SUPPURATION
Definition--Pus--_Varieties_--Acute circumscribed abscess--_Acute
suppuration in a wound_--_Acute Suppuration in a mucous
membrane_--Diffuse cellulitis and diffuse suppuration--
_Whitlow_--_Suppurative cellulitis in different situations_--Chronic
suppuration--Sinus, Fistula--Constitutional manifestations of
pyogenic infection--_Sapræmia_--_Septicæmia_--_Pyæmia_.
Suppuration, or the formation of pus, is one of the results of the
action of bacteria on the tissues. The invading organism is usually one
of the staphylococci, less frequently a streptococcus, and still less
frequently one of the other bacteria capable of producing pus, such as
the bacillus coli communis, the gonococcus, the pneumococcus, or the
typhoid bacillus.
So long as the tissues are in a healthy condition they are able to
withstand the attacks of moderate numbers of pyogenic bacteria of
ordinary virulence, but when devitalised by disease, by injury, or by
inflammation due to the action of other pathogenic organisms,
suppuration ensues.
It would appear, for example, that pyogenic organisms can pass through
the healthy urinary tract without doing any damage, but if the pelvis of
the kidney, the ureter, or the bladder is the seat of stone, they give
rise to suppuration. Similarly, a calculus in one of the salivary ducts
frequently results in an abscess forming in the floor of the mouth. When
the lumen of a tubular organ, such as the appendix or the Fallopian tube
is blocked also, the action of pyogenic organisms is favoured and
suppuration ensues.
#Pus.#--The fluid resulting from the process of suppuration is known
as _pus_. In its typical form it is a yellowish creamy substance, of
alkaline reaction, with a specific gravity of about 1030, and it has a
peculiar mawkish odour. If allowed to stand in a test-tube it does not
coagulate, but separates into two layers: the upper, transparent,
straw-coloured fluid, the _liquor puris_ or pus serum, closely
resembling blood serum in its composition, but containing less protein
and more cholestrol; it also contains leucin, tyrosin, and certain
albumoses which prevent coagulation.
The layer at the bottom of the tube consists for the most part of
polymorph leucocytes, and proliferated connective tissue and endothelial
cells (_pus corpuscles_). Other forms of leucocytes may be present,
especially in long-standing suppurations; and there are usually some red
corpuscles, dead bacteria, fat cells and shreds of tissue, cholestrol
crystals, and other detritus in the deposit.
If a film of fresh pus is examined under the microscope, the pus cells
are seen to have a well-defined rounded outline, and to contain a finely
granular protoplasm and a multi-partite nucleus; if still warm, the
cells may exhibit amœboid movement. In stained films the nuclei take the
stain well. In older pus cells the outline is irregular, the protoplasm
coarsely granular, and the nuclei disintegrated, no longer taking the
stain.
_Variations from Typical Pus._--Pus from old-standing sinuses is often
watery in consistence (ichorous), with few cells. Where the granulations
are vascular and bleed easily, it becomes sanious from admixture with
red corpuscles; while, if a blood-clot be broken down and the debris
mixed with the pus, it contains granules of blood pigment and is said to
be "grumous." The _odour_ of pus varies with the different bacteria
producing it. Pus due to ordinary pyogenic cocci has a mawkish odour;
when putrefactive organisms are present it has a putrid odour; when it
forms in the vicinity of the intestinal canal it usually contains the
bacillus coli communis and has a fæcal odour.
The _colour_ of pus also varies: when due to one or other of the
varieties of the bacillus pyocyaneus, it is usually of a blue or green
colour; when mixed with bile derivatives or altered blood pigment, it
may be of a bright orange colour. In wounds inflicted with rough iron
implements from which rust is deposited, the pus often presents the same
colour.
The pus may form and collect within a circumscribed area, constituting a
localised _abscess_; or it may infiltrate the tissues over a wide
area--_diffuse suppuration_.
ACUTE CIRCUMSCRIBED ABSCESS
Any tissue of the body may be the seat of an acute abscess, and there
are many routes by which the bacteria may gain access to the affected
area. For example: an abscess in the integument or subcutaneous
cellular tissue usually results from infection by organisms which have
entered through a wound or abrasion of the surface, or along the ducts
of the skin; an abscess in the breast from organisms which have passed
along the milk ducts opening on the nipple, or along the lymphatics
which accompany these. An abscess in a lymph gland is usually due to
infection passing by way of the lymph channels from the area of skin or
mucous membrane drained by them. Abscesses in internal organs, such as
the kidney, liver, or brain, usually result from organisms carried in
the blood-stream from some focus of infection elsewhere in the body.
