a sharp-pointed bistoury, and the incision should vary in extent
according to the circumstances of the case. The straight instrument,
used as described and represented in the “Practical Surgery,” p.
5[6], will be found to answer best in deep-seated collections; in
the more superficial it may be slightly curved. It is used as here
shown, only that the edge of the knife should be turned more downwards
before the integument is divided by withdrawing it. The aperture must
always be made at the most dependent part, which is also, generally,
the thinnest; thereby a free exit is allowed to the matter. If the
incision be not made in a dependent part, a considerable quantity
of the matter will be retained within the abscess, and can only be
evacuated at the time by squeezing the parts—at all times a very cruel
and improper practice—applying compresses, &c., which produce much
irritation and unnecessary inconvenience to the patient. The cavity
of the abscess inflames, the discharge becomes bloody and putrid, and
great constitutional disturbance is apt to follow. When, again, the
opening is sufficiently large, properly placed, and the matter flows
out through the elasticity of the coverings, no air enters, the cyst
gradually contracts, and the cure is soon completed.
When the abscess has been deeply seated, and the incision made through
a considerable thickness of healthy parts, it is sometimes, though very
rarely, necessary to introduce a small piece of lint between the edges
of the wound, otherwise they may speedily adhere, and the discharge
of the matter be in this way prevented. In consequence of smart
hemorrhage, also, it may be proper to stuff the wound with lint, and
retain it for an hour or two; but in general the practice of stuffing
abscesses, or the openings into them, is hurtful. After the incision,
as already remarked, it is unnecessary and injurious to discharge the
pus by forcibly squeezing the sides of the abscess; the application
of a poultice will promote the evacuation of the matter, and allay
the irritation. In chronic abscesses of large size, it is sometimes
necessary to make a counter opening—that is, an opening in a part of
the tumour opposite to the original opening, in order that the matter
may be more completely discharged. Setons introduced into the cavity
of phlegmonous abscesses some time after their evacuation, are highly
injurious, as causing much irritation in parts which are already in a
morbid state of excitement; but in chronic collections, which show
no disposition to heal, their use may sometimes be followed by good
effects, on the same principle that they were hurtful in the preceding
case; if they should not cause a sufficient degree of excitement,
they may be smeared with some stimulating ointment. In extensive
collections, in which the matter is not sufficiently evacuated by the
external aperture, injections are by some recommended, and, perhaps,
occasionally employed: in those abscesses which are comparatively
recent, and in which the surrounding parts are still in a state of
over-excitement, they are quite inadmissible. The employment of setons
and injections in any case of abscess is not much to be commended or
trusted to. Caustic, the potassa fusa, may be frequently employed with
advantage for opening chronic abscesses, especially when they are the
consequence of glandular enlargement, and undermine the integuments,
which show no tendency to adhere to the subjacent parts. The potass
is best used in the solid form and well pointed; not in paste, as
is sometimes practised. By its application the unhealthy surface is
destroyed, and the surrounding parts are stimulated so as to assume
a sufficient degree of action to throw off the portions which have
become useless, and to form new and healthy granulations, whilst the
surrounding effusion of lymph or serum is for the most part speedily
absorbed. But it can never be employed in acute abscesses without
aggravating the disease; and in collections which are deeply seated,
it cannot be of much service, for in these a considerable thickness of
healthy parts must be destroyed, and if the potass be applied, it will
afterwards be necessary to cut through the slough, as was practised by
the older surgeons, in order to evacuate the matter and give relief to
the patient; or else to continue the application of the caustic for an
inordinate space of time, which is a practice altogether unnecessary,
extremely cruel, and productive of much irritation, constitutional as
well as local.
