Chapter II
.)
It is seldom that a superficial collection of pus can be mistaken for anything else. In small and superficial abscesses (boils, furuncles) as pus approaches the superficial layer (epidermis) of the skin it may be discovered through its thin covering. In deep lesions there is often a doubt, even on the part of the most experienced. The measure now usually resorted to for purposes of diagnosis and exact recognition is the exploring or aspirating needle. The old exploring needle was one of good size, having a groove along which, after introduction, pus might pass. Since the almost universal use of the hypodermic syringe, a small aspirating needle attached to the ordinary syringe is the measure commonly adopted. Such a needle may be introduced into the brain, into the liver, or into almost any and every soft tissue without danger, and if properly manipulated is almost sure to facilitate detection of pus. Exploration done with either of these means and for this purpose should always be conducted as an aseptic, even if a minor operation, in order that no extra infection may be added from without. The skin should be carefully washed, the needle sterilized, etc.
It is good surgery to resort to the knife either for the above purpose or in order that by a longer incision or by opening the cavity deep exploration may be made. Such explorations are of benefit even though a circumscribed collection of pus is not found, since by relief of tension and local abstraction of blood they act in a revulsive way and do much good. Acting upon the same principle the trephine or the bone chisel may be used for the purpose of opening the cranium and exploring for pus, or of opening into the medullary canal of the long bones and hunting there for that which is suspected.
=Treatment.=--As soon as suppuration threatens speedy measures should be adopted, either for the purpose of bringing about resorption, or of favoring and hastening suppuration. In theory antiseptic applications are demanded; in practice they are sometimes of benefit. These may consist of mere soothing applications, as a lead and opium wash, or some other wet or dry astringent applied upon the surface; or they may consist of cold applications, which by their astringent action will limit the amount of exudate and prevent its further infection. Or advantage may be taken of the properties of moist heat, and the application of hot poultices or fomentations may encourage exudation, but particularly quicken superficial breaking down, and thus hasten the time when the phlegmon shall point, or come sufficiently close to the surface to show that its contents are pus and permit of evacuation. Such local applications, therefore, give relief from pain and hasten favorably the suppurative process. In cases of phlegmonous infiltration, the application of an ointment composed of resorcin 5, ichthyol 10, mercurial ointment 35, and lanolin 50 parts, or else the Credé silver ointment, is beneficial. Under the influence of these antiseptic and sorbefacient preparations, and of moist heat, many phlegmonous infiltrations assume a kindlier type, and may secure the actual resorption of pus.
Finally in almost every case pus must be evacuated. Here the universal rule may be applied, to which there are practically no exceptions, and which should be stamped on the mind of every student and young practitioner. It is--that _pus left to itself will do more harm than will the knife of the surgeon if judiciously used for its evacuation_.
## Action taken in accordance with this rule may be considered wise and
timely. The operation of evacuation may at one time be a mere puncture, or possibly the aspirating needle alone will be enough; at other times it requires extensive and careful dissection and entails no little responsibility. This is particularly true in such deep-seated suppurations as those around the appendix and in the brain, while in the deep-seated bone lesions of this character the use of the bone chisel or the cutting forceps may be of use. But the rule holds good, no matter where the pus may be, and as long as good judgment is shown in the operative procedure nothing but good can come from recognition of this law. After the evacuation of pus the cavity should be cleansed and disinfected with hydrogen dioxide, perhaps even with caustic pyrozone, or, if these are not at hand, with other suitable antiseptic solutions.
Ordinary judgment should be exercised in evacuating every abscess, in order that opening be made at that point which in the common position of the body shall be most favorable to drainage by mere gravity alone. If circumstances compel opening when advantage cannot be taken of gravity, then one or more _counteropenings_ should be made at points selected where drainage may be best effected, and where anatomical conditions do not make it injudicious to incise. Drainage should be favored by the introduction of a drainage tube or of other aids, such as gauze, strands of catgut, bundles of horse-hair, etc. Finally, a dressing should be applied which is both protective and absorbent, and in quantity sufficient to make compression of the walls of the abscess cavity--not sufficient to obstruct drainage, but enough to favor prompt adhesion of surfaces, which by speedy granulation shall ensure prompt healing.
Abscesses are found in proximity to large vessels or dangerous anatomical regions, when care must be exercised in opening them. Here careful dissection should be made under an anesthetic. This is true of abscesses in the neck and of those around the appendix, for example, where the general peritoneal cavity is shut off only by more or less delicate adhesions, and where the surgeon must literally feel his way with great precaution lest adhesions be torn and the previously protected cavity infected. At other times, especially in abdominal abscesses, it is necessary to pack sponges or absorbent gauze in and about the parts, so that any fluid which may escape may be absorbed by these dressings.
