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Clinical Remarks ON A CASE OF SEVERAL CONSECUTIVE ABSCESSES AND MORBUS BRIGHTII.
The pelvis represents a portion of a female screw, admitting male screw, (the foetal head,) of an oblong shape. But the male and female screws, in the case of the pelvis and foetal head, are not accurately adjusted at all points. There is, however, a general adjustment in the shape of the fcetal head and the arrangement of the pelvic diameters. It is only at the points where the posterior part of the parietal bone, or of the occiput, comes in contact with the planes of the ischium and pubis, that the thread of the male screw bites, as it were, the thread of the female. It is here that the spiral direction is impressed upon the foetal cranium. The line of this portion of the spiral or screw may be made out by chalking the salient point of the foetal head, and moving it through the pelvis in the direction it takes in parturition. The chalk line marked upon the pelvis by this proceeding will show, accurately, the track of the segment of the thread or groove of the female screw, through which the prominent portion of the head passes. The two halves of the pelvis also represent portions of two screws, the inclined planes of which are arranged in opposite directions. Thus, if the head be placed in the second position, the spiral movement is reversed from that which obtains in the first position, and the long diameter of the fcetal cranium moves from the transverse, or the left oblique, to the anteroposterior diameter. In the case of labour occurring in the first, the right shoulder moves upon the right portion of the spiral or screw formed by the right ischium and pubis, and glides down it, just as the head does in the second position. In the second position, on the contrary, after the delivery of the head, the left shoulder rotates upon the planes of the screw or spiral of the left side of the pelvis, and passes out with a movement similar to that which belongs to the head in the first position. Perhaps the screw or spiral motion is seen still more distinctly in the common terminations of the third and fourth positions. Here, rather more than one-fourth of a circle is completed in the movement which brings the occiput from the right or left sacro-iliac synchondrosis, to the right or left ramus of the pubic arch. The movement is distinctly spiral, only that when the head presents in the occipito-posterior position, it has to pass through a spiral having a larger diameter than when the head presents in the occipito-anterior positions. The two lines marked upon the following diagram mark the different paths through which the head glides when it presents in the first and fourth position, and passes towards the anteroposterior diameters. In both it is distinctly screw-like, or spiral. A similar diagram of the right side of the pelvis would give the lines of the spirals traversed by the head in the second and in the third positions, when the head is born in the
it to descend. In practice, these considerationsare imwith reference to the direction in which traction can be used to the greatest advantage in delivery by the long or short forceps; rectifying the positions of the head in the case of presentations in the third and fourth positions; and in other causes
portant
a
operative proceedings.
Clinical ON
A
Remarks
CASE OF
SEVERAL CONSECUTIVE ABSCESSES AND
MORBUS BRIGHTII. BY
WILLIAM
COULSON, ESQ.,
SURGEON TO ST.
I
MARY’S
HOSPITAL.
( Concluded fi’om page 535.) LET
gentlemen, turn to the nature of these successive abscesses, and this naturally leads us to a consideration of the causes on which they depend. They are of constitutional origin, seated in the subcutaneous or inter-muscular cellular tissues, and are multiple, but succeeding each other at various intervals. These leading characters will at once enable you to us
now,
them from a number of other abscesses of a chronic Thus their seat distinguishes them from the chronic glandular abscesses of scrofulous subjects; their successive appearance in various parts shows that they differ from psoas abscess and other collections of matter depending on disease in a distant bone ; while their local appearances are quite distinct from those produced by collections of matter during syphilis &c., which ordinarily arise from disease in the subjacent bone, or have more the character of ulcer than of abscess. It is not easy to group together these successive abscesses under different heads, according to their evident or presumed causes, and I am not aware that any attempt of this kind has been made; yet it is necessary to do so. I have, therefore, occipito-anterior position. after much consideration, endeavoured to classify them, though it is probable that the arrangement which I offer may not include all the varieties ; for we sometimes meet with the disease in such a form that it is impossible to discover its cause. However this may be, I think that we may distinguish three principal groups. One will include chronic successive abscess ; the other the true cold abscess ; and the third will embrace successive abscesses from contamination of the blood. Each of these forms is connected with a peculiar state of the general health. Chronic successive abscess depends on scrofula ; the true cold abscess must for the present be referred to a general purulent diathesis ; while the third form depends, in my opinion, on infection of the blood from animal poisons or pus. Scrofula, gentlemen, as you all know, is a pyogenic diseasethat is to say, in plainer terms, it is a general affection, the local manifestations of which are very commonly attended by suppuration. Now, scrofulous persons are very subject to abscesses. The external lymphatic glands are often, the seat of collections of matter ; but these softened glandular tumours are so different from the successive abscesses of which I now speak, Outline of the internal surface of the left half of the pelvis. The that it is unnecessary for me to dwell on them. Abscesses are two curved lines mark the path of the head in the first, and in also formed in scrofulous persons in connexion with diseased the occipito-anterior termination of the fourth positions. bone immediately beneath them ; but these likewise are clearly The contractions of the uterus and abdominal muscles con- different from successive abscesses, although they may appear stitute the vis à tergo which moves the fcetal head down the to form with a certain degree of succession. In the first place, planes of the ischum and pubis. No rotatory movement ap- their seat is different ; in the next, they are the effects of dispears to be given to the foetal head by the pains. The spiral ease in the bone, occurring only over those points where the direction depends entirely upon the portion of the spiral in- bone is diseased, and ir. most cases evidently traceable to it. clined plane formed by the osseous surfaces. If any weight or But scrofulous persons are subject to two kinds of abscesses, pressure be placed upon a male screw, adjusted in the chamber both of which are seated in the subcutaneous cellular tissue, or box of the female, it has the tendency to descend the spiral and are direct manifestations of the constitutional malady, not plane. We see this familiarly exemplified in the press for secondary effects of some other lesion which that malady may stamping letters, in which a weight at the top of the screw have nrnrluced_ The first kind is of an inAammatorv natiirp-
separate nature.
