and no animal structure is exempt from their operation. They do not take the initiative in inflammation, but act subserviently to prior changes. Ulceration, when it occurs, is consecutive to adhesion and suppuration, in almost all cases; and although suppuration may now and then pass without ulceration, in the same manner as adhesion prevents suppuration, yet the frequent case of ulcerative inflammation succeeding to abscess, and the very rare existence of ulceration without pus, constitute the ulcerative, third in order, of the processes of inflammation." 187.

The following are valuable practical observations:

"Although ulcer' is a comprehensive name for sores formed by the ulcerative inflammation, in many states and phases of their existence such sores exhibit no ulcerative action, as when that mode of inflammation is arrested. The interstitial absorption is the process by which what is called a healthy (healing) ulcer is dressed, levelled, and prepared for skinning, and it is only when this natural, not morbid, action, has superseded the ulcerative, that the healing process is fully established. No sore can heal while ulcerative absorption (the inflammatory process) continues either upon the edge or the centre. This mode of inflammation is so directly opposed to the adhesive, and so adverse to the healing, that being arrested, the hindrance to healing is removed. To put an end to it, therefore, is the surgical indication. This is done by constitutional and local treatment jointly; in some cases the one, and in some the other plan avails most.

"To know the character of ulcers and treat them accordingly, is a subject of the first importance to the practical surgeon, and well worthy of his science, though often not so regarded. They admit of a general classification, but present many varieties and anomalies. The great distinction is the presence or absence of the ulcerative inflammation, i. e. the morbid condition and action of the absorbents, by which the ulcer was formed. An inflamed is an ulcerative ulcer; so is an irritable, and more or less so is also an indolent or callous ulcer: in the gangrenous or sloughing ulcer, ulcerative inflammation is, as in gangrene, a necessary remedial agent for the purpose of separating the dead from the living parts, thus clearing the surface for sound granulations, and the edge for skinning. It is not necessary that ulceration should have existed prior to granulation, although granulation must succeed to ulceration; an ulcer has no other means of repair. The adhesive, then, is the curative termination of ulcerative inflammation; and, if for any reason the part is incapable of this action, disorganization and death is the consequence.

"It is, as we have shown, by ulcerative following suppurative inflammation, that matter and foreign bodies are brought to the surface and extricated, and that preternatural openings of communication, fistulæ, and sinuses are formed. But happily the adhesive action has gone before in the majority of such cases, and consequently, both external and internal openings and passages are defended by it, and the ulcerative process guided and circumscribed. Thus abscesses point, and effusions of the secreted fluids are prevented, and preternatural communications of the viscera with the surface are walled off and shut out from the system. If sudden injury or a cachectic state of the body anticipate this adhesion, and the ulceration is undefended, the worst consequences ensue." 198.

Cicatrization. This is the finishing stage of the adhesive process, and the completion of the process of granulation. It is rapid in proportion as the diameter of the ulcer is small, the surface level, and the secretion of pus diminished. A reason of the difficulty with which a sinus heals is the abundant secretion of pus from its surface. Others are its limited contact with the skin, and the non-development of granulations, which appear, however as soon as the sinus is laid open. When an ulcer has formed

upon an old cicatrix, its healing is usually tedious, owing to the defective quantity of surrounding free cellular membrane for the formation of granulation, and to the imperfect condition of the circulation in secondary formations.

"It has been a question whether skin is formed from the margin of the vessels of the skin, or upon the surface, by the vessels of the granulation. This I have no difficulty in answering. Certainly by the surrounding skin; for, first, we see it gradually advancing from the margin, and equally reducing the diameter of the sore from day to day; secondly, we never see the skinning process without the described preparation of the border, and the process is quicker or slower in propor tion to the distance of the skin from the centre; thirdly, the insular patches frequently observed upon the bed of an ulcer, especially unhealthy ones, may always be traced to a portion of undestroyed skin, thus confirming the fact. Lastly, the cicatrization beneath the surface, as of abscesses and fistulæ, is not, as before observed, by the formation of skin, or of proper granulation, but by an adhesive process, which tacks the skin to the subjacent cellular texture condensed by inflammation, drawing it inwards into folds and puckers; in short, a process similar to that which we see in the obliteration of cysts by pressure, and in the formation of solid tumours, to which the skin becomes adherent during their growth. It is very common to see these folds and indents of skin over scirrhous and other tumours, having so precisely the appearance of cicatrices after an abscess or an operation, that we are erroneously led to believe one or the other must have taken place.

