continues to be discharged. I do not know any circumstance under which their employment should be withheld. The issue should not be made on the same side of the spine as that where the abscess is, if presenting in the loins, but on the other side, and opposite the outer margin of the m. quadratus lumborum. And, if there be abscess in both lumbar regions, the issues should be put in above and below them. But, if the swelling present in the top of the thigh, as in the psoas abscess specially so called, it may then be made on the same side, or, indeed, on both sides issues may be introduced. The issue should never be made upon the ridge of the spine, as, on account of the nearness of the spinous processes to the skin, the periosteum and ligaments covering their tips may be involved in the slough, and the processes themselves become necrotic. Neither should it be made over or upon the abscess itself, as the separation of the slough will open its cavity. Large issues I do not think advisable: a slough as large as a sixpence, made with caustic potash, will, when thrown off, leave a wound as big as a shilling. which is large enough to hold three or four glass beads, and amply sufficient, as with but little attention the issues can be kept open for a considerable time, and, when they seem disposed to heal, their surface must be smeared with the caustic potash sufficiently to produce a fresh slough, and, on its separation, the peas are to be again introduced. The intention of the issues is to divert the diseased action going on in the vertebral column, which is generally the cause of psoas or lumbar abscess, as already mentioned, and is a practice which I have found eminently successful.-J. F. S.

(2) Much difference of opinion still exists among surgeons as to the propriety of waiting the self-evacuation of these abscesses, or of puncturing and emptying them either entirely or partially.

ABERNETHY asks, when the abscess "protrudes the integuments, that they, from distension, become irritated; that their temperature is slightly augmented; what are we then to do? Are we to wait till evident signs of inflammation appear? I think not. I would relieve them from distension, by emptying the abscess through a wound made by an abscess lancet. I would open the abscess for a reason which appears paradoxical on its first proposal, which is that it may be kept closed. We can empty a cavity, and by healing the wound keep it afterwards shut, and no inflammation ensues. If nature opeus the cavity by ulceration, the opening is permanent and the inflammation consequent must be endured." (p. 153.)

The practice of puncturing large abscesses with a trocar, seems to have been first advised by DECKERS, in 1696; he left the canula in the cavity stopped with a cork, and let out the matter at intervals. The same proceeding was also adopted by BENJAMIN BELL. Tapping these abscesses with a small trocar was also recommended by CROWTHER, who always introduced it at the same spot. He thought that the aperture so made did not ulcerate, nor allow the matter to escape after being dressed. In addition to drawing off the pus with a trocar, LATTA (a) advises, that after this is effected, the end of the canula, which had been introduced at the bottom, should be pressed gently up to the top of the abscess, the trocar introduced into it and thrust through the skin, and then, being withdrawn, a skein of silk to be passed through the canula, which is also to be removed, and thus a seton formed. (p. 36.) The introduction of the seton is, I should consider, a very dangerous experiment, as likely to excite inflammation, always too much to be dreaded, in a part too prone to run into that condition. I have never pursued this practice, nor, for the reason just mentioned, should I be disposed to do so. And, as to puncturing with the trocar, I do not see any advantage to be obtained from it, and certainly cannot believe the wound would heal more speedily than a simple puncture with a lancet.-J. F. s.

ABERNETHY'S peculiar treatment consisted in puncturing with "an abscess lancet introduced with very little obliquity so far that the wound of the cyst of the abscess should be half an inch in length, and that of the integuments, of course, a little longer. A wound of that size is generally sufficient to give discharge to the solid flakes which will occasionally block up the opening without much poking. It is necessary that the flow of matter should be uninterrupted, so that no air should gain admittance; it is, therefore, right to make pressure on the abscess, in proportion as it is emptied. The abscess where it presents itself is emptied before that part of it in the loins is completely so. The surgeon should then press the sides of the wound together with his finger and thumb, so as to prevent the ingress of air, and desire the patient to cough repeatedly, which will impel the matter from the internal part of the abscess into that which is punctured. When the abscess is emptied as much as possible, the wound should be attentively wiped, and the edges placed in exact contact, and retained in that state by strips of plaster." (p. 154.) A compress is then put on, but no bandage; the patient is

