When the contents are purulent. it is better to make a free opening that will easily admit the finger. If the wall that separates the abscess from the vagina is thin we may by using Sims's speculum incise it with a bistoury at the most prominent point and enlarge it with a blunt-pointed bistoury. When the wall is thick it is advisable to open it layer by layer, in order to be able to control hemorrhage or to avoid the ureter when the incision is made high up. To facilitate the evacuation of the contents, and for washing out the cavity with a two to three per cent. solution of carbolic acid, it is advisable to introduce a glass or rubber drainage tube.
Large abscesses projecting into the abdominal wall can be opened through these walls, and if they communicate with an abscess in Douglas's cul-de-sac it is advantageous to pass a drainage tube from the abdominal wall into the vagina. In this way A. Hegar opened an abscess in the lines alba successfully.
Incision of Parametric Abscesses.—Authorities differ as to whether it is better to open these abscesses early or wait for a spontaneous opening. These different opinions result from the fact that some authors made their observations on the more frequent smaller pus centres in hard masses of exudation, while others dealt with the rarer large pelvic abscesses. Scanzoni, C. Braun, M. Duncan, Schroder and others are not in favor of early opening of these abscesses, which principle is correct according to our experience with abscesses originating in hard masses of exudation in the pelvic cellular tissue; because it is frequently observed that these masses become absorbed after having caused circumscribed redness or even bulging over the outer half of Poupart's ligament. Another reason is that the pus centres are often remote from the surface and only occupy a small space in the mass, and can be detected only by inflicting serious injury, which would be justifiable only if we were certain that the whole mass of exudation would rapidly undergo suppuration and evacuation after opening the abscess; but as it often happens that comparatively small collections of pus, which open spontaneously, soon become closed, and the major part of the hard mass has to undergo absorption, it is more practical in such cases to allow the pus to reach the surface and perhaps to promote this by poultices.
If these abscesses after becoming superficial do not open spontaneously, or if there is reason to believe that they are the cause of severe fever, septic poisoning or extension of the inflammatory process, we should not hesitate to open them.
Surgical interference is indicated in all cases where it is evident that large formed in or about the pelvis. The treatment is the same whether they originate in the peritoneum or parametrium, for in large abscesses it is practically impossible to distinguish between the two forms. It is best to open them where they approach the surface and where the pus can have a free exit. If the abscess bulges into the vagina it can be opened there, but we should avoid opening them through the rectum, because, besides the fact that faeces may find their way into the abscess cavity, the after-treatment is more difficult. On the abdomen we should evacuate below the point of reflection of the peritoneum—that is to say, a little above and external to the middle of Poupart's ligament.
A. Hegar has for some time endeavored to treat surgically at an early date even deep-seated parametric abscesses. He proposed in suitable cases
to make an incision over Poupart's ligament, push the peritoneum to one side, and go down deep outside of it along the horizontal ramus of the pubis. In this way it is easy to reach the side of the bladder and base of the broad ligament. Hegar has also tried to find deep parametric abscesses through the ischio-rectal fossa. After dividing the skin and superficial fascia from the tuberosity of the ischium to the tip of the coccyx, the finger can easily penetrate through the loose adipose tissue to the inferior and external surface of the elevator ani, and from thence with a little more difficulty to the seat of the parametric abscess.
order to reach a prognosis in inflammatory diseases of the pelvic organs it is necessary to consider their etiology and the severity and duration of the ushering-in symptoms. If the disease occur in child bed or follows operations on the genital tract of non-pregnant women, and if it is accompanied by a continued frequent pulse (140 to 160) and a temperature of from 104° to 106° F., and a peculiar changed expression in the face, indicating that severe constitutional disturbance is present, the process is usually caused by intense infection and the prognosis is as a rule unfavorable. Although the severer symptoms of septicaemia are absent, the prognosis is doubtful when the pelvic peritoneum is involved, becoming more grave in proportion to the range of the fever, tenderness and tympanites. With these symptoms the patient may recover in from six to ten days, or die within the same time from general peritonitis. A favorable prognosis as to recovery may be made in cases where the peritonitis is limited to the deeper portion of the pelvis, or to the coverings of single organs, or if the process is subacute from the beginning. These cases are not attended by high fever, tenderness or tympanites.
The longer the process lasts, and the higher the temperature, the more serious are the consequences If of short duration it may leave no trace, but if of long standing the patient may become an invalid for life. When lasting from six to fourteen days the prognosis as regards life may he favorable, although adhesions between the uterine annexe and the abdominal wall may have formed. The longer the inflammatory process lasts the more probable it is that the uterus, ovaries, Fallopian tubes and the sub-peritoneal connective tissue participate in the disease. The more organs involved the more serious tile consequences.
The most favorable prognosis in every respect can be made in cases attended by fever only from two to four days, and in which the pelvic peritoneum was only slightly involved. The mass of exudation in these cases may become absorbed in from eight to fourteen days, and the patients entirely recover.
The formation of pus centres in hard masses of exudation, and the formation of external sinuses do not render the prognosis unfavorable; on the contrary it is frequently observed that in these cases the hard masses of exudation become more rapidly absorbed. Also when these masses suppurate and form abscesses which are evacuated spontaneously or artificially the prognosis is about the same. On the other hand the prognosis is very unfavorable in those fortunately rare eases where, in extensive masses of exudation, pus centres and fistula' extend in every direction, and evacuate by multiple openings. Many of the patients suc cumb from long-continued suppuration.