Part 5

After an abscess bursts, the proper application is a warm poultice, which should be continued in general as long as there is any stool, or hard margin; that is to say, until the increased quantity of diseased organic particles, which were formed during the inflammation, be absorbed, and the vessels at that part have either assumed the suppurative or natural action. After this, the orifice ought to be covered with a slip of lint, and moderate pressure applied over the surface of the abscess, by which the sides are kept in constant contact, and reunion is accelerated. Good diet is also necessary, for we thus increase the powers of recovery, or keep up a proper action, and renew the vital principle, the quantity of which has been lessened during the inflammation, both by the continuance of a state of overaction, and by the remedies which are employed to diminish the action; for a state of real and permanent weakness is thus induced.

This poultice does not require to be so hot, nor changed so frequently, as before the full formation of matter.

If this produces pain, we may in general conclude that it has been used too soon.

It sometimes happens, that suppuration takes place very slowly, and the action seems to be performed with little vigour. In this case, if the abscess be allowed to burst of itself, we both lose time, and are often, in the end, disappointed in a cure, the healing process not taking place. It is therefore useful, in these cases, to have recourse to other agents besides heat. If the pain be trifling, and the suppuration be what may be called chronic, or approaching to it, we will perhaps succeed, by applying gentle pressure on the abscess, by means of a thin roller, and laying a warm poultice over this. But, when this fails to increase the action, we ought to pass a seton, by which we evacuate the matter, and keep up the subsequent action to a degree sufficient for producing recovery. In doing this, however, it is necessary to attend to the state of the tumor; because, if, in every instance, we pass it from the highest to the lowest part, we shall sometimes make the part give way in a third place. If, for instance, the abscess be much thinner at the apex than elsewhere, or, if the action have made considerable progress toward the surface, then the stimulus of the action increases the performance of the natural process which was going on, and the action continues to extend itself until the part gives way. In these cases, then, we ought to pass the seton from the thin part to the lowest part; and this, in general, will, from the sympathy of association, be sufficient to excite the action of the whole internal surface.

When we resolve to use the seton, the following is the easiest method of introducing it: Make a puncture with a lancet either into the upper, or the thinnest, and most prominent part of the tumor, according to circumstances; and, into this puncture, introduce, using the lancet as a directer, a probe, having a piece of tape passed through its eye. The lancet is then to be withdrawn, and the probe pushed down to the under part of the abscess, where its point will be felt under the skin. A small incision is here to be made upon the knob of the probe, which is next to be passed through, and the tape drawn after it. The matter is then to be slowly pressed out; the tape is to be folded; and the abscess bound up with a compress and roller, so as to make moderate pressure upon it. Next day, the dressings are to be removed, and a clean piece of the tape drawn through, after which, pressure is again to be applied.

The size of the tape, the time which the seton ought to be employed, and the degree of pressure to be used, must be regulated by backwardness of the action, and the imperfection of the healing process.

If, either from improper management, or the morbid condition of the action, the abscess, after it bursts spontaneously, or is opened by art, continue to suppurate, without undergoing the ulcerative action preparatory to healing, then we find, that either the sides remain quite separate, producing a cavity, extended more or less, or one particular portion remains open, forming a sinus. Both of these cases require a treatment, which, in its principle, is the same, namely, the indication of the ulcerative action.

In the first case, we shall frequently succeed by means of the seton, especially if we use pressure alongst with it; for, by keeping the internal surface in close contact, we tend to check the purulent, or suppurative action, and produce organic particles. We may also succeed, by using stimulating injections, of such a strength as to produce a moderate degree of smarting. Of this kind are, wine and water, solutions of white vitriol, corrosive sublimate, &c. These ought to be used frequently in the course of the day, and pressure employed during the intervals. Incision, or laying the part open, is, being the most severe, the last remedy which is to be had recourse to. Small chronic abscesses may be laid open during their whole diameter; but larger ones require only to be cut up for a certain length.

This is exactly similar to an encysted tumor which has been opened, and requires the same treatment. The internal surface becomes thick and somewhat hard, like that of a cyst. It differs from an encysted tumor only in its cause and origin.

