CHRONIC PELVIC ABSCESS. 
A CONTRIBUTION TO THE DIFFERENTIAL DIAGNOSIS 
OF ABDOMINAL TUMORS. 
E-ST .A.. T'. EEICH, ID., \ 
Professor of Diseases of Women, College of Physicians and Surgeons, Baltimore'pfrurgcon'~fh 
charge of the Maryland Woman’s Plospital, etc. 
{Read at the Clinical Society of Maryland). 
There is probably no branch of prac- 
tical surgery which presents to the prac- 
titioner so many difficulties as the differ- 
ential diagnosis of tumors in the abdom- 
inal and pelvic cavities. Although the 
literature of gynecological surgery can 
show a considerable number of individual 
cases bearing upon this subject, no def- 
inite rules can as yet be laid down for 
our guidance. In fact, in most of the 
cases reported mistakes had been made 
in the diagnosis, and they were made 
public by the writers with the object of 
warning others against similar errors. 
With a like view I desire to report the 
following cases, trusting that the import- 
ance of the subject, and the unsatisfac- 
tory manner in which it is treated by 
systematic writers, may be sufficient ex- 
cuse for occupying your time with the 
details. I am convinced that a recollec- 
tion of the errors made by ourselves or 
others will be of more value, when at 
any time we shall be confronted with a 
difficult case, than the remembrance of a 
dozen successes. Of course to appreciate 
the relative value of different factors in the 
problem, and to arrive at its correct solu- 
tion,other qualities than mere memory are 
needed; or, as Matthews Duncan puts it: 
“For a good diagnosis there are wanted 
common sense, a knowledge of and ex- 
perience in disease, and a watchfulness 
against already known sources of error.” 
Assuming the possession of the first two 
of these elements of success on your 
part I shall endeavor to increase the 
“ known sources of error” by the follow- 
ing cases: 
Case i.—April 20, 1876. Mrs. R. 
C.; white; American; aged 43 years. 
Menstruation began at 15 years, and has 
always remained regular. She was mar- 
ried in her 16th year, and had three 
children, the last one 16 years ago. She 
was a large, well-nourished woman, who 
had always led an active life up to the 
time of beginning of the illness for which 
she sought advice. 
During a period of nearly four years 
she had complained of severe paroxys- 
mal pains in the left pelvic region, lasting 
one or tvyo days. These attacks were 2 
frequently accompanied by nausea and 
vomiting. A vaginal examination made 
a year and ten months previous to the. 
above date, revealed an irregular, hard 
nodular tumor ig the Peft iliac region and 
somewhat posteriorly. There was no 
fever. In view of the symptoms and the 
results of the physical examination, a 
probable diagnosis of cancer was ven- 
tured. Dr. Alan P, Smith, who saw the 
consultation, also agreed as to 
the probability of the tumor being can 
cerous. As in consequence of this diag- 
nosis there was no hope of complete 
relief, palliative treatment alone was or- 
dered. A year and a half after the pa- 
tient first came under treatment, and 
three and a half years after her illness, 
she was again examined in company with 
Dr. James R. Chadwick, of Boston, who 
was then in the city. The conditions 
noted at this examination were entirely 
different from those observed eighteen 
months before. The tumor, which form- 
erly occupied the left postero lateral 
region of the pelvis had entirely disap- 
peared, and a firm, round, movable 
tumor, about the size of an adult head, 
was found occupying the hypogastric 
region. The most prominent portion of 
the tumor was in the middle line and 
reached somewhat above the umbilicus. 