A too common result of abscess, when inertly treated, is the formation
of a _Sinus_; that is, a canal, the circumference of which is condensed
by deposited lymph, and which furnishes a discharge of unhealthy
purulent matter, frequently thin and gleety. Several sinuses frequently
unite, and evacuate their contents by one opening. Previously to
treating a sinus, its extent must be carefully examined by the probe;
this requires considerable caution, for the full extent of the canal
may not be discovered, in consequence of its tortuous course, or
from its diverging into collateral branches; or the probe, by being
used too forcibly, may pass into parts altogether unconnected with
the morbid cavity. Thus, in exploring a sinus at the lower part of
the leg, or in the foot, the probe may be pushed to a considerable
extent beneath the tendinous sheaths of the muscles, and induce the
surgeon to adopt treatment unnecessarily severe. In the treatment,
we may at first employ setons, injections, and graduated pressure,
as formerly explained; and if these fail, the canal must be freely
laid open by the knife—a mode of practice much more effectual; then
there is formed a cavity similar to that of a recent abscess, and to
be treated accordingly. Incision is most frequently necessary when
the sinus exists in adipose substance, in tendinous structure, in
parts possessed of little vitality, and in patients of a sluggish and
enfeebled constitution. In sinus, as well as in chronic abscess, the
potass is of essential service; a stick of it may be introduced into
the canal, and if the sinus is superficial, the integuments may be
divided by this caustic as effectually as by the knife. The indolent
and callous surface of the sore is thereby destroyed, and the effects
are similar to those which have been already mentioned, when speaking
of the use of potass in abscess; in fact, by its application the sinus
is transformed into an acute and open abscess. Foreign bodies, such as
diseased and dead portions of bones, must be early removed; for it is
to be remembered that these are much more frequently the cause than the
consequence of suppuration.
The healing of an abscess which has been opened closely resembles the
process of union by the second intention in a flesh wound; granulations
arise, attended by the secretion of pus, the cavity gradually
contracts; the surrounding effusion is absorbed along with a portion of
the adipose matter; and on the granulations reaching the surface, new
skin is formed, and the parts coalesce.
After abscesses have been opened, the fomentations, poultices, or
warm-water dressing, as recommended in the treatment of ulcers, are
to be continued, but only for a limited time. The power of the system
must be carefully supported by exposure to a pure atmosphere; by
nourishing food; by the exhibition of wine, tonics, and such medicines
as promote digestion. In cases where the system is unusually inert, it
may be proper to administer stimulants. The most powerful stimulants
are frequently necessary, and by steady perseverance in the use of
them, patients have often been saved in very hopeless circumstances.
Great attention must be paid to the bowels, and the secretions poured
into them, for on the condition and quality of these the state of
the constitution materially depends. The internal Use of cantharides
is often advantageous in chronic suppurations and abscesses, but
it is inadmissible in cases where enlarged glands occupy dangerous
situations, either externally or internally; unless the tumours are in
progress towards resolution, suppuration is certainly induced, and may
be productive of the worst consequences. The glands not unfrequently
become enlarged during the exhibition of this medicine; and such an
occurrence must be watched attentively. In illustration of the good
effects of stimuli in certain cases, it may be mentioned that the
cavities of abscesses are often speedily effaced by granulations, and
that obstinate sores frequently contract and cicatrise, after the
occurrence of a febrile attack, though they had previously shown no
disposition to heal.
In glandular swellings, Deobstruents, as they have been called, are
used; and with this view, mercury is often had recourse to; this
medicine, however, instead of producing a salutary effect, very
generally tends still farther to impair the constitution. Preparations
of iodine, exhibited both externally and internally, appear to be
sometimes of use when the swellings have become stationary, or are
inclined to subside. Iodine may be given in combination or not with
iron. It is a medicine exhibited very generally and indiscriminately,
and is very much more trusted to than it deserves to be. When the
tumours are irritable, fomentations may be employed, and advantage
taken of sea-bathing, warm or cold. The common adhesive or soap
plaster, spread on soft leather, or the ammoniacal plaster, are often
applied with advantage to indolent glandular swellings. Blistering is
sometimes resorted to with good effect, and in some situations pressure
may be usefully employed.