=Accompanying Disturbances.=--The disturbance of function which accompanies all congestion and exudation, whether provoked by specific irritants or not, has been alluded to; but in cases of surgical infections, especially those which produce local suppuration, disturbance of function is much greater, while there are other disturbances which sometimes constitute the worst feature of these cases. The _presence of pus_ is often indicated, especially when deeply seated, by one or more _chills_, and the occurrence of a chill is always marked to varying degree by _pyrexia_. It is conceded that the chill is an expression of a general septic disturbance; but it is necessary also not to forget that general septic disturbance is a frequent accompaniment of pus which is not evacuated as soon as formed. Moreover in certain cases suppuration and septic infection seem to occur synchronously, one being local, the other general.
Pus may also be suspected beneath a surface which is red, tender, swollen, edematous, and pitting on pressure. When fluctuation is added to these indications any element of doubt is thereby dissipated.
Other indications of the presence of pus are a well-marked leukocytosis, coupled with the iodine reaction indicating the existence of glycogen in the blood, the presence of indican in the urine, and the positive results frequently obtained by making cultures from the blood. When pyogenic bacteria are found in the blood the inference is very plain, and both treatment and prognosis are influenced. In such a case the introduction into the blood of an antiseptic such as Credé’s soluble metallic silver or of the antistreptococcus serum, is plainly indicated. The absence of bacteria from the blood, under these circumstances, does not disprove the presence of pus, but their presence gives a very serious character to the disease, and should lead to a most guarded prognosis. Invasion of the blood by staphylococci is nearly twice as serious as when streptococci gain entrance. Suppuration of the bones and of the tendon sheaths is liable to produce such invasion.
The other disturbance with which suppuration is so often complicated is _septic infection_. In fact it may be questioned whether pyrexia is not an expression of this condition. Any collection of pus, no matter how small, may show signs of septic infection; and, on the other hand, large collections may be formed without serious septic symptoms--in other words, suppuration and expressions of septic infection may be blended in almost every conceivable way. Sepsis as a distinct condition will be described in another chapter.
It is important to summarize what may become of pus when once it has formed and is not promptly evacuated. Pus when long present may be--
A. _Absorbed_;
B. _Encapsulated_; and
C. _Undergo various degenerations or chemical alterations_.
A. _The possibility of the absorption of pus_, or, what is equivalent to it, its spontaneous disappearance, has been mentioned. While it does not usually take this course, it may thus disappear; as, for instance, in the anterior chamber of the eye in cases of _hypopyon_, or in various other localities, particularly when present only in small amounts. The absorption of pus is purely a matter, as far as we know, of phagocytic activity plus the power of the tissues to take up various fluids.
B. _Encapsulation._--This occurs only when pus has been present for some time and when the virulence of the pyogenic organisms is not intense. We may get encapsulation of pus in any part of the body, the most typical illustration naturally being within the bones. Around the purulent focus, as around any other irritating foreign body, the capsule is formed by condensation of surrounding tissue. This is the way in which most cold abscesses with their limiting membranes are produced, those produced by tubercle bacilli having slight irritating properties. Inasmuch, then, as the biological activity in such a focus is small, there is time for such encapsulation; while by the membrane thus formed, or the sanitary cordon, already referred to, protection is afforded to the surrounding tissues. In such a collection fresh infection may incite acute disturbances again, and many abscesses which thus lie latent for a considerable length of time are fanned, as it were, into a conflagration, when a new and acute inflammation is produced.
C. _Of the various metamorphoses and chemical changes_ that occur in that which was originally pus, the caseous and the calcific are the most common. These also are connected largely with the tuberculous process, although calcareous particles are found in the pus of
## actinomycosis. Under their respective heads these degenerations will be
more particularly described.
Certain names have been given to collections of pus in different localities or under peculiar circumstances. A collection of pus in the anterior chamber of the eye is known as _hypopyon_; when in any preëxisting cavity, it is known as _empyema_ of that cavity, the _distinction between empyema and abscess_ being that “abscess” means a circumscribed collection where previously there was no cavity, while “empyema” implies a normal cavity, without respect to size or location, filled with this abnormal fluid. The term _empyema_, when not used in connection with some particular cavity, is understood to refer to a collection of pus in the pleural cavity. Other names also are used which are particulate and distinctive; in these the prefix _pyo_ is used while the suffix indicates the part involved; thus we have _pyothorax_, _pyopericardium_, _pyarthrosis_, etc.
SINUS AND FISTULA.
