PELVIC ABSCESSES: THEIR SURGICAL

ANATOMY, DIAGNOSIS AND TREAT-

MENT, WITH A STATEMENT OF CASES. By J. R. Wallace, P.H.A.,

Bengal Service. The subject of "Pelvic Abscesses" is one that involves

no small amount of interest to both the anatomist and

surgeon, from the fact that the purulent collections

occurring in and about the pelvis, and receiving different names to characterise their locality, render a thorough knowledge of the anatomy of the textures concerned

essentially necessary to a correct and intelligible diagno- sis. It is intended, by means of an aggregated series of

notes, clinical observations and statistics of cases, to pre- sent this subject in a detailed and comprehensive form.

In the term Pelvic Abscess may be included the

group known as True Pelvic, Gluteal, Ischio rectal, Perinai- cal, Lumbar, Psoas, Iliac, Abdomino-parietal and Ileo-

lumbar,?all of which, from their surgical and anatomical relations one with the other, may justly be embraced in a description of this subject.

Surgical Anatomy.?The pelvic fascia is the thin

membranous lining of the cavity of the pelvis continu- ous with the fascice of the iliacus and psoas muscles.

Attached above to the pelvic brim, and below to the inner surface of the bone near the attachment of the obturator

internus, it extends backwards to invest the obturator

vessels and to cover the pyriformis and obturator

internus to their insertion at the upper margin of the

great trochanter ; is continued on to be attached to the

lower part of the pubic symphysis where it blends with

the fascia of the opposite side, forming an additional

support to the anterior wall of the pelvic outlet and

strengthening the triangular ligament. From this point a whitish band of ligamentous structure is distinctly seen

passing along to the ischial spine, which marks the

division of the pelvic fascia into two layers (the obtura- tor and recto-vesical fascice) and the attachment of the

148 THE INDIAN MEDICAL GAZETTE. [June 1, 1880.

levator ani. The former of these layers invests the ob-

turator internus, forms the sheath of the pudic vessels

and liei'ves, and finally constitutes the membranous

fining of the ischio-rectal fossa. The latter or visceral

layer descends, investing the prostate, bladder and rec-

tum. The iliac fascia, which is so important a structure

in the study of "pelvic abscesses," encloses the psoas and iliacus musSles?the portion investing the psoas is

attached above to the ligamentum arcuatum internum

of the diaphragm, internally to the sacrum, and by a

series of arched processes to the inter-vertebral substances

and prominent margins of the bodies of the vertebra}.

Externally, this portion of the iliac fascia is continuous

with the fascia lumborum. The part which invests the

Iliacus is connected externally to the whole length of the inner border of the crest of the ilium, and internally to the brim of the true pelvis. External to the femoral

vessels this fascia is intimately connected with Poupart's ligament, and is continuous with the transversalis

fascia ; but as the femoral vessels pass down the thigh, it forms the posterior wall of the femoral sheath under which the iliac fascia surrounds the iliacus and psoas to their termination and becomes continuous with the

iliac portion of the fascia lata. Tlie iliac vessels lie in

front of the iliac fascia, but all the branches of the

lumbar plexus are behind it : it is separated from the

peritoneum by a quantity of loose areolar tissue (Gray). With this detailed anatomical description the variety of courses which these abscesses take becomes intelligible :

thus, from one or other of the causes presently to be

enumerated, pus may collect beneath tte pelvic fascia,

producing its distension which is made known by the attendant fulness above the anterior superior spine of the ilium (true pelvic abscess) ; the pressure of the pus upon the lumbar plexus produces the pains in the thigh and

knee seen in this form of abscess ; from this point the

pus may be conducted along the tendons of the obtura-

tor internus and pyriformis, through the sacro-sciatic

notches, to diffuse itself into the nates constituting

gluteal abscess. It may however enter this region, as in

cases of chronic true pelvic abscess, by necrotic changes in the ilium, resulting in complete erosion and perfora- tion of its substance, the effect of immediate contact

with pus, or vice versa ; the pus of a gluteal abscess arising from coxalgia may, as is not infrequently the

case, pass through a necrotic opening in the acetabulum, beneath the pelvic fascia. Matter may also insinuate itself along the prolongations of the pelvic fascia to the

ischio-rectal fossa and is known as ischio-rectal abscess,

pointing in the perineum or discharging itself into the

rectum or into the vagina of the female. When thus

situate, the pus invariably acquires a stercoraceous odour

from permeation of gaseous decomposition products from the adjacent intestine : in the right side suppuration may be the result of pericoecal inflammation or perityph- litis (periccecal abscess), in which condition the diverticu- lum or vermiform appendix of the ccecum sloughs away and the liquid and gaseous contents of the intestine pass directly into the abscess cavity. This latter complica- tion is strikingly illustrated by the case from Professor McLeod's wards in the Medical College Hospital, and

reported in August's issue of tlie Indian Medical Gazette. Pus may however pass on in the direction of the vesical division of the pelvic fascia, to produce dysuria and even fatal obstruction to the urinary canal by its encroachment and pressure upon the ureters and

prostate, or it may even burst into the bladder.

