changes very typical of those which the system indicates. No approach towards healing is ever seen in such a state of the system. The degree of fever, the seat and the symptoms of the inflammation, must be taken as the index and measure of the changes which are wrought in the part. If the adhesive or granulating process has not commenced, it is prevented; and if it be in progress, it is destroyed. The ulcerative process becomes utterly indolent and ill-conditioned, or it passes into gangrene. The changes, more or less, are all on the losing side. The whole system is inflamed (1), and the local malady and its cure are merged in the general malady and its treatment. It is almost ludicrous to observe the nice distinctions and refinements of the ancient, and even of some modern surgeons, in the selection of local applications, when the parts take so subordinate a share of the disease, or are so far beyond reach of treatment by local remedies, as to be scarcely susceptible of good or harm. It is like galvanizing the muscles to restore life to the exanimate system.

"In inflammations which are set up by grave injuries, the system, if not at once disabled or in some way disordered along with the parts, is frequently predisposed to an earlier sympathy, induced by the shock which it has at the same time sustained. This sympathy constituting 'irritation,' is often of a more dangerous description than inflammatory fever, as I have elsewhere fully explained.*

"On the other hand, many inflammations having a very slight beginning, as regards their exciting cause, seem to owe their unmanageableness, and rapid transition from bad to worse, to a previously diseased or worn-out habit of body, and the typhoid diathesis prevailing in such circumstances. Some indeed originate from this cause independent altogether of local injury—such cases are always of serious aspect. But in favourable circumstances, of which youth and temperance are the foremost, the sympathetic inflammatory fever gets up gradually even after severe injuries, and evinces no more than what must be regarded as the unavoidable, nay, the gratifying proof of universal and salutary consent between the whole of its parts; and the career of inflammation towards the accomplishment of the purposes to which it is instinctive is but little retarded." 56.

Among the remarks upon Blood-letting, we select the following:

"The choice of measures, i. e. local or general blood-letting, is determined, partly by the relation of the parts affected to the centre of the circulation, and in part by the more or less urgent necessity that exists for disembarrassing the general functions, and arresting destructive inflammation. In visceral inflammation, venesection is indicated and warranted to the utmost extent that the powers of life will bear; for here the mass of blood is so altered and spoiled for its proper and healthy purposes by the direct implication of the blood-making and bloodpreparing organs in the disease, that relieving the system of its presence to the extent that can be borne, is the main resource we possess for its preservation. As we would remove a poison, a materies morbi, in such cases we take away blood. Its altered condition is palpable when eliminated from the body; it undergoes a peculiar separation of its parts, and presents other appearances not manifested by healthy blood. The difference of the blood within the vessels from that of health, is not less, if we could fully appreciate it. If inflamed blood be transferred into the vessels of a healthy animal of the same species, as his own is withdrawn, instead of supporting, it rapidly destroys life. A freer circulation through the smaller vessels, and those of the excretory glands especially, ensues

• Inquiry concerning Constitutional Inflammation, 1827.

almost immediately upon a full blood-letting: the sense of overwhelming oppression is relieved, and the inflammation, if not abridged by its effects, is disposed to a kindlier termination.

.

"There are two false doctrines concerning blood-letting for inflammation, which cannot be too strongly condemned the first, anticipatory blood-letting, by which I mean, the large and repeated detraction of blood before inflammation, being considered inevitable, has actually manifested itself-on the hypothesis of starving the action, and thus rendering it tractable-which is a direct attack on the vitality, and fatally prevents the action, if it do not destroy the resisting powers of the system. The second, continuing the employment of the lancet so long as the lastdrawn blood exhibits the signs of inflammation, which if drained to the last drop it would do; or, in other words, not reflecting that there is a line beyond which the practice becomes destructive instead of remedial; and that there are many inflammations which do not admit of arrest by depletion, and upon which other modes of treatment are efficient to this end, even though not an ounce of blood be drawn. Many lives have been sacrificed to the prevalence of these irrational and absurd notions, and many preserved in their extremity by being fortunately placed beyond the reach of the surgeon; especially, I am induced to believe, in military practice." 59.

Terminations or Results of Inflammation.-Dr. Bennett having shown that inflammation consists essentially in an exudation of the liquor sanguinis or blood plasma (i. e. the fluid portion of the blood composed of fibrin dissolved in serum), next adverts to the changes this exudation may be subjected to: i. e. the terminations of Inflammation.

