The effects of an incited action of the vessels on the system at large must now be adverted to; or, in other words, that general disturbance in the system which attends inflammatory incitation, and which occurs in a degree proportioned to the power of the exciting cause, and the kind of texture primarily affected. The functions both of the sanguiferous and nervous systems are deranged, producing a state termed Symptomatic or Sympathetic Inflammatory Fever. From some observations of my friend Mr. Gulliver, it is probable that this state is frequently, if not generally, dependent on changes in the blood consequent on inflammation. A sort of decomposition of part of the fluid and vitiation of the remainder; the fibrin being separated and effused into the injured part for the purposes of reparation, while the blood globules are converted into pus in the capillaries, and mixed with the circulating fluid. Thus the presence of pus in the blood may become the proximate cause of fever; but if an outlet to the matter be established, if it be discharged by the occurrence of suppuration in a cavity or on a surface, the case is benefited and the constitution relieved. This points to an important principle in practice. Nature puts it in operation in small-pox, for example—how favourable it is for the pustules to come out, and to what danger is not the patient exposed if they are repelled.
During the paroxysm of inflammatory fever all the secretions and excretions are diminished or suppressed; and hence the hot dry state of the skin, the thirst with foul and dry tongue, the scanty and high coloured urine, and the constipation of the bowels. This last symptom, however, though it may arise partially from the diminished secretion of mucus, yet is often dependent on disturbance of the functions of the brain and nerves. The pulsations of the arteries become rapid and strong, the sanguiferous system being unable to relieve itself by effusion, in consequence of the obstruction of the exhalants.
If the extreme vessels are in any way obstructed, and the general circulation in consequence much accelerated, the internal viscera become oppressed, and are interrupted in their functions; and relief is experienced only when relaxation occurs in the vessels upon the surface of the body. Thus, in any violent and continued exertion, there is a sense of oppression in the chest, and the functions of the encephalon are somewhat disordered, but as soon as perspiration breaks out the relief is instantaneous, and the animal can, without difficulty, persevere in its exertions.
In inflammatory fever, the breathing is often difficult, and the appetite declines; the patient is restless and watchful, and when he does sleep, he is not thereby refreshed. In the more violent cases, the sensorial functions are much disturbed; even delirium supervenes, with violent muscular exertion and convulsions, and may be followed by coma, should the local affection not subside. The delirium attendant on violent diseases and accidents may often be considered a beneficent effect of nature’s operations; for the patient, frequently losing all consciousness of his situation, seems to be under the influence of the most pleasing hallucinations, and is freed from the more lamentable state of severe mental as well as bodily affliction.
Writers on Inflammation have expatiated at great length on Sympathies; and these have been divided into, 1st, The Partial—the Remote, the Continuous, and the Contiguous;—Remote, when parts sympathise, though situated at a considerable distance from each other;—Contiguous, when the sympathetic action seems to be produced, in separate parts, merely from juxtaposition;—Continuous, when the action extends in parts which are of similar texture, and conjoined with that which is primarily affected.—2d, Universal, where the whole system suffers along with parts of it. For instance, the whole system is often disturbed by a deranged state of the alimentary canal, and, conversely, the bowels, or the skin, the brain, the osseous or any other of the textures, may suffer from a general disorder.
The system sympathises much more with some parts than with others; and we accordingly find that disorder in one part will give rise to alarming constitutional excitement, whilst in another, a much greater derangement in function and structure will apparently be almost entirely disregarded by the constitution.
Irritation is an effect of sympathy, and differs from inflammation, inasmuch as the functions of the nervous system, and not those of the sanguiferous, are disturbed;—the latter frequently supervenes on the former. Irritation is local, or constitutional. As examples of the strictly local species, may be mentioned that peculiar and dreadfully annoying sensation produced in the alveoli by the presence of a diseased tooth, or the irritation caused by ascarides in the rectum, or by stone in the bladder.
But, from this action being dependent on the nervous agency, irritation is frequently produced in a part remote from the source of the action. Thus, if an irritating cause of any kind be applied to the origin of a nerve, the effects of the irritation may be evinced in a part supplied by its extreme branches; while, if the cause is applied to the termination of a nerve, a similar action is produced at its commencement, and in parts supplied by nerves from the same origin. Thus, disease of the hip-joint causes pain in the knee, whilst dentition in children not unfrequently produces fatal effusion at the base of the brain; and again, irritation at the neck of the bladder frequently gives rise to pain in the feet.
