Part 5

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.

The most convenient and effectual mode of opening an abscess is with a sharp-pointed bistoury, and the incision should vary in extent according to the circumstances of the case. The straight instrument, used as described and represented in the “Practical Surgery,” p. 5[6], will be found to answer best in deep-seated collections; in the more superficial it may be slightly curved. It is used as here shown, only that the edge of the knife should be turned more downwards before the integument is divided by withdrawing it. The aperture must always be made at the most dependent part, which is also, generally, the thinnest; thereby a free exit is allowed to the matter. If the incision be not made in a dependent part, a considerable quantity of the matter will be retained within the abscess, and can only be evacuated at the time by squeezing the parts—at all times a very cruel and improper practice—applying compresses, &c., which produce much irritation and unnecessary inconvenience to the patient. The cavity of the abscess inflames, the discharge becomes bloody and putrid, and great constitutional disturbance is apt to follow. When, again, the opening is sufficiently large, properly placed, and the matter flows out through the elasticity of the coverings, no air enters, the cyst gradually contracts, and the cure is soon completed.