING FIBROIDS.1

BY E. H. STEVENS, M.D., CAMBRIDGE, MASS.

WHEN I accepted your secretary's kind invitation to present a case of suppurating uterine fibroid complicating pregnancy, with an operation, I expected to be able to refer to other cases of a similar nature which had been reported. With the limited time at my disposal for looking over files of medical journals and books of reference, I have been unable to find a single case. I presume there are many such cases which have escaped my attention. I hope some one will be able to refer me to such reports. Such cases must be relatively rare and therefore all the more in

In doubtful cases vaginal incision can be performed, the parts can be explored and will be no detriment to the performance of vaginal hysterectomy if necessary. When we are dealing with a peri-uterine collection which projects into the posterior cul-de-sac, vaginal incision is indicated. Even in those cases where a very prolonged inflammatory process has been present and has changed the walls of the pocket so that they have become sclerous and adherent, vaginal col-teresting. potomy may be indicated, provided that the pocket is a small one. Every time that the collection is situated high up in the pelvis, but is accessible to the finger in the vagina, the vaginal incision is indicated. When there are several pockets they may all be opened one into the other through the vaginal incision.

The case which I shall report to-night occurred in my practice in 1897. It has seemed to me of sufficient interest to warrant my bringing it to the notice of this society. In looking over the records of my obstetric cases (something over 2,200), I find mention of 18 cases where uterine fibroids complicated labor. In all of these cases the mother recovered. In only

In those cases where the collection is situated high up in the pelvis and cannot be reached by the finger stetrics and Diseases of Women, February 28, 1900.

1 Read before the Suffolk District Medical Society, Section for Ob