CHAPTER XVII. ABSCESS. (Part 5)

quantity of pus may bese great, or so near the front, that the bulging of the anterior abdominal wall may settle the matter without further examination. In obscurer cases it will be necessary to recall the normal limits of dullness, er tympany of the various organs, in order to determine the nature and degree of their displacement. Remember, too, that in all cases fallow> ing perforation the abscess cavity will contain gas which will be anather source of confusion, But after all, in the typical eases, guided by the history, the symptoms of sepsis and the local signs, one can rarely ge astray. Aseptic aspiration may be restorted to in the doubtful exses, and one need not hesitate to aspirate several times, But previous to aspiration the patient should be prepared amd should be operated upon immediately if pus is found. ‘The X-ray may be belpfal in diagnosis, since it shows an abnormal conformation of the diaphragm, and that it is immobile on the affected side. The great majority of sufferers from this condition not operated upon dic from sepsis. A general peritonitis may supervene. Lei to itself, the pus may open into the alimentary tract, Which as tobe regarded a3 a complication rather than a cure, for such cases Usually terminate fatally from slowly increasing sepsis. Tm Fare instance DIAGNOSIS OF SUBPHRENIC ABSCESS, 333 it may open through the abdominal wall. Most often, however, it extends toward the thorax, opening through the diaphragm into the Jung to be coughed up. Oftentimes the imminence of rupture into a bronchus may be predicated from increased pain in the shoulder of the affected side, increased cough and muco-purulent or sanguineous expectoration, and heightened temperature, The pleurisy nearly always present may be fibrous, serous, or purulent. An empyema, so originating, may even mask the primary condition: But whether the pus opens into a bronchus, or the digestive tube, or through the abdominal wall, the result of nature’s drainage is too doubtful. It is imperative to operate as soon a8 a diagnosis is made, for even a latent case may fire up suddenly and march to rapid death. The prognosis, in fact, does not depend more upon the character and skillfulness of the operation than upon its timeliness. Operation.—The method of operation depends upon the location of the pus; it may be (A) near the anterior abdominal wall, or (B) it may be inaccessible from the front. (A) If the epigastric region is bulging, the incision should be over its greatest prominence or where the abscess seems to point, Redness and edema of the skin should be taken as an indication that the pus is well walled off and that there is no danger of the incision opening into the general peritoneal cavity, which is an accident always to be guarded against, One may cut directly through these tissues whether it be in the linea alba or the line of either border of the rectus. ‘Once the cavity Is opened and emptied, it is to be carefully wiped out, for there are usually collections in its deeper parts; and before drainage is inserted it should be cautiously irrigated with normal salt solution or peroxide of hydrogen. Moynihan recommends the “‘cigarette drain” which may be well saturated with boracic acid. A counter-opening in the loin may be required for efficient drainage. ‘The cavity must fill in by granulation which may require six or eight weeks. (B) 1. If the abscess is behind the liver on the right side, an inci- sion along the costal margin is perhaps the best. Divide the muscles, or even resect the twelfth rib, and then, by blant dissection, follow the under surface of the diaphragm until the abscess cavity is reached. az 354 ARSCESS. hadrian ered cerac eet pole of the kidney and to draw it downward and forward, exposing renal fossa on the under surface of the liver, and thence work upward between the pesterior margin of the liver and the diaphragm. Insert drainage tubes packed about with iodoform gauze. 2. More often it is best to employ the transplewral route (Fig. 264), which will require resection of a rib or perhaps more than.one. ‘The incision exposes the eighth or ninth rib—right side; eighth or seventh— left side. (For technic of resection of rib, see page 441.) The Pia. 244.—Subphrmc alecene Opening in the mid-auillary line (Bryant) center of the incision lies in the axillary line and about three and one half inches of rib are to he removed, Now determine the condition of the pleura of which the extl-de-ssc is exposed. In this region the pleura is easily stripped away from the chest wall, and so room may be made to open the diaphragm without opening the pleural cavity... If this can be done, evacuate and drain the abscess as described above. Ordinarily it will be pecessury to open tte pleural cavity, which is first to be aspirated if it contains serum; or opened and wiped out ff contains pus. If it is not purulent it is likely to become so unless stepa are taken to prevent its infection by suturing the diaphragm to upper liys of the opening in the chest wall You are now ready to open the diophrogm and the pas cavity. PSOAS ABSCESS. 