These are terms applied to more or less _tubular channels abnormally connecting various parts of the body, or connecting some cavity with the surface of the body in a way anatomically quite abnormal_. Or they may be regarded as _tubular ulcers_, or ulcerated tunnels, connecting as above. A more exact distinction between the two terms would imply that a _sinus_ connects the surface with some deeper portion where a cavity is not normally present--_i. e._, with a focus of disease--whereas a _fistula_ properly refers to a tubular passage connecting natural or preëxisting cavities in an abnormal manner. Thus we speak of buccal, rectal, vesicovaginal fistulas, etc., whereas a passage leading down to an old abscess or to a focus of disease in bone, for instance, is properly referred to as a sinus. It is possible for the margins of a fistula to become more or less cicatrized and cease to be ulcerous, whereas the entire track of a sinus is practically a continuous ulcer, only tubular in arrangement.
=Causes.= A. =Congenital.=--There are numerous points about the body where, as the result of arrest of development or failure to grow, fistulous passages which are comprised within the normal fetal arrangements, but which should close later, either before or at birth, fail to do so. Thus we have congenital fistulas of the neck, persistent urachus, persistent omphalomesenteric duct, etc. These are in no sense primarily connected with diseased conditions, but may become so secondarily.
B. =Pre-existing Abscess with Unhealed Channel of Escape=--_e. g._, rectal, fecal, and other fistulas and sinuses which connect with tuberculous foci in any part of the body.
C. =Previous Traumatic or other Destruction of Normal Tissues=--_e. g._, vesicovaginal fistulas due to tissue death from pressure, buccal fistulas from gangrene of the cheek, as in noma.
D. =Foreign Bodies=--bullets, ligatures, etc.--which prove irritating or infectious enough to prevent absolute healing. More or less tortuous sinuses will generally be found leading down to the irritating material.
E. =The Presence of Necrosed or Necrotic Material=--_e. g._, a sequestrum in bone, which is usually evidenced by the presence of one or more sinuses.
=Treatment.=--If the determining cause is still acting, the treatment is to remove the cause. Consequently, when the sinus leads down to diseased bone or other dead or dying tissue, the complete evacuation of the cavity is necessary before the sinus may heal. If the cause is a foreign body, its removal should be at once insisted upon.
An excellent suggestion is to stain all fistulous tracks with methylene-blue; the blue trail after doing this may be followed, no matter how irregular its course (Fergusson). If the color is mixed with a little hydrogen dioxide, and this forced into a sinus mouth or a fistulous opening, it will carry the dye to all parts of the cavity. This may be used even in dealing with fecal fistulas or those extending deeply into the interior of the body or among the viscera.
Fistulas of congenital origin and those which connect two normal cavities of the human body are usually due to a cause which has ceased to act. Consequently we should endeavor solely to atone for the result. The direction and the course of a sinus may be learned by the use of a probe curved to suit and manipulated by a gentle hand, force never being required. Or sometimes, when the silver instrument fails to pass, a flexible bougie or catheter may be introduced. The character of the passage can be judged for the most part by the appearance of the discharges. With sinuses of recent origin leading down to recent suppurative foci it may be sufficient to enlarge the opening and to wash the cavity thoroughly. If a particle of gauze, tube, or sponge has been left therein, its removal is necessary to secure prompt healing. In cases of long standing antiseptic and stimulating substances should be injected or the interior should be cauterized with strong solutions of zinc chloride or silver nitrate, or with these melted upon the end of a probe. The _chronic_ sinus, as well as the chronic rectal fistula, is usually an expression of _local tuberculous disease_. Accordingly these passages may be found lined with the same dense, fungating membrane which lines a cold abscess cavity--the membrane, protective in its purpose, to which I have given the name _pyophylactic_. Whenever such tissue and such membrane are met with they should both be extirpated thoroughly, since in this way only can absolute eradication of the tuberculous infection be relied upon. After such complete excision--which means usually laying open the entire sinus--the parts may be brought together with sutures (this, at least, is usually possible about the rectum) to secure primary union; otherwise, the whole sinus, as well as the cavity to which it has led, must heal by the granulating process, both being kept packed with gauze or some other desirable foreign body acting as an irritant, thereby provoking more rapid formation of granulation tissue. When it is necessary thus to pack a cavity, or when it is desired to keep its upper exit open lest it heal before the lower part, ordinary white beeswax, as suggested by Gunn, makes a serviceable material. This can be molded in hot water to fit the cavity; can be tunnelled or bored for drainage; can be diminished in size as the cavity heals, and is absolutely non-absorbent.
Finally there are numerous plastic methods which have been resorted to in various parts of the body, most of which are made to comprise, first, the absolute eradication of the diseased tract, and, later, the closure of the wound thus made by transplantation or sliding of flaps, or any other plastic expedient which may be considered best. These, as well as the special treatment made necessary for particular forms of sinus and fistula, will be dealt with under their proper headings.
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