PELVIC. surgeon, occurring in and about the pelvis, and receiving different names to characterise their locality, render a thorough

Transcription

1 PELVIC ABSCESSES: THEIR SURGICAL AND TREATDIAGNOSIS ANATOMY, MENT, WITH A STATEMENT OF CASES. By J. R. Wllce, P.H.A., Bengl Service. The subject "Pelvic Abscesses" is one tht involves smll mount interest to both ntomist nd from fct tht purulent collections occurring in nd bout pelvis, nd receiving different nmes to chrcterise ir loclity, render though knowledge ntomy textures concerned essentilly necessry to crect nd intelligible dignosis. It is intended, by mens n ggregted series notes, clinicl observtions nd sttistics cses, to present this subject in detiled nd comprehensive fm. In term Pelvic Abscess my be included group known s True Pelvic, Glutel, Ischio rectl, Perinicl, Lumbr, Psos, Ilic, Abdomino-prietl nd Ileolumbr,?ll which, from ir surgicl nd ntomicl reltions one with or, my justly be embrced in description this subject. no surgeon, Surgicl Antomy.?The pelvic fsci is thin membrnous lining cvity pelvis continuous with fscice ilicus nd psos muscles. Attched bove to pelvic brim, nd below to inner surfce bone ner ttchment obturt internus, it extends bckwrds to invest obturt vessels nd to cover pyrifmis nd obturt internus to ir insertion t upper mrgin gret trochnter ; is continued on to be ttched to lower prt pubic symphysis where it blends with fsci opposite side, fming n dditionl suppt to nteri wll pelvic outlet nd strengning tringulr ligment. From this point whitish bnd ligmentous structure is distinctly seen pssing long to ischil spine, which mrks division pelvic fsci into two lyers ( obturt nd recto-vesicl fscice) nd ttchment

2 THE INDIAN MEDICAL GAZETTE. 148 levt ni. The fmer se lyers invests obfms sheth pudic vessels nd liei'ves, nd finlly constitutes membrnous fining ischio-rectl foss. The ltter viscerl lyer descends, investing prostte, bldder nd recturt internus, tum. The ilic fsci, which is so imptnt structure in study "pelvic bscesses," encloses psos nd ilicus mussles? ption investing psos is ttched bove to ligmentum rcutum internum diphrgm, internlly to scrum, nd by series rched processes to inter-vertebrl substnces nd mrgins bodies vertebr}. prominent Externlly, this ption ilic fsci is continuous with fsci lumbum. The prt which invests Ilicus is connected externlly to whole length inner bder crest ilium, nd internlly to brim true Externl to feml vessels this fsci is intimtely connected with Pouprt's ligment, nd is continuous with trnsverslis fsci ; but s feml vessels pss down thigh, it fms posteri wll feml sheth under which ilic fsci surrounds ilicus nd psos to ir termintion nd becomes continuous with ilic ption fsci lt. Tlie ilic vessels lie in front ilic fsci, but ll brnches lumbr plexus re behind it : it is seprted from peritoneum by quntity loose reolr tissue (Gry). With this detiled ntomicl description vriety courses which se bscesses tke becomes intelligible : thus, from one or cuses presently to be enumerted, pus my collect beneth tte pelvic fsci, producing its distension which is mde known by ttendnt fulness bove nteri superi spine ilium (true pelvic bscess) ; pressure pus upon lumbr plexus produces pins in thigh nd pelvis. knee seen in this fm bscess ; from pus my be conducted long tendons t internus nd pyrifmis, through this point obtur scro-scitic itself into ntes constituting bscess. It my however enter this region, s in cses chronic true pelvic bscess, by necrotic chnges in ilium, resulting in complete erosion nd perf- notches, to diffuse glutel substnce, effect immedite contct with pus, vice vers ; pus glutel bscess rising from coxlgi my, s is not infrequently cse, pss through necrotic opening in cetbulum, beneth pelvic fsci. Mtter my lso insinute itself long prolongtions pelvic fsci to ischio-rectl foss nd is known s ischio-rectl bscess, pointing in perineum dischrging itself into rectum into vgin femle. When thus tion its situte, pus invribly cquires stercceous odour gseous decomposition products from intestine : in right side suppurtion my be result pericoecl inflmmtion perityphlitis (periccecl bscess), in which condition diverticulum vermifm ppendix ccecum sloughs wy nd liquid nd gseous contents intestine