CHAPTER XVII. ABSCESS. An abscess is a circumscribed collection of the liquefied products of infective inflammation. There are two kinds of abscesses, differing in their etiology, clinical history, prognosis, and treatment. The acute abscess is due most generally to the activity of certain of the cocci. The chronic (cold) abscess is nearly always due to the Bacillus tuberculosis. The content of the acute abscess is pus; that of the chronic abscess, though resembling pus, may be merely the liquefied cascated matter of the tubercle without any pus cells whatever. An acute abscess presents all the cardinal symptoms of inflammation: constitutional disturbance, pain, heat, redness, swelling, all in greater or less degree, depending on the locality. A chronic abscess may present none of these symptoms except swelling, and where swelling is not perceptible the abscess is frequently unsuspected. An acute abscess is of very rapid development—the chronic of quite slow growth, as a rule. An acute abscess demands immediate evacuation by free incision and drainage. The chronic abscess very often permits only of aseptic puncture, followed by the injection of detergent remedies, and aseptic occlusion. Each occurs by choice in certain locations. The incision, the special dangers and details of treatment depend on the anatomy of the parts, so that the more common abscesses require individual consideration, and in that connection the general principles that underlie the subject may be elaborated.
The prevention of pus formation should be attempted in all acute infectious inflammations by means of the timely application, in favorable localities, of hot antiseptic poultices or prolonged immersion in hot antiseptic solutions. Even though the treatment fails to prevent suppuration, it will at least limit it. Such an antiseptic poultice may be made by applying absorbent cotton soaked in hot boric acid solution and covering it with oiled silk or gutta-percha. In this manner heat and moisture are retained.
<Callout type="important" title="Important">Treatment of an acute abscess must be immediate to prevent further tissue damage.</Callout>
The old flaxseed-meal poultice is more often than not the breeder of germs and therefore distinctly non-surgical—a domestic makeshift. Some of the “antipblogistic” glycerinated and sterile clay pastes often render an excellent service, Treatment.—The evacuation of an abscess is by many regarded as a small procedure in minor surgery. It may be nothing more, and yet, as Lejars says, in certain cases it is a formidable task straining the resources of the most practised.
Abscesses have too much been regarded as simple conditions which the merest tyro might treat, We all know of patients who have died of these operations; of others who have been disabled by the failure to perform them, or by their being tardily or improperly done. And how often tardily done! But what excuse can one make for delay after pus has definitely formed, for any attempt to bring about its absorption is futile. Delay merely means that the collection augments, destroys more tissues, acquires diverticula without end, which may need to be opened up time and time again, or may require months to heal, and eventually give rise to irremediable contractions and adhesions.
<Callout type="risk" title="Risk">Delaying the evacuation of an abscess can lead to severe complications such as tissue destruction and adhesions.</Callout>
It is one of the most important and least varying rules of surgical practice that every acute abscess, superficial or deep, must as early as possible be incised, emptied, and drained. Another point: do not wait for fluctuation, which is so commonly the practice. If the suppuration occurs in the deeper structures, fluctuation may be delayed. But there are ample indications otherwise; the rapid increase of swelling, the radiating pains, fever, and subcutaneous edema give sufficient evidence that pus is present. In certain regions, the thick and brawny skin and fascia is as significant as fluctuation itself, On the scalp, for instance, this brawny edema is a definite symptom of suppuration. In the belly walls, as Lejars remarks, the consistency of a deep abscess reminds one of sarcoma, The edema is superficial; the suppuration, deep. The two processes go together and when the first is present, one may unhesitatingly diagnose the second.
The fengéh of the incision is of the greatest importance. Nothing is more unsatisfactory than the mere stab, or puncture, of an acute abscess. The incision, cutting through the middle, parallel with the most important structures, should open up the whole length of the cavity. In this manner no pockets are left behind, and, besides, a long, smooth incision will in the end leave the least scar. A counter-incision may be necessary. Once the abscess is opened and the pus has ceased to flow, wipe out the cavity with sterile gauze and irrigate with sterile water or some antiseptic. If diverticula are found, they too must be freely opened up and irrigated. Insert a drain.
If the abscess was small and the incision made early, it is proper to dispense with the drain; but if the suppuration is extensive, the best means of preventing large scar formation is to employ drainage. Observe, says Lejars, that the whole therapy of abscesses is contained in these two words, “empty” and “drain.” You do nothing more—there is nothing more to be done—and it is sufficient.
<Callout type="tip" title="Tip">Early incision of an acute abscess can prevent severe complications.</Callout>
The treatment of a cold abscess differs from that of an acute abscess in that incision is not the method of choice. There is always great danger of infection when the abscess cavity is opened up and for that reason incision must be done with circumspection—with an absolute asepsis. There is not the urgency present in the acute case. Puncture is the method of choice, Employ the strictest antisepsis. Wash with soap and water, but not too vigorously lest the abscess wall be ruptured; complete the disinfection with alcohol and ether. Employ only such instruments as are carefully sterilized. Use a trocar of sufficient size that the grumous fluid will not occlude it. Do not puncture the summit of the tumor if the skin is quite thin, but select a point where the tissues are sufficiently resistant to close when the trocar is withdrawn. At the end of the evacuation the fluid may need to be aspirated. It may be discolored by some blood from the puncture. Injection with some stimulating and antiseptic fluid should follow. Ethereal solution of iodoform has the advantage of distending the cavity by gas formation and reaching all the diverticula; but it has the dis- advantage that it is toxic. Inject 5 to 10 c.c. of a 10 per cent. solution; leave the trocar in place, closing its orifice with the finger. When the cavity becomes distended, remove the finger and the ether spurts out.