In the treatment of large indolent collections, it was proposed by
Mr. Abernethy to make a small and indirect aperture, and to evacuate
the contents of the abscess as often as the matter accumulated; but a
degree of constitutional irritation frequently supervenes upon this
proceeding, and the discharge becomes bloody, putrid, and mixed with a
considerable quantity of gaseous fluid. The discharge of blood probably
arises from the usual support being taken away from the vessels
ramifying on the surface of the cavity, in the same way that blood is
effused into the cavity of the abdomen, in consequence of the too rapid
evacuation of the serum in ascites.
Suppuration, more especially when extensive and long continued,
is attended with a peculiar species of fever, termed Hectic. This
fever is the remote consequence of local injury, or disease, whereas
symptomatic inflammatory fever is the immediate one. The incessant and
long-continued addition of pus to the blood may be the cause of hectic
fever. In cases of pulmonary consumption, pus globules are almost
uniformly detected in the blood. This fact has been noticed by Dr. Davy
and Mr. Gulliver. The pus is probably carried along the capillaries,
where it is always forming in chronic abscesses: in short, all the pus
formed is not separated from the blood. Hectic probably arises from
the never-ceasing addition of a little pus to the blood, inflammatory
fever from the sudden addition of a large quantity. In long-continued
disease, particularly internal, the hectic occasionally occurs before
the existence of suppuration is indicated; and it does not always
supervene upon suppuration, even though extensive. Hectic has been
supposed to arise from the absorption of pus; but pus cannot well be
absorbed without disintegration of its particles (and then it would
be no longer pus), for their diameter exceeds that of the more minute
bloodvessels and absorbents. Abscesses occasionally disappear, without
this event being followed by any unpleasant symptom.
Hectic fever is most apt to arise in constitutions originally weak; and
usually either from some incurable disease of a vital organ, or from
extensive affection of a part not essential to life; but it may also be
induced without any local assignable cause.
The general symptoms are those of a low and gradual fever, attended
with great debility; the pulse is frequent, unequal, small, and sharp;
the general surface is pale; there is flushing of the face, hands, and
feet; the skin, at one period, is cold and clammy, sometimes dry and
rough—at another, it is bathed in profuse perspiration, especially
towards evening; chills alternate with flushing; the appetite is much
impaired; diarrhœa supervenes; pale-coloured urine is voided in great
quantity, often with a lateritious sediment; there is want of sleep,
and great anxiety; the eyes are sunk, and of a glassy hue; the features
become changed; there is great emaciation; the patient, gradually more
and more weakened, falls into a state of coma, and expires.
A condition, somewhat resembling sympathetic fever, occasionally
supervenes in a constitution that has been suffering from hectic,
when any additional irritation occurs, and this fever has been called
_Irritative_. The sanguiferous system becomes more excited—the
secretions are suspended—the sensorium is disturbed; but still the
symptoms are accompanied with the peculiar debility characterising the
state of hectic. It frequently follows the opening of large chronic
abscesses by a minute aperture, in the manner formerly described and is
relieved only by free evacuation of the confined matter.
In the treatment of hectic, the local disease giving rise to the
symptoms, if it cannot be cured by other means, must be removed by
operation. Thus, if hectic is consequent on long-continued, but not
extensive, disease of bone, the affected portion is to be taken away;
if from extensive chronic disease of an arm or leg, the limb must be
amputated.