pss directly into bscess cvity. This ltter compliction is strikingly illustrted by cse from Press McLeod's wrds in Medicl College Hospitl, nd from permetion djcent [June 1, in August's issue tlie Indin Medicl Gzette. Pus my however pss on in direction vesicl division pelvic fsci, to produce dysuri nd even ftl obstruction to urinry cnl by its encrochment nd pressure upon ureters nd prostte, it my even burst into bldder. repted Originting in dso-spinl disintegrtion, pus my be conveyed long continutions fsci ilic with fsci lumbum, to point in loin fming lumbr bscess, pssing me directly fwrds by its communictions with fsci trnsverslis to point in bdominl wll nd be termed bdomino-prietl bscess : commonly however, in dso-spinl disese, mtter mkes its wy long sheth psos to feml rch nd points below Pouprt's ligment, on me inner spect thigh, nd is recognised s psos bscess: it is irrittion this muscle nd bsption its fibres, dependent upon pressure exerted by presence pus within sheth psos tht cuse inbility to wlk nd extend leg ffected side tht is so chrcteristic this disese. Suppurtion products from spinl-disese my pss simultneously on eir side vertebrl column into sheths both psos nd present "double" psos bscess. From loin, mtter my be conducted iuto ilicus sheth by communictions lumbr with ilic fsci nd constitute ilic bscess which lwys points bove Pouprt's ligment, owing to influence fsci ilic (Stnley), while in psos bscess tumour is beneth Pouprt's ligment, in front feml vessels. Pus within sheth ilicus my so distend it s to give evidence tumefction in both loin nd lower nteri bdominl wll t sme time, nd thus be styled ilio-lumbr bscess. Pus my even be conveyed from upper ptions vertebrl column, s cervicl nd superi dsl, into pelvis : thus, contents bscesses in se regions pss fwrd under pillrs diphrgm, down side t nd ilic vessels into ilic foss ; from here mtter my present in ny fms lredy described, it my wk its wy downwrds into dducts thigh, burrowing long into poplitel spce, beneth muscles clf leg to point ner nkle (Erichsen), converting series primrily clerly defined nd circumscribed bscesses into single ttuous bscess cvity, yielding enmous quntities pus, unequlled in bulk, by suppurtion in ny or prt body. The generl symptoms suppurtion, viz. tumefction, disturbnce with flucin ll se fms bscess, but it is exhustion inseprble from ttendnt pruse nd long-continued dischrges, giving rise to low snic fm pyrexi known s hectic, which renders se cses so unmngeble* nd ten cuses m to terminte ftlly. Pelvic bscesses re chiefly lot strumous nd debilitted, but y re ten seen in Bengl s sequele to intermittent fevers common in this prt Indi. Judging from sttistics, it my be ssumed tht s pin, rigs nd constitutionl tution, re invribly present

3 July 1, 1880.] PELVIC ABSCESSES.?BY J. R. result strum, pelvic bscesses ffect those below dult yers ; when rising from violence, dult life principlly; when from fever debility, ll ges re ffected indiscrimintely. When n bscess this kind tkes plce in helthy individul lymph, which is poured out in erly inflmmty stges, serves s boundry wll nd limits spred suppurtion ; but when it occurs in broken-down constitution, no such brrier is nd suppurtive inflmmtion becomes In certin loclities se bscesses present fmed, diffuse. specil symptoms which re t once chrcteristic nd dignostic s to sitution pus. In Psos Abscess, leg ffected side is flexed, re is inbility to wlk extend leg, nd we my look f evidences spinl disese, which, if it be present, will be distinguished by spinous projection, wekness bck, constnt tenderness nd pin nd scrulous ppernce : tumour is seen below Pouprt's ligment. In Ilic Abscess we hve pin less, leg is not flexed s rule, n is re so much difficulty inconvenience experienced in extending leg, s in psos bscess, nd tumour is bove Pouprt's ligwhen rising from coxlgi, usul signs ment. hip-joint disese re present, nd we my suspect tht pus hs pssed into pelvis down thigh, should we find suddenly tht fluctuting tumour glutel region (ttended by pin, rigs, nd incresed tenderness on gently pushing femur ginst cetbulum) hd disppered without ny externl opening. In two cses subsequently quoted, suppurtion bout hip-joint hd occurred, nd pus pssed into pelvic cvity through n opening