GEN. I. SPEC. II. Apostema psoaticum. Psoas ab scess. Abscess may discharge itself by different outlets. the deceptive manner of its attack, medical advice, and particularly a free use of purgatives and the lancet, which might have been of essential service at first, is fatally postponed; and the symptoms are regarded as those of an accidental strain. After the abscess is formed, however, the pain, in most cases, increases considerably; and the matter may be discharged into the cavity of the abdomen, where it would soon be fatal. On this account it obeys the law of instinct we had lately occasion to notice; follows, in most instances, the course of the psoas muscle, and points externally a little lower than the inguinal glands; or it passes down the thigh, where, however, it is apt to dissever the muscles and form sinous abscesses. Sometimes, though rarely, the matter passes through the muscles of the back, and is discharged in the loins; and in a few instances it has been known to fall into the cavity of the back part of the pelvis. The abscess, therefore, is highly dangerous; since under the most fortunate circumstances it is so long in pointing externally, even if it should make any visible pointing at all, that the patient usually sinks under a hectic fever, productive produced by the local irritation. While in most cases, in which it has made a natural opening for itself, it has been found connected with so many deep sinuses, which cannot be followed up, that the same effect ensues. Highly dangerous: and often of fatal hectic. Medical treatinent rarely of avail. Surgical treatment discrepant. No mode of medical treatment has been found productive of any good purpose; and the cause has been, in a very early stage of the suppuration, given over to the surgical practitioner. Yet even here different individuals have pursued different lines of conduct. Mr. Bell advises an early evacuation of the matter, lest the bones should become injured; while Mr. Abernethy apprehends less danger from its being suffered to remain, and at last evacuates it at different intervals, and by successive operations: by which means the cyst, in which the pus is principally lodged, may have an opportunity of contracting; and this, he thinks, it has a greater tendency to do than in abscesses where the inflammation is more violent. He is also attentive to close the opening the instant the matter is discharged, so as to prevent any increase of the inflammation by an access of air. GEN. I. SPEC. II. Apostema psoaticum. Psoas ab scess. real cause of danger. The real cause of danger does not seem to have been hitherto hit upon; but it may probably be referred to that tendency to a rapid spread of inflammation over Suggestion their entire surface, which Mr. Hunter has shown to ex- as to the ist in all internal cavities, and the hazard of which is in proportion to the extent of the cavity; a subject already touched upon in the discussion of puerperal fever, and which we shall have other opportunities of illustrating as we proceed, particularly in some cases of varicose enlargement of the veins. Now in the disease before us we have not, it is true, any natural cavity, but we have an artificial cavity of long standing, and large extent, in a highly irritable state, and which is therefore peculiarly predisposed to run into all the fatal effects of large natural cavities, when injured or otherwise rendered imperfect. The author throws out this hint, however, for future and general consideration. DIFFUSE PULSATING TUMOUR IN THE REGION OF THE THIS is also a very fatal disease; and usually terminates in one of the following ways: Firstly, The substance of the liver is gradually and almost entirely absorbed from long continued irritation: the melancholy accompaniments of which are a tedious icterical marasmus, hectic fever, great anxiety, and a sa GEN. I. SPEC. III. Terminates variously. Extensive absorption of the liver. GEN. I. SPEC. III. Apostema hepatis. Abscess of the liver. The apo steme may open into the cavity of the ab domen. The pus may find a nious and fetid diarrhoea, which is the forerunner of death. Secondly, The abscess breaks internally and discharges a sanious pus into the belly; by which means the rest of the viscera are affected; and the terminatton is marasmus, ascites, and dissolution. Thirdly, The pus sometimes finds a passage into the biliary ducts, and thence into the intestines; from these it is occasionally thrown into the stomach and vomited in the form of a dark offensive material: but far more gepassage in- nerally it is carried downward and produces a violent looseness. Acids and acescent medicines may here palliate for a time; but the issue is always fatal. to the intestines. The apo steme may burst externally. The pus may be carried off by absorb tion. Fourthly, The enlarged liver becomes, in some cases, united by adhesive inflammation to the peritonæum, and the abscess opens externally; and, in