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INE  NATIONAL LIBRARY OF MEDI CINE N A T I O N A I I I B R A R Y O F M E D I C I N E  N A T I O N A I I I B R A
   •    XV. <r/ •

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AN  OUTLINE
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INFLAMMATION  AND ITS EFFECTS:
FIRST PRINCIPLES OF SURGERY.
GEORGE T. jtfORGAN, A.M.

     LECTURER ON SURGERY IN ABERDEEN.

i^BRA^
     PHILADELPHIA:
CAREY  &  HART.
1841. 
 
STUDENTS OP SURGERY,
THIS WORK,
INTENDED TO ASSIST THEM IN THEIR LABOURS,
IS RESPECTFULLY DEDICATED
EY
THE AUTHOR.
'tngn b
 
 
  The first principles  of Surgery with which the student should
make himself familiar  are  those relating to inflammation and its
effects.  An intimate acquaintance with this subject is of as great
importance to the practical surgeon as that of fever to the practical
physician.  Independent of any interest attached to the investigation
of its  phenomena,  the researches  of modern pathologists have
shown  that disordered vascular action forms  the ground-work
of many diseases, and, at some period or other, accompanies almost
all.  Diseases may be of themselves  purely inflammatory; or in-
flammation may be united with them,  or  supervene during any
part of their course.   Many cases which formerly went under the
very convenient title of nervous, as,  /or example, amaurosis, are
now known to be in general the result of inflammation or its effects;
and hence, an opposite and more successful line of treatment has
been adopted.  So  readily is this species of morbid action kindled
up,  and so widely diffused is the structure in which it has its seat-
wherever,  indeed, vascularity can be detected—that  we need not
wonder at its so frequent  occurrence.  The  time is probably not
far  distant when the nature of disease will be better understood;
and when  inflammation will be allowed to hold a more prominent
share in its constitution than is even yet assigned to it.
   By the  surgeon,  inflammation may be considered under two
 points  of  view—either as  a morbid process, requiring its approach
 to be carefully watched and every means adopted to keep it in sub-
jection ; or, as an act  of restoration on the part of nature to repair
 injuries or get  rid of foreign bodies  introduced within the system.
 Tliis apparent discrepancy5\vith respect to the ultimate effects pro-
 duced by  inflammation, gave rise to a discussion amongst some of
 the older  writers, as to whether it should be viewed as a salutary
 or  destructive process.  The question may be readily and satisfac-
 torily answered.   When inflammation takes place in any of  the
 o-reat cavities of the body, from the application of cold to the surface, 
iv                      INTRODUCTION-

it may, if unchecked, either lead to the loss of life or so impair the
structure of organs as to render them ever afterwards incapable of
performing their proper functions; hence it is assuredly a morbid
action intended to answer no good end, and causes the most serious
and fatal consequences.   On the other hand, how highly useful,
nay, indispensably  necessary, is  inflammation?  Without it, the
progress of mortification could never be arrested and the dead parts
cast off from the living;  the mouth of a bleeding artery could not
be permanently closed; no collection of purulent matter or foreign
body travel to the nearest outlet and be discharged; no chasm
made by ulceration  filled up;  no breach of surface repaired;  no
wound healed; and hence, no operation attempted.   We may go a
step farther, and state that, besides the salutary effects thus naturally
obtained, inflammation is frequently induced by the surgeon where
he wishes to  obliterate some cavity or canal, as in the radical cure
of hydrocele or in the treatment of a sinuous ulcer.  Suited for the
purposes now mentioned, inflammation must always be of a limited
and peculiar character; when too sluggish, it requires to be urged
on;  when too violent, it  must be repressed.  We are,  therefore,
taught that inflammation  is the most fatal of all diseases; and, in
fact, with a few exceptions, all diseases threatening speedy destruc-
tion to  life spring  from it; while, again, it  is the only way  by
which  lost parts can be restored,  or the effects of injuries repaired.
Without it, in short,  the  business of the surgeon would, in many
cases, be at an end.
  In calling  the student's attention to this subject, we have never
deemed it necessary to make any apology for the  length  of time
occupied in its discussion, as we consider that on this knowledge
depends, in a great measure, the success of his future labours.  We
have no hesitation in stating, from our own individual experience,
that one of the greatest errors committed in the first acquirement
of a surgical education is the hurrying over doctrines which appear
dry and uninteresting, and passing on to the consideration of inju-
ries and operations, without stopping to contemplate what it is that
renders the former so dangerous or leads so often to the necessity
for the latter. In this way, the separate parts of surgery are eagerly
sought after, while its fundamental principles are neglected; to use
a metaphor,  the branches are  cultivated while  the parent trunk
around which  they  entwine, lies forgotten.   But let the  student
turn in  what direction he  pleases, inflammation continually crosses
his path; it presents itself wherever he goes; its effects are revealed
to him  in every new state which comes under his notice • it is to 
INTRODUCTION.
prevent its inroad and subdue it when it has appeared, that he ob-
serves the experienced surgeon manifesting such anxiety; and it is
the great agent against which he is admonished he has to contend
in the ordinary routine of daily practice.   We cannot afford space
to enter  into  minute particulars; but let  him select any  subject
which is considered to belong to this branch of his profession;  let
him turn to wounds  and their  consequences; diseases-or  injuries
of the coats of the vessels;  those of the bones or joints; of the uri-
nary organs;  the organs of sense; the head, chest, or abdomen;
or  any of the various operations required, and we think  a little
reflection will teach him the intimate connection between all these
and  inflammation—the necessity, therefore,  for  the minute and
careful  study of the latter—and the  impossibility of making any
permanent and valuable progress without such  fundamental  in-
struction.  Wherever, indeed, we have  found this rule reversed,
there crude*and ignorant notions were sure to prevail.
   Were we to descend from what experience  has taught us and be
required to bring forward authority in vindication of the position we
have taken up, we tfould gladly appeal to one of the greatest names
left us  on earth; nor, under the  present circumstances, could we
stimulate the student to industry, should we be stepping far out of
our path in  bringing  before him a few of the most remarkable
features in the history of John Hunter.   Here he is furnished with
an instance  of an  individual, born in an obscure parish, receiving
scarcely the rude outlines of a common education, and bred at first
as a carpenter, who, by self-tuition, perseverance, and unwearied
 application,  gradually rose in life till he assumed the  most con-
spicuous place in the metropolis of his country.  We might, there-
fore, dwell  on his  professional  industry to illustrate what ours
 should be, or hold up his limited means and humble origin as an
 example for all to persevere.  To  his unceasing labours, Hunter
 was mainly indebted for the distinction he acquired; and, with the
 exception of a few hours allowed for repose, his indefatigable mind
 seems to have been ever at work.  He has done, in many  respects,
 for our profession, what Newton did for natural science.  He  was
 constantly bent on its improvement; and, in every department to
 which he turned his attention, we discover the traces of his masterly
 hand.   The  great monument of his industry, and that which  will
 hand down his fame  to all future ages, has fortunately been  pre-
 served; nor was it a mind of any ordinary description which thus
 ventured to shadow forth in one vast series the universe of  life.
 The conception, it has been said, was worthy of Milton ; the labour 
V
Vi                     INTRODUCTION.   .

could have been  achieved  by few men except Hunter.  Volumes
have been written on his genius; orations have been spoken in his
praise; but one glance round the gallery of his Museum is worth
them  all.   Where we asked for Hunter's  epkaph, we would  lead
the enquirer into this noble  edifice and say—
                "Si monumentum quaeras, circumspice."

  Such men as Hunter appear only onqe during the existence  of a
world; and it is  no easy task for posterity to speak concerning
them as they deserve.  The former reflection is startling but correct.
Thus, while Newton, Locke, Bacon, Shakspeare, Scott, and many
others, are infinitely removed from tl*£ rest  of mankind, Hunter
stands  alone in our profession.  When'*we think of all that he has
accomplished, we  are almost tempted to regard him as supernatural.
His life resembles the transit of a comet, which bewilders while it
excites admiration; which dazzles with-excess of brilliancy, and then
for ever disappears.  How humble do any of the men of the present
day appear when placed by the  side of Hunter.   In his immense
career, every thing bore reference to one gfeax idea—the discovery
and elucidation of nature's laws.  From the course of investigation
\vhich  he pursued, he stepped at once out of the night of darkness
into the full sunshine of knowledge.   The difficulti'es he had to
contend with, only add  an  intenser lustre to the glory he has ac-
quired; and any imperfections we now perceive in his writings are
as the shadows of a great landscape, rendering its prominent objects
more  distinct.  By his  own  exertions albne,  he liberated  many
parts of surgery from the impurities by which they were disfigured.
On the lofty elevation reared by his own labeurs'lie stood pre-emi-
nent ; and his history records all that gives life a value, and refines
and ennobles the species.  The peculiar  character which distin-
guishes any  past generation  must  alwa(y» be interesting  to  that
which  follows, and may afford matter  for much useful discourse;
but the peculiar  character  of man,  and of the mind of man__for
ever active, yet  for ever varying—is a theme of more permanent
utility and  sublimer interest.   Here our brief sketch  must close.
Earthly fame is too often like a withered leaf, at one time tossed by
the winds, at another,  trodden under foot of men;  but the grave of
Hunter will be for ever clad with the verdure of immortality.
  The importance which  Mr. Hunter attached to the study of
inflammation may be gathered from  the eagerness with which he
pursued the investigation of its phenomena.  What skill he  pos-
sessed in surgery is mainly to  be attributed to his  accurate  know- 
INTRODUCTION.
VI1
ledge of anatomy, and the profound views he entertained of disease.
His treatise on "Blood  and Inflammation" is invaluable, and will
always be  a lasting mark of his genius and reputation.   In it he
brought to  light much that was unknown or misunderstood, and he
stripped other parts of the absurd explanations  with  which they
were encumbered.  As in all his other works, we find him  taking
the deepest and most original views of morbid action, founded on
the closest observation and  experiment;  for, without these, Mr.