617
accompanied by heat, pain, ends in true scrofulous
and some redness of the skin; it ulcer, and it has not much tendency
mentioned; but,
from
causes
with which
we are
imperfectly
acquainted, instead of scrofula, a certain state of the general to become successive, although two or three such abscesses may health is produced, which we must call the purulent diathesis. form one after another. This is not the kind of abscess I This diathesis manifests itself in a tendency to successive forspeak of, although it is the one most commonly met with during mations of abscess in different parts of the body and in the scrofula. The true successive abscess of scrofula is, on the joints, without any lesion indicating the existence of scrofula, contrary, rare. The deposit of purulent matter in the cellular syphilis, or other constitutional disease. It is a serious affectissue is so slow and indolent that it excites little or no atten- tion, and indicates a deterioration, of the general health; tion until actual fluctuation is observed. The disease occurs but we are unable to say in what the change consists, and chiefly in young persons, from five to fifteen years of age, and are, therefore, compelled to fall back on the theory of a its duration is lon, the successive formations of matter extend- diathesis, which in reality merely covers our ignorance by exing from one to three or more years. The upper and lower ex- pressing a fact in general terms. Like the scrofulous abscess tremities are the principal seats of the disease, but the matter already described, it occurs more frequently in children than may collect about the neck, trunk, and groins. Ths matter is in adults ; but the general appearance of the persons labouring chiefly situated in the cellular tissue beneath the skin, but it may under this affection is quite different from that of scrofula. be deeper seated under the fascise. The progress of the abscess You know the general characters of the scrofulous temperais very slow; there is no other sign of the formation of matter ment, such at least as they present themselves at an early than a gradual softening, with, perhaps, some tenderness or stage, and before the constitution has given way under the ’even pain towards the end, when the skin is about to give way. disease. Now, the appearance of the persons to whom we The interior of each abscess is lined with the peculiar struc- would attribute the purulent diathesis is quite the reverse of ture which has been called "pyogenic membrane." This is this. They have no engorged lymphatic glands, no tumid lips, nothing more than a fibrous exudation which has become no prominent bellies, no ruddy complexions, no sores or ulcers. adherent to the walls of the abscess and undergone a certain on any part of the body: on the contrary, the face is pale, degree of vascular organization. It is then capable of secreting the complexion dirty, the body is thin, the skin dry, yet perpus, wnich it continues to do; it circumscribes the abscess like spires easily from weakness; the appetite is poor and capricious ; a kind of cyst, and thus has a tendency to perpetuate the the whole frame has an indescribable appearance of languor disease for an almost indefinite period. You will bear in mind and general deterioration which reminds one of plants that are the existence of this false membrane, and of its tendency to go withering in cellars, without light, air, or water, without any external injury, or any discoverable cause, beyond the general on secreting pus, for these points have an important bearing on state. An abscess forms in some part of the body, and is folthe treatment. Let us now inquire how this form of successive abscess is lowed at various intervals by other abscesses in different parts to be distinguished from other abscesses of a similar kind. of the cellular tissue. These collections of matter are, as I In the first place, they occur in scrofulous subjects-I do have said, essentially cold,--there is not the slightest trace of not mean persons who have a scrofulous appearance, but inflammatory action; and when the diathesis is well marked, persons actually labouring under scrofulous disease: for these purulent effusions often occur in the joints, or perhaps in the cold abscesses are the extreme expression of the pyogenic serous cavities. In these severe cases, the patient sinks under tendency of scrofula. Ou examining the patient, therefore, hectic fever, or is cut off by some internal effusion ; but when you will find evident traces of scrofula, disease of the osseous the diathesis is less marked (and its intensity varies in every system or of the skin-in a word, local scrofulous affections, case), the tendency to purulent deposit diminishes, and rapid which will assist in your diagnosis. The appearance and pro- recovery may take place on placing the patient in a more gress of the abscesses, after they have been opened, will like- favourable condition for improving the general health. wise hel[) to distinguish them. When superficial, they have a The diagnosis of this affection is not very difficult. The tendency to form scrofulous ulcers; when more deeply seated, only disease with which it is liable to be confounded is the they have a tendency to form fistulous canals with narrow cold scrofulous abscess just noticed. But we have no general soon
