matter, and the influence which it must produce on the general system when mixed with the mass of blood." (p. 368.) And BoUILLAUD (a) also ascribes the typhoid symptoms to the presence of pus in the system. TRAVERS (b), however, does not agree with these writers as to the existence of pus being the cause of the symptoms. He first distinguishes between the inflammation which terminates in the formation of pus, and that which terminates in depositing adhesive matter or lymph, extends to the trunks of the system, and sometimes, it is said, reaching the heart: the former condition is a protracted irritation, causing hectic and ending in exhaustion; the latter a typhoid fever which, speedily producing delirium, terminates within a few days: cases of the first kind, though always dangerous, sometimes recover, but of the second, he believes, never. He then proceeds: There have been many conjectures respecting the cause of the fatal termination of these cases, at which I confess I feel surprised; among others, the inflammations, by extension, of the heart or the membranes of the brain and the conveyance of pus into the circulation have been mentioned. Not to insist on the innocuous quality of pus, it should be observed, that the most rapidly destructive inflammation is that which has the true adhesive progress, in which no pus is secreted. But, if we consider the importance of the veins in the economy, the extent of surface which the collective area of the venous trunks afford, larger, I imagine, than any of the shut sacs of the body, and the diffused and disorganizing character of the inflammation, we can surely be at no loss to account for the disturbance of the system. It is an error to suppose that any quicker sympathy exists between the constitution and the venous, than the arterial or absorbent system. I say this because I have observed something like that superstitious alarm which is excited by events that we do not expect, and cannot explain, has been produced by the fatal catalogue of tied veins, and a comparison of this with the generally successful cases of tied arteries. All the mystery of veins is, as I have attempted to show, that they are indisposed to inflame, but, when excited, inflame by continuity; and therefore it is that the constitution sympathises so deeply.” (p. 286.) In a very excellent paper on phlebitis, ARNOTT (c) deduces from the collation of cases "the total disproval of the assertion, that death results from the extension of the inflammation of the vein to the heart." In none of the en instances following venesection was the superior cava affected, much less the heart; and, in half this number, inflammation had not reached to the subclavian or even to the axillary vein. In the cases where the inferior cava had become inflamed, the first is the only one in which the heart is represented to have been actually implicated; and here, the deposition of lymph terminating at the entrance of the emulgent vein, the observation is, that there were marks of diffused inflammation extending to the right aaricle of the heart, but the signs of adhesive inflammation terminated as above." *** With the exception of the instance just alluded to, I have only found two others in which it is alleged that the inflammation had extended from the vein to the heart, and in these the description is not very precise. Both cases are mentioned by RIBES (d). In one, occurring so far back as the year 1799, where the veins of the arm were infamed in connexion with gangrene of the hand from chilblain, "traces of inflammation" are stated to have been continued into the superior cava, and even to the interior of the right auricle and ventricle; and, in the other instance, where the saphena evinced tome signs of inflammation, in a case of mortification of the leg and foot, it is stated, in the same vague terms, that "the right auricle and ventricle of the heart, as well as the inferior cava at its insertion into this organ, had manifest traces of recent inflammaGon. It is to be regretted that RIBES has not distinctly specified what the "traces" were which he considered as indicative of inflammation in the lining membrane of the heart. (p. 42, 43.) From ARNOTT'S statement, it appears further that "there are considerable differences in the extent of vein occupied by inflammation in fatal cases of phlebitis. Sometimes the disease has spread into several or most of the veins of a limb from that primarily affected; at others it has not proceeded beyond the vessel in which it originally appeared," sometimes is "limited to a few inches only of a vein," and thus justifies the inference that the dangerous consequences from phlebitis bear no direct relation to the extent of the vein which is inflamed." (p. 44.) As regards the contents of the inflamed vessels, "in a number of them, where an open wound existed in the vein, pus was discharged from it during life; whilst in fourteen cases out of seventeen, pus, or pus in conjunction with lymph, was present in the vessel after death.