Hunter was, fortunately, not  much addicted to theory.   The most
interesting chapter is that on " The  Adhesive Inflammation," and
which contains all that is known on this subject in the present day.
Next we might reckon that on ulceration and the different kinds of
absorption which go on in the healthy and morbid states of the
body;  but it is needless to make selections from  a work  replete
with interest, and which should be carefully and frequently read by
every candidate for surgical fame.
   Since Mr. Hunter's time, many valuable observations  have been
made  on   inflammation, especially on the  nature  of the morbid
action itself; nor, even  now, does it  appear  a little singular that
this great man should have contented himself with reasoning on the
state of  the vessels rather than attempting to ascertain by experi-
ment their actual condition.  On this head, we are deeply indebted
to the early investigations of Drs. Philip, Thomson, and Hastings,
and, more recently, to the philosophical and accurate researches of
 Gendrin  and  Kaltenbrunner.   Nevertheless, much difference of
 opinion still exists, and much therefore remains to be accomplished.
 The more immediate phenomena of inflammation are so intimately
 connected with the structure and functions of the minute  vessels,
 that it is  impossible to understand the  one without  a constant
 reference to the other; and before the student looks narrowly into
 this part of the subject, we would recommend him to have his mind
 rightly informed respecting the capillary circulation.  Were the
 physical and physiological properties of the arterial system better
 known,  we should have  much less difficulty in answering the
 question, "what is the condition  of the vessels during inflamma-
 tion?" and to this want of knowledge do we attribute all the errors
 which have been committed, and all the useless discussions which
 have arisen.   The investigation might, in truth be so far defined, as
 an examination  into the difference between the healthy and morbid
 states of the capillary branches;  and hence the necessity of having
 a just conception of the one before we pretend to judge of the other.
 In  order  that we might not be  misunderstood on this intricate 
 VU1                     INTRODUCTION.

 question, we have taken the liberty of making a few  preliminary
 remarks on the nature of the vessels by which the first part of the
 circulation is carried on.  In the brief outline there given, we have
 only alluded to those points which are  essentially connected with
 the phenomena of inflammation; and, we may farther add, that the
statements contained in that and the succeeding section are derived
 either from our own or the  experiments of others.
   In the following pages, it has been our  aim to render  a  simple
 statement of known or acknowledged facts: they may, therefore,
 contain  nothing new or very striking.   We have likewise, as far as
 possible, endeavoured to avoid controversy, except where such was
 absolutely demanded; and then we have generally assigned what
appeared to us the strongest reasons for believing in  the particular
view set forth.  To prevent unnecessary reference to authorities, it
will be seen  that we have consulted the writings of Mr. Hunter and
Burns,  Drs. Philip, Thomson  and Hastings, and  Gendrin  and
Kaltenbrunner.  There are others of  minor importance to  which
we may also have occasionally referred.  In conclusion, our object
in publishing this work  has been, first,  to enable us to abridge  the
early part of our lectures, and allow longer time for the discussion
of other important subjects; and, secondly to furnish the surgical
student  with an outline of inflammation  and its effects brought
down to the present period. 
FIRST  PRINCIPLES  OF  SURGERY.
                         SECTION  I.

                  OF THE ARTERIAL  SYSTEM.

   The  arterial system is made up of a series of cylindrical tubes,
through which the blood is transmitted to all  parts of the body.
Each artery divides  into two or more smaller  branches, which
again subdivide into  others;  so that  the  vessels, as they recede
from  the heart, diminish in  size but increase in number.  The
arteries thus constitute so many descending cylinders, having an
arborescent or conical form, with the apex towards the heart.  The
sum of the  areas of the  branches into which any vessel divides is
always  greater than the trunk  from which the branches proceed.
On this subject, no  accurate calculation has  been made;  but,
according to Haller, it may  be stated nearly  as one  to  one and a
half.  The  ultimate terminations of arteries are so  minute as  to
escape detection with  the  naked eye.   They have, accordingly,
received the name of capillary—a phrase  in daily use, yet one to
which no accurate definition has been  affixed.  The same general
observations apply  to the distribution  of the veins, although these
are more numerous and larger than the arteries.   In estimating the
size of the  veins, we, of  course, begin  by tracing them  from their
origin  in invisible  vessels,  to their union or termination in the
larger trunks;  hence we state,  that the sum of the areas of the
small veins  exceeds that  of the superior or inferior  cava.  These
points are of great importance to remember, when  attempting  to
estimate the velocity of the  blood's  motion in the different series of
vessels;  as, according to the  ordinary laws of  fluids, it  must be
slower in the capillary arteries and veins than in  the larger trunks
of either system.
   When an artery of the middle size, as the popliteal, is examined,
it is found to consist of three distinct tunics, to each of which con-
siderable interest is attached, because on them depend the physical
and physiological properties of the vessel.  The first or outermost
coat, named also the cellular or  elastic, is made up of dense white
fibres, closely compacted together.  It is susceptible of great  dis-
tension, as evinced in cases of aneurism—highly  elastic, especially
in the longitudinal direction, as proved by cutting an  artery across;
       11— e                                    mgn I 
2
MORGAN'S PRINCIPLES OP SURGERY.
 and of such firm  structure, that a ligature drawn tightly around
 fails to divide it.   It varies much in thickness in different arteries,
 and even in different  branches of the same artery; circumstances
 which have not been  sufficiently acknowledged.  Thus it is more
 abundant in the aorta and large vessels, where elasticity is required;
 while it seems wanting in the'arteries of the brain.  It is connected
 to the common sheath  which  envelopes  arteries by means of  fine
 cellular tissue, which  is of great utility in checking hemorrhage
 when the vessels  are  cut across;  and into the cells of which is
 secreted a serous fluid  in the young, and an oily-looking substance
 in the adult subject.
   On  dissecting off the  outer tunic, we arrive at a number of
 fibres, placed obliquely round the artery, constituting segments of
 circles so united as to form rings, having a  yellowish hue in the
 larger, and a reddish colour in  the smaller vessels, and divisible,
 in the former, into several layers.  These  constitute the middle or
 fibrous tunic; or,  as it has been named  by some, the muscular or
 proper membrane of arteries.   It is distinguished from  the outer-
 most coat by its fibrous appearance, by the difference  in its distri-
 bution throughout the  vessels, and by its physical and organic pro-
 perties.   The fibres are flattened, dense, elastic, and easily divided
 by the pressure of a ligature.   They are much  more apparent in
 the small  than in  the  large vessels; and,  therefore, proportionally
 thicker  in  the former than in the latter, being opposed  in  this
 respect to the external tunic;  they cannot, however, be traced in
 arteries less than a line in diameter, and seem to be also wanting
 in those  of the brain.  The identity  of the  fibres  of the  middle
 tunic with  those of muscle, has, for many years, been a subject of
 keen dispute.  After a  repetition of some of the experiments, and a
 careful consideration of the arguments  on both sides, we have
 been forced  to the conclusion, that the arterial fibre has nothing in
 common with that of  muscle.   We will only allude, at present, to
 a few of their physical differences.   In  the first place, it has been
 sufficiently proved that the structure of artery  contains no fibrin,
 a substance  which  enters  so  abundantly into the formation of
 muscle.  Beclard,  indeed,  has  stated,  in his  treatise on  general
 anatomy, that he  discovered fibrin  in the composition of artery;
 but he  hesitates to  consider it as proper  muscular  or fibrinous
 tissue.   Berzelius  and Dr. Young  have denied the  existence of
 fibrin in the arterial tunics; and we are not aware that the result
 of their analysis has been  contradicted by any succeeding chemist.
 Other striking proofs of the difference in  the composition of artery
 and muscle  are afforded by the application of alcohol, diluted acids
 or hot fluids, not corrosive  in  their  nature.  All  these  agents
shrivel and  harden  the arterial tissue—a  phenomenon depending
 on the more complete coagulation of one of its chemical  principles
 (albumen); while they  exert no  change on the  muscular substance.
 The fibres of muscle are also much looser in structure than those
of artery; neither  do  they possess the elasticity so conspicuously 
THE ARTERIAL SYSTEM.
3
seen in the latter.  The effects of compression are widely different.
When  muscular  fibres are surrounded with  a tight ligature, they
undergo a sort of strangulation ; when  the experiment is repeated
on those of arteries, they are divided or cut.   For these and other
reasons, we dissent from the doctrine of the arterial and muscular
fibres being  one and the same; a doctrine which  has been too
readily, and without due precaution, admitted.
  The third  or internal coat of arteries is their  lining membrane,
thin, smooth, and transparent.; and  unlike either of the  others, by
extending uniformly  throughout the  whole  system.  It is readily
divided by the ligature, neither admitting of extension, or possess-
ing elasticity; and, although apparently weak, is yet strong enough
to resist  dilatation from the impetus of the  blood after the outer
tunics  have  been dissected off.  In  properties, it resembles the*
serous  membranes;  being  moistened  by a  watery  fluid in health,
and throwing out adhesive lymph when attacked by inflammation.
The arterial system thus made up, is admirably adapted  for  con-
veying  the  blood to the most  distant parts of the body.   The
strength of the different branches may be conceived from the expe-
riment of Dr. Hales, in which a force equal to a column of water
one hundred and ninety feet high  was required for bursting the
carotid of a dog.  Under this pressure, the vessel did not previously
dilate,  but burst at once;  and from which it may be  inferred, that
dilatation of the  coats  of  arteries,  as  in  aneurism,  can  only be
effected gradually and by length of time.
