to the lymph-abscess of this paragraph, of which I was then ignorant than to a collection of synovia, as I thought it perhaps might be. The patient was a healthy country lad, seventeen years old, who three years previously had received a blow on the upper outer part of his left thigh, but seemed to have recovered from its effects. Two months since he noticed a swelling on the outside of the same thigh, about a hand's breadth above the knee-cap, which gradually increased both downwards and upwards, so that at his admission it occupied the outer and fore part of the thigh, from a little above the knee to near the great trochanter, fluctuated distinctly, and was presumed to be an abscess in the outer chamber of the femoral sheath. Fifteen minims of tincture of muriate of iron in mucilage thrice a day were ordered, to excite absorption, which was continued for nearly three weeks without benefit. The thigh then having increased, and fluctuation and swelling having extended about the whole knee, I made, by the direction of my then colleague TRAVERS, whose patient he was, an incision two inches long, about the middle of the outside of the thigh, expecting to evacuate pus or open the femoral sheath; but neither pus nor any other fluid escaped, although I cut into the m. vastus externus an inch deep. A tent of lint was left in the wound to keep it open, and hasten the escape of pus if any should make its way through the wound; but none appeared, and in the course of a fortnight the wound had entirely healed. The tincture of iron, which had been continued to this time, was now left off, and two grains of iodide of iron thrice a day, ordered in its stead. A week after the whole thigh was wrapped in mercurial ointment, and swathed in a roller. This treatment was continued for three weeks, but without any diminution in size, or apparent change; fluctuation was still very distinct, and the fingers of one hand being applied, whilst pressure was made with the other hand alternately above, a thrilling fluctuation was felt. It was therefore determined to introduce a grooved needle about the middle of the thigh, and some fluid very similar to synovia escaping by it, an abscess lancet was then, with my colleague's consent, thrust in, making an opening an inch long in the skin, and half its length in the sheath, from which escaped about twenty ounces of the seemingly synovial fluid, which nearly emptied the cavity, leaving a rather moveable lump about the middle of the fore part of the thigh, the character of which I could not make out. The edges of the wound were carefully brought together, the limb rolled, and in four days union had taken place. A week after another free puncture below the former voided a quart of the same fluid as before, and on applying heat it coagulated speedily and almost entirely. The wound was left open, and a roller applied above and below it; but in the course of a week it had again united, and fluid was again secreted, though in smaller quantity. A solid but moveable swelling had at this time also formed to some extent around the wounds. The iodide of iron was then omitted, and, instead, was ordered decoction of sarsaparilla four ounces, with five grains of iodide of potash twice a day; the whole thigh to be enveloped in ointment of iodide of potash. Three weeks after the solidification had increased, and the fluctuation generally was less distinct, and soon after the ointment was given up, and mercurial plaster applied. Two months after, having begun to take the iodide of potash, the thigh had much diminished, there was less fluctuation, the middle outer skin was almost solid, and there is less effusion about the knee. The diminution of size and fluctuation continued, and in about two months he was able to walk about. He continued with us about four months longer, and, when he left the house, the swelling about his knee, although not completely subsided, had so considerably diminished as not to interfere with his walking.-J. F. S.]

18. Ulceration (Exulceratio, Lat.; Verschwärung, Germ.; Ulcération, Fr.) is distinguished from suppuration, in being connected with an actual destruction of parts, (by ulcerative absorption,) and with the secretion of a thin, acrid, fetid, and variously coloured pus-like fluid. It arises either immediately from inflammation, or from a preceding abscess. Its causes are either local injury,—for instance, improper treatment of the abscess which has been opened,-or general disease, as scrofula, syphilis, and

so on.

[In considering the subject of ulceration, or " ulcerative inflammation," as he most properly calls it, HUNTER first indicates the economy of the absorbent vessels, and speaks of them in two views: first, as they absorb matter, which is not any part of the machine; secondly, as they absorb the machine itself." The former of these functions is of two kinds, of which the one absorbs external matter, either applied to the skin or received into the alimentary canal; and the other takes up internal matter, as many

VOL. I.

