troubled him during his illness, and, another having died on 22nd December, he again became alarmed, and sunk on the following morning without any other especial cause. The examination of the body on the third day after death presented the following remarkable and unexpected appearances, as he had never made any complaint, nor had the attendants more than myself noticed any circumstance which could lead to the expectation of the results which occurred.

The body generally was thin, but not much emaciated. The slough on the rump had exposed a large portion of the sacrum. Between the crest of the right ilium and the great trochanter, the soft parts were prominent and fluctuating.

The heart and lungs were perfectly healthy.

All the abdominal viscera were healthy except the liver, which was much enlarged, and extremely pallid, and had degenerated into fat to an extreme degree.

The right m. iliacus was raised from the concavity of the ilium; prominent, tense, fluctuating when touched, and the fluctuation communicated to the external prominence between the iliac crest and trochanter. When the muscle was cut into, a large quantity of dirty stinking pus was found filling the iliac pit internally, and communicating through the ischiatic notch, of which the edge had become carious and rough, with a quantity of similar pus extravasated among the gluteal and all the muscles in the neighbourhood of the back of the hip-joint. All the muscles were separated from each other, and had assumed a greenish appearance. In front of the joint there was only a small collection of pus, and the muscles were seemingly healthy. The hipjoint contained a small quantity of dirty purulent fluid; there were slight traces generally of synovial inflammation, specially at the notch, and where the acetabulum was devoid of cartilage. The right ilium was rough and carious on both external and internal surface, and the right sacro-iliac symphysis so extensively destroyed that slight force separated the bones, the surfaces of which were carious.

The left knee-joint: nearly all the articular surfaces deprived of their cartilage, small isolated patches alone remaining, and the exposed surface of the bone being everywhere rough and carious. The crucial ligaments were only partially destroyed. Neither of the vertebral bodies were affected with disease.-J. F. S.

My friend Dr. RIGBY (a), in his account of contagious or adynamic puerperal fever, speaks of a peculiar kind of abscess following attacks of that disease, which we saw together in several instances at the General Lying-in Hospital. "Where," says he, "the constitution has borne the brunt of the attack without immediate collapse, and the local mischief been controlled by appropriate means, we find that fresh efforts are made to rid the circulation of the morbid matter with which it is infected. The patient is suddenly seized with severe pain, with heat, redness, and swelling of one of the large joints, presenting all the appearance of arthritic or rheumatic inflammation, and also of certain muscles especially, the supinatores of the arm, the glutæi and gastroenemic. The painful spot soon becomes hard, it is intensely tender, and in two or three days the feeling of fluctuation indicates the formation of an abscess, from which a large quantity of greenish coloured pus mixed with blood and serum, is discharged. The cellular tissue beneath the skin and between the muscles is equally affected, and, if examined when the abscess is just beginning to form, will be found of a dirty brown colour, softened, infiltrated, and here and there condensed with lymph or pus, precisely as in cases of gangrenous erysipelas: the muscular tissue has entirely lost its red colour, and closely resembles the appearance of boiled meat, its structure so softened as to tear easily under the fingers, and interspersed with deposits of immature lymph and purulent fluid, the commencement of what would have been an abscess. Like gangrenous erysipelas, the extent of the abscess does not seem to be limited by a surrounding wall of healthy lymph, as seen in a common phlegmon, but, if deep beneath the surface, it continues to spread in all directions, until nearly the whole limb appears to be implicated in one immense abscess: hence, in those patients who have recovered under these attacks, the limb has frequently been rendered useless, the muscles being atrophied and coherent." (p. 291.) The following observation of the same writer in reference to the contagious nature of these abscesses is extremely important. "That the discharges from a patient under puerperal fever are in the highest degree contagious, we have abundant evidence in the history of lying-in hospitals. The puerperal abscesses are also contagious, and may be communicated to healthy lying-in women, by washing with the same sponge; this fact has been repeatedly proved at the Vienna hospital; but they are equally communicable to women not pregnant: on more than one occasion the women engaged in washing the soiled bed linen of the General Lying-in Hospital, have been attacked with abscesses in the fingers or hands, attended with rapidly spreading inflammation of the cellular tissue." (p. 292.)] (a) A System of Midwifery, Lond., 1844, forming part of TWEEDIE's Library of Medicine.