If pressure be employed early, to a considerable degree, the irritation of the means employed produces pain, and a morbid increase of action, unless we keep down the action by cold, as will be explained when considering the treatment of ulcers.

The second case, has generally been considered as a species of ulcer, and has been named the sinus ulcer; but, although the orifice may sometimes possess the diseased ulcerative action, yet the sinus itself still continues in the suppurative state, and, therefore, cannot heal. These sinuses depend, in different instances, upon very different causes, and, therefore, require a variation in the treatment. The most simple species of sinus may be called mechanical, and is produced by matter flowing from a neighbouring cavity, and which cannot be freely discharged: Thus, for instance, if a deep abscess open at the highest part, or at a point above the level of its bottom, the matter constantly oozes out, and keeps the canal open. This is most apt to occur, when abscesses are formed deep amongst muscular parts; in which case, although the matter point at the centre, yet an accumulation must take place below, and the matter must continue to be discharged by the aperture, when it becomes so abundant as to be raised to the level of the opening; or, being once raised, it continues to flow out. The cure of this may at first be attempted mechanically, by tight bandages, which press out the matter, and keep the sides in contact; but, if the disease have been of long duration, then, whatever may have been its nature at first, we find, that the suppurative action extends along the mechanical sinus, which then becomes affected with a chronic action; in which case, it becomes similar to the second species of sinus. We must, in this species, make an opening at the most dependent part, and employ the means which will be now mentioned in considering the second species, or that produced in consequence of the suppurative action becoming chronic or habitual, independent of any mechanical cause. This may take place, although the aperture have been originally in a proper place, and the matter, instead of being retained and keeping up the disease, shall have been regularly discharged. The case in which this is most likely to happen, is that in which the abscess has been very tedious in its progress, and the action has been, from the first, slow. The distinction betwixt this species, and those which remain to be mentioned, is founded upon the absence of the symptoms which they possess, and by our examination with the probe, which points out the cause and extent, and informs us whether we be near a bone. The orifice is flabby, and has the appearance of the indolent ulcer. The cure of these sinuses is to be attempted, by pressing out the matter by means of proper bandages, or by making a dependent opening, which is generally necessary, at the same time that we raise the action of the part to a proper degree, and render the suppurative action acute and vigorous; in which case, it naturally terminates in the ulcerative, and thus the part has its structure restored. This is most easily effected, by passing a seton, and applying a proper degree of pressure, diminishing the size of the seton gradually, and in proportion to the vigour of the action and the approximation toward health. When, from the situation of the sinus, we cannot pass a seton (which rarely happens in this species of sinus), injections of wine may be used frequently, and pressure applied during the intervals. When these means fail, which is seldom the case, the part should, if its structure permit, be laid open. If this sinus have remained long open, its surface, like that of the chronic abscess, becomes changed, and a coat is formed, like the cyst of a tumour. When this is thick and hard, the sinus has been called a fistula, and it has been deemed necessary to dissect out the tube; but it is in general sufficient to use the remedies which increase the vigour of the action, and make it run its natural progress; such as the seton, or a free incision, if the parts be superficial, or no considerable vessel or nerve runs the risk of being wounded.

The third species of sinus is that in which the suppurative action is kept up by the operation of some adventitious cause; such as a caries bone, diseased cartilage, or the lodgement of a foreign body; as, for instance, a ball, a splinter of wood, bit of cloth, &c. This species is distinguished by our feeling the extraneous body, or diseased bone, with the probe, and by the fungous protuberance, or papilla, which shoots out from the orifice. In addition to the method of curing other sinuses, we must here endeavour to remove the adventitious cause, which is generally very difficult to be done. If the foreign body be deep, or if the diseased bone lie deep, and the sinus be narrow, we can do little in this way; sometimes, indeed, by enlarging the external part, we can come at the foreign body with a pair of small forceps, and may extract it, or may accelerate the exfoliation of the diseased bone; but we can have no certainty of success. If, however, the sinus be superficial, which sometimes happens in caries of the tibia, &c. it ought, in every instance, to be fully laid open, and the bone exposed, and treated in the way immediately to be mentioned. When this cannot be done, we may sometimes, by conveying the proper remedies through a tube down to the bone, procure exfoliation; or may, by setons, injections, and pressure, procure a temporary cure; but, as long as the adventitious cause remains, we cannot expect a permanent recovery. It is observed, that sinuses, when they can be healed in these circumstances, break out again upon very trifling exertions, and very frequently are renewed, after a short interval, in spite of all our precautions; such as rest, warmth, &c.