which resemble the nstulae from carious bone; but integumpnt is always more The scrofulous or less separated from the subjacent tissues. ulcer at the orifice of the abscess is a very characteristic mark, and cannot be ini,,:taken, for nothing like it occurs in the other forms. There is also another peculiarity hich is worthy of notice. Although the abscesses are formed in succession, yet, from their having little or no tendency to heal, those first formed continue to remain open, and we find several suppurating cavities in different parts of the body. In the other forms this does not occur, for the abscess heals in one part to break out at another, and we seldom have many open at the Even when the abscess heals, there is a peculiar same time. appearance, to which I must direct your attention, as it will assist your diagnosis. The abscess, as I have said, is essentially cold-thatis to say, unattended by any of the signs of inflammation ; but this is true only so long as it remains a closed cavity. When the abscess is opened, some slight inflammation ’, of the skin, with partial destruction of the integument, ensues, and the cicatrix left is of a dull-red colour, irregular in shape, and adherent to the subjacent tissues. The appearance of any abscess which may have he,lled should therefore be noted, as useful indications may be drawn from it. Successive abscesses occur underdifferent form from those just noticed, though in many particulars they may seem to be very analogous. The local characters of the abscesses are the same; but they are so completely illflolent-the absence of all inflammatory action is so entire-that they merit the name of true cold abscesses. The circumstances under which they are developed are likewise somewhat similar to those attending scrofulous abscess; but careful examination will not fail to establish many points of difference. The form of the disease to which I now allude occurs in individuals of deteriorated constitution ; in children, also, whose general health has given way under the want of all that is most essential to liff—sufE.cieut foocl and pure air. Eruptive diseases, also, and the crowding of hospitals, prisons, &c., seem to predispose to it by clebilitating the constitution. Under these circumstances, a curious effect is produced on certain individuals. Generally speaking, scrofula would be developed under the circumstances just
orifices,
round the orifice of the fistula the
I
618
characters of scrofula, nor any of the local effects of that disease in other parts of the body. The abscesses are not lined with a pyogenic membrane, for the imperfect exudations which sometimes partially line them do not deserve that name. The abscesses, therefore, are not clearly circumscribed; they have more tendency to spread, and might more correctly bedesignated effusions of pus than abscesses. When opened, the orifices have no tendency to assume the appearance of scrofulous ulcers, but the edges of the wound remain flaccid and inactive, from want of power to set np reparative action. The number of these abscesses is much greater than what we observe in the scrofulous form, and will depend on the intensity of the diathesis ; but the quantity of matter contained in each is not
commonly
so
great.
The third form of successive abscess, gentlemen, is very interesting. It occurs more frequently than either of the preceding, and from the circumstances which attend it, the cases I come rather wit,hin the domain of surgery than of medicine. have referred the origin of these cases to some contamination of the blood, yet I must confess to you that we sometimes meet with examples in adults of apparently good health, where it is, impossible to trace either the remote or the immediate cause of disease. The usual history of these cases is as follows :-A patient has undergone some slight operation, or suffered some slight injury. He may, for example, have been cut for fistula, as oscurred to a patient in this hospital not long ago; or he may have pricked his finger, as in the case of John K-. The patient enjoys tolerably good health,and does not appear to be much debilitated by any previous affection. He goes on well for some time, when an abscess is suddenly discovered under the skin at some part of the body. This is opened, and soon heals, when another abscess breaks out elsewhere. Successive abscesses are thus formed for some time, healing in one place to form in another, until at last the disposition to secrete matter ceases, and the patient gets well. These, gentlemen, are very obscure cases, and therefore worthy of all our attenThe peculiar characters of the local disease are commonly well marked; but it is very difficult to make out the nature of the constitutional influence under which these suc-
tion.
cessive abscesses are developed. They differ from the two preceding forms in several respects. The pus is secreted much more rapidly in these abscesses, and their successive duration
is much shorter. Here the disease ends in a few weeks; in the former cases it lasts for months together. The abscesses
zencrally, though not always, accompanied by some signs inflammatory action. In fact, they are subacute in form, though chronic in duration. The skin over the abscess is not inflamed, but there is commonly some pain and tenderness to the touch. The purulent matter is sometimes diffused, sometimes ciroumsoibed into a regular abscess, but there is no pyogenic membrane. When opened, these abscesses usually heal in a short time. The only affection with which they are likely to be confounded is the acute or subacute (lepositions of pus which take place successively under the influFrom these, also, they ence of pyaemia and animal poisons. Their course and are distinguished by several characters. are
that any meddling with the abscess may only accelerate a fatal result. In the subacute abscesses of the third foi-iii, simple local treatment llsnallv suffices for the cure. The matter is evacuated with the 1,Lticet; the sides of the abscess may be brought together hy compression, and, with proper -ttteiicion to the general health, the abscess heals and recovery takes place.
