No. 328.

LONDON, SATURDAY, DECEMBER 12. [1829-30.

LECTURES ON SURGERY,

MEDICAL AND OPERATIVE,DELIVERED AT

St. Bartholomew’s Hospital;

BY MR. LAWRENCE.

LECTURE XI.

On 5uppuration, Formation of Abscess,and T2,eatffte)tt.

SuppuRATioN, Gentlemen, is the forma-tion of the fluid which is called pus. It isone of the effects of inflammation ; there-fore wherever we find pus, we are sure

either that there is, or that there has been,inflammation of the part. Pus is a whitishor yellowish fluid, varying in consistencefrom that of thick cream to that of water ;and it is found, on microscopic examination,to consist of globules floating in thin fluid,in that respect bearing some analogy to theconstitution of the blood. The differencein consistence, and in the other propertiesofpas, depends chiefly on the nature and onthe degree of the inflammation, and on thestructure of the part in which it is formed.Pus is sometimes thick and homogeneous ;sometimes it is curdy, flaky, or clottish;that is, it consists of parts that are thicker,swimming, or contained, in a thinner fluid ;sometimes it is serous or watery; sometimesit is viscid or slimy.

I have spoken to you of suppuration asan effect of inflammation ; but the formationof pus is not confined to the circumstanceswhich were then explained and alluded to.Pus may be formed on the denuded surfaceof the skin, for example, after the applica-tion of a blister. It mav be formed on thesurface of inflamed mucous membrane, andthat of inflamed serous membrane, and thatof inflamed synovial membrane. It may beformed on the surface of wounds, and ofulcerations ; and, lastly, it may be formedin consequence of inflammation in the inte-rior, or in the substance of various orgaiis ;

and when pus is thus formed, the collectionof fluid which it constitutes is called anabscess.An abscess, therefore, consists of a col-

lection of purulent matter in the inteuor ofany part of the body, excepting, however,the regular or normal cavities; for when pusor any other kind of fluid is deposited inthem, we call it an effusion, and not anabscess.

Inflammation, as I have already informedyou, varies very greatly in different in-stances, in the violence of its symptoms,and in the rapidity of its progress ; some-times going through its course within a veryshort time, at others occupying a very longperiod ; and the formation of matter, or sup-puration, partakes, in this respect, of thatvariety of character which is observed inthe inflammation that produces it. You mayhave pus completely formed, an abscess fullydeveloped, in the course of a very shorttime, that is, in the course of two or three

days for instance ; or you may have thecollection increasing and remaining in thepart, without coming to a head for severalweeks or months, or even, perhaps, years.We might, therefore, designate suppurationas we do inflammation, by the terms acuteand chronic, and, in fact, we speak con-stantly of chronic abscess, though we donot exactly use the term acute abscess; wemore generally talk of phlegmonous abscess,to denote those collections of fluid whichare produced by the most violent and rapidforms of inflammation.

I shall first, then, speak to you of the pro-gress of inflammation as it occurs in phleg-monous abscess. When the inflammationhas proceeded to a considerable degree,matter is deposited in the centre of the in-flamed part. The inflamed textures, as Ihave already mentioned to you, become insome measure softened, or, at least, theirpower of cohesion is lessened by the pro-gress of inflammation. This change goes onto its utmost extent in the centre of the in-flamed part, where pus is secreted ; and, infact, portions of the textures actually losetheir cohesion. They may be said to bebroken down; and when this effect is pro-

duced in the textures of the part, there is

362

effusion into them from the inflamed vessels,at this period, of a thin serous appearance,something like a bloody effusion. When ’I

say that there is a portion of the texturesof the inflamed part broken down, and thatthen there is effusion from the inflamed ves-

sels, I do not allude to any mechanical pro-cess, but to a change of condition, the resultof a vital action. We now begin to perceivewhite spots of matter disseminated here andthere, in the part which is the seat of thegreatest action, and these soon unite, so as

to form one cavity. The cavity which isthus formed, enlarges ; it increases in size,pushing aside the cellular substance and thesurrounding soft parts, which yield more or

less, according to their nature. Now suchof these parts as are firm and resisting, donot give way at first to the process I havementioned. Blood- vessels, nerves, tendons,these form elevations or ridges on the sidesof the abscess, and sometimes they consti-tute a sort of fraenum, or bridle to the ab-scess, crossing from one side to the other.The surface of the cavity, when we ex-

amine it, is found soft and pulpy, and it

presents a greyish appearance. If we takethe handle of a knife, we can scrape off apulpy, greyish substance, which is gene-rally supposed to consist of the coagulablelympli effused by the inflammatory action.It appears, indeed, not organised, althoughit closely adheres to the surface of the part.When we thus scrape off this grey pulpycovering, we find that the interior of theabscess presents the appearance of a densetexture, that has been compared, and notvery inaptly, to that of a mucous membrane.It is reddish in colour, firm, compact, andtolerably uniform in structure. This kindof membranous structure constitutes whatwe technically call the walls or parietes, thesides, the sac, or the cyst, of an abscess.In fact, if this part, with the matter it con-tains, were dissected out, the abscess wouldthen present a bag or cyst. The internalsurface of this cyst is in contact with thematter which the abscess contains. To theexternal surface, the surrounding cellularmembrane, and other pasts in which theabscess is formed, are closely adherent,being condensed-rendered preternaturallyfirm in texture by the inflammatory process.This condensation extends to a greater orless degree around the abscess, unt.l yougradually come to the natural textures of thesurrounding parts. In the early stage ofthe formation of pus, there is a considerable