(4) Recherches Cliniques pour servir à l'Histoire de la Phlebite : in Revue Médicale, June, 1824. (6) Essay on Wounds and Ligatures of Veins; in COOPER and TRAVERS's Surgical Essays, vol. i. Edition. London, 1818. 8vo.

(c) A Pathological Inquiry into the Secondary Effects of Inflammation of the Veins; in MedicoChirurg. Trans., vol. xv. 1829.

(d) Revue Médicale for July, 1825.

In two instances, no mention is made of pus, the contents of the veins being described in the one as "adhesive matter," in the other, where the cava was concerned, as "flakes of lymph." In one case only, where the inflammation occurred in a vein previously diseased, or in a vein, the branches of which at least were varicose, neither pus nor lymph was found in the vessel. "It results from this statement, that, although pus is present in the great majority of fatal cases of phlebitis, and that, although it should appear from the character of the general symptoms, and the effects produced upon animals by the injection of a similar fluid into their vessels, the passage of pus into the circulation is probably the principal, yet the circumstances do not justify us in regarding it as the sole, cause of the secondary affection. In addition to the presumed absence of pus in two instances, and its declared absence in a third, it may be remarked that the early appearance of the symptoms in some cases seems scarcely to correspond with the time usually required for the production of pus, as in one which occurred to FREER, (quoted by HODGSON, p. 551,) where they came on suddenly, four hours after ligature of the saphena." (pp. 44, 45.)

"The secondary affection in phlebitis usually shows itself in from two to ten or twelve days after the receipt of the injury which has occasioned the inflammation in the vein; where the vessel has been previously diseased, sometimes sooner. *** The duration of this affection offers some variety," (pp. 51, 53,) death taking place at different periods from the fourth day to the end of the seventh week. The remarkable morbid appearances recited by ARNOTT are, in the chest, effusions of sero-purulent fluid into the cavities of the pleura and pericardium, exudation of coagulable lymph on the surfaces of the heart and lungs, hepatisation of the latter organ, infiltration of pus into its tissue, or small collections like a mixture of pus and lymph, pus also in the muscular substance of the heart. *** In the cellular substance, intermuscular as well as subcutaneous, pus and sero-purulent fluid have been extensively deposited, sometimes in collections like abscesses, at others, appearing more like an effusion into its cells than as resulting from the common process of inflammation. These collections more frequently occur in the vicinity of joints. *** In the joints, a most violent inflammation of the synovial membrane, its distension with purulent matter, destruction of the cartilage and baring of the bones. *** In the eye, opacity of the cornea, injection of its blood-vessels, and destructive changes in its humours or its coats. Besides these affections, there were found in five instances within the cranium opacity and thickening of the tunica arachnoides, effusion between it and the pia mater, and increased secretion into the ventricles. In nine the head was not examined, and in three no morbid appearances were noticed." (pp. 53, 57.) The conclusion at which ARNOTT arives is, "that death in cases of phlebitis does not take place from the inflammation extending to the heart; whilst the history and character of the symptoms which precede this event, the very small portion of vein which is sometimes found to have been inflamed, and the general presence of pus in its cavity, all tend to establish, that the entrance of this fluid into the circulation is the principal cause of the alarming and fatal consequences of phlebitis, a similar influence being perhaps also possessed by any inflammatory secretion from the vein." (p. 61.)

On the inflammation of the femoral and iliac veins, which occurs in puerperal women, which sometimes, but not always, gives rise to Phlegmasia dolens, Dr. ROBERT LEE (a) observes, that," whether the inflammation of the coats of the veins be simple adhesive inflammation, or inflammation of a specific kind connected with the puerperal state, and differing, not only in the degree of intensity, but in its essential nature from phlebitis after venesection, it is difficult to determine. The peculiar character of the symptoms seems strongly to favour the latter opinion, though it cannot be denied that the disease occasionally assumes the form of common phlebitis, fatal cases having occurred where pus has been found secreted by the internal coats of the iliac veins, and death caused by inflammation and apostematous deposits of matter in the lungs and other remote organs of the body." (p. 145.)]