of
Notes of Three Lectures ON THE
PHYSIOLOGICAL ACTION STRYCHNIA
OF
termination are different. They are much more chronic than DELIVERED BY the abscesses of acute pyaemia, but they are less chronic than GEORGE HARLEY M.D., scrofulous or cold abscess. Their termination is commonly TEACHER OF PRACTICAL PHYSIOLOGY AND HISTOLOGY IN UNIVERSITY favourable; they are less painful, Jess likely to be accompanied COLLEGE, LONDON. by articular disease than pyasmio abscesses, and, above all, they are not attended by the general symptoms of acute infection of the blood. Finally, in fatat cases, as in the one DR. HARLEY, after briefly explaining to his class the reasons which I have just related to you, where the patient has been which induced him, at the present time, to alter the prescribed - cut off by some intercurrent disease, we do not find the order of his course, and to take up the subject of Stryohnia, secondary deposits of pysemia in the lnngs, liver, or other organs. To what cause, then, you will ask me, are we to proceeded to demonstrate, by direct experiment-] stly, the attribute this form of successiveabscess? I regret that 1 can manner in which the substance in question enters the system ; only offer vou an hypothesis, but it is the one which appears to 211clly, its mode of action ; and 3rdly, the way in which it me to approach nearest to the truth. I consider that, in a animal life. great many cases at least, these successive abscesses a,re con- destroys The following is a brief summary of the remarks made :— nected with some chronic poisoning of the blood, just as the !i To the first question—How is strychnia or any of its comacute depositions of pyaemia, glanders, puerperal phlebitis, &c., ’i are connected with acute blood-p’dsoning. It is true that we pounds, all of which have a similar physiological action, recan find only three circumstances in which the two sets of ceived into the system ?-the answer is, by absorption ; the cases agree--viz., in there being a primary suppuration, in the manner of this absorption being very various. The poison is .successive formation of the abscesses, and in their seat. If of the stomach and intesabsorbed the mucous membrane by there be any analogy between them, we must admit that the intensity of the poison is not snSicient to develop the disease tines, when administered by the mouth, as in the case of the fully, but that produces only partial alterati, ns. The history animal now operated upon (a frog) ; it enters directly into the of the small-pox and other diseases produced I ya..lil1Utl poisons circulation when introduced through a wound, as is now dotte. shows how considerably their effects differ according to the insolution of strychnia was introduced into the cellular (Some tensity of the cause-so much so, that the effects of the same of another frog.) It is absorbed by the skin, as will be poison were formerly regarded as distinct diseases. But the tissue chief reason which I can offer in support of my theory is the shown in the case of this third frog, uoon whose back a few fact I h Lve more than once observed, that these abscesses, drops of acetate of strychnine are new poured. The poison may, in fact, be introduced into the body in every though apparently so innoxious, may at any time merge into acute pyaemia, with its general symptoms and fatal termination. conceivable manner : by the mouth or by the rectum ; by the I must now say a few words about treatment. As the local disease has a constitutional origin, our treatment must be at cellular tissue or by the organs ; by the epidermis covering the To the scrofulous form you will of external surface, or by the serous membranes lining the interior once general and local. course oppose an anti scrofulous mode of treatment. I need cavities of the body. When once the poison has entared the not dwell on this method, which has been frequently explained blood, its mode of action is in all cases identical. to you; but I would observe that cotl-liver oil, which is so effictThe time required for the development of the cious in many forms of scrofula, does not seem to possess the of strychnine varies, however, in different species of qualities over these same power abscesses. You will find greater advantage from administering iodine internally. Hocal treatment is imlis- animals, and even individuals of the same species, being influpensable in this form, and you will understand the necessity of enced by the age, strength, &c., of the animal. The rapidity local means by remembering what I said relative to the pyo with which this substance kills depends, moreover, on three genic membrane. The tendency of this membrane to secrete distinct causes :-a, the form, solid or fluid, in which the poison pus must be checked, unless you are prepared to see it go is administered, the latter form being the most favourable for on supplying matter for months. General remedies may check the tendency, but they must be assisted by local means. absorption; b, upon the part of the body at which it is introVarious methods are employed. Some surgeons expose the duced, its action being the more speedy the quicker it obtains cavity of the abscess, and fill it with lint; others prefer the entrance into the circulation : for example, it affects the system subcutaneous incision; others, again, employ stimulant injec- more rapidly when injected into a vein than when given by the tions of various kinds. The treatment I prefer consists in mouth (see below, second experiment on dog); it is absorbed ,evacuating the contents of the abscess freely by incision, and much more rapidly when introduced into the thoracic or then employing iodine injections to change the vital properties of the pus-secreting membrane. This method is ()fficacious, and, abdominal cavity than when applied to the skin. In proof of according to my own experience, more rapid in its effects than this I take two drops of a solution of acetate of strychnine, so .any other. weak that each coutain not more than1/1000 of a grain ; In the successive abscesses which depend on a purulent dia- dilute still furtherdrop with a small quantity of water, and divide thesis, anti-scrofulous remedies only act in so far as they improve the general health. Cod-liver oil and iodine are not specially the solution into two equal portions. In one portion I place a indicated. The bitter tonics and iron are to be preferred ; but frog, in order that the strychnia may be absorb d into his body no internal remedies will have any effect without a radical through the skin; the remaining portion I inject into the change from the hygienic circumstances under which the dia- abdominal cavity of a second frog, exactly similar to the first thesis has been developed. When the abscesses are small, and in rize. The frog into whose abdomen TJuTi of a grain of not numerous, they may be opened by the subcutaneous incision abscesses he iodine stimulated may Larger hy injec- strychnia was injected will become tetanic very much sooner the collection the one into contact with whose skin an equal quantity of but when of matter is very considerable, tions, and the general health greatly deteriorated, it is to be feared the Doison has been brought.