portion of this condensed or hardened sur-face surrounding the cyst of the abscess; -,but in proportion as the collection of pus in-creases, the surrounding hardness becomesless in extent. the p&rietes, or walls, or

cyst of the abscess, are obviously caused bya condensation of the cellular texture of the

part, in consequence of the effusion of lymphinto it under the inflammatory action. The

inflammatory disturbance which proceed3 tothe length of suppuration in the centre ofthe inflamed part, produces the effect of in.terstitial deposition in the circumference.In the language of Mr. Hunter, the inflam.mation in the centre is suppurative inflam-mation, and the inflammation in the sur.

rounding part is adhesive inflammation.The cyst, which is thus formed, constitutesa natural barrier which contains the pus,insulates, separates, it from the suiroucdmstextures. If it were not for this barrier, thepus would be disseminated in the cellu!arstructure round the part in which it is de-

posited, and, like serum in anasarca, mightpass extensively over the whole of the limbfor example. The condensation of the cel.lular texture around the inflammatory pro.cess, prevents this extension, which wouldotherwise take place ; it confines the changeto the part in which it has immediatelyoccurred.The pus, which is contained in an abscess

formed under these circumstances, is thick,homogeneous, and generally of a whitishcolour. When I say it is thick, I mean it isequal in thickness to the thickest kind ofcream, and sometimes, in fact, it is more so,coming near to the consistency of a softsolid, such as butter. Generally speaking,the higher the degree of inflammation, thethicker the pus which is produced by it.This is the idnd of pus pathologista havecalled good pus-laudable pus; that is, thekind of purulent secretion which is pro-duced by a high degree of inflammation oc.curring in a healthy individual. That, nodoubt, must be the reason which has givenrise to the term of-good laudable pus. Thethick and uniform pus, found under thesecircumstances, is found to be heavier thanwater ; so that if it be received into a ves-sel of water, it falls to the bottom ; and thathas been considered a criterion to dis.

tinguish between purulent and mucous Ee.cretion. A very great deal of trouble hasbeen taken to establish a criterion of differ-ence between the two ; for, under certaincircumstances, it becomes a matter of im.portance to consider whether a fluid is a

suppurative fluid, or a mucous secretion.

Unfortunately, however, no. very disfinetcriterion of difference has yet been found in

I animal chemistry, between the thick creamyfluid found in an abscess, and the ordinaryexhalation of mucous membranes. Gene.

rally, there are such obvious differences,that we are not in any want of a minute cn-terion ; but we are to recollect that, underinflammation, those membranes which secrete mucus, come to secrete a fluid whichis afterwards very like pus. And I believethere is no certain teat by which it tan be

363

discovered, whether a certain animal fluid isthe natural product of mucous membrane,o of the suppurative process of inflamedvessels; that is, there is, I believe, no cer-tain test by which we can distinguish pusfrom mucus. Mucus certainly floats in watergenerally, instead of sinking to the bottomas pas does, but this is by no means constan t.Now the mucous secretion which takes

place from the bladder, sinks to the bottomof the chamber-pot in the urine, though theurine is a great deal heavier than water.

iiucus is ropy, slimy, and viscid, while pusdoes not present any thing of this charac-ter, But, then, when we view the gradualprogress of the inflammation by which mu-ms sometimes assumes the character of pus,we become still more puzzled, in the appli.cation of a criterion for discovering the dif-iaeaee.Pus is secreted from the surface of the

cavity which contains it-secreted or ex.ialed, Heretofore an opinion has beenentertained that pus is produced by a

breaking down of the natural textures ofthe part; this idea, no doubt, having arisenfrom the existence of the cavity that is

( found in a part where the suppuration has,

taken place. You see a large excavation,and the first impression is, that the puscontaiued there has consisted of the na-

wral textures that before filled the cavity,! wbich, by some strange process, have been’ reduced to the form of pus. Again, it

í has been supposed that pus is formed byrome stagnation or putrefaction of the fluidsoithe part. It has further been maintained

iliat pus can only be formed in consequenceof a process of ulceration ; and thus whenpus bas proceeded from any of the mucouscavities having external outlets, it has been

, supposed that ulceration existed in those. parts, to account for the discharge of the

pus. All these notions, of course, havevanished, in proportion as correct physio-lagical observations have prevailed, and inproportion as minute examinations havebeen instituted after death ; and though,

-

even not many years ago, several contro-Tersies existed on these points, they are

-

now so completely settled, that it is notworth while again to revert to them.

