blood; in fact, we were visited by a rather rare disease, hospital gangrene, one which I trust I may never see again. Luckily, out of a good many patients who were so attacked, and in all parts of the hospital almost simultaneously, not one perished. Many of the wounds and ulcers were frightfully extended; but they speedily got clean, and healed soon afterwards very kindly. *** After the separation of the sloughs, a circular clean granulating surface was left. We were at a loss to account for this invasion: there was nothing as regarded the hospital, its ventilation, or drainage, or management, the dressing of sores, &c., that could be blamed. The disease came upon us suddenly, and as suddenly disappeared; and I need not tell you that we have seen nothing of the kind since."

My friend ARNOTT informs me that in January, 1835, in one of the female wards of Middlesex Hospital three cases occurred which might be classed under the head of hospital gangrene, of which the following is a short account:-

CASE 1.-The disease attacked a common ulcer of the leg; the surface became black and pulpy, with a broad very red margin of integument, a raised edge, and great pain. From the size of half-a-crown, the disease extended and occupied, ere it was stopped, a space of a large wash-hand saucer, exposing the muscles and bone. It was arrested by the application of pure nitric acid, and the removal of the patient into another ward.

CASE 2.—The disease appeared on an ulcer by the side of the anus, presented the same character, but was arrested by balsam of Peru, locally, and a grain of opium every six hours, internally. The disease recurred, and the patient was removed from the hospital.

CASE 3-A punctured wound of the chest did not heal, but that of the integument enlarged by the conversion of the tissue into a grayish pulpy substance, (not black, and without the fiery margin and intense pain of the other cases,) more like phagedæna. It was stopped by balsam of Peru. "I have never seen,” he says, “"a similar case in the Middlesex Hospital before or since."

I have mentioned the above cases of hospital gangrene, because they are, as far as I can ascertain, the only instances of the disease which have been seen in either of the London hospitals for many years. Cases occurred many years since in the old Westminster Hospital, and also in the York Hospital at Chelsea, which latter being a military establishment, the disease was believed to have been brought home by the sick and wounded soldiers from abroad. With these exceptions, I have the best grounds for stating that in no other hospital in London has it existed in the memory of either of the present surgeons; so that it is a disease entirely unknown to them, excepting to the few who have seen it elsewhere.

LAWRENCE (a), speaking of sloughing phagedæna, observes “that these occurrences generally take place in women of the town under the particular circumstances I have now stated; but it is by no means exclusively confined to cases in which the origin might be supposed to be venereal. I remember a very bad instance in this (St. Bartholomew's) hospital, in a case that was under the care of Dr. LATHAM, by whom I was requested to see it on account of the sloughing phagedæna. It was a young woman who had had the small pox very badly. The disease had rendered her very weak, and diarrhoea came on. There was a considerable discharge from the vagina, and a constant moisture of the parts by a discharge from the rectum. Thus the skin of the nates became highly inflamed, and in fact a large excavation of sloughing phagedæna formed on each buttock, and she was reduced to a very low state by the disease. Dr. LATHAM asked me what I thought could be done; and, having examined her, I thought badly of the case, but that we might destroy the excavations in her buttocks, which were nearly as large as a good sized teacup, and possessing all the characters that I have mentioned. They were treated by nitric acid applied with lint wrapped round the end of a probe till the sore was saturated with it, and a brown escar produced; the surrounding parts having been previously well dried, to prevent the spreading of the acid beyond the sore. Port wine was liberally allowed her and she got well. This was a cause of a common kind, in which you could not ascribe the effect to syphilitic disease. Now, as far as I can understand the affection called hospital gangrene, it is the same as the sloughing phagedæna I have now described." (p. 454.) I think there is little doubt that this was a case of hospital gangrene and not of the so-called sloughing phagedæna. But it is difficult to make out whether LAWRENCE holds them as distinct or as the same disease; though probably the former, as, in speaking of "the treatment" of hospital gangrene, specially, he says, it, "in other respects, is the same as I have mentioned for sloughing phagedana." (p. 455.)

(a) Lectures, as above.

I cannot agree with SAMUEL COOPER, that the sloughing phagedana, of which an account, founded on the cases to which LAWRENCE refers in his Lectures, is given by WELBANK (a), "certainly resembles hospital gangrene," as described in books. The sloughing phagedana was certainly an endemic supervening on venereal excoriations or sores, and not hospital gangrene. I shall advert to it hereafter, in speaking of chancre, or venereal ulcers.

