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 INAUGURAL DISSERTATION 
 
 LUMBAR ABSCESS. 
 
 SUBMITTED TO THE PUBLIC EXAMINATION OF THE 
 
 FACULTY OF PHYSIC 
 
 UNDER THE AUTHORITY OF THE TRUSTEES OF COLUMBIA COLLEGE, 
 IN THE STATE OF NEW-YORK, 
 
 The Right Rev. BENJAMIN MOORE, D.D. President] 
 
 FOR THE DEGREE OF 
 
 DOCTOR OF PHTSIC, 
 
 BY WILL 
 
 CITIZEN OF THE STATE OF NEW-YORK. 
 
 If it be consonant with truth and experience it matters not 
 from whom it may differ. Pott. 
 
 NEW-YORK: 
 
 Printed by T. (2 J. SWORDS, Printers to the Faculty of Physic 
 of Columbia College, .No. 160 Pearl-Street. 
 
 1804. 
 
/Aff. 
 
TO 
 
 WRIGHT POST, Esq. 
 
 Professor of Anatomy and Surgery in Columbia College, 
 
 For his assiduous and generous Attention during the Author's 
 Professional Studies; 
 
 CHARLES SMITH, DANIEL M'CORMICK, 
 
 AND 
 
 GILBERT ROBERTSON, Esquires, 
 
 For their Personal Friendship ; 
 
 THE FOLLOWING 
 
 DISSERTATION 
 
 Is respectfully dedicated. 
 
INTRODUCTION. 
 
 AMONG the many diseases to which mankind 
 are subject, there are, perhaps, few that have 
 proved more fatal in their termination than that 
 of which we are about to speak. Every innova- 
 tion in practice that may tend to palliate the suf- 
 ferings, or prolong the life of a fellow creature, 
 may be deemed an object of some importance. 
 
 From the observations which I have been able 
 to make upon diseases, my mind has uniformly 
 been impressed with the necessity of paying more 
 strict attention to the state of the solids of the 
 system than is ordinarily done; for upon them 
 depends the state of the fluids. 
 
 I shall lay it down as a general position, that 
 diseases are produced by the action of foreign 
 agents applied directly or indirectly to some part 
 of the system capable of being brought into 
 motion, thereby producing an excitement greater 
 than natural, or by the abstraction of those agents 
 upon whose influence the natural actions depend. 
 
 Dr. Cullen, in his First Lines, vol. i. sect. 43, 
 says, that a diminished action of vital parts con- 
 stitutes atony. Now, where the ordinary actions 
 of the system are lessened there cannot be such 
 an expenditure of excitability; consequently the 
 
6 On Lumbar Abscess. 
 
 capability of the system to be operated upon is 
 increased: hence I conclude that the atony of 
 Dr. Cullen and the direct debility of Dr. Brown 
 are synonymous. That excitability is accumu- 
 lated by the abstraction of stimuli, I think is 
 proved from what takes place in several diseases. 
 In Cholera the great prostration of strength 
 that is produced by the sudden evacuation of the 
 contents of the stomach and intestines render the 
 system so highly susceptible, that spasm and con- 
 vulsion are its common attendants. The predis- 
 position to Puerperal Fever, occasioned by the 
 expulsion of the contents of the impregnated 
 uterus, goes far to prove this fact. In this dis- 
 ease, not only inflammation of the uterus is pro- 
 duced, attended with general febrile irritation, 
 but frequently the inflammation is extended to 
 all the abdominal viscera; the pressure which 
 had uniformly sustained and supported them dur- 
 ing the term of gestation being withdrawn. The 
 evacuation of the water of Ascites often produces 
 a sudden derangement of the system, and fre- 
 quently lays the foundation for peritoneal inflam- 
 mation, unless the abdomen is equally supported 
 by bandage. The spontaneous bursting of the 
 tumour formed at the sacrum in the disease called 
 Spina Bifida, occasions such sensibility of the 
 parts affected, as to produce inflammation, which 
 generally terminates in death. 
 
 In all those cases the cause is no doubt a sub- 
 duction of stimuli ; but they are mechanical sti- 
 
On Lumbar Abscess. 7 
 
 muli, arising from support and distention, and 
 though extraneous to the system, yet they have 
 become habitual by their continuance. 
 
