Smaller pus centres usually evacuate themselves through a laceration in the cervix, which most probably was the starting-point of the process. Without previous symptoms of suppuration, small quantities of pus often quite suddenly escape through the vagina. The discharge of pus may last for several days or may for weeks with occasional interruptions. By digital examination the opening is usually not found, but by the aid of a speculum we have several times seen it in a laceration of the cervix.
The next most frequent point of evacuation is above Poupart's liga ment. In this locality the pus usually appears after the fever has lasted from three to six weeks. This region becomes painful and hard; later we find small soft spots that pit on pressure, then appears a circumscribed elevation in the course of Poupart's ligament, the centre of which becomes softened. Finally the skin over the ligament, usually at its centre, rup tures, and a smaller or larger quantity of pus is evacuated, at times in more than one place.
Only part of the mass of exudation degenerates, and after the discharge of pus, it is only slightly diminished in size.
Absorption may take place even after pain, elevation, and reddening about Poupart's ligament have occurred, and this fact proves that, as we have already stated, fully developed pus centres may be absorbed.
The course of cases that evacuate at Poupart's ligament is usually favorable. The discharge of pus, which gradually becomes thin and finally serous, lasts from one to two weeks; but even this variety may run a tedious unfavorable course, with the formation of sinuses.
Other rupture sites are rarely seen, and then only very late in the disease, in which case the pus cavities exist for a long time, on account of being remote from the point of perforation. Several times we have seen pus escape through the sacro-sciatic formen, in which cases the su perior and inferior borders of the gluteus maximus were perforated. In one case where the vesico-vaginal septum was implicated, the opening closed only after fifteen months, in another case only after two and a half years.
We have often seen pus centres gradually discharge through the blad der, without giving rise to special pain. The presence of large quantities of pus in the urine, and a frequent desire to micturate, called attention to it. Nearly as often the pus escapes in large quantities through the rectum accompanied by diarrhoea.
Rarely does a parametric abscess rupture at a point higher up in the abdominal wall. Cases where sub-peritoneal abscesses evacuate near the navel, as mentioned by Leopold and Lomer, are very rare; as also are the cases where an abscess evacuates through the quadratus lumborum, as reported by Meinert; still more rare is the evacuation of these abscesses through the perineum or labia majors. Very rarely it is observed that
while the surroundings of the uterus are free, suppuration takes place in hard muse:: remote from this organ. The masses remaining in the psoas and iliacus often undergo suppuration very late, constituting the so called ilio-psoas abscesses, and they usually evacuate under Poupart's liga ment.
Most of the cases in which the pus escaped through a single opening, although often lasting for a long time with severe consequences, termi nated in recovery. There are other cases where pus centres form in differ ent portions of large masses of exudation, communicating with each other by sinuses, and here rupture usually occurs through more than one open ing; occasionally one of these openings may become closed, the symptoms abate, and it seems as though recovery would take place, but soon new perforations occur accompanied by hectic fever, leading to a fatal termi nation in spite of surgical treatment. In a few cases, of which only one terminated without contraction of the hip joint, we saw the patients suc cumb after the lapse of one to four years from the beginning of suppu ration. In the case that lasted four years, several perforations occurred above and below Poupart's ligament, others between the anterior superior and inferior spines of the ilium, one at the lower border of the gluteus maximns, and in the course of the disease the bladder and rectum be came also perforated. In spite of the large amount of pus evacuated daily, there were not found on examination extensive pus cavities, but the whole left side of the pelvis was filled with hard masses, which extended to the iliac foram, and these masses were invaded by smaller or larger pus centres, which communicated with each other as well as externally. In another instance, with a large amount of pelvic exudation, several per forations occurred, and in the course of the disease a portion of intestine became adherent to the abscess wall, and was perforated so that fieces escaped with the pus just below the anterior superior spine, and the patient died after the process had lasted for a year. Less frequently large abscesses are formed in the pelvic cellular tissue, and when they are they may give rise to no marked fever or seriously impair the health of the patient. But the pus extensively destroys the soft parts of the pelvis, in volving its muscles and bony wall.