It ti further supposed, in order to producea fluid possessing all the characters of pusin their full develonment, that a certainjorUCfSS of elaboration is necessary; that is,that the fluid is deposited in a part, first illa certain state, and that it undergoes changeswhich gradually bring it to pus ; and thisseems to be countenanced by the term ma-turation, or ripening, used by the old writers.Now the fact is, that pus is secreted at:rre; there is no passing through changes ;there is no elaboration which bringa it intothat couditiop, except so far as regards the

first process ; for then, as I mentioned toyou, there is an actual separation of the

part, in order to form that cavity in whichit is deposited. The fluid first secreted hasa serous, and sometimes a bloody character,though afterwards we find, in the same part,the secretion possessing all the charactersI have described to you as belonging to pus.That only applies, however, to the com-mencement of the process ; and in the same

way in the instance of denuded skin, and alsoof inflamed mucous membrane, we do not findthat the fluid first secreted, has all the ulti-mate qualities of pus. A serous fluid is firstpoured out on the inflamed skin, and that isgradually changed into a fluid containingglobules, which constitutes pus. There is asimilar change from the colourless viscidsecretion of serous membrane to that of thethick purulent secretion, which proceedsfrom mucous parts. 1n some instances we

see appearances which lead one to supposethere is really something like giving way,and breaking down of the parts in whichsuppuration takes place. Now, some timeago, I had a patient in this hospital, who hadbeen sent from the Fever Hospital, in whoman abscess had formed in the hip ; I madea puncture, and allowed it to discharge. Asit ran out it appeared to me to look partlylike oil and I saw, when it was pouredinto the vessel, that it consisted of well-formed pus, and a good deal of oil. Afterthe opening had discharged for a consider-able time, I found something obstruct theflow through the aperture ; I laid hold ofthat, and taking it away, I found it to be aconsiderable portion of adipose substance ofthe part that had been floating in the ab.scess, and the oil which came out had been,no doubt, contained in the adipose cells.

In the case of suppuration of certainglands, there is an obvious admixture of thesubstance of the part with the pus; this isthe case, for instance, with respect to theliver, where part of the substance is foundin the pus, giving it what is called its hepa-tic appearance. The pus is of a brownish-blue colour, derived from the colour of thetexture of the liver.The surface then of the abscess secretes

the pus which the abscess contains, and itis also capable of absorbing, or taking upagain the fluid which it has deposited ; it isa secreting and absorbing surface ; hencewe may regard the cyst of an abscess as akind of new organ developed in the body.

Symptoms.—With regard to the symptomsof suppuration ; when inflammation has beenof a violent kind, when it has been rapid inits progress, when there has been consider-able pain, and that preternatural throbbingwhich characterises it, we may expect thatsuppuration will occur. The actual form-ation of matter in the part is characterised

364

by a remission of the local pain ; the painbecomes less severe ; it seems frequently tostop altogether ; soon, however, a kind ofdull aching sensation, a sensation of weightoccurs in the part; there is a sense of

tension, and in cases of the formation ofmatter, a kind of pulsation-a pulsation syn-chronous with that of the heart, takes

place immediately before the formation ofmatter ; and during the time it is forming,it is not uncommon to have rigours or shiver-ings, and these have generally been regard-ed as one of the most certain signs of matterin the abscess. Now the truth is, thatmatter frequently forms without the occur-rence of rigours, and rigours often occur

when no suppuration takes place ; there isno necessary connexion between the occur-rence of rigours and suppuration. Rigoursoccur in most of the spontaneous inflarnma-tions of the body.The most unequivocal evidence, however,

of matter having formed in a part, is thesoft feel which the presence of matter com-municates to the hand of the examiner.When you come to feel the part, you aresensible that a fluid exists in it; and ifyou feel it with your two hands, makinga pressure alternately with the one and theother, you find that the fluid car. be per-ceived moving from one side to the other,and that it thus imparts the sensation ofwhat is called fluctuation. It is often a

matter of consequence to ascertain whethermatter is formed or whether it is not, andhence we frequently have to examine the

part very carefully in order to discover thispoint. It is difficult to describe sensations,and I do not know that it can be done ; Ican only say, you will be able to ascertainthe kind of feeling that is communicated bythe presence of matter by actually examin-ing parts where suppuration has taken

place.When matter has formed at some depth

from the surface, of course it becomes diffi-cult to ascertain the fact. When vou are

examining a part, in which the point is verydoubtful, it is not, perhaps, so well to placethe fingers of the two hands upon it, and topress alternately with them, because youoften, ill this way, produce a hind ofimpulsefrom cellular infiltration; but if you place thefingers of one laud upon the pai t, let themremain at rest, and make pressure with thoseof the other, and if you feel a fluctuationagainst the fingers at rest, you may prettysafely conclude that the formation of matterLas occurred.