 Upon these principles I shall endeavour to 
 prove, in the prosecution of this Dissertation, 
 that the vitiated secretion and febrile commotion 
 attendant upon Psoas Abscess chiefly, if not 
 solely, depend upon the sudden and entire eva- 
 cuation of the contained matter. 
 
 HISTORY OF LUMBAR ABSCESS. 
 
 THIS disease has derived its name from its 
 situation, which is generally in the lumbar re- 
 gion, though it sometimes originates near the 
 sacrum, in the cavity of the pelvis; under which 
 
 circumstance this epithet is improperly applied. 
 It has likewise been designated by the term 
 Psoas Abscess, when it originates in the cellular 
 substance near the psoas muscle, and in the su- 
 perior parts of the pelvis, which is its most com- 
 mon seat. Persons of a scrophulous habit are 
 more peculiarly subjected to its attacks, though 
 its existence may frequently be traced as the 
 effects of external violence on the part. The 
 symptoms which denote its presence are pain 
 and uneasiness about the loins. These are in- 
 creased by particular motions of the lower ex- 
 tremities, such as rolling the thigh and turning 
 
8 On Lumbar Abscess. 
 
 the toes outward : but so little is the inconveni- 
 ence with which it is sometimes attended, that 
 the pointing of the matter in some distant part 
 is the first sure indication of the disease. 
 
 The inflammation being slight, is insufficient 
 to produce adhesions in the surrounding parts, 
 by which the matter might be confined: hence 
 it descends by its own gravity through the cellu- 
 lar substance, and shows itself in different situa- 
 tions, remote from its origin. The pus thus 
 formed is generally deposited either on the inter- 
 nal part of the thigh, or near the rectum, or in 
 the loins, or, as most frequently happens, in the 
 course of the vessels running under Poupart's 
 ligament. The integuments retain their natural 
 appearance: the tumour is unaccompanied with 
 pain, and may be handled without the least in- 
 convenience, or producing pain and uneasiness 
 to the patient; and, by placing him in a horizon- 
 tal position, the matter may, by pressure, fre- 
 quently be forced into the cavity of the abdomen; 
 it likewise receives an evident impulse during the 
 paroxysms of coughing. The disease being thus 
 formed, as the only mean of producing relief, 
 the pus is to be evacuated, which, on the first 
 discharge, is, in general, perfectly bland and in- 
 odorous. This, however, is succeeded by an 
 icterous and extremely foetid matter, accompa- 
 nied with a symptomatic fever, which seldom 
 fails to terminate the sufferings of the patient by 
 lingering death. 
 
On Lumbar Abscess. 9 
 
 I shall now proceed to investigate the cause of 
 that particular derangement which succeeds the 
 ordinary evacuation of the matter in Lumbar 
 Abscess; conceiving that, should this be ascer- 
 tained, the indication of cure would naturally- 
 present itself. As the constitutional derangement 
 corresponds with the topical affection, our first 
 inquiry will be — 
 
 To what cause may we attribute the local in- 
 flammation subsequent to the discharge of the 
 matter? And, 2dly. How far does this tend to 
 the production of that febrile commotion and 
 vitiated secretion which generally succeed such 
 evacuations? 
 
 The admission of air into the cavity of the abscess, 
 after the evacuation of the pus, was formerly sup- 
 posed to be the cause of all the mischievous effects 
 which followed. These it was thought to induce, 
 1st. By excessively stimulating the cyst, and 
 thereby producing inflammation; and, 2dly. By 
 promoting the putrefaction of the contained pus, 
 to the absorption of which (in a state of putridity) 
 the constitutional derangement which succeeded 
 was attributed. Let us examine these opinions, 
 and see how far they are supported by facts. 
 
 We daily see air applied to large excoriated 
 surfaces, as well as to ulcers in different parts of 
 the body, without producing any extraordinary 
 inflammation, or sensibly changing the state of 
 the matter secreted. But to this it may be ol> 
 jected, that there is a difference between the sur* 
 
 2 
 
JO On Lumbar Abscess. 
 
 faces of those parts of the body which are con- 
 tinually exposed to the contact of air, and of 
 those cavities which, from their natural situa- 
 tion, are more peculiarly exempted from its in- 
 fluence. To this I answer, that the admission 
 of air into the cellular substance in Emphysema 
 is a case perfectly in point. This is a secreting 
 membrane, in every respect similar to that which 
 is the seat of Psoas Abscess ; and yet we find that 
 air has in this way not only been admitted, but 
 even in such quantities as to produce a disten- 
 tion of the whole body, without being attended 
 by the least inflammation whatever. The ex- 
 periments of Mr. Ashley Cooper, as related by 
 Mr. Abernethy, likewise prove that those dele- 
 terious effects w _ hich have been attributed to air, 
 when allowed to come in contact with ulcerated, 
 surfaces and secreting membranes, are not attri- 
 butable to that agent. 
 