poisonous
than
619
it to descend. In practice, these considerationsare imwith reference to the direction in which traction can be used to the greatest advantage in delivery by the long or short forceps; rectifying the positions of the head in the case of presentations in the third and fourth positions; and in other causes
portant
a
operative proceedings.
Clinical ON
A
Remarks
CASE OF
SEVERAL CONSECUTIVE ABSCESSES AND
MORBUS BRIGHTII. BY
WILLIAM
COULSON, ESQ.,
SURGEON TO ST.
I
MARY’S
HOSPITAL.
( Concluded fi’om page 535.) LET
gentlemen, turn to the nature of these successive abscesses, and this naturally leads us to a consideration of the causes on which they depend. They are of constitutional origin, seated in the subcutaneous or inter-muscular cellular tissues, and are multiple, but succeeding each other at various intervals. These leading characters will at once enable you to us
now,
them from a number of other abscesses of a chronic Thus their seat distinguishes them from the chronic glandular abscesses of scrofulous subjects; their successive appearance in various parts shows that they differ from psoas abscess and other collections of matter depending on disease in a distant bone ; while their local appearances are quite distinct from those produced by collections of matter during syphilis &c., which ordinarily arise from disease in the subjacent bone, or have more the character of ulcer than of abscess. It is not easy to group together these successive abscesses under different heads, according to their evident or presumed causes, and I am not aware that any attempt of this kind has been made; yet it is necessary to do so. I have, therefore, occipito-anterior position. after much consideration, endeavoured to classify them, though it is probable that the arrangement which I offer may not include all the varieties ; for we sometimes meet with the disease in such a form that it is impossible to discover its cause. However this may be, I think that we may distinguish three principal groups. One will include chronic successive abscess ; the other the true cold abscess ; and the third will embrace successive abscesses from contamination of the blood. Each of these forms is connected with a peculiar state of the general health. Chronic successive abscess depends on scrofula ; the true cold abscess must for the present be referred to a general purulent diathesis ; while the third form depends, in my opinion, on infection of the blood from animal poisons or pus. Scrofula, gentlemen, as you all know, is a pyogenic diseasethat is to say, in plainer terms, it is a general affection, the local manifestations of which are very commonly attended by suppuration. Now, scrofulous persons are very subject to abscesses. The external lymphatic glands are often, the seat of collections of matter ; but these softened glandular tumours are so different from the successive abscesses of which I now speak, Outline of the internal surface of the left half of the pelvis. The that it is unnecessary for me to dwell on them. Abscesses are two curved lines mark the path of the head in the first, and in also formed in scrofulous persons in connexion with diseased the occipito-anterior termination of the fourth positions. bone immediately beneath them ; but these likewise are clearly The contractions of the uterus and abdominal muscles con- different from successive abscesses, although they may appear stitute the vis à tergo which moves the fcetal head down the to form with a certain degree of succession. In the first place, planes of the ischum and pubis. No rotatory movement ap- their seat is different ; in the next, they are the effects of dispears to be given to the foetal head by the pains. The spiral ease in the bone, occurring only over those points where the direction depends entirely upon the portion of the spiral in- bone is diseased, and ir. most cases evidently traceable to it. clined plane formed by the osseous surfaces. If any weight or But scrofulous persons are subject to two kinds of abscesses, pressure be placed upon a male screw, adjusted in the chamber both of which are seated in the subcutaneous cellular tissue, or box of the female, it has the tendency to descend the spiral and are direct manifestations of the constitutional malady, not plane. We see this familiarly exemplified in the press for secondary effects of some other lesion which that malady may stamping letters, in which a weight at the top of the screw have nrnrluced_ The first kind is of an inAammatorv natiirp-
separate nature.
