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constitution of the patient. The precise situation of the abscess will exercise considerable influence: if it exist on either side of the anus the symptoms will be less severe than when it is situated anteriorly, as other important and very sensitive parts are then involved and their functions interfered with: thus, in the male, the neck of the bladder, the prostate gland, and the urethra will be affected, and the flow of the urine interrupted. In the female, abscess in the anterior walls of the rectum, if allowed to pursue its course, may open in front into the vagina, and posteriorly into the rectum, and induce the very distressing condition of recto-vaginal fistula.

It is not always easy by touch to satisfy ourselves of the existence of pus in this region: readily to detect fluctuation, it is necessary to possess in an eminent degree the "tactus eruditus," tactus eruditus," "a gift of rare value, perhaps innate, yet doubtless capable of being acquired by the education of the finger and the judgment.' The difficulty arises from the elasticity of the cellular tissue, somewhat simulating fluctuation, and also from the depth from the surface at which the matter is often formed. In the latter case, we may not be able to gain any information by the appearance or by the touch of the external parts; but by intro

*Principles of Surgery,' by James Miller, F.R.S.E, Second Edition, 1850, p. 208.

ducing the finger into the rectum, we shall be able to detect it bulging into and diminishing its capacity: if fluctuation is not distinct, and there be any doubt about it, two fingers of the one hand should be introduced, and made to press the suspected abscess outward, whilst, with the fingers of the other hand, counter-pressure is made, and we shall thus be able to ascertain with greater certainty the presence of fluid.

When symptoms of the formation of acute phlegmonous abscess exist, the patient should confine himself to the horizontal position, leeches should be applied to the part, followed by hot fomentations and emollient cataplasms. If the patient be robust and plethoric, general bloodletting may be necessary, particularly if much fever exist: the bowels must be opened by mild laxatives, drastic purgatives being avoided, as they would be productive of more harm than good, by determining blood to the rectum, and inducing violent straining and disturbance of the surrounding structures: the diet must be low and unstimulating in quality; diluents, which may be freely allowed, will be beneficial in reducing the feverishness. Should there be any difficulty of micturition, the warm hip-bath must be had recourse to, and if retention of urine occur, warm anodyne enemata must be administered, should the warm-bath

not be sufficient to overcome it; if these fail to afford relief, the catheter must be used before the bladder becomes over distended.

We must not be too sanguine in adopting these means to prevent the formation of pus, though we shall occasionally succeed in doing so; yet, if we do not, we shall have lessened the force of the morbid action. When it is evident that the formation of matter cannot be prevented, comfort and benefit will be derived from the application of hot fomentations and warm cataplasms, by their soothing and relaxing effects on surrounding parts. As soon as there is sufficient reason to suspect the presence of pus by the accession of rigors, by detecting fluctuation, or by a feeling of bogginess in the centre of the hardened part, a free incision must at once be made; waiting till the superimposed tissues are thinned, and pointing of the abscess takes place, is a practice to be avoided, as the cavity of the abscess will increase, and there will be a greater probability of the bowel being denuded, or a communication being established by the formation of an opening for the exit of the matter through it, in which case fistula in ano is certain to be the result.

Opening an abscess is a very simple operation, and easily accomplished; but having frequently witnessed the infliction of unnecessary pain by the incision

being made improperly, I may be pardoned here saying a few words on the manner in which it ought to be done. A variety of instruments of different forms are sold in the shops, under the title of abscesslancets; but not one of which is half so good as a simple straight bistoury, with a fine point and smooth sharp edge; it should be held lightly between the thumb and first two fingers of either hand, if the operator be ambidextrous, so that in the case of any unsteadiness or sudden movement on the part of the patient, the hold may at the moment be released. The blade of the bistoury, held perpendicularly to the surface, should be gently pushed into the soft parts till the point has entered the suppurating cavity; this will be ascertained by the cessation of resistance to its onward progress, and by the freedom of motion admitted, also by the matter welling up by the side of the instrument: after the point has been made to penetrate a sufficient depth, the handle should be inclined somewhat, and, by a slightly sawing motion, the incision carried to the requisite extent. observing this method, the pain of the operation is much lessened. Abscesses are frequently opened with an ordinary lancet, which is inserted and made to cut its way out by elevating the point: this occasions much pain, in consequence of the skin, the most sensitive part of the body, hanging and dragging on

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the edge of the instrument.

In many books, the expression, a plunge of the lancet or bistoury, is made use of; a surgeon's knife should never be plunged anywhere; no saving of time or pain is effected by such a procedure: the limits of the puncture must thereby be uncertain; and the walls of an abscess are liable to be transfixed, or parts wounded that it would be most desirable to avoid.

When an abscess is deep-seated by the side of the rectum, and a considerable thickness of tissues exists between it and the external surface, advantage will be gained by endeavouring to make it bulge, by introducing the fingers into the bowel in the same manner as when making an examination; the knife is then to be steadily carried down to it, and, the point having entered the cavity, the incision of the extent requisite is to be made at once. Some surgeons, after puncturing the cavity of the abscess with a sharppointed knife, prefer enlarging the wound with a probe-pointed bistoury.

In the subacute abscess, Dr. Bushe advised several small punctures instead of one free one. I think most surgeons will be inclined to practise the latter. I have seen buboes treated in a hospital by a series of small incisions or punctures, under the idea of preventing any scars after cicatrization; but the plan was always unsuccessful: the matter not finding a free

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