When suppuration has taken place, thecavity of the abscess extends itself in a’,ldirections. It becomes larger and larger,2nd in this extension we observe, of course,that it enlarges most readily in those direc-

tions in which the resistance is least. Gene-rally speaking, therefore, the cavity of theabscess tends to enlarge towards the exter.nal surface of the body, because, in thatdirection, there is the least resistance to

its development ; or it tends to increasetowards the surface of any of the mucouscavities or canals of the body. This pro-gress of an abscess, however, towards theexternal surface of the body, or towards anyof the natural mucous outlets, does not dt.pend simply on the circumstance of therebeing less resistance in those directions, forabscesses will take either of those courses,even although there should be much lessresistance to their progress in other direc-tions. Supposing abscess, in fact, takes

place in the parietes of the abdomen orchest, and that the seat of the abscess isnearly on the external surface of the serousmembrane of either cavity, the matter will,in the majority of instances, pass throughthe muscular parietes of the chest or abdo.men, and present externally, although itmay be covered only by the thin serous

membrane in the other direction. And so,generally, however deeply an abscess mayhe formed, and covered externally by partsthick and unyielding, the obvious tendencyof the process is to a removal of the partsthat are situated between the collection andthe skin, and consequently to bting the mat.ter to a discharge externally, either throughthe natural external surface, or into some ofthe mucous outlets of the body. In the

progress of the abscess towards the externalsurface, there is a gradual removal of theparts which intervene between the collec-tion and the skin. Here, therefore, a newprocess takes place. So far as we havehitherto seen, we have suppurative inflam.mation produci1Jg’ the deposition of pus inthe cavity of the abscess, and adhesive in-flamination consolidating the textures whichsurround the abscess, forming a barrier tolimit and insolate it from the surrounthugparts. But another, and quite a different

process, is necessary, in order to bring thematter to the external surface. You musthave a regular removal of the parts which in-tervene between the abscess aud the surface;and you find that those parts are regulalyand progressively removed, so that the ex-ternal coverings of the abscess become thin-ner and thinner, and the feeling of fluid be-comes more and more obvious ; the fluctua-tion, as it is technically called, is more easilypetcpived. As this process goes on, the

swelling in the circumference of the abscessbecomes reduced, and, at the sarne time, thecentral portion where the sense of fluctua-tion is perceived, swells more considerably,raising up a sort of prominence of the skin;that prominence often assumes a pointedform, and we then begin to see the part at

365

which the abscess will break. This is thestage of the process which is technicallycaled the pointing of an abscess. Whenthe matter approaches to the surface, the.,a becomes red, tense, and shining. Ase skin becomes thinner and thinner, thisredness becomes deeper in tint; it assumes:ae. hue. Lastly, the skin ulcerates, andthen the matter escapes at the opening. Ifre cut cle covering the ulcerated part ofthe skin be very thick, as in the palm ofthe land, or the sole of the foot, you willb that the matter will elevate the cuticle,it it will often separate the cuticle exten-sively from the cutis, and thus, though thehas given way, the pus is not dis-charged externally; but when the cuticle israised in this manner, it ultimately gives!!B also, and then the matter escapes. Atfirst a certain quantity, one, escapes at theaperture thus made, for the opening formedby the ulceration of the skin, is, in general,a very small one ; but as much escapesthrough it it as relieves the tension, and thei"tient is considerably relieved from thepain he has before experienced. The sidesd the abscess contract in consequence ofiiii., diminution of the quantity of its con-tents. When a fresh quantity of pus hastaen screted, it again flows out at the

opening, and the size of the aperture be-comes larger: it progressively increases, soas to allow the whole to drain away. Thesices of the abscess again contract, the aper-t.re becomes smaller, it cicatrises, the partbeals, and thus a natural cure takes place.Sometimes, however, in parts where mo-

tion is constantly occurring, and also in

some places where we do not accurately ob-wre the condition of the part, the cavityc: the abscess does not become completelya.utzrated; it is reduced to a small exteiat,but still there is an external opening, frommatter escapes, and we find that thathas into a small tube of various extent inc derent instances ; that small tube, which is..- remains of the abscess, and the external-.i, through which the matter is dis-_r.;:d, ccnstitute what is called a fistula.’);i’. fistula means merely a tube ory P,

Treatment.—I have next to consider the of an abscess of the kind of which:...: been speaking to you. I have men-- : to you, that the sides of the abscess’- capable of absorbing, as well as of secret-, s. We may, therefore, conclude, thatprocess oi inflammation could be com-’’-’ put a stop to, the pus contained in

-h,,es would be taken up by the absorb-:. and thus that a natural cure of the’ - mightt he effected without the mat-- ’‘ .=T dIscharged at all. In this way,- .:.c,es abscesses are cuyed, without’-;: their bursting or being opened. It

is, however, not a very frequent mode ofcure, and certainly, as a general rule, wemay say, that when matter has formed in a

part, it either must be discharged by thenatural process I have now mentioned toyou, or be let out by a surgical operation.