 In order to determine this fact, he inflated 
 the abdomen, thorax, and cellular substance of 
 different dogs, and carefully closed the aperture 
 through which the air was impelled. The con- 
 sequence was, that the air was absorbed from 
 the cavities, the wounds healed by the first in- 
 tention, and little or no inflammation was ex- 
 cited. But even admitting that a certain part 
 of atmospheric air, viz. its oxygen, is capable 
 of stimulating the living solids of an animal body, 
 and that a proportion of air is admitted into the 
 cavity of an abscess after an evacuation of the 
 
On Lumbar Abscess. 1 1 
 
 matter, still this would not contain but little 
 more than one fourth part of oxygen, which is 
 the only ingredient possessed of stimulating pro- 
 perties; but it must be likewise remembered that 
 even this is confined in the cavity, and perfectly 
 at rest : hence there can be no new accession of 
 air, and the small quantity of oxygen then within 
 the cyst is quickly absorbed by the effused fluids. 
 As to the azotic portion which remains, experi- 
 ments have sufficiently proved that it may be 
 applied to ulcerated surfaces with perfect im- 
 punity. 
 
 From these facts combined, I conceive that 
 I am authorised to conclude that the admission 
 of air into the cavity of a Lumbar Abscess is 
 not the cause of that peculiar derangement of 
 the part which succeeds an evacuation of the 
 matter. I shall endeavour to show, from a va- 
 riety of circumstances, that this principally, if 
 not entirely, depends upon that collapsed and un- 
 supported state of the parts which necessarily 
 arises from a complete and entire discharge of 
 the pus. It has been laid down as a law of the 
 animal economy, that when a portion of usual 
 or accustomed stimuli is suddenly subducted 
 from a part or the whole of the system, there 
 excitability is generated or increased; and that 
 the part becomes susceptible of impressions in 
 proportion to the subduction. Now, the matter 
 of Lumbar Abscess must be considered as a sti- 
 mulus, since not only as it respects the system it 
 
12 On Lumbar Abscess. 
 
 is evidently extraneous, but likewise as it dis- 
 tends and supports the surrounding parts: hence, 
 when this stimulus of distention is suddenly with- 
 drawn by an evacuation of the matter, direct de- 
 bility must necessarily succeed; in consequence 
 of which the parts become preternaturally sen- 
 sible to the application of other stimuli. In this 
 way I can readily suppose that a stimulus, whe- 
 ther produced by the wound which is made to 
 evacuate the matter, or in any other way, may, 
 upon this accumulated excitability, produce con- 
 siderable inflammation. But if the parts were 
 not rendered preternaturally sensible, why should 
 a wound inflicted in them produce such violent 
 effects, since the point in which it is made can- 
 not be considered as involved in the original dis- 
 ease, but merely as the receptacle of matter 
 formed at a distance? Hence no symptoms of 
 inflammation appear until deprived of their usual 
 support, by a complete evacuation of the matter. 
 This then I presume to be the cause of that local 
 inflammation which generally succeeds the ope- 
 ration. 
 
 We shall next consider the cause of the viti- 
 ated state of the secretion, and shall endeavour 
 to ascertain how far it may depend upon the 
 debility which is induced, and the topical inflam- 
 mation which is consequent upon the collapsed 
 state of the cyst. I assume it as a fact, and I 
 am warranted by general opinion, that pus is 
 the effect of an altered secretion: if so, it must 
 