*

"The extraordinary rapidity with which an ulcer sometimes forms skin, compared with its usual rate, conveys, with other circumstances, the not incorrect impression of the vessels of the surface indirectly aiding its formation. This is resulting from the contraction of the vessels of the granulations, in their union and levelling, giving a glazed appearance to their surface as the secretion ceases, and the (quasi) pellicle begins to form. But the act of cicatrization consists not in any fresh deposit: it is simply the last stage or completion of vascularization which renders the transparent lymph surface nebulous or opaque, and this always commences from the margin whence the vessels are derived, and is progressive from the circumference to the centre. The actual form of membrane is never accomplished, such as could be separated by fair dissection at any stage, from a cicatrix; it is a permanently opaque, unsecreting surface, a condensation of the new lymph with the cellular texture beneath or surrounding it, serving the negative purpose of a semi-organized covering, viz. protection to the part. Like all other new structures, it is a copy, and differs, as all copies do, whether of nature or art, from the original." 207.

Our space will allow of our making but one or two extracts from the excellent chapter upon Gangrenous Inflammation. Mr. Travers, after describing the ordinary forms of acute and chronic or dry gangrene, proceeds thus:

"Gangrenous inflammation may be primary, i. e. no other mode of inflammation going before it. The circulation of the part and neighbourhood becomes stagnant, and the vessels both arteries and veins, are choked with broken and semi-solid coagula. Is it due to the vehement intensity of the local inflammation and consequent exhaustion of the nervous life of the part? or to a constitutional condition, which renders the solid and fluid elements incapable of entertaining the functions of the part, on which depend its temperature and principle of resistance to external agents, in other words, its life? In all cases not produced by external injury, and in many that are so produced, I believe the latter is the true explanation.

Gangrenous inflammation, in the larger number of cases, is secondary to intense cutaneous and cellular inflammation, and so common is this association, that the term 'gangrenous erysipelas,' and carbuncular abscess are in practical use to denote these combinations, and the distinction of gangrenous from adhesive and suppurative inflammation. It is an acute inflammation directly disorganizing, because the resisting power of the parts affected by it is inadequate to sustain the circulation; this becomes stagnant and imperfectly coagulated in the larger vessels, for the blood loses the coagulating principle as it dies, while a non-vital transudation of their fluid contents loads the surrounding cells with sanies, with which pus is intermixed, where the suppurative process has preceded the gangrenous; and the whole texture perishes and putrefies. That it is a substantive mode of inflammation is shown by its occasionally idiopathic existence, as well as its distinctly-marked primary characters; by its supervention in decayed or diseased habits on very slight forms of injury; and especially by its tendency to spread along the neighbouring sound parts from the extremity towards the centre.” 216.

The constitutional nature of the affection is thus stated

"Gangrenous inflammation, therefore, is to be regarded as essentially of constitutional origin in all circumstances: its local termination is the same disorganization as follows from the work of destroying agents in this extreme result only do the inflammation of gangrene, and the state of gangrene touch and analogize. When we speak of an inflammation passing into gangrene, we convey that the system is the medium through which such a change is expected and effected, and that thereby the whole character of the action is changed. For the process of sloughing (separation or disjunctive ulceration) to the extent necessary to clear a wound of spoiled textures, is a local process indispensable, and which excites no reasonable alarm, if the surrounding inflammation is of the adhesive kind, and the ulceration confined to the adhesive line, accompanied by a free suppuration.These are indications of tranquillity of system and consequent power of the parts, whether the destruction is to the extent of a caustic issue, or involves the hand or foot. But if the spot of acute gangrene, idiopathic or from injury, be surrounded by the gangrenous inflammation, which spreads rapidly, and kills as it spreads, without provision for its arrest or its separation, we turn with well-founded alarm to the system of which it is a part, taking no comfort from the small extent or perfect reparableness, in other circumstances, of the mischief hitherto inflicted. We feel that so indicated, the failure of constitutional power is the fearful odds against which we have to contend, and this is corroborated by inquiry into the constitutional symptoms, and the pre-existing state of the patient's health and habits.

"To conclude, gangrenous inflammation, always originating in weakness, whether violence be combined with it or not, is never a process conservative of structure; and in this regard stands contrasted to all other inflammatory processes." 226.

We have perused both these books with much satisfaction and profit. The authors regard the same phenomena very differently; and each states his case very ably. In Mr. Travers' work the views of Hunter on inflammation are fully illustrated, and the various phenomena of the disease delineated with graphic powers of no ordinary description: while in that of Dr. Bennett, a difficult and obscure subject is lucidly treated, and an attempt made to apply to the explanation of anormal productions a theory which has so much contributed to the elucidation of the nature of healthy structure.

FIRST REPORT OF THE

THE

INTO

COMMISSIONERS FOR INQUIRING STATE OF LARGE TOWNS AND POPULOUS DISTRICTS. Vol. the First and Second. 1844. [Second Article.]