The tumor was regarded by Dr. Chad- 
wick as a fibroid, and the change of posi- 
tion explained by supposing the fibroid 
when small to have been embedded 
in inflammatory exudation, on the ab- 
sorption of which it became movable 
and changed its position as already in- 
dicated. During the interval since her 
former treatment the patient’s health had 
very much improved, and she had gained 
in flesh and color. She still suffered 
from paroxysms of severe pain at inter- 
vals, and as the tumor, from its size, gave 
her considerable discomfort by pressure 
on surrounding organs, she begged that 
an operation might be performed to give 
her relief. With the advice and con- 
currence of Dr. Chadwick, the removal 
of the supposed fibroid by laparotomy 
was decided upon. The operation was 
done some two months later in the 
presence of a number of physicians of 
this city. Upon making an incision in 
the median line, the tumor was readily 
brought into view. There were no peri- 
tonitic adhesions. After the tumor was 
exposed, slight fluctuation could be made 
out. An explorative puncture was made 
with a hypodermic syringe, which yielded 
pure pus. -A trocar was then introduced 
aTid a large quantity of pure pus drawn 
off. The cyst walls were thick and 
fibrous, and were adherent to the left 
side and floor of the pelvis and left side 
of the uterus. An India-rubber drain- 
age tube was passed from the abdominal 
wound through the abdominal cavity, 
cyst and Douglas’s cul de sac, into the 
vagina. The wound was then closed, 
retaining one end of the drainage tube 
at its lower border. A constant stream 
of carbolised water was allowed to flow 
through the drainage tube slowly from a 
reservoir placed alongside of the bed 
and slightly above the level ol the body. 
The patient died on the fifth day, of 
septicaemia. 
On post-mortem examination it was 
found that the enlargement consisted of 
an abscess, which had evidently com- 
menced in the left iliac region, extending 
between the folds of the left broad liga- 
ment and so forming a large cyst. The 
uterus was pushed forwards against the 
symphysis pubis and slightly to the right 
side. The cyst-walls consisted of peri- 
toneum, condensed connective tissue and 
inflammatory exudation. The walls 
were not of uniform thickness, but ap- 
peared thinned in spots as if some of 
the layers of the cyst-wall had yielded at 
these points to the distending pressure 
from within. 
The drainage tube failed in its intended 
functions entirely. It soon became sur- 
rounded by inflammatory exuda'ion and 
adhesions between the intestines and peri- 
toneum. The tube was thus completely 
isolated and the antiseptic fluid prevented 
from escaping into the peritoneal cavity. 
The flowing out of septic fluids from the 
abdominal cavity through the drainage 
tube was likewise prevented by these 
conditions. 
This case teaches that fluctuation can- 
not always be made out, even when a 
large amount of fluid is present. It may 
be masked by the distention, the thick- 
ness of the cyst-wall, or an excessive 
deposit of fat in the abdominal walls. 
In considering the case in all its bearings 
I was compelled to acknowledge an 3 
error of omission in not making an 
exploratory puncture before resorting to 
laparotomy. I have since then deter- 
mined never to pronounce an abdominal 
tumor solid until after aspiration. 
Case 2.—May 5, 1877. E. B., single; 
aged 25 ; white ; American ; seamstress. 
Menstruation commenced at the age of 
17 and was regular and painless up to 
sixteen months ago. Since then it had 
become irregular and painful. Has had 
considerable leucorrhoea. Appetite and 
digestion are good No pain on loco- 
motion, micturition or delecation. The 
case was seen in consultation with the late 
Prof. T. R. Brown, who had diagnosti- 
cated a solid uterine fibroid. The uterus 
could not be isolated from the tumor 
which extended nearly to the umbilicus 
and conveyed the impression of a large 
interstitial fibroid. There were some of 
the constitutional symptoms indicating 
suppuration, but no fluctuation could be 
detected in any part of the growth. The 
patient was unmarried, had never been 
pregnant, and had undergone no opera- 
tion upon the uterus. There was con- 
sequently no reason to suspect pelvic 
cellulitis or abscess. In accordance, 
however, with the determination before 
expressed, never to pronounce positively 
on the nature of any abdominal tumor 
without an exploratory puncture, an 
aspirator needle was introduced, and to 
the surprise of Dr. Brown and myself, 
upwards of a pint of pure pus was with- 
drawn. The patient then passed out of 
my hands, but opportunity was given a 
year later for another examination which 
showed that the tumor was no longer 
round and hard. It had become soft, 
much larger, and fluctuation was very 
distinct. There was evidently a cavity 
containing fluid distinct from the abdom- 
inal cavity. 1 have since been informed 
that the patient had entirely recovered. 