  The  arterial tissue is highly organised,  being supplied  with
blood-vessels, nerves, and absorbents   The nutritious arteries, the
vasa vasorum, as they are  named, are remarkable for coming  from
a neighbouring branch, and not  from the trunk itself which  they
supply; they anastomose very sparingly with those either above or
"below, and can be traced  only  to the  fibrous tunic, although the
effects of disease  show the lining membrane to be also copiously
supplied.   The nerves are principally  derived from  the ganglions
of the  great sympathetic, arid partly also  from the  cerebrospinal
system ;  they can only be distinctly traced on the larger branches,
and seem to  be lost in the second tunic. It is important  to recollect
the origin and distribution  of the nerves, as  we  will have occasion
to refer to them  hereafter.  Lymphatics cannot be  demonstrated
either by injection or the microscope ;  but  their presence is  proved
from the  ulcerations seen  in the inner coats of arteries, and  from
the manner in  which a ligature  is detached.
   Before speaking of the physiological properties of the arteries, let
us briefly allude  to what is  known respecting  their  terminations.
When an artery, according to Haller, is traced to its final division,
it will  be found to  end—either in  a red vein or veins—in an
excretino- duct, as in any of the glandular  organs—in an exhalant,
as on the skin  or a serous  membrane—in  very  minute vessels, as
lymphatics__or in a colourless vessel, arteria non  rubra, through
which red blood does  not  circulate  in the healthy state.   The
                                                mgn V 
4
MORGAN'S PRINCIPLES OF SURGERY.
ultimate distribution of arteries is discovered by injecting the vessels
with quicksilver in the dead body, or by examining them with the
microscope in the living ;  and both of these inform us that arteries
terminate in red veins.   But  although either method affords  the
only proof on which we can depend, certain changes going forward
in the living body tend to support the opinion that arteries have
other terminations.  Thus the phenomena of secretion  and nutri-
tion prove  the  distribution of arteries  to exhalant surfaces and
secreting organs; but whether, as Haller has supposed, the vessels
thus ramifying become at once continuous with the secreting duct
of a gland, or form the exhalant tube in the surface of a membrane;
or whether,  as stated by  Mascagni, the arteries have  lateral  pores
through which the secreted  or exhalant  fluid passes directly from
the blood—we are, in the mean time, perfectly unable to determine.
In  like  manner, from  injections  having in  some instances been
transmitted from arteries  into lymphatics, Magendie has espoused
the doctrine first promulgated by Bartholine, that there is a direct
communication between these two sets of vessels ;  but the proof of
this is  not  yet  complete.  Again, the termination of  arteries  in
vessels capable of only transmitting the colourless portion of  the
blood, rests on such evidence  as  to make it  no longer a matter of
uncertainty.   When the  course  of  the  blood, in the transparent
parts of an  animal, is watched  with the microscope, the vessels
through which it passes are seen  to become gradually smaller, till
at length  we can  only detect  a single globule within their canal.
Our means  will not permit us to carry the  examination farther;
but the inference is fair,  that there are vessels still more minute
which we cannot perceive, and through which the colourless por-
tion of the blood is moving.  Nay,  we are perfectly assured that
many textures are  nourished by  transparent, vessels alone, for the
phenomena of acute inflammation and  mechanical irritation have
shown that  such textures may   be  suddenly distended with  red
blood ; and  thus the vascularity of parts, which are colourless  in
the natural state, is rendered apparent by  disease.  Setting aside,
therefore, part of the hypothetical description given by Haller (for
he  himself allows,  that where direct investigation failed, he had
recourse  to  the  uncertain evidence  of  analogy),  we  may admit
without much fear of  future  contradiction,  that  arteries, when
traced  to their  ultimate  terminations,  either become continuous
with a red vein or veins,  or pass  into colourless vessels, or ramify
in secreting  organs or textures  in  a way at present  unknown to us.
   Founded  partly on this view of the minute arteries  conveying
red or pale blood,  Bichat  has described the capillary system under
three  different heads; in organs in  which  it contains blood,  as
muscles;  in organs in  which it contains blood and other fluids, as
bone; and in parts in  which  it  contains no blood, as in  ligament
or tendon.  Such  an arrangement  is quite useless in a  practical
point  of view, it being sufficient to  show that parts  are  either
coloured or  colourless, according to the size of  the  vessels with 
THE ARTERIAL SYSTEM.
5
which they  are  supplied, and the blood  which  is  circulating
through  them.   To  this system of vessels, invisible  to  the un-
assisted eye. but directly demonstrated by the aid of the microscope,
and  indirectly observed through  the  presence of inflammation,
ought we to restrict the term  capillary.  Under this head also, and
with equally good reason, should be included the  commencement
of the veins; so that we may  describe the capillary system as made
up of all those minute vessels which are interposed between  the
arteries and  veins, forming the terminations of the one and  the
commencement of the other.   No stricter definition can be given,
as it  is impossible to  say where the arteries end  and the veins
begin; and, in all  probability, the distinctive characters of either
are here  intimately blended together.
  The capillaries have been  usually arranged under  two sets or
orders—those  interposed between  the  arteries and veins of  the
general system, and those forming the communications between
the pulmonary vessels.   In the first, the  blood is changing from
the scarlet  colour we  find it  in the arteries to the modena hue it
acquires  in the veins;  in the  second, it is purifying itself by expo-
sure to the  atmospheric air,  reacquiring its vermilion tint, and
along with it those properties which are necessary  for the  support
of animal  life.  The capillary system is thus at  once the most
extensive and important in the body.   Of the number of vessels
included under this name, we cannot form  the most remote con-
ception.  They exist  in myriads wherever  organised  structure is
found, and from  the appearance under the  microscope, or during
the existence of inflammation, we might be almost  led to  suppose
that the  human body  was one  complete  net-work of arteries and
veins.  Of its importance, it is sufficient to  notice,  that the capil-
lary system is that in which the vital functions of secretion, nutri-
tion, exhalation,  and animal  heat, are  going forward—in  which
the blood in the general circulation is changed  from crimson  to
dark, and again in the lungs  from dark to crimson—in which the
phenomena of inflammation  more  immediately reside—in  which
the earliest and most important  deviations from health, leading to
every species of morbid  action,  might  probably be traced—and to
which, insignificant as it may at first seem, the larger vessels are
entirely subservient.
  When a transparent texture in a living animal is placed under
the  microscope,  the capillary circulation is readily brought  into
view.  No definite arrangement of vessels,  either as to size, number,
direction, or mode of  termination,  can  be perceived.   In some of
the vessels, three or  four globules of blood are  moving  abreast;
others seem  only capable of admitting one.  Some continue in a
straight line; others are reflected back, and terminate immediately
in a  vein.    Some send off  lateral  branches into  veins  running
parallel  to them; in  others,  one  artery  ends in a corresponding
vein ;  while again, three or four branches may be observed to be
continuous, with only one venous trunk.  The capillaries anasto- 
6
MORGAN'S PRINCIPLES OF SURGERY.
mose freely with each other, the veins more so than  the  arteries;
the  latter are also smaller  and less numerous  than the former.
Dr.  Marshall Hall,1 who appears to have investigated the  anatomy
of the capillaries  with a wonderful degree  of  minuteness, has
described these vessels as different from either arteries or  veins, in
as far as they retain a uniform  size.   According  to  him,  a minute
artery is observed finally to divide into two branches, equally large
as the trunk from which they proceed, and  to  anastomose with
others of nearly the same magnitude as themselves.   To this latter
order of vessels, in which the blood moves so much more slowly
that  its individual globules  may he counted, he restricts the  name
of capillary. The capillaries would, therefore, be vessels of uniform
diameter, neither becoming smaller by subdivision, like the arteries,
nor  larger, by inosculation,  like the veins.  The arrangement in
the lungs is somewhat  different, the arteries giving off capillaries
from their  sides as well as  extremities,  and  the  veins receiving
them in like manner;  neither  do the  small arteries subdivide  so
minutely as in the general  circulation, but terminate more imme-
diately in capillaries,  which  are farther distinguished  by a  more
free anastomosis.   The  uniform diameter which  he ascribes  to the
vessels, has the effect of detaining the  blood in the lungs for  the
more complete exposure of the fluid to the action  of the air, and in
the different organs for the  better performance of  their functions.
With respect to these observations on the pulmonary capillaries, in
the saurian and  batrachoid reptiles, to which  Dr. Marshall  Hall's
researches extend, we have nothing to remark; but as regards cir-
culation, either in the web of the frog's foot or  the mesentery  of the
rabbit, we  have never been able to observe any  thing  like  the
definite arrangement here laid down.  It is, however, just to state
that, in an investigation where  so much deception may  exist,  no
two  accounts  can  be expected to  correspond, and Dr.  Marshall
Hall's means of information may have been better than ours.
   In consequence of the extreme minuteness of the capillaries,  no
correct account can be given of their structure, evsn were  it agreed
upon what does and what does  not constitute this order of vessels.
In observations on the structure and functions of  the blood-vessels,
contained in  the first part of Mr. Hunter's treatise, we find it laid
down, that the fibrous or muscular coat is stronger and more dis-
tinct in the small arteries than the large;  and in  proportion as the
vessels diminish in size, so in like manner does the  middle  tunic
increase in strength, to enable the blood to be circulated by a power
inherent in the  arteries themselves, and independent of any  direct
influence derived from the heart.   Every anatomist will  willingly
admit, that the  fibrous  tunic  is  most distinct  in  arteries  at  a dis-
tance from the centre of the circulation ; but the mind must not be
led away by this statement to suppose, that the same structure is
equally perceptible in  the capillaries, because in these  no such
1 Essay on the Circulation of the Blood. 
THE ARTERIAL SYSTEM.
7
fibres can  be detected, nor, in fact, in any vessel less than a line
in diameter.  The capillary system, although intermediate between
the arteries and veins, cannot be regarded as consisting exclusively
of either ;  for the distinctive characters of each are necessarily lost.
