somewhat of the consistence of cream. It is very little inclined to
putrefaction, less so, perhaps, than any animal fluid not oily. It
is composed of globules, and a clear transparent fluid, coagulable,
it has been said, by the muriate of ammonia. When a solution of this
salt produces any change, it is by rendering the pus more ropy; not
coagulation, but a sort of gelatinisation follows. It is said also to
be sweet and “mawkish to the taste.”
In unhealthy pus, such as already noticed, or in vitiated
muco-puriform secretion, the colour and consistence are different, and
flakes, resembling portions of lymph, are seen floating in it: they
consist of fibrin thrown off with the pus, instead of being used for
reparation and bounding the extent of the abscess; and by this latter
circumstance such fluid is distinguished from the pure or laudable pus.
In purulent matter also, especially that of an unhealthy character,
the existence of a quantity of sulphureted hydrogen is indicated by
the blackening of silver probes, and of various substances applied to
the sore. It is necessary to bear in mind, that a matter resembling
pus in many particulars, but in reality differing essentially from it,
has generally been regarded as true purulent fluid; for it results,
from some observations of Mr. Gulliver, that the pulpy matter, so
frequently found in the substance of fibrinous clots of the heart and
veins, is simply fibrin which has coagulated and passed into the state
of softening, which he regards as a very frequent elementary disease.
The subject is one of great interest, because it is connected with the
theory of suppuration, and tends to modify materially our views on the
pathology of the veins.
The symptoms attendant on suppuration vary much according to the
nature of the parts involved. In general, it is accompanied with the
subsidence of acute pain and fever; but, in unyielding textures, the
increase of swelling, by the formation of purulent matter, is often
attended with an aggravation of the symptoms, and with an increase
of danger to the structures affected. The pain which accompanies
suppuration is dull, and attended with a sensation of fulness and
throbbing, and an increase of the tumour; ultimately the parietes
of the abscess become absorbed, and the collection, being more
superficial, the most careless observer must be convinced of its
existence, by the less equivocal signs of fluctuation and pointing.
In general, especially when the abscess is deeply seated, a greater
or less degree of œdema surrounds it, producing a soft pitting
tumour; but not unfrequently, when the degree of excitement is more
intense, lymph, instead of serum, is effused, rendering the part more
hard and resisting: in such cases it may be difficult to discover
the existence of purulent matter, and the tactus eruditus, as it is
called, will be found of material service; for, though pus is neither
acrid nor corroding, still, if allowed to remain for any long period,
much mischief may be caused—the bones may become diseased—muscles
and tendons may slough—and the matter may discharge itself, by means
of ulceration, into certain cavities and canals, and produce very
serious consequences. Of the bad effects produced by the pressure and
irritation of extensive and undisturbed collections of purulent matter,
every practitioner must have seen numerous examples. Still, through
prejudice, erroneously conceived opinions, or servile imitation, the
greatest dread seems, with many, to exist of the practice of giving a
free exit to the contents of such depôts.
The symptoms and sensible signs of suppuration are usually preceded
by shivering, recurring at intervals, and commonly terminating in
profuse perspiration. But this is by no means an unequivocal sign of
the occurrence of suppuration; and this process very often takes place
without any feeling of rigor.
