PUS IN OVARIAN FLUIDS. 
BY 
JAMES R. CHADWICK, M. I)., 
Fellow of the American Gynecological Society, Corresponding Fellow 
of the Obstetrical Society of London. 
Reprinted from the Medical and Surgical Reports of the Boston City Hospital, 
Second Series, 1877. 
BOSTON: 
PRESS OF ROCKWELL AND CHURCHILL, 
No. 3 9 ARCH STREET. 
1 8 7 7. THE SIGNIFICANCE OF PUS IN OVARIAN FLUIDS. 
By James R. Chadwick, M. D. 
This exceptional ingredient of ovarian fluids has been very 
insufficiently considered by writers upon ovarian tumors, 
whether from a clinical or a pathological stand-point. 
As pus is always the result of inflammation in some form, 
we should naturally expect that its presence in ovarian fluid 
would be universally accepted as evidence of this process ; 
yet nowhere do I find this to be the case. 
The only indications of cystic inflammation adduced in the 
clinical histories of ovarian tumors are the symptoms attribu- 
table to septic or pyemic fevers; i. e., chills, high pidse and 
temperature, general malaise, emaciation, etc. Pain seems 
to be generally absent, unless the peritoneum participates in 
the inflammatory action. These symptoms are undoubtedly 
well marked and characteristic in acute inflammation of the 
cyst-wall, and demand the early removal of the tumor by 
operation. The ten cases of ovariotomy, recently reported 
by Keith,* in which the cysts were found to be the seat of 
acute suppuration, are proofs of the good results which may 
be expected from operative procedures. 
Kiwisch,f Baker Brown,J Klob,§ Jos. Kroker,|| J. A. 
* On Suppurating Ovarian Cysts. Edinburgh Medical Journal, Feb., 1875. 
fKlinische Vortrage, 1852, Abth. IL, p. 85. 
J On Ovarian Dropsy, 1868, p. 12. 
§ Pathologische Anatoinie des weiblichen Sexualorgane, 1864, pp. 361, 362. 
|| Ueber die Ursachen der spontanen Perforation von Ovariencysten. In. 
Diss., 1869, p. 16. 2 
SIGNIFICANCE OF PUS IN OVARIAN FLUIDS. 
Baldy,* Peaslee,j- Barnes,§ Spiegelberg,|| and 
a few others, make very brief allusions to acute inflamma- 
tion of ovarian cysts. But none seem to be so conversant 
with this complication as Mr. Spencer Wells; hence, I 
offer no apology for quoting from him at some length. 
"The ovarian cysts, and more especially the complicated 
kinds, are liable to become inflamed, either spontaneously 
or as the consequence of some accident or operation, such 
as tapping. The disease may run on rapidly with intense 
symptoms and general peritonitis to a final termination; or 
it may be more localized, and lead to suppuration in the 
cavities. This may go on for some time, with the produc- 
tion of pus as in a common abscess ; or the contents of the 
cysts may be converted into any of the foul, disgusting 
fluids, the result of decomposition. The fatal termination, 
if the cysts be not removed, may be due to diffuse peritonitis, 
but more commonly to septic or pyemic fever, the result of 
blood changes set up by absorption, or by admixture, more 
or less direct through the vessels of the cyst, of the putrid 
fluids or gases with the blood. In other cases, ulcerative 
action in the walls takes place ; they then give way, and are 
perforated." If 
The concluding paragraph of this quotation describes the 
special condition to which I propose to call attention in this 
paper. I cannot better introduce the subject than by citing 
the observation upon which is based the subsequent argument. 
* Des accidents de la ponction abdominale des kystes de 1'ovaire. These 
de Paris, 1859, p. 23. 
t Ovarian Tumors, 18-72, pp. 173, 175. 
J Histoire des kystes de 1'ovaire, 1873, p. 252. 
§ Clinical History of the Diseases of Women, 1873, pp. 343, 344, 3G0. 
|| Ueber Perforation der Ovarienkystome in die Bauchhdhle. Archiv fur 
Gynajkologie, 1870, Bd. I., Heft. 1, p. G7. 
U Diseases of the Ovaries. London, 1872, p. 78. SIGNIFICANCE OF PUS IN OVARIAN FLUIDS. 