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*

of the secreted juices, the fat and the earth of bones, &c.; both, however, serve principally to the nourishment of the body as well as to other and even hurtful purposes. The second function, that of "removing parts of the body itself, * 容 * may be viewed in two lights." The one view presents them as causing "a wasting of the whole machine or part, * * which I call interstitial absorption, because it is removing parts of the body out of the interstices of that part which remains, leaving the part still as a perfect whole. But this mode is often carried further than simply wasting of the part; it is often continued till not a vestige is left, such as the total decay of a testicle." The other view exhibits them as "removing whole parts of the body," and "may be divided into the natural and diseased." Under natural circumstances the absorbents are to be considered as the modellers of the original construction of the body;" for "no alteration can take place in the original formation of many of the parts, either in the natural growth, or that formation arising from disease, in which the absorbents are not in action, and take not a considerable part: this absorption I shall call modelling absorption. *** Absorption, in consequence of disease, is the power of removing complete parts of the body, and is in its operation somewhat similar to the first of this division or modelling process, but very different in the intention, and therefore in its ultimate effects. This process of removing whole parts in consequence of disease, in some cases, produces effects which are not similar to one another; one of these is a sore or ulcer, and I therefore call it (the absorption) ulcerative. In other cases no ulcer is produced, although whole parts are removed; and for this I have not been able to find a term; but both may be denominated progressive absorption. ***** It may be difficult at first to conceive how a part of the body can be removed by itself; but it is just as difficult to conceive how a body can form itself, which we see daily taking place; *** but this I may assert, that wherever any solid part of our bodies undergoes a diminution, or is broken in upon, in consequence of any disease, it is the absorbing system which does it. When it becomes necessary that some whole living part should be removed, it is evident that nature, in order to effect this, must not only confer a new activity on the absorbents, but must throw the part to be absorbed into such a state as to yield to this operation. This is the only animal power capable of producing such effects, and, like all other operations of the machine, arises from a stimulus or an irritation; all other methods of destruction being either mechanical or chemical. The first by cutting instruments, as knives, saws, &c.; the second by caustics, metallic salts, &c. The process of ulceration is of the same general nature in all cases; but some of the causes and effects are very different from one another." (pp. 440, 2.) “This process of the removal of parts of the body, either by interstitial or progressive absorp tion, answers very material purposes in the machine, without which many local diseases could not be removed, and which, if allowed to remain, would destroy the person. It may be called in such cases the natural surgeon. It is by the progressive absorption that matter or pus, and extraneous bodies of all kinds, whether in consequence of or producing inflammation and suppuration, are brought to the external surface; it is by means of this that bones exfoliate; it is this operation which separates sloughs; it is the absorbents which are removing old bones, while the arteries are supplying new ones; and, although in these last cases of bones it arises from disease, yet it is somewhat similar to the modelling process of the system in the natural formation of bone; it is this operation that removes useless parts, as the alveolar processes when the teeth drop out, or when they are removed by art; as also the fangs of the shedding teeth, which allows them to drop off; and it is by these means ulcers are formed. It becomes a substitute in many cases for mortification, which is another mode for the loss of substance; and in such cases it seems to owe its taking place of mortification to a degree of strength or vigour superior to that where mortification takes place; for, although it arises often from weakness, yet it is an action, while mortification is the loss of all action. In many cases it finishes what mortification had begun, by separating the mortified part. These two modes of absorption-the interstitial and the progressive-are often wisely united, or perform their purposes often in the same part which is to be removed; and this may be called the mixed, which I believe takes place in most cases, as in that of extraneous bodies of all kinds coming to the skin; also in abscesses, when in soft parts. It is the second kind of interstitial absorption, the progressive and the mixed, that become mostly the object of surgery, although the first of the interstitial sometimes takes place so as to be worthy of attention. This operation of the absorption of whole parts, like many other processes in the animal economy, arising from disease, would often appear to be doing mischief, by destroying parts which are of service, and where no visible good appears to arise

from it:

but in all cases it must still be referred to some necessary purpose; for, we may depend upon it that those parts have not the power of maintaining their ground, and it becomes a substitute for mortification; and, indeed, in many ulcers we shall see both ulceration and mortification going on; ulceration removing those parts that have power to resist death." (pp. 444, 5.)

As regards the absorption of whole parts from disease, it would appear," says HUNTER," that they are capable of being absorbed, from five causes: first, from parts being pressed; secondly, from parts being considerably irritated by irritating substances; thirdly, from parts being weakened; fourthly, from parts being rendered useless; fifthly, from parts becoming dead." (p. 446.)

"The dispositions of the two parts of the living body, which absorb and are absorbed, must," says HUNTER, "be of two kinds respecting the parts; one passive and the other active. The first of these is an irritated state of the part to be absorbed, which renders it unfit to remain under such circumstances; the action excited by this irritation being incompatible with the natural actions and the existence of the parts, whatever these are, therefore become ready for removal, or yield to it with ease. The second is, the absorbents being stimulated to action by such a state of parts, so that both conspire to the same end. When the part to be absorbed is a dead part, as nourishment or extraneous matter of all kinds, then the whole disposition is in the absorbents. (p. 446.) Many parts of our solids are more susceptible of being absorbed, especially by ulceration, than others, even under the same or similar circumstances, while the same part shall vary its susceptibility according to circumstances." (p. 447.)