Originating in dorso-spinal disintegration, pus may be

conveyed along the continuations of the fascia iliaca with the fascia lumborum, to point in the loin forming lumbar abscess, or passing more directly forwards by its communi- cations with the fascia transversalis to point in the

abdominal wall and be termed abdomino-parietal abscess : more commonly however, in dorso-spinal disease, the

matter makes its way along the sheath of the psoas to

the femoral arch and points below Poupart's ligament, on the inner aspect of the thigh, and is recognised as psoas

abscess: it is the irritation of this muscle and the

absorption of its fibres, dependent upon pressure

exerted by the presence of pus within the sheath of the

psoas that cause the inability to walk and extend the

leg of the affected side that is so characteristic of

this disease. Suppuration products from spinal-disease may pass simultaneously on either side of the vertebral

column into the sheaths of both psoas and present a

"double" psoas abscess. From the loin, matter may be conducted iuto the iliacus sheath by the communications of the lumbar with the iliac fascia and constitute iliac

abscess which always points above Poupart's ligament, owing to the influence of the fascia iliaca (Stanley), while in psoas abscess the tumour is beneath Poupart's ligament, in front of the femoral vessels. Pus within

the sheath of the iliacus may so distend it as to give evidence of tumefaction in both the loin and lower

anterior abdominal wall at the same time, and thus be

styled ilio-lumbar abscess. Pus may even be conveyed from the upper portions of the vertebral column, as the cervical and superior dorsal, into the pelvis : thus, the

contents of abscesses in these regions pass forward

under the pillars of the diaphragm, down the side of the aorta and iliac vessels into the iliac fossa ; from here

the matter may present in any of the forms already described, or it may work its way downwards into the

adductors of the thigh, burrowing along into the popliteal space, beneath the muscles of the calf of the leg to

point near the ankle (Erichsen), converting a series of

primarily clearly defined and circumscribed abscesses

into a single tortuous abscess cavity, yielding enormous quantities of pus, unequalled in bulk, by suppuration in any other part of the body. The general symptoms of suppuration, viz. tumefaction,

pain, rigors and constitutional disturbance with fluc-

tuation, are invariably present in all these forms of

abscess, but it is the exhaustion inseparable from the attendant profuse and long-continued discharges, giving rise to a low asthenic form of pyrexia known as

hectic, which renders these cases so unmanageable* and often causes them to terminate fatally. Pelvic

abscesses are chiefly the lot of the strumous and

debilitated, but they are often seen in Bengal as sequelae to the intermittent fevers common in this part of India.

Judging from statistics, it may be assumed that as the

July 1, 1880.] PELVIC ABSCESSES.?BY J. R. WALLACE, P. H. A. ^9

result of struma, pelvic abscesses affect those below adult

years ; when arising from violence, adult life principally; when from fever or debility, all ages are affected indis- criminately. When an abscess of this kind takes place in a healthy individual the lymph, which is poured out

in the early inflammatory stages, serves as a boundary wall and limits the spread of suppuration ; but when it

occurs in a broken-down constitution, no such barrier is

formed, and the suppurative inflammation becomes diffuse. In certain localities these abscesses present special symptoms which are at once characteristic and

diagnostic as to the situation of the pus. In Psoas

Abscess, the leg of the affected side is flexed, there is

inability to walk or extend the leg, and we may look for evidences of spinal disease, which, if it be present, will be distinguished by spinous projection, weakness of the back, constant tenderness and pain and a scrofulous

appearance : the tumour is seen below Poupart's ligament. In Iliac Abscess we have the pain less, the leg is not flexed as a rule, nor is there so much difficulty or in-

convenience experienced in extending the leg, as in

psoas abscess, and the tumour is above Poupart's liga- ment. When arising from coxalgia, the usual signs of hip-joint disease are present, and we may suspect that

pus has passed into the pelvis or down the thigh, should we find suddenly that a fluctuating tumour of the gluteal region (attended by pain, rigors, and increased ten-