Local impressions, injuries, or irritations, though apparently of little importance, frequently produce irritation which affects the whole system, and is therefore termed constitutional. Syncope sometimes follows the passing of a bougie along the urethra. We meet with too many instances of constitutional irritation following severe injuries or operations, especially if attended with much hemorrhage. In general, there is considerable prostration of strength; the patient is anxious and restless; his sleep is disturbed; the pulse is weak and fluttering, occasionally intermittent; the tongue is white and loaded; the appetite is gone; the stomach rejects the little food which the patient is able to take; he is startled and annoyed by the slightest external impression. At this period of the disorder, rigors generally occur, and are followed by a sense of heat, and by perspiration; then the above symptoms gradually decrease, and the patient recovers; but in certain instances his breathing becomes quick and somewhat oppressed, attended with a peculiar spasmodic elevation of the nostrils; all the secretions are diminished, the intellectual functions become impaired, and there are occasional convulsive twitchings; coma supervenes, preceded by a low muttering delirium, and followed by death.
This action, as well as every other, is much modified by the importance of the part which is the source of the action, and by the constitution of the patient. It is more severe in children than in adults. The affection will be more fully detailed, when treating of local injuries, and the management of patients after severe operations.
The Causes of Inflammation come next to be considered; and first, of the proximate cause or theory. The different states of the Vessels, in their healthy and in their incited condition, have given rise to much discussion. In the first place, considerable difference of opinion exists as to the relative share which the heart, the larger arteries, and the capillaries, have in propelling the circulating fluid in a state of health. Some physiologists are inclined to attribute the principal power to the heart, the blood being propelled and returned, according to them, almost entirely by the vis a tergo; while they suppose that the arteries possess merely a degree of elasticity or tonicity. Considering the arteries as elastic tubes, performing an indispensable part in the propulsion of the blood, we will now briefly consider their state in inflammation.
Passing over the different theories of error loci, spasm, &c., which have at various times been entertained, let us first examine the condition of the capillary vessels, for these are primarily and principally concerned. In inflammation, the balance of the circulation is destroyed, but a diversity of opinion has existed as to the precise nature of the change which occurs. It has been supposed, and perhaps correctly, that the circulation is, in the first instance, much accelerated in the capillary vessels of an inflamed part; but it has been satisfactorily proved by experiment, that, after inflammation is fairly established, the blood circulates more slowly than in the healthy state of the vessels. There appears, in fact, to be, as insisted upon by some writers on the subject, a state of excitement, then of collapse, followed, if the life of the part is not destroyed, by reaction. When a part is stimulated, the circulation is accelerated, and a greater quantity of blood is transmitted by its vessels: if the excitement is speedily removed, they recover themselves, though perhaps a little dilated, and no inflammation ensues. If, for instance, a foreign body of any kind gets entangled betwixt the upper eyelid and the bulb of the eye, and it is permitted to remain a few moments only, redness of the whole surface of the conjunctiva takes place, but it is transitory, and disappears entirely some short time after the extraction of the foreign body. If, however, it is permitted to continue longer in contact with this sensible surface, the membrane reddens more and more, and becomes thickened. Violent pain, with discharge of tears, and alteration of the secretion from the mucous surface, take place, ophthalmia is, in fact, established. If the exciting cause is applied for a sufficient length of time, the extreme vessels lose their contractility, they are weakened, become dilated, and the contained blood circulates slowly. When inflammation is fairly established in a part, the capillaries become considerably dilated, and the blood is often completely stagnated in the inflammatory point. In the circumference of this focus, it is accelerated as formerly noticed: the blood is probably stagnated for two or three days in the capillaries and in the contiguous cellular tissue, when the action is at all violent. It, however, begins to move again; it loses its colouring matter, while stagnated; the fibrin is assimilated to the neighbouring parts, or rather effused, so as to cause the thickening, and the blood globules have possibly undergone a change, and been converted into those of pus. If the disease be of a limited extent, and without breach of surface, they are carried into the circulation very gradually, and in such small numbers as not to produce injury to the health; otherwise the contamination of the blood by a large quantity of pus causes inflammatory fever. It is probable that the permanent dilatation occurs in consequence of the larger vessels in the immediate vicinity being incited, and propelling more blood into the minute capillaries than they can readily return into the corresponding veins; and in consequence of so great a degree of distension being produced, the vessels are incapable of again speedily contracting; the blood, also, from being stagnant, becomes of a darker colour. The larger trunks propelling blood into the distended and comparatively inert capillaries, which are incapable of transmitting into the veins the same quantity of fluid which they receive, will cause the throbbing or pulsating sensation. The blood circulating in the parts around is sometimes apparently changed in quality; it is redder, flocculi appear floating in it, and the globules disappear. These last may have been broken down, or partial decomposition may have taken place from a loss of vital power in the vessels themselves.