The only cases that I have seen, with the slightest resemblance to hospital gangrene, were the sloughy stumps now and then occurring, perhaps more frequently during those years, formerly, when our wards were much troubled with erysipelas. The operation would either seem to be going on favourably for two or three days, the patient comfortable, and adhesion in progress, when a sudden change would set in, the stump become painful, swollen, hard, and red, the un-united part become sloughy, and the united part falling asunder, and soon also becoming sloughy; or, the stump never making any attempt at union, but soon becoming painful, swollen, and sloughy. In either case, the patient himself hot, dry, flushed, with brown tongue, and foul alvine discharges, the pulse quick, irritable, delirium and death supervening. I said such cases occurred, perhaps, more frequently when erysipelas was rife; but they really do happen when no erysipelas is in the ward at the time, nor has been for many months, and they occur not unfrequently in primary amputations in stout persons who have been accustomed to large quantities of beer or spirits, or of both, and from which they are not unfrequently entirely at once (and, as I consider, improperly) debarred; and hence, with a greater call than usual upon the powers of the constitution, are left to meet it with diminished means. Such cases are to be considered merely as resulting from want of power; but they are never epidemic or contagious, and must not be confounded with, hospital gangrene, which, however frequent it may be elsewhere, is, in London, at the present time, and has been for years, unknown by personal experience to most hospital surgeons.-J. F. S.]

36. The characteristic of hospital gangrene is its quick extension and the decomposition of the tissues without any special residue; if the grayishwhite mass in certain cases be not so considered. Hospital gangrene is an extension of a wound or of a sore intermediate between ulceration and mortification.

37. The cause of hospital gangrene is the operation of a peculiar contagious matter, either upon wounds and the ulcerated parts or upon the whole body. The contagion develops itself usually in hospitals, where the air is deteriorated, many patients huddled together, and the bandages not kept clean; specially in unhealthy places, as gaols and so on. We know not how long the contagious matter may retain its activity. Probably the constitution of the atmosphere, the weather and climate influence the development and character of hospital gangrene. The susceptibility to contagion is not diminished by its having once been acted upon; on the contrary, it seems to have increased. The contact of the contagious matter with the wound is either the consequence of want of care in dressing it, its long exposure to the action of the air infected with contagion, or its having been covered with bandages in which the poison is retained. The contagion may happen to every person, and in every kind of wound and ulcer: it rarely, however, alters specific ulcers, whilst on the contrary a bilious constitution, mental affections, great feebleness, typhus fever, appear to be most favourable to it. The character of the disease itself may be changed by the constitution of the patient, and by the state of the weather; it may even become inflammatory, in which case the wound is encircled with a red ring, the pain is severe and throbbing, the pulse quick and hard, and the bleeding which occurs produces relief. Hospital gangrene is always a very dangerous complication of wounds and sores. Accidental circumstances may render the danger still greater; for instance, if it be impossible to give the patient

(a) Medico Chirurg. Trans., vol. xi. 1821.

attacked with the disease better air and better nursing, and so on. Left alone, hospital gangrene is usually fatal. If it have proceeded to a certain extent, art is rarely of any avail.

For the Literature of Hospital Gangrene, see p. 98.

38. After the appearances and terminations of inflammation, which have been described in general terms, we now come to those variations which inflammation may offer to our notice.

The existence of inflammation depends always on unnaturally raised vital processes: manifold circumstances, however, may change the appearances and course of inflammation, and these changes are only to be considered as modifications of simple inflammation; and the more so, the less they correspond to what we understand by increased vital action. The inflammation may be classed, 1st, according to its appearances and course; 2nd, according to its causes; 3rd, according to the structure of the parts attacked.

