Elements of Surgery. Robert Liston

the giving way of an abscess into the former canal. The breathing is also seriously impeded by enlargement of the bronchial glands, by the pressure of which the lungs may be much condensed, and unfitted for their functions. The immediate effect of enlargement of the mesenteric glands, is interruption to the passage of the chyle, and a consequent decline of the powers of life. Such tumours in the abdomen have been mistaken for enlargement of the liver, spleen, ovarium, &c., and the most noxious treatment employed.

      Inflammatory glandular enlargements terminate either in resolution, in delitescence, or in suppuration; sometimes in death of the part. When the tumour, after having attained a certain size, gradually disappears, it is said to be resolved; when, however, it is rapidly discussed, it terminates in delitescence; the difference between the terms being the same as when used to express the corresponding terminations of inflammatory swelling in general.

      Suppuration is by far the most usual termination, and the matter is frequently evacuated through numerous small apertures, exposing the gland denuded and prominent in the middle of the chasm; in such cases, the gland proves the source of much irritation, and must be destroyed, otherwise the cure is extremely tedious.

      Though inflamed and swelled lymphatic glands very generally disappear by suppuration, it is to be remarked that the conglomerate glands, though often violently inflamed, seldom, if ever, have pus formed in them; in mumps, for instance, the action often runs very high, yet abscess of the parotid is rare. The submaxillary salivary glands are often supposed and said to be inflamed and enlarged; the conglobate glands superficial to them are in such cases only affected.

      Collections of pus in the lymphatic glands or cellular substance, in patients of a weak constitution, (whether naturally or in consequence of disease,) are attended with little or no pain, or inflammatory action; and although it is probable that inflammation does precede the formation of such purulent depôts, still it is generally so slight as not to attract the attention of the patient or his attendant. The sensation is dull and uneasy, rather than painful; and, even after the accumulation of a considerable quantity of purulent matter, redness of the surface and pointing do not occur till a late period. The contained matter is thin, flaky, and of a brownish colour. The collections often attain a very great size, and, if improperly treated, terminate in the formation of numerous and extensive sinuses.

      The skin, particularly that of the face, becomes, in very many cases, affected either primarily or secondarily with scrofulous ulceration, which commonly extends to the neighbouring textures. The disease has sometimes been mistaken for cancer, and other affections of a malignant nature, and has received various names accordingly. The integuments in the neighbourhood of the ulcer are of a purple hue, and become undermined, from the extension of the disease in the subjacent cellular tissue. The discharge is thin and gleety—the sore is of an unhealthy and debilitated character, and makes but little attempt at reparation; its surface is covered by a viscid fluid, and sloughing occasionally occurs in consequence of the extreme debility of the parts. Numerous sinuses frequently extend in a superficial direction, and render the cure more tedious and complicated.

      Those of a scrofulous constitution are most liable to be affected with caries, softening, and other diseases of the bones and their coverings; these, however, will afterwards be treated of, along with ulceration of cartilages, diseases of ligaments and synovial membranes, lumbar abscess, &c.; all of which affections, in the plurality of instances, are connected with the strumous diathesis.

      In the treatment of abscesses, the principal indications are, to remove any degree of inflammatory action with which the surrounding parts may be affected—to keep the part moist, clean, and at rest—to remove all source of local irritation—to promote and accelerate the progress of the matter to the surface—and, lastly, to give it free vent; for though it sometimes happens that collections of purulent matter disappear, still the occurrence is so rare, that to treat abscess generally when in an advanced stage with the expectation of resolution would be highly injudicious. By blistering and pressure, however, tumours containing a small quantity of purulent fluid can occasionally be discussed. Warm fomentations afford great relief, especially at the commencement, when there still remains a considerable degree of surrounding inflammation. These may be either what are termed anodyne, or not; in general, fomentation with chamomile flowers or hops, contained in a woollen bag, and wrung out of warm water, will be found the most convenient and efficient, and is well entitled to the term anodyne, which is usually applied to others of a complicated, and not more efficacious, character. Poultices are of material service, particularly when the collection is advancing to maturation; and their composition is of little importance, provided they are moist, warm, and soft. Stale bread soaked with hot water, or an equal quantity of grated bread and linseed meal, (if not adulterated with mustard, as is sometimes the case,) mixed with sufficient quantity of boiling water, form excellent and soothing cataplasms. Their use, however, may be persevered in too long; for, after an abscess has given way, the suppuration may be kept up in consequence of continuing the poultice. The opening will enlarge, the skin become undermined, loose, and flabby, the abscess will extend, while the process of granulation may be in a great measure suspended. In many cases, the poulticing cannot be continued until an opening has formed naturally, and the cure is often much accelerated by the artificial evacuation of the matter. When the abscess is situated deeply, or beneath a fascia, a free and early opening must be made. For example, when suppuration has occurred in the cellular tissue beneath the fascia lata of the thigh, it at first naturally tends towards the surface, but its progress is impeded by the tendinous aponeurosis; a painful feeling of tension is thereby occasioned, and the matter extends where there is least resistance, making its way in all directions into the surrounding cellular tissue—separating the muscles—isolating the arterial trunks—burrowing beneath the fascia over the whole limb, and producing most serious, and often irreparable mischief, with violent constitutional disturbance. The bad effects of delay are again daily witnessed in neglected cases of paronychia; most excruciating pain is produced—the system is seriously affected—the tendons slough, and the member is rendered useless.

      By the continued presence of purulent matter, absorption, ulceration, caries, and even death, of bone, is frequently produced, all which might have been prevented by its evacuation. If pus collect in the neighbourhood of cavities or canals, it is of the utmost importance that it be early discharged; and the evil effects of negligent and dilatory treatment are well exemplified in the following cases:—A patient had been allowed to suffer, for a long time, under an extensive abscess at the lower part of the neck, beneath the origins of the sterno-mastoid muscles. The abscess at length gave way externally; but the patient was at the same time seized with profuse expectoration of pus, and during expiration the air escaped through the external openings in the neck. It was evident that the abscess communicated with the trachea, and it also appeared to have extended deeply into the mediastinum. The patient soon perished, but there was no opportunity of examining the parts. In another case of extensive abscess at the root of the neck, an opening was proposed, but delayed. At length, the abscess gave way spontaneously; and from the circumstance of portions of solid as well as fluid ingesta escaping by the external opening, it was evident that the œsophagus had ulcerated. The cure was very tedious, but ultimately complete, and apparently much accelerated by free counter openings.

      In suppuration of the cellular substance in the neighbourhood of the anus, the matter may present itself externally, whilst it is making extensive progress internally; and if a free opening is not made, fistula ani is the result. The propriety of an early evacuation of purulent matter in important, or very sensible, organs, such as the eye and testicle, is very evident.

      The larger arterial and venous trunks appear not to suffer from suppuration, for in purulent depôts we find them entire, and much thickened by copious effusion of lymph into their outer cellular coat and sheath; the nerves, however, are not so much protected, or do not appear to resist the pressure and insinuation of pus, and suffer along with the other tissues.

      

The most convenient and effectual mode of opening an abscess is with 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. 56, will be found