In general, the removal of the hectic cause is followed by immediate
melioration of the symptoms, even though the patient has been reduced
to an almost moribund condition: the feeble hectic pulse of 120 or 130
sinks in a few hours to 90, and becomes more full and strong; anxiety
and restlessness cease, and a patient sleeps soundly the first night
after the operation, who for weeks had scarcely closed his eyes; the
cold sweats and colliquative diarrhœa immediately subside, and the
urine loses its sediment; in effect, all the hectic symptoms disappear,
and are succeeded by such as indicate a marked improvement in the power
and energy of the constitution; and the rapidity with which these
changes take place is in many cases truly astonishing. Nourishing food,
wine, tonics, &c., must be given, in the first instance sparingly, and
afterwards gradually increased in quantity, according as the stomach
can bear them; for it is not to be overlooked, that incautious and too
liberal use of them may be productive of irretrievable evils, as the
action of the system may be increased beyond its resources, in the same
way as the imprudent application of stimulants to a part debilitated
by an excessive degree of cold causes its sphacelation, in consequence
of the arterial action induced being greater than what the power of
the part can support. The mineral acids may be useful in checking
the inordinate perspiration; opium, astringents, and absorbents, in
arresting the diarrhœa; but all are of little avail unless the exciting
cause is removed, and to this latter circumstance the attention of
the practitioner ought therefore to be chiefly directed. It is not
always quite safe, however, to free the patient at once of a great
suppurating drain. Upon the healing up of extensive and long-continued
ulcers, it is often necessary, in order to prevent oppression of and
congestion in the viscera of the chest, abdomen, or head, to insert an
issue or seton, and gradually withdraw it. In amputations also, more
especially in patients above the middle period of life, to rid them of
disease which has caused hectic and wasting, in consequence of profuse
discharge, it is often advisable to keep part of the wound open, so
that it may suppurate, heal, and dry up slowly.
_Mortification_, or the death of a part, is also one of the results
of inflammatory action, and the term has been subdivided into
_Gangrene_ and _Sphacelus_. Gangrene is that state in which the
larger arterial and nervous trunks still continue to perform their
functions; a portion of the natural temperature remains, and the part
may be supposed still capable of recovery. Sphacelus, again, expresses
complete death, when, putrefaction being no longer resisted, the part
becomes black, cold, insensible, and fetid; but, in general, the
distinction between the terms is not strictly attended to. A division
of more importance is into humid and dry, or traumatic and chronic,
gangrene; humid or traumatic being applied to mortification produced by
external injury; dry or chronic to that resulting from a constitutional
cause.
Mortification is not always a result of inflammation; it is sometimes
preceded by incited action of the vessels, sometimes not. It follows
as a matter of course that if inflammatory action is so violent as to
cause stagnation of blood in most or all the vessels of a part, and
this is continued, there must be a consequent failure of nutrition,
which will terminate in mortification.
Humid or traumatic gangrene frequently occurs without previous
inflammation, the injury being so severe as at once to deprive the
part of its vitality. Dry or chronic mortification is often unpreceded
by inflammatory action, or at least it is slight and of very short
duration. It is preceded by stagnation, or is at all events coincident
with this stagnation, not in the smaller vessels only, but in the
trunks leading to the affected part. In humid gangrene, swelling with
erethismus generally precedes the death of the parts; whereas in
the dry, whether the surface change colour immediately or not, they
shrink immediately. In the former they quickly lose their vitality,
and consequently retain a considerable portion of their fluids; in the
latter the process is much slower, and they become dry and shrivelled.
The most common remote cause of spontaneous mortification is a rigid
state of the arteries, most frequently met with in the inferior
extremities of elderly persons, in consequence of the deposition of
calcareous matter between the internal and middle coat; this calcareous
degeneration may be confined to a part of the limb, or may pervade
the whole of it, and even extend throughout the arterial system.
There are many cases in which disease of the arteries has existed,
though no gangrene occurred; but this by no means invalidates the
assertion, since, when arteries are thus affected, the part cannot
withstand sphacelus when exposed to any of its immediate causes. An
attempt has been made to connect mortification with an inflamed state
of the arterial coats. This opinion is not confirmed by experience.