355 some cases a perforation will be found in the diaphragm, and this is to be merely enlarged; or, if inconvenient for drainage, may he disre- garded and the incision made lower down. Drain. A single case will exemplify some of the characters and progress of the disease. A farmer, thirty years of age, had suffered for several years with a severe affection of the stomach, of which no definite diag- nosis had been made. Though debilitated, he was yet able to do his work about the farm, Without warning he was suddenly seize with a violent hematemesis, The attack continued for some hours without relief and the total amount of blood vomited was appalling. But gradually the bleeding ceased, leaving the patient prostrate. A tardy convalescence followed, interrupted by an intermittent fever diagnosed as malaria. A month elapsed and he was brought to bed with a fresh access of “ague"— chills, fever, and exhausting sweats. At this time a consultation ex- posed the real character of the process. There was a vast accumu- lation of pus in the left side involving the abdomen and thorax, A constant irritating ‘cough, a bloody sputum, severe pain in the left shoulder, and increased fever and dyspnea seemed to indicate the nearness of rupture into a bronchus. In fact this occurred within a few hours after our examination. A Iarge amount of pus was coughed up and with temporary relief. An operation was refused. Indeed, it offered but little hope so late in the course of the disease. A week later he died. Had the perforation of the gastric ulcer been recog nized, or even later the character of the sepsis been understood, an operation would have saved his life. PSOAS ABSCESS. Psoas abscess is a term sometimes rather loosely applied to purulent collections in the iliac region. Properly speaking, it is a tubercular abscess haying its origin in caries of the lower cervical, dorsal, or lumbar vertebre. It is necessary to recall the arrangement of certain muscles and fascias, The psoas muscle, a rounded fleshy mass, lying alongside the bodies of the lumbar vertebne, extends across the pelvic brim, and passes in front of the hip-joint to be inserted into the lesser trochanter. 356 ADSCESS. ‘The iliacus, its companion muscle, occupies the iliac fossa and con- verges below in a tendon which merges with that of the psoas. These muscles are covered by the iliac fsscia which is so attached as to make the iliac fossa practically a closed compartment, ‘The fascia is separated from the muscles by a loose areolar tissue in which suppuration may originate and which constitutes an fifac abscess This fascia on its other side i separated from the perito~ neum by another layer of connective tissue—the subperitoneal areolar tissac, which is liberally supplied with fatty tissue and constitutes a site of lowered resistance to germs originating in the pelvic viscera, the cecum, the sigmoid, and the appendix. Suppuration under this layer usually ends as a pelvic abscess, Itis evident, therefore, that an Hiac abscess beginning as such, andab- scess in the subperitoneal tissues, are quite distinct from psoas abscess, except that all have common points of possible opening, ‘The fiac fascia covers the muscles in the iliac fossa, butit also extends upward in such manner as to ensheath the psoas and separate it from the bodies of the vertebne- : In the case of caries, the products of decomposition may lurst through the vertebral ligaments and the sheath, and thereafter follow the psoas muscle downward. The muscle itself may be decomposed in whole or part, and the accumulating pus may be directed by the tubu- lar sheath to its point of termination below Poupart’s ligament to the outer side of the iliac vessels. Or, again, the abscess may burst through the sheath higher up and point in the loin (lumbar abscess); or may point just above Poupart's ligament in the gluteal region, the pelvis, the scrotum, or thigh. The diagnosis of psoas abscess rests upon the history of the case, which points to spinal trouble, and upon the presence of ductuating swelling In the itiac fossa, or below Poupart’s ligament. Usually the hip i flexed in some degree, as by that position the tension in the psoas is relieved. ‘This flexion and some apparent stiffness in the joint might lead to a mistaken diagnosis of hip-joint disease. The swelling & Io be distinguished, also, from a hernial tumor, by the fact thatit a fluc tuating and lies at the outer side of the iliac vessels, Mi ai OPERATION FOR PSOAS ABSCESS. 43? Treaiment.—As in all cases of tubercular abscess, secondary infec- tion and amyloid degeneration are most to be dreaded. For that reason, spontaneous rupture and treatment by small incision and prolonged tubal drainage are equally dangerous. As carly as possible an aseptic evacuation must be practised. This may be accomplished by puncture and the subsequent injection of jodoform emulsion; this seems the advisable procedure, if the abscess is pointing in the region of Poupart’s ligament, and it is likely that the destructive process in the vertebra is in abeyance. In general, most authorities recommend the operation of Treves, by the lumbar route. Operation.—Begin by locating the last rib, the crest of the ilium, and the outer border of the crector spinw. The incision, two and one-half inches long, with its center half way between these bony Iand- marks, follows the outer border of the erector spin and exposes at first the lumbar fascia, Divide the first layer of the lumbar fascia and expose the erector spine. Develop its outer border the whole length of the wound and retract the muscle inward, exposing the middle layer of the lumbar fascia. Divide this layer which exposes the quadratus lumborum. Divide the quadratus lumborum along the line of its attachment to the tips of the transverse processes, which exposes the deep or an- terior Jayer of the lumbar fascia. Divide this layer and finally the peoas magnus is exposed. Divide the attachment of the psoas magnus sufficiently to introduce the finger, which opens up the abscess cavity and determines the condition of the carious vertebra, ‘The abscess cavity is to be treated by thorough irrigation with an antiseptic solution, wiped vigorously, or even curetted. The various layers are sutured without drainage and an antiseptic dressing applied. Previous to suturing, the cavity may be filled with iodoform emul- sion; or, as Walsham suggests, after the cavity is cleansed it may be packed with strips of iodaform gauze, which are to be changed on the third or fourth day. If at the end of a week no pus has appeared and the cavity is lined with healthy granulations, the wound may be closed by secondary suture.