I think the most frequent examples ofcure of abscesses by absorption are affordedin cases of venereal bubos, and in those for-mations of matter in the neighbourhood ofthe groin. There is a young woman at

present in Magdalene’s Ward, in this hos-

pital, in whom a considerable portion ofmatter formed in a bubo has been ab-sorbed. She came into the ward with avenereal sore, of about the size of a six-

pence, on the inside of the labium, and abubo in a state of suppuration. The skinwas of a bright-red colour, and very thin;the bubo must have contained at least all

ounce of matter, if not more. In fact, theskin was so red and thin, that I thought itshould be opened ; and I do not know whatcircumstance it was, that led me to post-pone the operation on that day. When Isaw this patient on the next visit, it did notappear larger in size, it did not give hermuch pain, indeed it was rather easier, andI did not then open it. The next time Isaw her, it appeared evidently to be goingaway; the skin covering it was wrinkled,the enlargement was less, the rednessseemed gradually to be diminishing, thefluctuation became less obvious, and nowthe matter is entirely removed. The treat-ment has consisted simply in keeping thepatient at rest; she has had a poultice overthe part, and she has taken mercury illmoderate doses.The dispersion of an abscess in this way,

however, does not happen often enough, tolead us to lay down any general mode oftreating it, with reference to that particularobject. It may be said, however, that themere occurrence of suppuration in a part isnot a sufficient reason for giving up the em-ployment of those antiphlogistic means wehad been previously using, with a view ofreducing inflammation. There is often veryconsiderable inflammation existing, a greatdeal of hardness around, and redness of thepart, though matter has formed at one point;hence we often continue with advantage theapplication of leeches, for instance, andthe general means calculated to lessen in-flammation, such treatment being likely, ifthe case admits of it, to favour the disper-sion of matter by absorption.When pus has formed, we may leave the

progress of the case to nature, and allow theprocess to go on, which I have just describ-ed to you, keeping off n!l those causes thatwould be likely, either locally or generally,to disturb such natural process. Thus, weshould keep the part at rest, keep it cover.

366

ed with soft pooltices, keep the patient onproper diet, an I pay attention to general Bhealth. In that way we may allow theabscess to go through its natural course, to,break, to discharge of itself, and to heal upunder a course of simple dressing. Frequent-ly, however, we find it necessary to dis-

charge the matter by an artificial opening,and different modes have been taken for

accomplishing that purpose. Thus, abscesseshave been opened by seton, by caustic, bypuncture, bv incision. In the discharge ofan abscess by seton, a needle containingthread, is passed through the cavity fromside to side, and the thread is left in the

opening tl.us m:de, allowing the matter, bythese means, gradually to find its way out.There is no kind of advantage belonging tothis mode of evacuating an abscess. In

phlegmonous abscess, it is obviously inad-missible, on account of the irritation it pro-duces, and, in fact, so destitute of advantageis it, in any way of viewing it, that it is com-pletely abandoned. In the mode of openingan abscess by caustic, the prominent, or

pointing part, that is, the thin part of theskin, is rubbed over with pure potash; andthe slouch formed by it is allowed to sepa-rate or drop off, and the matter is then dis-charged ; or in the slough thus formed, anopening is made with the knife, and thematter is let out in that way. This is akind of proceeding which is not generallyapplicable. Perhaps the only case in whichcauatic can be advantageously used in open-ing abscesses, is in instances of bubo, wherethe skin is become very thin, when it hasbeen considerably detached from its subja.cent parts, and where, consequently, a por-tion is likely to lose its vitality ; where partof the skin will become sloughy, or verylivid, and then, almost immediately, on theapplication of the caustic, it will be remov.ed, and the matter discharged.

1 should have mentioned to you, in speak-ing of the natural bursting of abscess, thatwhen the skin has been rendered very thinby the approach of the matter to the sur-

face, when it has been detached from itsvascular attachments below, it not unfre-quently happens, that a portion of the verythin skin 1)erliaps sloughs, and thus the mat-ter escapes in consequence of that processof sloughing. -

Generally, therefore, when we attempt todischarge tba contents of an abscess, we doit v the direct means of puncture, or inci-sion, making an opening with a cutting in-strument, very commonly a broad lancet hasbeen used, called an abscess lancet, whichhowever, in many respects, is not a veryconvenient instrument. I think you wiilfind the best instrument is a large, strong,straight, double-edged bistoury, with a lan-cet point. It penetrates very easily in con.

sequence of its sharp point and size; andwhen you have carried it into the abseas,you can easily extend the opening to anysize you desire. 1 find it the most comen:.ent instrument for the purpose, and tl:ere.fore 1 always employ it-a pretty strong,double-edged bistoury, and pointed like alancet. With this instrument (showing it)you make an opening, if you simply punc.ture the abscess, equal in size, to the breadthof the blade ; or, if you wish to make it

larger, after you have carried the blade in,you extend the aperture with a slight motionof the hand, as fur as you wish. if the skinhas become very thin, you will generallyfind it necessary to make a short incision, morder to let the matter out, otherwise theopening will heal up and prevent its escape.It is not necessary, however, to make a largecut as is sometimes done in an abscess, andstill less is that proper to be done, which Ihave sometimes seen-the operatori ntioducehis finger into the abscess and turn it round,in order to destroy the fraena, as he said. Iremember seeing a surgeon of n large hos-pital introduce his finger into an abscess,turn it round several times, give the patienta great deal of pain, and think he was doinga very clever thing indeed. (Laughter.) Infact, the mere discharging of the matter, bythe introduction of a knife, is apt to producean irritation of the part and if in addition

to this, you use any violence not necessaryfor the purpose, you of course augment thatincreased irritation. For this reason it is