A knowledge of the possible avenues of infection is of clinical
importance, as it may enable the source of a given abscess to be traced
and dealt with. In suppuration in the Fallopian tube (pyosalpynx), for
example, the fact that the most common origin of the infection is in the
genital passage, leads to examination for vaginal discharge; and if none
is present, the abscess is probably due to infection carried in the
blood-stream from some primary focus about the mouth, such as a gumboil
or an infective sore throat.
The exact location of an abscess also may furnish a key to its source;
in axillary abscess, for example, if the suppuration is in the lymph
glands the infection has come through the afferent lymphatics; if in the
cellular tissue, it has spread from the neck or chest wall; if in the
hair follicles, it is a local infection through the skin.
#Formation of an Abscess.#--When pyogenic bacteria are introduced into
the tissue there ensues an inflammatory reaction, which is characterised
by dilatation of the blood vessels, exudation of large numbers of
leucocytes, and proliferation of connective-tissue cells. These
wandering cells soon accumulate round the focus of infection, and form a
protective barrier which tends to prevent the spread of the organisms
and to restrict their field of action. Within the area thus
circumscribed the struggle between the bacteria and the phagocytes takes
place, and in the process toxins are formed by the organisms, a certain
number of the leucocytes succumb, and, becoming degenerated, set free
certain proteolytic enzymes or ferments. The toxins cause
coagulation-necrosis of the tissue cells with which they come in
contact, the ferments liquefy the exudate and other albuminous
substances, and in this way _pus_ is formed.
If the bacteria gain the upper hand, this process of liquefaction which
is characteristic of suppuration, extends into the surrounding tissues,
the protective barrier of leucocytes is broken down, and the
suppurative process spreads. A fresh accession of leucocytes, however,
forms a new barrier, and eventually the spread is arrested, and the
collection of pus so hemmed in constitutes an _abscess_.
Owing to the swelling and condensation of the parts around, the pus thus
formed is under considerable pressure, and this causes it to burrow
along the lines of least resistance. In the case of a subcutaneous
abscess the pus usually works its way towards the surface, and "points,"
as it is called. Where it approaches the surface the skin becomes soft
and thin, and eventually sloughs, allowing the pus to escape.
An abscess forming in the deeper planes is prevented from pointing
directly to the surface by the firm fasciæ 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
œdematous 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, œdema 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 œdema 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
hæmophylics, 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 œdematous. 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 gonorrhœal 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,
œdematous, 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 _septicæmia_ 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. _Hæmorrhage_ 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 hyperæmia 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 hyperæmia.
_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 œdema, 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 toxæmia 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 anæsthesia, 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 œdema 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 fasciæ 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 hyperæmia by Bier's method,
and, if this is done early, suppuration may be avoided. If pus forms,
small incisions are made, under local anæsthesia, 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.
Cellulitis of the _sole of the foot_ may follow whitlow of the toes.
In the _region of the ankle_ cellulitis is not common; but _around the
knee_ it frequently occurs in relation to the prepatellar bursa and to
the popliteal lymph glands, and may endanger the knee-joint. It is also
met with in the _groin_ following on inflammation and suppuration of the
inguinal glands, and cases are recorded in which the sloughing process
has implicated the femoral vessels and led to secondary hæmorrhage.
Cellulitis of the scalp, orbit, neck, pelvis, and perineum will be
considered with the diseases of these regions.
CHRONIC SUPPURATION
While it is true that a chronic pyogenic abscess is sometimes met
with--for example, in the breast and in the marrow of long bones--in the
great majority of instances the formation of a chronic or cold abscess
is the result of the action of the tubercle bacillus. It is therefore
more convenient to study this form of suppuration with tuberculosis
(p. 139).
SINUS AND FISTULA
#Sinus.#--A sinus is a track leading from a focus of suppuration to a
cutaneous or mucous surface. It usually represents the path by which the
discharge escapes from an abscess cavity that has been prevented from
closing completely, either from mechanical causes or from the persistent
formation of discharge which must find an exit. A sinus is lined by
granulation tissue, and when it is of long standing the opening may be
dragged below the level of the surrounding skin by contraction of the
scar tissue around it. As a sinus will persist until the obstacle to
closure of the original abscess is removed, it is necessary that this
should be sought for. It may be a foreign body, such as a piece of dead
bone, an infected ligature, or a bullet, acting mechanically or by
keeping up discharge, and if the body is removed the sinus usually
heals. The presence of a foreign body is often suggested by a mass of
redundant granulations at the mouth of the sinus. If a sinus passes
through a muscle, the repeated contractions tend to prevent healing
until the muscle is kept at rest by a splint, or put out of action by
division of its fibres. The sinuses associated with empyema are
prevented from healing by the rigidity of the chest wall, and will only
close after an operation which admits of the cavity being obliterated.