The blood globules are, perhaps, merely compressed; for whenever motion is produced in the fluid, they speedily reappear. Fresh globules also find their way into the affected capillaries from neighbouring vessels. The alteration in the component parts of the blood has been supposed to depend upon the previous state of the inflamed vessels in which it is contained: it is said soon to reassume its natural appearance, when brought into a healthy vessel, and reference is made to experiments on the web of the frog’s foot. When once altered, it is, however, questionable if the blood ever reassumes its natural appearance; of course the blood which takes the place of that which was stagnated in the capillaries will be natural. If there have been extensive inflammation, and therefore much altered blood, one of two things will happen, viz., inflammatory fever and its consequences, or the discharge of the offending matter (the altered blood) as pus. We may also conclude that the blood of an inflamed part undergoes chemical changes; for when the part becomes gangrenous, the blood then loses its red colour, and assumes a yellowish-brown hue, from the absorption of its colouring matter, which necessarily implies an alteration in its chemical constitution. It seems not unlikely, that the change which is early observed in the appearance of the blood of an inflamed part is the commencement of a chemical process, which, if the vessels do not regain their contractile power, terminates in the total destruction of the ordinary properties of that fluid. It is probable that the more modern speculators in medical science have paid too little attention to the state of the fluids, and to the fact that, when diseased action occurs in a part, its secretions and supplying fluid are very considerably changed.
But the blood in inflammation also undergoes a change, observable after its removal from the circulation, and especially when the system sympathises with the part affected. The blood, it is generally believed and stated, does not coagulate so quickly as in the natural state, or else, it is said, the red globules, being increased in specific gravity, fall rapidly to the lower part of the containing vessel, so that a yellowish crust appears on the surface of the crassamentum or clot; and this appearance is termed the inflammatory or buffy coat. The blood extracted from the veins of a patient labouring under inflammatory fever often appears to coagulate very quickly; but it contains an unusual proportion of fibrin. In certain states of inflammation, this crust is also much contracted, so that its marginal circumference is at a considerable distance from the sides of the containing vessel; its margins also are elevated and inverted; its upper surface is smooth, whilst the under adheres firmly to the coagulum; and in this state the blood is said to be cupped, as well as buffed. The appearance of the buffy coat is not peculiar to the inflammatory state, but is apparently dependent on hurried circulation, however occasioned. It frequently presents itself in blood removed from the circulation during pregnancy, and in several other conditions of the system, apparently altogether unconnected with inflammatory excitement. In these circumstances, however, the contracted or cupped appearance of the coagulum is hardly ever observed. An ignorance of the above fact leads to dangerous practice, inasmuch as certain practitioners will bleed, and continue to bleed, for very equivocal inflammatory symptoms, conceiving themselves fully warranted in so doing by the presence of the buffy coat. This coat is often not so apparent in the blood first drawn as in that afterwards abstracted.
In inflammation, as was formerly remarked, a greater quantity of blood not only flows into the capillary vessels, but it also escapes from them, or is extravasated. This may occur with or without rupture of the vessels, and to a greater or less extent, according to the violence of the action, and the texture of the part.
When local inflammatory action exists to a considerable degree, the general circulation is more or less disturbed. The heart, and the larger vessels supplying the capillaries, which are more immediately concerned in the local action, subsequently sympathise with the part affected, and, acting with greater vigour than usual, propel the blood into the extreme branches; so that the inflammatory excitement may be said to be gradually communicated by the continuous sympathy, till the whole sanguiferous system becomes subject to its influence. The degree of this general excitement depends greatly on the texture and function of the part primarily affected.
The term Passive Inflammation has been applied to that state in which the larger vessels are not excited, or have ceased to sympathise with the capillary branches. The term Chronic Inflammation is properly limited to the consequence of the acute inflammatory action, the part remaining turgid and swollen, the vessels over-distended with dark blood, but with little or no pain, and without heat or throbbing. Congestion is also employed to denote fulness of the vessels, large as well as small, when no sign of excited circulation, or of decided inflammatory action, has occurred. It is most frequently used, however, when describing the condition of an internal organ. An over-distention of a particular set of vessels may certainly exist (as a consequence of inflammation, or altogether unconnected with it), unattended with inflammatory action. These two states ought to be carefully distinguished from a similar condition of the vessels, attended with inflammation; for practice, which would be beneficial in the one case, is highly prejudicial in the other, and lamentable examples of the non-attention to this distinction are every day observed.
It may here be mentioned, that some have denied the existence of vitality in the blood; and to some minds it may, perhaps, be difficult to conceive how a fluid should be possessed of this principle. But no one can either doubt or deny that the blood, in its distribution, in its manner of receiving increase, in the secretions furnished by it, and in its various morbid changes, is governed by certain laws and principles which cannot be explained by those of chemistry or mechanics, but must belong to some other power. It is allowed, and has been promulgated by all authors, that the blood is one of the most active agents in the animal economy—in repairing waste, in affording peculiar fluids necessary in that economy, in supplying organs with materials for carrying on their functions, &c.; and yet all this, according to some, is accomplished by a dead animal fluid; no one can plausibly object to the laws by which the blood is governed being referred to the power of life, and to their being called Vital Principles.
