Of Inflammations and Abscesses.
AS almost all Abscesses are the Consequences of Inflammations, and these produce a Variety of Events, as they are differently complicated with other Disorders, it will be proper first to make some Inquiry into their Disposition. Inflammations from all Causes have three ways of terminating; either by Dispersion, Suppuration, or Gangrene; a Schirrhous Gland is always mentioned as a fourth, but I think with Impropriety, since it seldom or never occurs, but in venereal, scrophulous, or cancerous Cases; when it is the Forerunner, and not the Consequence of an Inflammation, the Tumour generally appearing some Time before the Discolouration.
But though every kind of Inflammation will sometimes terminate in different Shapes, yet a probable Conjecture of the Event may be always gathered from the State of the Patient's Health. Thus Inflammations happening in a slight Degree upon Colds, and without any foregoing Indisposition, will most probably be dispersed: Those which follow close upon a Fever, or happen to a very gross Habit of Body, will generally imposthumate: and those which fall upon very old People, or dropsical Constitutions, will have a strong Tendency to gangrene.
If the State of an Inflammation be such, as to make the Dispersion of it safely practicable, that End will be best brought about by Evacuations, such as plentiful Bleeding and repeated Purges: the Part itself must be treated with Fomentations twice a Day: and if the Skin be very tense, it may be embrocated with a Mixture of three Fourths of Oil of Roses, and one Fourth of common Vinegar, and afterwards be covered with Unguent. Flor. Samb. or a soft Ointment made of white Wax and sweet Oil, spread upon a fine Rag, and roll'd on gently. I know that almost all Surgeons are averse to the Application of any Thing unctuous to an inflamed Skin, upon the Supposition of its obstructing the Pores, and by that Means preventing the Transpiration of the obstructed Fluids, which is imagined to be one of the Ways that an Inflammation is removed; but whether this Reasoning be founded on Practice or Theory only, I am not clear; though I think it very certain, that Inflammations left to themselves, often grow stiff and painful, and are to be eased by any Medicine that makes them more soft and pliable; which should not incline us to believe that relaxing Medicines interrupted the Disposition to a Cure: However, to preserve some sort of Medium, in Inflammations of the Face, where they are esteemed most dangerous, it may be made a Rule to use nothing more oily than warm Milk, with which the Face may be embrocated five or six Times a Day. If after four or five Days, the Inflammation begin to subside, the Purging-Waters and Manna may take Place of other Purges, and the Embrocation of Oil and Vinegar be now omitted, or sooner, if it has begun to excoriate. The Ointment of Wax and Oil may be continued to the last; or if upon Conclusion of the Cure, the Itching of the Skin should be troublesome, it may be better relieved by the Application of Nutritum, which is an Ointment made of equal Parts of Diachylon and sweet Oil, melted softly down, and afterwards stirred together with a little Addition of Vinegar till they are cold. During the Cure, a thin Diet is absolutely necessary, and in the Height of the Inflammation, the drinking of thin Liquors is of great Service.
Here I have supposed that the Inflammation had so great a Tendency to Discussion, as by the Help of proper Assistance to terminate in that Manner; but when it happens that the Disposition of the Tumour resists all discutient Means, we must then desist from any farther Evacuations, and, as much as we can, assist Nature in the bringing on a Suppuration.
That Matter will most likely be formed, we may judge from the Increase of the symptomatick Fever, and Enlargement of the Tumour, with more Pain and Pulsation; and if a small Rigor come on, it is hardly to be doubted: Inflammations after a Fever, and the Small-Pox, almost always suppurate; but these presently discover their Tendency, or at least should be at first gently treated, as though we expected an Imposthumation. It is a Maxim laid down in Surgery, that Evacuations are pernicious in every Circumstance of a Disease, which is at last to end in Suppuration: But as Physicians do now acknowledge, that Bleeding on certain Occasions in the Small-Pox, is not only no Impediment to the Maturation, but even promotes it; so in the Formation of Abscesses, when the Vessels have been clogged, and the Suppuration has not kindly advanced, Bleeding has sometimes quickened it exceedingly; but however this Practice is to be followed with Caution. Purges are, no doubt, improper at this Time; yet if the Patient be costive, he must be assisted with gentle Clysters every two or three Days.