Bichat  conjectured that the internal tunic of the  arteries is pro-
longed  to form the ultimate tube of the  minute vessels, and thus
becomes continuous  with the veins ;  hence  he infers, that the
common membrane of red blood is  identified with  the common
membrane  of black blood.  The supposition  is natural, that the
serous tunic of the arteries and veins should be found in the capil-
laries, independent of the fact of this membrane being essential to
the free  movement of the blood along the vessels; but if experiments
have shown the extreme branches to be irritable, and if this property
of irritability resides only in the middle tunic,  then we must allow
the capillaries to be invested also with a fibrous structure.
   Let us now briefly  examine some of  the physical and physiolo-
gical  properties of the arteries.  In  doing so, we  need scarcely
observe that it is necessary to  divest  the mind of all previous
notions  respecting the muscular powers or otherwise of the vessels,
and to look calmly and attentively into the phenomena presented to
us.  The first, though perhaps not the  most important, property of
arteries is their elasticity, distinguished  from all  others by remain-
ing equally after death as during life.   It resides principally in the
outer tunic, partly in  the middle, and least, if at all, in the internal.
It is much  more conspicuous in the large than in the small vessels.
When an  artery is divided, either in a dead  or  living subject, its
cut ends recede, and may again be made to approach each other  ;
or when a  weight  is attached to the  lower extremity  of  the vessel,
it will be extended lengthways,  and then suddenly  retract  when
the extending force is removed.  So strongly does this elastic power
exist in arteries, that Dr. Gordon applied thirty pounds avoirdupois
to a portion of the carotid in a man, before the coats of the vessel
gave way.   By virtue of their elasticity in  the longitudinal  direc-
tion, arteries restore  themselves after being elongated in the ordi-
nary motions of the body, as we see exemplified in those which
pass across the cavity of a joint.
   Arteries  are likewise elastic in  the circular or transverse  direc-
tion, and  this  may probably  be  dependent both on  the first and
second  tunics.  Elasticity in this way is shown, by the mouth of a
divided artery being found open, and always preserving its  cylin-
drical form—circumstances  by which we are enabled to distin-
guish arteries from veins in searching for and tying the vessels in
wounded parts.  Other proofs of the circular  elasticity of arteries
are derived from their extension and subsequent retraction in this
direction, and  from the compression exerted  on the finger when
introduced into the mouth of  an  artery so as  to distend it.   The
diameter of arteries is probably greater after death than during life,
as their elasticity  cannot then be counteracted by the contractions
of the fibrous tunic.  During the quiescent state of the circulation, 
8
MORGAN'S PRINCIPLES OF SURGERY.
the circular elasticity of the arteries does  not  seem to be brought
into play,  at  least,  to an extent appreciable  to  the  naked  eye.
Nothing now appears more absurd, than  the  vast influence attri-
buted at one period to the elastic  powers of arteries in carrying on
and maintaining the circulation ;  while how little is to be ascribed
to this, under ordinary circumstances, may be shown by a simple
experiment.  When a* large artery, as the carotid  in a horse, is
exposed, no motion is perceptible so long as  the animal remains
quiet;  nor can the circulation through it be ascertained,  unless the
finger  be applied to the sides of the vessel.  Dr.  Parry thus first
explained the true cause of the arterial pulse,  which had been set
down by some to the dilatation and contraction of the artery; by
others, to an elongation during the systole of the ventricle ; and by
Bichat, to a change of place in the vessel;  but which,  in reality, is
caused by the  compression of the finger obstructing the  free trans-
mission of the blood.  The phenomenon, however, varies a little,
according  to the direction of the artery.   In  the experiment, for
example, just  mentioned, neither dilatation, contraction,  or motion
of any kind are visible, while the animal  remains free from alarm,
and  the same  may be  observed in  any other artery which takes a
straight direction ; but in arteries that are curved, as the temporal,
the vessel is moved from  its place at each stroke of the heart, so as
to allow the pulsations to be distinctly counted.  It is  evident that
the impulse from the current of blood against  the  curvature of an
artery  must either  cause  that portion of the vessel to dilate, or to
change its  place; and if, in no ordinary case,  the former can be
observed, the latter must  invariably follow.  Bichat, therefore, was
so far correct in  the explanation he gave of the arterial pulse.   No
violent  action  of the heart, in  the several trials  we  have made,
could effect, dilatation of an artery; for when the animal struggles,
and the contraction of the  ventricle becomes short and  rapid, the
carotid  leaps from  its place, and is rendered tortuous.
   On comparing these results with what  we observe in arteries in
the dead subject, it  becomes obvious, that, in the living animal,
some counteracting  force prevents dilatation.   This can only be
ascribed to a  vital contractile  power  inherent  in the  middle or
fibrous  tunic.  These two powers are continually opposed to each
other during life; the  elastic tending  to increase the diameter of
the artery, the contractile to lessen it;  and it is from the full  con-
tinuance of the former after life is extinct, and the necessary cessa-
tion of  the latter, that we find the arteries larger  after death.  In
the dead  body, the blood is not sufficient to fill the vessels • in the
living,  on the other hand, the arteries are always full of blood
moving  towards the veins.  At  each stroke of the  ventricle the
column is moved  forwards; and instead of the force of the heart
being  expended in  effecting dilatation of the vessels, it is wholly
employed  in propelling the fluid onwards.  Hence the  amount of
power economised by arteries not dilating during the circulation of
their contents.  These  observations  show that arteries  are  not 
THE ARTERIAL SYSTEM.
9
mere elastic tubes,  otherwise  they would be acted on, and again
react, according to  the  distending  force applied.   They likewise
teach us  how little this  property of elasticity is concerned in the
movement of the blood, and how extremely overrated its influence
has been by many physiologists.  If we were allowed to form an
estimate of its use, we should say that, in the longitudinal direction,
elasticity enables arteries to accommodate themselves to the motions
of the body; while, in the circular direction, it preserves their cylin-
drical form, and keeps their canals open, thus opposing the  action
of the fibrous tunic.   It  exercises no active influence, however,
over  the  circulation of the blood ;  for neither dilatation nor  con-
traction are visible, when an artery, in a living animal, is laid bare.
   The  arterial  system displays organic  properties  totally unallied
to elasticity, and the consideration of which  is of fur more essential
importance to the physiologist.   These may be distinguished from
what we have just investigated; first, by their ceasing shortly after
animal life has been extinguished ; and, secondly, by their residing
solely in  the middle tunic.  They are ultimately  to  be resolved
into a power of contraction possessed by the transverse fibres of the
second  coat; the precise  nature of which, however,  has been a
subject of the keenest dispute.   By some, these fibres are believed
lo be muscular, and accordingly they speak of the  muscularity of
the arteries; by others, who are unwilling to admit an  hypothesis
which has never been proved,  but who yet  believe in an active
power of  contraction, it is called the irritability, tonicity, contrac-
tility, or  vital  force of the arteries;  while a  third  party  have
described the vessels as mere passive tubes, destitute of every thing
save elasticity.   We cannot afford  space to enter  at length upon
this controversy, or refer to all the usual leading authorities of the
day.  We must  content ourselves with pointing out simply  what
we deem the most important particulars.
   When describing the second tunic of the arteries, we stated  that
it was elastic, compact,  and easily divided  by the pressure  of a
ligature—that the effect of alcohol, warm fluids, and diluted acids,
was  to crisp and harden its texture—that no fibrin had been dis-
covered in  its composition, according to the  best  analysis  of the
present  time—and  that,  for  these reasons principally, we  are
inclined  to doubt the  identity of its fibres  with those of muscle.
Dr. Marshall Hall has endeavoured to prove that the  arteries  are
both  muscular in  structure and  irritable  in property, but  his
proofs of the former are  unsatisfactory.  The experiments, again,
of Haller and Bichat  have gone to establish the doctrine that the
arterial  system is destitute of any  vital  power  of contraction,
although Haller very singularly espoused the opinion of the irrita-
bility of the arteries.  Bichat,  therefore, if not  the  earliest, was at
least the first successful opponent of the theory of vital contraction.
According to his researches, no mechanical or chemical  agents,
applied  as  stimuli,  are  capable of  producing any  change in the
living arterial  membrane; neither  are contractions visible  when 
10
MORGAN'S PRINCIPLES OF SURGERY.
the fibres are dissected off  in  layers.  Opium  has  no effect in
paralysing the fibres of arteries, as it does those of muscles;  nor
has galvanism any  power in causing their contraction.   Nysten
has since performed some experiments which would seem to coun-
tenance the opinions of Bichat.  In a few cases of violent death in
the human subject, this individual  found galvanism insufficient to
produce any  contraction in the aorta, while the heart could still be
made to act;  and the same experiment was  tried, and with the
same effect, on the aorta of a dog.   But we  cannot receive this as
any  evidence of the passive condition of arteries;  because the
power  of contraction resides in the fibrous tunic, and the aorta,
at its commencement,  and for some part of its course, is made up
nearly, if  not entirely, of elastic substance.  In performing experi-
ments with a  view to ascertain the  properties of the  arterial  system,
sufficient  attention  has not  been  bestowed on the difference of
structure in the different branches  ; and thus the peculiarity in the
tissue of the  aorta not only  explains the apparent absence  of con-
tractility, but likewise  the statement made by Magendie, that this
vessel is visibly dilated at each stroke of the ventricle.