Certain circumstances give rise to inflammation, and have been called its Exciting or Immediate Causes. Among the external applications producing inflammation, stimulants bear a conspicuous part; the effects of which, in causing this action, are well shown by many experiments that have been performed on the lower animals: by the application of ammonia, spirits of wine, or common salt, for example, to the diaphanous web of a frog’s foot. As stimulants usually causing inflammatory action, by their being applied to the surface of the body, may be enumerated acids, alkalies, certain salts, animal substances, such as cantharides, the juices of many plants, many poisons, an excessive degree of heat, &c. Any solid substance, though by no means acrimonious in its quality, may act as an exciting cause, as by pressure or friction.
Wounds also, especially when of considerable size, and occurring whilst the constitution is in an unhealthy condition, give rise to local, and occasionally general, inflammatory action.
This action is besides frequently produced by injury from an obtuse body causing a bruise or fracture; by the lodgement of extraneous substances, or of decayed portions of the system,—such as portions of bones, tendons, &c.; or by irritating matter generated in the system itself,—by concretions, tumours, vitiated secretions, &c.
One of the most frequent causes of inflammation is cold; the action of which, however, cannot always be readily explained. In some instances, it appears to act directly on a part, as in inflammation of the mucous membrane lining the organs of respiration: in others, its action is indirect, probably by disturbing the equality of the circulation, the inflammation occurs in a part distant from the surface the temperature of which had been diminished. In the great majority of instances in which inflammation has occurred, in consequence of very intense cold, it is produced by the sudden application of heat whilst the temperature of the part is greatly below the natural standard, as will afterwards be more particularly illustrated. But the inflammatory action may be produced, even though no heat be afterwards applied directly to the part, by its vessels being too rapidly brought into a degree of action similar to that of the surrounding parts which are in their natural condition. Sudden and general diminution of temperature seems to act as an exciting cause, by producing an instantaneous suppression of the transpiration. Another exciting cause of the inflammation, is the retention of the secreted fluids, causing unnatural distension of canals or cavities, and is exemplified by cystitis occurring in consequence of retention of urine. Certain states of the constitution are justly supposed to excite inflammation, in particular textures. Other exciting causes of inflammation might be enumerated, but these will be more naturally explained, and more fully considered, whilst treating of inflammation of the various tissues and organs. Their effects are various and diversified, according to the intensity of the cause, the structure, function, and sympathies of the part affected, and the state of the system. And it is also to be remembered, that not unfrequently inflammatory action appears, whilst we can assign no cause for its production.
Inflammation is said to terminate in Resolution, Suppuration, and Mortification. The application of the word termination, however, is injudicious; for in general the inflammatory action, though much abated, is not extinguished by the occurrence of suppuration or mortification, but often continues in the surrounding parts with unabated intensity; and not unfrequently several of the terminations occur combined with each other.
Adhesion has also been mentioned as a termination of inflammation, but perhaps improperly; for, although in certain parts of the body, as in the serous cavities, adhesion is produced in consequence of inflammatory action, and during its progress, still the process of adhesion is altogether independent of this action in other textures, such as the cellular. In the uniting of a flesh wound, a certain degree of incited action of the blood vessels is necessary for the accomplishment of the adhesive process; but should that incited action reach the inflammatory pitch, the union by the first intention is interrupted, and the wound must heal by granulation with suppuration. The process of adhesion will be more properly attended to when treating of wounds.
The various terminations of inflammation are salutary or destructive, according to circumstances; but resolution is, in general, the one most to be desired; complete resolution, however, perhaps seldom occurs; after the inflammatory action has attained a certain point, this cannot be expected to happen.
Resolution takes place in consequence of the reëstablishment of the circulation in the capillaries, in which the blood had stagnated; hence the diminution of the increased action in the larger vessels—the effused fibrin, at the same time, if there was much swelling, is partly absorbed. The circulation in the part becomes again natural, and the circulating fluid also resuming its healthy properties, the redness and sensation of throbbing cease. In consequence of the bloodvessels regaining their contractility, the nervous system is no longer preternaturally stimulated, and thus the increased sensibility is done away with. In short, when inflammation terminates in resolution, the part is left in the same state in which it was previous to the supervention of the attack. It is not an instantaneous process, but gradual in its completion.
Again, it not unfrequently happens, when inflammation has occurred in the surface, and continued for a short period, that it spontaneously disappears, and does not again return; the action is said to terminate in Delitescence, and of course this is always a favourable occurrence. But if the inflammation, after having suddenly disappeared, attacks another part at a distance from that first affected, the change is termed Metastasis. If the inflammation leaves an internal viscus, and appears on the surface of the body, the circumstance is favourable; but if it leaves the latter to attack the former, the result is highly dangerous.
