REPORT OF A 
CASE OF PELVIC ABSCESS, 
WITH AUTOPSY. 
Remarks Upon the Treatment. 
By HENRY T. BYFORD, m. d., 
Containing the Discussion of the Chicago Gynecological 
Society, December 18th, 1885. 
CHICAGO: 
CLARK & LONGLEY, PRINTERS. 
1886. Report of a Case oV Pelvic Abscess. 
WITH REMARKS TREATMENT. 
By HENRY T. BYf6rD, m. d., Chicago. 
Mrs. T., aged twenty-five years ; married five years; German 
descent; of nervous temperament; small and slight in figure, 
but in good general health, consulted me, during the fall of the 
year 1884, for sterility and dysmenorrhcea. She had never men- 
struated without pain, but had otherwise enjoyed good health. 
An examination revealed a small uterus and cervix, with 
acute anteflexion and consequent apposition of the anterior 
and posterior uterine walls. Slippery elm tents, used about 
once in eight days, alternated with glycerine tampons, had for 
their effect a gradual relief of the dysmenorrhcea. 
About the middle of the following February, I was called 
to her house to treat her for pelvic cellulitis, contracted a week 
before while returning home from a dance. The whole pelvic 
connective tissue seemed involved, and large tender lumps could 
be felt externally in the left iliac region. 
Six weeks from the beginning of the attack, an abscess 
opened into the anterior wall of the rectum, about two inches 
from the external anal orifice. On account of the extreme 
debility of the patient, her horror of operative procedures, and 
the absence of any well marked fluctuation, all surgical inter- 
ference with the suppurative process had been out of the 
question. 
Attempts were then made at thorough antiseptic treatment, 
but neither elastic nor fle>fible-metal tubes, although easily 
introduced into the abscess, could be tolerated there longer 
than a few hours at a time. Antiseptic irrigations of car- 
bolic and boracic acid solutions, used four times a day, were 
(Read before the Chicago Gynaecological Society, December ISth, 1885.) then relied upon, but were inefficacious, for the pockets often 
discharged foul-smelling pus soon after the dressings. 
In the meantime the pulse remained in the neighborhood 
of 120, and the temperature fluctuated between 990 and 102° 
F.; attacks of acute suffering and septicaemic diarrhoea required 
opiates for their relief; the bacillus tuberculosis was discovered 
in the pus; yellow pigmentary deposits covered her face; 
emaciation became extreme, her weight ranging between eighty- 
two and eighty-three and one-half pounds. Her courage began 
to fail, and finally, after the concurrent recommendation of the 
consultants, Drs. Wm. H. Byford, J. E. Owens, Geo. M. Cham- 
berlin and Martin Matter, she consented to an operation. 
Accordingly, on the 6th of June, Dr. Wm. H. Byford ope- 
rated according to his usual method in such cases. After 
etherization, he forcibly dilated the sphincter of the anus, tore 
open the fistulous track with the finger, and then enlarged the 
opening in the same manner, in the direction of the lowest part 
of the cavity, until it readily admitted two fingers. I then made 
a digital examination, and found the abscess to extend across 
he pelvis, behind the uterus and broad ligaments, to a point 
above the level of the fundus uteri on the left side, and to be 
filled with bands and projecting masses of granulation-tissue 
of about the consistency of freshly coagulated blood. Previ- 
ous treatment, except to diminish and control the septicaemia, 
had evidently been a complete failure. All of this medullary 
tissue was then scooped out with the finger and the cavity 
thoroughly cleansed with a two and a half per cent, solution of 
carbolic acid. 
The highest temperature after the operation was 990 F., on 
the day following. Perfect drainage had been secured, for at 
the time of each dressing no pus was found inside of the 
abscess. 
2 3 
June 12th. Abscess-opening still an inch in diameter, 
without any apparent injiuration about its edges. Tempera- 
ture normal. Patient allowed to get up. Expressed herself 
as feeling perfectly well. 
June 16th. Took a buggy ride with benefit. Weight 
eighty-four pounds.. 
