THE ORIGIN AND TREATMENTOF PUS ACCUMULATIONS

IN THE FEMALEPELVIS.

—BY

THOMAS A. ASHBY, M. D.,

Professor of Gynaecology in Baltimore MedicalCollege, etc.

BALTIMORE, MD.

BALTIMORE :

Journal Pc blinking Company Print.No. 309 Park Avenue,

1889.

THE ORIGIN AND TREATMENTOF PUS ACCUMULATIONS

IN THE FEMALEPELVIS*

Pns accumulations in the female pelvisare more frequent than was at one timesupposed. They owe their presence toa number ofcausative influences. Broad-ly speaking, pus follows in the wake ofinflammatory processes, both of localand remote origin, the inflammatoryprocess of local origin being by far themost common. The pelvic cellular tis-sue is involved either primarily or sec-ondarily, the process in each instancehaving its special mode of developmentand each pursuing its own clinical his-tory. The older classification of pelvicinflammations, under the general termof “parametric,” was coined to designatean inflammatory process, compositein its character and general in its in-volvement of the pelvic tissues.

•Bead before the Medical and Chirurgical Facultyof Maryland at its Semi-AnnualMeeting, held atHagerstown, Md., Nov. 13, 13, 1889.

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Thus the metrimn, the cellular andpelvic peritoneal tissues were supposedto be jointly the seat of inflammatoryinvolvement, and the results were ofgraver significance than those whiSifollowed a pure and simple cellulitis.The points of difference between thedifferent seats of the inflammatory actionweie deteimined with great difficulty,and the clinician could not always besure whether the inflammation wr as para-metric, or simply confined to the uterus,its cellular investment, or to the pelvicperitoneum.

In the acute stage of inflammatoryaction, the indications for treatmentwere so similar that differential pointswere not essential. But as the acuteprocess subsided and its results weremade manifest, it became less difficult tesay whether resolution had been com-plete, whether adhesions had formed,and whether a pus accumulation was theresultant. This latter result at oncedefined the location of the inflammatoryprocess in the pelvic cellular tissue, andthe indications for treatment were morepronounced.

The old theory of parametric inflam-mation traced the extension of the process,from the uterus to its peritoneal and cel-lular environments by direct continuity

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of tissue along the lymph channels.Thus the inflammation began as a me-tritis, extended to the cellular tissue,and finally involved the pelvic peri-toneum.

Recent clinical and pathologicalstudies have shown the incorrectness ofthese theories in numerous instances,and we now recognize the fact that pel-vic pus accumulations have an entirelydifferent origin in the larger number ofcases observed, and a very different clin-ical and pathological history.

When .Noeggerath asser'sd that latentgonorrhoea in the male established pelvicinflammation in the female through aspecific influence, the significance of hisobservations was not fully appreciated.The progress of clinical study has notonly sustained this view, but has ex-tended the idea years before advancedby Bernntz that the one salient featureof pelvic peritonitis is'salpingitis. Thisobserver demonstrated by post-morteminvestigations, thatpelvic peritonitis wasmost often found in those patients whohad died with the clinical history ofpelvic cellulitis, the real seat of the in-flammatory process having been confinedto the pelvic peritoneum, associatedwith tuba! inflammation and tubal pusaccumulations.

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Of thirteen cases of pelvic peritonitis,in nine, one or both tubes contained pus,in two the contained material was tuber-cular, and in one the peritonitis was dueto cancer of the ovary. The cause ofthe inflammation he found due, in alarge proportion of cases, to gonorrhoea,which had travelled along the uterinemucous membrane until it had reachedthe tubes, and here it had expended itsvirulence in provoking pus accumula-tions.

The observations made by Bernutzas far back as 1862,have been strength-ened and confirmed by the clinical ex-perience of Tait, Polk, Wylie and others,and the conclusion has been reachedthat tubal pus accumulations are thechief pathological conditions found inpelvic inflammations. The train ofpathological events follows a most natu-ral history, and can be observed in itssuccessive stages until the pus tube isevolved, and even after it has rupturedinto the pelvic cellular tissue and madeits escape through its selected outlets.Beginning with a traumatism ot theuterine mucous or parenchymatous tis-sues, the inflammation extends along theepithelial route to the tube, or hayingits origin in septic or gonorrhoeal poison,the same route is followed until tubal

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inflammation is induced. The inflam-matory action may end here by resolu-tion, or it may go on to develope moredisastrous consequences. In not a fewcases the septic process passes into theabdominal cavity, where local or generalperitonitis results, fatal or non-fatal incharacter, according to varying condi-tions.