derness on gently pushing the femur against the

acetabulum) had disappeared without any external

opening. In two of the cases subsequently quoted, suppuration about the hip-joint had occurred, and the pus passed into the pelvic cavity through an opening in the acetabulum, the result of necrosis, discovered after death. The pathology of pelvic abscesses does not differ

from that of suppuration in other parts of the body generally. Thus, when due to strain or external violence, we may have simply a bruising of the soft textures with more or less cutaneous ecchymosis, leading on subse-

quently to active determination of blood to the injured tissues, the consequent cell proliferation, the exudation and infiltration,?all of which inflammatory phenomena may culminate in suppuration or the formation of an

abscess. If the bruising be more intense, we may have actual rupture of the smaller blood vessels, tearing of muscular fibres, and the attendant haemorrhage or

extravasation. The blood so transuded is often re-absorb-

ed, but in other instances the distension it occasions, in the sheath of a muscle for example, may so interfere

with the nutritive changes of the structures concerned, as primarily to influence the alteration in the nature of

the extravasated blood, or its conversion into pus, which, when formed, always absorbs and liquefies the tissues with which it comes in contact : or secondly, independent of

any changes in the blood itself, the malnutrition follow-

ing distension and injurious pressure, may result in in-

flammatory phenomena and suppuration within a mus- cular sheath, or any tissue similarly circumstanced.

Pelvic suppuration when occurring as a sequel of intermit, tent fever, depends upon enfeeblement of vitality, and

impoverishment of the blood. It is stated that in this

condition the preponderance of the colorless corpuscles

or leucocytes, forms an important factor in the produc- tion of suppuration after the protracted fevers of Ben-

gal. When collections of pus within the pelvis are due

to molecular disintegration of bone as in caries of the

bodies of the vertebra?, seen in Pott's angular curvature

of the spine, sacro-iliac disease, coxalgia and necroses

of the iliac bones, we have special morbid changes,

namely, perversion of nutrition of the bone, abnormal

vascularity, a softening and breaking down of its tissue

which consists in the production of an inflammatory granulation-tissue from the medullary structure of the

bone, and absorption of the compact tissue ; ulceration

follows, with a gradual separation of the osseous particles which mix with the pus formed as a constant product of granulation. The Etiology or causation of pelvic abscesses may be

described as (a) predisposing, and (b) exciting : in each case the source of disease may act locally or through the medium of the constitution.

(a.) Predisposing : (1) strumous diathesis, (2) general debility, (3) defective condition of the blood, (4) pro- tracted intermittens.

(b.) Exciting : (1) injury or violence, as blows, falls, strains, contusion, from injurious pressure upon the

psoas and iliac muscles, in protracted labour dependent upon disproportion of the foetal head and pelvis ; (2) caries of bodies of vertebrae in spinal disease ; (3) necro- sis of iliac bones ; (4) coxalgia; (5) extension of disease in other parts, as in inflammation of the vermiform appen- dix of the ca?cum, involving the p3oas and iliac muscles ;

(6) septicaemia in its various forms, as hospitalism, pelvic cellulitis, &c. ; (7) empyremic perforation of pleu- ra, the pus passing heneath pillars of diaphragm into

pelvic cavity ; (8) irritation of abdominal wall or areolar tissue of abdominal cavity by obstructed gall-stones or hardened faeces.

Diagnosis.?We require often to distinguish the vari- ous forms of pelvic abscess from other tumours occurring in these parts, as they present in common with them many physical signs, which are likely to mislead the

surgeon : thus, they may simulate hernia or aneurism, or be mistaken for malignant growths, especially Ence-

phaloid, which, in Bengal, comes frequently under the observation of the student of clinical surgery : pelvic adenoid, renal and ovarian tumours should also receive a

passing consideration in diagnosis. From hernial seen

about the inguinal region, as bubonocele or a crural, taking,?as it sometimes does?an irregular course up-

wards to the anterior iliac spine, pelvic abscesses may be known by their history, the presence of fluctuation, pain, fulness and throbbing, inability to extend the leg (in psoas) from its naturally flexed condition, the absence of tympanitis, gurgling and the diminution in size upon

pressure being applied over the tumour. Both femoral

hernia and bubonocele simulate psoas and iliac abscess, in that the tumour in either case dilates on coughing or

when the patient is made to assume the erect posture, and diminishes when recumbent. Hydrocele of the cord

may sometimes so distend the tunica vaginalis as to

give rise to bulging of the abdomino-inguinal parietes resembling abscess : such a swelling or tumour is