June 23d. A little pus found in the abscess at each dress- 
ing. Sphincter ani firm and contracted, causing some trouble 
by retaining pus, and interfering with irrigation. Attempted 
forcible dilatation with the aid of cocaine hydrochlorate, but 
failed to secure sufficient anaesthesia. Abscess-opening con- 
tracting. 
June 25th. A. M.,*temperature 99 2-50 F.; P. M., 99 3-10. 
June 28th. A. M., temperature 98 4-5. Not much discharge. 
Pain in iliac region and breasts, such as she formerly felt be- 
fore menstruating. Abscess-opening almost closed by the 
uterus being drawn back over it. Would not consent to 
another operation. 
June 29. An increase of discharge. 
June 30. Dilated the abscess-opening with a large sponge 
tent, and washed it out thoroughly. 
July 1. Temperature normal. Pains gone. Weight 
eighty-eight pounds. 
She was now allowed to visit her relatives in Chesterton, 
Indiana, where she came under the care of Dr. D. D. Marr. 
He continued the antiseptic irrigations, and used sponge tents 
as often as the opening contracted. He reported to me as 
follows: 
“July 8th. Patient has gained two and a half pounds 
“ in weight. Pulse 115. 
“July 16. Gain of half a pound. Less discharge. A sup- 
“ pository of iodoform is left in abscess after each dressing. 4 
“July 28th. Patient much improved. Rode twenty miles 
“ a few days ago in a buggy. Heavy (deposits of phosphates in 
“ the urine. A pocket of pus is giving trouble by filling and 
“ discharging. Iodoform insufflations commenced. 
“Aug. 12th. Abscess was closed up for a few days. This 
“ was accompanied by night-sweats and pains, and was soon 
“ followed by a copious discharge of fetid pus.” 
After consulting together, we decided to allow a solid piece 
of sulphate of copper to dissolve in the abscess-cavity. 
Aug. 20th. The doctor writes: “Owing to an epidemic in 
“ a little village near here I have been very busy and put off 
“ reporting Mrs. T’s condition. I placed a piece of sulphate 
“ of copper, weighing a dram and a half, in the abscess (well 
“ up), which had a most wonderful and I hope happy effect. 
“ * * * The opening of the abscess, previous to the using 
“ of the sulphate, was contracted, thickened and indurated, so 
“ that it was quite difficult to introduce a finger, but after tho 
“ use of the remedy the induration and thickening disappeared, 
“ so that two fingers can be inserted, and the opening seems 
“ thin and quite dilatable. I believe this action has extended 
“ over the whole abscess wall, with the exfoliation of the pyo- 
“ genic membrane, which came away in shreds and patches 
“ (much to my surprise). The only inconvenience was that 
there was somewhat of a seeping of the sulphate into the 
“ rectum, which resulted in some irritation. Mrs. T. is im- 
, “ proving, and feeling stronger and greatly encouraged.” 
The abscess healed rapidly after this. Her pulse became 
normal, and her appetite unusually keen. By the first of Sep- 
tember, two weeks after the cauterization, she had gained 
thirteen pounds, declared herself to be as well and strong as 
ever in her life,, and was visiting all over the town in almost 
childish enjoyment- of her regained health and vigor. A 5 
shallow depression was all that was left of the abscess. The 
menstrual flow had not shown itself since the commencement 
of her illness. 
Early in September she was attacked with the then prevalent 
epidemic, dysentery, and died on the 23rd instant. 
At the post-mortem examination, made about thirty hours 
after death, I was somewhat hampered on account of a pro- 
mise, exacted by the husband, that no organ should be taken 
out of the body, and by the fact that I had but thirty minutes 
for work before train-time. The body had again become 
extremely emaciated. Abdomen was flat. An incision was 
made from a little above the umbilicus to the pubic bone. The 
pelvis was filled posteriorly with a solid mass of plastic tissue, 
which had drawn the uterus backwards to within about half 
an inch of the sacrum, so as to put the anterior vaginal wall 
upon the stretch, and had buried the uterus and other pelvic 
organs in its substance. Both round ligaments were seen 
issuing from this mass. It was necessary to cut down about 
half an inch before reaching the depressed uterus, and to tear 
through solid tissue behind it to arrive at the rectuni below. 