(a) Practical System of Surgery, vol. i.

to lie perfectly quiet, and the wound, being dressed every second day, "generally united by adhesion, though sometimes otherwise, for it may discharge a little, and yet unite firmly. The abscess thus treated is as free from inflammation as it was before it was punctured. The abscess will, however, fill again, and that sometimes even rapidly. In the first cases which I attended, I punctured pretty regularly after the expiration of a fortnight, and I found in general that the abscess contained about one-third less of fluid. * * * After having discharged the contents of the abscess three or four times, I found that it was not necessary, nor, indeed, easily practicable to puncture it at the end of the fortnight, because it was so little filled and prominent." (pp. 155, 6.)

ASTLEY COOPER supports ABERNETHY'S mode of treatment. He says:-"Let the abscess proceed until you observe a redness or blush of the skin, and then adopt Mr. ABERNETHY's plan of making a valvular opening into the part, so as to discharge the matter, and close the wound almost immediately. The danger does not arise from the quantity of matter accumulated, but from the irritation produced by the attempts of nature to close the abscess and fill the cavity by the process of adhesion. Four days after the abscess is opened violent symptoms of constitutional irritation are apt to come on, such as great depression of strength, loss of appetite, and the patient is soon reduced to the lowest extremity. It is extremely desirable to prevent the occurrence of these symptoms, and the plan of Mr. ABERNETHY is the best that has ever been suggested by any Surgeon with a view of preventing them." (p. 461.)

LAWRENCE also advocates ABERNETHY's practice, as it "gets rid of the continuance of an abscess of this kind without incurring the risk of the inconvenience" which arises when," as in opening a phlegmonous abscess, an incision is made and the matter let run out, and then applying a poultice over it, the access of air into the abscess produces decomposition of the pus which it contains, the matter becomes fetid, the surface of the abscess is inflamed, and the secretion from its sides becomes exceedingly altered, thin, and stinking, extremely irritating to the portion which is in contact with it. The inflamed surface of the abscess is a source of sympathetic disturbance in other parts in the alimentary canal or in the vascular system, and thus arises fever of a different kind.” (p. 396.)

Other writers, as KIRKLAND, prefer" the tumour being suffered to break of itself, and its contents to drain gently off, through a very small aperture, which prevents the free ingress of air and violent symptoms; for, when a large tumour of this sort forms on the inside of the thigh, and breaks in a large opening, in such a manner that the air has already passage, we frequently see a violent colliquative fever succeed, that closes the scene in a very short time. But, though small openings should be obtained if possible, they too seldom secure the patient." (p. 199.)

JOHN PEARSON observes on this point:-"Some of the older Surgeons, and the French Surgeons (of his time) in general, advise a free opening to be made, or the introduction of a seton. It hath been thought more advisable, by other practitioners, to permit the abscess to burst spontaneously. Several of the modern Surgeons recommend a very small aperture to be made, and the ulcer to be treated in a very gentle manner. My own experience is in favour of the last mode of treatment, and I have been so happy as to see it followed by a perfect cure of the disease." (p. 103.)

DUPUYTREN "considers it dangerous to open symptomatic abscesses, resulting from caries of the spine, which has yielded to treatment. So to proceed is to re-excite the principal malady, and to lose all the benefit of long and active treatment. He, therefore, recommends giving up these abscesses to the mere efforts of nature; and he follows the same practice even when all remedies have been unavailing to cure the caries." (p. 139.) The practice I have pursued, which has been for many years past commonly followed at St. Thomas's Hospital, has been either to permit the abscess to break of itself, or only to puncture it when the skin has so reddened and thinned at one point that there is no chance of its bursting being avoided. The puncture should not be a large one, nor do I think making it valvular is of any consequence, as I make no effort to produce its union. It should be of sufficient size to permit the escape of the pus, which should flow out, if it may be so said, at the pleasure of the abscess, which should, on no account, be squeezed or kneaded, to empty its cavity. If thus left to itself the pus flows slowly and the sides of the abscess gradually fall together, though without at once uniting, and accommodate themselves to their new condition, so that ultimately the original abscess becomes only a more or less capacious sinuous cavity, which, if the disease originate in the spine, gives vent to the pus there formed, and may itself also, for a longer or shorter time, furnish the discharge. I have not generally observed the hectic symptoms which by some Surgeons are described as almost certainly occurring when large abscesses,