On Lumbar Abscess. 1 3 
 
 depend upon a particular state of the vessels. 
 "Whenever great debility prevails in the system 
 generally, or in a gland locally, the secreted fluid 
 loses its natural appearance, and is discharged 
 from the vessels in a crude and undigested state, 
 owing to their not being able to perform their 
 usual functions. This frequently happens in the 
 stomach, liver, and other glands, in cases of 
 great debility, and is more particularly exempli- 
 fied in the instance of ordinary ulcers which are 
 situated upon the extremities of those who are of 
 an enfeebled habit of body. Every person con- 
 versant with surgery must often have observed 
 that these will at first appear well-conditioned, 
 the granulations of a good healthy colour and 
 firm, the pus perfectly bland and of a proper 
 consistence; but in a short time an obvious 
 change takes place, the granulations become 
 full and assume a fungous appearance, the secre- 
 tion becomes thin, ichorous, and extremely fetid. 
 To prove that this arises from debility of the 
 part, we need only advert to the method of cure, 
 that is, tight bandaging, which is alone fre- 
 quently sufficient to alter the appearance of the 
 ulcer; but if aided with bark, wine, and a ge- 
 nerous diet, the parts may soon be completely 
 restored to a healthy state. All plasters that 
 are used in the form of bandage, and all stimu- 
 lant ointments, generally called digestives, act 
 upon the same principle. 
 
 The fever attendant upon this disease has been 
 
14 On Lumbar Abscess. 
 
 attributed to an absorption of the matter con- 
 tained within the sack, and to its being conveyed 
 into the circulating vessels. We shall first in- 
 quire how far this cause is capable of producing 
 the effect. 
 
 Mr. John Hunter says, fc We may remark, that 
 in large abscesses that have not been preceded 
 by inflammation, the hectic disposition seldom or 
 never comes on till after they are opened."* If 
 this be fact, as it most undoubtedly is, ought 
 not absorption to be greatest whilst pressure is 
 greatest? It is a law of the animal economy, that 
 pressure produces absorption; and yet we find 
 that, under the most favourable circumstances for 
 the absorption of this matter, no ferver arises. 
 Dr. Reid, in his Essay on Phthisis Pulmonalis, 
 observes, " If absorption was really the cause of 
 hectic fever, it would be present always, and in 
 every case where matter was present, or real pus 
 spit up from the lungs ;"f yet daily experience 
 proves the contrary. Can it be supposed, on the 
 other hand, that, after the evacuation of the mat- 
 ter, absorption takes place and fever is produced? 
 This appears to me equally inconsistent; for after 
 the cyst is deprived of its support, the parts be- 
 come extremely debilitated, the absorbents in 
 common with every other part; and this debility 
 is obvious by the thinness of the discharge, it 
 merely being poured out from the extremities of 
 
 * Vide Hunter on the Blood, vol. ii. p. 224. f vide Reid > P- 86 - 
 
On Lumbar Abscess. 1 5 
 
 the relaxed and enfeebled vessels, and is not a 
 perfect secretion. But if we admit that the mat- 
 ter may be absorbed, is it possible that it can 
 have such powerful effects upon the system? 
 Mr. Hunter, in speaking on this subject, pro- 
 proses this question: " If absorption of matter 
 produces such violent effects as are commonly 
 ascribed to it, why does not venereal matter do 
 the same?"* and yet we find buboes of consi- 
 derable size, which are just ready to break, ab- 
 sorbed and taken away in a few days, and no 
 fever excited. Certainly if the absorption of 
 ordinary pus could produce fever, that of a spe- 
 cific matter ought to do the same, 
 
 " When matters of an injurious nature are 
 taken into the system by absorption, the absor- 
 bents are first inflamed, the lymphatic glands 
 conjested, and the poison arrested. If this pro- 
 duce fever, it is not hectic, but of a more violent 
 and active kind."-)" 
 
 " We likewise find very large collections of 
 matter which have been produced without visible 
 inflammation, such as many of the scrofulous 
 kind, and which are wholly absorbed, even in a 
 very short time, yet no bad s)mptoms follow."J 
 
 I conclude this part of the subject with saying, 
 that if hectic fever depended upon the absorp- 
 tion of matter, no patient ought to recover of this 
 
 * Hunter on the Blood, vol. ii. p. 223. 
 
 f Vide Abernethy's Surgical and Physical Essays. 
 
 J Hunter on the Blood, vol. ii. p. 223. 
 
16 On Lumbar Abscess. 
 
 disease until suppuration had ceased ; but this we 
 know to be contrary to truth. From this collec- 
 tion of evidence I infer, that the fever induced 
 in this disease is not owing to the absorption of 
 matter, but to some other cause. 
 