Of all the Applications invented to promote Suppuration, there are none so easy as Pultices, but as there are particular Tumours very slow of Suppuration, and almost void of Pain (such, for Instance, are some of the scrophulous Swellings) it will be less troublesome in these Cases to wear the Gum-Plaisters, which may be renewed every four or five Days only. Amongst the suppurative Pultices, perhaps there is none preferable to that made of Bread and Milk softened with Oil; at least, the Advantage of any other over it, is not to be distinguished in Practice. The Use of suppurative Plaisters in hasty Abscesses, or Inflammations in a weak or dropsical Habit of Body, is by no Means adviseable, as they are apt to sit uneasy on the Inflammation, are often painful to remove, when we enquire into the State of the Tumour, and by their Compress, in bad Constitutions add something to the Disposition of the Part to mortify. The Abscess may be covered with the Pultice twice a-day, till it be come to that Ripeness as to require opening, which will be known by the Thinness and Eminence of the Skin in some Part of it, a Fluctuation of the Matter, and generally speaking an Abatement of the Pain previous to these Appearances. The Manner of opening an Abscess I shall describe, after having spoken of a Gangrene, which is the other Consequence of an inflammation.
The Signs of a Gangrene are these: the Inflammation loses its Redness, and becomes duskish and livid; the Tenseness of the Skin goes off, and feels to the Touch, flabby or emphysematous; Vesications filled with Ichor of different Colours spread all over it; the Tumour subsides, and from a duskish Complexion, turns black; the Pulse quickens and sinks, and profuse Sweats coming on, at last grow cold, and the Patient dies.
To stop the Progress of a Mortification, the Method of Treatment will be nearly the same, from whatever Cause it proceed, except in that arising from Cold; in which Case we ought to be cautious not to apply Warmth too suddenly to the Part, if it be true, that in the Northern Countries they have daily Conviction of Gangrenes produced by this Means, which might have been easily prevented by avoiding Heat; nay, they carry their Apprehension of the Danger of sudden Warmth so far, as to cover the Part with Snow first, which they say, seldom fails to obviate any ill Consequence.
The Practice of scarifying Gangrenes, by several Incisions, is almost universal, and, I think, with Reason, since it not only sets the Parts free, and, discharges a pernicious Ichor, but makes way for whatever Efficacy there may be in topical Applications. These are different with different Surgeons, but I believe the Digestives softened with Oil of Turpentine are as good Dressings as any for the Scarifications; and upon them, all over the Part, may be laid the Theriaca Londinensis, which should be always used in the Beginning of a Gangrene, before the Necessity of scarifying arises; or what is equally good, if not often preferable, a Cataplasm made with Lixivium and Bran, and applied warm, which will retain its Heat better than most other Topicals. There are some who insist upon having had particular Success in the stopping of Gangrenes, from the Use of the Grounds of strong Beer mixed with Bread or Oatmeal; but there are hardly any Facts less proper to infer from, than the ceasing of a Mortification, since we see amongst the Poor that are brought into the Hospitals, how often it happens without any Assistance; however, it is certain, that Service may be done by spirituous Fomentations, and the Dressings above-mentioned, which are to be repeated twice a-day: Medicines also given internally are beneficial, and these should consist of the Cordial kind, though at present the Bark is ordered by a great many Surgeons as the sovereign Remedy for this Disorder: After the Separation of the Eschar, the Wound becomes a common Ulcer, and must be treated as such. There are two ways of opening an Abscess: either by Incision or Caustick; but Incision is preferable in most Cases. In small Abscesses, there is seldom a Necessity for greater Dilatation than a little Orifice made with the Point of a Lancet; And in large ones, where there is not a great Quantity of Skin discoloured and become thin, an Incision to their utmost Extent, will usually answer the Purpose; or if there be much thin discoloured Skin, a circular or oval Piece of it must be cut away; which Operation, if done dexterously with a Knife, is much less painful than by Caustick, and at once lays open a great Space of the Abscess, which may be dressed down to the Bottom, and the Matter of it be freely discharged; whereas after a Caustick, tho' we make Incisions through the Eschar, as is the usual Practice, yet the Matter will be under some Confinement, and we cannot have the Advantage of dressing properly, till the Separation of the Slough, which often requires a considerable Time, so that the Cure must be necessarily delayed, besides, that the Pain of burning, continuing two or three Hours, which a Caustick usually requires in doing its Office, draws such a Fluxion upon the Skin, round the Eschar, as sometimes to indispose it very much for healing afterwards. In the Use of Causticks, it is but too much a Practice, to lay a small one on the most prominent Part of a large Tumour, which not giving sufficient Vent to the Matter, and perhaps the Orifice soon after growing narrow, leads on to the Necessity of employing Tents; which two Circumstances more frequently make Fistulas after an Abscess, than any Malignity in the Nature of the Abscess itself. the Event would more certainly be the same after a small Incision; but I observe, that Surgeons not depending so much on small Openings by Incision, as by Caustick, do, when they use the Knife, generally dilate sufficiently: whereas in the other way, a little Opening in the most depending Part of the Tumour usually satisfies them: but as the Method of making small Orifices for great Discharges, is for the most part tedious of Cure, very often requiring Dilatation at last, and now and then pernicious in the Consequence above-mentioned, and even making the adjacent Bones carious, I thought it might not be useless to caution against this Practice.