   The conclusions  at  which Bichat arrived have been  completely
overthrown by  the experiments  of  Vershuir, Thomson,  Parry,
Philip,  Hastings, Wedemeyer, and Posieulle, all of whom confirm
the opinion embraced by Mr.  Hunter, that  arteries possess a vital
power of contractility inherent in  their living fibre.  A capability
of acting upon  their contents—by contracting so  as to diminish
the diameter of their canal, and again relaxing  so as to enlarge it—
can be  shown to exist in arteries by so many direct  experiments,
and  is so  strongly confirmed  by  other  evidence,  that no doubt
need be longer  entertained  respecting it, whatever name may be
bestowed, or objections raised as to its exact nature.  This irrita-
bility is displayed by all the  branches of the  aorta, being still more
conspicuous in the small than the large  vessels;  and  it  was on
account of being endowed  with this property, and not from  any
positive demonstration, that  we stated our belief of the  capillaries
possessing a fibrous tunic.   The arteries are under the influence of
various stimuli or  irritants, such as acids, alkalies, alcohol, the
scalpel, galvanism,  (fee.  In  applying  stimuli  to  the coats of
arteries, it is  necessary to draw a line of distinction between those
which cause  constriction at the expense of their mechanical pro-
perties, and  those  which simply  act  by inducing contraction of
their fibres.   We do not think  that this distinction has been suffi-
ciently attended to  by those who  have made  experiments on  the
subject; and it would not require much address to prove  that the
conclusions to which many have come are on this account alone
illegitimate.   Thus,  when  acids  and alkalies,  or  even  strong
alcohol, are applied  to the coats of arteries  in  living animals  we
are told they cause contraction, and that this  is sufficient proof of
irritability.  Contraction, no doubt, follows their application ; but the
vessel, in most instances, is  rendered incapable of again relaxing • 
THE ARTERIAL SYSTEM.
11
its coats,  when examined, are found  destroyed;  and  its  tissue
crisped and shriveled from the action of these  agents on the con-
tained albumen.   Hence,  such is assuredly no evidence of con-
traction, which should alternate with, or at least be followed by,
relaxation.  It is still more  important to beware  of this  fallacy
when  investigating  the  properties  of the capillaries;  for these
vessels, from  their greater delicacy of structure, are more  readily
injured.   When alcohol, for example, is employed to point out the
irritability of the extreme vessels, it will  be found  that  their con-
traction is not so much  owing to the stimulus given by the fluid
as to the intense cold caused by its evaporation, and which is often
sufficient'to coagulate the blood.  Dr. Marshall  Hall,  in  experi-
menting on the web of the frog's foot, has stated that, by the appli-
cation of alcohol, two distinct layers of capillaries are brought into
view; one superficial,  in which  the  motion  of the blood  is sus-
pended ; the  other deep  seated, in which  it still continues to move.
The distinction into a superficial and deep layer, does not depend,
so far as we have  been  able  to observe, on any such arrangement
of the vessels, the motion of the blood being  merely retarded in
those placed nearest the  surface from the  effects of cold.
   When any of the liquid agents we have mentioned are used in a
diluted form, they act like ordinary  stimuli, and do not affect the
structure  of the vessels.   Applied in  this way, they produce con-
striction of the artery at the  point irritated ;  which  constriction,
after  remaining for  a time,  is succeeded  by relaxation.   Weak
volatile alkali, applied to the web of the frog's foot, or the mesen-
tery of the rabbit, causes immediate contraction and paleness of the
part,  followed  by  relaxation, turgidity of the  vessels, and slower
circulation.   When  the coats of the  arteries are irritated  with a
needle or point of  a scalpel,  the same  effects ensue,  only  more
limited in extent, from the nature of the  exciting cause.  Similar
phenomena may be obtained  by the application of galvanism to the
capillaries, and the late researches of Dutrochet and Wedemeyer
have  shown that the contractile power of these vessels is under the
immediate influence of this agent.  The capability of contracting
upon  their contents is admirably seen in the capillaries, by watch-
ing the changes going forward when the circulation through the
larger arteries is  interrupted.  Thus, when  a ligature is drawn
tightly round the limb of a frog, or when the aorta has  been tied,
or the heart  itself is  cut out and removed,  the blood may be
observed circulating with little interruption through the  capillaries.
It was this power of maintaining the circulation after the heart had
ceased to  act, that  Bichat first described  under the name of insen-
sible  organic contractility ; and it is owing to its influence entirely
that, the smaller arteries are found empty after death.  Dr. Marshall
Hall  has  contended  that  there is no proof that the capillaries are
irritable:  but herein we  beg to differ from him, and to maintain
that,  independent of other evidence, direct experiments prove the
contrary, and  these are  so readily performed that no suspicion of
their  validity can  be entertained. 
12
MORGAN'S PRINCIPLES OF SURGERY.
   The contractile power  of  arteries  may be further illustrated.
 When irritating fluids are injected into  these vessels, in  a living
 animal, great difficulty is  experienced in pushing them onwards
 into the minute branches; while, in  the dead subject, the same
 experiment may be repeated with ease.  It  must be evident that
 the resistance in this  case cannot be  attributed  to any other pro-
 perty of the arteries than  their power of contraction ;  for did  it
 depend on elasticity, a bland fluid would be  as strongly resisted as
 an irritating, and both  would be equally so after death  as during
 life.   The tonic contraction of arteries remains for a short time
 after  an animal  has   been killed; and when, according  to Mr.
 Hunter, an injection is pushed into the vessels of one newly dead,
 it is apt to be forced back from the smaller into the larger branches.
 It is impossible to inject the capillaries immediately after  animal
 life has been put out, as Bichat, Parry, and others, have observed ;
 the injection being only transmitted through the larger branches
 communicating  with veins.  These experiments are likewise  so
 many proofs that the contractile power is greater in the small than
 in the large arteries.   When a portion  of an  artery,  removed from
 a living animal  or one newly dead, is distended  with water, and
 then allowed to contract, the amount of reaction is greater than the
 force  used in distension, as measured by the height of a column of
 mercury the water will support;  and this  phenomenon  may  be
 observed to continue for a short time after death.  If a large artery
 in the living  body, as, for  instance, the carotid in an ass, or  the
 crural artery of  a dog, be  rubbed for  half a minute, between  the
 finger  and thumb, its  diameter, at the point so  treated,  becomes
sensibly increased.  Upon  cutting out a  portion containing the
dilated part, the  whole  contracts pretty equally ;  and on slitting it
up longitudinally, the pressure appears to have produced no ecchy-
 mosis or injury to the coats of the vessel.1 When a  large  artery,
as the posterior tibial of a dog, is laid bare and exposed for a time,
 its diameter, according  to Mr. Hunter, becomes so much contracted
as almost to obstruct the circulation through it.  The contraction
of the  diameter of an  artery is also seen by simply removing  a
portion of the vessel from the living animal,  when it will be found
gradually to diminish  to half its former size.  When an arterv is
surrounded with a ligature, it contracts both  above and below  as
far as  the  nearest anastomosing branch.  Dr. Parry has  farther
stated that, if the thread is merely placed round the vessel without
being tightened, the latter contracts at the point—where the former
lies in contact with it;  but retains its original magnitude on either
side.  The  last  direct  proof of the contractility of arteries which
we shall mention, is drawn from  the  phenomena observed when
the vessels are cut across.   When an artery, as the radial or ulnar
is wholly divided, its  calibre  becomes  gradually diminished in  a
circular direction ; the stream of blood, which first flowed  in jets
1 Mayo's Outlines of Physiology. 
THE ARTERIAL SYSTEM.
13
successively decreases in volume, till  at length it only oozes, and
then finally stops.   When a large vessel, as the carotid, is similarly
treated, a slight contraction of its extremity may still be observed ;
but the impetuous flow of blood speedily proves fatal, and there is
not time to  watch  the  changes induced.  The contraction  and
subsequent closure of the mouth of a bleeding artery, arise solely
from the action of the transverse fibres,, and cannot be explained,
as some have asserted, by a languid state of the  circulation, or a
stronger disposition  in the blood to coagulate ; in the first place,
because  these could not produce the effect in question;  secondly,
because  the phenomena  are  observed  prior  to the occurrence  of
either, and where they have been specially guarded against.  We
are indebted  to the  late  Dr. Jones for illustrating the  efficacy of
this principle in  diminishing the amount of  hemorrhage;  and it
would appear, from his experiments, that it is better  seen in some
of the lower animals than in man.  The vital  contraction observed
in the extremities of divided arteries, extends throughout the whole
arterial system while hemorrhage is going on; and it is from this
circumstance  that the vessels are enabled to adapt themselves to
the quantity of fluid in circulation.   Bichat has termed this adap-
tation  contractilite par defaut  oVextension—in other words,  con-
tractility from want of a distending agent; but all  attempts to  con-
nect it with any other mode of explanation are evidently erroneous,
and, in the experiments made both by  Mr. Hunter and Dr. Parry,
it was  found that the arteries in  animals dying of hemorrhage  con-
tracted  to a smaller dimension  than  that which they maintained
after life had been some time extinct.
   Besides the direct evidence furnished of a vital or tonic contrac-
tility, inherent in the arterial  fibre, there are other phenomena
occurring in the human  body  which necessarily  bring us to the
same   conclusion.   These  we  may  generally state  to be—the
remarkable  local  distributions of blood,  and  the enlargement of
vessels  taking place independent of the action of the  heart-^the
effects  of agents  in promoting  or  retarding this  species of local
plethora—and  the  forces  required  to carry  on  the  circulation.