bursting or being opened, at once empty themselves; and I apprehend that when the sac inflames and hectic fever comes on, the cause is rather in the irritable state of the constitution than in the emptying of the abscess. I am not prepared to say, nor would I advise a large puncture and the immediate emptying of the abscess; but, from repeated observation of the practice of others, corresponding to my own above described, viz., the gradual evacuation, either by bursting or by a moderately large puncture, I am convinced that this plan of proceedings is the best.-J. F. S.

The issues are to be still kept up, even after the puncture has been made, for the purpose of diverting the original disease, as already mentioned; and this practice is in accordance with ABERNETHY's recommendation, that "an issue should be made in the loins, which is likely to be beneficial by its counter-irritation, even when the abscess is not connected with diseased bone; but, when it is, then an issue will be more serviceable and necessary." (p. 151.)

As regards injecting the sinuous cavities into which, after a time, these abscesses are converted, PEARSON states, that "some of the older writers forbid the use of injections in the lumbar abscess; but their reasons seem to be founded upon mistaken ideas of the true situation of the disease. Solutions of copper, vitriol, or even tepid sea water may sometimes be applied in this way with considerable advantage." (pp. 103, 4.) ASTLEY COOPER also says, he "has seen benefit from injecting the abscess, (I presume when it has become fistulous,-J. F. s.): the injection usually employed is the sulphate of zinc or alumen; it promotes the adhesive process in the interior of the abscess, glues its sides together, and lessens the purulent secretion." (p. 461.) DUPUYTREN states "that cauterization may be employed advantageously; but the actual cautery must be straight and exactly run through the canal. In other cases it may be convenient to have recourse to injections of nitrate of silver, or of nitric acid, largely diluted with water, taking care that these liquids do not escape in their course. For these injections he employs twenty or thirty grains, or a drachm of nitrate of silver to a pint of distilled water, and injects it with a siphonous syringe." (p. 148.)

184. There is danger when the cavity of the abscess inflames after the discharge of the pus; and attempts must be made to diminish the inflammation by quiet, by suitable antiphlogistic treatment, and by discharge of the pus. If symptoms of hectic fever are indicated, or the opening of the abscess become fistulous, (the cause of which may be some internal process still going on, such as caries of the lumbar vertebræ or thickening of the walls of the abscess,) the powers of the patient must be supported as much as possible, and, if a general cause can be found out, we must endeavour to counteract it.

[When the cavity of the abscess is inflamed it is known by the great pain caused by slight pressure on the surface, and by the escape of a thin, fetid, frothy matter from the aperture, whether made by ulceration or artificially. It is generally accompanied by the hectic symptoms; but, sometimes, ABERNETHY observes, "both the local and constitutional diseases are of a more purely inflammatory kind;" under which circumstance, the above-mentioned discharge and the hectic symptoms are deficient. Sometimes" the fever is at first inflammatory, then hectical, and, when the local complaint becomes indolent, the general state of the patient's health is no longer affected." And ABERNETHY says, he has "known a considerable space of time elapse between the first bursting of a lumbar abscess and its assuming that morbid state which is so peculiar to those diseases, and which produces a corresponding affection of the system in general." (pp. 221, 2.)

In conclusion, it is right to mention the important observation made by PEARSON, that, "although the larger arteries have been known to be surrounded with purulent matter for a considerable length of time without suffering any injury, yet this is not universally the case; there have occurred many instances where erosion has taken place, and the person has been suddenly destroyed with hemorrhage." (pp. 99, 100.) M'DOWELL (a), however, mentions a case in which "ulceration took place in a portion of the ilium adhering to the cyst of the abscess: and the contents of the bowel, after having passed into the abscess, escaped through a fistulous opening near the spine of the ileum. Ulceration also of the external iliac artery followed about an inch and a half above POUPART's ligament, and sudden death resulted from the blood escaping in large quantities into the cavity of the abscess." (pp. 912.)]