 An author, in speaking of Psoas Abscess, ob- 
 serves, " A symptomatic fever generally attends 
 this complaint, and closes the scene. But what 
 is very remarkable, this fever does not come on 
 during the time the matter is confined, nor to 
 any degree for forty-eight hours after the matter 
 is let out. This circumstance is extraordinary, 
 as it cannot arise from the absorption of matter, 
 for that must have been greater before the open- 
 ing; nor from a wasting in consequence of the 
 evacuation of the matter, as that was before ex- 
 travasated, and was extraneous with respect to 
 the constitution; nor from the admission of air, 
 for that in other cases does not produce such 
 effects : we are therefore at a loss to know why 
 the symptomatic fever does not occur till after 
 the discharge of the matter."* To answer this 
 query shall be my next inquiry. 
 
 We have endeavoured to prove that the ab- 
 sorption of pus is inadequate to the production 
 of the disease: we shall see how far it may de- 
 pend upon the irritation caused by the local in- 
 flammation induced upon the surface of the cyst. 
 The cause of the local inflammation has been 
 
 * Motherby's Dictionary, 
 
On Lumbar Ab$ces$< 17 
 
 already investigated, and has been proved to de- 
 pend upon the collapsed state of the parts from 
 the sudden subduction of the contained matter, 
 thereby producing a preternatural degree of ex- 
 citability in the parts to be operated upon by any 
 stimulus applied. " In some cases," says Mn 
 Hunter, " as in Lumbar Abscess, the extent of 
 surface to inflame is immense, in comparison to 
 the original disease, and of course when such 
 abscesses do inflame, the symptoms in the con- 
 stitution are in the same proportion."* 
 
 From these data the subject is fully explicable: 
 here is an extensive surface rendered preternatu* 
 rally sensible, inflammation suddenly takes place, 
 and the constitution is rendered susceptible of 
 the impressions by the sympathetic association of 
 parts. That the symptomatic fever must depend 
 upon the previous local inflammation induced, 
 and this inflammation upon the direct debility 
 attendant upon the collapsed state of the cyst, 
 we shall endeavour to prove from the following 
 cases: 
 
 " I have seen large Lumbar Abscesses open 
 of themselves on the lower part of the loins, 
 which have discharged a considerable quantity 
 of matter, then close up, then break out ane w> 
 and so on for months, without giving any other 
 disturbance; but when opened, so as to give a 
 free discharge to the matter, inflammation has 
 
 * Vide Hunter on the Blood, vol. ii. p. 113- 
 
 3 
 
18 On Lumbar Absceso. 
 
 immediately succeeded, fever has come on, and, 
 from the situation of the parts inflamed, as well 
 as their extent, death in a very few days after 
 has been the consequence."* These are full in 
 point. While the cyst retained support enough 
 to keep up a proper degree of excitement, no 
 unusual degree of excitability could be produced; 
 and as no unusual stimulus was applied, no in- 
 flammation could be excited: but when the mat- 
 ter was completely evacuated by an artificial 
 opening, the parts were rendered susceptible by 
 the abstraction of the stimulus of support; the 
 irritation of the wound, and the excitability of 
 the parts being increased, inflammation takes 
 place, and, consequently, a general affection of 
 the system by consent of parts. 
 
 It may be asked, if the fever accompanying 
 this disease depends upon local irritability, and 
 not upon the absorption of the matter, why does 
 not the irritation attending the amputation of a 
 limb, or the inflammation of the pleura, &c. 
 produce a fever of the same type with that of 
 hectic, accompanied with exacerbations and 
 remissions? The reason, I think, is obvious. 
 Where a part of the body has acquired a preter- 
 natural sensibility, by the loss of the stimulus of 
 support, distention, and habit, the common and 
 ordinary stimuli of life shall operate upon it with 
 increased violence: here is not a direct applica- 
 
 f Vide Hunter, vol, ii. p. 119. 
 
On Lumbar Abscess. 19 
 
 tion of stimulant power, so as to produce a sud- 
 den and permanent action, which shall continue 
 the same as it was when first induced, without 
 intermission, until the parts are no longer capa- 
 ble of supporting that action, and they fall into 
 a state of indirect debility; but a part rendered 
 preternaturally sensible by a peculiar cause, that 
 shall be operated upon at different times by the 
 common stimuli of life, and as often as they are 
 applied, so often w T ill a paroxysm be produced. 
 Dr. Darwin, in his Zoonomia, says, " If the 
 degree of quiescence occasioned by the defect of 
 stimulus be very great, it will recur a second 
 time by a slighter cause than that which first in- 
 duced it. If the cause which first induced the 
 second fit recurs the succeeding day, the quoti- 
 dian fever is produced ; if not till the alternate 
 day, the tertian fever," &c. 
 