617
accompanied by heat, pain, ends in true scrofulous
and some redness of the skin; it ulcer, and it has not much tendency
mentioned; but,
from
causes
with which
we are
imperfectly
acquainted, instead of scrofula, a certain state of the general to become successive, although two or three such abscesses may health is produced, which we must call the purulent diathesis. form one after another. This is not the kind of abscess I This diathesis manifests itself in a tendency to successive forspeak of, although it is the one most commonly met with during mations of abscess in different parts of the body and in the scrofula. The true successive abscess of scrofula is, on the joints, without any lesion indicating the existence of scrofula, contrary, rare. The deposit of purulent matter in the cellular syphilis, or other constitutional disease. It is a serious affectissue is so slow and indolent that it excites little or no atten- tion, and indicates a deterioration, of the general health; tion until actual fluctuation is observed. The disease occurs but we are unable to say in what the change consists, and chiefly in young persons, from five to fifteen years of age, and are, therefore, compelled to fall back on the theory of a its duration is lon, the successive formations of matter extend- diathesis, which in reality merely covers our ignorance by exing from one to three or more years. The upper and lower ex- pressing a fact in general terms. Like the scrofulous abscess tremities are the principal seats of the disease, but the matter already described, it occurs more frequently in children than may collect about the neck, trunk, and groins. Ths matter is in adults ; but the general appearance of the persons labouring chiefly situated in the cellular tissue beneath the skin, but it may under this affection is quite different from that of scrofula. be deeper seated under the fascise. The progress of the abscess You know the general characters of the scrofulous temperais very slow; there is no other sign of the formation of matter ment, such at least as they present themselves at an early than a gradual softening, with, perhaps, some tenderness or stage, and before the constitution has given way under the ’even pain towards the end, when the skin is about to give way. disease. Now, the appearance of the persons to whom we The interior of each abscess is lined with the peculiar struc- would attribute the purulent diathesis is quite the reverse of ture which has been called "pyogenic membrane." This is this. They have no engorged lymphatic glands, no tumid lips, nothing more than a fibrous exudation which has become no prominent bellies, no ruddy complexions, no sores or ulcers. adherent to the walls of the abscess and undergone a certain on any part of the body: on the contrary, the face is pale, degree of vascular organization. It is then capable of secreting the complexion dirty, the body is thin, the skin dry, yet perpus, wnich it continues to do; it circumscribes the abscess like spires easily from weakness; the appetite is poor and capricious ; a kind of cyst, and thus has a tendency to perpetuate the the whole frame has an indescribable appearance of languor disease for an almost indefinite period. You will bear in mind and general deterioration which reminds one of plants that are the existence of this false membrane, and of its tendency to go withering in cellars, without light, air, or water, without any external injury, or any discoverable cause, beyond the general on secreting pus, for these points have an important bearing on state. An abscess forms in some part of the body, and is folthe treatment. Let us now inquire how this form of successive abscess is lowed at various intervals by other abscesses in different parts to be distinguished from other abscesses of a similar kind. of the cellular tissue. These collections of matter are, as I In the first place, they occur in scrofulous subjects-I do have said, essentially cold,--there is not the slightest trace of not mean persons who have a scrofulous appearance, but inflammatory action; and when the diathesis is well marked, persons actually labouring under scrofulous disease: for these purulent effusions often occur in the joints, or perhaps in the cold abscesses are the extreme expression of the pyogenic serous cavities. In these severe cases, the patient sinks under tendency of scrofula. Ou examining the patient, therefore, hectic fever, or is cut off by some internal effusion ; but when you will find evident traces of scrofula, disease of the osseous the diathesis is less marked (and its intensity varies in every system or of the skin-in a word, local scrofulous affections, case), the tendency to purulent deposit diminishes, and rapid which will assist in your diagnosis. The appearance and pro- recovery may take place on placing the patient in a more gress of the abscesses, after they have been opened, will like- favourable condition for improving the general health. wise hel[) to distinguish them. When superficial, they have a The diagnosis of this affection is not very difficult. The tendency to form scrofulous ulcers; when more deeply seated, only disease with which it is liable to be confounded is the they have a tendency to form fistulous canals with narrow cold scrofulous abscess just noticed. But we have no general soon