The instances of local determinations of blood  from various causes,
both mental  and physical, are so familiar to every one as scarcely
to require being  pointed  out.   The suffusion of the countenance
from shame, the increased flow of saliva from the sight or smell of
food during  hunger, the redness of the  skin from friction, the
momentary3 vascularity of the conjunctiva from the contact  of a
foreign body, are  examples of this description, and all may  take
place" without any alteration in the force or frequency of the heart's
action.   In a similar manner we find that arteries increase in size
and become tortuous.  When a ligature is placed round  the  main
artery of a limb, the anastomosing branches immediately enlarge to
carry on the circulation.   Witness also the tortuous course of the
arteries supplying the parts  of  generation in animals during the
season of heat, of those of the  arteries during pregnancy, of those 
14
MORGAN'S PRINCIPLES OF SURGERY.
supply organs from which periodical secretions are furnished, or of
tissues in which morbid tumours have sprung up.  In many cases,
also, of local inflammation, and in what are termed passive hemor-
rhages, increased quantities of blood are transmitted to  and con-
tained in parts, where not only is there a want of increase in  the
heart's action, but where the general circulation, together with  the
powers of life, is flagging.  And we would particularly  point  out
this fact to the attention of the student, because it affords  an expla-
nation of a  peculiar plan of treatment successfully adopted, and
constitutes a most important  feature in practical medicine, little
appreciated and still less understood.  In many of these  instances
where the distribution of the blood  is altered, and determinations
made towards local parts, it has been  supposed,  by Dr. Charles
Parry, that there is a prior increased action of the heart.  Grant-
ing, however, this were  true, the general circulation  might be thus
accelerated,  but the greater flow of blood through certain channels
could  not be accounted for, without admitting the  principle that
arteries have within themselves a source of local action.  The vital
contractility of arteries  consists in  the  power which the fibres of
the middle tunic possess of shortening and elongating themselves,
by which means the diameter of the vessels is increased or  dimi-
nished so as to admit  more or less blood, and by which, also, the
circulation of that fluid must  be influenced.   It  is, therefore, an
interesting question to enquire, how the coats of the arteries  stand
affected as to contraction or relaxation ?  Or, in other words, what
is the condition of the artery which gives rise to the determination
of blood? The answer to this, however, is so intimately  connected
with the  theory of inflammation, that we defer its consideration till
we come to  treat of the  latter.
  The tonic contractility of arteries  is under the influence of ex-
ternal and internal agents, the most  conspicuous  of which are heat
and cold, the abstraction of blood, and  the emotions of  the  mind.
Heat relaxes the contracted fibres, and thus enlarges the calibre of
arteries.   We have examples of this in the renewal of hemorrhage
from wounds, when warmth is applied ; and by the greater fulness
of the radial artery, contrasted with  that on the opposite side, when
the arm is immersed in hot water.  Blood drawn  from the median
basilic vein, under these circumstances, flows more rapidly;  and
as this rapidity depends on the quantity passing through  the artery,
it is a strong evidence  of the relaxation and enlargement of the
vessel.  Cold produces, as might be anticipated, opposite effects to
those of  heat;  it increases the contractile power of arteries,  and
thereby directly diminishes  their diameter.   When  small bleeding
vessels, as those in the face of stumps, are spunged with cold water
the hemorrhage ceases.   When the arm is held  for some time in
cold water,  the skin  shrivels,  and the  pulse  at the  wrist becomes
smaller.   This, performed at the same time with the experiment of
plunging the other arm in warm water, enables us to observe better
the  condition of the radial  arteries  as  to fulness, and the bulk of 
THE ARTERIAL SYSTEM.
15
the two  extremities from the quantity of blood  in  circulation.
When an irritant is applied to a transparent animal texture, so as
to cause increased redness, turgidity of the  vessels,  and slower
motion of the  blood,  bathing  the  part in cold water makes  the
vessels contract, and restores the previous paleness.
   Abstraction of blood from the system  under ordinary circum-
stances increases  the  vital contractility of arteries,  and by  that
means keeps the internal arterial  tunic in close contact with  the
circulating mass.  This phenomenon is best seen in animals dying
of hemorrhage, and is progressive  with the loss of blood ; it is an
important provision in nature for lessening the risk from wounds
where arteries  are divided, as well  as in enabling  the vessels effec-
tively to carry on the  circulation.   We should have supposed
a priori, that the loss of blood would have the effect of relaxing
the arterial  fibres, and thus enlarging the diameter of the vessels;
but the  fact is  otherwise, as shown by contraction going on till the
mouth of the  divided artery is closed—by arteries in animals
perishing of hemorrhage acquiring  a less  dimension  than  they
maintain after  life is  extinct—and by the necessity for a certain
relation  subsisting at all  times between the size of the vessels and
the quantity of fluid  in  circulation.   There are a few instances
where the abstraction  of blood makes the pulse at the wrist fuller,
and which  appear an exception to what we have now stated.   In
inflammation of the serous membrane of the intestines, the pulse,
from being small  and wiry, becomes soft and full after  free de-
pletion.  Here  the relaxation is  probably induced  by the relief
given to the local disorder, which,  taking  place  in structures  sup-
plied from  the  same nervous source as arteries, has  the effect  of
causing contraction of their fibrous  tunic.  When more blood  is
afterwards  taken  away, the usual  changes in the condition of the
pulse ensue, and  therefore our statement is  not invalidated,  that
abstraction  of blood increases the vital contractility of arteries.  It
is to  the ever-varying state of the contractile power of arteries that
 we  trace the  different  relations of the pulse as to  hardness and
 softness, smallness and fulness;  and it  is by means of it, coupled
 with the force  of the heart's action, that we estimate the amount of
 vital power within the system in many cases of disease and decay.
   The  emotions  of the  mind influence  the  tonic contractility  of
 arteries, and the  effect  varies according to the particular mental
 chano-e  which  is present.  Thus,  shame causes increased redness,
 as seen in the act of blushing;  while fear  blanches the counte-
 nance, and diminishes the fulness of the  pulse at the wrist.   We
 do not stop to  enquire on what these opposite states depend ;  they
 are referable to the  laws which  regulate local determinations  of
 blood and  which  we mean afterwards to consider.   The power of
 contraction and relaxation inherent  in the arterial fibre is without
 the control of the will, and  is therefore to be ranked  among the
 phenomena belonging to organic life  It is still, however,  in a
 general way,  under  the influence of the  brain and  nerves,  as 
16
MORGAN'S PRINCIPLES OF SURGERY.
 witness the effect of mental emotions.  It is, moreover, intimately
 united in sympathy with the heart; for  without this consent the
 circulation could not be steadily carried on.  We might point out
 the  connection  subsisting between the  heart  and arteries  in  a  .
 variety of ways; but the details, though extremely  interesting,
 would lead us too  far, on the present  occasion, into the regions of
 physiology.  The origin and distribution of the nerves supplying
 the  arterial fibres  enable  us to explain  their consent with the
 heart's action, and why, Ike this organ, their contraction and re-
 laxation  are independent of any immediate impression from the
 brain or spinal cord.
   The evidence now adduced, leaves no room to doubt that arteries
 possess a power of acting totally distinct from elasticity ; and were
 anything  farther required on this  subject, we might refer to the
 indirect proofs furnished by a consideration of the forces required
 to maintain the circulation.   This necessarily leads us to discuss
 the question, whether the heart is the sole agent engaged in effect-
 ing  the movement of the  blood, or whether any additional assist-
 ance is derived  from the arteries?  The  easiest and most certain
 method of arriving at the truth on this important point, is to con-
 trast the estimated  force of the heart's action with the obstacles to
 be overcome in carrying on the circulation, and to institute a careful
 examination into the experiments made with a view  to ascertain
 the influence of the capillaries.   It is much to be regretted that our
 information  on  both these heads is still  unsatisfactory, and espe-
 cially as respects the capillary circulation.  The force with which
 the left ventricle of the heart  contracts  has been very  differently
estimated, by some even supposed to exceed a thousand  pounds in
weight.  The most accurate calculations have been furnished by
 Dr. Hales, although  there  is reason to believe that they likewise
 fall short  of the truth.  This  gentleman, after numerous experi-
 ments instituted on horses, ascertained the height of the column of
 blood in a glass tube inserted into the larger arteries, and compared
 that with the area of the left ventricle in  the same animal.  He
supposes, in the  human subject, that the blood in the caroted artery
 would rise in the tube about 7\  feet;  the internal area  of the left
 ventricle being equal to 15 square inches ; these multiplied into 1\
 feet, would give 1350 cubic inches of blood pressing upon the ven-
 tricle when it first begins.to contract, and to overcome which would
 require a weight equal to 51.5 pounds.  The first part of this pro-
 position, viz.—that  the blood would rise to a certain height above
 the level of the left ventricle, is a mere hypothesis, for believing in
 which no evidence  can be adduced.   We ought to recollect that
 the heart is a muscular, not an  elastic organ, capable of contracting
 more strongly at one time than  at another, receiving likewise more
 or less blood into its cavities, and enabled  from both these circum-
 stances of modifying the  distance to  which its fluid  would be
 emitted, or rise  in a glass  tube, especially in an artery so near as
 the carotid.   The contractile power of the vessels would also in- 
THE ARTERIAL SYSTEM.
17
 fluence all such  phenomena; for when an opening is made in an
 artery, a current  of blood is established towards it from the anasto-
 mosing branches, as well  as  from those between  it and the heart.
 For these reasons it is quite impossible to determine, with any thing
 even approaching to accuracy, the  force with which the left ven-
 tricle of the  heart contracts.   The  calculations of Dr. Hales have
 been regarded  by many as a close approximation to the truth; in
 our estimation, they are far too high, and we do not think the pres-
 sure exerted  upon the blood during  the systole of the ventricle can
 exceed  a few pounds.  Some  idea may be formed, as  Sir Charles
 Bell has  suggested,  of the force with  which the heart  emits its
 blood, from the pressure  required to stop the current through a
 large artery in its vicinity, and which may at any time be readily
 accomplished by the finger.  Forming our judgment on this,  and
 on what is witnessed when large arteries  are wounded, we are in-
 clined to believe that the blood would not rise one-half the  distance
 which Dr. Hales supposed, and we look upon all that has been
 written regarding the immense power of the heart, as totally with-
 out foundation.
  The obstacles,  on the other hand, to the circulation of the blood
 are  both  great and numerous.  They arise chiefly from the elas-
 ticity of the arteries, especially those nearest the heart; the viscidity
 of the blood and  its friction along the sides of the vessels ;  the  in-
 creasing area of the  arterial  system and the frequent subdivisions
 and  tortuousness of its  branches; the minuteness, reflections,  and
 inosculations of the innumerable capillaries, and  the extreme dis-
 tance of many of these from the seat of power; and the  effect of
 gravity on  the  ascending column  of the blood.   The  collected
 amount of these, contrasted  with  the feeble  efforts of the heart,
 must at once convince us  that this organ, unassisted by some other
 power, would be  unable to carry on the circulation.   But although
 the heart alone is insufficient  for the general distribution of the
 blood over the body, there is little question that its impulse reaches
 to the remotest branches, and influences the motion of the fluid in
 the most extreme  vessels. We prove this by the simple experiment of
 Magendie, which consisted in tying  a ligature round the thigh of a
 dog, including every part of it except the artery and vein by which
 the circulation was to be carried on.   When an opening was then
 made in the vein, the blood immediately flowed—pressure being
 exerted  on the artery, the hemorrhage  ceased, although the vein
 was  full ;  the constriction removed, the  bleeding  recommenced.