"What have hitherto been considered as the terminations of inflammation, viz. adhesion, softening, induration, suppuration, granulation, ulceration, gangrene, &c. modern pathology has shown to be in themselves highly complicated processes. John Hunter was of opinion that these various results were explained by supposing the inflammation to undergo certain modifications, or that it terminated differently according to certain tendencies which it possessed; hence the terms adhesive, suppurative, ulcerative, and gangrenous inflammation. According to the view, however, which we have endeavoured to establish, viz. that inflammation essentially consists in an increased exudation of blood-plasma, it follows that this process in every tissue and under all circumstances is the same. The exudation having once taken place, any further changes we may observe in it will depend upon the amount or rapidity with which it is poured out, the tissue in which it occurs, its chemical and vital proportions, and the accidental circumstances which modify or destroy growth both in the vegetable and animal world. Whenever the exudation of blood-plasma poured out coagulates, it can only be removed from or assimilated to the economy by one of two results, viz by death, or by passing into organization. When it does not coagulate, which is an occurrence of great rarity, it may again pass into the vessels by endosmosis, and in this way the parts return to a normal state. Resolution, however, as at present understood, is a very compound process It is used to express the disappearance of the inflammation without its producing any external lession. In this manner it may follow hæmorrhage, softening, or suppuration, and great difficulties impede our attempts to ascertain with exactitude how, under these circumstances, the exuded and organized bloodplasma is absorbed For this reason, therefore, we shall discuss this portion of our subject in the following order :-1, the Termination of Inflammation in Death of the Part. 2. In Organization. 3. In Resolution." 44.

We regret that our space will not allow us to follow the author into the

details of this subject: we may, however, present a brief sketch of the conclusions he arrives at, for the purpose of exhibiting his application of the doctrine of Cytogenesis to the explication of the various phenomena resulting from inflammation. The nature of the cellular theory of Nutrition, which has accomplished so much in simplifying and generalizing our knowledge of the intimate structure of animated beings, has already been explained in this Journal. As the solid, coloured, corpuscules of the blood are subservient to the maintenance of the animal heat of the system, so is the fluid portion, the liquor sanguinis, the essential element of nutrition, the plasma destined to supply the material of every variety of structure. In this "nucleated cells are formed, which are again ultimately developed into the different textures, or made subservient to the function of secretion." When the exudation of this blood-plasma takes place in a defective degree, we have atrophy induced; but when, on the contrary, from the distended and attenuated state of the capilliaries, it exudes in excessive quantity, inflammation is said to be present: and the nature of the termination of the inflammation depends upon the changes which are wrought in this excessive exudation. Why these should differ in different cases is not always explicable, any more than why, from the same plasma in its normal condition, so great varieties of ultimate structure are evolved. The termination of inflammation in the death of the part, is termed mortification or moist gangrene when acute, and ulceration when chronic. Of the former Dr. Bennett observes:

"Occasionally a very large amount of blood-plasma is thrown out, constituting a violent inflammation: a greater or less number of capillaries are also ruptured and blood corpuscules are more or less mixed up with the liquor sanguinis exuded. The exudation thus formed compresses the part so as to obstruct the blood-vessels, and prevent the continuance of any circulation in it. Under these circumstances, instead of forming a blastema for the production of new organisms, it undergoes chemical changes which induce in it decomposition, and the part is said to be mortified."

Mortification arises from various other circumstances besides inflammation, as the effect of different chemical or mechanical injuries in directly destroying the tissues, or the leading vessels supplying the part, the obstruction of the arteries in the aged, &c. Examples of mortification from inflammation are seen after burns, exposure to frost, some forms of erysipelas, &c.-the excessive amount of exudation from all these causes obstructing the circulation.

In ulceration there is less exudation thrown out than in neither undergoes decomposition nor organization, but acting as a foreign. gangrene, which body upon the circulation of the surrounding parts, thus causes their death. Examined by the microscope it is found to contain numerous minute granules, mingled with some imperfectly formed cells. It, and the structures compressed, eventually become broken-down into a semi-fluid mass, which obtains exit at the surface.

Termination of Inflammation in Organization.-Organization consists

No. 99.

* See Med.-Chir. Review, Vol. 40, p. 1; Vol. 41, p. 124.

7

in the formation and development of nucleated cells, and, in the great majority of cases, the blood-plasma exuded in inflammation forms a blastema or germen for their production. Under different circumstances, however, various degrees of such development occurs; and the author enumerates four varieties of modes in which organization may be effected, in each of which the microscopic characters of the cellular resulting production differ. 1. From the exudation may be formed certain plastic corpuscules and primitive filaments, constituting lymph, as seen on the surface of the serous membranes. 2. It may be transformed into what the author terms exudation granules, masses and cells, forming the inflammatory softening of parenchymatous organs. 3. It may be transformed into corpuscules (pus) constituting suppuration. Purulent matter does not therefore, as supposed by Hunter and his followers, result from an altered action of the vessels, secreting it from the blood: but is a fluid having its own distinct nucleated corpuscules floating in the liquor puris, and results from changes which have been operated in the exuded plasma.