In the Absorbent Vessels, inflammation arises either from external injuries and so on, or from some morbid matter which they have taken up. It is indicated by painful red swelling of the absorbent vessels up to the nearest gland. It usually terminates in resolution.

[Inflammation of the absorbent vessels may arise without either injury or the absorption of morbid matter, but simply from irritation, as frequently seen in whitlow or other inflamed condition of the fingers or toes, as when they have been chafed or after the

(a) On the Pathology of Phlegmasia dolens; in Medico Chirurg. Trans. vol. xv. 1829.

application of a blister. The red streak or streaks which indicate the inflamed absorbent vessel or vessels, is generally little thicker than a stout thread, pale towards its edges, can at first scarcely be called a swelling, but is more like a streak of paint on the skin, and only after some time has a slightly knotted feel. It runs along the limb with great rapidity, and will in the course of a few hours enter the cavities of the trunk. It terminates in suppuration less frequently and less quickly than inflammation of the veins. Generally it subsides as the irritation which has excited it is relieved, and I do not remember to have observed continuance of the cordlike feel long after the inflammation has ceased.-J. F. S.

In reference to these red streaks, HUNTER observes:-" These reddish streaks are supposed to be absorbents, becoming inflamed by their carrying a stimulating fluid. I am apt to suppose them to be absorbents; but I do not conceive that this effect arises from absorption. If it arose from such a cause, it should be uniform; the cause should always exist when the effect takes place. It is first to be observed that it only takes place in certain constitutions, in which absorption one way or other explains nothing; and I find upon observation that this effect shall be coeval with the inflammation where no suppuration has taken place. I have even seen it arise from accident, prior to the possibility of inflammation taking place, viz., in the time of the pain arising from the immediate effects of the accident; this was in the finger, from the prick of a clean needle, which had been for some time pricking new buckskin leather; the glands in the arm-pit were sore, sickness attended with its usual symptoms, such as oppression, was nearly immediate. Its direction from the source of the circulation is another strong proof of its not arising from absorption, and its taking place at some distance is also a corroboration of the same opinion. Another strong circumstance in favour of this opinion is, that the morbid poisons do not produce this effect where we know absorption has taken place. Thus the venereal seldom or never produces it." (p. 275.)

I have seen earthy deposits in the absorbent vessels of the skin, and also of the spermatic cord, giving them the appearance of corallines.-J. F. S.]

Inflammation of Nerves or rather of their sheaths is no very rare circumstance. As the nerves have but few nutritive vessels, the usual symptoms of inflammation, viz., heat, redness, and swelling, are present only in a slight degree. It begins with formication, torpor, frequently with severe darting pain, which spreads in paroxysms, like electric shocks, along the branches of the nerves; and to these are added febrile excitement, cramps, and convulsions. The inflammation may have either a chronic or acute course; the former we observe in ischias nervosa and many neuralgies, the latter in tetanus, hydrophobia, and so on. On examination we find the nervous sheaths especially affected, reddened, swollen; the nervous matter is frequently dissolved, as if grangrenous; often there are produced exudations in the nervous sheaths, or degeneration of the nerves.

Inflammation in the Bones occurs either in the periosteum or in the medullary membrane, or in the substance of the bone itself. In all these cases the symptoms are different, especially according to the acute or chronic course of the inflammation. In inflammation of the Periosteum, (Periostitis,) a circumscribed swelling with more or less acute pain is produced by exudation between the bone and the periosteum. If the inflammation do not resolve, it runs on to hardening, gouty thickening, exostosis, into caries, necrosis, and more rarely into fungous degeneration. Inflammation of the Medullary Membrane is characterized by deep-seated, gnawing pain, at last the bone itself swells throughout its whole thickness; and, if the inflammation do not resolve, it runs on to closing up of the medullary canal, or suppuration and destruction of the bone from within outwards, in necrosis or fungous degeneration. In inflammation of the Bone itself thickening throughout its whole extent (Hypertrophy) may occur, with closing of the medullary hole, ulceration, necrosis, and different kinds of degeneration of the bony tissue.

