[Reprinted from the American Gynaecological and Obstetrical Journal 
for February, 1896.] 
SUPPURATIVE PELVIC PERITONITIS: REPORT OF A 
CASE * 
By H. G. Anderson, M. D., New York. 
The case which I bring to your attention to-night, and which I 
hope may serve as the text for valuable discussion on certain mooted 
questions of procedure, is that of a woman aged thirty, married five 
years, never pregnant. 
The first menstruation occurred at the age of fourteen and was 
regular until two years before marriage, when it began to be profuse 
and of seven or eight days’ duration. About one year before marriage 
she had an attack of peritonitis following an unusually painful men- 
strual period. 
After marriage, owing to the change from an active to an indolent 
life, she grew very fleshy. To reduce this she began the excessive use 
of vapor and other baths followed by severe exercise in the form of 
long wralks. 
This was continued for two years, during which time she had two 
attacks of pelvic peritonitis, occurring each time after a Turkish bath 
taken during the menstrual period. 
She placed herself under treatment for a constant pain in the right 
side of the pelvis, dating from the last attack of peritonitis. 
The uterus was forward and immovable. There was some indura- 
tion in each broad ligament. Treatment improved this condition 
somewhat until, owing to imprudence during menstruation, she began 
to have acute pelvic pain, and tenderness over right side of the lower 
abdomen ; temperature about 102° F. After a few days a swelling 
could be felt high in this side of the pelvis extending above the pelvic 
brim. Owing to the absence of bowel symptoms, the probability of 
appendicitis was excluded. There was a severe chill followed by a 
temperature of 104° F. Under ether anaesthesia this tumor could be 
distinctly felt through the vagina but did not bulge into that passage. 
* Read before the Woman’s Hospital Society, December ro, 1895. 
Copyright, 1896, by J. D. Emmet, M. D. 2 
II. G. Anderson, M. D. 
An incision was made posterior to the uterus, and by the trocar 
several ounces of pus were evacuated. After this the temperature 
fell to ioi° or io2° F., but not below that point. This continued for 
two weeks, when there was another and more severe chill followed by 
a temperature of 105°. The pulse was very weak and rapid; the 
urine was passed involuntarily ; vomiting was severe and frequent. 
Vaginal touch was excessively painful. The condition was one bor- 
dering on collapse. 
Under chloroform anaesthesia a tumor was felt high up on the 
left side. This was tense and not movable. With the aspirator there 
was drawn from this mass nine ounces of serous fluid, somewhat 
blood-stained. The opening was enlarged and gauze drainage in- 
serted. Stimulating enemata and hypodermic injections wpre freely 
given and the patient rallied slowly from the shock. 
Twenty-four hours later the condition was much improved, but 
the temperature was still above 104°. Chloroform was again given 
and a finger passed into the cyst sac, at the upper limit of which a 
bulging could be indistinctly felt. A trocar was passed along the 
finger through the cyst wall and into the mass beyond, evacuating 
about four ounces of offensive pus. A rubber drainage-tube was in- 
serted and the cavity irrigated with peroxide of hydrogen—one fourth 
strength. 
After this the temperature rapidly fell to normal. The control of 
the bladder was restored, and the general condition rapidly improved. 
Eight weeks after this operation a discharge of offensive pus and 
blood occurred, and pus appeared in the urine. The face, hands, and 
feet were swollen, and the amount of urine greatly diminished. The 
temperature rose to 102°. Examination of urine showed one fourth 
of one per cent, of albumin, few renal and bladder epithelial cells, 
unaltered pus and blood cells in abundance, strongly acid. 
A sinus was found to exist at the site of the original incision. 
This was dilated, a small amount of pus was evacuated, and the 
cavity irrigated with peroxide. 
For a week after pus had ceased to exist in the sinus there was 
still pus in the urine. This, however, was not constant. I drew the 
urine by catheter, then irrigated the bladder with boric-acid solution. 
A few moments later the patient passed about three ounces of clear 
pus. Both specimens were examined. The first clear with no pus ; 
the second composed almost entirely of unaltered pus and blood 
cells. At no time was there urine present in the discharge from the 
abscess, showing there was no communication between this cavity and Suppurative Pelvic Peritonitis: Report of a Case* 
3 
the bladder. The unaltered pus and blood cells showed they were of 
cystic rather than renal origin. The origin of the pus is obscure, but 
may have been in some smaller cavity which was not broken up by the 
finger. From this time recovery was uninterrupted. 
