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.