39. If the inflammation make its appearance with a certain intensity of its symptoms, and proceed rapidly, it is called acute; but, contrariwise, chronic, when the intensity of the symptoms is slight and their duration protracted, which condition may be either primitive or consecutive, depending on the constitutional condition. In regard to its character inflammation is further divided into simple, erethitic, torpid, malignant, and obscure. In simple inflammation all the symptoms of inflammation are present in a corresponding degree; it runs a speedy and most commonly satisfactory course; it is almost peculiar to strong persons, who have good health; its termination, if not resolution, is generally suppuration. The erethitic and torpid character of inflammation are merely modifications according to the constitution of the patient and the degree of the inflammation. In the erethitic inflammation the symptoms have not the same degree of severity as in simple inflammation; the sensibility is, however, distinctly increased, and it therefore especially appears in persons of delicate constitution. The torpid inflammation has a remarkably tedious course, and its symptoms seem to depend rather upon a local obstruction of the circulation in the capillary-vascular system than upon an accelerated vital activity; all the signs of active congestion are wanting, the part is not bright red, but dusky and brownish. It occurs specially in weak, reduced, cachectic subjects. Simple inflammation may also, under improper treatment, assume a torpid character. Malignant inflammation (Inflammatio maligna, gangrænosa) is often painless, or accompanied by an obtuse, heavy pain and dusky redness: its cause is sometimes manifest as the effect of deleterious or contagious matter; at other times, it is unknown: it supervenes on typhus and putrid fevers, and usually runs into gangrene. Obscure inflammation (Inflammatio occulta, clandestina) is that which is little or not at all indicated by symptoms.

40. Inflammation is divided, according to its different causes, into idiopathic, symptomatic, specific, and sympathetic. Idiopathic inflammation is the consequence of external violence; it exists as a local disease, and its severity is regulated by the degree of the injury and the condition of the subject. Symptomatic inflammation, at least the definite form under which it first appears, depends on internal causes, and the inflammation itself is to be considered only as a reflection of the general disease. If this be of a specific nature, as syphilis and so on, the inflam

72

INFLAMMATION OF SKIN, CELLULAR TISSUE, GLANDS,

mation is said to be specific. Sympathetic inflammation is the consequence of a consensual change in the mutual relations which one part holds to another, by which their diseased affections become shared by both. The metastatic inflammation which passes from one organ to another is in close connexion with the sympathetic.

Symptomatic inflammation is either the original symptom of general disease, or an originally idiopathic inflammation acquires, through the general disease, a definite character.

41. In whatever part inflammation may occur, its peculiar seat is always in the capillary-vascular system. But its symptoms vary according to the different conditions of the affected part.

Inflammation of the Skin, if not severe, terminates in resolution with scaling of the cuticle, and not unfrequently also with dropsical swelling. In a more active inflammation a fluid is poured out beneath the cuticle producing vesications and pustules. If the inflammation be tedious without being active, the cuticle is destroyed; the fluid poured out by the exposed vascular net thickens into crusts. If the inflammation extend to the subjacent cellular tissue, it is generally severe and runs into suppuration.

Inflammation of the Cellular Tissue is usually accompanied with much ill-defined redness, with firm elastic swelling, much tension and throbbing pain; it does not resolve except it be in a mild form; its usual termination is suppuration, not unfrequently gangrenous destruction of the cellular tissue.

[This important affection of the cellular tissue, which has only within the last twenty years been particularly noticed, though commonly spoken of under the common title of erysipelas, is described more at length by our author, at page 103, "as a metastatic deposit in the cellular tissue, and one of the causes of his Erythema symptomaticum seu consensuale. Doubtless, it may be, and occasionally is, metastatic; but, generally it is idiopathic. It has of late years become common, and is a very rapid and dangerous disease, unless early and properly treated. Its importance is so great, that it is as fully entitled to a proper chapter as erysipelas, from which it most decidedly differs. But it will be, perhaps, more convenient to insert what I have to add where the subject comes under consideration in our author's arrangement, rather than to remove and drag his paragraphs into places for which he had not intended them, under pretence of making his meaning more clear, as if the author did not best understand his own view of the subject he discusses; a proceeding which has been occasionally practised in English translations, which I think cannot be too much deprecated, and the least inconvenience of which is, that it is not unfrequently impossible to refer from the original to the translation, or from the translation to the original.-J. F. S.]

Inflammation of the Glands mostly exhibits not very acute but rather dull pain, no great heat, very solid circumscribed swelling, which also extends itself into the surrounding parts. Its termination is similar to that of inflammation in the cellular tissue, except that glandular inflammation most commonly assumes a chronic character, and then easily passes into hardening.

