As the cavity shrinks in size and becomes lined with granulations, the gauze can be removed; in the meantime dry dressings are all that are required.
Chronic Abscesses are in the great majority of cases of tuberculous origin, and must be treated differently from the acute form. The aim of the surgeon should be not only to effect evacuation of the purulent or cheesy contents, but to remove every trace of the tuberculous tissue by scraping, curetting, or dissecting out the walls of the cavity under an anesthetic. It is needless to say that as the contents of most chronic abscesses are sterile, strict antiseptic precautions should be maintained to prevent the introduction of pyogenic organisms. After the thorough removal of the cavity walls and of all necrotic tissue by irrigation, the space is to be lightly packed with sterilised gauze, no drainage-tube being used when possibly avoided. In some instances gauze can be dispensed with, the lips of the incision being sutured, and a layer of dry dressing laid over the part. In the more extensive chronic abscesses after the removal of the gauze secondary sutures may be applied as granulation has become established; absolute rest to the limb or part involved is also essential.
Where inflammatory pain and cedema have already spread into the neighbouring tissues the best procedure is to apply a boric acid compress. Layers of lint soaked in warm saturated horic acid solution and covered by oiled silk procure, without danger of secondary infection, all the bene fits that could be obtained from the older septic applications, as linseed poultices. Carbolic Lotion (r in 4o), Spirit Lotion (I in 3), weak Per manganate or Corrosive Sublimate Solution may be used in a similar manner either as a poultice or, if uncovered by impervious dressing, as an evaporating lotion.
In order to avoid the dangers of an infection of the healthy, freshly incised skin wound by the bacilli, which sometimes are found active in old tuberculous abscesses, some surgeons recommend aspirafon of the cavity, followed by flushing with hydrogen Peroxide, etc., and the injection of Iodoform Emulsion, or a solution of this drug in ether; but better results are obtainable by free incision, removal of the cavity lining, and suturing without drainage.
Where a shrunken cavity remains connected with the surface by a sinus splendid results are obtained by forcibly injecting through the sinus a warmed mixture of Bismuth Carbonate 33 parts, and Vaseline 67 parts, and permitting_ it to he slowly expelled by the contraction of the tissues. The injections should be repeated every few days, and sinuses of tubercu lous origin which have remained discharging for many years may be com pletely healed up in a few weeks or months by this method.
Beck accepts the rules laid down by Calot for the treatment of chronic abscesses: (I) That it is not permissible to open such abscesses when they are not easily accessible; (2) that it is a pressing duty to open chronic abscesses when there is danger of spontaneous rupture. As regards Calot's third rule—(3) that it is permissible to open those chronic abscesses which are easily accessible, even if spontaneous rupture is not threatening, Beck urges the necessity of putting off the operation so long as the patient has little pain and no high fever, provided that there is no steady deterioration in the general health.
When the chronic abscess threatens to rupture, Beck's method is to make an incision of rather more or less than half an inch into the cavity, empty it of its contents, after which not more than too firms. (31 oz.) of a io per cent. Bismuth-Vaseline paste is then injected through the incision; gentle massage is applied over the whole neighbourhood of the abscess in order to insure if possible the complete penetration of the paste into every recess of the abscess cavity. A fresh sterile gauze bandage is applied daily, and as the walls of the abscess tend to shrink, the paste is expelled constantly in small amounts through the original wound; should the latter heal it must be opened by a fresh incision, but re-injec tion of the paste is not necessary.
The consistency of the paste, which should be injected in a warm con dition and of creamy fluidity, permits the egress of all secretion, whilst at the same time it acts as an efficient barrier to the introduction of all organisms from without. One injection sometimes suffices to effect a cure. It is devoid of pain or irritation, though a marked local leucoc•tosis supervenes, and there is very little danger of bismuth-poisoning. The method is very suitable for the treatment of suppurating glands, pararectal abscesses, and all chronic abscesses connected with bone disease.
Recurring acute or chronic abscesses should always call for Vaccine treatment to supplement the surgical measures, the vaccine being pre pared from cultures obtained from the seat of suppuration; in the case of tuberculous abscesses the vaccine is prepared from Tuberculin.
The special treatment of abscesses in different parts of the body will be described under their separate headings. See also the article on Lymph adenitis.