3 
Ovarian Cyst ; Ulceration of the Cyst-wall ; Per- 
foration with Fatal Results.* 
February 24, 1874. - Josephine de L., aged 20 years, 
single, had pain in the right hypochondrium five years ago, 
which recurred after varying intervals for three years, was 
absent for a year, but for the past twelve months has been 
very severe,-and has extended to the other side. A swell- 
ing appeared in the right hypochondrium nine months ago, 
and has since gradually extended to the whole abdomen,- 
the girth now measuring thirty-nine inches. On percussion 
the abdomen was flat throughout. The only symptoms had 
been headaches, palpitation, tenderness of the abdomen, and 
occasional vomiting. 
On March 22d the patient was tapped, and twenty-eight 
pints of a clear, nearly colorless fluid of syrupy consistence 
drawn from the tumor. On April 24th she was discharged. 
On September 5th she re-entered the hospital with the 
abdomen again distended, and suffering from vomiting and 
dyspnoea. Two days later ten pints of a clear mucilaginous 
fluid were drawn with the trocar. On September 10, 1874, 
she was discharged. 
On January 7th, 1876, she reported that the cyst had not 
begun to refill until February, 1875, when she had a severe 
fall; since that time she had been tapped, outside of the 
hospital, four times, at intervals of five, three, three, and 
two months, respectively, the last having been two and a 
half months ago. No new symptoms had occurred; the 
tenderness in the right hypochondrium was very marked. 
On January 20th twenty-seven pints of a " dirty, gray- 
colored fluid, with a ropy sediment," were drawn with the 
trocar. The fluid (specific gravity 1050) contained albu- 
men, and a small quantity of sugar (?) pus and mucus. 
The patient was discharged on January 22. 
* For the notes of this case I am indebted to an abstract from the records 
of the hospital, by Dr. C. W. Brown, late House Physician, and to a brief 
synopsis that was published by Dr. Edes (in whose service the case occurred), 
in the Boston Medical and Surgical Journal for Aug. 17, 1876. 4 
SIGNIFICANCE OF PUS IN OVAPJAN FLUIDS. 
She re-entered on March 6th, and was tapped on the 14th ; 
twenty-seven pints of a fluid resembling pea-soup were 
removed. On March 16th she was discharged. 
On April 18th she entered, with severe pain in the back 
and right side of the abdomen. Tenderness, on pressure, 
extended throughout the abdomen. On the next day twenty 
pints of purulent fluid, the last part of which was thick and 
flocculent, were drawn with the trocar. She suffered severe 
cramp-like pains for twenty-four hours, requiring large doses 
of morphine. On the 22d she was discharged. 
On May 24th she re-entered, with the abdomen again 
fully distended, and quite painful ; pulse, 100; temperature, 
98.4. On the next day nineteen pints of a milky fluid were 
removed, the last portion being thick and ropy. There was 
no pain subsequent to the tapping ; and she was discharged 
on the 29th of May. 
At this operation I was present, by Dr. Edes' request, and 
tried ineffectually to discover some cause for pus in the 
fluid. There was no fever or unusual tenderness in the 
abdomen. 
About three weeks later the patient called at my office, 
at Dr. Edes' suggestion, to make arrangements for ovari- 
otomy at her home. The tumor bad then nearly refilled. 
In consequence of the hot weather to be expected in the 
month of July, I recommended that she should be again 
tapped in the hospital, as soon as necessary, and that the 
operation should be performed at or about August 1st. 
On June 28th Miss L. entered the hospital in a state of 
collapse, with no pulse at the wrist, and vomiting a 
"coffee-ground" fluid. The tumor was tapped, and much 
purulent fluid evacuated. She sank during the operation, 
and died twenty minutes later. It was afterwards learned 
that she had been taken suddenly with extreme pain and 
vomiting on the day before entrance. 
"The autopsy disclosed general peritonitis. On the right 
side of the median line lay the greater part of a compound 
ovarian cystic tumor, the largest cyst being adherent to the 
abdominal walls at the median line, as well as slightly to 
the omentum. Its walls were from a sixteenth to an eighth SIGNIFICANCE OF FUS IN OVARIAN FLUIDS. 