The older authors supposed that pus was derived from the solids—or that
it was formed by the melting of dead animal matter—or that it was the
result of putrefaction; in accordance with which latter opinion, the
term pus was given to the fluid; but such opinions have long since
been justly exploded. Pus is generally supposed to be separated from
the blood by the secreting power of the bloodvessels of an exposed
and inflamed part, in consequence of their having assumed a new
mode of action. The secretion from exposed surfaces is not at first
purulent, but is transparent, serous in fact, and is somewhat of a
gelatinous appearance; and it is only, it is said, after exposure to
the atmosphere for some time, and when drying, that it presents the
appearance of globules. Pus is often formed where the secreting surface
has not been exposed to the air; on opening an abscess, the parietes
of which had been previously entire and not much attenuated, purulent
matter of the usual properties is discharged. It has been asserted
that pus globules may be formed independently of any vital action; and
that, if the serous fluid be removed immediately after its secretion
by a granular surface, and kept in a temperature similar to that of
the inflamed part, and be at the same time freely exposed to the air,
globules will appear in as short a period as when the secretion is
allowed to remain in contact with the sore. Some have also supposed
that the mere admission of air into the cellular substance causes
suppuration; but this is far from being correct. In chronic purulent
depôts, however, the admission of air, by favouring putrefaction
probably, often produces most serious results; other causes are
generally in operation at the same time, as will be afterwards more
fully explained.
Pus was formerly regarded as irritating and corroding, and was
therefore carefully removed from every granulating sore; but purulent
matter, though it may prove a source of irritation to the neighbouring
parts, does not disturb the surface which secretes it, but, on the
contrary, protects the tender granulations, and acts as a temporary
cuticle. A crust is formed by the evaporation of the thinner part of
the fluid; and we frequently see small sores healing rapidly when thus
protected. In some instances, we adopt the hint given to us by nature,
and produce a scab by the application of powders, lunar caustic, &c.
The discharge does not always consist of laudable purulent matter.
Pus formed in the diseased part itself has particular characters,
according to the tissue involved; thin and greyish in bones, opaque and
caseiform in cellular tissue, flocculent in serous, and greenish and
thready in mucous membranes; it is said to be reddish in the liver, and
yellowish-grey in muscles. Its sensible properties are various, often
very offensive when proceeding from a cavity containing decayed bones,
and it degenerates in consequence of disturbance of the constitution,
or of the part affected. It is also frequently suppressed, in
consequence of over-action in the vessels of the part, or from debility,
partial or general.
Suppression of a purulent discharge is to be regarded as an untoward
symptom, fraught with considerable danger, being generally followed by
the most violent constitutional disturbance. Certain cases would seem
to warrant the belief that a species of metastasis occurs; that the
matter is absorbed, and again deposited in some other part, perhaps
of the utmost importance in the animal economy. The danger arising,
when the pus is not separated from the blood, has already been adverted
to. No wonder, if from any cause it does not escape by its accustomed
channel, that an effort should be made to deposit it somewhere else,
for the temporary relief of the system. The most vascular parts are
commonly chosen, as the lungs, spleen, and liver. In the cavities
of joints, also, matter is often found in great quantities. This is
sometimes indicated by the occurrence of tenderness and swelling for
only a short period previously; but, in other cases, its presence
has never been suspected. In purulent collections, after wounds from
accident or operation, on the suspension of the discharge, the patient
becomes affected with severe constitutional irritation, and gradually
sinks; the existence of purulent depôts in the viscera of the chest or
abdomen, being perhaps not indicated by any, unless very equivocal,
symptoms, and these appearing only a short time before dissolution. A
late writer has endeavoured to connect this with inflammation of the
veins; but such an opinion is not borne out by observation, although
the two circumstances may occasionally coexist. In many cases the veins
of a limb are found filled with pus, yet their coats present no marks
of inflammatory action having existed in them. Their mouths are open in
the wound, from failure of that healthy action by which they would have
been closed by coagulated lymph, and the matter appears to be taken up
by them as secreted.
From the discharge varying according to the state of the system, the
latter can in general be accurately ascertained by examination of the
sores which afflict the patient.
In collections of matter not far removed from the surface, the most
superficial, and generally the most dependent, portion of the parietes
appears inflamed; its inner surface is gradually absorbed; and, when
it has thus become attenuated, a portion of the integument sloughs or
ulcerates. A communication is established with the diseased parts,
through the external surface, thus providing an aperture for the
evacuation of the matter—of extraneous substances—or of parts of the
body which have either mortified, or otherwise become useless to the
system. In such collections, more especially if deeply seated, the
matter generally seeks the surface, or extends in the course of the
bloodvessels.