(a) In Dublin Journal of Medical Science, vol. iv.

VII.-OF INFLAMMATION OF THE NAIL-JOINT, OR WHITLOW.

GARENGEOT, Traité des Opérations de Chirurgie. Paris, 1720, 8vo. Vol. III.—Translated as, A Treatise of Chirurgical Operations, according to the Mechanism of the Parts of the Human Body. London, 1723. 8vo.

LE DRAN, HEN. FR., Traité des Opérations de Chirurgie. Paris, 1742. 8vo.-Translated as, The Operations in Surgery of Monsieur LE DRAN, by Mr. GATAKER. 3rd. Edit. London, 1757. 8vo.

FOCKE, Diss. de Panaritio. Götting., 1786.

MELCHIOR, Diss. de Panaritio. Duisb., 1789.

FLAJANI, Osservazioni Pratiche sopra il Panereccio. Roma, 1791. 8vo.

VOGT, Diss. de Paronychia. Viteb., 1803.

SUE, P., Réflexions et Observations Pratiques sur le Panaris; in Recueil des Mémoires de la Société Médicale d'Emulation de Paris, vol. ii.

WARDROP, J., An Account of some Diseases of the Toes and Fingers; with Observations on their Treatment; in Med.-Chir. Trans., vol. v. p. 129.

DUTEIL, Dissertation sur la Panaris. Paris, 1815.

CRAIGIE, D., Pathological and Practical Observations on Whitlow, in the Edinburgh Med. and Surg. Journal, April, 1828, p. 255.

185. Whitlow, or Inflammation of the Nail-Joint of the Fingers and Toes, (Panaritium, Onychia, Paronychia, Lat.; Umlauf, Wurm, Germ.; Inflammation des Doigts, Panaris, Fr.,) according to its seat and the consequent variations of its severity, usually presents itself in the following four degrees:

[The following mode of deriving the term whitlow, as given by BECKETT (a), is interesting:-" The old English word hawe signifies a swelling of any part. Thus, for instance, a little swelling on the cornea, was anciently called the hawe in the eye; and the swelling that frequently happens on the finger, on one side the nail, was called whitehawe, and afterwards whitflaw or whitlow." (p. 52.)

The division of whitlows employed by CHELIUS was first proposed by GARENGEOT, and is generally followed; but, excepting the first species, which is well marked, I am rather disposed to agree with GIBSON (b), that "these varieties, however, are in a great measure arbitrary; for it is not always in the power of any surgeon to declare from examination of the part, what particular texture is affected." (p. 186.)—J. F. S.]

First. If the inflammation be entirely superficial at the root or side of the nail, the pain is not great; the swelling does not spread beyond the first joint of the finger, but quickly passes to the outpouring of a purulent matter which lies immediately beneath the skin, and assumes a bluish colour; the pain only becomes severe when pus has collected beneath the nail, which generally falls off, and a new one soon grows.

[This whitlow is ABERNETHY's Paronychia ungualis. It begins with slight inflammation, accompanied with a throbbing, and by degrees raises up a small white semitransparent bladder, the whiteness of which depends on the thickness and opacity of the cuticle. It seems, as LE DRAN says, to be "only a disease of the skin, which, being slightly excoriated or irritated from some external cause, inflames, and is followed by a collection of purulent serum between the cuticle and true skin." (p. 413; Fr. edit., p.539.)] If the whitlow be left without puncture, it continues increasing, stripping the cuticle of the true skin, and distending it more and more, till at last, finding a crack or a thin part, it bursts, and the pus is discharged But the continued pressure has ulcerated the cutis and then, as JOHN HUNTER observes, "the soft parts underneath push out through the opening in the cuticle, like a fungus, which, when irritated from any accident, give a greater idea of soreness, perhaps, than any other morbid part of the machine ever does. This is owing to the surrounding belts of cuticle not having given way to the increase of the parts underneath, by which means they are squeezed out of this small opening, like paint out of a bladder." (p. 470.)