; found necessary, merely to make a punctureor incision, and to let the matter dram out o!itself. It is by no means necessary to squeezethe part, in order to get out all the matterthe abscess contains. You are not to considerit as a matter of importance, completely to

empty the bag. Nature does not ; shem .akeaan opening, and a small part flows out; that

heals, she repeats the operation, more of itflows out. The mode she adopts, is to get it

out by gradual discharges. If the openingmade is to be attended by a considerable irri-tation, through squeezing it, there is notonlyno advantage, but obviously a good dealotdisadvantage produced by the operation.Then after making the puncture or incision,let the matter slowly run out, cover the partwith fomentations, or something of that na-ture, soft and moist, for half an hour, so tllstthe matter may be more abundantly dis-charged, by the shrinking of the sides of theabscess, and then cover the part over with apoultice, till it heals.Now it becomes of considerable import.

ance to determine what are the cases inwhich an abscess may be left to its naturalcure, and what are those in which it is de-sirable to make an artificial opening for thedischarge of the matter. When the col-lection is near the surface of the body, and

367

when it is seated in in unimportant part,you may leave it to itself-allow nature todo tbe business. But there is a variety ofcases in which you wish to abridge the

Izrod of inflammation, or to limit its ex-

tent; and for these purposes it becomes

necessary that you should resort to ther;,,asure of artificially opening the abscess.

I have stated to you, generally, that thematter of an abscess gradually approaches,I) the surface of the body ; but when thematter is formed deeply in a part, and whenH meets, in its progress to the surface, withmtain textures of an unyielding kind, itcannot approach to the skin, or, at allvents, its approach is’ considerably retard.ed; and being resisted in this direction, itextends to other parts where less resistanceis otered. Thus when matter is formedunder fascia—the fascia of the thigh, foreiaiiple, a very tough and unyielding part-it will be a long time before it can make itsway through that fascia ; and not beingable readily to get through, it extends underit, and the abscess becomes much larger insize than it would be but for this circum-stance, When matter forms deeply in a

limb, for instance under the muscles, itmeets with more or less resistance, and inthis way, either from its being resisted bythick unyielding fascia or tendons, its pro-gress to the surface is retarded. Under alltnese circumstances, it becomes proper tomake an opening for the discharge of thematter, as soon as yon can satisfy your-selres that matter exists; and we, there.

fore, early open an abscess, if it takes placein the fore arm, or in the thigh, and moreparticularly if it takes place either in thepalm of the hand or sole of the foot. There

is a very dense fascia covering those parts,and the integuments and cellular substancealso are particularly firm and unyielding, sothat matter does not come to the surfacewhen it forms there; on the contrary, be-ing deep-seated and confined by fascia, itmakes its way along the course of the ten-passing under the annular ligament-for initince, of the wrist into the fore-arm,and producing very extensive mischief. Youmust, therefore, as early as possible, openan abscess in those places ; and sometimes,Khen you cannot feel the fluctuation, whenyou cannot ascertain, by external examina-tion, that any matter is actually formed, eventhen you must make an opening.T’ e same reason applies still more strong-

ly to the case of matter formed in the neigh-hood of bones, as in necrosis, for therematter is confined by all the firm tex- of the limb. When matter forms in.:. situations it may extend, if it be not

charged by an opening, the whole length:; t:JV bone, and thus lead, perhaps, to the

death of the entire length of one of the longbones of the extremities.When active inflammation takes place in

a part, where there is a large quantity ofcellular and adipose substance, there theabscess will become very considerable, un-less you discharge it early ; this is parti-cularly the case about the anus and in theperineum. All such collections should be

discharged as speedily as possible. This isstill more particularly the case in the form-ation of matter where there is a good deal ofloose cellular membrane that is covered ex-

ternally by muscles, or other parts, as in theaxilla, in the ham, in the groin, in the neck.In the neck there is a considerable quan-tity of cellular membrane by the sides ofthe tracliea and œsophagus, and about thecarotid artery, jugular vein, and the accom-panying nei-ves those parts are coveredexternally by fascia, and also by the sterno-cleido-mastoideus muscle. It not unfre-quently happens, that formation of mattertakes place in the cellular membrane of the

neck ; and in consequence of the collectionbeing covered externally by the sterno-

cleido-maatoideus and fascia under it, it hasno disposition to make its way externally ;t in fact, the matter here will descend alongthe course of the vessels of the neek to-’ wards the cavity of the chest, unless it bedischarged. There is not only this danger,1 but the patient suffers excessively duringthe time the pus is forming in consequence* of the large nerves that traverse the neck,The matter frequently presses on the ceso-phagus, or pharynx, or against the trucliev. ;* hence you will find that very active febrile

disturbance is produced in these cases. Youe will see a patient, with matter formed undere the jaw, delirious for several successive

’’ nights. Here then you will proceed to makee

an opening as soon as you can gain sufficient proof that matter has formed.

