the puncture, to introduce between the lips of the wound a very small portion of lint, with a long end hanging out: this is to be removed when the first poultice is replaced a few hours after making the puncture, which by that time is sufficiently established.— J. F.S.]

56. Escharotics are employed in the following manner: a piece of linen spread with sticking plaster, and in which a properly shaped hole has been cut, is to be so laid upon the abscess that the aperture should correspond with the point where it is intended to be emptied. The hole in the plaister is then to be filled with bruised and moistened caustic, and covered with sticking plaster. After six or eight hours the plaister is to be removed, if the caustic have produced a good slough, or the walls of the abscess have been eaten through and the pus escaped. The slough is to be pierced with a lancet and the abscess emptied, or, if the emptying does not seem urgent, the slough may be allowed to separate, and then the lancet is to be introduced. The pus is to be discharged by moderate pressure in an unbroken stream, the aperture to be covered with sticking plaster and a bandage applied. The walls of the abscess frequently at once unite, but most commonly a smaller quantity of pus collects, the emptying of which is to be performed by a second puncture, and the union furthered by a compressing bandage.

57. In passing a seton through an abscess an aperture with a lancet is to be made at its upper part, through which a blunt probe, armed with a bundle of several cotton threads some yards long is to be passed to the very bottom of the abscess, till its extremity is felt against the skin. An assistant retains the probe in this situation, and the skin being rendered tense, a cut is made upon the probe, which is then to be drawn out and the seton introduced into the cavity of the abscess. This may be done with a seton needle, in which case the parts covering the abscess are to be raised into a fold and then transfixed with the needle. When the abscess is emptied, the opening is to be covered with charpie and sticking plaster, the seton thread fastened, the whole covered with a compress and supported with a proper bandage. A fresh portion of the thread is to be drawn in daily. When the suppuration has diminished the threads are to be withdrawn and the union of the walls promoted by regulated pressure. In many cases the seton may be removed in three or four days, if the walls of the abscess have acquired a sufficient degree of inflammation to unite by proper pressure.

58. In general the opening of abscesses with a cutting instrument is most preferable. The application of escharotics is accompanied with great pain; a part of the skin is always destroyed, in consequence of which a large scar remains. The seton is also painful and excites more or less severe inflammation. These modes of opening are therefore restricted to those cases in which it is desirable to excite a certain degree of inflammation, as will be presently mentioned in speaking of cold abscess. The employment of caustic in critical abscesses, in order to hasten and bring about their opening at an earlier period, may be conveniently replaced by the proper use of poultices, and the ordinary method of opening with the lancet.

[Puncturing abscesses is in all cases to be preferred. Escharotics are never permissible, as they produce a certain slough, the prevention of which is one object in emptying an abscess. The introduction of a seton is almost as objectionable; for the inflammation of the sac of the abscess which it excites will often be uncontrollable and hasten hectic fever.-J. F. S.]

59. The so-called Cold Abscess (Lymph-Abscess) resulting from lingering inflammation, (par. 15,) in which the covering skin is but little or not at all changed, may sometimes be dispersed by resolving poultices, infrictions, and plasters, by producing artificial wounds in the neighbourhood, by the application of the moxa, and so on, with simultaneous attention to the constitutional disorder. This, however, seldom happens, and since, after they have been opened in the way of ordinary abscesses, or have opened of themselves in consequence of the diminished vital activity of their walls, and the generally depressed state of the system, a very ill-conditioned and frequently fatal thin and copious suppuration sets in, special modes of proceeding in the treatment of these abscesses are therefore directed, in order partly to prevent the entrance of the air in opening them, partly to excite by the emptying of the swelling, such degree of inflammation as will produce their union, or the secretion of a good plastic pus, and then the cure is effected as in common abscess.