In any case it is necessary to disinfect the track, and, it may be, to
remove the unhealthy granulations lining it, by means of the sharp
spoon, or to excise it bodily. To encourage healing from the bottom the
cavity should be packed with bismuth or iodoform gauze. The healing of
long and tortuous sinuses is often hastened by the injection of Beck's
bismuth paste (p. 145). If disfigurement is likely to follow from
cicatricial contraction--for example, in a sinus over the lower jaw
associated with a carious tooth--the sinus should be excised and the raw
surfaces approximated with stitches.
The _tuberculous sinus_ is described under Tuberculosis.
A #fistula# is an abnormal canal passing from a mucous surface to the
skin or to another mucous surface. Fistulæ resulting from suppuration
usually occur near the natural openings of mucous canals--for example,
on the cheek, as a salivary fistula; beside the inner angle of the eye,
as a lacrymal fistula; near the ear, as a mastoid fistula; or close to
the anus, as a fistula-in-ano. Intestinal fistulæ are sometimes met with
in the abdominal wall after strangulated hernia, operations for
appendicitis, tuberculous peritonitis, and other conditions. In the
perineum, fistulæ frequently complicate stricture of the urethra.
Fistulæ also occur between the bladder and vagina (_vesico-vaginal
fistula_), or between the bladder and the rectum (_recto-vesical
fistula_).
The _treatment_ of these various forms of fistula will be described in
the sections dealing with the regions in which they occur.
_Congenital fistulæ_, such as occur in the neck from imperfect closure
of branchial clefts, or in the abdomen from unobliterated fœtal ducts
such as the urachus or Meckel's diverticulum, will be described in their
proper places.
CONSTITUTIONAL MANIFESTATIONS OF PYOGENIC INFECTION
We have here to consider under the terms Sapræmia, Septicæmia, and
Pyæmia certain general effects of pyogenic infection, which, although
their clinical manifestations may vary, are all associated with the
action of the same forms of bacteria. They may occur separately or in
combination, or one may follow on and merge into another.
#Sapræmia#, or septic intoxication, is the name applied to a form of
poisoning resulting from the absorption into the blood of the toxic
products of pyogenic bacteria. These products, which are of the nature
of alkaloids, act immediately on their entrance into the circulation,
and produce effects in direct proportion to the amount absorbed. As the
toxins are gradually eliminated from the body the symptoms abate, and if
no more are introduced they disappear. Sapræmia in these respects,
therefore, is comparable to poisoning by any other form of alkaloid,
such as strychnin or morphin.
_Clinical Features._--The symptoms of sapræmia seldom manifest
themselves within twenty-four hours of an operation or injury, because
it takes some time for the bacteria to produce a sufficient dose of
their poisons. The onset of the condition is marked by a feeling of
chilliness, sometimes amounting to a rigor, and a rise of temperature to
102°, 103°, or 104° F., with morning remissions (Fig. 10). The heart's
action is markedly depressed, and the pulse is soft and compressible.
The appetite is lost, the tongue dry and covered with a thin
brownish-red fur, so that it has the appearance of "dried beef." The
urine is scanty and loaded with urates. In severe cases diarrhœa and
vomiting of dark coffee-ground material are often prominent features.
Death is usually impending when the skin becomes cold and clammy, the
mucous membranes livid, the pulse feeble and fluttering, the discharges
involuntary, and when a low form of muttering delirium is present.
[Illustration: FIG. 10.--Charts of Acute sapræmia from (a) case of
crushed foot, and (b) case of incomplete abortion.]
A local form of septic infection is always present--it may be an
abscess, an infected compound fracture, or an infection of the cavity of
the uterus, for example, from a retained portion of placenta.
_Treatment._--The first indication is the immediate and complete removal
of the infected material. The wound must be freely opened, all
blood-clot, discharge, or necrosed tissue removed, and the area
disinfected by washing with sterilised salt solution, peroxide of
hydrogen, or eusol. Stronger lotions are to be avoided as being likely
to depress the tissues, and so interfere with protective phagocytosis.
On account of its power of neutralising toxins, iodoform is useful in
these cases, and is best employed by packing the wound with iodoform
gauze, and treating it by the open method, if this is possible.