 Hectic fever is attended throughout with a 
 morbid frequency of pulse, with exacerbations 
 at evening, and remissions in the morning. Now, 
 the continued frequency of pulse depends upon 
 the uniform local irritation, the evening exacer- 
 bation upon the excitability of the system gene- 
 rated during the morning remission, brought into 
 action by the stimulus of food, heat, light, and 
 sound, with all the ordinary excitants of life 
 that have their action during the day: thus, 
 when the fever is first induced by the local affec- 
 tion, the force with which the excitants were 
 applied being but slight, the paroxysm of conse- 
 
20 On Lumbar Abscess. 
 
 quence must be of short duration. The produc- 
 tion of the second paroxysm must depend upon 
 the excitability accumulated during the remission 
 and the effect of stimuli during the day: hence 
 we have at evening an increase of action, and 
 in the morning a remission of the symptoms. 
 
 From the observations already made, the me- 
 thod of prevention and cure of this disease more 
 readily present themselves. In its incipient stage, 
 when it is confined to the loins, and before mat- 
 ter is formed, certain symptoms obtain, that, to a 
 person conversant with the disease, would give 
 the strongest probability of its commencement, 
 such as pain in the loins, accompanied with a 
 difficulty of moving the thigh, taking place in 
 persons who are of delicate health or of a scro- 
 fulous disposition : but these symptoms being 
 common to many ordinary complaints, make us 
 too inattentive to such circumstances -, whereas, 
 if the disease was taken in its forming stage, all 
 those dreadful symptoms which are generally the 
 consequence might be prevented by early atten- 
 tion. Surgeons of the greatest respectability 
 agree as to the mode of treating this disease in 
 its commencement. The means are general and 
 local. The general are those that may tend to 
 relieve congestion; such as evacuations from the 
 system (if the disease should be occasioned by 
 local injury), by the lancet, by the bowels, and 
 by the skin. The local comprehend scarifica- 
 tions, blisters, setons, &c. to the loins, perfect 
 
On Lumbar Abscess. 21 
 
 rest, with a strict confinement to bed, as mo- 
 tion of the lower extremities certainly tends to 
 aggravate the symptoms, by bringing into action 
 the psoas muscle, with those contiguous. If 
 these remedies are used, the patient has every 
 probability of recovering without farther disease. 
 But as it frequently happens that the pointing of 
 the matter in some distant part is the first symp- 
 tom that presents itself, we are now to consider 
 the mode of relief best adapted to this stage of 
 the disease. As at this time there is no general 
 affection of the system, and the patient is in or- 
 dinary health, our attention is first led to the re- 
 moval of the matter confined within the cyst. 
 Different Surgeons have recommended different 
 modes of evacuating this matter. Mr. Bell pre- 
 fers the introduction of a trocar when the case 
 is obvious; but, as this disease may be confounded 
 with others, he thinks a scalpel should be used, 
 cutting down carefully, as in hernia, until the 
 matter flows. 
 
 Mr. Ford, in his Observations on the Disease 
 of the Hip-Joint, seems clearly of opinion that 
 abscesses should be left to themselves to burst 
 spontaneously, and the matter evacuated in that 
 way. Mr. Abernethy recommends discharging 
 the pus by introducing a lancet through the inte- 
 guments, then passing it for a small distance be- 
 tween the skin and fascia, and then by depres- 
 sing the point of the lancet to puncture the cyst. 
 The advantages accruing from a small opening, 
 
2 2 On Lumbar Abscess. 
 
 and that made with a keen cutting instrument, 
 are, the matter is evacuated, and as little vio- 
 lence done to the parts as possible, so that inflam- 
 mation might not be induced. But, unfortunately 
 for us, the practices hitherto pursued for the 
 evacuation of the matter have generally been un- 
 successful: some few solitary cases have occured 
 in which the patients have recovered without 
 much suffering, but the majority have fallen a 
 sacrifice to the symptoms that have succeeded 
 the operation. 
 