VOL. I.

G

42. The Prognosis of inflammation is very various; it depends specially on its severity and character, on its causes, on the constitution of the subject, and on the parts in which it is situated.

43. The Treatment of inflammation generally purposes to effect its resolution, except in certain critical inflammations, in wounds with much contusion, and in furuncles.

The first indication is the removal of the cause, if it continue to operate. If the inflammation be not very great, this alone is often sufficient. If the cause cannot be removed, or the inflammation have advanced to a certain extent, the plan of treatment includes all the means which are implied in the term antiphlogistic mode of cure. In those inflammations which are connected with much fever we must employ bleeding, nitrate of potash, and other antiphlogistic remedies, with cooling diet and rest. If the inflammatory symptoms are thereby diminished, calomel is specially useful to hasten the absorption of the lymph_effused into the cellular tissue, and to prevent its coagulation. If the inflammation have an erethitic character, if it be accompanied with greatly increased sensibility, we endeavour after the above-mentioned antiphlogistic treatment to lessen it by opium in connexion with proper antiphlogistic means, such as mercury, hyoscyamus, and hydrocyanic acid, laurel water, and so If gastric impurities exist, they must be removed by vomiting and purging. In malignant inflammation the treatment must particularly depend on the kind of accompanying fever; the antiphlogistic treatment is then to be used only with circumspection. If the inflammation have a specific character, if it be connected with a dyscratic affection, we must act according to the degree of the inflammatory reaction, first on the antiphlogistic plan and then against the dyscracy: the antiphlogistic treatment, however, in this case, requires to be pursued with moderation.

on.

[JOHN HUNTER, in treating "of the methods of resolution by constitutional means,” makes many very excellent remarks on blood-letting, the object of which, as just mentioned, is to produce the contraction of the vessels, and which is always to go "hand in hand" with the soothing or lessening irritability, or the action of dilatation, by means of sedatives, relaxants, and stimulants, sudorifics, &c. Neither of these proceedings "can possibly lessen the original inflammatory disposition:" they may, however, "in some sense be reckoned direct; for, whatever will produce the action of contraction in the vessels, is counteracting the action of the dilatation. Lessening the power of action belonging to any disposition can only lessen or protract the effects, which, however will be of singular service, as less mischief will be done, and it will often give the disposition time to wear itself out. Means employed on this principle, should be such as give the feel of weakness to the constitution; which will affect the part, and will make the vessels contract; but this practice should not be carried so far as to produce the sense of too much weakness, for then the heart acts with great force and the arteries dilate. Bleeding, then, as a general principle, is to be put in practice: but this must be done with judgment; for I conceive the effects of bleeding to be very extensive. Besides the loss of any quantity of blood being felt, in proportion to the quantity lost, an universal alarm is excited, and a greater contraction of the vessels ensues, than simply in proportion to this quantity, in consequence as it would appear of a sympathetic affection with the part bleeding.

"As many patients that seem to require bleeding have been already bled, it may not be improper to inquire how they bear or are affected by bleeding; for, certainly, all constitutions (independently of every other circumstance) do not bear this evacuation equally, and it is probable, that its effects on inflammation may be nearly in the same proportion; if so, it becomes a very useful caution; for, although the loss of blood may as a general principle be set down as a weakener, and probably the greatest, as we can kill by such means, yet the loss of certain quantities in many constitutions is necessary for health; this is either when there is a disposition to make too much blood, or a constitution that cannot bear the usual quantity; in such, when

known, bleeding with freedom is certainly necessary.