5 
of an inch in thickness, roughened on the inside, and con- 
tained a somewhat gelatinous fluid, with much pus. At the 
upper part, and somewhat to the left, was a small perfora- 
tion, perhaps one-eighth of an inch in diameter, which 
corresponded to a reddened, rough, and ulcerated patch 
upon the inside. It was about four inches above and to the 
left of the place where the trocar usually entered the cyst. 
The other cysts were much smaller and filled with clear 
gelatinous material." 
The wall of the main cyst showed several large raised 
ridges, without any corresponding depressions on the out- 
side ; these formed the borders of several quite deep and large 
pouches, so that they seemed to be the remnants of the 
walls of former subordinate cysts. Many of the ridges 
were covered with a pseudo-membrane, beneath which was 
granulation-tissue, with absence of epithelium; in other 
words, they were the seat of ulceration. There were many 
extensive irregular patches of similar character, intersected, 
and very generally bounded, by slightly raised ridges of 
firm, white tissue, seemingly cicatricial. In other parts 
these ridges formed a complicated, radiating net-work, with 
intervening pouches of healthy cyst-wall. Fully two-thirds 
of the cyst-wall showed such evidences of present or past 
ulceration. 
Dr. R. II. Fitz has kindly sent me the following descrip- 
tion of the microscopic appearances : - 
" That portion of the cyst-wall presenting the roughened 
papillary appearance, and apparently bearing a false mem- 
brane, showed an occasional papilla, and a membrane 
composed of evident agglomerated pus corpuscles. Di- 
rectly beneath this membrane there was no cylindrical 
epithelium, though at intervals pouches extended downwards 
for a short distance, and were lined with cells of such a 
character. 
"The tissue beneath the false membrane occasionally 
resembled a granulation tissue, the numerous cells being 
collected about rather large and frequent vessels running 
vertically towards and nearly to the surface. The smoother, 6 
SIGNIFICANCE OF PUS IN OVARIAN FLUIDS. 
whiter portions of the wall of the cyst were covered with 
no epithelium, and were composed of parallel bundles of 
fibres, separated by broken chains of cells. These parts of 
the cyst were more fibrous and less cellular than the more 
deeply seated portions." 
It will be noticed in the above history that a " clear, 
mucilaginous fluid " was obtained from the cyst on Sept. 
10th, 1874; that the character of the fluid removed at the 
four tappings, outside of the hospital, during 1875, is 
unknown; but that on Jan. 20th, 1876, and at every subse- 
quent tapping, the fluid contained pus. Pus was conse- 
quently forming in the cyst for at least five .months before 
the patient's death, and perhaps for several months pre- 
viously. 
On the other hand it will be remarked that there were at 
no time such symptoms of inflammation of the cyst-wall as 
are indicated, even though briefly, in medical literature. 
There was no general malaise, no loss of strength or flesh, 
no fever, no chills ; the pulse and temperature were normal 
on the only occasion when they were recorded. 
This discrepancy between the patient's condition and the 
purulent character of the fluid produced a deep impression 
upon my mind when I was present at the tapping on May 
24th, and led to a long, but futile search for an explana- 
tion in the works upon the pathology and clinical features of 
ovarian tumors. 
The fatal result and autopsy have, happily, revealed "the 
missing link." The formation of the pus is shown to have 
been due, not to acute inflammation, which might have been 
recognized, but to a form of chronic inflammation of the 
lining of the cyst-wall, which may be designated as ulcera- 
tion. This process undoubtedly had its origin in the fre- 
quent punctures of the cyst with the trocar, and is the 
pathological condition to which many authors allude ; but 
which has - so far as I can learn - never been recog- 
nized prior to removal of the tumor, or to the death of the 
patient. 
This case, therefore, suggests that pus in the fluid taken SIGNIFICANCE OF PUS IN OVARIAN FLUIDS. 
7 
from an ovarian cyst is, in the absence of symptoms point- 
ing to acute inflammation, pathognomonic of ulcerative 
action in the cyst. 
The perforation of the cyst-wall, in the course of this 
process, indicates the imminent danger to which patients are 
subject, under these circumstances, and calls for quite as 
prompt operative interference on the part of the surgeon 
as do the symptoms of acute inflammation.