THE PRE-FISTULAR ABSCESS
When a certain limited portion of tissue stagnates in its circulatory life, it dies, and must be got rid of. Nature cuts off its blood supply, and it dies; and when the circumscribed mortification of the tissue is sufficiently advanced, the abscess bursts and discharges, and if there be no morbid vis a tergo, the abscess begins to heal, and Nature is not very long in mending the lesion in the continuity of her tissues.
One sees the whole philosophy of the thing, Nature’s simple and yet adequate way of working, when a foreign body is in the living tissue, and Nature sets about turning the intruder out. I have often watched the process, as no doubt most people have. It is simply this : Take the case of a thorn driven into the tissue of the hand and breathing off; there is first the lesion, then the foreign body-the broken off thorn. Next we have heat, pain, redness, and swelling-the classic Calor, dolor, rubor, tumor; then the outermost portion dies, becomes purulent, rotten, the foreign body is then expelled slowly at the mattering dead spot or point.
If there be an obstacle to its exit the whole just described process keeps on repeating itself, there is a burrowing process which is continued until a point of exit is reached, or failing the possibility of this, Nature will at times encapsule it. But, assuming the possibility of an easy exit, the process is not a long one, and as soon as the foreign body is not rid of, Nature needs no further help (the individual being normally or even only fairly healthy), but forth with mends the gap in the tissues by carnification, and there is an end of tie, only the young newly carnified tissue being very vascular will remain for a time red, until, in fact, the new vascular loops (being no longer needed) atrophy.
Thus the foreign body being ejected, and the gap made up its passage mended by carnification (healed up), there is nothing more to be said, the affair is at an end.
But it is not thus with the pre-fistular abscess, and therefore necessarily not thus with the fistula itself; here we have to do not only with the morbid matter (stuff) that caused the abscess, but with an internal abscess and fistula causing disease that is more or less constantly at work, an the product of this disease requires an outlet which the prefistular abscess was meant to prepare, and which is represented by the fistula. Had Nature got rid of all the morbid product the exit would no longer be needed, and the fistula would very soon heal up “of itself,” as the saying goes.
Everybody knows that if he gets a thorn into his flesh, and he forthwith pulls it out entire and entirely, he is spa red the relatively long and round-about process that Nature adopts if it is felt in, and which we have just attempted to describe.
A good surgeon, therefore, in all cases to get at the intruded foreign body and extract it. But the surgeon seeks in other processes to come to Nature’s aid, and instead of waiting for an abscess to mature and burst, he makes a free incision and lets out the pus or what not. Now, where there is an obstacle to its exit (such as a fascia) this is no doubt not only good practice, but is imperative to prevent needless tissue destruction burrowing, and the formation of sinuses, with the concomitant fever, pain, and exhaustion. But where there is no great obstacle in the way of a spontaneous bursting, I feel very sure that it is best not to incise, but to let the boil ripen and burst, and in the meantime “go for” the cause of the said boil by treating the patient with the proper remedies. When this is successfully done, and the boil bursts of itself, the discharge is more free, and the consequent organismic depuration more complete.
On this effort of Nature to rid herself of noxious substances a system of treatment by manipulation has been furnished, and which has been named Kellgrenism, in honour of its discover Kellgren. This system has an organ of its own called the Tocsin, edited by Dr. Frederick A. Floyer, a man of very great ability and learning. From its issue of September 1st, 1889, I take their own account of the system, because it fits into my subject at this point.