ABSCESS.
In the great majority of cases of acute and chronic abscess the presence of pyogenic organisms is the causal factor, and all treatment must be directed by this consideration. The localised inflammation which is so liable to eventuate in suppuration may under certain favour able conditions resolve itself without reaching the stage of pus formation; thus the vital resistance afforded by the patient's tissues or blood may be sufficient to neutralise the destructive action of the chemical poison secreted by the cocci or bacilli. the surgeon attempted to increase this resistance by large doses of Quinine, Iron, Belladonna, Sulphides, etc., administered by the mouth, a practice which is rapidly falling into disuse. The Vaccine method has been frequently employed with success in many conditions, as in boils, acne, and erysipelas, by hypodermic injections of graduated doses of the sterilised organisms causing the disease.
The Preventive measures are—(r) In gunshot wounds, excision of the tissues immediately surrounding the tract of the missile must be carefully carried out. (2) Absolute rest to the affected part. (3) Elevation of the limb, in order to restore the disturbed circulation and to prevent conges tion and oedema, which by increasing tension endanger the vitality of the tissues. (4) Moist warmth acts in a similar manner by causing their relaxation, hence the value of poultices in the early stage when the skin is still unbroken. (5) Cold, by causing contraction of the small vessels, effects the same purpose when continuously employed. With these latter measures may be combined—(6) The use of local anodynes, such as the old green B.P. extract of Belladonna or Ichthvol, diluted with glycerin. (7) Counter-irritants of a mild type, as strong tincture of Iodine, may sometimes be found to prevent the suppuration of superficial lympha tic glands. (8) When, notwithstanding the use of the above agents, tension continues to rise and threaten the integrity of the affected tissues, a number of small incisions or deep punctures may be made, so as to drain the part of its increased blood and lymph supply, and the effect may be intensified by the application of a cupping-glass or by Bier's method of applying an elastic ligature at a distance above the seat of inflammation so as to cause venous congestion without interfering with the arterial circulation.
Where pus has already formed, and an acute abscess has resulted, the above agents are inadmissible, and no time should be lost in waiting for the pointing of the pent-up collection towards the surface, for by delaying its evacuation further necrotic action in the surrounding zone is encouraged.
A free incision should be made, therefore, without delay by a sharp pointed bistoury, without waiting for unequivocal signs of obvious fluctuation. In deeper abscesses, where the surgeon is in doubt, a hypo dermic or grooved needle may be inserted to clear up the diagnosis. For the evacuation of superficial small collections of pus, the application of a spray of Ether or Ethyl Chloride will establish the necessary degree of local anesthesia; and sometimes it may be found sufficient to touch the skin with the stopper of the Carbolic Acid bottle, which causes numbness and materially lessens the pain of the incision, or Cocaine may be injected.
For the opening of deep abscess a higher degree of anesthesia is usually necessary, and chloroform narcosis may be employed. The skin having been washed with any antiseptic solution, a free and deep incision should be made with due regard to the configuration of the surface markings, so as to minimise the deformity of the resulting scar and to insure drainage. After the evacuation of the pus, the wall of the abscess cavity should be gently rubbed with sterile gauze, and swilled with weak antiseptic solu tion. Where there has been any evidence of burrowing, and especially in abscesses situated in the neighbourhood of large vessels, as in the neck or axilla, Hilton's plan consists in inserting through a deep skin wound the closed blades of a pair of dressing forceps, which can be forcibly opened so as to separate the deeper tissues and insure thorough evacuation without endangering arteries or important nerves. In very large abscesses, especially where the necessary line of incision does not afford efficient drainage, a counter opening at the most dependent part may lie required, and a drainage-tube inserted. The old plan of a small puncture through which the abscess contents were forcibly squeezed, and then a fine drainage-tube inserted, has given way to the free incision, swabbing of the wall of the cavity, and the packing of the sac loosely with dry sterilised gauze. after thorough irrigation. In large abscesses with much necrotic tissue, which cannot be safely extracted at the time of incision, a wide drainage-tube must be inserted, and the cavity flushed out daily with weak antiseptic till all sloughs are removed. Hydrogen Peroxide, when cautiously used, affords excellent results.