You will see that, under the circumstancesI have mentioned, you are obliged to ope-rate for the discharge of matter when it isseated so deeply that you cannot have theevidence of fluctuation, and, in fact, yoamust make an opening when the quantity isso small that it would hardly produce fluc-tuation. What then are the evidences bywhich you are to satisfy yourselves thatmatter has formed 1 You must consider the

history of the case ; you must consider thesymptoms that have attended the origin andprogress of the complaint ; you must con-sider the pain the patient has endured, andthe general appearances. There is usually,in the neighbourhood of the part, a swellingfrom serous infiltration, that is a symptom.of importance too, in enabling you to deter-mine what should be done. When the

symptoms are very urgent, and, from theassociation of circumstances I have just

368

mentioned, you have come to the conclusionthat matter probably has formed, thoughyou cannot feel any sufficient pulsation or:fluctuation, you are fully justified in makingan opening, though sometimes the matterdoes not afterwards actually flow out; thereis no great harm in making a puncture tosee whether matter has formed or not. Youwill sometimes, however, have to go verydeep, in order to get at the pus; sometimesyou will have to penetrate the whole lengthof the blade ; and, further, particularly whenthe operation is in the neck, you must becareful of the place in which you make thisincision, in order to avoid injuring any blood-vessel, or other important part. It is ne-

cessary, too, in these places, where the mat-ter lies deeply, to make a f)-ee opening,because in so doing you cut through partsthat are in a healthy state, and if the sidesof the opening you make were to remain incontact they would speedily close, and theflow of the matter would be prevented; youmust, therefore, make a freer opening herethan when the matter has approachednearer the skin. You must not only makesuch free opening, but in order to preventthe sides from adhesion, you must put some-thing between the edges of the wound, toprevent their union by adhesion, allowing itto remain for foUI -and-twenty or eight and-forty hours.

Matter must be evacuated as early as

possible, when it forms in any parts that areof a dense or unyielding structure, such aswhen it takes place in the theca of theflexor tendons of the fingers, and more particularly if the parts, besides being dense andunyielding, possess a considerable quantityof blood-vessels and nerves in the neigh-bourhood, because the process of suppurationoccurring in parts thus organised, is attendedwith excessive pain. This applies to all theformations of matter that take place about thefingers. The pain accompanying such for-mation ofmatter is of the most severe kind,and you cannot too speedily relieve the

patient from his sufferings. Moreover, asthere is very little disposition in the matterto come to the surface, it is very likely toextend along the theca to the tendons andinto the palm, and thus give rise to veryconsiderable mischief. In all these cases,then, make an opening, even though youshould not be absolutely certain that thematter has formed. There can be no risk,if you have any knowledge of anatomy, ofwounding any particularly important part;the worst is, that you make a puncture inthe skin, without actually discharging thematter.When matter is seated in the neighbour-

hood of any of the great cavities of the bodyor large joints, it is expedient to open theabscess early ; not that there is any great ‘

fear of the matter penetrating into those ca.vities, but it does so occasionally: and ithas sometimes happened, that matter form-

ing in the parietes of the abdomen or chest,has found its way into the chest or abdomen,and destroyed the patient.An opinion formerly existed, that wlx-re

matter formed, it had the power of corrodingor eating its way into the cavities. I neednot say, that this is quite an erroneous no.

tion. I need not say, there is no groucdfor ascribing any quality of this kind to c,,]-lections of matter. The resistance to the

discharge of matter in a part, produces theinjurious consequences. Matter does not

corrode, or chemically act on any part ; andone is almost surprised to find, in works

published even in the present day, notionswhich seem to favour some opinions of thatsort. I read only a day or two ago, ofmatter approaching the surface under the

process of " erosion" of the part-in thatway removing the surface ; and that, too, inan article that was in other respects ex.tremely well written.Another case in which collections of

matter should be opened is, where they areproduced by the introduction into the cellu-lar membrane of any irritating fluid, such asthe effusion of urine or f’meal matter. The

only way to limit the mischief which willbe produced by such directly irritative

causes, is to make free and early openings.When matter forms in parts which are

of great importance to life in consequenceof their functions, such as in suppurationabout the fauces, at the entrance of the plia-rynx—suppuration about the larynx-anyformation of matter that presses either uponthe trachea or œsophagus—all these shouldbe opened as early as possible. And this, Ibelieve, will nearly conclude the enumera.tion of the cases in which it is importauttoopen abscesses early—in which it is iml,ort.ant to anticipate the process of nature, in

bringing the abscess to an external dischargemuch sooner than it would be brought, if itwere left to its natural course.