Progressive absorption is divisible into two kinds, one without suppuration, and the other with. The absorption which does not produce suppuration may take place, either from pressure made by sound parts upon diseased parts, or by diseased upon sound parts." (p. 454.) The absorption attended with suppuration, “which I call ulceration," is connected with the formation of pus, being either a consequence of it or producing it, and is that which in all cases constitutes an ulcer. It is this which principally constitutes the progressive absorption. This differs from the foregoing in some circumstances of its operations. It either takes place in consequence of suppuration already begun, and then the pus acts as an extraneous body, capable of producing pressure; or absorption attacks external surfaces from particular irritations or weakness, in which case suppuration, forming an ulcer, must follow, let the cause of that breach or loss of substance be what it may." (p. 456.)

"This process of ulceration or absorption with suppuration, is almost constantly attended by inflammation, but it cannot be called an original inflammation but a consequent, which gave rise to the term 'ulcerative inflammation.' It is always preceded by the adhesive inflammation, and perhaps it is simply this inflammation which attends it." (p. 457.)

"The effect, then, of irritation, as above described, is to produce first the adhesive inflammation in such parts as will readily admit of it, and, if that has not the intended effect, the suppurative takes place, and then the ulceration comes on to lead the matter already formed to the skin if it is confined." (p. 458.) "Any irritation which is so great as to destroy suddenly the natural operations of any one part, and the effect of which is so long continued as to oblige the parts to act for their own relief, produces in some parts, first, the adhesive inflammation; and, if the cause be increased or continue still longer, the suppurative state takes place, and all the other consequences, as ulceration; or, if in the other parts, as secreting surfaces, then the suppurative takes place immediately, and, if too violent, the adhesive will succeed; or, if parts are very much weakened, the ulcerative will immediately succeed the adhesive, and then suppuration will be the consequence. This species of ulceration in general gives considerable pain, which pain is commonly distinguished by the name of soreness; * but it does not attend all ulcerations, for there are some of a specific kind, which give little or no pain, such as the scrofula; but, even in this disease, when the ulceration proceeds pretty fast, it gives often considerable pain: therefore the pain may in some degree be proportioned to the quickness of its operation. The greatest pain which in general attends this operation arises from those ulcerations which are formed for the purpose of bringing the matter of an abscess to the skin, as also where ulceration begins upon a surface, or is increasing a sore: whether the increase of pain arises from the ulcerative inflammation singly, or from the adhesive and ulcerative going on together in the same point, is not easily determined; but, in some cases, these three are pretty rapid in their progress, and it is more than probable that the pain arises from all these canses. In those cases where ulceration is employed in separating a dead part, such

* *

as sloughing, exfoliation, &c., it is seldom attended with pain: perhaps it may not be easy to assign a cause for this." (p. 459.)

The following are some of TRAVERS's observations on this important subject:"Ulceration, when it occurs, is consecutive to adhesion and suppuration, in almost all cases; and, although suppuration may now and then pass without ulcerations, 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." (p. 187.) "Ulcerative absorption never occurs but as an inflammatory process, and the action of the absorbents in this process is therefore exclusively a morbid one, and generally partakes of an increase proportionate and corresponding to the opposed action of morbid secretion." (p. 188.)

"The ulcerative, being a purely vital action of the absorbents proper to the part affected, goes on progressively, either by perforation of the substance, or by an encroachment on the surface, or by undermining and separating parts prepared by dis organization or actual death for being cast off. The texture of the part determines which of these modes of action is employed. The cornea, the cartilage, and bone present the penetrating and circumscribed, foveolous or fossulated ulcer, a pit or chink; the cellular membrane presents the hollowing and undermining process, as in the sinuses and pouches of abscess in cellulous parts and on the margin of indolent ulcers, also between the articular extremities of bones and their cartilages; the spreading or superficial ulceration is best exemplified in the skin. But it is always by the absorbents proper to the inflamed surface that this action is carried on."` (p. 190.)

"The ulcerative process stands between the life and death of parts subjected to its action, and administers to either, according to the circumstances of the case; being the instrument of reparation in the suppurative and adhesive inflammation, and of separation and removal of the waste and decayed, in the suppurative and gangrenous. It is the agent of granulation in the former, of sloughing in the latter, case, suppuration being the common link by which these extreme processes are connected. Without granulation ulceration is a wasting process; with it, a repairing one. In like manner, ulceration without suppuration is a devastation without means of control or repair." (pp. 191, 2.)