The finger broke through into the rectum, behind the dimpled 
cicatrix that marked the site of the former outlet of the 
abscess. The left broad ligament was then felt to be repre- 
sented by, or inclosed in, a tough band half an inch thick 
antero-posteriorly, extending from the uterus to the left side 
of the pelvis. The left ovary could not be found. A small 
flat piece of what seemed, to be ovarian tissue was found 
adhered to the bladder on the right side. The right broad 
ligament was apparently disorganized and inseparable from the 
plastic deposit. The rectum was held inflated at the point 
where it fssued from the pelvis, was dark colored and injected 
on its external surface, and blackish and softened on the 6 
internal. Neither the appearance nor the odor of an abscess 
could anywhere be discovered. 
Allow me in this connection to quote the following extracts 
from a letter, written to me by Dr. Marr on the twenty-eighth 
day of the same month : 
“Yours of the 26th is at hand. * * * Owing to the 
“ hurried examination, I extended it somewhat after you left, 
“ with the result of fully confirming your views of the uterus 
“ and its appendages. * * * I extended the examination 
“ to the alimentary canal, and found the conditions peculiar to 
“ that disease (epidemic dysentery) extending over the whole 
“ of the large intestine and a part of the smaller, with intense 
“ congestion of the stomach and peritoneum. The mucous 
“ membrane the larger bowel was very dark, ulcerated 
“ and sloughy, the inflammation extending to the muscular 
“ coat.” 
There seem to have been two hinges, as it were, upon which 
the treatment of this abscess turned: First, the operation per 
rectum; second, the cauterization by sulphate of copper. 
Both secured a large opening at the lowest portion of the 
pyogenic cavity, and brought away the unhealthy granulation- 
tissue. Had the patient consented to have the unobstructed 
outflow of the pus maintained by one or two subsequent dila- 
tions, similar to the first one, the cure would undoubtedly 
have been more rapid. As it was, the contracting sphincter 
and abscess outlet rendered the drainage and irrigation imper- 
fect. Progress toward recovery was, however, again inaugur- 
ated upon the melting away, by the sulphate of copper, of the 
newly and imperfectly formed cicatricial tissue, reproducing 
the opening made at the time of the operation; and by the 
destruction [of the degenerative deposits, and cauterization of 
the chronic pyogenic surface. The only kind of treatment 
preferable to this free drainage and clearing out method, is the 7 
strictly antiseptic, which, after the pus has once found a way 
into the rectum, can only be accomplished by first closing this 
septic inlet. 
The treatment by a counter opening in the vagina is much 
less preferable, because a recto-vaginal fistula, difficult of cure, 
and liable, like anal fistula, to inoculate the system with tuber- 
culosis, would be left. 
The treatment by abdominal incision cannot for a moment 
be entertained, for at least two reasons: 
ist. It is necessarily followed by a recto-abdominal fistula 
of great length, which is incapable of being promptly cured, 
and is apt to become an unfailing source of systemic infection. 
Those patients already operated upon, as far as reported, have 
usually either died shortly, or within a year or two, imperfectly 
cured. They would have, on an average, lived about as long 
without the operation. In fact, it is not impossible that one 
such, whom I had an opportunity of watching for a short 
time previous to the operation, would finally have recovered 
through the process of nature. To operate as does Lawson 
Tait, before the abscess has discharged, and then treat it anti- 
septically through its single opening, is an entirely different 
matter. 
2nd. The danger of an abdominal incision should never be 
incurred without a prospect of compensatinion the way of 
bettering the patient’s chances of recovery. Neither theory 
nor practice as yet proves such compensation to be attainable. 
In some cases one dilatation per rectum,'without after-treat- 
ment, has sufficed for a cure; in other cases two or more,with 
subsequent antiseptic irrigations, have become necessary. But 
as a general rule it may be said that,'unless instituted too late, 
the procedure is safe and the recovery sure. 
3100 Forest Avenue. 8 
Professor Christian Fenger made some remarks on lapa- 
rotomy as compared with other operations, of which the fol- 
lowing is a brief abstract: 
When a peri-uterine abscess points somewhere in the vag- 
ina around the lower part of the uterus, no surgeon would, of 
course, think of doing anything but opening the abscess, in- 
serting a drainage tube, and by washing out, endeavoring to 
effect the closure of the cavity. But in some cases the open- 
ing into the vagina is just as ineffective as a spontaneous open- 
ing into the rectum. In obstinate cases of this kind laparoto- 
my, at a later period, will have to be performed. 