A caries of the bone is at all times a disease which is difficult to manage, both on account of the mechanical obstacles which we have to overcome, and the slowness with which the affected parts perform their actions either of disease or recovery. The divisions of this disease have generally been taken from the appearance of the caries, and its extent. We have the dry caries, the worm-eaten caries, the spongy, or carnous caries, &c. and we have the deep and superficial. But, as the cure of these is to be conducted on the same principles in all of them, and as they are most probably different degrees of the same complaint, it will be more useful to divide them into those which affect bones lying deeply, and those which affect the more superficial bones; because these different cases are attended with very different circumstances and symptoms. The first is preceded by an abscess, which forms generally with much pain, runs its course slowly, and does not burst for a considerable time. When it does open, its sides do not ulcerate, at least universally, but a sinus remains, the mouth, or exposed part of which only, assumes the ulcerative action. The second is more rarely preceded by any abscess, but is either coeval with the ulcer of soft parts, (both being produced by mechanical violence) or it succeeds the ulcer, and is caused by it. This ulcer belongs to the third genus, and will be afterwards described.

When a bone becomes carious, the periosteum is completely detached, and, therefore, it is felt to be rough by the probe. Its colour becomes first of a dull white, or dirty yellow, which it either preserves, or changes for the intermediate hues betwixt these and black. It is generally more porous than formerly, and lighter; but these qualities vary, from very slight degrees, to the appearance of a light coralline.

In treating of the cure of caries, the first thing is, to determine by what means the disease of the bone may be removed; and, secondly, what modification our treatment must undergo, in consequence of the caries belonging to the first or second species. From the very earliest periods, we find the application of stimulating and corrosive remedies recommended in this disease. The actual cautery, euphorbium, mineral acids, scalding oil, the essential oils, and warm balsams, have been universally employed, and frequently alternated with rasping and perforating the bone. This proceeded from observing, that, on the one hand, mild applications had no effect, and, on the other, that the natural slowness of exfoliation was overcome by the use of these more powerful remedies. A caries of a bone is correspondent to a mortification of a soft part; and, therefore, it is impossible to restore the diseased part to health, or life. Our chief object, then, must be to prevent the disease from spreading, and to procure a speedy separation of the dead portion. The first is much less under our power than the second; for, it is most probable, that, in the majority of instances, at least of those of a simple nature, the disease, from the first, extends a certain length, affecting a portion of the bone, and that it afterwards makes very little progress. There is, however, a specific disease which affects the bone in common with the soft parts. The bone becomes rough, and suppurates; and the soft parts have a fiery appearance: This has been called the phagedenic caries. Cancer, scrophula, lues, and other specific actions, also spread after they are once induced. The second object is to be effected by such means as operate upon the vitality and action of the part, and those which act mechanically. Those which tend mechanically to remove the dead portion, are perforations down to the sound part, which we know has happened, by the bleeding which ensues; or, we may saw down this length with a trephine. We thus, by cutting off the communication of part of the diseased surface with the adjacent parts, kill it completely, sooner than could otherwise happen, and likewise stimulate the parts below to assume the ulcerative action, and throw it off. We may also sometimes be able to turn out these portions with a levator. Those which act more exclusively, by affecting the action of the part, are stimulating applications; such as heat, acids, &c. The actual cautery is so terrifying to the patient, that it is now laid aside; and it is likewise liable to this objection, that it may, by its operation on the neighbouring parts of the bone, produce disease in them. The potential cautery is more useful, and may frequently be employed with advantage, either in a solid form, as to callus, &c. or dissolved in water, and applied with a pencil. M. Sue, in his notes to Ravaton’s Practique, &c. recommends l’eau mercurielle, or solution of mercury, in nitrous acid. By these means, the sound part below assumes the ulcerative action, its connection with the diseased portion is then destroyed, and reparation takes place. The ulcer of the bone is red, and its surface covered with innumerable granulations, which rise up to the level of the surrounding parts, after which a cicatrice is formed. These granulations in the bone are absorbed, and others more perfect are deposited in their place, until at last they become completely osseous.