In those cases in which tubal pus ac-cumulations are observed, adhesive in-flammation closes the tube at its outerand inner orifices, and the pus, findingno convenient outlet, swells the tube,until it reaches varying proportions orruptures at its point of least resistance.

Outlets for the pus are made into theuterus, into the peritoneal cavity, or intothe pelvic cellular tissue, and in accord-ance with the route chosen, presents asubsequent clinical history.

The progress of the inflammatoryaction may follow an acute or chroniccourse, and it is not unusual to find indi-cations for treatment in the acute stagepassed over unobserved and callingloudly for remedial measures when achronic condition has been reached.

These conditions are observed underdifferent forms and presenting widelydifferent histories and characteristics.If the patient survives an acute process,

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she may apparently recover from theseverity of the inflammatory action, yetnnder these apparently favorable cr-cumstances, the tube may have beendamaged, adhesions may have formed,and subsequent outbreaks may occurat any unfavorable moment. Thestatement has been made upon goodauthority that in pyosalpinx recoverycan only be insured by removal of thetubes (Skene, Diseases of Women p.550.) This statement, of course, has re-ference to a complete and final result,for it is well-known that women may goaround with pus tubes, in fair degree ofhealth, for months and possibly years,though at intervals subject to attacks ofpelvic inflammation. In one ofthe caseswhich 1 shall subsequently report,! havereason to believe that the pus tubeexifted for over four years.

Nothing is so sure as that pyosalpinxmay have both an acute and chroniccourse.

In the clinical study of pus tubes, thequestion of diagnosis presents numerousdifficulties. When the tube assumes asausage shape and feel, its detection isnot so . difficult, but when the pus sachas become largely distended and fillsthe entire pelvis, pressing the uterus,bladder and rectum to the wall, literally

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as well as figuratively speaking, fluctua-tion becomes diificult, if not impossible,the walls of the cyst are thickened frominflammatory lymph deposit, and thepelvis appears as hard and resisting asif the uterus and pelvic organs werefixed with plaster of Paris. This condi-tion may be mistaken as readily for aninflammatory induration and adhesionsas for a pus sac. Laparotomy here pre-sents the only correct way of establishingthe true condition, as it opens up theonly successful method of treatment.

The pathological and clinical historyof pelvic cellulitis, strictly so-called, dif-fers essentially from that described underthe head of pelvic peritonitis, but withwhich it has been so often associated.In pelvic cellulitis, the inflammatoryprocess is confined to the loose cellulartissue around the uterus, though it mayinvolve the uterine parenchyma and theperitoneal layer. This cellular tissue isfound in loose meshes beneath the re-flected peritoneum both in front }dabehind the uterus, at the junction ofoqnbody with the cervix. Inflammatoryaction is aroused in this region, both bytraumatic arid septic influences. It fol-lows in the wake of operative proceduresupon the cervix, as a result of abortionand child bearing, where lacerations

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occur, and by the introduction ofspecific contagia from the conditionsnamed.

The extension of the inflammation isdirect and through the lymph streamand not as in salpingitis, by continuity ofan epithelial membrane. The processdoes not differ from inflammation of thecellular tissue elsewhere. There is firstcongestion, followed by an effusion ofblood serum, and later on exudation ofthe higher organized constituents of theblood. The process may stop here, res-olution taking place with an absorptionof the effused material. Finally sup-puration may occur, with destruction ofthe cellular tissue, sloughing and pus.The pus accumulation may fill the loosespace between the uterus and its perito-neal folds and extend until it has madean outlet through into the peritonealcavity or into the vagina, bladder, orrectum. Its favorite route is throughthe vaginal wall, into the anterior orposterior vaginal fornix. Should theoutlet be ample, drainage is completeand the pus cavity closes by favorableresolution. Where this result does notoccur, the accumulation may persist andthreaten life by septic absorption or byless favored outlets for its drainage. Thepelvic tissues may become honeycombed

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by small abscess cavities, and go on todevelope a train of symptoms, both per-sistent and chronic in character. In thevast majority of cases, pelvic cellulitis isan acute process, which only assumes achronic type when drainage has beenimperfect. It differs in this respectmost markedly from tubal pus accumu-lations, and enables one to differentiatethe two diseases by this historic fea-ture.