There is, however, no doubt that secondary invasion of 
septic poison, when the abscess is opened from the vagina, is 
much more difficult to prevent than invasion into the abscess 
from the abdominal opening. It is only in this way that we 
can account for the difference in the course of the after-treat- 
ment of peri-uterine. abscesses opened through the vagina 
and through the abdominal cavity; a difference that Law- 
son Tait rightly calls attention to as being decidedly in favor of 
the abdominal operation. Here the abscess closes more 
quickly, and the course of the after-treatment is much less 
febrile than in the vaginal operation. 
Sometimes a peri-uterine abscess will point into the rectum, 
sufficiently low down to permit of an opening here. It does 
not seem probable that the access from the rectum will be 
very promising, as effective drainage is next to impossible; 
but the cases of cure by spontaneous opening into the rectum 
evidently make an operation here permissible, and perhaps 
advisable, but only as a trial. If the abscess does not retract 
within a reasonable time, other measures must be resorted to. 
It is needless to state that if a parametritic abscess points 
DISCUSSION. 9 
anywhere along the iliac fossa, it should be opened and drained 
from this point; but this does not belong to my subject of to- 
night, as 1 desire to call attention only to strictly circum-uterine 
abscesses, which can only be reached from the vagina or from 
the supra-pubic region. 
When a circum-uterine abscess does not point downward, 
and, in fact, does not point anywhere, it is then the surgeon’s 
task to find the safest way into the abscess through a smaller 
or larger amount of surrounding tissues. 
We shall first consider the vaginal operation : 
When so eminent an authority as Schroder, of Berlin, advo- 
cates this method of reaching a high peri-uterine abscess there 
must be cases in which this operation is advisable. From a 
general point of view an extra-peritoneal outlet of the abscess 
through the vagina would seem to be safer than laparotomy, 
upon the same grounds as a vaginal hysterectomy is safer 
than Freund’s abdominal hysterectomy, and Schroder’s suc- 
cessful operation, already mentioned, vouches for the method. 
At the same time, I firmly agree with Lawson Tait, that 
there are some grave objections to the vaginal operation. In 
the first place, a high-seated peri-uterine abscess is difficult to 
reach. It is difficult to work with safety two or three inches 
above the introitus of the vagina, in tissues that are immov- 
able, and where the parts cannot be drawn down toward the 
operator. These difficulties are, of course, of less importance 
in the master hands of an operator like Schroder, but increase 
i n significance for less experienced surgeons. 
But the operation through the vagina is more or less an 
operation in the dark. We may be dissecting up along the 
posterior surface of the neck of the uterus, and may open 
into recesses of the peritoneal cavity between the abscess and 10 
the uterus. Further, it might be easy in this place to open 
into the rectum. 
Another danger, especially in abscesses between the two 
layers of the lateral ligament, might easily arise from the rup- 
ture of the large uterine vessels running in the wall of the sac. 
It would be exceedingly difficult, and I should say next to 
impossible, under such circumstances, to secure and ligate 
these vessels, the point of ligation being so high up, the 
working space so small, and the tissues so immovable. 
All those objections and dangers we do not encounter in 
laparotomy. We can see distinctly, and recognize with our 
own eyes, every particle of tissue we have to divide; the large 
uterine vessels, if divided, can easily be taken up and ligated. 
There is no risk of having any communication between the 
abscess and the peritoneal cavity, which we cannot either close 
up or drain. 
If the laparotomy lasts longer, and gives more technical 
work to the surgeon, it seems to me that these objections are 
fully balanced by the advantage of not being obliged to ope- 
rate in the dark, of not having to battle with enemies that we 
cannot see, and consequently cannot guard against. 