If we use the solution, we must, if the bone be very porous, or spongy, apply only a little at once, otherwise it may sink down, and injure a part which we do not wish to act on.

There is a curious case of caries, which is frequently met with: The diseased part, instead of being cast off, is surrounded by a covering of new bone, (except at one portion, where a sinus and ulcer is formed in the soft parts) and may be felt rattling within it. In this case, there is necessarily a permanent enlargement of the part, from the additional bony matter; and this, together with the sinous openings, and the internal caries, being felt with the probe, form the character of the disease, which has been called necrosis, a term which formerly implied merely mortification. The cure of this complaint is to be accomplished by extracting the diseased part, when it becomes loose, if the opening in the case be sufficiently large; if not, it is to be enlarged with the trephine, &c. See the works of Ruysch, Default, &c.; and, more lately, the publication of Mr. Russel.

The next point which merits our attention, is the situation of the bone, and the circumstances which attend the caries. When superficial, a fungous ulcer is produced, and the modification which this situation requires in the application of the general plan will come afterwards to be attended to; the modification in the treatment which is required in sinuses has been mentioned above. It may here only be remarked, that, where the sinuses are superficial, they may be laid open, which will induce the ulcerative action in their course, and allow us to apply the proper remedies to the bone; but where they run deep, we must either allow the disease to run its natural progress, and treat the constitution according to the effects produced, or, by means of a canula, convey a piece of caustic to the diseased part, in the same way as we treat obstinate strictures of the urethra, &c. When, with the probe, we feel the bone loose, we may assist its exit with the forceps, or by enlarging part of the sinus, according to circumstances.

When these sinuses communicate with joints, and depend upon diseased cartilages, tendons, or articulating surfaces of the bones, we can do very little in the way of curing them by injections or incisions; because we cannot thus remove the disease of the joint, but may increase it. Issues placed over the joint, with rest, cleanliness, and good diet, country air, &c. are the remedies chiefly to be employed in these cases; or, if hectic be induced, and these remedies fail, we must remove the diseased part, if this, on account of its situation, be practicable. When, however, these sinuses are superficial, and depend upon tendons not immediately connected with the articulation, it may be useful to lay them open, and treat the disease of the tendons with caustic, like a caries of a bone, or with escharotics, and stimulating applications.

The fourth species of sinuses, are those where a specific action exists, and prevents the healthy ulcerative action from forming. Of this kind is the scrophulous sinus, which is generally accompanied with a caries bone, or diseased cartilage, and, therefore, is a complicated sinus. This is distinguished, where the bone is diseased, by a shining or polished red skin, like a cicatrix, surrounding the fungus papilla at the orifice of the sinus, or the scrophulous-looking sore which exists there. When no caries bone exists, we have no papilla, but only the diseased ulcer at the orifice. In both cases, there are generally the marks of a scrophulous habit. In the first case, we are to treat the sinus as if it were of the third species. In the second case, we are to treat it as if of the second, conjoining the proper remedies internally, as will be mentioned in considering the cure of scrophulous action. These sinuses, although healed, have a tendency to break out again, especially in the spring or summer.

These sinuses cannot be considered in this dissertation.

This may sometimes be produced by the formation of an abscess, without any evident cause; but at other times it is produced by wounds, &c. in scrophulous habits.