In inflammation of the Mucous Membranes, their secretion is stopped at the onset; at the same time, increased warmth and sensibility, heavy pain and great redness make their appearance, a secretion of thin somewhat acrid fluid, the thickness of which increases, becomes creamy, and of perfectly mild character. No tissue so readily as the mucous membrane acquires a morbid disposition to inflammation. When affected with long-continued inflammation their spongy cellular tissue becomes loosened, swelled, thickened, and the vegetation on it often is so changed that new formations, polypous excrescences, are developed. In active

inflammation, or in long-continued flow of mucus, ulceration and destruction of the underlying parts frequently occur. Very rarely do inflamed mucous membranes become adherent.

[In reference to the kind of inflammation which occurs in mucous membranes, HUNTER says:-"In internal canals, (I make a difference between an internal cavity and a canal; they are very different in their construction, their uses, and also their mode of action in disease are very different,) where adhesions in most cases would prove hurtful, the parts run immediately into the suppurative inflammation, the adhesive inflammation in common being excluded; such parts are the internal surface of the eyelids, nose, mouth, trachea, air-cells of the lungs, esophagus, stomach, intestines, pelvis of the kidneys, ureters, bladder, urethra, uterus, vagina, and indeed all the ducts and outlets of the organs of secretion, which all these parts mentioned may be in some degree reckoned, and which are commonly called mucous membranes. In such parts, if the inflammation is but slight, the suppurative in common takes place, which is almost immediate, as it is not retarded by the adhesive stage, which accounts for the quickness of suppuration of these parts in many cases. *** Since those surfaces are, in general, secreting surfaces, suppuration would appear to be only a change in the secretion; and I think I have visibly seen, or could visibly trace, the one change gradually leading into the other; the different parts, therefore, of which the pus is composed, will not always be in the same proportion, so that the matter will seem to vary from true matter towards that of the common secretion of the part, and vice versâ; but this does not alter the position, for it is common to matter from a sore, and even common to our ordinary secretions. If this inflammation which produced suppuration on those surfaces becomes more violent, or has something of the erysipelatous disposition, we find that it moves from the suppurative to the adhesive, and throws out the coagulating lymph." (p. 241, 2.)]

The Serous Membranes have great disposition to inflame; the inflammation is very painful, usually appears suddenly, spreads quickly, and easily passes into resolution, adhesion, transudation, and mortification, but rarely into ulceration. Serous membranes often thicken, either by the cellular tissue upon their external surface or by plastic membranes, or even in their own proper substance. Chronic inflammation of serous membranes appears mostly in the form of dropsical affections.

[Serous membranes are the circumscribed cavities which, with "the cellular membrane or the body in general," belong to the first order of parts into which the body is divided by HUNTER, and in relation to which he observes:-"When inflammation takes place in the first order of parts, it is commonly the adhesive; but it will be according to circumstances whether the suppurative or the ulcerative follows first." (p. 253.) "The adhesive inflammation serves as a check to the suppurative, by making parts which otherwise must infallibly fall into that state, previously unite, in order to prevent its access, as was described in the adhesive inflammation being limited; and, where it cannot produce this effect so as altogether to hinder the suppurative inflammation itself from taking place, it becomes, in most cases, a check upon the extent of it" (p. 365;) of which inflammations of the pleura, or surface of the lungs, presents a good example; "the adhesive inflammation takes place, and the surfaces are united, which union going before the suppurative confines it to certain limits, so that distinct abscesses are formed in this union of the parts; and the whole cavity of the thorax is not involved in a general suppuration." (p. 366.)

The peculiar disposition of serous membranes to assume in preference adhesive inflammation is remarkably contrasted with the equally special preference of mucous membranes for the suppurative inflammation. The construction of closed cavities by the serous, and of canals by the mucous membranes, afford the ready explanation of these peculiarities. Any opening, therefore, in a serous membrane puts it in an unnatural condition, and, consequently, if it were attacked with suppurative inflammation, the pus produced requiring an aperture for its escape, such unnatural state would be induced, and the functions of the membrane interfered with or destroyed: therefore, most commonly, adhesive is the kind of inflammation occurring, which only diminishes the cavity (the lesser evil) without opening it; and when, more rarely, suppurative inflammation ensues, it is most usually shut off from the general cavity by adhesive inflammation, as in spurious empyema; and only in few cases existing without such adhesion. Whilst, on the contrary, were mucous canals attacked with adhesive inflammation, they would