 Nearly the same  thing happens on  performing venesection at  the
 bend of the arm; for when the bandage, by which the circulation
 through  the superficial  veins is arrested, is made so tight  as to in-
 terrupt  the  flow  through the artery, little  or no  blood  can  be
 obtained.   It is stated in some cases where  the heart is acting
 violently, that a pulsation  synchronous with, and dependent upon,
 the  stroke of the ventricle, is  perceptible in the  veins.  But  we
may remark that  this phenomenon is only observed in the veins of
       11—f                                     2mgn 
18           MORGAN'S PRINCIPLES OF SURGERY.
 the neck, and is probably derived from the contact of the neighbour-
 ing arteries; for although  the latter have no perceptible motion in
 ordinary states of the  circulation, repeated trials on animals show
 that  they become  tortuous  and leap from their place when the
 contractions of  the ventricle are short and rapid.  If, however, the
 principle explained in Magendic's experiment is correct, that the
 flow  of blood through the large veins is affected by the vis a tergo
 derived  from the heart and arteries, then it is plain that the capil-
 laries, by order  of procedure, must be under  the same influence ;
 and  hence we may infer  that the action of the ventricle, although
 not the sole  moving  power, is essential  to the circulation of the
 blood throughout the whole of the extreme vessels.
   Some idea of the resistance offered  to the course of the  blood
 may  be  conceived  from the difficulty with which  an injection is
 forced along in  the dead body after all vital contractility has ceased;
 and so rare is it to effect the filling of  the veins from the arteries,
 by means of the  finest injection instead of a thick viscid fluid, that we
 cannot suppose  any power at the commencement of the aorta suffi-
 cient to transmit the blood throughout all  parts of the body.   If, by
 pressure with the finger on an artery close to the source of the circu-
 lation, the force  of the  left ventricle can  be easily counteracted, how
 are we to imagine that a column of blood, subjected to all the obstacles
 we have mentioned, can be moved through an almost infinite  series
 of tubes, till it again reaches the right  auricle of the heart?   But
 setting aside this sort of evidence altogether, we can  show experi-
 mentally that the arteries assist in the circulation.   When the web
 of the frog's foot or mesentery of the rabbit is examined with the
 microscope, the  capillary circulation is seen  going on for  a full
 hour  and upwards after the great vessels about the heart have been
 tied, or this organ itself removed; and it is from the vital power of
 contractility remaining for a  short time  after death that we always
 find the  arteries empty and  the veins  distended.  Were arteries
 mere  elastic tubes, the  blood  would cease  to flow through them as
 soon as the heart had ceased to act; but that  such is not the case
 is proved by the experiment now  related, or by making an opening
 in the vessels.  Another  proof of the  agency of the  arteries in
 carrying on the  circulation is said to be derived from animals  with-
 out a  heart, and of which the imperfect human foetus is  an example-
 but some doubts are thrown  over this by the fact of such a fcetus
 being always a twin, receiving its blood  through the same placenta
 as the healthy child, and the heart of the  latter may thus commu-
 nicate its impulse to the former.
  The arteries,  therefore, contract  upon their contents, and  push
 the blood  onwards  into the veins.  They  seem likewise to have a
 propulsive action derived from the oblique course which  the fibres
 of the middle tunic take, and by which  the  column  of blood is
urged more strongly onwards than could be effected by mere dimi-
nution of their canal.  The amount of tonic contractility residing
 in an  individual  artery would be small j but taken collectively as 
THE ARTERIAL SYSTEM.
19
 it exists in  all the branches, it would, on the other hand, be very
 great.  There is no ground for the assertion, that  because pain is
 not  experienced when  coats  of arteries  in living animals are
 irritated, they are therefore insensible to their contents  and inca-
 pable of acting.  Many other  structures are similarly situated  as
 respects external agents, and are only under the influence of their
 own proper stimuli.   The contractility of arteries is excited by the
 contact of the blood with their lining membrane, in the same  way
 as the movements of the heart  are caused by the presence of fluid
 within  its  chambers;  and, as  already stated, both the heart  and
 arteries have the same relation to the nervous system.  It is plain
 also that a perfect consent must exist throughout the whole of the
 arterial system  in propelling  the blood onwards  into the veins,
 otherwise the contractions of the lower portion of  a  vessel would
 arrest the  progress  of the fluid in  the upper; and contractility
 being still  more  conspicuous  in  the  small  branches than in the
 trunks,  we conclude that  the ramifications of nerves accompany
 the invisible terminations of arteries.  It is  from this interrupted
 supply of nervous energy that we  account for all  those  irregular
 distributions of blood which vary from  the simple  act of blushing
 up to that which constitutes inflammation ;  and we need seek for
 no better evidence of the connection  between the nervous system
 and the capillary circulation than the derangement  in the function
 of the secreting and exhaling vessels during  the presence of fever.
   From what has now been advanced  respecting the circulation,
 it would appear that the heart  and  arteries are equally engaged  in
 carrying on  this important function.  Without the one, the blood
 could not be transmitted in successive jets,  nor that vis a tergo
 derived which seems essential to  its motions in the  veins; without
 the other, the contents  of the vessels could not  be conveyed to the
 most distant parts of the body, and again brought back to  the chest.
 We are not, therefore, among  the  number of those who  consider
 that the blood, as it passes through  the capillaries, is beyond the
 influence of the  heart, oscillating backwards  and forwards, and  at
 length moving on in the only direction left it.  No  such  wavering
 motion can be perceived by the microscope, neither can the indivi-
 dual globules of the circulating mass  be distinguished, unless some
 cause of stagnation is present.   The impulse of the heart, however,
 is much diminished before the blood  reaches the extreme vessels.
 The motion of the fluid, as it traverses the capillaries, is more con-
 tinuous  than in the  branches  immediately  before,  and  viewed
 through the  microscope in the transparent part of  an animal, the
 blood"visibly flows in one  continued stream from the arteries  into
 the veins.   The  motion of the blood through  the  capillaries  has
been supposed to depend on the difference in the electrical relations
of the fluid in the  arteries and veins; but we have no right  to
explain  a natural fact by the admission of a principal  of which we
have  no proof, and however satisfactorily this might account for
the systematic circulation, where the blood is changing from scarlet
                                                 mgn  2* 
20            MORGAN'S PRINCIPLES OF SURGERY.
 to dark, it would not apply to that through the lungs, where the
 phenomena are exactly reversed.   Neither will the  attraction  of
 fluids of different  densities  for each other through  porous  sub-
 stances, as so  ably investigated by Dutrochet, explain the motion
 of the blood in vessels endowed with a vital power of  contractility,
 and  having a  separate independent action  of their own.  All
 attempts  to" illustrate the  intricate operations  of life,  by referring
 them to physical laws, are  both delusive  and hopeless.
  It is impossible to determine accurately the  velocity with which
 the blood  moves in the different vessels.   We neither know the
 exact amount  in circulation, nor how  much  is emitted  at  each
 contraction of the ventricle; and if even  both were ascertained, the
 variation in the size of the different  vessels,  and  that, too, at dif-
 ferent periods, would leave us still at a loss to decide.  In consider-
 ing this point, the student will do well to remember the difference
 between the mean  velocity of a single  pulsation  and that of the
 column of blood.   The  arteries in the  living  body are constantly
 full during the ordinary state of the circulation, the  fluid within
 them receiving a distinct impulse from each fresh  portion thrown
 out at the systole of the ventricle. The blood at first moving in jets
 through the larger arteries gradually loses its projectile motion, till
 at length in the capillaries  it flows in one continuous stream.  The
 impulse communicated to the column of blood by  each successive
 portion  as it leaves  the  heart, travels, according to  the calculations
 of Dr. Young, at the rate of sixteen feet in a second,  nearly three
 times the length of  the body in a person  of short stature;  the beat
 of the pulse should, therefore, appear synchronous with the action
 of the ventricle, and the throb of the arteries be simultaneous over
the  body.  The velocity of a pulsation, however,  gradually dimi-
nishes as the  distance increases; and hence a distinct interval of
time elapses between the impulses of the  heart against the ribs, and
the  beat of the artery at the  wrist.   If,  in a living dog,  a small
puncture is made in the ventricle, and another  in the  main artery
 of a hind extremity, a distinct interval is  perceived between the jets
of blood.   We have seen it repeatedly stated, in works, too, of con-
siderable merit, that the arteries in one part of  the  body may have
their  pulsation increased in frequency beyond that of others, or
even of the heart itself—as the  radial artery in  whitlow  beating
more  quickly  than  that of the opposite  arm.  We need scarcely
observe that this is a great error; the impulse given to the  blood is
derived from the heart and not from the  arteries, and therefore the
pulsation cannot be  more frequent in one  part of the bodv  than in
 another.                                             y
  The mean velocity of the column of blood is  much less than the
impulse transmitted through  it; being, in the  aorta, according to
the  authority lately quoted, about 8 inches in a second.  The  cal-
culation has been made by  taking the average quantity of blood in
an adult to be 40 pounds, and  supposing  from  one  to  two ounces
thrown out by each contraction of the  ventricle, at  the rate of 120 
THEORY OF INFLAMMATION.
