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2 There is prompt relief in such cases; but there is more trouble where a lesion has arisen internally of itself which causes swellings and tends to suppuration. I have described elsewhere the various classes of abscession, and I have pointed out the suitable medicaments; it now remains to speak of those which should be treated by surgery. Before the abscession becomes hardened, the overlying skin should be scarified and a cup put on, in order to draw outwards whatever bad and corrupted matter has collected; and it is right to repeat this every[p. 301] third day until every indication of inflammation has gone. It may be, however, that the cupping has no effect; for at times, although seldom, it happens that the abscess is enclosed in a covering of its own, which the ancients named a coat. Meges, because every such coat is sinew-like, said that no sinew could be produced under a lesion by which flesh is eaten away; but that when pus has been there for a long time, a callus forms round it. This has no bearing upon the mode of treatment, for the same thing ought to be done, whether it be a coat, or a callus. There is nothing to prevent a callus being called a coat, since it covers. Moreover at times the coat has formed after the pus has become more matured; so that what is under it cannot be drawn out by cupping. But this is readily recognized when the application of a cup causes no change. Therefore when that happens, or there is already hardening, there is no help from cupping, but as I have said elsewhere it is whilst matter is collecting that it has to be diverted or dispersed, or else matured. In the two former contingencies no further treatment is needed. When pus has matured, if in the armpits or groins it will not often have to be cut into. The same is true when the abscess is of moderate extent, so also when it is in the skin, or even in the flesh, unless the patient's weakness forces us to hurry; it is sufficient to poultice in order to make the pus come out of its own accord. For the place which has not felt the knife may generally escape without a scar. But if the abscess is more deeply seated, we must consider whether the part has sinews or not. For if it is free from sinews, it should be laid open with a red-hot cautery-knife;[p. 303] which has this advantage, that a small wound continues open longer for the withdrawal of the pus, and the resulting scar is small. But if there are sinews near by, the cautery is unsuitable, lest spasm of the sinews ensues or paralysis of the limb; then the scalpel becomes necessary. But although abscesses elsewhere can be opened even whilst immature, where there are sinews, we must wait for them to be fully matured, since the skin then becomes thin, and the pus joins it, and so is nearer to get at. Most abscesses require a linear incision; but in that termed panus, because it generally thins out the skin extremely, all the skin overlying the pus is to be cut away. But when the scalpel is used, care should always be taken that the incisions made are as few and as small as possible, but enough in number and extent to afford the necessary relief. For the larger cavities may at times have to be cut into rather widely even by two or three incisions, and cuts must be so made that the deepest part of the cavity gets a vent, lest any fluid should be left there to eat its way gradually into adjoining tissue, which was previously sound. Also it is natural that the skin should have to be cut away rather widely. For when the whole bodily habit has become vitiated in the course of a prolonged disease and the abscess cavity has extended widely and the skin over it has already become pallid, then we can recognize that the skin is already dead and of no further use; and therefore the excision of overlying skin is better, especially if the suppuration is round about the larger joints, and if the patient, confined to bed, has been exhausted by diarrhoea, and gained nothing from his food. But the skin should be so cut out as to[p. 305] leave a myrtle leaf shaped wound, in order that it may heal more readily: and this should be the constant rule, whenever, or for whatever reason, the practitioner cuts out skin. Where the pus has been let out, for the armpit or groin lint plugging is unsuitable, but a sponge squeezed out of wine must be put on. In other parts, if likewise a lint plug is unnecessary, a little honey will be infused into the cavity to clean it, then agglutinants put on: if lint plugs are needed, over them also should be placed sponges similarly squeezed out of wine. But it has been said elsewhere when plugging is, and is not requisite. In all other ways the same procedure is to be followed after an abscess has been opened by incision, which I have described for one which has ruptured under medicaments.
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