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BEABSOBPTION OP PUS. 179

were distinguished by the name of physiological reabsorption of pus, from that which was considered to be pathological, and the only question that remained was, in what way the first process with its favourable and the second with its malignant issue could'be accounted for. This matter finds its simple solution in the fact that pus as pus is never reabsorbed. There is no form, in which pus in substance can disappear by the way of reabsorption; it is always the fluid part of the pus which is taken up, and therefore what is called the reabsorption of pus may be referred to the two following possibilities.

In the first case, the pus with its corpuscles is at the time of the reabsorption still more or less intact. Then the pus becomes of course thicker in proportion as the fluid disappears. .This constitutes the long known thickening (inspismtiori) of pus, whereby is produced what the French term "pus concret," which consists of a thick mass, containing the pus-corpuscles in a shrivelled condition, when not only the fluid between the pus-corpuscles (pus-serum) but a part also of that present in them has disappeared.

Pus consists essentially of cells, which in their ordinary

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Fig. 03. A. Pus-corpuscles, a fresh, b after the addition of a little water, c—« after treatment with acetic acid, the contents cleared up, the nuclei which were in process of division, or already divided, visible, at e with a slight depression on their surface. B. Nuclei or pus-corpuscles in gonorrhoea; a simple nucleus with nucleoli, b incipient division, with depressions1 on the surface of the nuclei, c progressive bi-partition, d tri-partition. C. Pus-corpuscles in their natural position with regard to one another. 500 diameters.

1 By many held to be nucleoli.

condition lie close to one another (Fig. 63, C), and between which a small quantity of intercellular fluid {pus-serum) exists. Within the pus-corpuscles themselves lies a substance which is likewise provided with a great quantity of water; for nearly every specimen of pus, although it may look very thick when fresh, contains such a large amount of water that it loses a great deal more by evaporation than a corresponding quantity of blood. The latter only gives the impression of being more watery because it contains a great deal of free (intercellular), but relatively little intracellular, fluid, whilst in pus on the contrary there is a greater quantity of water in the cells, and less without them. When then reabsorption takes place, the greatest part of the intercellular fluid first disappears, and the puscorpuscles draw nearer to one another; soon, however, a part of the fluid from the cells themselves also vanishes, Fig. C*. an^ m proportion as this is the case,

a i they become smaller, more irregular,

i©® ®$ angular, and uneven, they assume the 0 G* most singular forms, lie closely pressed together, refract the light more strongly on account of their containing a greater quantity of solid matter, and present a more homogeneous appearance.

This kind of inspissation is by no means so rare a process as it is often assumed to be, but on the contrary of extremely frequent occurrence, and almost even more important than frequent. This is namely one of the processes which lead to the formation of the much discussed cheesy products which have recently been all included under the term tubercle, and concerning which it has been shewn, especially

Fig. 64. Inspissated, cheesy pus. a. Shrivelled pus-corpuscles, diminished in size, somewhat distorted, and looking more homogeneous and solid than usual, b. Similar corpuscles with fat granules. c. Their natural position with regard to one another. 300 diameters

INSPISSATION (tubehculization) OF PUS. 181

by Reinhardt, that they must to a very considerable extent really be referred to pus as their origin, and therefore be regarded as inflammatory products. Hereafter, we shall see that these observations have been employed for the deduction of false conclusions concerning tubercle itself; but that by inspissation inflammatory products can be converted into things which are called tubercles, is indubitable. It is precisely in the history of pulmonary tuberculosis that this operation plays a very prominent part. You have only to imagine shrivelled-up cells like these inclosed within the alveoli of the lungs and undergoing inspissation of their contents in one alveolus after another, and you will at length obtain a cheesy hepatization such as is usually described under the name of tubercular infiltration.