A solution of iodoform in glycerine may be used in the same way. Bismuth certain localities serves an excellent purpose. After the injection is completed seal the puncture with collodion. Several applications may be necessary for a cure. Constitutional treatment is of the importance, ABSCESSES OF THE SCALP.
These are found in three locations: 1, Superficial—that is, above the aponeurosis of the occipitalis. 2. Subaponeurotic—that is, between aponeurosis and the temporal bone. 3. Subperiosteal—between the periosteum and the bone.
- Superficial abscess, due to staphylococci, is quite loose and yet very painful on account of the resistance of the firm occipitalis muscle. The lymph nodes behind the ear and in the back of the scalp are enlarged and tender. The chief danger is in extension to the meningeal layers; or the emissary veins may carry infection to the sinuses, produce thrombosis or pyemia. Evacuate immediately by incision, first shaving the scalp in the immediate vicinity of the abscess. Remembering the manner in which the occipital and temporal arteries converge toward the apex, the incision may be made as to run parallel to the small vessels distributed to the occipitalis muscle. The cavity must be kept open by a strip of rubber tissue or a drainage-tube. A dressing of gauze, absorbent cotton and antiseptic should complete the treatment.
Change the dressing every day at first, 2. Subaponeurotic abscess is likely to follow wound infections. The streptococci follow the areolar tissues that separate the occipitalis from the temporal bone, and the spread of pus is limited by the septa of the areolar spaces. Septicemia, meningitis, and the actual dangers, and on these accounts immediate operation is demanded.
FURUNCLE OF THE FACE. Make a free incision under antiseptic precautions; that is, after shaving and cleansing the part involved. Do not attempt irrigations, above all, in these cases, for the fluid percolating through the loose areolar tissues spreads the infection. Good drainage alone will suffice.
The dressings must be changed frequently at first and must be firm enough to prevent movement of the occipito-frontalis muscle. If the abscess develops under the temporal fascia, it will not point toward the surface, owing to the extreme density of this fascia, but toward the mouth or neck through the ptergo-maxillary fossa. Even though there be no fluctuation (usually indeed, none can be detected), the diagnosis can, nevertheless, be certainly made from the presence of the edema, redness, and pain.
Make a vertical incision an inch or so in front of the ear and with the center about the level of the eyebrow. It may be necessary to go through the substance of the muscle to the bone. A few small arteries will be divided and will require ligation. It may be necessary at the first dressing to pack the cavity with gauze to control slight but persistent bleeding, Drainage by means of tubes may be employed subsequently.
- Subperiosteal abscesses differ from the others in that they are likely to be the result of bone inflammation, tubercular or syphilitic. The abscesses are limited to the area of one bone as the periosteum along the line of the sutures is continuous with the dura mater. This furnishes an easy means of entrance into the cranial cavity for the infection and in that manner meningitis result. For this reason, these abscesses, of whatever origin, should be evacuated at once and appropriate constitutional treatment instituted.
ABSCESS AND FURUNCLE OF THE FACE. The danger in these conditions is that phlebitis beginning in the facial vein may spread to the cavernous sinus, so free is the communication by numerous branches between these venous channels. Especially to be feared are these furuncles beginning on the upper lip or median parts of the face. They may be fatal in a few days. Nearly always the staphylococcus pyogenes is the active causative agent and one need not usually be at a loss to trace the mode of entrance of infection.
Early incision is imperative in all such acute septic processes. The best form of local anesthesia in these conditions is by freezing with ethyl chloride spray. Hypodermic injections are best avoided. The incision must be deep to be effective, and in making it two points are to be borne in mind, the resulting scar and injury to the branches of the facial nerve. In severe cases even these points must be disregarded. Even more certain than free incision is central puncture with a fine thermo-cautery, followed by the Bier suction treatment. If it is a carbuncle of the diffuse type, accompanied by edema of the face and inflammation of the veins, crucial incision with curettement must be undertaken.
The dressing of gauze may be held in place by adhesive strips.
ABSCESS OF THE NASAL SEPTUM. Following a blow upon the nose, bleeding ensues and, two or three days later, obstruction. Looking into the child's nasal fossa, they are seen to be filled with a bright red, tender, fluctuating swelling over the cartilaginous portion of the septum. The whole nose becomes swollen, and painful.
The treatment is evacuation by a free incision of the mucous membrane over the septum at the point of greatest fluctuation. To operate, apply a 4 per cent. solution of cocaine to the membrane, and after waiting a minute or two, make an incision the septal wall from above downward and forward with a slender, bistoury. Douche the nasal fossa frequently with a mild, antiseptic. Recovery usually follows within a week, although in neglected cases, necrosis of the cartilage may occur.