In the treatment of pus accumulationsfollowing a pelvic cellulitis, the indica-tions all point to an early outlet for thefluid. Drainage is the one importantmethod, and this may be secured byaspiration, by free incision through thevagina and in rare cases by opening theabdomen, breaking up the abscess cavi-ties, and free drainage through thewound, or by making a conjoined vagi-nal outlet.

In those long standing cases wherethe inflammatory process has covered alarge area, where the tissues have beenhoneycombed with abscess cavities,wherecicatricial tissue is extensive, and wherepus has made its escape through undesi-rable routes, such as the bowel, bladderand uterus, laparotomy offers the mostpractical method of disposing of the in-flammatory products. lam clearly

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of the opinion that the surgeon shouldattempt to clean out the entire seatof trouble and invite a closureof the excavation by cleanliness andgood drainage. He may in this wayremove the debris of a slow inflammatoryprocess and secure a positive cure, whereinvalidism and ultimate death were incourse of progress. In my judgment,this latter method for the termination ofpelvic cellulitis is infrequent and we willalmost invariably find in these cases ofsupposed chronic abscess following acellulitis that a pus tube exists in con-nection with the trouble, either of pri-mary or secondary origin. A laparotomyalone will determine this point, and thisis the procedure jpar excellence for thiscondition.

It may be pertinently asked, what ad-vantages are offered by a laparotomy ?

I answer, Ist. It presents the only ac-curate method of determining the loca-tion, extent and nature of the pus accu-mulation. 2nd. It presents the onlymethod for the complete removal of thepus sac and for thorough cleansing anddrainage of the region involved. 3rd. Itis, comparatively speaking, a safe pro-cedure when properly instituted. 4thIt offers the most reasonable hope of acomplete cure of the patient.

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With these arguments in support of alaparotomy, one might hastily concludethat the abdominal section was clearlydemanded in the treatment of every caseof pelvic abscess due to salpingitis. Icertainly would not assume such a posi-tion as this. In my opinion, pus tubes canand do get well without laparotomy. Thepus accumulation in the tube does notdiffer from a pus accumulation in otherlocalities when adtquate and properdrainage is secured for the escape of thepus. Should an opening remain at theuterine orifice of the tube, pus will seekan outlet by this route, or should a favo-rable route be chosen along the uterinewall and through the vaginal fornix, asimilar result would be reached. Drain-age is the one important consideration,and it is this factor which determinesthe gravity of the pus tube or of anypelvic pus accumulation. It is only inthe exceptional case that successfuldrainage is accomplished without sur-gical intervention, and it is this factwhich makes the indications for a lapa-rotomy more conspicuous. - That a lapa-rotomy wdll sooner or later be demandedin the majority of cases of pus tubes, Ithink our growing experience goes toprove. The question of gi eatest practi-cal moment, therefore, arises in deter-

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mining when to attempt to remove thepns tubes and when to leave them alone.Just here professional opinion mayarrange itself in two opposing ranks,neither of which is actuated by conserva-tism and matured reflection. One factionmay hastily seize the knife and removeevery pus tube which is found ; the otherfaction may undervalue the claims of alaparotomy and allow cases suitable forthis procedure to perish without an at-tempt at a curative measure. Bothfactions are wrong. The intermediateground is safely reached if symptoms,clinical history and surroundings arecarefully studied and weighed. It isjust as sure that we can wait too longbefore doing a laparotomy, as that wecan operate too hastily. In my judg-ment, these cases require careful studyand a conscientious regard for pro-nounced indications before we jump intothem. Unless the inflammatory processis so pronounced and the pus so apparentand its presence so threatening as to de-mand prompt and decisive action, thesurgeon should wait and employ pallia-tive methods of treatment until positiveindications arise. These indications arefound upon a careful studyof thehistory,symptoms and physical condition of thepatient. The history of the case will

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present an explanation of the origin ofthe trouble, in traumatic or septic influ-ences ; the symptoms will reveal severepelvic pain, high and fluctuating tem-perature, loss of appetite, night sweats,emaciation and general adynamia andcachexia; the physical examination willreveal the area of tenderness on pressure,the character of the local swelling, thepresence of the distended tube in manycases, and other positive evidences of puscavities. When these indications arepresent, the time for a laparotomy hasbeen reached and should be carefullyapproached without too great delay,otherwise the pus tube may rupture androutes be chosen for drainage which willcomplicate the removal of the tube at alater day. Success come? in the man-agement of these cases in seizing theopportunity at the right moment andbefore the pus tube has established suchrelations to the surrounding tissues as tomake its removal both dangerous andmost difficult.