17. BEINL, RUST, and others, consider the nature of the so-called lymph-swelling to be an extravasation of lymph, depending on a rupture of the lymph-vessels, or on an unnatural extension of their walls, and they explain the gradual sinking of the powers of the constitution and so on, which occur at the latter period of the disease, and after its bursting, by the continued loss of the lymph (a). The observations made on the fluid contained in these swellings (which RUST imagined to be only in the earlier period of the disease, transparent and colourless) have shewn that it has more of the properties of pus than of actual lymph, and WALTHER has decidedly proved that the acceptation of the term lymph-swellings in the sense just mentioned is inadmissible; that they must be considered only as abscesses (lymph-abscesses) preceded by a stealthy, if not a sensibly perceptible, inflammatory condition, which, however, on account of the too much depressed vital activity, could not produce a plastic consistent pus, but only a secretion of a thin more or less turbid lymphatic fluid. The opinion advanced by BEINL that the strongest and most healthy subjects are commonly more subject to this disease than the weakly, that men more than females, and that, without an external injury, a general diseased condition is incapable of producing a lymph-abscess, is incorrect, and has been disproved by RUST. How frequently, even by writers on lymph-swellings, cold abscesses and such collections of pus as have formed at distant parts (congestion-abscess) (b), in consequence of carious destruction of the bones of the vertebral column, have been taken for lymph-swellings, and treated as such, I myself have frequently observed.

NASSE (c) describes a case in which a powerful healthy young man, in consequence of an external injury, had a swelling formed on the upper part of the thigh, the contents of which, after opening, perfectly resembled lymph. The pouring out of a clean transparent fluid could not be allayed by any treatment recommended for lymphswellings, and the patient was exposed to the danger of hectic consumption. The local use of a solution of nitrate of mercury alone brought the lymph-vessels to close. This case (which I myself saw, although only once, in passing through Halle, and convinced myself of the continued outflowing of clear lymph which could be increased by pressure) proves that a collection of lymph in the cellular tissue is possible, as the consequence of an actual tearing of lymph-vessels by external violence, the exudation from which ceases only by obliteration of the torn vessels. Cases of this kind are, however, undoubtedly very rare; to them alone can be applied the term lymph-swelling in its proper sense, and therefore the above advanced opinion, "that the cases commonly spoken of as lymph-swellings are merely modifications of abscesses," is rather confirmed than contradicted. This opinion LANGENBECK (d) has also advanced; although, he adds, that not unfrequently a swelling is observed on the elbow, which is formed sometimes from a local cause, and sometimes also without, is situated immediately on the olechranon, and contains a clear lymphatic fluid enclosed in a cyst, which deserves the name of lymph-swelling, I must yet deny this assertion, as this swelling at the elbow joint is a dropsy of the mucous bag there situate, and may be compared to the Hygroma cysticum patellare. Just as little also can I agree with the opinion of EKL (e), who considers the lymph-swelling as an expanded mucous bag in which there is a diseased secretion going on. ZEMBSCH (ƒ), according to KLUGE, in order to accommodate the different opinions of writers, distinguishes, 1st, the acute and chronic lymphswelling, as idiopathic and symptomatic disease; 2nd, the false lymph-swelling or lymphatic abscess.

[A case marked in my note-book, "Collection of synovial fluid within the femoral sheath," which occurred in St. Thomas's Hospital in 1839, seems to me more nearly allied

(a) J. A. SCHMIDT, über den Grund der Todtlichkeit de Lymphgeschwulste; in Abhandlungen der Medic. Chirurg. Jos. Akademie in Wien, vol. ii.

(b) A. PAULI, Bemerkungen über Congestions abscesse; in RUST's Magazin, vol. vii. p. 383, vol. viii. p. 434.

(c) Archiv für medicinische Erfahrung von HORN, NASSE, und HENKE, vol. i. 1817, p. 377. (d) As above, vol. ii. p. 197.

(e) Bericht über die Ergebnisse; in Chirurg. Klinikum zu Landshut. Landshut, 1824. 4to. (f) Ueber du Lymphgeschwülst; in Rust's Magazin, vol. xxvii. p. I.

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

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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, 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 absorption, 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.)

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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.)

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"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 causes. In those cases where ulceration is employed in separating a dead part, such