Cold abscesses, as they are called, often contain as much flaky
fibrinous matter as true pus: hence one of the signs of inflammation,
swelling, is absent; the fibrin being discharged instead of having been
added to the neighbouring parts.
As formerly remarked, suppuration occurs much more readily in some
constitutions than in others; and patients peculiarly liable to the
formation of abscesses, without any great degree of previous excited
action of the bloodvessels, are said to labour under _Struma_ or
_Scrofula_. These terms are by some used to denote a distinct or
specific disease, while others consider them merely as a peculiar state
of the constitution.
The strumous diathesis is said to be marked by hair and irides of a
very light colour, and by the skin being of a peculiar white hue; but,
in some instances, the complexion is unusually dark and sallow. The
upper lip generally presents a swollen appearance, as also the columna
and alæ of the nose. The organization throughout is delicate, and the
patient is frequently of a handsome, though infirm, structure.
Constitutions, in every respects strong and originally vigorous, may,
from various causes, become weak, and present many of the symptoms
usually termed scrofulous. I recollect a young patient, born of healthy
parents, who had enjoyed excellent health, becoming covered with ulcers
and chronic abscesses, in consequence of exposure to cold during
menstruation.
To the continued irregular and imprudent exhibition of mercurial
_alteratives_, as they are called, may be attributed the cachectic and
scrofulous constitutions of many thousands of patients of all ages.
The strumous diathesis is said to depend upon a want of balance, or
proportion, between the solids and circulating fluids. Want of action
and power in the organs forming and circulating the blood, disordered
digestion, and various other circumstances which it is unnecessary
to detail, have also been considered as causes of this state of the
constitution.
Many suppose that the diathesis, or a disposition to the diathesis,
is always congenital; and this opinion is supported by the majority
of cases. However, certain circumstances produce a scrofulous habit
of body in patients who previously appeared to be vigorous and
healthy, and untainted with any peculiar disposition to disease. Of
these predisposing causes may be mentioned, a poor diet, an impure
atmosphere, exposure to damp and cold, inattention to cleanliness, the
latter circumstance acting sometimes by producing local irritation:
in fact, whatever deranges the general health, seems, in many cases,
to induce the strumous diathesis. Some constitutions are incapable
of resisting any unusual incitement of the vascular system, or of
repairing the consequences of the action, or of any injury, in
whatever way inflicted. In such individuals, all the parts of the body
are deficient in power—some, however, are more so than others, and,
consequently, more readily give way; thus, the lymphatic system, the
mucous membranes, the skin, the bones and their coverings, generally
suffer in the first instance.
Glandular swellings of all kinds, and in all situations, often
followed by suppuration, are apt to occur from irritation of various
descriptions, but more so in constitutions originally weak, or which
have become debilitated by disease or any other cause. The larger
glandular tumours are formed by congregation and agglutination of
the smaller ones, and by the deposition of adventitious matter in
the connecting cellular substance; separation of the smaller tumours
composing these, naturally, or under the use of deobstruents exhibited
internally, or applied to the surface, is a highly favourable sign, and
equally encouraging to the surgeon and the patient.
Dentition, the presence of carious teeth, of stumps of teeth;
excoriations behind the ears, eruptions on the scalp, affections of
the lining membranes of the eyelids, mouth, or nose, of the skin of
the face, are daily found giving rise to glandular swellings in the
neck; whilst irritations in the urethra, excoriation or slight disease
about the anus, corns or sores about the feet or toes, produce similar
affections of the glands in the groin. Such sources of irritation are,
of course, to be looked for in the first instance, and will often
materially influence the diagnosis, though too much is occasionally
attributed to their influence. Such glandular tumours, however,
sometimes occur spontaneously, or, at least, without any evident
cause. They have been mistaken for other diseases, according to their
situation—for aneurism, hernia, or venereal bubo; the latter mistake is
often committed unintentionally by the ignorant, or designedly by the
unprincipled.