this case, there is a chance of cure. The opening should be expedited by a caustic or the knife: and the cure will greatly depend upon the nature of the fluid which is discharged. Fifthly, There is reason to believe that in a few rare instances the matter is carried off by absorption, when a sometimes healthy granulation takes place, and a cure is completed without any opening. This termination is more reasonably to be expected in a constitution otherwise sound, and where the liver has not been weakened or rendered torpid by any former affection. It is hence rather to be looked for in a temperate than in a tropical climate, and in youth than in advanced life. Often a sequel of hepatitis. These cases may, indeed, be regarded as sequels of hepatitis; though it is possible that pus may be thrown into the penicilli and biliary pores of the liver by a metastasis from some other organ, as it not unfrequently is into the tubules of the kidneys, and thence conveyed to Not always the bladder. When the cure takes place without an opening, it is not always an easy matter to determine for a certainty that pus has actually been formed. But sometimes we can trace a fluctuation; and at other times the subsidence of the tension, pain, and pulse, after one or two severe shivering fits, may be regarded as suffi easy to de tect pus when no opening. Yet the symptoms often sufficient to decide. GEN. I. In a case of this kind that occurred SPEC. III. Apostema Abscess of the liver. cient indications. to me in a young gentleman of about thirteen years of age, the shivering was so considerable as to make the hepatis. teeth chatter; and within eight and forty hours the pulse sunk from a hundred and forty to a hundred and twenty; and the abdominal tension and tenderness were considerably abated; as was also the distressing cough with which he had almost perpetually been harassed for some weeks. He was put upon a tonic plan of columbo and sulphuric acid immediately after this change, and recovered gradually. SPECIES IV. APOSTEMA EMPYEMA. Lodgement of Matter in the Chest. FIXT PAIN IN To the symptoms enumerated in the above definition Hippocrates adds*, edema of the feet, hollowness of the eyes, and a gurgling sound on shaking the shoulder. Of these additional signs, the first two belong rather to the hectic fever that generally accompanies empyema, than to the disease itself. The last has sometimes been met with in modern times+. Dr. Cullen regards empyema as a mere sequel of pneumonia, which with him includes inflammation of the pleura, as well as of the GEN. I. SPEC. IV. Symptoms noticed by Hippo crates. Not always a sequel of pneumonia as presumed by Cullen. GEN. I. of matter in lungs, but as it may take place from inflammation of the SPEC. IV. mediastinum, pericardium, or diaphragm, to say nothing Apostema Empyema. of that from external injuries, and as it is often doubtful. Lodgement what particular organ is directly injured, a separate species seems decidedly called for. Goekel, indeed, de-, scribes a case in which the pericardium was affected in connexion with the right lung, and to such an extent. that both were totally consumed. the chest. Most fre duced by Most frequently, however, an empyema is produced quently pro- by the bursting of a large vomica of one of the lungs the bursting into the cavity of the pleura. In which case the cough, of a vomica. becomes more frequent than before this result, and is Diagnostics sion and the stethoscope. either dry, or accompanied with a scanty, frothy, and noisy expectoration. The breathing becomes extremely difficult, with repeated fainting fits, and the dew of a cold. sweat hanging over the throat and forehead: the cheeks and lips are of an ominous red, while the nails are livid, the pupils dilated, and the sight dim. Death usually succeeds to the rupture of the aposteme in a few hours. If percussion or the stethoscope be employed, before of percus- the vomica has broken, to the part in which the matter is seated, little or no sound will be returned in consequence of the pressing fulness which exists there but if these methods be resorted to afterwards, it will be found restored in a considerable degree to the part affected from the hollowness which now exists there, while it will be comparatively found diminished in the posterior and inferior parts of the chest to which the discharged load is transferred. For the history and rela-. tive value of these diagnostics the reader must turn to the treatment of PHTHISIS in the ensuing volume *. Pus not always to be referred to any par ticular organ. In some instances, however, there is no organ to which, the pus can be referred as a process of ulceration; and to such an affection Mr. Hewson has several references. "The cavities of the pleura, pericardium," &c. says he, "are sometimes observed to contain considerable quantities of pus without the least marks of ulceration. In Vol. III. Cl. 1. Ord. tv. Gen. III. Spec. v. |