Treatment.—In the treatment of inflammation, with a view of procuring resolution, our attention must be first directed to the exciting cause: it is, if possible, to be discovered, and removed. Thus, foreign bodies are to be extracted—fractures reduced—strictures divided—unnatural accumulations of fluid withdrawn, &c. In many cases, if the exciting cause is removed, nothing more is required; the inflammation speedily subsides. If the cause cannot be removed, or if, after its removal, the inflammation proceeds unabated, the arterial action must be reduced by general and local abstraction of blood. By general depletion, the action of the whole sanguiferous system is diminished, as well as of those vessels more immediately engaged in the morbid action; but the affected capillaries are still dilated, and less capable than the larger trunks of effective contraction to propel their contents; and are therefore only sufficiently depleted by the local abstraction of blood, by leeches,3 cupping, punctures, or incisions.4 Blood may be drawn either from arteries or from veins. In Arteriotomy, the blood is discharged more rapidly, and its flow is of longer continuance, than from a vein, so that the system may thereby be almost completely deprived of its circulating fluid; and perhaps a more speedy impression may be made on the inflammatory action. One objection to venesection is, that after frequent and copious venous hemorrhage, the internal vessels become gorged with blood, and a disposition to apoplexy is induced.
But bleeding is not to be had recourse to without due consideration of the age, strength, constitution, and idiosyncrasy of the patient; if employed, it must be modified according to these; and it has already been mentioned, that depletion is not always to be persevered in on account of the presence of the buffy coat.5
Bleeding is materially assisted in reducing the activity of the circulation, by the employment of saline purgatives, along with nauseating doses of antimony. Diaphoretics are of essential service in promoting the action of the exhalants, and thereby relieving the affected capillaries. The exhibition of opium is frequently advantageous, more especially after depletion, in allaying the painful sensations when severe, and averting reaction, and also in procuring refreshing sleep, when the patient is anxious and restless. Digitalis has been administered, with the view of reducing the arterial action; but it has been fully established, that this medicine acts at first as a direct stimulant, and that it is only after its use has been continued for some time that its effects become sedative.
The local applications to an inflamed part are sometimes made hot, sometimes cold. The latter will perhaps be at first the more grateful to the sensations of the patient. They are, however, with greater propriety employed before inflammatory action is fairly established, and they act by constringing the superficial vessels with which those more deeply seated sympathise to a certain extent; but warm fomentations are more pleasant and useful when inflammation has really taken place; they relieve the pain more effectually, and at the same time promote the cutaneous transpiration; they relax the surface moreover, effusion is thus encouraged, the deeper vessels are so far relieved of their load, and the pressure upon, and stimulation of, the nerves are thus diminished. After the violence of the symptoms has abated somewhat, the vessels still, however, being loaded with blood, the inflammation in fact having become chronic, stimulants may with propriety be applied directly to the affected parts; these are employed, perhaps, with greatest advantage immediately after the bloodvessels are unloaded by leeching, scarification, or punctures; this practice is borne out by the result of experiment and observation. It is seen, that after the vessels have become dilated, and the blood has stagnated in them through the infliction of injury, or the application of some stimulating substance, that the employment of another and different stimulus immediately causes the contraction of the capillaries, and the renewal of active circulation.
During an inflammatory attack, the patient should be allowed very little food, and what he does receive must contain little nutriment in proportion to its bulk. But in many cases it is unnecessary to enjoin such abstinence, as the patient has no appetite, and refuses food.
In inflammation of deeply-seated parts, such as the apparatus of some articulations, it is a frequent mode of assisting the completion of resolution to excite inflammatory action in an external, and consequently less vital and important part. This is accomplished by the application of stimuli, caustics, cautery, setons, &c.
It appears that the stimulating substance produces an incited action of the bloodvessels, or a revulsion, according to the older authors, in the part to which it is applied; and that, consequently, the neighbouring arterial trunks, in order to sustain that incited action, supply the part with a larger proportion of their contents than it usually receives; and the necessary consequence of the stimulated part receiving an additional supply of blood is, that the part originally inflamed receives less. The effect, indeed, seems analogous to that of topical bleeding, with this difference—that it is more permanent. Besides, it determines suppuration on the surface, and so renders it less necessary for the vessels to produce pus in a worse situation—the deeper seated parts.
But it must be borne in mind, that this method is not to be resorted to in the commencement, or during the active state, of the inflammatory action, but only when that action has begun to decline, otherwise the disease may be much aggravated, instead of being relieved.
If, notwithstanding all the means employed to procure resolution, the inflammatory action continues unabated, the result next to be desired and accelerated is Suppuration; and with this view, it becomes necessary to change the treatment, both local and general.