(a) Phil. Trans., 1720, vol. xxxi.

(b) Institutes and Practice of Surgery, vol. i.

HUNTER gives the following reasons (the correctness of which must be readily admitted) why the abscesses "about the nails, commonly called whitlows, more especially in working people, give so much pain in the time of inflammation, and are so long in breaking, even after the matter has got through the cutis to the cuticle; the thickness of the cuticle, as also the rigidity of the nail, acting in those cases like a tight bandage, which does not allow them to swell or give way to the extravasation; for in the cuticle there is not the relaxing power, which adds considerably to the pain arising from the inflammation; but when the abscess has reached to this thick cuticle it has not the power of irritation, and therefore acts only by distension; and this is, in most cases, so considerable as to produce a separation of the cuticle from the cutis for a considerable way round the abscess." (p. 469.) * "All of which circumstances taken together, make these complaints much more painful than a similar-sized abscess in any of the soft parts." (p. 469.)]

Second. When the inflammation is situated in the cellular tissue beneath the skin, and commonly at the bulbous end of the finger, the pain is very severe on account of the tension of the thickened skin. If the inflammation pass into suppuration, fluctuation cannot readily be perceived, and the pus makes itself an outlet with difficulty.

[This form might not inaptly be called Paronychia cellulosa, as, in the inflamed cellular tissue of other parts, the inflammation is disposed to spread; the whole finger often becomes affected, and the disease occasionally extends into the hand itself. The severity of the pain is great, because, as LE DRAN observes, "the skin of the finger is of very close texture, and therefore cannot yield to the increased size of the inflamed parts which it encloses, consequently the tension, pain, and fever are more violent." (p. 414; Fr. edit. p. 542.)]

Third. If the inflammation be situated in the sheaths of the tendons, the pain, which is specially situated on the front of the finger, is very severe, and strikes up through the whole arm to the shoulder; upon the finger only a slight swelling is to be observed, but it spreads so much the more over the greater part of the hand to the wrist, and even to the fore arm. Severe fever usually accompanies it. If the thumb, fore, or middle finger be attacked, the pain ascends outwards upon the front of the hand; but, if the ring or little finger be attacked, then the pain is continued along the ulnar surface to the elbow-joint and up to the arm-pit. When suppuration occurs, fluctuation is not distinguishable on account of the deep situation of the pus. The inflammation readily spreads to the periosteum, and destruction of the phalanges often ensues.

[This form is ABERNETHY'S Paronychia tendinosa.

TRAVERS (a) observes that "this, the case of acute paronychia," as he calls it, "is frequently accompanied with absorbent inflammation, but not invariably; nor is it on this account more serious. Matter is secreted by the inflamed synovial surface of the tendinous sheath, or the particular fascia investing the tendinous extremity of a muscle of the arm or leg; or beneath a ligamentous expansion, as the palmar or plantar aponeurosis." Sometimes the symptoms supervene in a few hours after the injury, sometimes not for days, so that the patient scarcely recognises the injury, usually a small penetrating wound. If the wounded thumb or finger is disfigured by excessive oedema, the symptoms of disturbance are less severe than when, with great tension, the swelling is inconsiderable and void of fluctuation, so as to make the existence of matter doubtful. The quantity of pus is so small, and the relief of discharging it so great, as to demonstrate that its situation alone had given rise to the intense pain. Is it owing to the partial escape of matter into the cellular substance, or to the inflammation having originally attacked this texture, exterior to the theca or fascia, and affected the interior only by sympathetic connexion, that the symptoms are less urgent when the oedema is present ?" (pp. 216, 17.)

LE DRAN considers this form of whitlow to differ from the preceding in not being consequent on phlegmonous but erysipelatous inflammation: and he does "not think that an erysipelas affecting these parts, and forming a whitlow can proceed from an in

VOL. I.

(a) On Constitutional Irritation, part i.