Manual of Surgery Volume First: General Surgery. Sixth Edition.

by Alexis Thomson; Alexander Miles

In some abscesses, such as those in the vicinity of the anus, the cavity should be laid freely open in its whole extent, stuffed with iodoform or bismuth gauze, and treated by the open method.

It is seldom advisable to wash out an abscess cavity, and squeezing out the pus is also to be avoided, lest the protective zone be broken down and the infection be diffused into the surrounding tissues.

The importance of taking precautions against further infection in opening an abscess can scarcely be exaggerated, and the rapidity with which healing occurs when the access of fresh bacteria is prevented is in marked contrast to what occurs when such precautions are neglected and further infection is allowed to take place.

Acute Suppuration in a Wound.—If in the course of an operation infection of the wound has occurred, a marked inflammatory reaction soon manifests itself, and the same changes as occur in the formation of an acute abscess take place, modified, however, by the fact that the pus can more readily reach the surface. In from twenty-four to forty-eight hours the patient is conscious of a sensation of chilliness, or may even have a rigor. At the same time he feels generally out of sorts, with impaired appetite, headache, and it may be looseness of the bowels. His temperature rises to 100° or 101° F., and the pulse quickens to 100 or 110.

On exposing the wound it is found that the parts for some distance around are red, glazed, and œdematous. The discoloration and swelling are most intense in the immediate vicinity of the wound, the edges of which are everted and moist. Any stitches that may have been introduced are tight, and the deep ones may be cutting into the tissues. There is heat, and a constant burning or throbbing pain, which is increased by pressure. If the stitches be cut, pus escapes, the wound gapes, and its surfaces are found to be inflamed and covered with pus.

The open method is the only safe means of treating such wounds. The infected surface may be sponged over with pure carbolic acid, the excess of which is washed off with absolute alcohol, and the wound either drained by tubes or packed with iodoform gauze. The practice of scraping such surfaces with the sharp spoon, squeezing or even of washing them out with antiseptic lotions, is attended with the risk of further diffusing the organisms in the tissue, and is only to be employed under exceptional circumstances. Continuous irrigation of infected wounds or their immersion in antiseptic baths is sometimes useful. The free opening up of the wound is almost immediately followed by a fall in the temperature. The surrounding inflammation subsides, the discharge of pus lessens, and healing takes place by the formation of granulation tissue—the so-called “healing by second intention.”

Wound infection may take place from catgut which has not been efficiently prepared. The local and general reactions may be slight, and, as a rule, do not appear for seven or eight days after the operation, and, it may be, not till after the skin edges have united. The suppuration is strictly localised to the part of the wound where catgut was employed for stitches or ligatures, and shows little tendency to spread. The infected part, however, is often long of healing. The irritation in these cases is probably due to toxins in the catgut and not to bacteria.

When suppuration occurs in connection with buried sutures of unabsorbable materials, such as silk, silkworm gut, or silver wire, it is apt to persist till the foreign material is cast off or removed.

Suppuration may occur in the track of a skin stitch, producing a stitch abscess. The infection may arise from the material used, especially catgut or silk, or, more frequently perhaps, from the growth of staphylococcus albus from the skin of the patient when this has been imperfectly disinfected. The formation of pus under these conditions may not be attended with any of the usual signs of suppuration, and beyond some induration around the wound and a slight tenderness on pressure there may be nothing to suggest the presence of an abscess.

Acute Suppuration of a Mucous Membrane.—When pyogenic organisms gain access to a mucous membrane, such as that of the bladder, urethra, or middle ear, the usual phenomena of acute inflammation and suppuration ensue, followed by the discharge of pus on the free surface. It would appear that the most marked changes take place in the submucous tissue, causing the covering epithelium in places to die and leave small superficial ulcers, for example in gonorrhœal urethritis, the cicatricial contraction of the scar subsequently leading to the formation of stricture. When mucous glands are present in the membrane, the pus is mixed with mucus—muco-pus.