The two cases which I shall now re-late will explain this point with moreaccuracy than descriptive language.

Case I.—Annie J., set. 27, married,was admitted into the Good SamaritanHospital on July 27,1889, suffering withintra-pel vie abscess of over four months

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duration. Her condition at this timewas deplorable. She was emaciated toa mere skeleton, was greatly debilitated,with temperature ranging Irom 101° to103°, quick and feeble pulse, profusenight sweats, severe pelvic pain, colli-quative diarrhoea, cystitis, her stools andurine largely made up of pus. Physicalexamination levealed a chronic pelvicinflammation and pelvic abscess, whichhad opened in o both rectum and blad-der, had burrowed through the abdomi-nal muscles, and was about ready toopen through the skin in the medianline.

Previous History. —The previous his-tory was involved in obscurity, but thefollowing facts were obtained: She en-joyed excellent health up to the time ofmarriage, in February last. Shortlyafter marriage she had a severe vagini-tis (gonorrhoeal?), which was followedby pelvic inflammation. The diseasehad continued until the present condi-tion had been reached.

The diagnosis made was salpingitis, ofgonorrhoeal origin, resulting in pelvicperitonitis and pelvic abscess.

Treatment.—The condition of thispatient was so depressed that I seriouslyhesitated whether I should allow her todie without operative interference, or do

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a laparotomy and take the chance of aresult. I finally decided to open theabdomen and drain the pelvic cavity.On August 2, she was anaesthetized anda free opening made through the skininto the subcutaceous pus cavity. Puain large quantities freely dischargedthrough the incision. Introducing theindex finger, the pelvic cavity was foundhoneycombed with pus cavities, walledin by lymph deposits, adhesions and dis-organized tissue. Deep down in thepelvis a pus tube was found packed inbetween the uterus and rectum, dis-tended with pus. It was adherent inevery direction, and in attempting toenucleate it its walls gaveaway and puswas freely discharged into the pelvis. Itwas removed without much difficulty,though soihewhat torn in the attempt.

The rectal opening was in free com-munication with the abscess cavity, andfecal matter was found in it. The ab-domen was thoroughly washed and adrainage tubeleft in for subsequent clean-ing and drainage.

The patient rallied after the operationand on the following morning her tem-perature had fallen to 99°, her appetitewas fair, pain was absent, bowels loose,but general condition favorable.

The pelvic cavity was washed out

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carefully, two and often four times with-in twenty four hours. Some pug, serumand fecal matter came through thedrainage tube at each washing. Hertemperature never rose above 99°, Shetook milk freely, suffered no pain, andhad no vomiting. The diarrhoea con-tinued until her death, on the Bth dayfrom asthenia.

Remarks. —The condition of this pa-tient prior to the laparotomy gave littleor no encouragement for this procedure.It was a forlorn hope which stimulatedme to attempt to do something to relievesuffering, alleviate symptoms and savelife. Could this patient have been op-erated on prior to the rupture of the tubeinto the rectum and bladder, and beforeshe had been reduced by prolonged suf-fering and emaciation, her life couldhave been saved. The abdominal sectionconferred a marked relief to her andshe would, in my judgment, have re-covered, if she had had greater recuper-ative power.

Case lI.—B. S., set. 27, married, nochildren, one abortion and one miscar-riage. Abortion took place at the ageof 16, at which time she was ill for sev-eral weeks. Health fair until the ageof 19, and good from this age until 22,when she miscarried, which was followed

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by pelvic inflammation. Her health hasnot been good from that time until dateof present history. About the middleof August of the present year, she tookcold during menstruation, whichresultedin a complete suppression, followed bypelvic peritonitis.