ABSCESS OF THE EYELIDS. The loose connective tissues of the eyelids favor exudation and edema. An abscess occurring here is usually due either to sepsis or to septic infection entering from the face or periostitis of the margin of the orbit. Early treatment of discolorations of the eyelid may prevent not only the unsightly discoloration (“black eye”), but also a later abscess.
To prevent discolorations apply cooling or evaporating lotions or wring a gauze compress out of ice-water and apply to the lid, renewing the compress every two or three minutes. Do not allow the compress to cover the nose, else acute coryza may result. Apply in this manner for an hour and repeat every second or third hour for twenty-four hours. A solution of arnica (2 oz.), in water (1 pt.), may be applied, or Ammonii Chloride, x Aleoho!, 1 Aque, 10
If discoloration appears, apply flannel cloths wrung out of hot water, for an hour at a time, three or four times daily, and follow with gentle massage for five to ten minutes. Before applying the heat it is better to smear the lid with vaseline. Ointment of yellow oxide of mercury is excellent to use with massage. If an abscess appears make an incision parallel with the muscle fibers, Apply antiseptic, absorbent dressings.
ABSCESS OF THE LACHRYMAL GLAND. Abscess of the lachrymal gland is rare, yet doubtless is often overlooked. It is seen in infancy, usually traceable to some of the infectious diseases. The abscess breaks into the superior cul-de-sac and recovery follows.
ABSCESS OF THE EXTERNAL AUDITORY MEATUS. Abscess of the external meatus is extremely painful and alarming, but in fact not particularly dangerous. The meatus is closed by the swelling, but a stab with the point of the knife or, if it is more deeply situated, an incision in the direction of the long axis of the meatus, will cause a speedy disappearance of the symptoms. Gentle douching with an antiseptic solution, and, after drying, occlusion with absorbent cotton, will soon complete the cure.
ABSCESS OF THE PAROTID GLAND. An inflammation begins in the parotid gland, the result of local infection or secondary to an abdominal disease or injury (most frequently involving the pancreas, perhaps), and nearly always suppuration follows. The severe forms are dangerous; happily however, even if left to take its own course, the pus works its way to the surface of points at the pharynx. It may burrow down to the anterior mediastinum. The special dangers are meningitis, septic poisoning, and thrombosis. When the swelling is great, pressure interferes with the venous current and, as a result, cerebral congestion, headache, and finally delirium ensue.
The pus may open into the middle ear and infection by that route reaches the brain, Suppuration of the temporo-maxillary articulation may follow. Treatment.—It, when the swelling first appears, a probe be passed into Stenson’s duct and the gland be pressed from the outside, a few drops of pus may be squeezed out and this may serve to head off a general suppuration. If the entire gland becomes involved, antiseptic poultices should be applied to hasten the localization of the pus As soon as redness and edema indicate the most probable situation of the pus, an effort must be made to evacuate it. Several structures are to be avoided; Stenson’s duct (a fistula is likely to follow its division), the facial nerve, the carotid arteries, the tempore maxillary vein and other vessels of lesser importance may be wounded.
If the anterior part of the gland is involved, the incision is made parallel with and below Stenson's duct. The skin and fascia are divided and retracted and an effort is made to burrow into the depth of the gland with a probe or grooved director.
Key Takeaways
- Acute abscesses require immediate evacuation by incision and drainage.
- Chronic abscesses often need puncture, injection of antiseptic fluids, and aseptic occlusion.
- Early diagnosis and treatment are crucial to prevent complications.
Practical Tips
- Always use sterile techniques when treating abscesses to avoid introducing new infections.
- For facial abscesses, incisions should be made carefully to avoid damaging the facial nerve.
- In cases of suspected sepsis or meningitis, seek immediate medical attention even if the abscess appears minor.
Warnings & Risks
- Delaying treatment can lead to severe complications such as tissue destruction and adhesions.
- Incorrect incision techniques may result in infection or damage to surrounding tissues.
- Using non-sterile equipment during abscess treatment poses a significant risk of introducing new infections.
Modern Application
While the surgical techniques described in this chapter are rooted in historical practices, many of the principles—such as the importance of early diagnosis and sterile technique—remain crucial for modern survival situations. Understanding these concepts can help prevent severe complications from abscesses, even without access to advanced medical facilities.
Frequently Asked Questions
Q: What is the most important step in treating an acute abscess?
The most important step in treating an acute abscess is immediate evacuation by incision and drainage. Delaying this can lead to severe complications such as tissue destruction and adhesions.
Q: How should a chronic abscess be treated differently from an acute one?
A chronic abscess should not be incised but rather punctured, followed by the injection of antiseptic fluids. This approach minimizes the risk of infection and allows for aseptic occlusion.
Q: What are some signs that indicate an abscess is present?
Signs that may indicate an abscess include rapid swelling, radiating pain, fever, subcutaneous edema, and in certain regions, thick and brawny skin or fascia. The presence of these symptoms should prompt immediate medical attention.