60. The modes of treatment to this end are, the emptying of the swelling with a lancet puncture or with a trochar, without admitting air, after which the opening is to be closed with sticking plaster, a moderately compressing bandage applied, and the opening frequently remade, till the union of the walls of the abscess has taken place (ABERNETHY opening with the lancet after the previous application of caustic (BEINL ;) the introduction of a seton or a bundle of silk threads, to be withdrawn on the third or fourth day, and the cure then perfected by compression (WALTHER;) tapping with the trochar and injection of red wine, solution of bichloride of mercury, or of nitrate of silver (SCHAACK ;) or of boiling hot water (RUST;) or a solution of fully neutralized nitrate of mercury (NASSE ;) the laying open of the swelling longitudinally throughout half its length, and filling it with charpie moistened with solutions of caustic (ZANG ;) and the removal of the skin from the whole extent of the swelling (CALLISEN.)

61. The variety of these modes of treatment proves, that neither of them separately taken is sufficient to meet our wishes. The choice of them must therefore be guided by the difference of constitution, by the more or less weak state of the cellular walls and by the size of the swelling. If the tumour be not be very large and the constitution of the patient still tolerably good, perfect closing of the cavity of the abscess may usually be produced by repeated puncture with the lancet or trochar, or at least it may be so much diminished that we may be able to effect a cure by laying it open with a bistoury, and filling it with charpie, moistened with irritating remedies, especially solution of nitrate of mercury. In swellings of larger size it is far preferable to make the opening with caustic, or by the introduction of a seton. If the cure be not in this way effected, and, if suppuration threatening exhaustion occur after artificial or spontaneous opening, it is proper to remove from the front wall of the swelling as much as may be allowable, or to fill the whole cavity with charpie, which, according to the various degrees of irritating, is to be moistened with a stronger or weaker solution of nitrate of silver, or nitrate of mercury, to bring about a good suppuration. I am, however, convinced, that by the employment of these violent modes of treatment, the very worst symptoms are often produced which are dreaded in the common mode of treating abscesses. At least, I have in very many cases of cold abscess made the opening at the proper spot in the usual

way with the lancet, and, without the use of any other local means than moist warm poultices, the cure has been effected more quickly and with less trouble than by other modes of treatment. The opinions relative to the treatment of this cold or lymphatic abscess are so various, doubtless because they are confounded with congestive abscess and with the swellings of mucous bags (par. 17.) Corresponding general means must be employed with the local treatment; we must use strengthening remedies bark, rhatany, sweet flag, with diluted acids, a strong nourishing diet, and attention must be paid to cleanliness and good air.

According to KLUGE (a), the lymph should be discharged by an incision, or, if that be not sufficient, the whole front wall of the swelling must be cut away, the opening of the hardened lymphatic vessel must be found, which is usually superficial and easily discernible by the trickling of the lymph; a bristle must be introduced into its open mouth, and then the vessel must be slit up for half an inch or an inch, until the healthy trunk is reached. The bristle is then to be removed, and either a compressing bandage applied, or, if there do not occur a proper degree of inflammation, the opened lymph-vessel must be touched along the part which has been slit open with a pointed piece of nitrate of silver up to the healthy portion, and then the compress applied.

Upon the subject of opening abscesses consult

ABERNETHY on Chronic and Lumbar Abscesses, in his Surgical Works, London, 1815, vol. ii. p. 153.

SCHAACK und MURSINNA, über de oft unzulängliche Hülfe bei lymphatischen Geschwülsten in MURSINNA'S Journal, vol. i. p. 2.

1800.

BEINL, A., von einer eigenen Art Lymphgeschwülst, und der zweckmässigsten Methode, die selbe zu heilen. Wien, 1801. In Abhandl. der med. chir. Josephin Akademie in Wien, vol. ii.

RUST, einige Reflexionen über die Natur und Heilung der Lymphgeschwülste, in HARLESS Jahrbüchern der teutschen Medicin und Chirurgie, vol. i. p. 155. And in RUST's Magazin, vol. i.

JACOPI, Operazioni e Sperienze fatti nel instituto clinico di Chirurgia di Pavia nel anno 1812, 1813, vol. ii.

CHELIUS, in neuen Chiron herausgegeben von TEXTOR, vol. i. part i.