Above all, disuse and a proper position of the affected part must not be neglected. Unless absolute repose is strictly enjoined and attended to, and the return of blood from the inflamed tissues is favoured, very great difficulty will, in the majority of cases, be experienced in removing any of the signs or symptoms of inflammatory action, even by the most energetic means, general or local. This will be more fully insisted upon in the progress of the work.
It has already been stated, that the blood is stagnated in the capillaries occupying the centre of the inflamed part, as well as extravasated in the contiguous cellular tissue. Pus has long been considered as a secretion; but, from the time of Mr. Hunter downwards, a great similarity between the globules of pus and those of blood has been recognised: the former, however, are spherical, larger, and rougher on the surface, and are not so regular in size as those of blood; their diameter is between 1/2000 and 1/3000 of an inch, although some of the globules may be occasionally seen a little larger or smaller than these measurements. Smaller particles are also detected, the molecules of the pus globules, each of which contains two or three. These molecules are insoluble in acids, soluble in caustic alkalis, and can be freed from the fibrous capsule in which they are contained, and of which the pus globule is composed, when treated with acetic acid. The appearance of the pus globules and molecules is here shown upon a scale, the squares of which are 1/4000 of an inch. These small particles were pointed out to me by my friend, Mr. Gulliver, nearly two years ago, as constituting an important element in suppuration. It results from his observations that the entire pus globule is composed in its central part of these minute molecules, the diameter of which is from 1/10666 to 1/8000 of an inch, cemented together, as it were, by a superficial deposit of matter possessing all the properties of coagulated lymph. And these minute nuclei constitute a proximate animal principle, possessing such well marked characters as to justify us in regarding them as peculiar in their nature, and essential to the composition of the pus globule. Thus they resist putrefaction with remarkable pertinacity, are very dense, and spherical in form, and are insoluble in some acids which act with facility on albumen, fibrin, or the blood-corpuscle. They are easily seen by treating a little recent pus with sulphurous acid, which so acts on the pus-globule as to render the nuclei distinctly visible through its fibrinous capsule; by sulphuric acid the external part of the pus-globule is quickly dissolved, and the nuclei, somewhat shrunk, are seen in considerable numbers floating separately about the field of vision. The instrument used by Mr. Gulliver in these observations was a compound achromatic microscope, with a deep object glass, having one-eighth of an inch focal length.
In many constitutions, the slightest incited action of the vessels is followed by the formation of pus, and the appearance of a depôt of purulent matter is often the first indication that such action has existed; but in the majority of instances, the deposition of pus is preceded by the usual characters of well-marked inflammatory action. Suppuration occasionally occurs without previous solution of continuity; for pus is frequently contained in the serous and mucous cavities, when no breach of continuity can be discovered, at least we find a fluid not distinguishable from purulent matter; it may be a vitiated secretion, but still it presents the usual characters of pus. But it occurs, generally, when there has been a previous læsion of structure, and in this case its progress is most distinctly marked. In exposed cellular texture, for example, particles of blood are effused; the serum is afterwards absorbed, and the lymph remains; this latter gives transmission to minute vessels which deposit the purulent fluid, whilst others secrete particles of organised matter to form granulations, in order to repair the loss of substance. This process is often unattended with any great degree of constitutional disturbance, because the fibrin effused sets a bound to the pus, and is the provision against its being mixed in large quantities with the blood. In healthy suppuration, the separation of fibrin and pus from the blood in this way seems to have direct relation to each other; and in unhealthy inflammation, when this does not take place, the consequences are mixture of pus with the blood as formerly noticed. In the latter form of suppuration the fibrin, instead of being assimilated to the contiguous mass, is mixed with the pus; hence the proneness to putrefaction of such discharge, and its disposition to coagulate spontaneously when evacuated. This kind of suppuration, being matured generally without thickening of parts, has been sometimes pointed out as suppuration independently of previous inflammatory action.
After purulent matter has begun to accumulate under the surface, the pressure thereby occasioned produces condensation of the neighbouring cellular tissue, which, along with the previously effused lymph, forms the parietes of the abscess; and in proportion as the matter accumulates, the cavity enlarges by the successive processes of ulceration of portions of its parietes, by continued effusion of lymph, and by farther condensation of the surrounding parts. Thinning of the parietes takes place by ulcerative absorption, particularly towards the surface—or, if that be difficult, towards a mucous outlet—as is exemplified by the bursting into the bowels or bronchiæ of abscess of the liver.
But in some instances, when no lymph is previously effused, and no cyst is formed, the matter is not confined, but pervades the cellular substance extensively, and is generally followed by more or less sloughing of that tissue, and by great constitutional disturbance. This most frequently occurs in patients of a debilitated habit, in whom the incited action has been so slight as not to cause the effusion of lymph, by which nature usually sets bounds to the suppurating process.