150 THE INDIAN MEDICAL GAZETTE. [June 1, 1880.

usually painless, does not receive any impulse from

coughing, is smooth, elastic, fluctuating and semi-

transparent. Iliac, is distinguishable from psoas abscess by the former pointing always above Poupart's ligament, while the latter presents below it: in the former we have not the perfect, inability to extend the leg of the affected side, which is an invariable and constant symptom of the latter. Again iliac abscess affects adults and women after parturition chiefly, whereas psoas abscess is more

generally seen in children, and is usually associated with

spinal disease. Aneurismal tumours of the pelvic vessels, which have attained some size, may be taken for suppura- tive swellings at first, but more minute examination will

give evidence of pulsation corresponding with the heart's

systole, a bruit heard on applying the stethescope, a

diminution in size of the tumour by pressure upon the main artery at a point above the swelling, which can be

emptied by pressure. Such however is the reverse with

pelvic abscesses, they do not pulsate, no bruit is dis-

cernible in them, and pressure does not alter their dimen- sions. Encephaloid of the pelvic bones, often runs an

extremely rapid course, and is likely from its active

growth, the attendant pain and deceptive fluctuation, to impress one with the belief of its being a pelvic abscess. The cancerous cachexy should be looked for, and the

co existence of a similar swelling in any other part of the

body, should rouse a suspicion of encephaloid : the

appearance of large tortuous veins over the surface of

the tumour will point to medullary cancer, and the

application of a fine trocar in such cases will be of

extreme value in diagnosis, as the escape of pus is con-

clusive evidence of abscess, while by the aid of the

microscope we can determine the presence of the larger variety of scirrhus cancer cells and diminutive stroma, so characteristic of encephaloid. In Adenoid growths within the pelvis, the general derangement of the lymphatic system will point to the true nature of the disease

(Hodgkin). Renal tumours may be known from lumbar

abscess by an exclusion of symptoms, as in hydrone- phrosis, renal hydatid, cystic degeneration or renal

cancer, the possibility of recognizing their existence

would be nil, in the absence of urinary disturbance,

Perinephritic abscess may however point in the loin and

be readily taken for true lumbar abscess, but in the

former the symptoms are more acute, and the pain deeply seated. The cystic, fibro-eystic, fibrous or

malignant varieties of ovarian disease are distinguish- able from pelvic abscesses by their situation and

certain concomitant symptoms. The presence of pus within the ischio-rectal fossa may be ascertained by passing the finger into either the rectum or vagina, when fluctuation can easily be felt.

Treatment.?The surgical treatment usually adopted, though various in application, tends mainly to the evacuation of pus, and the prevention of decomposition or putrefaction within the abscess cavity : to these ends the following procedures have been resorted to :

(a.) Valvular incision.

(b.) Lister's antiseptic method. (c) Aspirator. (d ) Free incisions with or without drainage,

Valvular incisions of Abernethy have for their ob-

ject the exclusion of air from an abscess cavity, and are made by tightly drawing aside the skin covering the abscess, then pushing a knife directly into the

sac, and before the pus has ceased to flow from the open-

ing thus made, the skin is brought into its normal

position, so that the aperture in it and that in the

sac may no longer directly communicate. This some-

times has the effect of totally keeping out the air and thus preventing decomposition, and tension having been removed from the abscess walls, the pus may be absorb-

ed, or it may re-collect and require a repetition of tliia

operation or the trial of some other measure for its eva-

cuation. Should putrefaction take place,?which is

known by the pus having become foetid?it is best to

lay open the cavity freely 'under antiseptic precautions for in this way putrescent pus can be changed and a

healthy action set up in the diseased part. So also, if

pus re-accumulates rapidly, this method can favorably be adopted.

(b.) Lister's Antiseptic Method.?It is needless to go into a minute description of this mode of treating

abscesses, which has for its design (a) free evacuation

of the pus, (b) complete and perfect exclusion of atmos-

pheric air uncharged with the vapor of carbolic acid, and (c) materials used for dressings, such as will absorb

the pus and keep it sweet. To these ends the surface

of the abscess should be thoroughly cleansed, all hair

and adherent particles removed, the skin should then be oiled, and while a spray of carbolic vapor is blown

constantly over the parts, an incision should be made, the

pus evacuated, and a thick layer of protective and " an-

tiseptic gauze" applied : over this a piece of oil silk coated with copal varnish or gutta percha tissue pre- viously dipped into carbolic lotion, is placed and the whole bandaged so as to leave no part of the dressing uncovered. Instead of the " carbolic gauze" used by Professor Lister, boracic ointment spread upon boracic lint has been largely and effectually used in the treat-