Case 3.—March 4, 1880. Mrs. K, 
aged 33 years; married; born in Ger- 
many and leading an active life. Men- 
struation began in her eighteenth year, 
recurring every three weeks and gener- 
ally profuse in quantity. Digestion 
moderately good and action of bowels 
regular. Has been married since her 
21st year, has had five children, and no 
abortions. Her last pregnancy termin- 
ated four months ago. She was sent to 
me by a professional friend who had 
made a probable diagnosis of ovarian 
tumor. 
The patient’s appearance was emaci- 
ated and anemic. Her tongue was coated 
and appetite somewhat impaired, but 
there was no fever. The lower part of 
the abdomen was occupied by an en- 
largement in the middle line which pre- 
sented all the indications of a cyst. Per 
vaginam the tumor could be made out as 
an elastic swelling in the roof of the vagina 
and behind the uterus which was pushed 
forward. No induration could be de- 
tected by the vaginal examination, al- 
though it was carefully searched for ; the 
rapid growth of the tumor and its 
appearance after parturition having raised 
a suspicion of pelvic abscess. The ab- 
sence of lever, however, and the fact that 
all induration was wanting in the vaginal 
roof lor so short a period after confine- 
ment seemed to exclude pelvic cellulitis 
and abscess. The diagnosis of ovarian 
cyst was therefore provisionally endorsed 
and the patient made preparations to 
enter the Maryland Woman’s Hospital 
lor operation. Preparatory to this a 
tonic of iron, quinine and strychnia, was 
ordered, together with a mercurial purge. 
Two weeks later she entered the hospital, 
but with a marked change in symptoms. 
The purgative had produced a decided 
diarrhoea, the discharge being profuse 
and very offensive. She was now also 
markedly hectic, the fever being high 
and regular in its evening exacerbations. 
The tumor was reduced to one-hall its 
former size, and its upper portion was 
resonant under percussion. It was be- 
lieved that the cyst had ruptured into 
the intestine and that its contents had 
been partly discharged and the re- 
mainder undergone suppuration and 
decomposition. It was decided to as- 
pirate the tumor at once in order to 
remove its remaining contents which 
were evidently the cause of the fever. 
A quantity of exceedingly offensive pus 
and gas was drawn off, after which the 
symptoms somewhat improved. In a 
few days the cyst again filled. With the 
aspirator the cavity was again emptied of 
very fetid pus, and then washed out 
some twelve or fifteen times with carbo- 
lised water until all fetor had dis- 
appeared. The water was injected in 4 
sufficient quantities to fully distend the 
cavity each time, in order to remove all 
the pus it might contain. Five days 
later the cavity again filled, with a recur- 
rence of the fever and symptoms of the 
typhoid condition. No adhesions could 
be made out between the cyst and the an- 
terior abdominal wall. It had become 
evident that the tumor was a pelvic ab- 
scess, and that constant drainage of the 
cavity was necessary in order to obtain a 
cure. A larger aspirator-trocar was now 
introduced and the canula allowed to 
remain after the pus had been evacuated. 
The cavity was distended once a day by 
carbolised water which flowed through 
the canula from a rubber tube leading 
to a reservoir above the bed. In the in- 
tervals constant drainage was kept up 
by a syphon arrangement which pre- 
vented the entrance of air into the cyst. 
At the end of five days the cavity 
was completely obliterated. No more 
fluid could be injected, and nothing 
drained away through the tube. The 
canula was then removed, and the punc- 
ture dressed with carbolised oil. In a 
short time the patient had completely 
recovered, and she is now again pregnant. 
In order to show that I am not alone, 
but in very good company in making 
the diagnostic errors in the cases here 
reported, I shall give abstracts of a few 
cases presenting similar difficulties, which 
have occurred to some of the most 
eminent surgeons and gynecologists. In 
these cases abdominal tumors, which 
were afterwards shown to be pelvic ab- 
scesses, have been mistaken for preg- 
nancy, fibroid tumors of the uterus and 
ovarian cysts. To mistake any abdom- 
inal growth for normal pregnancy, espec- 
ially if the patient can be kept some 
time under observation, seems to me 
only an evidence of carelessness on the 
part of the observer, and I have no 
doubt that with an increase in our knowl- 
edge of the clinical history and relations 
of abdominal and pelvic new-formations, 
whether solid or cystic, the differentia- 
tion between them will become in time 
easy and certain. 
