PELVIC ABSCESS.

With a Case Reported to the St. Louis Medical Society.

By Wм. S. EDGAR, M.D., St. Louis.

The patient from whom this portion of rectum was removed post mortem was a long time confined to his bed with a low grade of fever, and suffering acute pain in the lumbar and pelvic regions. Psoas abscess was diagnosed at first, but as no discovery of pus was made in the course of the psoas muscles, the case was in doubt until pus was discharged from the bowels, showing, if it had originated in the course of the psoas muscles, it had taken a different direction, and descended into the sub-peritoneal tissue of the pelvis back of the rectum, thence ulcerating through into the rectum.

When it was suspected an abscess had opened into the bowel, a favorable prognosis was indulged, and for twenty days the patient seemed to improve, when suddenly acute pain occurred in the lower part of the pelvis. All action of the bowels was suspended, and peritoneal inflammation set in, which soon terminated in death.

On post mortem examination, it was revealed that the walls of the abscess had given way, emptying its contents into the pelvic cavity, together with the contents of the bowels, which now passed through the opening from the alimentary canal into the sac of the abscess, and thence into the pelvic cavity.

Abscesses of less dimensions often form in the vicinity of the rectum, and discharge into it, or follow it down to the sphincter, terminating in fistula.

In the female they form more frequently in connection with the appendages of the uterus, either from extravasation of blood from rupture of vessels connected with its ligaments, or from the escape of blood from the Fallopian tubes ; also from traumatic causes.

*The parts involved were presented to the Society for inspection.

The extreme importance of a careful physical examination of the entire topography of the pelvic region, until the exact character and location of the disease is discovered, is well illustrated in the following case:

In January last I was requested to see a lady in consultation with her physician, Dr. CRAIG, of Arcadia, Illinois. The lady had been confined to her bed three weeks with a low grade of fever, and much pain in the back and pelvic regions, constipated bowels, and incontinence of urine.

Disease of the bladder or uterus, or both, was suspected, but the exact condition not known. The suffering was much the same as is common in pelvic cellulitis, except that the difficulty of retaining urine was greater.

A sound was passed into the bladder, to determine the presence of calculi, with negative result, except that the posterior wall of the bladder was thrust forward. Suspecting that the uterus was resting against the bladder by the deviation of that organ termed anteversion, digital examination was made in the vagina, which discovered the os uteri resting hard against the rectum, the fundus forward against the bladder, resisting attempts with the sound to rectify it. Also, an unusual tumefaction and pressure was perceived above the os uteri, at the cul-de-sac of the vagina.

Injections of warm water were used to clear the rectum, and digital examination in the rectum and vagina were made at the same time (the index finger of each hand being used); fluctuation was perceived between the vagina and rectum high up. A bivalve speculum was next introduced into the rectum (after the patient was chloroformed), and an exploring needle passed in the direction of the fluctuation through the walls of the bowel. On the withdrawal of the instrument, pus was observed in the groove. A trocar was now pushed in the track of the exploring needle, the speculum was withdrawn, as well as the trocar, when pus escaped through the cannula to the amount of a pint. Thus was the abscess discovered and tapped, to the great relief of the patient, who ultimately recovered perfect health.

This abscess was situated between the rectum and uterus, pressing the rectum, causing pain in that organ and constipation; also pressing forward against the uterus, carrying that organ against the bladder, preventing the accumulation of urine, and creating a constant desire to pass it as it entered the bladder.

Of course, simultaneously with the evacuation of the contents of the tumor, relief came to all these parts.