Tumours formed by the enlargement of glands are frequently productive
of dangerous consequences. If situated in the neck, they may render
breathing and deglutition extremely difficult, and in the event of
their suppurating, the purulent matter may be discharged into the
trachea or gullet; fatal results have followed the giving way of an
abscess into the former canal. The breathing is also seriously impeded
by enlargement of the bronchial glands, by the pressure of which
the lungs may be much condensed, and unfitted for their functions.
The immediate effect of enlargement of the mesenteric glands, is
interruption to the passage of the chyle, and a consequent decline of
the powers of life. Such tumours in the abdomen have been mistaken for
enlargement of the liver, spleen, ovarium, &c., and the most noxious
treatment employed.
Inflammatory glandular enlargements terminate either in resolution, in
delitescence, or in suppuration; sometimes in death of the part. When
the tumour, after having attained a certain size, gradually disappears,
it is said to be resolved; when, however, it is rapidly discussed, it
terminates in delitescence; the difference between the terms being
the same as when used to express the corresponding terminations of
inflammatory swelling in general.
Suppuration is by far the most usual termination, and the matter is
frequently evacuated through numerous small apertures, exposing the
gland denuded and prominent in the middle of the chasm; in such cases,
the gland proves the source of much irritation, and must be destroyed,
otherwise the cure is extremely tedious.
Though inflamed and swelled lymphatic glands very generally disappear
by suppuration, it is to be remarked that the conglomerate glands,
though often violently inflamed, seldom, if ever, have pus formed in
them; in mumps, for instance, the action often runs very high, yet
abscess of the parotid is rare. The submaxillary salivary glands are
often supposed and said to be inflamed and enlarged; the conglobate
glands superficial to them are in such cases only affected.
Collections of pus in the lymphatic glands or cellular substance, in
patients of a weak constitution, (whether naturally or in consequence
of disease,) are attended with little or no pain, or inflammatory
action; and although it is probable that inflammation does precede the
formation of such purulent depôts, still it is generally so slight
as not to attract the attention of the patient or his attendant. The
sensation is dull and uneasy, rather than painful; and, even after the
accumulation of a considerable quantity of purulent matter, redness of
the surface and pointing do not occur till a late period. The contained
matter is thin, flaky, and of a brownish colour. The collections often
attain a very great size, and, if improperly treated, terminate in the
formation of numerous and extensive sinuses.
The skin, particularly that of the face, becomes, in very many cases,
affected either primarily or secondarily with scrofulous ulceration,
which commonly extends to the neighbouring textures. The disease has
sometimes been mistaken for cancer, and other affections of a malignant
nature, and has received various names accordingly. The integuments
in the neighbourhood of the ulcer are of a purple hue, and become
undermined, from the extension of the disease in the subjacent cellular
tissue. The discharge is thin and gleety—the sore is of an unhealthy
and debilitated character, and makes but little attempt at reparation;
its surface is covered by a viscid fluid, and sloughing occasionally
occurs in consequence of the extreme debility of the parts. Numerous
sinuses frequently extend in a superficial direction, and render the
cure more tedious and complicated.
Those of a scrofulous constitution are most liable to be affected with
caries, softening, and other diseases of the bones and their coverings;
these, however, will afterwards be treated of, along with ulceration
of cartilages, diseases of ligaments and synovial membranes, lumbar
abscess, &c.; all of which affections, in the plurality of instances,
are connected with the strumous diathesis.