D. Warren Brickell reports the fol- 
lowing case (Am. Journ. Med. Sci., 
April, 1877, p. 363): In September 
1873, was called to see a woman and 
give an opinion as to the existence of 
pregnancy. The history was as follows : 
“ In the previous spring she had gotten 
quite wet on the street during the exist- 
ence of the catamenia, and was, within 
a few hours, the subject of arrest of the 
function, accompanied with pain and 
fever. She treated herself several days, 
but growing worse called in a physician. 
He treated her during a month or more 
for malarial fever, and when she called 
attention to a tumor in the pelvis, he 
pronounced her pregnant. As soon as 
she was able to travel he ordered her to 
the Virginia Springs. At the springs 
she remained for a month, and although 
she improved in general health, the tu- 
mor grew steadily. On reaching New 
York she sought the advice of a mid- 
wife, who told her she was pregnant; 
then she called in a physician of stand- 
ing, who corroborated the opinion. Ex- 
ternal examination revealed a perfectly 
central tumor, somewhat pear-shaped, 
with the larger end upwards, and fully 
the size of a five month’s pregnant 
womb. It was rather tender to the 
touch and lacked the elasticity of the 
pregnant womb. Auscultation revealed 
no heart-sounds or placental souffle. 
The touch, per vaginam, revealed the 
small unimpregnated uterus high up, and 
pushed over to the left. The sound, 
applied through the speculum, proved 
the depth of the organ to be normal, and 
in all respects it seemed to be in a healthy 
condition. The tumor was readily felt 
in every direction per vaginam. It 
could be caught readily between the ex- 
ternal and internal hands, and there was 
a good deal of mobility.” 
Dr. Brickell states that he promptly 
told the patient he had no doubt the 
supposed pregnant womb was simply a 
collection of pus. As the patient was 
obliged to leave immediately for New 
Orleans, she was advised to consult the 
late Dr. Choppin on her arrival. After 
some time she sent for him to attend her 
in what she still believed her approach- 
ing confinement. After an examination 
Dr. Choppin told her that she was not 
pregnant but that he was inclined to 
suspect fibroid. Some time afterwards 
the tumor burst into the rectum dis- 
charging large quantities of pus; later 
discharge of pus also took place through 
the bladder. 5 
In this case two physicians and a mid- 
wife had diagnosticated pregnancy, one 
suspected fibroid, and the reporter the 
true condition. 
• Emmet gives the details of a case* in 
which a fibroid tumor of the posterior 
wall of the uterus was diagnosticated by 
two skilled physicians of New York. 
Dr. Emmet found a cystocele, present- 
ing at tbe labia, and due to the crowding 
forward of the enlarged uterus. What 
seemed to be a large nodulated fibroid 
tumor was found on its posterior wall. 
On elevating the cervix on the point of 
the fingers and tilting the fundus forward 
against the pubis, the tumor was made 
evident to several gentlemen present at 
the examination. The facility with 
which the size and relation of the tumor 
to the uterus could be accurately mapped 
out through the abdominal wall was 
shown by Dr. Emmet 
Three weeks after the patient entered 
the hospital she was operated for the 
cystocele The operation was suc- 
cessful, the sutured lines being per- 
fect except about half an inch near 
the neck of the bladder where a 
few sutures had torn out. Seven weeks 
later the small opening left was closed by 
four sutures. Two days afterward the 
patient had an exceedingly offensive 
movement of the bowels. “ Shortly 
afterwards,” continues Dr. Emmett, “the 
expression of the patient’s face indicated 
that some trouble was brewing, but there 
was no special symptom to indicate what 
it was. The pulse was 95 per minute, 
the skin and tongue in a normal condi- 
tion, and the abdomen free from tender- 
ness on pressure.” 
“ No change took place until five 
o’clock the following afternoon, when 
suddenly she had two copious fetid 
evacuations per rectum. The pulse rose 
rapidly to 170, the tongue became dry, 
tbe body covered with a clammy sweat, 
and she sank into a profound collapse.” 
She died the following evening. 