I suspect these abscesses are more frequent than is apprehended, only a more searching and critical physical examination is needed to demonstrate the fact; and the failure to discover at an early moment and properly treat these occurrences of pelvic cellulitis, is a fruitful source of permanently impaired health. Particularly is this the case with those practitioners who are in the habit of referring disease to derangements of the "vital principle" as the primary cause of all ailments. Constitutional remedies are always in requisition by them, to the constant neglect of local disease and local treatment, until months and ever years pass without the true nature of the disease being discovered, or anything done to remove it. In some instances we have met with, a simple digital examination per vaginam would have disclosed the true character of the disease and saved the sufferer years of pain and infirmity. In one case we found the remains of an abscess, of fibroid consistence, two inches in diameter and from one-half to three-fourths of an inch in thickness, occupying the space between the uterus and rectum, and descending between the walls of the vagina and rectum. This case had been of over three years' standing; from the history given by the patient, it probably originated in extravasation of blood from rupture of vessels connected with one of the broad ligaments of the uterus, and was treated all this time by a quasi homœopath for "rheumatic or neuralgic derangement." The proper examination at an early day would doubtless have discovered an abscess in the cellular substance between the folds of peritoneum, as in the case above described,

persistently displacing the uterus anteriorly, to the great discomfort of the bladder and the descending bowel by pressure of the tumor in that direction likewise.

While we cannot approve the examination, either digital or by speculum, of females for slight ailments, when the disease is serious enough to require a prescription every few days for months we believe it criminal neglect to continue guessing and groping in the dark, when a careful physical examination might at once afford the demonstration of what is necessary for permanent relief.

ON THE differenTIAL DIAGNOSIS OF DISEASES OF THE ABDOMINAL VISCERA.

Read before the St. Louis Medical Society, June 26th, by G. HURT, M.D., St. Louis.

Our success in the diagnosis of diseases of the internal organs will depend much upon the accuracy of our knowledge of their anatomical and functional relations.

We detect disease by the existence of certain phenomena called symptoms, which consist for the most part of perverted, exaggerated, suspended, or otherwise deranged functional action. But the same symptoms are common to several varieties and grades of disease, and in fact to those of an opposite pathological character, constituting a frequent source of error in diagnosis. Pain, for example, which is a pathognomonic symptom of neuralgia, is likewise a prominent symptom of inflammation, and is often present in many other forms of disease.

It is not so much, then, to the simple presence of a particular symptom as it is to the different grades and modifications which it may present, that we are to look for success in the diagnosis of diseases of the internal viscera.

But in studying the character and import of symptoms, the character and susceptibility of the textures involved must likewise be considered. For, as a rule, the symptoms will depend upon the nature and extent of the lesion,

together with the quality and susceptibility of the textures involved; and hence, if the lesion be inflammatory and recent, and involve the muscular and parenchymatous textures, the inflammation will probably be of the acute sthenic grade, and the pain will be more or less continuous and throbbing, with occasional exacerbations which are described as lancinating. But if the mucous and cellular tissues are alone involved, the pain is usually obtuse or dull. But pain in the abdomen may be also a symptom of mechanical distention from repletion, or of muscular contraction, excited by the presence of morbid secretions or unhealthy or too long retained ingesta, and in distinguishing between pain as a symptom of these different kinds of lesion, it is important to bear in mind the fact that in inflammation the pain is continuous, and attended with more or less soreness and tenderness on pressure over the parts affected, whereas in the absence of inflammation the pain, though ever so violent at times, is disposed to remit or intermit occasionally, and is usually relieved by pressure. In inflammation there is also more or less fever, with acceleration of pulse, while in the neuralgias the temperature and pulse are usually normal.

But it happens frequently that inflammations supervene in the course of other diseases, a complication which it is of the utmost importance to be understood before any plan of treatment is adopted. Under such circumstances it may be necessary to note farther

Ist. The position of the patient, and whether he lies quiet, as if afraid to move, or is tossing from side to side.

2d. Whether the abdomen is full or empty, hard or elastic, smooth and flaccid or irregular and full of lumps.

3d. Whether the tongue is moist and clean, or dry and furred; whether pale and flaccid, or red and contracted. 4th. Whether the urine is copious, scanty, or entirely suppressed.

A well directed inquiry into these several points will be of great service in determining the nature of the lesion.