The general treatment is carried out on the same lines as for other
infective conditions.
#Chronic sapræmia or Hectic Fever.#--Hectic fever differs from acute
sapræmia merely in degree. It usually occurs in connection with
tuberculous conditions, such as bone or joint disease, psoas abscess, or
empyema, which have opened externally, and have thereby become infected
with pyogenic organisms. It is gradual in its development, and is of a
mild type throughout.
[Illustration: FIG. 11.--Chart of Hectic Fever.]
The pulse is small, feeble, and compressible, and the temperature rises
in the afternoon or evening to 102° or 103° F. (Fig. 11), the cheeks
becoming characteristically flushed. In the early morning the
temperature falls to normal or below it, and the patient breaks into a
profuse perspiration, which leaves him pale, weak, and exhausted. He
becomes rapidly and markedly emaciated, even although in some cases the
appetite remains good and is even voracious.
The poisons circulating in the blood produce _waxy degeneration_ in
certain viscera, notably the liver, spleen, kidneys, and intestines. The
process begins in the arterial walls, and spreads thence to the
connective-tissue structures, causing marked enlargement of the affected
organs. Albuminuria, ascites, œdema of the lower limbs, clubbing of the
fingers, and diarrhœa are among the most prominent symptoms of this
condition.
The _prognosis_ in hectic fever depends on the completeness with which
the further absorption of toxins can be prevented. In many cases this
can only be effected by an operation which provides for free drainage,
and, if possible, the removal of infected tissues. The resulting wound
is best treated by the open method. Even advanced waxy degeneration does
not contra-indicate this line of treatment, as the diseased organs
usually recover if the focus from which absorption of toxic material is
taking place is completely eradicated.
[Illustration: FIG. 12.--Chart of case of Septicæmia followed by
Pyæmia.]
#Septicæmia.#--This form of blood-poisoning is the result of the action
of pyogenic bacteria, which not only produce their toxins at the primary
seat of infection, but themselves enter the blood-stream and are carried
to other parts, where they settle and produce further effects.
_Clinical Features._--There may be an incubation period of some hours
between the infection and the first manifestation of acute septicæmia.
In such conditions as acute osteomyelitis or acute peritonitis, we see
the most typical clinical pictures of this condition. The onset is
marked by a chill, or a rigor, which may be repeated, while the
temperature rises to 103° or 104° F., although in very severe cases the
temperature may remain subnormal throughout, the virulence of the toxins
preventing reaction. It is in the general appearance of the patient and
in the condition of the pulse that we have our best guides as to the
severity of the condition. If the pulse remains firm, full, and regular,
and does not exceed 110 or even 120, while the temperature is moderately
raised, the outlook is hopeful; but when the pulse becomes small and
compressible, and reaches 130 or more, especially if at the same time
the temperature is low, a grave prognosis is indicated. The tongue is
often dry and coated with a black crust down the centre, while the sides
are red. It is a good omen when the tongue becomes moist again. Thirst
is most distressing, especially in septicæmia of intestinal origin.
Persistent vomiting of dark-brown material is often present, and
diarrhœa with blood-stained stools is not uncommon. The urine is small
in amount, and contains a large proportion of urates. As the poisons
accumulate, the respiration becomes shallow and laboured, the face of a
dull ashy grey, the nose pinched, and the skin cold and clammy.
Capillary hæmorrhages sometimes take place in the skin or mucous
membranes; and in a certain proportion of cases cutaneous eruptions
simulating those of scarlet fever or measles appear, and are apt to lead
to errors in diagnosis. In other cases there is slight jaundice. The
mental state is often one of complete apathy, the patient failing to
realise the gravity of his condition; sometimes there is delirium.
The _prognosis_ is always grave, and depends on the possibility of
completely eradicating the focus of infection, and on the reserve force
the patient has to carry him over the period during which he is
eliminating the poison already circulating in his blood.
The _treatment_ is carried out on the same lines as in sapræmia, but it
is less likely to be successful owing to the organisms having entered
the circulation. When possible, the primary focus of infection should be
dealt with.
