The principles and practice of modern surgeryPark, Roswell
Science
The principles and practice of modern surgery
Park, Roswell
Surgery
One inevitable law seems to govern collections of pus, that when
they _advance_ or migrate in any direction it is in that of _least
resistance_. This causes them to take peculiar and sometimes disastrous
courses, but it is a law which is never violated. It leads to the
bursting of abscesses into the brain, into the pleural cavity, into the
peritoneal cavity, the bowel, and elsewhere; it leads to a condition
where pus may travel along a path even a foot or more in length,
rather than come to the surface, a distance of perhaps an inch, and
affords one of the best reasons for early operative interference so
that the disastrous effects of burrowing may be obviated. When the
pus is limited to a drop or fraction thereof the abscess is called a
_furuncle_, especially when in the skin. The average “boil” of the
layman is a subcutaneous or subfascial abscess. When the infiltration
is pronounced, and when there has been more or less extensive
destruction of tissue, with perhaps formation of numerous outlets for
the escape of pus and detritus, it is known as a _carbuncle_. (See
Chapter XXVI.) In certain conditions small superficial furuncles or
boils form, sometimes in great number and almost synchronously, or, as
it were, in crops. This condition is known as _general furunculosis_.
=Signs and Symptoms of Abscesses.=--The appearances by which pus may
be suspected or detected are those of congestion and hyperemia, more
or less abruptly circumscribed and markedly accentuated. Along with
these there is more or less edema or edematous infiltration of the skin
and overlying tissue, which permits of that peculiar appearance known
as “pitting on pressure.” Often, too, there is a distinctly edematous
swelling of the parts, especially around the margin, with brawny
infiltration of the centre of the infected area. Numerous vesicles
occasionally are noted upon the skin, which may be filled with reddish
serum. When softening and pus formation occur, there is a condition
which to the palpating fingers gives the characteristic sensation known
as _fluctuation_. Fluctuation simply points out the presence of fluid
beneath; but when in an area marked as thus described fluctuation is
noted, it means the presence of pus. It is detected by manipulating in
a direction parallel to and concentric with the axis of the limb or
part. The pain is also in most instances significant; patients speak
of it as having an intense and throbbing character. With these local
signs occur symptoms indicating some degree of septic intoxication, _i.
e._, pyrexia, chills, malaise, sweats, etc., which are corroborative
indications, their intensity being a reasonably correct index of the
severity and gravity of the local infection.
When a deep-seated abscess is suspected a careful blood count will
often permit a diagnosis to be made. This is conspicuously true of
cases of appendicitis. If leukocytosis is established there should be
immediate operation. (See Chapter II.)
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