Volume 1

Green's Encyclopedia and dictionary of medicine and surgery / edited by J. W. Ballantyne.

Date:
1906-1909
Catalogue details

Licence: Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)

Credit: Green's Encyclopedia and dictionary of medicine and surgery / edited by J. W. Ballantyne. Source: Wellcome Collection.

Provider: This material has been provided by The University of Glasgow Library. The original may be consulted at The University of Glasgow Library.

    34/576 (page 16)
    stitutional and local phenomena of suppuration are present. When the abscess is superficial, the red brawny condition of the skin with softened centre makes the diagnosis easy; but when placed more deeply, fluctuation is not generally obtainable because of the resistance of the overlying tissues. In the latter case, the localised hardness may simulate growths in the viscera beneath ; and the fact that vomiting is a fairly common symptom in these abscesses, makes the resemblance the more mai'ked. Tiie contents of the deeper abscesses are frequently foetid. Treatment.—In an early stage, before sup- puration has occurred, hot fomentations locally, and the administration of salines internally, may succeed in producing absorption of the inflammatory products. In consequence, how- ever, of the tendency of these abscesses to burrow, an incision should be made as soon as the presence of pus is suspected ; and for the same reason it is necessary to adopt thoroughly eflScient drainage, especially if several fistulous openings have formed. The possibility of such an abscess bursting into the peritoneal cavity also makes early operation imperative. The usual antiseptic precautions should be adopted. After the dressing has been applied, the ab- dominal muscles should be kept as (]uiet as possible by means of strapping, and the patient should be kept in bed till healing occurs. Some sort of support, as a preventive of hernia, should be afterwards worn for some months if the suppuration has been at all extensive. If the abscess is secondary to the presence of pus in some distant focus from which it has spi'ead, it is obvious that the primary condition must be treated before healing can be obtained in the abdominal abscess. Retro-Peritoneal Abscess When we consider the extensive area covered by the cellular tissue behind the peritoneum, it becomes apparent that the causes of suppura- tion in this region are very numerous. Amongst these may be mentioned perforating ulcer of the duodenum; suppurative inflammation of the kidney, liver, spleen, etc. ; disease of the vei'miform appendix, csecum, colon, female gener- ative organs, etc.; Pott's disease of tlie spine or primary tubercular deposit in the retro- peritoneal tissue ; empysema; injury, etc. Most of these will be considered in connection with the organs or diseases with which they are associated, and to these reference must be made. The looseness of the cellular tissue is favourable to wide extension of the pus, though its posi- tion is determined largely by the seat of its origin, by gravitation, and by the guidance of the lines of least resistance. Thus an abscess originating in appendicitis would be expected near the csecum, but an empysema which had found its way through the diaphragm might gravitate in the lumbar region. For anatomical reasons large extravasations of pus at the lower part of the abdomen would not be likely to pass beyond Poupart's ligament, but they might travel along the spermatic cord in the inguinal canal. On the other hand, retro - peritoneal suppuration may rise to any heiglit under the diaphragm, when it would be called a sub-phrenic abscess (t;w/e Diaphragm ). Symptoms and Diagnosis.—The varied causa- tion renders it impossible to mention symptoms occurring in all cases, beyond those common to deep suppuration anywhere, such as high fever, tenderness, sweating, and perhaps wasting, rigors, and pyaemia. To state the matter as broadly as possible, the symptoms resemble disease of the abdominal viscera in the neighbourhood of the abscess, and from which it may have originated. This, how- ever, makes the diagnosis difficult, and many mistakes have occurred. The less acute forms are very insidious, and large abscesses may form, and the patient be- come much debilitated, before the local condi- tion is discoverable, ffidema of the skin may sometimes point to the presence of deep sup- puration ; but in many cases the skin (except for any bulging that may be present) remains quite unaffected, unless the abscess is fortunately finding its way to the surface. In most acute cases a hard but ill-defined tumour forms sooner or later, and can be felt either through the anterior abdominal parietes or bulging into the loin. Should the suppuration extend under the diaphragm tlie symptoms of sub-diaphrag- matic abscess will be found. The proximity of the intestines produces decomposition of the contents of most of these abscesses. Treatment.—In all cases the abscess should be freely opened and the contents evacuated, with the usual antiseptic precautions. Beyond this general statement everything depends upon the origin of the abscess. Thus a perinephric abscess is best opened in the loin behind the peritoneum; but in many cases where the posterior part of the peritoneum is pushed for- ward, it is desirable to perform coeliotomy and stitch the edges of the incision in the abscess sac, after examination of its contents, to the parietal wound. Drainage is desirable in most cases, but is usually unnecessary in those of tubercular origin. Each case must be treated according to its anatomical position, causation, etc. The patient's strength will require support with generous diet, stimulants, and tonics. Abdominal Aneurysm. Symptoms . . . . . .17 Course and Terminations . . .19 Differential Diagnosis . . . .19 Treatment ...... 20 Aneurysm of the abdominal aorta is of much rarer occurrence than aneurysm of the thoracic aorta (according to Crisp, out of 551 cases of