#Pyæmia# is a form of blood-poisoning characterised by the development
of secondary foci of suppuration in different parts of the body. Toxins
are thus introduced into the blood, not only at the primary seat of
infection, but also from each of these metastatic collections. Like
septicæmia, this condition is due to pyogenic bacteria, the
_streptococcus pyogenes_ being the commonest organism found. The primary
infection is usually in a wound--for example, a compound fracture--but
cases occur in which the point of entrance of the bacteria is not
discoverable. The dissemination of the organisms takes place through the
medium of infected emboli which form in a thrombosed vein in the
vicinity of the original lesion, and, breaking loose, are carried
thence in the blood-stream. These emboli lodge in the minute vessels of
the lungs, spleen, liver, kidneys, pleura, brain, synovial membranes, or
cellular tissue, and the bacteria they contain give rise to secondary
foci of suppuration. Secondary abscesses are thus formed in those parts,
and these in turn may be the starting-point of new emboli which give
rise to fresh areas of pus formation. The organs above named are the
commonest situations of pyæmic abscesses, but these may also occur in
the bone marrow, the substance of muscles, the heart and pericardium,
lymph glands, subcutaneous tissue, or, in fact, in any tissue of the
body. Organisms circulating in the blood are prone to lodge on the
valves of the heart and give rise to endocarditis.
[Illustration: FIG. 13.--Chart of Pyæmia following on Acute
Osteomyelitis.]
_Clinical Features._--Before antiseptic surgery was practised, pyæmia
was a common complication of wounds. In the present day it is not only
infinitely less common, but appears also to be of a less severe type.
Its rarity and its mildness may be related as cause and effect, because
it was formerly found that pyæmia contracted from a pyæmic patient was
more virulent than that from other sources.
In contrast with sapræmia and septicæmia, pyæmia is late of developing,
and it seldom begins within a week of the primary infection. The first
sign is a feeling of chilliness, or a violent rigor lasting for perhaps
half an hour, during which time the temperature rises to 103°, 104°, or
105° F. In the course of an hour it begins to fall again, and the
patient breaks into a profuse sweat. The temperature may fall several
degrees, but seldom reaches the normal. In a few days there is a second
rigor with rise of temperature, and another remission, and such attacks
may be repeated at diminishing intervals during the course of the
illness (Figs. 12 and 13). The pulse is soft, and tends to remain
abnormally rapid even when the temperature falls nearly to normal.
The face is flushed, and wears a drawn, anxious expression, and the eyes
are bright. A characteristic sweetish odour, which has been compared to
that of new-mown hay, can be detected in the breath and may pervade the
patient. The appetite is lost; there may be sickness and vomiting and
profuse diarrhœa; and the patient emaciates rapidly. The skin is
continuously hot, and has often a peculiar pungent feel. Patches of
erythema sometimes appear scattered over the body. The skin may assume a
dull sallow or earthy hue, or a bright yellow icteric tint may appear.
The conjunctivæ also may be yellow. In the latter stages of the disease
the pulse becomes small and fluttering; the tongue becomes dry and
brown; sordes collect on the teeth; and a low muttering form of delirium
supervenes.
Secondary infection of the parotid gland frequently occurs, and gives
rise to a suppurative parotitis. This condition is associated with
severe pain, gradually extending from behind the angle of the jaw on to
the face. There is also swelling over the gland, and eventually
suppuration and sloughing of the gland tissue and overlying skin.
Secondary abscesses in the lymph glands, subcutaneous tissue, or joints
are often so insidious and painless in their development that they are
only discovered accidentally. When the abscess is evacuated, healing
often takes place with remarkable rapidity, and with little impairment
of function.
The general symptoms may be simulated by an attack of malaria.
_Prognosis._--The prognosis in acute pyæmia is much less hopeless than
it once was, a considerable proportion of the patients recovering. In
acute cases the disease proves fatal in ten days or a fortnight, death
being due to toxæmia. Chronic cases often run a long course, lasting for
weeks or even months, and prove fatal from exhaustion and waxy disease
following on prolonged suppuration.
_Treatment._--In such conditions as compound fractures and severe
lacerated wounds, much can be done to avert the conditions which lead to
pyæmia, by applying a Bier's constricting bandage as soon as there is
evidence of infection having taken place, or even if there is reason to
suspect that the wound is not aseptic.
If sepsis is already established, and evidence of general infection is
present, the wound should be opened up sufficiently to admit of thorough
disinfection and drainage, and the constricting bandage applied to aid
the defensive processes going on in the tissues. If these measures fail,
amputation of the limb may be the only means of preventing further
dissemination of infective material from the primary source of
infection.
Attempts have been made to interrupt the channel along which the
infective emboli spread, by ligating or resecting the main vein of the
affected part, but this is seldom feasible except in the case of the
internal jugular vein for infection of the transverse sinus.
Secondary abscesses must be aspirated or opened and drained whenever
possible.
The general treatment is conducted on the same lines as on other forms
of pyogenic infection.