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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.