"An ulcer is a patent and familiar illustration of the pathology, not only of the ulcerative, but of all the processes of inflammation; and, as it is that vital action by which not only the dead are separated from the living, but the living are removed, which have undergone such organic changes, or lost so much of their vital power as to be incapable of resisting absorption, it may be regarded, as before observed, as an agent for life and death, and, if in one case the natural surgeon,' (HUNTER,) in another the natural destroyer." (p. 196.)]

19. Hardening (Induratio, Lat.; Verhärtung, Germ.; Induration, Fr.) occurs when during inflammation the fluids effused into the cellular tissue (par. 4) collect, thicken, and connect the walls of the cells together. Vessels pass into the connecting mass, which becomes organized, and the nutrition of the swelling depends on these vessels. If they are numerous or much expanded, the volume of the part is correspondingly increased, and permanent coagulable lymph is deposited, fatty or even bony masses are produced. If the walls of the cells become firmly united together without further deposit in the swelling, the hardened part sometimes becomes smaller than in the healthy state. The hardness of the indurated part varies according to the quantity of lymph effused in the cellular tissue, according to the structure of the part, according to the course of the previous inflammation, and the duration of the hardening. The skin upon the swelling is commonly not changed: the vessels, however, may be varicose, or the skin itself may be intimately united with the swelling. In this manner are formed, consequent on inflammation, various degenerations, enlargement of parts by hypertrophy, sarcomatous, steatomatous degenerations, and so on.

20. In the hardened parts, if no peculiar irritation exist, the sensibility is

lessened, the circulation seems to proceed but imperfectly, because the nerves are completely enveloped in the plastic mass which connects the several parts, and the more minute vessels are closed: hence the temperature is lower, often sensibly so to the patient himself. Sometimes not the least inconvenience arises from the hardening; but it may run into inflammation, ulceration, and cancer (a).

In every part inflammation may run into hardening; but especially in long-continued insidious inflammations; in organs which possess a low degree of vitality, in glands, and those organs in which the very numerous ramifications of vessels are surrounded with dense cellular tissue, in persons of atrabiliary constitution, who have had much mental anxiety, have been subject to scrofula or other diseases which depend upon unnatural mingling of the juices.

21. The transition of Inflammation into Softening (Erweichung, Germ.) produces changes directly contrary to those caused by hardening, viz., diminished cohesion and consistence-liquescence. It occurs only in long continued dyscratic and cachectic inflammations; it is always connected at the onset with collections of serous, not plastic, matter in the parenchyma of the part, which is therefore sometimes loosened up and thickened; or it consists in actual deliquescence and dissolution of the parts, probably consequent on diminished or changed nervous influence. It may, to a certain extent, be considered as the intermediate condition between ulceration and mortification. The softer and looser the texture of an organ, so much the more readily does softening take place, though it also occurs in hard organs; for example, in the bones : childhood is most subject to it. In many swellings softening precedes and accompanies their giving way.

22. Mortification (Gangræna, Sphacelus, Lat.; Brand, Germ.; Gangrene, Sphacele, Fr.) is the passage of inflammation into partial death, and the mortified part is subject to the general chemical laws. We usually distinguish with the name of mortification two conditions, viz., the hot Mortification, (Gangræna, heissen Brand, Germ.; Gangrene chaude ou Asphyxie des parties, Fr.,) in which the living power is not perfectly extinguished, and in which it may be restored to its natural action, (here there is but a certain degree of inflammation,) and the cold Mortification, (Sphacelus, kalten Brand, Germ.; Gangrène froide, ou Sphacele, Fr.,) in which the part is actually dead.

[The division here employed by CHELIUS is that proposed by Dr. JOHN THOMSON. TRAVERS objects to the terms mortification and sphacelus on the following ground :—“ I do not," says he, " employ the term 'mortification' because it is not technically explicit, and has been vaguely and indiscriminately used. Nor shall I use the term 'sphacelus,' because gangrene is a sufficient synonyme, if the term gangrenous inflammation be accepted, which presents the stages of recoverable and irrecoverable, threatened and devitalized texture. A gangrened part is never restored. By the arrest of gangrenous inflammation, the gangrene may be circumscribed, and, by the supervention of other processes, the dead may be cast off, and the living part repaired with more or less loss of substance. The special use of the term sphacelus has been to designate a state of utter death, in which the part becomes subject to chemical changes, as if severed from the body, and such meaning I affix to the substantive term 'gangrene.'" (p. 208.) Hence it will be observed that TRAVERS's gangrenous inflammation, and his gangrene, are synonymous with CHELIUS's hot mortification, and with his cold mortification.-J. F. S.]

23. Mortification truly consists in the extinction of vascular and nervous activity, in consequence of which partial death ensues. This transition

(a) WENZEL, Ueber die Induration und das Geschwür in indurirten Theilen.

8vo. Mainz, 1815.