A system of practical medicine. By American authors. Vol. 4

by Unknown

The best method of washing out the cavity is by the fountain syringe, to which a long double canula can be attached; or, probably better, the syphon. It would be unsafe to force water into the sac.

It is well for the patient if the situation of the abscess be such as to render its evacuation through the vagina feasible, for then the opening is made at the most dependent portion, and consequently drainage is more easily and thoroughly accomplished; but, unfortunately, the location of the tumor may be so high up as to compel the removal of the pus through the abdominal wall.

Almost the same rules as to the selection of the method of operating and of the election of the point for puncture or incision will apply here as in the operation through the vagina, provided pointing has taken place. I am less favorable to aspiration, however, when the puncture must be made through the walls of the abdomen—first, because reaccumulation is almost certain to take place; and, second, because there is danger of leakage of pus into the peritoneal cavity, since it is difficult by this means to thoroughly empty the sac, and impossible to wash it out and keep it drained.

If pointing has occurred, a free incision should be made at once and the cavity thoroughly emptied, and, if necessary, washed out. The opening must not be permitted to close until the cavity has healed from the bottom.

Where pointing has not occurred and the abscess is so deeply seated that it cannot be safely reached from the vagina, and does not distend the abdominal walls, I would urge greater delay, in the hope that it may approach the surface more nearly. If, however, the condition of the patient be such as to demand immediate action, the operation of laparotomy should be selected as the more thorough and less dangerous method of releasing the pus and of after-treating the abscess.

An incision two inches in length should be made through the linea alba, midway between the umbilicus and pubes, and, after all bleeding is stanched, the peritoneal cavity opened. The index finger should then be passed in and the surface of the abscess-wall explored. It will be a fortunate circumstance if the sac be found adherent to the peritoneal surface, where the incision is made, for it can then be opened without entering the peritoneal cavity. To prevent the escape of pus into this cavity the sac should now be evacuated with great care. For this purpose the aspirator is well adapted, but a small trocar, to which a few feet of rubber tubing has been previously attached, through which to conduct the pus into a convenient receptacle, will answer almost as well. The opening in the sac should next be slightly enlarged by an incision (not torn); it should then be included in the sutures, which are now placed to close the abdominal wound. After the sutures have been introduced the pus-cavity should be washed out with the bichloride or carbolic-acid solution, and a glass drainage-tube placed in the lower angle of the incision, when the edges can be brought together and adjusted around it.

The after-treatment required will be the same as if the opening had been made through the vagina.

The sac must be made to close from the bottom. It may become necessary to stimulate the surface by the injection of a weak solution of nitrate of silver, four to eight grains to the ounce of distilled water, or with the tincture of iodine, one part to four of water.

Cases are sometimes met with in which the pus has burrowed and formed sinuous tracts which are difficult to reach and drain. It may then be necessary to make a counter-opening in the vagina after first cutting through the abdominal wall. These are usually old, neglected, chronic cases, in which the abscess has discharged spontaneously into the bowel too high up to be properly emptied, or which have opened into the bladder or somewhere on the abdominal wall, or possibly taken one of the circuitous routes alluded to under the head of Pathology.

No fixed rule can be set down for the management of these grave cases. Each one must be treated on its individual merits. A ripe experience and judgment are necessary here to decide whether it is best to operate or to pursue a course of masterly inactivity, depending upon the use of hygienic and tonic remedies and time to bring about a cure. I have known instances where patients have recovered spontaneously after having been reduced to the lowest extremity. I have also known others who have died soon after submitting to operative interference. Some of the spontaneous recoveries, however, are only apparent, for the old sinuses often reopen and discharge pus as before, or the pus may be discharged at some new and remote point, the patient finally succumbing to the ravages of a disease from which she flattered herself she had escaped.