The special points of interest in this case are : 
1. Recurrent attacks of pelvic peritonitis, the last going on to 
suppuration. 
2. The occurrence of a serous cyst, separate and distinct from 
the abscess cavity, yet apparently originating at the same time and 
from the same cause. 
3. The interrupted occurrence of pus in the bladder without evi- 
dence of cystitis or nephritis, or of communication with the abscess 
cavity. 
In the non-puerperal state, pus, outside of the Fallopian tube or 
the ovary, is a comparatively infrequent condition. Hence a glance 
at the pathological steps of the abscess formation may not be amiss. 
There first occur the phenomena of any inflammation ; hypersemia 
and dryness of the peritonaeum, with exfoliation of its epithelial layer, 
which changes its usual smooth, glistening surface to a dull reddish 
appearance. Next there is an exudation of serum and fibrin, or 
serum, fibrin, and pus in varying proportions. 
If the exudation be chiefly of serum, it may become encysted by 
a fibrinous exudation and may be reabsorbed. 
The exudation of fibrin produces abundant false membrane and 
gives rise to adhesions between coils of intestine and between the 
uterus and neighboring organs and pelvic wall. After recovery these 
adhesions become thin and stretched, but probably do not disappear. 
In a subacute or recurrent peritonitis the likelihood of suppuration 
increases with each attack. 
Suppuration may be present from the beginning or may be a sec- 
ondary event. 
The inflammatory process forms adhesions and serum-filled spaces 
which may coalesce, and by the addition of irritating matter, most 
frequently from the Fallopian tube, suppuration occurs. The co- 
existence of the cyst and abscess in the case reported would seem to 
be thus explained. 
As to the treatment of these collections of fluid, the general surgi- 
cal rule that where there is pus evacuate it, applies here with equal 
force, the question being as to method. 
When the pus is situated low in the pelvis, having origin in the 
cellular tissue, it is generally agreed that vaginal incision and drainage 4 
H. G. Anderson, M. D. 
is the only procedure. The cases of doubt are those in which the 
pus, as in the case reported, is situated high in the pelvis, extending 
above the brim. 
In favor of the abdominal method it is urged that a more radical 
operation may be done ; that the field of operation is in sight, and ad- 
hesions may be more intelligently broken up ; that not only is the pus 
removed, but also the containing walls and pyogenic membrane—the 
source of the suppuration—which, if left, would invite a recurrence of 
the trouble. 
By the vaginal method, however, with least shock to the patient, 
we can evacuate the pus or serum, wash out the cavity with peroxide 
and drain. If necessary, at some future time we can open the abdo- 
men and remove the sac without the risk of infection that a primary 
section would have involved. 
If fluctuation can be detected through the vaginal walls, or where 
there is likelihood of the pelvic organs being fused together, then vag- 
inal incision is indicated and promises good results. 
This more conservative method, too, may result in saving useful 
appendages. 
Other advantages of the vaginal method that may be mentioned 
are : i. It leaves no scar. 2. There is no danger of a subsequent 
hernia. 3. The abdominal viscera are not handled. 4. Patients may 
submit to this who would refuse the abdominal section. 5. It may 
be used when the intestinal adhesions are so firm that to remove the 
diseased structures would probably result fatally. 
The removal of the uterus in cases of extensive suppuration, espe- 
cially in those cases in which the endometrium is the seat of purulent 
inflammation, is attended with less shock than by the abdominal op- 
eration and leaves the parts in condition for perfect drainage. How- 
ever, it may still be a question if curettage of the uterus with incision 
and drainage of the abscess will not'produce as satisfactory results. 
In conclusion, then, I would say that while the ideal operation in 
suppurative disease of the pelvic peritonaeum may be coeliotomy with 
entire removal of diseased structures, yet the best interest of the pa- 
tient is subserved by vaginal incision and drainage, leaving the ques- 
tion of an abdominal section for the subsequent development of the 
case to decide.