The post-mortem examination proved 
the supposed fibrous tumor to have been 
a large abscess, with several smaller 
ones communicating with it, between the 
peritoneum and uterus, which had rup- 
tured into the rectum. The abscesses 
were encysted within a common sac and 
free from adhesions above, except at 
one point, to a portion of the small in- 
testines. The other adhesions extended 
along the bottom of the cul-de-sac, from 
the uterus to the rectum. Some thicken- 
ing of the left broad ligament was lound. 
Dr Emmet, in commenting on the 
case, says,* “I fear that [ would be liable 
to fall into error in any similar case not 
presenting a previous history more to 
the point, and where the patient was in 
good health, the uterus being somewhat 
enlarged and menstruation more profuse 
than natural. The absence of fluctuation 
was due to the density of the cyst, while 
the mobility of the uterus, the mass in 
connection with it, and its nodulated 
surface added greatly to the perplexity.” 
Dr. Emmet concluded, after an examina- 
tion of the specimen, that the abscess 
was primary, and not the result of the 
breaking down of the fibroid tumor 
Rheinstadter, of Cologne, reports a 
case (Archiv f. Gynaekologie, Bd. 14, p. 
501) in which an encapsulated perimetri- 
tic abscess, lasting for several years, had 
been mistaken for ovarian tumor by 
several competent gynecologists. The 
tumor was globular, originating in the 
pelvic cavity and reaching to the umbil- 
icus. The uterus could not be isolated; 
the sound entered in the normal direc- 
tion to the usual depth. The clinical 
history was that of recurrent perimetri- 
tis. Very little pain on palpation, ex- 
cept at one point in the left groin where 
the abscess pointed. Incision and drain- 
age; spontaneous opening of abscess into 
the vagina. On the following day an 
attempt was made to connect the two 
openings for the purpose of through 
drainage, but this was found impossible. 
Three months subsequently, patient is 
entirely well; tumor entirely disappeared. 
Dr. Alfred C. Post (N. Y Med. Ga- 
zette, Nov. 27, 1881, p. 672) reported 
the following case during a discussion on 
obscure pelvic tumors before the New 
York Academy of Medicine : A woman, 
aged 60, was admitted to the Presbyte- 
rian Hospital with a large abdominal tu- 
mor, which, on examination, was found 
to be half firm, very hard and globular, 
* Principles and Practice of Gynecology, 2nd 
edition, p. 275. 
* lb. p. 277. 6 
while the other half fluctuated. The 
conclusion was arrived at that it was a 
fibro-cystic tumor. It was aspirated, and 
about seven pints of fluid containing pus 
was evacuated. It is very probable that 
this was likewise a case of pelvic abscess. 
Schlesinger, quoted by Bandl (Hand- 
buck der Frauenkrankheiten, Red. von 
Billroth, V Abschn., p. 133) relates the 
case of a woman aged 37, who died in 
one of the Vienna hospitals of cancer of 
the uterus. Her symptoms had begun 
nine months previously. The patient 
was emaciated and anemic Her abdo- 
men was distended on the right side by 
a tense tumor, extending from the sym- 
physis pubis to the arch of the ribs. On 
palpation the tumor seemed to be com- 
posed of large lobules; it was painful 
and immovable and dull on percus- 
sion. The right leg was strongly flexed 
at the knee and painful on extension. 
There were also pains in the abdomen 
and iliac region. No further clinical 
data are given in the report. 
At the post mortem examination the 
tumor was found to consist of a subperi- 
toneal abscess of the size of an adult 
head. It seems probable, from the 
meagre clinical details given, that either 
no diagnosis of the enlargement was 
made, or that it was not borne out by* 
the autopsy. 
In view of these difficulties in diagno- 
sis, which have been acknowledged by 
the best men in the profession as liable 
to occur to them, I think it advisable to 
use the aspirator in all cases of doubtful 
abdominal tumor before pronouncing 
definitely upon its nature. This would 
have prevented most of the mistakes 
made in the preceding cases. 
In all cases of pelvic abscess, the cavity, 
after evacuation of the pus. should be 
kept constantly drained by a syphon 
drain, and daily washed out with an an- 
tiseptic solution. By means of the syphon 
drain the entrance of air is prevented 
from without, and hence decomposition 
of the pus and septicaemia cannot take 
place. Obliteration of the cavity is also 
secured more rapidly in consequence of 
the constant and complete evacuation of 
its contents.