 The method of opening the cyst, recommended 
 by Mr. Abernethy, is, in my opinion, the most 
 preferable, and his reasoning upon the subject 
 most valuable. But, with all due deference to 
 the opinions of men so deservedly eminent, I 
 beg leave to propose to the consideration of the 
 gentlemen of the faculty, a mode of operating 
 which is the result of my reflections upon the 
 nature and progress of the disease. 
 
 After having ascertained the existence of the 
 disease, so as to warrant an operation, I would 
 recommend that the incision made for the dis- 
 charge of the matter be by a lancet passed in a 
 longitudinal direction as respects the thigh, ob- 
 liquely through the integuments and fascia in the 
 lowermost part of the tumour. The incision 
 thus made is to be small, and about one-fourth 
 of the matter evacuated; the orifice is then to 
 be closed, and a piece of adhesive plaster (the 
 least stimulating) applied over the wound, and 
 
On Lumbar Abscess:. 23 
 
 a broad flannel uniting bandage over that and 
 the most depending part of the tumour, endea- 
 vouring to press the matter upwards, so that the 
 wound may have every advantage of uniting by 
 the first intention. The patient is to be kept in 
 bed, in an horizontal position, avoiding every 
 thing that may tend to stimulate or bring on 
 excitement; such as, light, heat, sound, and sti- 
 mulating food. If the wound should unite and 
 heal soundly, it would be most advisable to 
 puncture the cyst in another place, to make the 
 next evacuation, which should be in the course 
 of three or four days after the first, and by the 
 same means let out about one-fourth of the 
 quantity remaining in the cyst, and so to continue 
 the evacuation gradatim until the cyst is com- 
 pletely emptied. 
 
 The advantages of this mode of treating the 
 disease, I think, must be obvious to every person 
 conversant with the laws of the animal economy. 
 By partially subducting the matter, the quantity 
 remaining in the sac, in conjunction with the 
 elasticity of the cellular substance, is equal to 
 the support of the parts concerned. When the 
 pressure is taken off the cellular substance reacts, 
 and the muscular fibres of the surrounding parts 
 contract, so as to adapt themselves to the quan- 
 tity they contain. In this way collapse is pre- 
 vented, and no excitability accumulated; conse- 
 quently no inflammation obtains, and the matter, 
 when let out at the second operation, retains its 
 
24 On Lumbar Abscess. 
 
 healthy appearance. As no local inflammation 
 is present, there is little or no cause for general 
 febrile affection; the patient, therefore, remains 
 unaffected, or if affected, the fever is very slight, 
 and the system soon becomes equalized; there 
 is no wasting of strength from excessive excite- 
 ment; the remedies given to support the patient 
 cannot act with violence, as the parts are not 
 rendered preternatural ly sensible by a sudden 
 loss of support, and the time allowed between 
 every evacuation gives opportunity to the parts 
 to gain their wonted tone. To prove what I 
 have said takes place under such circumstances, 
 I shall relate a case recorded by Mr. Abernethy 
 in his Treatise on Lumbar Abscess : — ■ 
 
 " Elizabeth Ridley, aged fifty-five, had, for 
 one year and a half before her admission into the 
 hospital, suffered much from bad health; she 
 then had a severe cough, accompanied with much 
 fever. About ten months ago she had a very 
 acute pain in her loins, which abated, in some 
 degree, ten weeks after its first attack; at that 
 time she observed a tumour in her groin, which 
 had gradually increased in size. The pain had 
 been continued, though at intervals it suffered 
 considerable abatement: the veins on the fore 
 part of the thigh had become varicous, and the 
 leg cedematous. The tumour was of a circular 
 form, about four inches in diameter. It had 
 much protruded the fascia, and matter was vio- 
 lently impelled into it on coughing. She now 
 
On Lumbar Abscess. 25 
 
 complained of occasional pain of her stomach, 
 of failure of appetite, and a costive state of her 
 bowels; her pulse was slow and feeble, her tongue 
 pale, and her health considerably beneath the na- 
 tural standard. 
 