But these are not the only advantages of laparotomy, as 
compared with the vaginal operation. The free access to the 
whole interior of the abscess cavity has also to be taken into 
account. By laparotomy, the abscess is laid open to about 
the same extent as a tubercular peri-articular abscess. We 
can examine the whole interior of such a cavity, and scrape off, 
or remove by other means, whatever objectionable material 
we may find, cheesy matter, tuberculous tissue, fungoid gran- 
ulations—since we can see clearly every place where the in- 
strument is applied, without any danger of going through the 
abscess wall into any surrounding cavity or organ. 11 
It is more than possible that this free access to the abscess 
wall has something to do with the speedy recovery subsequent 
to laparotomy, as compared with the vaginal operation.* 
But, of course, there will always be connected with laparo- 
tomy the inherited dread of opening that ominous peritoneal 
cavity. Modern surgery, however, is making steady progress 
in diminishing these dangers. Thus, the dread, as well as the 
safety of the patient, will, to a great extent, rest in, or depend 
upon, the care and skill ot the operator. 
Professor W. H. Byford: I do not wish to comment upon 
the contents of the paper further than to express myself in 
reference to the mode of operating adopted in consultation 
with the gentlemen mentioned. A large number of pelvic 
abscesses can be managed through the rectum with more 
facility and safety, than any other medium of approach to the 
deep-seated portions of the pelvic cavity. I do not know 
whether there are any cases wholly situated in the pelvic cavity, 
but that can be reached, opened and evacuated through the 
rectum. It may not always be the most eligible direction to 
approach collections of pus. In instances in which the pus 
is making its way toward the vagina, and fluctuation can be felt 
through the vaginal walls, it ought to be evacuated through 
that canal; but when the point of discharge is not thus indi- 
cated the exploration is most easily made through the rectum; 
and all chronic cases that have already commenced to discharge 
into the rectum can and ought to be treated from the cavity 
of that viscus. I would make ao exception, however high the 
opening might be, so it was within the pelvic cavity. By 
proper preparation the whole length of the rectum can be reached 
from the sphincter to the promontory of the sacrum, and from 
any part of it the pus evacuated; the pyogenic cavity explored 
and drainage and irrigation safely and securely accomplished. 
* Lawson Tait, op. cit. 12 
I believe the dangers of this mode of operating to be incom- 
parably less than by abdominal section; and the other results 
of the operation—such as drainage and disinfection—more 
complete. 
To effect the objects mentioned, the sphincter should be 
stretched to laceration; and until there is no tendency to 
immediate contractions of the anal opening, and till it can be di- 
N 
lated to the full extent of the rectal cavity. Thus thoroughly 
opened, the whole extent of the rectum can be explored with 
great facility and often by means of dilators can be seen, and 
instruments used under the eye of the operator. 
If the pus is to be sought after, palpation with the fingers 
becomes easy and satisfactory; if it is being evacuated, the ori- 
fice seen or felt and such treatment as is desired applied. I 
very much prefer stretching and tearing for the purpose of 
increasing the size of the discharging orifice to the use of cut- 
ting instruments. The opening will not so readily close and 
there will not be so much haemorrhage. 
In effecting the discharge of th($pus, we should remember 
that the reason why the pyogenic cavity is at no time wholly 
obliterated is because there are irregular loculi or pockets so 
situated that they do not empty themselves. The opening 
should therefore be made large; the parts torn by the fingers 
until this inferior margin of the opening is as far below the 
main body of the cavity as practicable. With the fingers the 
interior bands and partitions should be completely broken 
down and the interior of the -cavity rendered as nearly sym- 
metrical as possible. This will enable the whole of the contents 
of the cavity to escape by means of gravity, and the fluids 
used in irrigation find their way out without difficulty. In 
addition to this shaping of the cavity, the large granulations— 
generally so abundant—should be scraped away by the fingers 13 
or by a dull curette, thus freshening up the lining membrane 
of the pyogenic cavity and converting it from a state of indo- 
lent ulceration to one disposed to heal. This process of 
curetting also produces a change in the capillary circulation 
that makes nutritive processes more salutary. Often in very 
indolent cases the sphincter will recover contractile power to 
such a degree as to require one or more repetitions of the op- 
eration. The same thing may be said of the margin of the 
orifice in the intestine. We will be obliged to enlarge it and 
treat the cavity as before. 
