Abscess.
—Abscess is usually of the “cold” type. Its general character has been previously described. It may be of the purely tuberculous type, but is not infrequently the result of a secondary pyogenic infection. It is a consequence of neglect, but cannot always be prevented. Signs, both local and general, of the presence of pus or of pyoid are noted here, as under other circumstances. There is exaggeration of local tenderness, with development of tumor, which fluctuates as it approaches the surface. General septic features, proportional to the activity of the process and its location, accompany the local indications. Sometimes it occurs insidiously and with but few evidences.
Pus travels here in the direction of least resistance. The fascial planes of the body are mostly so placed as to protect important body cavities, consequently pus will travel usually around them and toward the surface, burrowing long distances, for instance, from the lower dorsal region to the groin along the psoas muscle. Cervical abscesses usually spread anteriorly toward the pharynx (postpharyngeal) and deeply into the thorax (mediastinal); they may open into the trachea or esophagus or externally through an intercostal space; or they may burrow laterally, opening behind the sternomastoid muscle. Dorsal abscesses usually travel posteriorly, opening not far from the spine, or they burrow downward and forward along the psoas so as to appear beneath Poupart’s ligament. Lumbar abscesses escape through the psoas sheath as psoas abscesses, so called, or between the fasciæ of the spinal muscles and those of the abdomen to appear upon the side; they may extend downward beneath the iliacus, escaping over the brim and into the pelvis and then out through the sacrosciatic notch. Of all these the psoas abscess, opening in the groin, is the most common. This will in time destroy the muscle fibers of the psoas, but it leaves the vessels and nerves intact, whose sheaths are much more resistant, and which can be found passing through such a cavity like cords through a chamber. This form of cold abscess, with its consequent bulging and final escape in the groin, has been mistaken for hernia as well as for abscess due to perinephritis and appendicitis. The most serious mistake would be to take it for a femoral hernia. The customary routes of all these collections of pyoid have been thus indicated. Nevertheless abscesses may burrow and appear almost anywhere. They will give rise to varying and to superadded symptoms, according to their location. For example, retropharyngeal abscess may seriously threaten respiration by pressure upon the upper air passages, while a collection of pus in the mediastinum might cause serious respiratory difficulty of another character.
Cold abscesses of spinal origin may remain stationary, the fluid portion of the pyoid material may even absorb, while the balance undergoes more or less degeneration and conversion into inert material, or they may slowly or rapidly increase in size. The best that can be hoped in such cases is absorption, with encapsulation of the solid residue. Even this may be a source of danger, as it is a focus of lessened resistance, in or about which subsequent trouble may result. Those abscesses which seem to remain stationary would best be let alone, hoping for subsidence under good treatment. Those which open spontaneously leave tuberculous fistulas behind them, which may possibly close in time, but which lead often to subsequent acute infection, and which are the bête noir of surgeons, for it is often impossible to heal them. The best that can be done in such instances is to wash them out, keep them clean, and guard them from infection from without. It is often possible to pass a tube along the sinus and through this to irrigate with a solution of iodine, of formalin, or of any other antiseptic which may be preferred. If anything be done with them in the operative way it should be as radical as possible, seeking the original lesion, thoroughly curetting its site and the whole interior of the cavity, and making ample opening so as to provide for effective drainage.
Retropharyngeal abscesses usually necessitate evacuation because of the obstruction which they cause within the pharynx. Lumbar and psoas abscesses may be let alone. When this is not practicable, then choice should be made between simple aspiration, aspiration with washing or injection of some antiseptic fluid, and free opening with radical treatment. In these cases we are to be guided by the peculiar features and surroundings of each, and by our own facilities for such work and for subsequent care of the case. An abscess which will soon rupture should be opened and counterdrained; but in one where this is not impending, and where home features are such that the patient can receive no adequate or prolonged care, it would be wiser to abstain. Under the best of circumstances in these cases it is always a difficult problem to decide. Even aspiration leaves at least a needle track to be subsequently infected, while the contents may be too thick to flow through a small trocar. Aspiration with thorough washing out and then with injection of emulsions of iodoform or of other irritating antiseptics have found favor with only a part of the profession. If any radical measure is to be adopted the greatest care should be given to carry out the principles expressed in the general consideration of cold abscesses. (See [p. 114].)
Diagnosis.
—Intelligent comprehension of signs and symptoms should enable one to make a diagnosis in most cases. Nevertheless the surgeon is occasionally in doubt and has to distinguish, for example, as between Pott’s disease and sprain, lateral curvature, hysterical spine, cancer, cord tumors, rheumatic arthritis, rickets, syphilis, actinomycosis, hydatid disease, acute osteomyelitis, i. e., non-tuberculous diseases, and certain abdominal affections followed by suppuration, such, for example, as peri-appendicular abscess. Moreover, spondylitis may be simulated in the course or as a complication of typhoid, scarlatina, gonorrhea, and other acute infections. Psoas abscess should be distinguished from perinephritic abscess as well as from acute appendicitis, which often causes psoas contraction, especially when the appendix is posteriorly placed and left in contact with that muscle. We may also have to distinguish this condition from sacro-iliac disease and from ordinary hip disease.
Prognosis.
—In some degree prognosis depends on what is meant by a cure. Absolute cure, with restoration to the original condition, is exceedingly rare. Arrest of disease, with improvement of deformity, is possible in cases seen early. Even considerable motion may be restored under suitable treatment. In late cases hectic, amyloid degeneration, and dissemination of the disease make the outlook very discouraging. At best its relief is slow and in time it is always chronic, no matter how rapid the onset, except in those instances where dissemination occurs early and rapidly, in which case there is little or no hope. In ordinary cases there is a certain tendency to spontaneous recovery, but not without deformity and impairment of function, while obviously the occurrence of abscess prolongs a case to a considerable degree.