which resemble the nstulae from carious bone; but integumpnt is always more The scrofulous or less separated from the subjacent tissues. ulcer at the orifice of the abscess is a very characteristic mark, and cannot be ini,,:taken, for nothing like it occurs in the other forms. There is also another peculiarity hich is worthy of notice. Although the abscesses are formed in succession, yet, from their having little or no tendency to heal, those first formed continue to remain open, and we find several suppurating cavities in different parts of the body. In the other forms this does not occur, for the abscess heals in one part to break out at another, and we seldom have many open at the Even when the abscess heals, there is a peculiar same time. appearance, to which I must direct your attention, as it will assist your diagnosis. The abscess, as I have said, is essentially cold-thatis to say, unattended by any of the signs of inflammation ; but this is true only so long as it remains a closed cavity. When the abscess is opened, some slight inflammation ’, of the skin, with partial destruction of the integument, ensues, and the cicatrix left is of a dull-red colour, irregular in shape, and adherent to the subjacent tissues. The appearance of any abscess which may have he,lled should therefore be noted, as useful indications may be drawn from it. Successive abscesses occur underdifferent form from those just noticed, though in many particulars they may seem to be very analogous. The local characters of the abscesses are the same; but they are so completely illflolent-the absence of all inflammatory action is so entire-that they merit the name of true cold abscesses. The circumstances under which they are developed are likewise somewhat similar to those attending scrofulous abscess; but careful examination will not fail to establish many points of difference. The form of the disease to which I now allude occurs in individuals of deteriorated constitution ; in children, also, whose general health has given way under the want of all that is most essential to liff—sufE.cieut foocl and pure air. Eruptive diseases, also, and the crowding of hospitals, prisons, &c., seem to predispose to it by clebilitating the constitution. Under these circumstances, a curious effect is produced on certain individuals. Generally speaking, scrofula would be developed under the circumstances just
orifices,
round the orifice of the fistula the
I
618
characters of scrofula, nor any of the local effects of that disease in other parts of the body. The abscesses are not lined with a pyogenic membrane, for the imperfect exudations which sometimes partially line them do not deserve that name. The abscesses, therefore, are not clearly circumscribed; they have more tendency to spread, and might more correctly bedesignated effusions of pus than abscesses. When opened, the orifices have no tendency to assume the appearance of scrofulous ulcers, but the edges of the wound remain flaccid and inactive, from want of power to set np reparative action. The number of these abscesses is much greater than what we observe in the scrofulous form, and will depend on the intensity of the diathesis ; but the quantity of matter contained in each is not
commonly
so
great.
The third form of successive abscess, gentlemen, is very interesting. It occurs more frequently than either of the preceding, and from the circumstances which attend it, the cases I come rather wit,hin the domain of surgery than of medicine. have referred the origin of these cases to some contamination of the blood, yet I must confess to you that we sometimes meet with examples in adults of apparently good health, where it is, impossible to trace either the remote or the immediate cause of disease. The usual history of these cases is as follows :-A patient has undergone some slight operation, or suffered some slight injury. He may, for example, have been cut for fistula, as oscurred to a patient in this hospital not long ago; or he may have pricked his finger, as in the case of John K-. The patient enjoys tolerably good health,and does not appear to be much debilitated by any previous affection. He goes on well for some time, when an abscess is suddenly discovered under the skin at some part of the body. This is opened, and soon heals, when another abscess breaks out elsewhere. Successive abscesses are thus formed for some time, healing in one place to form in another, until at last the disposition to secrete matter ceases, and the patient gets well. These, gentlemen, are very obscure cases, and therefore worthy of all our attenThe peculiar characters of the local disease are commonly well marked; but it is very difficult to make out the nature of the constitutional influence under which these suc-
tion.
cessive abscesses are developed. They differ from the two preceding forms in several respects. The pus is secreted much more rapidly in these abscesses, and their successive duration
is much shorter. Here the disease ends in a few weeks; in the former cases it lasts for months together. The abscesses
zencrally, though not always, accompanied by some signs inflammatory action. In fact, they are subacute in form, though chronic in duration. The skin over the abscess is not inflamed, but there is commonly some pain and tenderness to the touch. The purulent matter is sometimes diffused, sometimes ciroumsoibed into a regular abscess, but there is no pyogenic membrane. When opened, these abscesses usually heal in a short time. The only affection with which they are likely to be confounded is the acute or subacute (lepositions of pus which take place successively under the influFrom these, also, they ence of pyaemia and animal poisons. Their course and are distinguished by several characters. are
that any meddling with the abscess may only accelerate a fatal result. In the subacute abscesses of the third foi-iii, simple local treatment llsnallv suffices for the cure. The matter is evacuated with the 1,Lticet; the sides of the abscess may be brought together hy compression, and, with proper -ttteiicion to the general health, the abscess heals and recovery takes place.
