Alexis Thomson and Alexander Miles - Manual of Surgery

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An abscess forming in the deeper planes is prevented from pointing
directly to the surface by the firm fasciae and other fibrous structures.
The pus therefore tends to burrow along the line of the blood vessels
and in the connective-tissue septa, till it either finds a weak spot or
causes a portion of fascia to undergo necrosis and so reaches the
surface. Accordingly, many abscess cavities resulting from deep-seated
suppuration are of irregular shape, with pouches and loculi in various
directions--an arrangement which interferes with their successful
treatment by incision and drainage.

The relief of tension which follows the bursting of an abscess, the
removal of irritation by the escape of pus, and the casting off of
bacteria and toxins, allow the tissues once more to assert themselves,
and a process of repair sets in. The walls of the abscess fall in;
granulation tissue grows into the space and gradually fills it; and
later this is replaced by cicatricial tissue. As a result of the
subsequent contraction of the cicatricial tissue, the scar is usually
depressed below the level of the surrounding skin surface.

If an abscess is prevented from healing--for example, by the presence of
a foreign body or a piece of necrosed bone--a sinus results, and from it
pus escapes until the foreign body is removed.

#Clinical Features of an Acute Circumscribed Abscess.#--In the initial
stages the usual symptoms of inflammation are present. Increased
elevation of temperature, with or without a rigor, progressive
leucocytosis, and sweating, mark the transition between inflammation and
suppuration. An increasing leucocytosis is evidence that a suppurative
process is spreading.

The local symptoms vary with the seat of the abscess. When it is
situated superficially--for example, in the breast tissue--the affected
area is hot, the redness of inflammation gives place to a dusky purple
colour, with a pale, sometimes yellow, spot where the pus is near the
surface. The swelling increases in size, the firm brawny centre becomes
soft, projects as a cone beyond the level of the rest of the swollen
area, and is usually surrounded by a zone of induration.

By gently palpating with the finger-tips over the softened area, a fluid
wave may be detected--_fluctuation_--and when present this is a certain
indication of the existence of fluid in the swelling. Its recognition,
however, is by no means easy, and various fallacies are to be guarded
against in applying this test clinically. When, for example, the walls
of the abscess are thick and rigid, or when its contents are under
excessive tension, the fluid wave cannot be elicited. On the other hand,
a sensation closely resembling fluctuation may often be recognised in
oedematous tissues, in certain soft, solid tumours such as fatty tumours
or vascular sarcomata, in aneurysm, and in a muscle when it is palpated
in its transverse axis.

When pus has formed in deeper parts, and before it has reached the
surface, oedema of the overlying skin is frequently present, and the skin
pits on pressure.

With the formation of pus the continuous burning or boring pain of
inflammation assumes a throbbing character, with occasional sharp,
lancinating twinges. Should doubt remain as to the presence of pus,
recourse may be had to the use of an exploring needle.

_Differential Diagnosis of Acute Abscess._--A practical difficulty which
frequently arises is to decide whether or not pus has actually formed.
It may be accepted as a working rule in practice that when an acute
inflammation has lasted for four or five days without showing signs of
abatement, suppuration has almost certainly occurred. In deep-seated
suppuration, marked oedema of the skin and the occurrence of rigors and
sweating may be taken to indicate the formation of pus.

There are cases on record where rapidly growing sarcomatous and
angiomatous tumours, aneurysms, and the bruises that occur in
haemophylics, have been mistaken for acute abscesses and incised, with
disastrous results.

#Treatment of Acute Abscesses.#--The dictum of John Bell, "Where there
is pus, let it out," summarises the treatment of abscess. The extent and
situation of the incision and the means taken to drain the cavity,
however, vary with the nature, site, and relations of the abscess. In a
superficial abscess, for example a bubo, or an abscess in the breast or
face where a disfiguring scar is undesirable, a small puncture should be
made where the pus threatens to point, and a Klapp's suction bell be
applied as already described (p. 39). A drain is not necessary, and in
the intervals between the applications of the bell the part is covered
with a moist antiseptic dressing.

In abscesses deeply placed, as for example under the gluteal or pectoral
muscles, one or more incisions should be made, and the cavity drained by
glass or rubber tubes or by strips of rubber tissue.

The wound should be dressed the next day, and the tube shortened, in the
case of a rubber tube, by cutting off a portion of its outer end. On the
second day or later, according to circumstances, the tube is removed,
and after this the dressing need not be repeated oftener than every
second or third day.