This imperfect reabsorption, in which only the fluid constituents are reabsorbed, leaves the mass of solid constituents lying in the part as a caput mortuum, as a mass deprived of vitality and no longer capable of life. This is the kind of inspissation which we see occur on a large scale in the case of imperfect reabsorption of pleuritic exudations, when very large layers of a crumbling substance

Fig. 65.

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remain behind in the sac of the pleura; and also round about the vertebral column in caries of the vertebrae

Fig. 05. Inspissated haemorrhagic pus from a case of empyema, some of it in process of disintegration, a. The natural mass, containing granular debris, shrivelled pus- and blood-corpuscles. b. The same mass treated with water; a few granular, decolorized blood-corpuscles have become evident, c and d. After the addition of acetic acid. 300 diameters, and at d 520.

(Spondylarthocace), cold abscesses, &c. In all these cases the reabsorption is at an end as soon as the fluid has disappeared. Herein consists the evil import of these processes. For the solid parts which are not reabsorbed, either remain lying in the part as such, or they may afterwards soften, in which case, however, they do not usually undergo reabsorption, but for the most part give rise to ulceration. At all events what is reabsorbed is not pus, but a simple fluid composed in great part of water, a few salts, and it very small quantity of albuminous matter, and there can be no question but that we have here presented to us one of the most incomplete forms of reabsorption.

The second form of purulent reabsorption is that which constitutes the most favourable case, when the pus really disappears and no essential part of it need remain behind. But here too the pus is not reabsorbed as pus, but first undergoes a fatty metamorphosis; every single cell sets fatty particles free within it, breaks up and at last nothing further remains than fatty granules 'and intervening fluid. Then therefore

(fy 9re (£p there exist no longer either cells or ,jL. J,,.... pus; and their place is occupied by an *&$1$$S emulsive mass, a kind of milk, composed of water, some albuminous matter and fat, and in which even sugar has on various occasions been demonstrated, whereby a still greater analogy with real milk is brought about. It is this pathological milk, which afterwards comes to be reabsorbed—once more therefore not pus, but fat, water, and salts.

These are the processes which may be denominated "physiological reabsorption of pus;" a reabsorption, in

Fig. 66. Pus engaged in retrograde fatty metamorphosis (fatty degeneration). a. Commencement of the change, b. Fat-granule cells with nuclei still distinct. tr. Granule-globule (inflammatory globule), d. Disintegration of the globule, c. Emulsion, milky debris. 350 diameters.

PUS IN THE LYMPHATIC VESSELS. 183

which pus is not reabsorbed as such, but either only its fluid constituents, or its solid ones after they have been considerably altered by an internal transformation.

There is however certainly one case in which pus in substance may become the object, not exactly of a reabsorption, but at any rate of an intravasation, and where this intravasated pus may circulate within the vessels; I mean the case in which a vessel receives a wound or is perforated and pus passes through the opening into its interior. An abscess may lie close to a vein, burst through the walls, and evacuate its contents into the vessel. Still more easily can such a transit be effected in lymphatic vessels which run into open abscesses. The only question therefore is how far we are entitled to consider this case as a frequent one. As far as the veins are concerned, the possibility of such an occurrence has been for the last twenty years confined within somewhat narrow limits, and the notion of the reabsorption of pus in substance through the medium of the veins has been more and more abandoned; but about its taking place by means of the lymphatics people still pretty frequently talk, and indeed they have frequently occasion to do so.

But it is almost a matter of indifference whether the pus really finds its way into lymphatic vessels from the outside, or, whether, as others assume to be the case, it owes its origin to inflammation in the lymphatic vessels; ultimately, the question is always this, how far a lymphatic vessel filled with pus is capable of effecting an evacuation of its contents into the circulating stream of blood, and producing it genuine pyaemia. The possibility of such an occurrence must as a rule be denied, and indeed for a very simple reason. All the lymphatic vessels which are in a condition to take up pus in this way are peripheral ones, whether they arise from external or internal parts, and only after a somewhat lengthened course do they gradually reach the blood

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