When admitted into the Good Samar-itan Hospital, on August 27, an exami-nation revealed the following condition :

Temperature 103|°, pulse 100, respira-tion 30. Abdomen very tender, swollenand distended. Uterus firmly packed inpelvis and pushed towards the symphy-sis by a mass of exudation in Douglas’scul-de-sac. There were no appreciablesigns of pus.

Diagnosis. —Pelvic peritonitis, mostprobably of tubal origin.

The treatment employed was rest,hot vaginal douches, hot poulticesover abdomen ; in other words, the so-called antiphlogistic and palliative treat-ment for pelvic inflammation. Underthis regime the temperature fell to 100,pain grew less severe and general cond-tion improved.

Upon my first examination I wasstrongly impressed with the necessity ofmaking an abdominal section, but de-cided to try the method above indicateduntil more positive indications for a lap-

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arotomy were presented. After threeweeks of observation and tentativetreatment the opportunity arrived whichin ray judgment demanded the abdomi-nal section. Pain, high temperatureand evidences of sepsis returned, thegeneral condition grew worse, and I de-cided to open the abdomen for a clearerdiagnosis, for drainage and for removalof the pus tube, if practicable.

On Sept. 23, the patient was anaesthe-tized and the abdomen opened in themedian line. Evidences of general per-itonitis were soon encountered. Theomentum and intestine were adherentin numerous points to the abdominalperitoneum, to the uterus, bladder andtubal cyst. The omentum was deeplyinjected, tumefied and covered withflakes of lymph. The small intestinepresented a deep purplish hue, and inplaces was injected and tumefied. Atother points it was bound up in loose,friable adhesions. The uterus waspressed up against the bladder, and im-pacted in the pelvis between the uterusand rectum was an enormously distendedpus tube, over 3 inches in its diameters,adherent at every point to neighboringparts. The adhesions were for the mostpart easily broken from their attachmentand the tube was shelled out of its posi-

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tion by repeated efforts. It was rupturedin this effort, and a pint or more ofcrearav pus was poured out through theabdominal wound. The tube was finallyremoved, save that portion attached tothe uterus, which tore asunder from thetubal wall, leaving an opening at thispoint in the contour of the tube. Thepelvic cavity was thoroughly washedclean after the removal of the tube andloose particles of lymph, omentum andtissue were carefully picked out. Theabdominal wound was closed, save atthe lower end, in which a glass drainagetube was inserted. The patient wasgreatly depressed by the operation, butrallied by the next morning, Nauseaand vomiting were incessant. She wasunable to take food until after the 7thday, and was supported entirely onchampagne andApollinaris and ice water.iVlilk and beef-tea induced vomitingthe moment they were swallowed. Thedrainage tube was kept washed clean,out nothing but a small quantity ofbloody serum escaped from it. It waswithdrawn on the sth day, and a smallglass stem substituted for it to keep theabdominal wound open.

Up to the morning of the 6th day, thepatient had taken no nourishment exceptchampagne. Her emaciation and weak-

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ness were beginning to be alarming.With a view of sustaining her, I orderedan enema of tepid milk. This was in-jected slowly and carefully, and yet toray horror, on dressing the wound in theafternoon, I found milk with flakes offecal matter coming through the open-ing. In plain English, the rectum hadgiven away and a communication estab-lished between this viscus and theintra-pelvic cavity from which the pustube had been removed. With a fecalabscess, the complications of the casewere increased and the prognosis took amost gloomy turn. I however washedthe wound carefully, kept the patienton liquid diet, and by the third weekhad the satisfaction of seeing the fecaltract close spontaneously.

The patient made a satisfactory recov-ery, and was out of her bed by the endof the fifth week.ller temperature afterthe operation never reached above 100°.It ranged between 9SJ° and 991°, untilher recovery.

Remarks.—The two cases here re-lated teach the importance of an earlyoperation in these conditions.

In Case I, the patient came under mycare after the pus had made outletsthrough the rectum and bladder, andwhen she had reached such a deplorable

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condition as to defeat the advantages ofbetter methods of drainage.

In Case 11, I came very near waitingtoo long before doing the laparotomy.Out ofdeference to conservative methodsof treatment, and in view of her generalconditionand at'that time unfavorable sur-roundings, I deferred the abdominal sec-tion longer than in my judgment wasprudent. I came very near losing thispatient through delay. Whilst we mayerr in operating too soon, we may morecertainly blunder in waiting too long formore pronounced indications.1135Madison Avenue.