 " On the 8th of November I punctured the 
 lower part of the tumour with a lancet, carrying 
 it obliquely about half an inch between the skin 
 and the fascia, and discharged eleven ounces of 
 good pus, but did not empty the abscess. The 
 orifice of the skin and cyst did not then corres- 
 pond, and on coughing there was still perceived a 
 considerable impulse of matter from the cavity in 
 the loins. — I was unwilling to irritate the cyst by 
 the introduction of any instrument to separate the 
 lips of the wound, therefore I closed the orifice 
 with sticking plaster, and every thing remained 
 quiet till the third day, when, by a fit of coughing, 
 the orifice was burst open, and matter oozed from 
 beneath the plaster. If I suffered it to remain 
 open, my original plan of treatment would be 
 frustrated; I therefore resolved to let out the 
 collected matter, least distention of the fascia 
 and integuments should prevent the wound from 
 healing. I again introduced the lancet through 
 the same orifice, and wounded it so as to make 
 it bleed, and gave a discharge to five ounces of 
 pus; the abscess though did not even now ap- 
 pear to be completely emptied. I preferred to 
 introduce the lancet through the same orifice 
 rather than make another opening, that this new 
 
 4 
 
26 On Lumbar Abscess. 
 
 injury might excite in the divided parts a new- 
 disposition to unite. If I bad not again made 
 the separated parts bleed, they probably would 
 have united by granulations; their surfaces would 
 have been for some time kept separate by a puru- 
 lent secretion, and air would have been admitted 
 into the cavity of the abscess: but the effused 
 blood glued together these edges, and thus ob- 
 structed the aperture till its organization made 
 the reunion perfect. 
 
 " The woman suffered no evident alteration in 
 her health, but became much easier with respect 
 to her loins. The varicose veins and the oedema 
 of the leg now no longer appeared. These symp- 
 toms, doubtless, originated from the pressure of 
 her loins, occasioned by matter, of which it was 
 very evident there was a large collection. 
 
 " On the 18th the tumour was again punc- 
 tured, and eight ounces of fluid evacuated. The 
 matter before had been incompletely discharged; 
 now I believe the tumour was entirely emptied. 
 This last discharged matter was perfectly inodor 
 rous, and the thigh uninflamed. I made this 
 aperture, at the side of the tumour, with the edges 
 of the lancet held upwards and downwards, and 
 not transversely, as the former openings had been 
 made. This I did that the efforts employed in 
 coughing might have less effect in impelling the 
 matter through the orifice, which soon healed. 
 
 " In the following week she complained that 
 she was restless and could not sleep, neither had 
 
On Lumbar Abscess. 27 
 
 she her usual degree of appetite; her pulse, how- 
 ever, was not quickened, nor did any other signs 
 of constitutional indisposition appear. No matter 
 was now collected beneath the fascia, and after 
 waiting another week without any apparent col- 
 lection being made, on the 25th of November I 
 introduced a lancet through the fascia of the 
 thigh, with a design to admit the air into the 
 cavity of the abscess that remained. I did not 
 perceive any matter issue from the opening. As 
 the integuments covering the fascia were thicken- 
 ed, and showed some disposition to inflame, I 
 directed the aqua aceti lithargyrita to be applied 
 to them. On the following day some matter 
 flowed through the orifice; the patient supposed, 
 if collected, it might be a table spoonful. Nearly 
 the same quantity continued to discharge for 
 about a fortnight, and afterwards it gradually 
 diminished, and the wound healed. She was not 
 affected by fever in consequence of this last open- 
 ing, and seemed to suffer very little inconvenience 
 with respect to her health. She, however, com- 
 plained much of pains resembling those of the 
 rheumatism, which affected principally her hips, 
 though sometimes they attacked her loins. For 
 these pains she was placed under the care of the 
 Physician, and as her constitution was languid, 
 she was recommended to continue the medicines 
 prescribed for her as an out-patient." 
 
28 On Lumbar Abscess. 
 
 Although the practice in this case was con- 
 trary to the original intention, yet it appears to 
 me fortunate, for if the matter had been com- 
 pletely discharged, I doubt if the patient would 
 have so easily got through the .disease. The 
 quantity of matter remaining after the partial 
 evacuation afforded a sufficient support to the 
 surrounding parts to prevent excess of debility 
 from depletion; the vessels, therefore, retained 
 their tone, and the matter secreted from them 
 assumed its healthy appearance. As no unusual 
 excitability was induced, little or no inflammation 
 could be excited; for as soon as the pressure of 
 matter was withdrawn, the cellular substance 
 reacted and occupied the space. 
 
 THE END. 
 
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