"Before quitting this subject it is necessary to observe that the three varieties of corpuscules we have described frequently undergo important modifications. What has been said refers to what may be called the type of such formations. In individuals who labour under particular cachexies, as scrofula, syphilis, scurvy, &c., the corpuscules vary more or less in their characteristic properties. We believe. however, that the separation of the three kinds of corpuscules, which distinguish the three great products of inflammation, will facilitate the future study of the differences which these structures occasionally present. This the more so, as, according to our observations, it is rare, that the additions of reagents will not enable us to refer them to one or the other of these divisions."

4. The exudation may be transformed into permanent tissues.—The re generation of lost parts is accomplished or some substance is produced in - lieu of them. Complicated tissues are seldom regenerated, as the skin, lungs, brain, &c. ; but simple tissues are, as the filamentous, fibrous, and even the osseous. Of all reproductions the fibrous is most frequent. This new production of tissues from the plasma is accomplished by the formation of nucleated cells, exactly as is observed in the organization of the various tissues of the embryo. As an example of what occurs in other parts, mutatis mutandis, we may select the description of the processes by which wounds are united.

"After a time, which varies according as the blood more or less abounds in fibrin, the cut surface is glazed, as it is called, that is, the exudation has coagulated on the surface and is transformed into plastic lymph. If now the parts are accurately brought together, little more exudation takes place. Cells are formed, which rapidly pass into a fibrous formation, and healing, or union by the first intention is the result. When, however, the lips of the wound remain apart, or there has been loss of substance, the exudation is more copious externally than internally. The portion which is infiltrated into the tissue surrounding the sore, constituting the inflamed, red, and indurated margin, is transformed into exudation-cells, which, on breaking up, are absorbed. Some of these occasionally find their way to the surface, and become mixed with pus corpuscules,-a circumstance which probably, with some, has supported the supposition that these structures are different stages of one growth. On the other hand, the exudation which is poured out externally on the surface of the sore is very abundant, and

is transformed partly into the pus cells, and partly into primary cells, which are by the process of development, converted into fibres, and ultimately constitute the cicatrix. The portions of exudation which are undergoing this process are called granulations. As these become more numerous, the amount of pus diminishes, and a greater tendency is manifested in the exudation to pass into permanent tissue. At length, pus ceases to be produced, the whole exudation passes into fibres, a new surface is formed,-the which, contracting, after a time, constitutes a cicatrix." 62.

Why from the same plasma exuded into the inflamed tissues these particular transformations ar produced is not easy to explain; but there are certain circumstances which exert considerable influence in determining the particular kind of change, and of these Dr. Bennett mentions three. 1. The nature of the surrounding elementary structure. Thus, exudation in the neighbourhood of cellular tissue is developed into cellular tissue, and that near bone into bone; while every tissue is liable to hypertrophy, during chronic exudation. 2. The degree of vital power of the organism exerts much influence. Hence the imperfect organization of the exudation when the vital powers are low, or the constitution of the blood is changed. 3. Great influence is also exerted by the rapidity with which the exudation has taken place. If the inflammation has been acute, and the exudation large, one of the three forms of corpuscules, the exudation, plastic. or pus, is readily produced; but if it be chronic, and the exudation comparatively sparing, the higher degree of development of the cells into fibrous or other tissues, or the hypertrophy of various organs, results.

The Termination of Inflammation by Resolution-Resolution or absorption of the exudation may follow any of its transformations, with the exception of that which has converted it into permanent tissue. "The early phenomena first disappear; the capillaries recover their contractility; the attraction between the blood and the parenchyma ceases; and the blood within the vessels begins to oscillate, and at length flows in a continuous stream" Occasionally, but rarely, the plasma remains uncoagulated for some time after its exudation; and then, at the restoration of the natural condition of the vessels, may re-enter them by endosmosis unchanged. Once coagulated, it cannot be absorbed, unless again rendered fluid. The nucleated cells are broken up, and the transformed exudation reduced to a soft, pultaceous, diffluent substance.

"The disintegration of pus-corpuscules previous to absorption is evidently favoured by the pressure which the abscess receives from the contraction of the filamentous and elastic tissues that form its walls. This is shown by the increased hardness which always accompanies the disappearance of suppuration by resolution, and the good effects which result from direct pressure employed by the surgeon to discuss these swellings. In Berlin, the most successful treatment for bubo consists in simply placing a stone of one or two pounds' weight over the tumour in the groin, as the individual is lying on the back. It is probable, also, by increasing the contraction of the integuments, as well as by removing fluid from the neighbourhood of the part, that irritants, blisters, and cauteries, are beneficial in the resolution of abscesses."

The molecular fibrin which re-enters the circulation after the breaking up of the exudation, is for the most part eliminated by the kidneys.