In lumbar or psoas abscess, the disease begins in the lumbar vertebrze, which ulcerate and become carious, and the matter secreted either gravitates in the course of the muscle, being confined by its fibres or fascia, forming a tube, or proceeds directly dorsacl to the integuments of the loins. If it is confined by the fascia of the muscle, the matter sometimes gravitates to the groin, and presents itself either below or above Poupart's ligament, near the anterior superior spiuous process of the os ilium, or near the pubes; sometimes it emerges at the crural aperture and descends below or central of the fascia lata to the poples, and even retrogrades upwards or proximal to the tuberosity of the os ischium; at other times it gravitates into the pelvic cavity, emerges at the great sacro-ischiatic notch, and makes its appearance near the anus. In rare instances, the matter descends along both psox muscles, forming two abscesses or a double ab scess. Whenever the matter advances to the integuments or points, the skin at first is not dis coloured, but an impulse is given to the fluctua tion on coughing, and in a few days the skin be comes discoloured, inflames, ulcerates, and rup tures. The symptoms indicating this affection are remarkably insidious, being seldom apparent until the abscess points. The patient complains of weak ness and uneasiness in the region of the loins, which are much aggravated on ascending a stair, and he is easily fatigued with walking. Occasion ally there is felt considerable pain in the loins, which seems to follow acute inflammation of the vertebra; and not unfrequently there is distortion of the spine. As lumbar abscess is liable to be confounded with hernia and fungus hamatodes, we must be careful in our diagnosis before opening it. The history of the case, together with the fluctua tion of the tumour, which is tense in the erect, and nearly disappears in the horizontal posture, be coming softer, flatter, and looser; and when again placed in the erect attitude, by the impossibility of preventing the descent of the matter, lumbar ab scess is characterized. The treatment has been already described, with the exception of the injec tion of lime water. Lumbar abscess attacks youth, and the male more frequently than the female; however, Mr. Abernethy cites more cases of its oc curring between twenty and forty years of age, than at an earlier period.
Hectic fever, which particularly accompanies chronic abscess when opened, is characterized by the following symptoms. The patient begins to have a hot skin, especially in the palms of the hands and soles of the feet, a crimson blush on the cheeks, small quick pulse, loss of appetite, thirst, nocturnal perspirations, lateritious sediment in his urine and diarrhoea. There are exacerbations in the evening, there being a chilly, a hot, and a per spirative stage in succession like in intermittent fever. This is supposed by some authors to de pend on the absorption of the matter, but no hectic fever takes place until the matter is evacuated; by others to depend on the irritation together with the increased discharge, but in some cases of phthysis pulmonalis, where the individual wastes away with out the slightest irritation or pain, hectic fever ac companies the disease almost from the beginning; by others again, to be the consequence of a change in the system, induced by the process of suppura tion, or even of the previous inflammatory action that gives rise to this process. It appears rather
to be consequent on mere debility of constitution, which whenever it is so far exhausted from a dis charge in any disease, that the nervous and circu lating systems have not their accustomed supply of nutriment, i. e. the blood, then increased absorp tion goes on with great rapidity, while there is no nutrition, the nutritive lymph being removed by the discharge. The hectic fever which accompanies Nos talgia corroborates this view. Its treatment consists in light nutritive diet, diluted sulphuric acid, and the cretaceous or catechu mixture, when the bowels are affected, attending at the same time to the local affection producing it.
Mortification is one of the common terminations of inflammation, and occurs when the inflammatory action is so extremely violent as to destroy the structure of the nerves, arteries, veins, and contig uous textures, which are overpowered by exhaust ion; while the contiguous tissues are destroyed both by inflammatory action and by being gorged with blood, which coagulates in consequence of not being kept in motion. This is usually denominated acute gangrene, also inflammatory or humid gangrene. Gangrene is confined to that degree of mortification where sensibility, motion, and warmth are present: but when these phenomena cease, and the part as sumes a livid, brown or black colour, it is then termed sphacclus or complete mortification. Ety mologically, these terms do not admit of this ex planation, gangrene being derived from to feed upon, and sphacelus from to destroy. Some authors use both terms synonymously, while others consider that sphacclus should be applied only to mortification extending to the bones. Mor tification thus dependent on a severe degree of in flammatory action, is originally produced by che mical or mechanical stimuli. When the urethra or urinary bladder is injured, and the urine escapes into the cellular tissue of the perineum or scrotum, gangrene is frequently the result ; and this also oc curs when any of the abdominal viscera are forced out of their cavity and strangulated. Gangrene likewise takes place from the eating of cock-spur rye, the ossification of arteries, tumours impeding the return of the circulation of the blood, diseased condition of the arteries or veins producing coagu lation of the blood in their cavities, and from liga tures applied to the trunks of arteries or veins. Of the two varieties of imflammation, mortification is more liable to supervene to the erysipelatous, and still more so to their combination' or erysipelas phlegmonodes, and although all textures when in flamed do sometimes mortify, yet the most com pact, such as bone, skin, stomach and intestines, are the most prone to it, because their blood-vessels have not room to form ulcerative papilla; and the arteries are found to possess the greatest power of resisting mortification.