1885 Journal of the American Medical Association  
Gentlemen :\p=m-\This patient has a large interior abscess pointing in the right lumbar region. There is no deformity to suggest caries of the spine, but the caries might exist without the deformity being yet developed. The elder Gross put on record the statement that these abscesses always or nearly always spring from carious vertebr\l=ae\, and with like uniformity terminate in death. Erichsen and others are of the opinion that the causes are generally tubercle. Both these opinions are
more » ... s. The connective tissue in the interior lumbar region is liable to inflammation and suppuration from various causes, just like connective tissue anywhere, and when it occurs, a lumbar abscess results, whether the bone is diseased or not. Dr. Gross based his opinion on post-mortem statistics. Now we should reflect that all-important as dead-house studies are, yet the pa¬ thologist sees there only fatal cases, which differ in many respects from the thousands that recover, and do not appear before him. Some dead-house pathologists do not bear this in mind, and judge the living cases too much by the post-mortem conditions. Cer¬ tainly many cases of lumbar abscess recover under modern antiseptic treatment, and show no signs, either before or after, of tuberculosis. However, do not look at this matter entirely from one side. There is no doubt that in many cases caries does exist, and that part of these are tuberculous. We live in a somewhat non-tuberculous region as com¬ pared with the North Atlantic seaboard, tuberculous diseases here being, perhaps, thirty or forty per cent, less frequent than there. Hence I have no doubt that lumbar abscesses are less frequently tuberculous with us than with our Atlantic coast pathologists. However this may be, the patient before us is not proved to have either caries or tubercle. There is no proof of any syphilitic diathesis, and the urine 1Delivered at the Mercy Hospital, Chicago. contains no albumen. There is nothing to forbid the hope of entire recovery so far as external exam¬ ination goes. The patient has been already subjected to four as¬ pirations. The object of this was two-fold : First, a considerable number of lumbar abscesses can be completely cured by from three to eight applications of the aspirator; and secondly, if these fail, we at least keep the sac collapsed for a considerable time, and thus enable it to contract its walls and diminish its magnitude. When the aspirator method is suc¬ cessful in effecting a cure, you will observe that the pus grows more watery at each drawing, and finally may be almost pure serum. In this case, as you re¬ member, we have aspirated four times, washing out the cavity with carbolated water at the strength of two and one-half per cent., without effecting any improvement in the pus. I conclude that the aspi¬ rator plan will not be likely to succeed in this case, and we must proceed to treat it by the open method. Before the development of antiseptic surgery the opening of lumbar abscesses was greatly dreaded. Abundant and melancholy experience had shown that immediately after the opening the pus of the vast interior cavern underwent putrefaction, and by its absorption rapidly poisoned the patient. Hec¬ tic set in, exhaustion followed, and death early or late closed the case. I recollect well a gentleman who kept at his office work in fair health until the abscess was as thin as paper, and about to break spontaneously. In accordance with the doctrine then prevalent, I had postponed the opening to the latest possible moment. Seeing the rupture was about to take place, I took him from his office still in appar¬ ent good health, gave him tonics, and opened the cavity. A vast collection of pus rushed out, hectic soon followed, and in two weeks he was dead of blood poisoning. Now, with antiseptic measures, all this terror has vanished like an ugly dream. The internal caries, or tuberculosis, if present, may not be always curable, but the opening of the ab¬ scess is no longer a serious danger. Let me impress it upon you that so far as lumbar abscess alone is concerned, it is only dangerous when it is so com¬ plicated in its internal burrowings that it mechani¬ cally prevents you from disinfecting and draining all parts of it. We need here a bolder surgery than we have formerly practised to enable us to open up and tube the interior. You see this fluctuating tumor on the patient's right lumbar region, between the ribs and the crest of the Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 05/20/2015
doi:10.1001/jama.1885.02391180001001 fatcat:qr657sto7zgdrgr6oauvqnqz5u