The effects of the suppurative action upon the constitution, may be divided into those which are dependent upon the formation of the action, such as coldness, listlessness, &c. which are common to all new actions; and those which are peculiar to the action when fully formed. The first set requires no particular treatment, with an immediate reference to their removal; but their presence indicates the necessity of changing our method of cure, if we have not already done so. In conjunction with proper local applications, we must give light nourishing diet, with or without wine, according to the extent of the action and the weakness of the patient. Rest, and general warmth, are also necessary; but the heat ought not to be carried so far as to produce any considerable sensation, or sweating. Diaphoretics have been recommended; but there does not appear to be any necessity for their exhibition; because the cold, and other symptoms which we intend to relieve, depend upon the state of the local action, and are only to be removed by fully forming this action. Heat will not cure this coldness, or shivering, when the action which causes it is extensive; but, on the contrary, will frequently increase it, by accelerating the formative process. The immediate effects, then, or the primary symptoms of suppuration, require no particular treatment, with a view to their own removal, but are to be attended to as marks which point out the necessity of a change of treatment, with a view to keep up the action which induces them, and to prevent it from producing bad consequences afterwards to the constitution. Sometimes, indeed, in delicate people, suppuration at this period produces hysterical symptoms, such as languor, flatulence, or sometimes starting, tremors, and hysteric paroxysms, more or less distinct. The slighter affections of this kind may be frequently removed by a little warm wine and water; the more severe, by anodynes, conjoined with aromatic waters.

Mr. Hunter supposes that these are useful, “because they endeavour to keep up an universal harmony, by putting the skin in good humour, which quiets every sympathising part, and by counteracting the effects of irritability.” P. 381.

The second set of symptoms, or effects, are those which have been already described under the name of hectic, the production of which has formerly been explained. This action, when slight, has been called weakness, and has been considered as dependent upon the quantity of the discharge; but, for the reasons formerly mentioned, this cannot be admitted. The cure of this state is to be attempted, by lessening the local action, at the same time that we give soups, and other articles of nourishing diet, with a moderate proportion of wine, if this do not quicken the pulse, and produce heat of the skin. Anodynes in the evening, by procuring rest, will also be useful; but none of these remedies will produce their proper effect, unless the patient respire a pure air. Bark is considered as useful in these cases; but, unless good diet be conjoined, it is not of much benefit. If, however, we give the means of increasing the quantity of vital power, bark, by inducing an action more nearly resembling the natural one, will be serviceable; but, for this purpose, it must be exhibited in full doses. It is from giving this medicine too sparingly, and in cases where other causes, tending to counteract its effects, such as poor diet, bad air, &c. are allowed to remain and operate, that bark has been brought into disrepute.

When the general action is very considerable, then the exquisite hectic is induced, and the situation of the patient becomes alarming. When the local action is simply the suppurative or ulcerative action, we may consider that the general disease is also simple, and are to attempt the cure by the remedies which have been just now mentioned. In conjunction with such local applications as tend to check the local action, we must have recourse to all those means which tend to strengthen or renew the natural action of the system in general; for which purpose, we must attend, in the first place, to all the particular functions, or individual parts; and, in the second, to the whole in the aggregate. Under the second head are included bark and wine, with moderate exercise, and proper diet; in the choice of which, we must be directed by the nourishment which is yielded, and by the capability of digesting the articles which we employ. In general, milk, soups, and jellies, answer best. Under the first head are included such remedies as tend to promote digestion, such as steel, bitters, mineral acids, &c. although in general the bark will supersede their use. The state of the bowels must also be attended to, avoiding costiveness on the one hand, and diarrhœa on the other. The secretion of the skin must also be regulated, stopping the colliquative sweating, if possible, by getting up for some time when it commences. Lessening the quantity of bed-clothes, for a few minutes, will also sometimes interrupt it; but when it has continued long, it can only be checked by removing the diseased action. A full dose of the bark given before the accession of the sweat, may sometimes, by influencing the morbid action, prevent the discharge. The respiration must in particular be attended to; for, by breathing country and pure air, the action of respiration is more fully performed, and, consequently, the source of vitality is increased, and the effects of our other remedies are increased. The importance of a change of air can only be known by those who have observed how fast patients have recovered from operations when removed to the country, and clean lodgings, with well-aired beds, although before this they were daily sinking. Indeed no capital operation, which is likely to induce the suppurative action, ought to be performed, where cleanliness, and a free circulation of air, free from fœtor, cannot be procured.

Exercise may be used either on foot, or on horseback, or in a carriage; and its degree must be regulated by the strength. There are few patients who cannot bear moderate exercise (were it no more than walking half a minute in a garden), and who will not be the better of this.

Acids are supposed to check it; but they can only act by increasing the strength in a secondary way.