Surgery, a practical treatise with special reference to treatment / by C.W. Mansell Moullin ; assisted by various writers on special subjects.
- Mansell-Moullin, C. W. (Charles William), 1851-1940
- Date:
- 1893
Licence: Public Domain Mark
Credit: Surgery, a practical treatise with special reference to treatment / by C.W. Mansell Moullin ; assisted by various writers on special subjects. Source: Wellcome Collection.
Provider: This material has been provided by the Augustus C. Long Health Sciences Library at Columbia University and Columbia University Libraries/Information Services, through the Medical Heritage Library. The original may be consulted at the the Augustus C. Long Health Sciences Library at Columbia University and Columbia University.
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![SUP PUR A TION—ABSCESS. lliictuatinn and jjainless, with but little siffii of fever or inflaminatioii. The con- tents are usually thin anil rather oily, and not unfre(|uently it takes a long time for the patient to recover. Tympanitic ahscesses, containing gas as well as pus, are occasionally met with in the neighborhood of the alimentary canal, not necessarily in connection with the intestine, though this is very commonly the case. Diffuse suppuration is only met with when the action of the poison is very intense, or the resistance of the tissues exceedingly feeble, and is usually as.sociated with streptococci, as well as staphylococci. The sym])toms of inflammation may be well-marked, but not unfrecpiently they are altogether concealed, the fever assuming a tyjjhoid or adynamic type, and the nervous system being so over- powered that pain is scarcely felt. Diagnosis.—If the part involved is superficial, and the signs of inflammation are distinct, there is little or no difticulty ; when the converse of this is the case it may be impossible. The occurrence of a rigor, the presence of throbbing pain and of inflammatory adema, a softer spot appearing in the middle of a mass of hardened tissue, and the sensation of fluctuation, are the mo.st important diagnostic signs; but any of these may be absent, or even all of them, and it must always be remembered that fluctuation only indicates the presence of fluid, and of itself gives not the slightest clue as to its nature. In cases of doubt, and particularly where the diagnosis has to be made from cysts or soft solid growths (which may Ije attended by all the signs of inflammation—hectic, local heat, redness, swelling, and pain), it is advisable to make use of an exploring-needle (grooved .so that fluid can escape along it) or a long fine trocar and cannula. Very little harm can be done with either of these, if carefully used ; the liver, for example, may be punctured in all directions, almost with impunity ; and the result can be relied upon. Even in those cases in which a caseous mass prevents the exit of any fluid, evidence of its presence may generally be found at the end of the cannula when it is withdrawn. Treatment.—i. Acute abscesses.—Preventive measures may be tried first; but, as a rule, if there are fair grounds for suspecting suppuration, the sooner an incision is made the better. In cases in which pain is severe and tension high (as in whitlow, acute periostitis, and phlegmonous inflammation of the cellular tissue) it is certainly not advisable to wait. Free incision is the best prevention. Incision is the only method of treatment. If the abscess is i)ointing, or if, short of this, there is one spot more tender than another, or at which the skin is more adherent or oedematous, the question of locality is settled. Where there is no indication of this kind either the most dependent part is selected, or that which appears advisable for anatomical reasons. Superficial veins and nerves, for example, should be avoided ; natural folds of the skin selected as far as possible ; and, above all, especial attention paid to the depth, position, and direction of the more important structures, such as vessels and ducts. If an incision must be made in their neighborhood it should be parallel to them. No plunge should be made in opening an abscess. The spot is selected, and the scalpel or absce.ss-knife introduced perpendicularly until either the sense of resistance ceases or, when the blade is slightly rotated, the pus wells up round it. Sufficient length is obtained in cutting outward. Deep abscesses, lying among important structures, are opened either by dissection or by Hilton's method. If, for example, there is suppuration beneath the deep cervical fascia, and the position of the vessels is uncertain, an incision half or three-quarters of an inch in length is made through the superficial structures, and a steel director pushed into the most prominent part of the swelling. As soon as it reaches the fluid a little escapes along the groove. Then a pair of dressing-forceps, with the blades closed, is passed along the director, and the wall of the abscess, and the structures over it, torn as far as may be necessary by separating the handles. An abscess should never be scpieezed ; it only makes the granulations bleed. If the sac is small and the tension high the contents are soon forced out by the](https://iiif.wellcomecollection.org/image/b21213744_0059.jp2/full/800%2C/0/default.jpg)