M. Gendrin advanced the opinion that pus was nothing but transformed blood; but his experiments on frogs are at least doubtful, since Mr. Gulliver, on repeating them, could not by any means induce the process of suppuration in these animals. It has been rendered probable by this gentleman’s observations that suppuration is a sort of proximate analysis of the blood, the fibrin being added to the contiguous parts, as in causing them to swell, forming the cysts of abscesses; the blood globules altered into pus being discharged as useless and excrementitious matter.
Pure pus is heavier than water, of a yellowish-white colour, 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.
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. 56, 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.
When the abscess has been deeply seated, and the incision made through a considerable thickness of healthy parts, it is sometimes, though very rarely, necessary to introduce a small piece of lint between the edges of the wound, otherwise they may speedily adhere, and the discharge of the matter be in this way prevented. In consequence of smart hemorrhage, also, it may be proper to stuff the wound with lint, and retain it for an hour or two; but in general the practice of stuffing abscesses, or the openings into them, is hurtful. After the incision, as already remarked, it is unnecessary and injurious to discharge the pus by forcibly squeezing the sides of the abscess; the application of a poultice will promote the evacuation of the matter, and allay the irritation. In chronic abscesses of large size, it is sometimes necessary to make a counter opening—that is, an opening in a part of the tumour opposite to the original opening, in order that the matter may be more completely discharged. Setons introduced into the cavity of phlegmonous abscesses some time after their evacuation, are highly injurious, as causing much irritation in parts which are already in a morbid state of excitement; but in chronic collections, which show no disposition to heal, their use may sometimes be followed by good effects, on the same principle that they were hurtful in the preceding case; if they should not cause a sufficient degree of excitement, they may be smeared with some stimulating ointment. In extensive collections, in which the matter is not sufficiently evacuated by the external aperture, injections are by some recommended, and, perhaps, occasionally employed: in those abscesses which are comparatively recent, and in which the surrounding parts are still in a state of over-excitement, they are quite inadmissible. The employment of setons and injections in any case of abscess is not much to be commended or trusted to. Caustic, the potassa fusa, may be frequently employed with advantage for opening chronic abscesses, especially when they are the consequence of glandular enlargement, and undermine the integuments, which show no tendency to adhere to the subjacent parts. The potass is best used in the solid form and well pointed; not in paste, as is sometimes practised. By its application the unhealthy surface is destroyed, and the surrounding parts are stimulated so as to assume a sufficient degree of action to throw off the portions which have become useless, and to form new and healthy granulations, whilst the surrounding effusion of lymph or serum is for the most part speedily absorbed. But it can never be employed in acute abscesses without aggravating the disease; and in collections which are deeply seated, it cannot be of much service, for in these a considerable thickness of healthy parts must be destroyed, and if the potass be applied, it will afterwards be necessary to cut through the slough, as was practised by the older surgeons, in order to evacuate the matter and give relief to the patient; or else to continue the application of the caustic for an inordinate space of time, which is a practice altogether unnecessary, extremely cruel, and productive of much irritation, constitutional as well as local.
A too common result of abscess, when inertly treated, is the formation of a Sinus; that is, a canal, the circumference of which is condensed by deposited lymph, and which furnishes a discharge of unhealthy purulent matter, frequently thin and gleety. Several sinuses frequently unite, and evacuate their contents by one opening. Previously to treating a sinus, its extent must be carefully examined by the probe; this requires considerable caution, for the full extent of the canal may not be discovered, in consequence of its tortuous course, or from its diverging into collateral branches; or the probe, by being used too forcibly, may pass into parts altogether unconnected with the morbid cavity. Thus, in exploring a sinus at the lower part of the leg, or in the foot, the probe may be pushed to a considerable extent beneath the tendinous sheaths of the muscles, and induce the surgeon to adopt treatment unnecessarily severe. In the treatment, we may at first employ setons, injections, and graduated pressure, as formerly explained; and if these fail, the canal must be freely laid open by the knife—a mode of practice much more effectual; then there is formed a cavity similar to that of a recent abscess, and to be treated accordingly. Incision is most frequently necessary when the sinus exists in adipose substance, in tendinous structure, in parts possessed of little vitality, and in patients of a sluggish and enfeebled constitution. In sinus, as well as in chronic abscess, the potass is of essential service; a stick of it may be introduced into the canal, and if the sinus is superficial, the integuments may be divided by this caustic as effectually as by the knife. The indolent and callous surface of the sore is thereby destroyed, and the effects are similar to those which have been already mentioned, when speaking of the use of potass in abscess; in fact, by its application the sinus is transformed into an acute and open abscess. Foreign bodies, such as diseased and dead portions of bones, must be early removed; for it is to be remembered that these are much more frequently the cause than the consequence of suppuration.