of
Notes of Three Lectures ON THE
PHYSIOLOGICAL ACTION STRYCHNIA
OF
termination are different. They are much more chronic than DELIVERED BY the abscesses of acute pyaemia, but they are less chronic than GEORGE HARLEY M.D., scrofulous or cold abscess. Their termination is commonly TEACHER OF PRACTICAL PHYSIOLOGY AND HISTOLOGY IN UNIVERSITY favourable; they are less painful, Jess likely to be accompanied COLLEGE, LONDON. by articular disease than pyasmio abscesses, and, above all, they are not attended by the general symptoms of acute infection of the blood. Finally, in fatat cases, as in the one DR. HARLEY, after briefly explaining to his class the reasons which I have just related to you, where the patient has been which induced him, at the present time, to alter the prescribed - cut off by some intercurrent disease, we do not find the order of his course, and to take up the subject of Stryohnia, secondary deposits of pysemia in the lnngs, liver, or other organs. To what cause, then, you will ask me, are we to proceeded to demonstrate, by direct experiment-] stly, the attribute this form of successiveabscess? I regret that 1 can manner in which the substance in question enters the system ; only offer vou an hypothesis, but it is the one which appears to 211clly, its mode of action ; and 3rdly, the way in which it me to approach nearest to the truth. I consider that, in a animal life. great many cases at least, these successive abscesses a,re con- destroys The following is a brief summary of the remarks made :— nected with some chronic poisoning of the blood, just as the !i To the first question—How is strychnia or any of its comacute depositions of pyaemia, glanders, puerperal phlebitis, &c., ’i are connected with acute blood-p’dsoning. It is true that we pounds, all of which have a similar physiological action, recan find only three circumstances in which the two sets of ceived into the system ?-the answer is, by absorption ; the cases agree--viz., in there being a primary suppuration, in the manner of this absorption being very various. The poison is .successive formation of the abscesses, and in their seat. If of the stomach and intesabsorbed the mucous membrane by there be any analogy between them, we must admit that the intensity of the poison is not snSicient to develop the disease tines, when administered by the mouth, as in the case of the fully, but that produces only partial alterati, ns. The history animal now operated upon (a frog) ; it enters directly into the of the small-pox and other diseases produced I ya..lil1Utl poisons circulation when introduced through a wound, as is now dotte. shows how considerably their effects differ according to the insolution of strychnia was introduced into the cellular (Some tensity of the cause-so much so, that the effects of the same of another frog.) It is absorbed by the skin, as will be poison were formerly regarded as distinct diseases. But the tissue chief reason which I can offer in support of my theory is the shown in the case of this third frog, uoon whose back a few fact I h Lve more than once observed, that these abscesses, drops of acetate of strychnine are new poured. The poison may, in fact, be introduced into the body in every though apparently so innoxious, may at any time merge into acute pyaemia, with its general symptoms and fatal termination. conceivable manner : by the mouth or by the rectum ; by the I must now say a few words about treatment. As the local disease has a constitutional origin, our treatment must be at cellular tissue or by the organs ; by the epidermis covering the To the scrofulous form you will of external surface, or by the serous membranes lining the interior once general and local. course oppose an anti scrofulous mode of treatment. I need cavities of the body. When once the poison has entared the not dwell on this method, which has been frequently explained blood, its mode of action is in all cases identical. to you; but I would observe that cotl-liver oil, which is so effictThe time required for the development of the cious in many forms of scrofula, does not seem to possess the of strychnine varies, however, in different species of qualities over these same power abscesses. You will find greater advantage from administering iodine internally. Hocal treatment is imlis- animals, and even individuals of the same species, being influpensable in this form, and you will understand the necessity of enced by the age, strength, &c., of the animal. The rapidity local means by remembering what I said relative to the pyo with which this substance kills depends, moreover, on three genic membrane. The tendency of this membrane to secrete distinct causes :-a, the form, solid or fluid, in which the poison pus must be checked, unless you are prepared to see it go is administered, the latter form being the most favourable for on supplying matter for months. General remedies may check the tendency, but they must be assisted by local means. absorption; b, upon the part of the body at which it is introVarious methods are employed. Some surgeons expose the duced, its action being the more speedy the quicker it obtains cavity of the abscess, and fill it with lint; others prefer the entrance into the circulation : for example, it affects the system subcutaneous incision; others, again, employ stimulant injec- more rapidly when injected into a vein than when given by the tions of various kinds. The treatment I prefer consists in mouth (see below, second experiment on dog); it is absorbed ,evacuating the contents of the abscess freely by incision, and much more rapidly when introduced into the thoracic or then employing iodine injections to change the vital properties of the pus-secreting membrane. This method is ()fficacious, and, abdominal cavity than when applied to the skin. In proof of according to my own experience, more rapid in its effects than this I take two drops of a solution of acetate of strychnine, so .any other. weak that each coutain not more than1/1000 of a grain ; In the successive abscesses which depend on a purulent dia- dilute still furtherdrop with a small quantity of water, and divide thesis, anti-scrofulous remedies only act in so far as they improve the general health. Cod-liver oil and iodine are not specially the solution into two equal portions. In one portion I place a indicated. The bitter tonics and iron are to be preferred ; but frog, in order that the strychnia may be absorb d into his body no internal remedies will have any effect without a radical through the skin; the remaining portion I inject into the change from the hygienic circumstances under which the dia- abdominal cavity of a second frog, exactly similar to the first thesis has been developed. When the abscesses are small, and in rize. The frog into whose abdomen TJuTi of a grain of not numerous, they may be opened by the subcutaneous incision abscesses he iodine stimulated may Larger hy injec- strychnia was injected will become tetanic very much sooner the collection the one into contact with whose skin an equal quantity of but when of matter is very considerable, tions, and the general health greatly deteriorated, it is to be feared the Doison has been brought.
poisonous
than
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