Here it may not be amiss to observe, that notwithstanding the depending Part of an Abscess is esteemed the most eligible for an Opening, yet it is always on the Supposition that the Teguments are as thin in that Place as any other Part of it; otherwise it will be generally adviseable to make the Incision where Nature indicates, that is, where the Tumour is inflamed and prominent, though it should not be in a depending Part.
The indiscriminate Application of Causticks to all Abscesses, often runs into the same Mischief of Tediousness in the Cure, from a Cause exactly the Reverse of that I have been describing; for as in great Swellings they are seldom laid on large enough, and the Matter continues draining for want of a sufficient Opening; so in small ones, they make a greater Opening than is necessary, and therefore demand a greater Length of Time to repair the Wound. I confess the Disposition of Abscesses to fill up, after the Discharge of Matter, is so very different, that some few large ones do well after the mere Puncture of a Lancet, if the Orifice be made in a depending Part, and a proper Bandage can be applied; tho' if ever we trust to such an Opening, it should be in Abscesses about the Face, where we should be more careful to avoid the Deformity of a Scar than in any other Part, and where also the Method will be more likely to succeed, from their Situation; it being a Maxim in Surgery, that Abscesses and Ulcers will have a greater or less Tendency to heal, as they are higher or lower in the Body; however, even in Abscesses of the Face, if the Skin be very thin, it will be always safer to open the length of it, than trust to a Puncture only.
From this Account of the Method of opening Abscesses, it does not appear often necessary to apply Causticks; yet they have their Advantages in some respects, and are seldom so terrible to Patients as the Knife, tho' in fact they are frequently more painful to bear; they are of most use in Cases where the Skin is thin and inflamed, and we have reason to think the Malignity of the Abscess is of that Nature as to prevent a quickness of Incarning, in which Circumstance, if an Incision only were made thro' the Skin, little Sinuses would often form, and burrow underneath, and the Lips of it lying loose and flabby, would become callous, and retard the Cure, tho' the Malignity of the Wound were corrected: of this kind, are Venereal Bubos, which notwithstanding they often do well by mere Incision, yet when the Skin is in the State I have supposed, the Caustick is always preferable, as I have had many Opportunities of being convinced. It is to be observed, I confine this Method to Venereal Bubos; for those which follow a Fever, or the Small-pox, for the most part are curable by Incision only. There are many scrophulous Tumours, where the Reasoning is the same as in the Venereal; and even in great Swellings where I have recommended Incision, if the Patient will not submit to Cutting, and the Surgeon is apprehensive of any Danger in wounding a large Vessel, which is often done with the Knife, (tho' it may readily be taken up with the Needle and Ligature) yet as this Inconvenience is avoided by Caustic, it may on such an Occasion be made use of; but I think after the Eschar is made, it should be cut almost all away, which will be no Pain to the Patient, and will give a much freer Discharge to the Matter than Incisions made thro' it: however, in scrophulous Swellings of the Neck and Face, unless they are very large, Causticks are not adviseable, since in that Part of the Body, with Length, of time, they heal after Incision. Causticks are of great Service in destroying stubborn scrophulous Indurations of the Glands, also Venereal Indurations of the Glands of the Groin, which will neither discuss nor suppurate; likewise in exposing carious Bones, and making large Issues. The best Caustick in use is a Paste made with Lime and Lixivium Capitale, which is to be prevented from spreading, by cutting an Orifice in a Piece of sticking Plaister, nearly as big as you mean to make the Eschar, which being applied to the Part, the Caustick must be laid on the Orifice and preserved in its Situation, by a few Slips of Plaister laid round its Edges, and a large Piece over the whole. When Issues are made, or Bones exposed, the Eschar should be cut out immediately, or the next Day; for if we wait the Separation, we miscarry in our Design of making a deep Opening; since Sloughs are flung off by the sprouting new Flesh underneath, which fillsup the Cavity at the same time that it discharges the Eschar; so that we are obliged afterwards, to make the Opening a second Time with painful escharotick Medicines. To make an Issue, or lay a Bone bare, this Caustick may lie on about four Hours; to destroy a large Gland, five or six; and to open Abscesses, an Hour and a half, two Hours, or three Hours, according to the Thickness of the Skin; and what is very remarkable, notwithstanding its Strength and sudden Efficacy, it frequently gives no Pain where the Skin is not inflamed, as in making Issues, and opening some few Abscesses.