In the treatment of abscesses, the principal indications are, to remove
any degree of inflammatory action with which the surrounding parts may
be affected—to keep the part moist, clean, and at rest—to remove all
source of local irritation—to promote and accelerate the progress of
the matter to the surface—and, lastly, to give it free vent; for though
it sometimes happens that collections of purulent matter disappear,
still the occurrence is so rare, that to treat abscess generally when
in an advanced stage with the expectation of resolution would be highly
injudicious. By blistering and pressure, however, tumours containing a
small quantity of purulent fluid can occasionally be discussed. Warm
fomentations afford great relief, especially at the commencement, when
there still remains a considerable degree of surrounding inflammation.
These may be either what are termed anodyne, or not; in general,
fomentation with chamomile flowers or hops, contained in a woollen
bag, and wrung out of warm water, will be found the most convenient
and efficient, and is well entitled to the term anodyne, which is
usually applied to others of a complicated, and not more efficacious,
character. Poultices are of material service, particularly when the
collection is advancing to maturation; and their composition is of
little importance, provided they are moist, warm, and soft. Stale
bread soaked with hot water, or an equal quantity of grated bread and
linseed meal, (if not adulterated with mustard, as is sometimes the
case,) mixed with sufficient quantity of boiling water, form excellent
and soothing cataplasms. Their use, however, may be persevered in too
long; for, after an abscess has given way, the suppuration may be
kept up in consequence of continuing the poultice. The opening will
enlarge, the skin become undermined, loose, and flabby, the abscess
will extend, while the process of granulation may be in a great measure
suspended. In many cases, the poulticing cannot be continued until an
opening has formed naturally, and the cure is often much accelerated by
the artificial evacuation of the matter. When the abscess is situated
deeply, or beneath a fascia, a free and early opening must be made.
For example, when suppuration has occurred in the cellular tissue
beneath the fascia lata of the thigh, it at first naturally tends
towards the surface, but its progress is impeded by the tendinous
aponeurosis; a painful feeling of tension is thereby occasioned, and
the matter extends where there is least resistance, making its way in
all directions into the surrounding cellular tissue—separating the
muscles—isolating the arterial trunks—burrowing beneath the fascia
over the whole limb, and producing most serious, and often irreparable
mischief, with violent constitutional disturbance. The bad effects of
delay are again daily witnessed in neglected cases of paronychia; most
excruciating pain is produced—the system is seriously affected—the
tendons slough, and the member is rendered useless.
By the continued presence of purulent matter, absorption, ulceration,
caries, and even death, of bone, is frequently produced, all which
might have been prevented by its evacuation. If pus collect in the
neighbourhood of cavities or canals, it is of the utmost importance
that it be early discharged; and the evil effects of negligent and
dilatory treatment are well exemplified in the following cases:—A
patient had been allowed to suffer, for a long time, under an extensive
abscess at the lower part of the neck, beneath the origins of the
sterno-mastoid muscles. The abscess at length gave way externally; but
the patient was at the same time seized with profuse expectoration
of pus, and during expiration the air escaped through the external
openings in the neck. It was evident that the abscess communicated with
the trachea, and it also appeared to have extended deeply into the
mediastinum. The patient soon perished, but there was no opportunity
of examining the parts. In another case of extensive abscess at the
root of the neck, an opening was proposed, but delayed. At length, the
abscess gave way spontaneously; and from the circumstance of portions
of solid as well as fluid ingesta escaping by the external opening,
it was evident that the œsophagus had ulcerated. The cure was very
tedious, but ultimately complete, and apparently much accelerated by
free counter openings.
In suppuration of the cellular substance in the neighbourhood of the
anus, the matter may present itself externally, whilst it is making
extensive progress internally; and if a free opening is not made,
fistula ani is the result. The propriety of an early evacuation of
purulent matter in important, or very sensible, organs, such as the eye
and testicle, is very evident.
The larger arterial and venous trunks appear not to suffer from
suppuration, for in purulent depôts we find them entire, and much
thickened by copious effusion of lymph into their outer cellular coat
and sheath; the nerves, however, are not so much protected, or do not
appear to resist the pressure and insinuation of pus, and suffer along
with the other tissues.
[Illustration]