in cetbulum, result necrosis, discovered fter deth. The pthology pelvic bscesses does not differ from tht suppurtion in or prts body generlly. Thus, when due to strin externl violence, we my hve simply bruising st textures with less cutneous ecchymosis, leding on subsequently to ctive determintion blood to injured tissues, consequent cell prolifertion, exudtion nd infiltrtion,?ll which inflmmty phenomen me my culminte in suppurtion fmtion n bscess. If bruising be me intense, we my hve ctul rupture smller blood vessels, tering musculr fibres, nd ttendnt hemrhge extrvstion. The blood so trnsuded is ten re-bsbed, but in or instnces distension it occsions, in sheth muscle f exmple, my so interfere with nutritive chnges structures concerned, s primrily to influence ltertion in nture extrvsted blood, its conversion into pus, which, when fmed, lwys bsbs nd liquefies tissues with which it ny comes chnges in contct : in blood secondly, independent itself, mlnutrition follow- ing distension nd injurious pressure, my result in inflmmty phenomen nd suppurtion within musculr sheth, ny tissue similrly circumstnced. Pelvic suppurtion when occurring s sequel intermit, tent fever, depends upon enfeeblement vitlity, nd impoverishment condition blood. prepondernce It is stted tht in this colless cpuscles WALLACE, P. H. A. ^9 leucocytes, fms n imptnt fct in production suppurtion fter protrcted fevers Bengl. When collections pus within pelvis re due to moleculr disintegrtion bone s in cries bodies vertebr?, seen in Pott's ngulr curvture spine, scro-ilic disese, coxlgi nd necroses ilic bones, we hve specil mbid chnges, nmely, perversion nutrition bone, bnml vsculrity, stening nd breking down its tissue which consists in production n inflmmty grnultion-tissue from medullry structure bone, nd bsption compct tissue ; ulcertion follows, with grdul seprtion osseous prticles which mix with pus fmed s constnt product grnultion. The Etiology custion pelvic bscesses my be described s () predisposing, nd (b) exciting : in ech cse source disese my ct medium constitution. loclly through (.) Predisposing : (1) strumous disis, (2) generl debility, (3) defective condition blood, (4) pro- trcted intermittens. (b.) Exciting : (1) injury violence, s blows, flls, strins, contusion, from injurious pressure upon psos nd ilic muscles, in protrcted lbour dependent upon disproption foetl hed nd pelvis ; (2) cries bodies vertebre in spinl disese ; (3) necrosis ilic bones ; (4) coxlgi; (5) extension disese in or prts, s in inflmmtion vermifm ppendix c?cum, (6) septicemi pelvic cellulitis, r, pus involving p3os nd ilic muscles ; in its vrious fms, s hospitlism, (7) empyremic perftion pleupssing heneth pillrs diphrgm into &c. ; ; (8) irrittion bdominl wll reolr tissue bdominl cvity by obstructed gll-stones pelvic cvity hrdened feces. Dignosis.?We require ten to distinguish vri- bscess from or tumours occurring in se prts, s y present in common with m mny physicl signs, which re likely to misled surgeon : thus, y my simulte herni neurism, be mistken f mlignnt growths, especilly Ence- ous fms pelvic in Bengl, comes frequently under observtion student clinicl surgery : pelvic denoid, renl nd ovrin tumours should lso receive pssing considertion in dignosis. From hernil seen bout inguinl region, s bubonocele crurl, tking,?s it sometimes does?n irregulr course upwrds to nteri ilic spine, pelvic bscesses my be known by ir histy, presence fluctution, pin, fulness nd throbbing, inbility to extend leg (in psos) from its nturlly flexed condition, bsence tympnitis, gurgling nd diminution in size upon pressure being pplied over tumour. Both feml herni nd bubonocele simulte psos nd ilic bscess, in tht tumour in eir cse diltes on coughing when ptient is mde to ssume erect posture, phloid, which, nd diminishes when recumbent. Hydrocele cd my sometimes so distend tunic vginlis s to give rise to bulging bdomino-inguinl prietes resembling bscess : such swelling tumour is