In the case narrated in the paper, the action of the sulphate 
of copper seemed most useful and contributed the last influence 
necessary to the cure. 
I have said nothing about the more common items of treat- 
ment, such as irrigation, disinfection and stimulation. My 
intention is to show the facility with which, in many instances, 
these purulent collections can be reached and treated by dilat- 
ing and distending the rectum and the comparative safety ot 
such proceedings. 
Professor E. C. Dudley : The experience of Dr. Byford 
and others in the treatment of pelvic abscess by this operation 
must be considered as proving the great value of the operation 
in cases in which the abscess can be easily approached and 
thoroughly drained by dilatation of a sinus between the ab- 
scess-cavity and the rectum. It would, however, appear on 
general principles, that sufficiently free and long-continued 
drainage would in many cases be almost unattainable and that 
an abscess-cavity left thus to heal must often be the starting 
point of sinuses formed by the uncontrolled burrowing of pus 
in many directions. The almost inevitable invasion of the 
abscess-cavity by fecal matter is clearly a serious factor in 
connection with the history of these cases. The great mor- 14 
tality from pelvic abscesses opening spontaneously into the 
bowel demonstrates the inability of nature to provide for ade- 
quate drainage. Whatever question, therefore, we may raise 
relative to the advanced position of Dr. Wm. H. Byford, who, 
if practicable, would prefer to open a pelvic abscess through 
the rectum—even in those cases in which nature has not antic- 
ipated him—there can be no question about the propriety of 
enlarging and rendering more effective an opening already 
formed. I regret that the essayist has marred a most admirable 
contribution by the sweeping statement that in all cases in 
which drainage has been spontaneously established through the 
rectum Lawson Tait’s operation is contra-indicated. Nor can I 
imagine from what premises he has formed the conclusion 
that Tait’s operation prevents closure of the sinus between 
the abscess-cavity and the rectum. The question naturally 
arises whether Tait’s operation might not in such cases fulfil a 
well recognized surgical indication by establishing a free 
counter-opening for an abscess which otherwise might re- 
fuse to close on account of imperfect drainage and on 
account of its forming a blind sac for the retention of fecal 
matter. To a larger number of recognized authorities, who 
deem an opening into the rectum, whether produced by 
nature or by art, a grave misfortune, the query would 
naturally arise whether such an opening ought not to be 
supplemented by a counter-opening, which would bring the 
draining and cleansing of the abscess-cavity within the easy 
and absolute control of the surgeon. Furthermore, in 
view of the decided mortality which attends the spontaneous 
opening of pelvic abscesses into the rectum, and in view of 
the almost uniformly successful results recorded in the 
statistics of Tait’s operation already published by Mr. Tait 
and others, and in view of a very generally accepted rule 15 
that the operator in opening a pelvic abscess should strive 
to keep out of the rectum, I don’t think a statement that 
the rectum is to be preferred as the site of the primary 
operation ought to go on the records of this society un- 
challenged. 
Professor J. T. Jelks (present by invitation) thought a 
great mistake was made in waiting too long before operat- 
ing in cases of chronic pelvic abscess. 
Dr. Philip Adolphus thought the paper was beyond the 
pale of criticism. When the general symptoms indicated a 
collection of pus, the cavity should be searched for. If a 
cavity containing serum was found, an operation was contra- 
indicated. If the cavity contained pus, it should be evacu- 
ated. 
In closing the discussion, Dr. Henry T. Byford objected 
to the quotation of Lawson Tait’s statistical triumphs in this 
connection. In the last edition*of Tait’s Diseases of the 
Ovaries, abdominal section is recommended for those pelvic 
abscesses only that cannot be successfully evacuated from be- 
low. They are generally such as are situated high up, and 
do not point early in the vagina or rectum, or they are sup- 
purating hamiatoceles. 
The statement that the recto-abdominal fistula, left after 
abdominal section for a pelvic abscess that has already dis- 
charged into the rectum, would heal readily, like any artifi- 
cial anus, is not borne out by facts. Fistula? connecting the 
rectum with the external air have seldom healed, when left 
to themselves, before a long period of time had elapsed. 
Radical operative measures cannot (in these cases) be 
resorted to on account of the length, situation and relations, 
of the fistulous track.