* Every part

of the body under inflammation will not bear bleeding alike. I believe that the constitution bears bleeding best when the inflammation is in parts not vital, and those near the source of the circulation: whatever disturbs some of the vital parts, depresses, but not equally in all; and in them it becomes more necessary to be particular, for, in accidents of the brain, bleeding freely, even so as to produce sickness and fainting, is necessary. It is probable that the sickness attending such accidents, is designed to lessen the influx to the head, and occasion the vessels of the brain to contract." (pp. 335, 7.) "With regard to this evacuation," (blood-letting,) he observes further, "it is worthy of particular consideration, whether or not in all cases, where it can be put in practice, bleeding in or near the part will answer better than taking the blood from the general habit; for certainly less may be removed in this way, so as to have equal effect upon the part inflamed, (and probably upon every disease that is relieved by bleeding,) and yet affect the constitution less; for, although, in many cases, the general habit may be relieved by bleeding, yet the part affected, where it can act, will in all cases require this evacuation most, and local bleeding will keep nearer these proportions, whereas taking blood from the general system is just the reverse. * I have observed that there is something similar to sympathetic affection in bleeding. I conceive that all the sympathetic powers, the universal, continued and contiguous, may be brought into action from the local influence of bleeding. Thus, bleeding in the part inflamed, I can conceive, does more than simply emptying the vessels mechanically, for that would soon be restored from the general circulation; but it acts by continued sympathy, viz., the vessels of the part being opened, they contract for their own defence, and this is carried further among the vessels of the part; so that bleeding from the part acts in two ways, viz., mechanically by relieving the vessels of some blood, so as to allow them to contract in proportion as the load is taken off, and also to excite them to contraction in order to prevent the effusion of blood. I suppose, likewise, that contiguous sympathy comes into action; for this would appear from practice and observation to be a principle in bleeding: therefore, in inflammation of contiguous parts it is proper to bleed from the skin opposite to them." (pp. 338, 9.)

"Where the first indication for bleeding takes place, viz., where there is violent inflammation, with strength of constitution, bleeding freely will be of singular service. As it seldom happens that bleeding once will be sufficient in a considerable inflammation, the first or preceding blood taken becomes a symptom of the disease.

On the other hand, there may be indications for bleeding sparingly; first, when there is too much action with weakened powers; secondly, when there is a disposition to form but little blood; thirdly, when the part affected is far from the source of the circulation. From the above three dispositions that require bleeding sparingly or with caution, I may observe, that it will most probably be proper in all such cases to bleed from, or as near, the part affected as possible, in order to have the greatest effect with the loss of the least quantity of blood, more so than when the constitution is strong, because the constitution in such cases should feel the loss of blood as little as possible. *** But

in many cases the blood cannot be taken away from the part itself, but only from some neighbouring part, so as to affect the part inflamed." (pp. 339, 40.)

Bleeding should in all cases be performed with great caution, more particularly at first; and no more taken than appears to be really necessary; it should only be done to ease the constitution, or the part, and rather lower it where the constitution can bear it; but, if the constitution is already below or brought below a certain point, or gives the signs of it from the situation of the disease, then an irritable habit takes place. which is an increased disposition to act without the power to act with. This of itself becomes a cause of the continuance of the original disposition, and therefore will admit neither of resolution nor suppuration, but continue in a state of inflammation, which is a much worse disease than the former." (p. 344.)

44. Different as is the General treatment of Inflammation, no less so is the Local. The local means are, abstraction of blood, cold, moist, or dry warmth, salves and plasters, astringent, anodyne and derivative means. ["Wherever," says JOHN HUNTER," there has been a violence committed, or some violent action is going on, there is a greater influx of blood to that part. Lessening therefore that influx becomes one mode of relief; for, as the vessels dilate, they should not be encouraged in that action. Although the increased influx is to be considered chiefly as an effect, yet it is to be considered as a secondary cause; and, from our ignorance of the immediate cause, it is probably only through such secondary causes that