Where pus has formed in relation to important structures--as, for
example, in the deeper planes of the neck--_Hilton's method_ of opening
the abscess may be employed. An incision is made through the skin and
fascia, a grooved director is gently pushed through the deeper tissues
till pus escapes along its groove, and then the track is widened by
passing in a pair of dressing forceps and expanding the blades. A tube,
or strip of rubber tissue, is introduced, and the subsequent treatment
carried out as in other abscesses. When the drain lies in proximity to a
large blood vessel, care must be taken not to leave it in position long
enough to cause ulceration of the vessel wall by pressure.

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 oedematous. 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 gonorrhoeal 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_.

DIFFUSE CELLULITIS AND DIFFUSE SUPPURATION

Cellulitis is an acute affection resulting from the introduction of some
organism--commonly the _streptococcus pyogenes_--into the cellular
connective tissue of the integument, intermuscular septa, tendon
sheaths, or other structures. Infection always takes place through a
breach of the surface, although this may be superficial and
insignificant, such as a pin-prick, a scratch, or a crack under a nail,
and the wound may have been healed for some time before the inflammation
becomes manifest. The cellulitis, also, may develop at some distance
from the seat of inoculation, the organisms having travelled by the
lymphatics.

The virulence of the organisms, the loose, open nature of the tissues in
which they develop, and the free lymphatic circulation by means of which
they are spread, account for the diffuse nature of the process.
Sometimes numbers of cocci are carried for a considerable distance from
the primary area before they are arrested in the lymphatics, and thus
several patches of inflammation may appear with healthy areas between.

The pus infiltrates the meshes of the cellular tissue, there is
sloughing of considerable portions of tissue of low vitality, such as
fat, fascia, or tendon, and if the process continues for some time
several collections of pus may form.

_Clinical Features._--The reaction in cases of diffuse cellulitis is
severe, and is usually ushered in by a distinct chill or even a rigor,
while the temperature rises to 103, 104, or 105 F. The pulse is
proportionately increased in frequency, and is small, feeble, and often
irregular. The face is flushed, the tongue dry and brown, and the
patient may become delirious, especially during the night. Leucocytosis
is present in cases of moderate severity; but in severe cases the
virulence of the toxins prevents reaction taking place, and leucocytosis
is absent.

The local manifestations vary with the relation of the seat of the
inflammation to the surface. When the superficial cellular tissue is
involved, the skin assumes a dark bluish-red colour, is swollen,
oedematous, and the seat of burning pain. To the touch it is firm, hot,
and tender. When the primary focus is in the deeper tissues, the
constitutional disturbance is aggravated, while the local signs are
delayed, and only become prominent when pus forms and approaches the
surface. It is not uncommon for blebs containing dark serous fluid to
form on the skin. The infection frequently spreads along the line of the
main lymph vessels of the part (_septic lymphangitis_) and may reach the
lymph glands (_septic lymphadenitis_).

With the formation of pus the skin becomes soft and boggy at several
points, and eventually breaks, giving exit to a quantity of thick
grumous discharge. Sometimes several small collections under the skin
fuse, and an abscess is formed in which fluctuation can be detected.
Occasionally gases are evolved in the tissues, giving rise to emphysema.
It is common for portions of fascia, ligaments, or tendons to slough,
and this may often be recognised clinically by a peculiar crunching or
grating sensation transmitted to the fingers on making firm pressure on
the part.

If it is not let out by incision, the pus, travelling along the lines of
least resistance, tends to point at several places on the surface, or to
open into joints or other cavities.

_Prognosis._--The occurrence of _septicaemia_ is the most serious risk,
and it is in cases of diffuse suppurative cellulitis that this form of
blood-poisoning assumes its most aggravated forms. The toxins of the
streptococci are exceedingly virulent, and induce local death of tissue
so rapidly that the protective emigration of leucocytes fails to take
place. In some cases the passage of masses of free cocci in the
lymphatics, or of infective emboli in the blood vessels, leads to the
formation of _pyogenic abscesses_ in vital organs, such as the brain,
lungs, liver, kidneys, or other viscera. _Haemorrhage_ from erosion of
arterial or venous trunks may take place and endanger life.

_Treatment._--The treatment of diffuse cellulitis depends to a large
extent on the situation and extent of the affected area, and on the
stage of the process.

_In the limbs_, for example, where the application of a constricting
band is practicable, Bier's method of inducing passive hyperaemia yields
excellent results. If pus is formed, one or more small incisions are
made and a light moist dressing placed over the wounds to absorb the
discharge, but no drain is inserted. The whole of the inflamed area
should be covered with gauze wrung out of a 1 in 10 solution of ichthyol
in glycerine. The dressing is changed as often as necessary, and in the
intervals when the band is off, gentle active and passive movements
should be carried out to prevent the formation of adhesions. After
incisions have been made, we have found the _immersion_ of the limb, for
a few hours at a time, in a water-bath containing warm boracic lotion or
eusol a useful adjuvant to the passive hyperaemia.