A GLANCE Over Good's Nosology, where we survey the melancholy catalogue of ills to which flesh is heir, is enough to appal the stoutest heart; but a perusal of the miseries, malarias, and morbific agencies, laid open by the SANATORY COMMISSIONERS, may well "frighten the isle from its propriety," and drive into madness and despair the human philanthropist ! But the philanthropist is not always the philosopher. From a wide survey of human nature, he learns the mournful fact, that misery and death form a part of the wise system ordained by Nature's God for the government of mankind-and even of the brute creation. Were there no diseases and causes of diseases to curtail the natural range of existence, how long would the earth we inhabit afford food for the inhabitants? Even as it is, the population, in spite of bad drains, malaria, crowding, &c., with "the varying intensity of their operations," rapidly increases, rendering each successive generation more straitened for room, more worn by competition, more stinted in food, clothing, and wages, than their predecessors! Still, the rate of redundancy is greatly checked by these sad evils, that seem the inevitable lot of humanity. Suppose, for example, that by some strange combination of circumstances, the manufacturers in this country were, all at once, enabled to increase the wages of their workmen three-fold-to raise them from ten to thirty shillings a week? What would be the consequence? Marriages would be infinitely more numerous, and more early contracted-children would multiply more quickly-parents and children would live longer, from the increase of their comforts, both in food, clothing, and lodging-and, finally, the rate of increase in population would be doubled or trebled. In a few years— certainly in a few generations, the redundancy would be such, that wages would inevitably fall, from the excessive competition-and the miseries, privations, and premature decay, which we are now bewailing and endeavouring to remove or prevent, would accumulate to a similar or greater extent than they do at the present moment! Thus, the philanthropists are travelling in a circle. They are clearing away the causes of sickness and death, while their humane efforts are constantly tending to increase the original fons et origo of the evil-redundancy of population!

Nor can the philanthropist and the Christian halt in their humane endeavours to remedy ills that are, in fact, irremediable. The immediate causes and their dreadful effects are around them and before their eyesthe remote, but master-cause, is at a distance-dimly seen-little considered-and too generally denied. All the best feelings and impulses of our nature are enlisted in the attempt to palliate miseries which we cannot either cure or prevent. Charity, pity, hope, religion, morality, and humanity, all combine to urge us forward in the noble, though fruitless labour of expelling poverty, sickness, and death from the crowded cellars, hovels, mines, and factories of a redundant population!

In our last number we gave a general and comprehensive view of the Sanatory Report, and shall confine ourselves, in this article, to some particulars of a more local and specific character.

1. Dr. Southwood Smith.-The examination of this able and observant physician leads the van in these volumes. He states that the neglect of cleansing and drainage are the grand causes of sickness among the poor of the metropolis-especially in the "fever districts "-viz. "those localities where fever is always so prevalent as to be regarded as the ordinary seat of the disease."

"The fever districts of the metropolis are situated in different parts of it; and it is in accordance with ordinary experience to find fever raging in some of these districts, at the very time that others are enjoying a temporary immunity from it. In former years I have found, on my personal examination, some localities in which there was not a single house in which fever had not prevailed, and in some cases not a single room in a single house in which there had not been fever. I observed this particularly in certain localities in Bethnal-green and Whitechapel: now, during the present year, there has been a very remarkable absence of fever in these its ordinary seats, while in other districts it has been more than commonly prevalent." 2.

There is some discrepancy here. If a fever district always presents fever, how is it that one district will be free, and another scourged by the malady, at the same time-the bad drains and filth remaining the same? There must, therefore, be more than malaria engaged in the generation of fever, notwithstanding the "immediate neighbourhood of uncovered sewers, stagnant ditches and ponds, gutters always full of putrefying matter, nightman's yards, and privies the soil of which lies openly exposed, and is seldom or never removed."

It is not a little remarkable that Bethnal Green and Whitechapel should ever be free an hour from fever under such circumstances as above! But the essential cause of epidemic fever is just as little known as it was in the days of Hippocrates. That malaria, however, is a potent auxiliary to the invisible fiend, cannot be doubted, from the increased ratio of mortality in the malarious districts. It must be borne in mind, however, that wherever we find filth, crowding, and bad drainage, we also find poverty, with all its moral, physical, and mental miseries, ten thousand times more destructive to health than all the stinks that ever issued from the banks of Thames, Tiber, or Rhine.

Dr. Smith remarks, that the period of life most liable to fever, is that which intervenes between twenty and forty years-so that it (fever) may be considered as the disease of adolescence.

"Two consequences follow of the highest interest and importance. First, it is clear from these tables that the period of human existence during which fever can alone be said to be prevalent is from the age of twenty to forty; that is, the period of maturity, the most precious portion of the term of existence, that during which the individual is best fitted for all the duties and enjoyments of life, during which he is most capable of promoting the happiness of others, and of securing and appreciating his own. But of this period that portion which is incomparably the most subject to the ravages of this malady is the earliest portion. Now it must be borne in mind that the poorer classes usually marry and have families at earlier ages than the middle and higher, the great majority, at least of the women, being