4 THE INDIAN MEDICAL GAZETTE. 150 usully pinless, does not receive ny impulse from coughing, is smooth, elstic, fluctuting nd semitrnsprent. Ilic, is distinguishble from psos bscess by fmer pointing lwys bove Pouprt's ligment, while ltter presents below it: in fmer we hve not perfect, inbility to extend leg ffected side, which is n invrible nd constnt symptom ltter. Agin ilic bscess ffects dults nd women fter prturition chiefly, wheres psos bscess is me generlly seen in children, nd is usully ssocited with spinl disese. Aneurisml tumours pelvic vessels, which hve ttined some size, my be tken f suppurtive swellings t first, but me minute exmintion will give evidence pulstion cresponding with hert's systole, bruit herd on pplying stescope, diminution in size tumour by pressure upon min rtery t point bove swelling, which cn be emptied by pressure. Such however is reverse with pelvic bscesses, y do not pulste, no bruit is discernible in m, nd pressure does not lter ir dimensions. Encephloid pelvic bones, ten runs n extremely rpid course, nd is likely from its ctive growth, ttendnt pin nd deceptive fluctution, to impress one with belief its being pelvic bscess. The cncerous cchexy should be looked f, nd co existence similr swelling in ny or prt body, should rouse suspicion encephloid : ppernce lrge ttuous veins over surfce tumour will point to medullry cncer, nd ppliction fine trocr in such cses will be extreme vlue in dignosis, s escpe pus is conclusive evidence bscess, while by id microscope we cn determine presence lrger vriety scirrhus cncer cells nd diminutive strom, so chrcteristic encephloid. In Adenoid growths within lymphtic disese known be from lumbr tumours Renl my (Hodgkin). bscess by n exclusion symptoms, s in hydronephrosis, renl hydtid, cystic degenertion renl pelvis, generl derngement system will point to true nture cncer, possibility recognizing ir existence would be nil, in bsence urinry disturbnce, Perinephritic bscess my however point in loin nd be redily tken f true lumbr bscess, but in fmer symptoms re me cute, nd pin deeply seted. The cystic, fibro-eystic, fibrous mlignnt vrieties ovrin disese re distinguishble from pelvic bscesses by ir sitution nd certin concomitnt symptoms. The presence pus within ischio-rectl foss my be scertined by pssing finger into eir rectum vgin, when fluctution cn esily be felt. Tretment.?The surgicl tretment usully dopted, though vrious in ppliction, tends minly to evcution pus, nd prevention decomposition putrefction within bscess cvity : to se ends following procedures hve been rested to : (.) Vlvulr incision. (b.) Lister's ntiseptic method. (c) (d ) Aspirt. Free incisions with without dringe, [June 1, Vlvulr incisions Abernethy hve f ir object exclusion ir from n bscess cvity, nd re mde by tightly drwing side skin covering bscess, n pushing knife directly into sc, nd befe pus hs cesed to flow from opening thus mde, skin is brought into its nml perture in it nd tht in longer directly communicte. This somemy times hs effect totlly keeping out ir nd thus preventing decomposition, nd tension hving been position, so sc no tht removed from bscess wlls, pus my be bsbed, it my re-collect nd require repetition tlii opertion tril some or mesure f its evis cution. Should putrefction tke plce,?which known by pus hving become foetid?it is best to ly open cvity freely 'under ntiseptic precutions f in this wy putrescent pus cn be chnged nd helthy ction set up in disesed prt. So lso, if pus re-ccumultes rpidly, this method cn fvbly be dopted. (b.) Lister's Antiseptic Method.?It is needless to go into minute description this mode treting bscesses, which hs f its design () free evcution pus, (b) complete nd perfect exclusion tmospheric ir unchrged with vp crbolic cid, nd (c) mterils used f dressings, such s will bsb pus nd keep it sweet. To se ends surfce bscess should be thoughly clensed, ll hir nd dherent prticles removed, skin should n be oiled, nd while spry crbolic vp is blown constntly over prts, n incision should be mde, " npus evcuted, nd thick lyer protective nd over this : oil silk piece tiseptic guze" pplied coted with copl vrnish gutt perch tissue previously dipped into crbolic lotion, is plced nd whole bndged so s to leve no prt dressing uncovered. Insted " crbolic guze" used by Press Lister, bcic ointment spred upon bcic lint hs been lrgely nd effectully used in tretment mny glutel, ischio-rectl, ilic, psos nd lumbr bscesses, occurring in out-do Surgicl Clcutt Medicl College under Dr. Lwrie, nd in wrds College Hospitl; in fct