_Continuous irrigation_ of the part by a slow, steady stream of lotion,
at the body temperature, such as eusol, or Dakin's solution, or boracic
acid, or frequent washing with peroxide of hydrogen, has been found of
value.

A suitably arranged splint adds to the comfort of the patient; and the
limb should be placed in the attitude which, in the event of stiffness
resulting, will least interfere with its usefulness. The elbow, for
example, should be flexed to a little less than a right angle; at the
wrist, the hand should be dorsiflexed and the fingers flexed slightly
towards the palm.

Massage, passive movement, hot and cold douching, and other measures,
may be necessary to get rid of the chronic oedema, adhesions of tendons,
and stiffness of joints which sometimes remain.

In situations where a constricting band cannot be applied, for example,
on the trunk or the neck, Klapp's suction bells may be used, small
incisions being made to admit of the escape of pus.

If these measures fail or are impracticable, it may be necessary to make
one or more free incisions, and to insert drainage-tubes, portions of
rubber dam, or iodoform worsted.

The general treatment of toxaemia must be carried out, and in cases due
to infection by streptococci, anti-streptococcic serum may be used.

In a few cases, amputation well above the seat of disease, by removing
the source of toxin production, offers the only means of saving the
patient.

WHITLOW

The clinical term whitlow is applied to an acute infection, usually
followed by suppuration, commonly met with in the fingers, less
frequently in the toes. The point of infection is often trivial--a
pin-prick, a puncture caused by a splinter of wood, a scratch, or even
an imperceptible lesion of the skin.

Several varieties of whitlow are recognised, but while it is convenient
to describe them separately, it is to be clearly understood that
clinically they merge one into another, and it is not always possible to
determine in which connective-tissue plane a given infection has
originated.

_Initial Stage._--Attention is usually first attracted to the condition
by a sensation of tightness in the finger and tenderness when the part
is squeezed or knocked against anything. In the course of a few hours
the part becomes red and swollen; there is continuous pain, which soon
assumes a throbbing character, particularly when the hand is dependent,
and may be so severe as to prevent sleep, and the patient may feel
generally out of sorts.

If a constricting band is applied at this stage, the infection can
usually be checked and the occurrence of suppuration prevented. If this
fails, or if the condition is allowed to go untreated, the inflammatory
reaction increases and terminates in suppuration, giving rise to one or
other of the forms of whitlow to be described.

_The Purulent Blister._--In the most superficial variety, pus forms
between the rete Malpighii and the stratum corneum of the skin, the
latter being raised as a blister in which fluctuation can be detected
(Fig. 9, a). This is commonly met with in the palm of the hand of
labouring men who have recently resumed work after a spell of idleness.
When the blister forms near the tip of the finger, the pus burrows under
the nail--which corresponds to the stratum corneum--raising it from its
bed.

There is some local heat and discoloration, and considerable pain and
tenderness, but little or no constitutional disturbance. Superficial
lymphangitis may extend a short distance up the forearm. By clipping
away the raised epidermis, and if necessary the nail, the pus is allowed
to escape, and healing speedily takes place.

_Whitlow at the Nail Fold._--This variety, which is met with among those
who handle septic material, occurs in the sulcus between the nail and
the skin, and is due to the introduction of infective matter at the root
of the nail (Fig. 9, b). A small focus of suppuration forms under the
nail, with swelling and redness of the nail fold, causing intense pain
and discomfort, interfering with sleep, and producing a constitutional
reaction out of all proportion to the local lesion.

To allow the pus to escape, it is necessary, under local anaesthesia, to
cut away the nail fold as well as the portion of nail in the infected
area, or, it may be, to remove the nail entirely. If only a small
opening is made in the nail it is apt to be blocked by granulations.