VON WALTHER, über die wahre Natur der Lymphgeschwülste; in Journal für Chirurgie und Augenheilkunde, vol. i. p. 584.

62. The further treatment after opening an abscess must be quite simple; we must endeavour to keep up merely a free undisturbed escape of pus, and to preserve a proper vital correspondence. No further local treatment is required beyond the use of moist warm poultices. The edges of the opening draw together, the walls of the abscess approach and adhere, granulations (Fleischwarzen, Germ.) are produced from the bottom of the abscess by the development of fine vessels and delicate cellular tissue, which become more and more solid, are covered with a thin skin, and form a scar (Cicatrix, Lat.; Narbe, Germ.; Cicatrice, Fr.) A more active degree of inflammation, when continued or developed after the opening of the abscess, in consequence of which its edges swell, its neighbourhood becomes very sensitive, and the suppuration diminished, is usually consequent on improper treatment, on the use of tents and so on, and can only be relieved by the aforesaid treatment, which diminishes the irritation. 63. If a proper degree of vitality be wanting in weak constitutions or in abscesses in parts far distant from the heart; if the edges of the

(a) ZEMвSCH, as above.

abscess be flabby, insensible, discoloured; if a thin lymphatic sanious fluid be secreted; these are indications for the employment of more or less stimulating remedies, the ung. digestivum basilicum, the oil of turpentine, decoction of oak bark, bark with tincture of myrrh, filling the cavity of the abscess with charpie, strong solution of nitrate of silver, with which is to be moistened the charpie laid in the cavity of the abscess. But all these means are superfluous; the moist warm poultices are more effectual in raising the vital activity necessary for the secretion of good pus, the pus thereby more readily escapes, and the patient is saved from the troublesome and painful dressings by the sticking of the bandages. If the patient's strength fail and general weakness ensue, strengthening remedies, bark, rhatany, sweet flag, good nourishment, the enjoyment of pure air, and so on, are indicated.

64. If the edges of the abscess-aperture unite, whilst the secretion of pus continues, they may be easily drawn asunder or separated with a probe. Should the opening become too small, so that the pus cannot escape freely, it must be enlarged with the knife. If the granulations are developed too strongly, the proud flesh (Caro luxurians, Lat.; Wucherndes Fleisch, Germ.) must be touched with nitrate of silver and a compressing bandage applied, by which cicatrization is specially encouraged. 65. When the pus does not escape properly, but collects in the abscess, (which may depend on the opening being too small or upon some peculiar situation of the abscess,) it sinks down in consequence of its own weight, or the little opposition which the loose cellular tissue in the interspaces of the part offers to it, or the suppurative process may extend with failure of the adhesive inflammation, and, on the other hand, an ulcerative absorption may favour the extension of the abscess, and form cavities or canals which are called fistulous passages (sinus fistulosi.) These fistulous passages are often consequent on improper treatment, if the opening of the abscess be stopped by plugs, and so on, and the due flowing of the pus thereby prevented. Under these circumstances a much larger quantity of pus escapes from the abscess than from its size might be expected; especially if its neighbourhood be pressed in different directions; examination with the probe gives certain knowledge of its extent. If such fistulous passages remain long, their walls are overspread with a soft fungous membrane, similar to mucous membrane, which prevents the healing, and, when still longer continued, assumes a whitish, hard, callous condition.

The membrane of the fistula first pointed out by HUNTER, has been well described by VILLERME (a), LAENNEC, and BRESCHET (b).

[The passage in HUNTER here alluded to is the following:-"When the parts are unsound, and of course the granulations formed upon them unsound, we have not this disposition for union, but a smooth surface is formed, somewhat similar to many natural internal surfaces of the body, and such as have no tendency to granulate, which continues to secrete a matter expressive of the sore which it lubricates, and in some measure prevents the union of the granulations. I imagine, for instance, that the internal surface of a fistulous ulcer is in some degree similar to the inner surface of the urethra, when it is forming the discharge commonly called a gleet. Such sores have therefore no disposition in their granulations to unite, and nothing can produce an union between them but altering the disposition of these granulations by exciting a considerable inflammation, and probably ulceration, so as to form new granulations, and by these means give them a chance of falling into a sound state." (p. 480.)]