Lister's ntiseptic method hs been crried out by mens bcic cid preprtions with such mrked success in ll fms bscess, wounds nd ulcers, under Dr. Lwrie's cre, s to hve given this procedure highest estimtion in minds ll students in his clinicl clss. The superiity bcic cid s n ntiseptic over crbolic cid, is ttributble to its being less voltile nd less irritnt in its effect thn ltter ; fmtion pus is decidedly checked by its use, nd in mny instnces completely rrested, nd putrefction,?if rigid ttention be pid to spry nd creful bndging?is unknown to occur. The cvity bscess my lso be filled with bcic ointment, piece cidulted lint inserted into opening to ct s drin. (c.) The Aspirt is n exhusting syringe, provided with trocr ; fm pprtus in populr use by Dispensry cre Dieulfoy, nd lso simpler rrngement used in

5 June 1, 1880.j PERSONAL EQUIPMENT OF MEDICAL OFFICERS.?BY C. SIETHORPE. Medicl College Hospitl, hve been thoughly described in numbers this journl, in connection with lte Press Gyer's rept on its pplicthe tion in " effusion nd suppurtion in joints." success spirtion in pelvic bscess is dmirbly bne out by fvble results in lrge number recded cses. The pus should not be completely evcuted, s suction cts detrimentlly upon wlls n bscess, cusing sometimes rupture minute rteriole blood from which enters cvity nd is redily converted into pus. After removing fir quntity fluid bndge should be pplied, sufficiently tight, to ssist nd encourge bsption remining pus. (d.) Free incisions with without dringe.?incisions in pelvic bscess re best in cute fm, y should be mde t point swelling in which fluctution is most distinct, t most dependent prt, voiding vessels cutting long ir course, never cross. Free incisions re best, nd opening should be sufficiently lrge to dmit n esy escpe bscess pus, which ought to well out till wlls collpse ; no squeezing should.be hd recourse to. In lumbr psos dependent iipon spinl disese, re no hurry in using knife, but in iscliio-rectl periccocl, erly openings re indicted, s dely my should be led to rupture bscess into bowel from ttenution its wlls by pressure, nd consequent fmtion intrctible fistulse. In pelvic bscesses iginting from trumtic cuses, nd in which it is suspected hemrhge hs tken plce from rupture n rteril tering musculr fibres, s in ilic bscess due to strin, Sir Joseph Fyrer recommends erly incisions ; histy nd symptoms, he sys, being chief guides to dignosis in such cses. In pelvic bscesses pointing in nd bout groin, it hs been recommended (by Press Prtridge Clcutt, I think) to mke incision lwys below Pouprt's ligment,? method which is in vogue in College Hospitl : by this putrefction by entrnce re lessened, nd we hve st vlvulr insted direct communiction with bscess cvity, which is not cse when n incision is mde bove Pouprt's ligment. Dringe is contrivnce by which pus is constntly crried wy from n bscess cvity; its mens chnces ir into pelvic bscess, employment is obviously beneficil, but it should not be continued fter suppurtion flow pus hs cesed, s substnce used n begins to ct s feign body, nd irrittion it occsions ten sets up fresh inflmmty chnges, which, though y sometimes ssist in speedier closure wound, just generlly ten ct injuriously. The substnces used re dinry lint, sme s medicted, roll me recently invented tubes by Chssignc. "These consist nrrow tubes vulcnised Indi-rubber in which openings re mde by cutting out smll ptions with pir scisss t intervls bout qurter n inch, ech opening being 30ut size n dinry pulse ben " ctgut, Lectures). A (Crombie's fked probe is used f ir insertion, 151 but n dinry dressing fceps is just s good; one end tube is llowed to go to bottom bscess cvity, while or *nd hngs out: it is convenient to ttch piece silk ligture to mrgin outer end, s tube my pss completely into cvity, nd this ffds fcility f its extrction. When counter-opening is mde, one end tube is extruded through ech opening, nd both tied toger The medicl tretment pelvic on outer surfce. bscess ims t suppt constitution, which is best chieved by use cod-liver oil, ferruginous tonics, nd stimulnts. The following Tbulr Sttement0 cses is tken from recds Medicl College Hospitl, repts noted in Indin Medicl Gzette from time to time, nd from Army Hospitl Cse-books. * See next pge.