[Illustration: FIG. 9.--Diagram of various forms of Whitlow.
a = Purulent blister.
b = Suppuration at nail fold.
c = Subcutaneous whitlow.
d = Whitlow in sheath of flexor tendon (e). ]

_Subcutaneous Whitlow._--In this variety the infection manifests itself
as a cellulitis of the pulp of the finger (Fig. 9, c), which sometimes
spreads towards the palm of the hand. The finger becomes red, swollen,
and tense; there is severe throbbing pain, which is usually worst at
night and prevents sleep, and the part is extremely tender on pressure.
When the palm is invaded there may be marked oedema of the back of the
hand, the dense integument of the palm preventing the swelling from
appearing on the front. The pus may be under such tension that
fluctuation cannot be detected. The patient is usually able to flex the
finger to a certain extent without increasing the pain--a point which
indicates that the tendon sheaths have not been invaded. The
suppurative process may, however, spread to the tendon sheaths, or even
to the bone. Sometimes the excessive tension and virulent toxins induce
actual gangrene of the distal part, or even of the whole finger. There
is considerable constitutional disturbance, the temperature often
reaching 101 or 102 F.

The treatment consists in applying a constriction band and making an
incision over the centre of the most tender area, care being taken to
avoid opening the tendon sheath lest the infection be conveyed to it.
Moist dressings should be employed while the suppuration lasts. Carbolic
fomentations, however, are to be avoided on account of the risk of
inducing gangrene.

_Whitlow of the Tendon Sheaths._--In this form the main incidence of the
infection is on the sheaths of the flexor tendons, but it is not always
possible to determine whether it started there or spread thither from
the subcutaneous cellular tissue (Fig. 9, d). In some cases both
connective tissue planes are involved. The affected finger becomes red,
painful, and swollen, the swelling spreading to the dorsum. The
involvement of the tendon sheath is usually indicated by the patient
being unable to flex the finger, and by the pain being increased when he
attempts to do so. On account of the anatomical arrangement of the
tendon sheaths, the process may spread into the forearm--directly in the
case of the thumb and little finger, and after invading the palm in the
case of the other fingers--and there give rise to a diffuse cellulitis
which may result in sloughing of fasciae and tendons. When the infection
spreads into the common flexor sheath under the transverse carpal
(anterior annular) ligament, it is not uncommon for the intercarpal and
wrist joints to become implicated. Impaired movement of tendons and
joints is, therefore, a common sequel to this variety of whitlow.

The _treatment_ consists in inducing passive hyperaemia by Bier's method,
and, if this is done early, suppuration may be avoided. If pus forms,
small incisions are made, under local anaesthesia, to relieve the tension
in the sheath and to diminish the risk of the tendons sloughing. No form
of drain should be inserted. In the fingers the incisions should be made
in the middle line, and in the palm they should be made over the
metacarpal bones to avoid the digital vessels and nerves. If pus has
spread under the transverse carpal ligament, the incision must be made
above the wrist. Passive movements and massage must be commenced as
early as possible and be perseveringly employed to diminish the
formation of adhesions and resulting stiffness.

_Subperiosteal Whitlow._--This form is usually an extension of the
subcutaneous or of the thecal variety, but in some cases the
inflammation begins in the periosteum--usually of the terminal phalanx.
It may lead to necrosis of a portion or even of the entire phalanx. This
is usually recognised by the persistence of suppuration long after the
acute symptoms have passed off, and by feeling bare bone with the probe.
In such cases one or more of the joints are usually implicated also, and
lateral mobility and grating may be elicited. Recovery does not take
place until the dead bone is removed, and the usefulness of the finger
is often seriously impaired by fibrous or bony ankylosis of the
interphalangeal joints. This may render amputation advisable when a
stiff finger is likely to interfere with the patient's occupation.

SUPPURATIVE CELLULITIS IN DIFFERENT SITUATIONS

_Cellulitis of the forearm_ is usually a sequel to one of the deeper
varieties of whitlow.

In the _region of the elbow-joint_, cellulitis is common around the
olecranon. It may originate as an inflammation of the olecranon bursa,
or may invade the bursa secondarily. In exceptional cases the
elbow-joint is also involved.

Cellulitis of the _axilla_ may originate in suppuration in the lymph
glands, following an infected wound of the hand, or it may spread from a
septic wound on the chest wall or in the neck. In some cases it is
impossible to discover the primary seat of infection. A firm, brawny
swelling forms in the armpit and extends on to the chest wall. It is
attended with great pain, which is increased on moving the arm, and
there is marked constitutional disturbance. When suppuration occurs, its
spread is limited by the attachments of the axillary fascia, and the pus
tends to burrow on to the chest wall beneath the pectoral muscles, and
upwards towards the shoulder-joint, which may become infected. When the
pus forms in the axillary space, the treatment consists in making free
incisions, which should be placed on the thoracic side of the axilla to
avoid the axillary vessels and nerves. If the pus spreads on to the
chest wall, the abscess should be opened below the clavicle by Hilton's
method, and a counter opening may be made in the axilla.