Obstruction from coagulation of their contents, and inflammation of
the venous trunks, sometimes precedes death of the extreme parts in
old people, and seems to act as a direct cause. After wet seasons,
spontaneous gangrene has prevailed as an endemial disease on the
Continent, where rye is a principal article of food. The rye is subject
to a disease called _Ergot_; the grains become large, black, and have a
horny consistence; and the use of it, when thus diseased, is assigned
as the cause of gangrene. The patients who have suffered from the use
of this ergot or cockspur rye have experienced pain and heat, with
swelling, generally in the lower limbs, though occasionally in the
upper. These symptoms abating, the parts became cold, insensible, and
discoloured, and were gradually separated from the body. The disease
attacked patients of both sexes and every age, did not appear to be
infectious, and was frequently fatal. It has occurred in this country
from the use of unsound wheat. A tendency to mortification sometimes
arises from a peculiar state of the atmosphere, want of cleanliness,
poor and irregular diet, &c. Cancrum oris, for example, and sloughing
of the pudendum in children, occur in those of the poorer classes who
live in low, damp, and dirty situations; and little or no incited
action precedes the sloughing. The same may be said of the phagedænic
affections of the genital organs. Mortification and ulceration seem to
differ merely in this,—in the latter, a part which, from any cause, is
unfitted to remain a portion of the living body, is only prevented from
dying by absorption just as it is about to lose its vitality; whilst in
mortification the part perishes too soon, or in too great quantity, to
admit of absorption. Sloughing phagedæna is a sort of connecting link.
Mortification, to a greater or less extent, may be produced in any
constitution, and at any age, by the application of heated substances,
caustics, acids, &c.; by the effusion of acrid matter into the cellular
substances, as urine or putrid sanies; by the interruption of the
circulation and nervous energy, as from ligatures or improperly applied
bandages—or by natural strictures, as those in hernia and paraphymosis;
by continued pressure, more especially in such patients as have, from
long suffering and confinement, had the powers of the circulating
system weakened; and by violent contusions, as in fractures, compound
luxations, and gunshot injuries. A frequent source of mortification,
in inclement seasons and climates, is exposure to extreme cold. In
this case, the cold is not the direct, but the indirect cause; the
power of the parts is very much weakened by exposure to the low
temperature, and is thereby rendered incapable of resisting the incited
action which follows the stimulus of sudden transition from cold to
heat, even though the degree of increase in temperature should not
exceed that of the natural standard. That cold is not the direct cause
of mortification, has been undeniably proved by facts derived from
military practice. No symptoms of inflammation or gangrene occur when
the soldier is on duty, and continuously exposed to severe cold; but
they speedily present themselves after a rapid thaw has commenced, or
after the soldier has imprudently approached a fire. Soon after the
half-frozen person has begun to feel a little more comfortable from
sudden warmth, he becomes aware of pain, attended with a sensation of
itching in the extremities, generally the lower, which are considerably
swollen, and of a dull red colour; these, and other symptoms of
inflammation, are of no long duration, the action speedily runs its
course, and the part soon plainly indicates that gangrene has commenced.
When gangrene follows the tight application of a ligature, the death
of the part seems to depend more on obstruction to the circulation of
the blood, than on any diminution of the nervous energy, for we do
not observe that paralytic limbs are peculiarly liable to gangrene.
The surgeon frequently takes advantage of the fact that a part soon
dies when its supply of blood is cut off, or its return in the veins
interrupted; and has recourse to ligature for removal of parts, When he
considers it inexpedient to employ cutting instruments.
Mortification may be produced by the above-mentioned causes, either
immediately or consecutively; and it will occur in some constitutions,
or states of constitution, at some periods of life, in some structures,
and in some parts of the body, more readily than in others.
Inflammatory action is seldom so intense as to terminate in death of
the part, unless the power of that part has been diminished by previous
local or constitutional disease, or by injury; and the inflammation
preceding gangrene is all along attended by symptoms of so well-marked
debility, both local and general, that it is frequently designated the
Inflammatio Debilis. Of inflammatory affections, the erysipelatous
most frequently terminates in gangrene; in other words, the power of
resisting incited action is not so great in the cellular tissue and
skin as in other parts of the body.
[Illustration]