ment of many gluteal, ischio-rectal, iliac, psoas and

lumbar abscesses, occurring in the out-door Surgical Dispensary of the Calcutta Medical College under the care of Dr. Lawrie, and in the wards of the College Hospital; in fact Lister's antiseptic method has been carried out by means of boracic acid preparations with such marked success in all forms of abscess, wounds and ulcers, under Dr. Lawrie's care, as to have given this procedure the highest estimation in the minds of all the students in his clinical class. The superiority of boracic acid as an antiseptic over carbolic acid, is attributable to its being less volatile and less irritant in its effect than the latter ; the formation of pus is decidedly checked by its use, and in many instances completely arrested, and putrefaction,?if rigid attention be paid to the spray and careful bandaging?is unknown to occur. The cavity of

the abscess may also be filled with boracic ointment, or a piece of the acidulated lint inserted into the opening to

act as a drain.

(c.) The Aspirator is an exhausting syringe, provided with a trocar ; the form of apparatus in popular use by Dieulafoy, and also the simpler arrangement used in

June 1, 1880.j PERSONAL EQUIPMENT OF MEDICAL OFFICERS.?BY C. SIETHORPE. 151

the Medical College Hospital, have been thoroughly described in the numbers of this journal, in connection

with the late Professor Gayer's report on its applica- tion in " effusion and suppuration in joints." The

success of aspiration in pelvic abscess is admirably borne out by the favorable results in a large number of recorded cases. The pus should not be completely evacuated, as suction acts detrimentally upon the walls of an abscess, causing sometimes the rupture of a minute arteriole the blood from which enters the cavity and is readily converted into pus. After removing a fair

quantity of fluid a bandage should be applied, suffi-

ciently tight, to assist and encourage absorption of the remaining pus.

(d.) Free incisions with or without drainage.?Inci- sions in pelvic abscess are best in the acute form, they should be made at a point of the swelling in which fluctuation is most distinct, or at the most dependent part, avoiding the vessels or cutting along their course,

never across. Free incisions are the best, and the opening should be sufficiently large to admit of an easy escape of

pus, which ought to well out till the walls of the abscess

collapse ; no squeezing should.be had recourse to. In

lumbar or psoas dependent iipon spinal disease, there

should be no hurry in using the knife, but in iscliio-rectal or periccOcal, early openings are indicated, as delay may lead to rupture of the abscess into the bowel from atte-

nuation of its walls by pressure, and the consequent for- mation of intractible fistulse. In pelvic abscesses origina- ting from traumatic causes, and in which it is suspected haemorrhage has taken place from rupture of an arterial

or tearing of muscular fibres, as in iliac abscess due to

strain, Sir Joseph Fayrer recommends early incisions ;

the history and symptoms, he says, being the chief

guides to diagnosis in such cases. In pelvic abscesses

pointing in and about the groin, it has been recommended (by Professor Partridge of Calcutta, I think) to make

the incision always below Poupart's ligament,?a method which is in vogue in the College Hospital : by this

means the chances of putrefaction by the entrance

of air into a pelvic abscess, are lessened, and we have a sort of valvular instead of a direct communication with the abscess cavity, which is not the case when an incision is made above Poupart's ligament.

Drainage is a contrivance by which pus is con-

stantly carried away from an abscess cavity; its

employment is obviously beneficial, but it should not be continued after suppuration or the flow of pus has ceased, as the substance used then begins to act as a

foreign body, and the irritation it occasions often sets up fresh inflammatory changes, which, though they some- times assist in a speedier closure of the wound, just as often act injuriously. The substances generally used are ordinary lint, or the same medicated, a roll of catgut, or the more recently invented tubes by Chassaignac. "These consist of narrow tubes of vul- canised India-rubber in which openings are made by cutting out small portions with a pair of scissors at inter- vals of about a quarter of an inch, each opening being a 30ut the size of an ordinary pulse bean " (Crombie's Lectures). A forked probe is used for their insertion,

but an ordinary dressing forceps is just as good; one end of the tube is allowed to go to the bottom of the abscess cavity, while the other *nd hangs out: it is con-

venient to attach a piece of silk ligature to the margin of the outer end, as the tube may pass completely into

the cavity, and this affords facility for its extraction.

When a counter-opening is made, one end of the tube is

extruded through each opening, and both tied together on the outer surface. The medical treatment of pelvic abscess aims at support of the constitution, which is best achieved by the use of cod-liver oil, ferruginous tonics, and stimulants. The following Tabular Statement0 of

cases is taken from records of the Medical College Hos- pital, reports noted in the Indian Medical Gazette from time to time, and from Army Hospital Case-books.

* See next page.