Hitherto I have supposed the Surgeon has had the Opportunity of opening the Tumour at the most eligible Time, that is, when the Skin is thin, and the Fluctuation of the Matter very sensible; which is always to be waited for, notwithstanding it be very much taut, to open critical Abscesses before they come to an exact Suppuration, in order to give Vent sooner to the noxious Matter of the Disease; but in opening before this Period, Practitioners miss the very Design they aim at; since but little Matter is deposited in the Abscess before it arrives towards its Ripeness, and besides, the Ulcer afterwards grows foul, and is less disposed to heal.
When an Abscess is already burst, we are to be guided by the Probe where to dilate, observing the same Rules with regard to the Degree of Dilatation, as in the other Case; the usual Method of dilating, is with the Probe-scissars, and indeed, in all Abscesses, the generality of Surgeons use the Scissars, after having first made a Puncture with a Lancet; but as the Knife operates much more quickly, and with less Violence to the Parts, than Scissars, which squeeze at the same time that they wound, 'twill be sparing the Patient a great deal of Pain to use the Knife, where-ever it is practicable, which is in almost all Cases, except some Fistulas in Ano, where the Scissars are more convenient. The manner of opening with a Knife, is by sliding it on a Director, the Groove of which prevents its being misguided. If the Orifice of the Abscess be so small, as not to admit the Director, or the Blade of the Scissars, it must be enlarged by a Piece of Sponge-tent, which is made by dipping a dry Bit of Sponge in melted Wax, and immediately squeezing as much out of it again as possible, between two Pieces of Tile or Marble; the Effect of which is, that the loose Spunge, being compressed into a small Compass, if any of it be introduced into an Abscess, the Heat of the Part melts down the remaining Wax that holds it together, and the Sponge sucking up the Moisture of the Abscess, expands, and in expanding, opens the Orifice wider, and by degrees, so as to give very little Pain.
The usual Method of dressing an Abscess, the first time, is with dry Lint only, or if there be no Flux of Blood, with soft Digestives spread on Lint. If there be no Danger of the upper Part of the Wound reuniting too soon, the Dossils must be laid in loose; but if the Abscess be deep, and the Wound narrow, as is the Case sometimes of Abscesses in Ano, the Lint must be crammed in pretty tightly, that we may have afterwards the Advantage of dressing down to the Bottom without the use of Tents, which are almost universally decried in these Days, though they still continue to be employed too much by the very People, who would seem to explode them most; so difficult is it to be convinced of the true Efficacy of Nature in the healing of Wounds. Formerly, the Virtues of Tents have been much insisted on, as it was then thought absolutely necessary to keep Wounds open a considerable time, to give Vent to the imaginary Poison of the Constitution; it was supposed too, that they were beneficial, in conveying the proper suppurative or sarcotick Medicines down to the Bottom of the Abscess; and again, that by absorbing the Matter, they preserved the Cleanliness of the Wound, and disposed it to heal. But this Reasoning is not now esteemed of any force; Surgeons at present know that a Wound cannot heal too fast, provided that it heal firmly from the Bottom; they are very well satisfied also from what they see in Wounds, where no Medicines are applied, that Nature of herself shoots forth new Flesh, and is interrupted by any Pressure whatsoever; besides, as to the Conceit of Tents sucking up the Matter, which is esteemed noxious to healing, they are so far from being beneficial in the Performance of it, that they are of great Prejudice; for if the Matter be offensive in its Nature, tho' they do absorb it, they bring it into Contact with every Part of the Sinus; and if it be prejudicial by its Quantity, they do Mischief in locking it up in the Abscess, and preventing the Discharge it would find, if the Dressings were only superficial; but in fact, Matter when it is good, is of no Disservice to Wounds with regard to its Quality, and Surgeons should therefore be less curious in wiping them clean, when they are wider and painful. That Tents are Impediments to Healing rather than Assistants, we may learn from considering the Effect of a Pea in an Issue, which by Pressure keeps open the Wound just as Tents do; and if there are Instances of Wounds healing very well notwithstanding the use of Tents, so there are also of Issues healing up, in spite of any Measures we can take to keep a Pea in its Cavity. In short, Tents in Wounds, by resisting the Growth of the little Granulations of Flesh, in process of Time harden them, and in that manner produce a Fistula; so that instead of being used for the Cure of an Abscess, they never should be employed but where we mean to retard the Healing of the external Wound, except in some little narrow Abscesses, where if they be not crammed in too large, they become as Dossils, admitting of Incarnation at the Bottom; but Care should be taken, not to insinuate them much deeper than the Skin in this Case, and that they should be repeated twice a-day, to give Vent to the Matter they confine. Sometimes they are of Service in large Abscesses, particularly of the Breast, where the Matter cannot discharge itself by the Orifice already made, and yet does not point sufficiently to any other Part for an Opening, tho' it make Signs whither it would tend, if it were a little confined. In such an Instance, a Tent plugging up the orifice would make the Matter recur to the Part disposed to receive it, and mark the Place for a Counter-opening: but Tents do most good in little deep Abscesses, whence any extraneous Body is to be evacuated, such as small Splinters of Bone, &c.