In Journal de Médecine, par LE ROUX, July, 1815. Dictionnaire des Sciences Médicales, vol. viii. p. 206. vol. ii. part iv.

Journal von GRAEFE und WALTHER,

66. These fistulous passages may be generally avoided by the treatment already mentioned. If the fistulous passage be still recent, the free escape of the pus may be effected by a suitable enlarging of the opening, by the entire division of the fistulous passage, if it be superficial; or, if the bottom of the passage be near the skin, by means of a counter opening; for the latter purpose a probe is introduced, with which the bottom of the passage and the skin above it are raised, and then the probe is to be cut upon. The further treatment is to be according to the preceding rules. In still longer continued fistulous passages, especially when their walls have become callous, we endeavour to excite a proper degree of inflammation of the walls of the passage, usually by the introduction of a seton, or of a bundle composed of many threads, which is tied together externally upon the fistulous passage, and daily drawn tighter (LANGENBECK) (a), or by the injection of irritating fluids (H. DEWAR) (b); for instance, a solution of nitrate of silver, of bichloride, or nitrate of quicksilver, or by the introduction of a bougie, the point of which has been smeared with powdered nitrate of silver (CRAMER) (c), (VON WALTHER) (d), and so on, and then, by a regulated pressure throughout its whole extent, to produce union of its walls. Where a satisfactory dilatation of the fistulous passage is possible, the cure may be effected without these painful remedies by the careful avoidance of any bandage which might interfere with the escape of the pus, and by close attention to the before-mentioned rules.

According to LANGENBECK, the introduction of a ligature is, in many cases, preferable to incision, which oftentimes is impracticable without injuring large vessels, and so on. By the ligature inflammation is produced, the surface of the abscess becomes red and painful, the secretion of ichorous fluid is diminished, good consistent pus and near the ligature shooting healthy granulations are produced, and the skin becomes more firm and solid. As these symptoms come on, the ligature is to be gradually drawn tighter. In common cases, the ligature requires to be used only from four to eight days, to produce its effects. If it should be necessary to cut through the wall of the fistulous passage with the ligature, the remaining cavity must be filled with charpie.

67. During suppuration the practitioner must pay especial attention to the condition of the digestive organs; for impurities in the intestinal canal are frequently the cause of unhealthy pus; neither must pure healthy air be forgotten.

If the suppuration be continued on account of any dyscracy, the proper means for its counteraction must be employed.

On the treatment of abscess compare

VON KERN, Annalen der chirurgischen Klinik zu Wien, vol. i. 1807, vol. ii. 1809. VON WALTHER, über die topische Behandlung und über den Verband der eiternden Wunden, der Abscesse, Geschwüre und Fisteln, in Journal für Chirurgie und Augenheilkunde, vol. ix. part ii.

68. The treatment of the Hardening into which inflammation has subsided has a double object, viz. its dispersion or its removal with the knife. The resolution of the hardening is only possible when the lymph poured into the cellular tissue has not yet consolidated the walls of the part with each other, and its natural structure is not yet entirely lost; consequently, when the induration is still recent and not very hard. If there be also decided dyscracy, the curative treatment must be first directed to it.

(a) Von der Behandlung der Fistelgänge, der Schusscanäle und grosser Eiter absondernden Höhlen; in Neue Bibliothek für die Chirurgie und Ophthalmologie, vol. i. p. 2, par. 313.

(b) On the Treatment of Sinuous Ulcers; in Medico-Chirurgical Transactions, vol. vii. p. 487.

(c) Beitrage zur Heilung der Fisteln und Geschwüre; in Heidelberger clinischen Annalen, vol. x. part i. p. 71.

(d) Uber Hohlgeschwüre und Fisteln; in Journal von GRAEFE und WALTHER, vol. v. p. 1.