In many of the cases I have now alludedto, it may be necessary, at the same timethe opening is made into the abscess, to em-ploy such antiphlogistic treatment as shallbe calculated to limit the inflammation,which may be supposed still to exi,t:n aconsiderable degree. In any deep-seatedformation of matter which you open inthis way, you may, perhaps, apply leechesfreely to the part, or even sometimestake blood from the arm, though you makean opening to discharge the matter. ’ll,a

opening of the abscess is not at all a rea-

son why you should not employ antiphlo-gistic means. ’I’hus if you have an abscessin the hand, and open it, you may wrrprobably find it necessary, as I have said,

369

in consequence of the swelling and redness:: mie blood from that arm. You may com - the two circumstances--open the ab-MS quickly, in order to limit the extent;’ the matter, and employ antiphlogisticment, in order to prevent the recurrenceof inflammation.

CLINICAL LECTURE

DELIVERED AT

St Thomas’s Hospital, November 27,BY MR. GREEN.

TRANSFUSION OF BLOOD.

The subject which I have to introduce torarnotice this morning, Gentlemen, is thesucessful case of compound f, actura ofthe tibia and fibula, in which I performedthe operation of transfusion. The patient,whose name was Samuel Tockning, his agethirty years, apparently a strong and healthy’c. had been accustomed to take a goodcr! of exercise, was admitted into Luke’sWard, at three o’clock on the afternoon ofthe second of November. It was stated,that Wililst working at the Docks, a quan -’h of gravel had given way, and fall-

ing on him bad broken his leg, and the acci-dent had bappened about an hour before hismission into the hospital. On examina-:: , the fracture was found to be an oblique!;:-, between the middle and lower thirds,extending in a line upwards and outwards,and the lower portion projecting consider-over the upper; the external woundwaeytensive, and the fractured extremitiesding and covered with dtrt, &c., whichwas removed by the dresser. I will showyou the bones, for their appearance is in-’-’h, and I might, perhaps, better ex-

to you the situation into wilieli they e thrown. (’rhe bones were shown afterture, when Mr. Green explained, thatfractured extremities of the tibia had

>-r.a;e each other, thereby preventingpossibility of reducing’ the fracture with-: se aid of the saw.) It appears, thatm-eatension was made in order to re-the fracture, but this being found im.icable, it was thought better to allowto remain until my arrival ; the pulse:: then 66, weak and labouring. In the, when I came, I found it impossible

the fracture, and therefore sawedabout an inch of the lower extremity of

with Hey’s saw; and it is worthythat there was more than usual li

.: in in sawing off the bone, on accountbeing 0 unu5ually dense, which, with.

the firmness and strength of the muscularfibre, &c., served to show that he was in a

good state of health; having then broughtthe fractured extremities together, a littlelint was laid over the wound, and the limbput up in Amesbury’s apparatus, in the

straight position, with the heel raised, byplacing a small cushion underneath to favourthe return of blood. With respect to thedressing, it will be observed that nothingbut lint was employed. Sir Astley Coopermentions, in his lectures, that a piece oflint, soaked in blood from the wound, isthe best application one can employ in suchcases, and I have always found it to be so ;it excludes the air, and sits closely, adaptingitself to the parts ; and, perhaps, its beingblood may be one reason why it should bebetter than any thing else.On the following day I found he had slept

several hours, but complained of consider-able pain in the limb ; skin hot and dry ;pulse 90, full, hard, and vibrating, sp thatreaction had very soon taken place, showinga previous good state of health and a vigo-rous constitution. It was of course veryrequisite that a certain degree of inflamma-tion should take place, and here was a

healthy reaction, only that it was excessive.It was desirable to reduce this, for it was

by no means improbable that gangrenewould supervene ; I therefore ordered hima dose of the house physic, that is, a mixtureof the common Epsom salts and infusion ofsenna, and directed some leeches to be

applied to the leg.On the 4th, the pain in the limb was

relieved, and the bowels had been openedseveral, I believe seven, times. This wasa greater effect than I had anticipated fromthe medicine, or than was desirable, as weshould not wish, in such cases, to remove

all constitutional reaction, but merely to re-duce it a little; the pulse was 105, andtongue white.On the 5th, be was much the same as on

the preceding day ; there was some fever,but he was evidently lower ; doubttesstbis-proceeded from the excessive action on thebowels, 1 therefore ordered him some beef-tea, instead of slops, which alone he hadhitherto been taking, and as there was someoozing from the wound, I ordered a bread-

poultice to be applied, in order to prcmotea bfalthy discharge. I preferred bread inthis instance to lifiseed-meal, because it islighter and lies more loosely.On the 7th, the wound is stated to have

been looking well, but there was a sloughover some part of it, as indeed one migutexpect, considering the nature of the wound ;it was a bruised wound, and iii which CQJ,.siderable injury bad been done to the sur4

rounding parts. The bowels had not beea

opened since the violent action of the house