The healing of an abscess which has been opened closely resembles the process of union by the second intention in a flesh wound; granulations arise, attended by the secretion of pus, the cavity gradually contracts; the surrounding effusion is absorbed along with a portion of the adipose matter; and on the granulations reaching the surface, new skin is formed, and the parts coalesce.
After abscesses have been opened, the fomentations, poultices, or warm-water dressing, as recommended in the treatment of ulcers, are to be continued, but only for a limited time. The power of the system must be carefully supported by exposure to a pure atmosphere; by nourishing food; by the exhibition of wine, tonics, and such medicines as promote digestion. In cases where the system is unusually inert, it may be proper to administer stimulants. The most powerful stimulants are frequently necessary, and by steady perseverance in the use of them, patients have often been saved in very hopeless circumstances. Great attention must be paid to the bowels, and the secretions poured into them, for on the condition and quality of these the state of the constitution materially depends. The internal Use of cantharides is often advantageous in chronic suppurations and abscesses, but it is inadmissible in cases where enlarged glands occupy dangerous situations, either externally or internally; unless the tumours are in progress towards resolution, suppuration is certainly induced, and may be productive of the worst consequences. The glands not unfrequently become enlarged during the exhibition of this medicine; and such an occurrence must be watched attentively. In illustration of the good effects of stimuli in certain cases, it may be mentioned that the cavities of abscesses are often speedily effaced by granulations, and that obstinate sores frequently contract and cicatrise, after the occurrence of a febrile attack, though they had previously shown no disposition to heal.
In glandular swellings, Deobstruents, as they have been called, are used; and with this view, mercury is often had recourse to; this medicine, however, instead of producing a salutary effect, very generally tends still farther to impair the constitution. Preparations of iodine, exhibited both externally and internally, appear to be sometimes of use when the swellings have become stationary, or are inclined to subside. Iodine may be given in combination or not with iron. It is a medicine exhibited very generally and indiscriminately, and is very much more trusted to than it deserves to be. When the tumours are irritable, fomentations may be employed, and advantage taken of sea-bathing, warm or cold. The common adhesive or soap plaster, spread on soft leather, or the ammoniacal plaster, are often applied with advantage to indolent glandular swellings. Blistering is sometimes resorted to with good effect, and in some situations pressure may be usefully employed.
In the treatment of large indolent collections, it was proposed by Mr. Abernethy to make a small and indirect aperture, and to evacuate the contents of the abscess as often as the matter accumulated; but a degree of constitutional irritation frequently supervenes upon this proceeding, and the discharge becomes bloody, putrid, and mixed with a considerable quantity of gaseous fluid. The discharge of blood probably arises from the usual support being taken away from the vessels ramifying on the surface of the cavity, in the same way that blood is effused into the cavity of the abdomen, in consequence of the too rapid evacuation of the serum in ascites.
Suppuration, more especially when extensive and long continued, is attended with a peculiar species of fever, termed Hectic. This fever is the remote consequence of local injury, or disease, whereas symptomatic inflammatory fever is the immediate one. The incessant and long-continued addition of pus to the blood may be the cause of hectic fever. In cases of pulmonary consumption, pus globules are almost uniformly detected in the blood. This fact has been noticed by Dr. Davy and Mr. Gulliver. The pus is probably carried along the capillaries, where it is always forming in chronic abscesses: in short, all the pus formed is not separated from the blood. Hectic probably arises from the never-ceasing addition of a little pus to the blood, inflammatory fever from the sudden addition of a large quantity. In long-continued disease, particularly internal, the hectic occasionally occurs before the existence of suppuration is indicated; and it does not always supervene upon suppuration, even though extensive. Hectic has been supposed to arise from the absorption of pus; but pus cannot well be absorbed without disintegration of its particles (and then it would be no longer pus), for their diameter exceeds that of the more minute bloodvessels and absorbents. Abscesses occasionally disappear, without this event being followed by any unpleasant symptom.
Hectic fever is most apt to arise in constitutions originally weak; and usually either from some incurable disease of a vital organ, or from extensive affection of a part not essential to life; but it may also be induced without any local assignable cause.
The general symptoms are those of a low and gradual fever, attended with great debility; the pulse is frequent, unequal, small, and sharp; the general surface is pale; there is flushing of the face, hands, and feet; the skin, at one period, is cold and clammy, sometimes dry and rough—at another, it is bathed in profuse perspiration, especially towards evening; chills alternate with flushing; the appetite is much impaired; diarrhœa supervenes; pale-coloured urine is voided in great quantity, often with a lateritious sediment; there is want of sleep, and great anxiety; the eyes are sunk, and of a glassy hue; the features become changed; there is great emaciation; the patient, gradually more and more weakened, falls into a state of coma, and expires.