The Use of Vulnerary Injections into Abscesses has been thought to bear so near a Resemblance to the Use of Tents, that they both fell into Disrepute almost at the same Time. It has been said in their Favour, that in deep Abscesses where no Ointment can be applied, they digest, cleanse, and correct the Malignity of the Pus; but the Fact is, that they do so much Mischief by frequently distending the Parts of the Abscess, first, when they are injected, and afterwards, by their Addition to the Matter generated in the Abscess, that they are hardly proper in any Case: though one of the great Mischiefs of Injections and Tents both, has been a mistaken Faith amongst Practitioners, that where-ever their Medicines were applied, the Part would heal; and upon that Presumption, they have neglected to dilate Abscesses, which have not only remained incurable after this Treatment, but would often have done so for want of a Discharge, if they had been dressed more superficially.
In dressing Wounds, it is common to apply the Medicines warm, or hot, upon the Supposition that heated Ointments have a stronger Power of digesting, than cold; but as any Medicine will soon arrive to the Heat of the Part it is laid on, whether it be applied hot or cold, the Efficacy of the Heat can avail but little in so small a Time; and as Dossils dipt in hot Ointments are not cleanly, and even grow stiff and painful, besides that the Patient is liable to be burnt by laying them on too hot, I think it rather preferable to apply them cold, or perhaps in Winter a little warmed before the Fire after they are spread; observing, if the Ulcer be uneven, to make the Dossils small in order to lie close. Over the Dossils of Lint may be laid a large Pledgit of Tow spread with Basilicon, which will lie softer than a desensative Plaister; for this, though designed to defend the Circumference of Wounds against Inflammation or a Fluxion of Humours, is often the very Cause of them; so that the Dressings of large Wounds should never be kept on by these Plaisters, where there is Danger of such Accidents; and it is on the account of the Unfitness of Plaisters of any kind for an Inflammation, that I have omitted to mention any of them as proper Discutients in that Disorder. In this manner, the Dressings may be continued, till the Cavity is incarned, and then it may be cicatrised with dry Lint, or some of the cicatrising Ointments, observing to keep the Fungus down, as directed before: If the Drying-ointment be the Cerat. de Lapid. Calam. the Stone must be thoroughly levigated before it be put into it, otherwise the Ointment will be corrosive.
In the Course of Dressing it will be proper to have regard to the Situation of the Abscess, and as much as possible to make the Patient favour the Discharge by his ordinary Posture and to this end also, as what is of greater Importance than the Virtue of any Ointment, the Discharge must be assisted by Compress and Bandage; the Compress may be made of Rags or Plaister; though the latter is sometimes preferable, as it remains immoveable on the Part it is applied to. The Frequency of Dressing will depend on the Quantity of Discharge; once in twenty-four Hours is ordinarily sufficient; but sometimes twice, or perhaps three times, is necessary. I have before mentioned, not to be too scrupulously nice in cleaning a Wound; but it is worth remarking, that a Sore should never be wiped by drawing a Piece of Tow or Rag over it, but only by dabbing it with fine Lint, which is a much easier Method for the Patient: the Parts about it may be wiped clean in a rougher Manner, without any Prejudice. I do not think the Air has that ill Effect on Sores as is generally conceived; nor would the large Abscesses on Beasts, which are often exposed to the Air the whole Time of Cure, do well, if it were so very pernicious as is represented; but as it tends to the making a Scab, and in Winter is a little painful to the new Flesh, it will be right to finish the Dressing as quick as may be without hurrying. Another Caution necessary in the Treatment of Abscesses, is, That Surgeons should not upon all Occasions search into their Cavities with the Finger or Probe, as it often tears them open and indisposes them for a Cure.