21
feet in a minute.   The contraction of the ventricle, however, only
occupies a third of the time from one complete systole to another,
and  therefore 120 divided by  3 gives 40 feet in a minute; this
again  multiplied by 12,  to reduce it to inches, and then divided
by 60, gives 8  inches in a second as the velocity of the  blood's
motion in the aorta.  The mean velocity of a  pulsation would
accordingly be  16 feet in a second, while that of the column of
blood would be 8 inches  only in the same space of time.  But the
arteries form a number of descending cylinders, the combined areas
of which  exceed those of the trunks from which  they are derived.
In a state  of heath, therefore, while the vascular system is uniformly
distended, no congestion  present in any part, and the arteries trans-
mitting the whole quantity of blood received by them into the veins,
it follows  that the velocity of the fluid in the extreme branches will
be less than in the aorta, just in proportion as the  sum of the com-
bined areas  of the former exceeds that of the latter.  For the same
reason, namely, increased capacity, the motion of the blood  in the
veins is slower than in the arteries, and in the branches of the veins,
than in either of the venae, cavce.   The  velocity  of  the  blood's
motion is extremely liable to variation, as whatever tends to dimi-
nish or increase the relative area of the vessels must exert on it a
corresponding change.  This is a subject of the highest importance
in a pathological point of view, and one  which seems to be greatly
misunderstood.   Much valuable knowledge would accrue from a
careful investigation  into the irregularities which happen  in the
vascular system, and the provisions made by nature to avert their
 bad effects.
      SECTION II.

THEORY OF INFLAMMATION.
  To establish a just  theory of inflammation is a point of the
highest importance in medical science, as tending directly to  im-
prove our knowledge of morbid action, and enabling us to lay down
precise rules of treatment, free from all appearance of empiricism.
This  is a subject still involved in dispute, and one on which even
experimental research has failed to produce conviction.  We enter
upon it, therefore, more with the view of recording the^ phenomena
we have observed, and making up our history of the disease,  than
with any hope of assisting in the adjustment of so mtricate a pro-
blem   The difficulties we have to contend  with,  in  watching the
circulation in a state of health, apply themselves with double  force
when investigating the nature of inflammatory action; and  were
^acquaintance with the former more  enlarged, our knowledge 
22
MORGAN'S PRINCIPLES OF SURGERY.
 of the latter would be comparatively easy.  The more immediate
 phenomena of inflammation are  confined  to  the  minute  blood-
 vessels,  and to the changes going forward in them, our attention
 must therefore be first directed.  There is one way only of arriving
 at the truth, and that is, by inducing the disease in the transparent
 parts of an  animal,  observing with  the  microscope the  changes
 which ensue,  and marking carefully the order of their occurrence.
 Nothing satisfactory can be elicited by considering  the symptoms
 duringlife, or examining the alteration of structure left after death.
 On neither of these two heads can we reason correctly.  From the
 first,  any conclusions as to  the state of the circulation  must be
 vague and uncertain.  From the  second still  less can be gathered
 respecting the  process of inflammation, because its  effects alone
 are visible; the  morbid action which led to  them has ceased with
 life.
   Two  theories of inflammation have long  occupied the attention
 of pathologists—the one setting forth that the action of the vessels
 is increased;  the other that it is diminished—and both  of these
 have  been  warmly supported.  We are of opinion that the question
 has been two exclusively confined to a mere consideration of the
 state of the vessels; and that many essential parts of the  process
 have, on this account, been overlooked.   In proof of this, we assert
 that more valuable  information  has been  lately contributed  by
 Gendrin and Kaltenbrunner than by all who have preceded them;
 and we are especially indebted to the last mentioned writer, whose
 observations  have been limited to the changes  presented in a part
 labouring  under inflammation, without  having entered into any
 hypothetical  discussion  as  to the  state of the  vessels.  And had
 those  making experiments not looked too narrowly into the points
 at issue,  and endeavoured only to  combat one opinion for the sake
 of establishing another of their own, we should  long ere now have
 had a more just and satisfactory account of inflammatory action.
  Two or  three  positions respecting the state of an inflamed part
 have been  universally admitted.  First, that it contains more blood
 than one in a natural  condition ; secondly, that its vessels  are dis-
 tended or dilated ;  and, thirdly, that minute  branches which only
 previously allowed entrance to  a  colourless  fluid,  now  contain
 coloured globules.  The controversy has been, whether the vessels
 have their action increased, and are transmitting more blood through
 them in a given  time : or whether  their action is diminished, and
 there  is a stagnation of their contents.  W7hen  the circulation  of
 the blood was unknown, and the old doctrines of the liver prepar-
 ing and  sending forth this  fluid  believed in,  physicians were  so
 satisfied of the existence of humours and spirits, and of the possi-
 bility of  blood and bile being  poured out or pent up in  different
 parts of the body, that the occurrence of inflammation was  easily
 explained.   The  peculiar kind of disease was supposed to depend
upon  the kind of humour  prevailing; thus, blood  gave  rise  to
phlegmon,  and bile to inflammation of the skin.   They conceived 
THEORY OF INFLAMMATION.
23
that the blood and the different humours might stagnate simply for
want of an expulsive power, and to this they gave  the  name of
congestion ;  while, if there was  a sudden rush of humours to a
distant part,  it was cnlled a defluxion.   These rude  notions  pre-
vailed in the  schools till the time of Boerhaave, who constructed a
new theory of his own,  and supported it with all the  learning and
ingenuity of which he was so eminently possessed.  The diameters
of the blood-vessels and of the globules of blood were attempted to
be measured, and calculations were made as to their relative fitness
for each other.  The application of mechanical  philosophy to the
science  of medicine was then a favourite study; and  Boerhaave
conjectured  that  particular vessels were set apart  for the reception
of certain globules.   His theory of inflammation was remarkably
simple.   If a globule was  pushed into a vessel  too  small for its
reception, it  naturally obstructed the blood behind it; and, to this
accidental occurrence, he gave  the expressive name of error loci.
He farther considered that the properties of the blood were altered
—that its gluten  (now the  coagulating lymph) was increased in
quantity, while its thinner parts were drained off by the occurrence
of  diarrhoea, sweating,  and  the like.   The fluid  thus  rendered
more viscid  and tenacious, obstruction of the vessels readily ensued.
The cause of obstruction, and likewise that of inflammation being
discovered,  the treatment was to be conducted on the principle of
thinning the mass of blood by means of substances  termed atten-
uants, and which consisted  chiefly of the alkalies,  mercury, and
some of the  neutral salts.  We  cannot pay greater homage to
 Boerhaave  than acknowledge,  that the  fundamental part of his
 doctrine is borne out by the investigations of the present  day; we
 see his error loci and the changes induced on the blood  in every
 instance of inflammation—the manner in which  he explained them
 is alone fanciful.
   The mechanical theory of Boerhaave, as well as the humoral
 patholoo-y which had preceded  it, gradually fell before  the more
 stately and  substantial system of the solidists, from among whom
 sprung the  celebrated Cullen, who, revising the doctrine of Stahl
 and Hoffmann, applied  them, in a greater  state of refinement,  to
 the explanation of disease.  The obstruction of the blood which
 occurs in inflammation was attributed  to a spasm of the  extreme
 vessels to overcome which the use of nauseating doses of antimony
 and ipecacuan was enjoined.  AVe shall examine this hypothesis at
 more length when treating of fever ; suffice it at present to remark,
 that  no such  obstruction is observed at the commencement of in-
 flammation, nor is there any proof of the extreme  branches being
 affected with spasm.
    An increased action of the vessels of an inflamed part, was rirst
 sugo-ested by Gorter, a disciple of the famous  Stahl.   He  consi-
 dered the  proximate cause of inflammation as  an  increased vital
 action of the arteries, whereby the  blood  is driven with greater
 force into the colourless vessels.  When this increased action took 
24           MORGAN'S PRINCIPLES OF SURGERY.

place in  all the vessels of the body, it produced fever;  when only
limited to a few. inflammation was the consequence.   The doctrine
of an increased' action of the vessels has been advocated by the late
Dr.  Parry of Bath, by Mr. James of Exeter, and by several who
have written detached papers on this subject.  It has  been said that
Mr.  Hunter entertained similar views;  but his opinion on  the na-
ture of inflammatory action is not clearly stated ; nor  does it appear
from his writings that he had ever made any experiments in order
to ascertain  the state of the minute vessels.   We find him calling
the act of inflammation an increased action of the vessels, which
at first consists simply in an  increase or distension  beyond  their
natural size.  "This increase seems to depend upon a diminution
of the muscular powers  of the vessels,  at the same  time that the
elastic power of the artery must be dilated in the  same proportion.
This is, therefore,  something more than simply a common  relaxa-
tion, we  must suppose it an action in the parts to produce an in-
crease of size for a particular  purpose."  It is difficult  either to
comprehend or affix any precise meaning to such language;  and
without pursuing the analysis, we  think it evident that this great
man found himself involved in a serious dilemma, and framed the
best hypothesis he could to make his escape.
   In modern times, the vague phrase of increased action has been
considered by many to denote all the changes induced in the capil-
lary vessels, and quite adequate therefore to explain  the process of
inflammation.   It would be satisfactory,  before  going farther, to
have a more correct definition of what increased action means, for
every affection of the vessels so named does not  certainly amount
to inflammation.   The  supporters of this doctrine have founded
their views on different circumstances ; and first, on the  augmented
strength in the pulsation  of the arteries leading to  the affected part.
When the hand is the seat of inflammatory action,  it is well  known
that the radial artery pulsates with greater  strength than  that on
the opposite arm; nay, some have even gone the length of stating,
that the pulsations are not only stronger but more  frequent—an
error to which we alluded  in our  remarks on the circulation,  If
the augmented force with which the  principal arteries  pulsate ex-
tended throughout the  minute branches, then a state of increased
action  must necessarily be present; but this is not the  case.   We
will allow that  the  hypothesis is so far  correct;  but we may ask,
does this increased  activity in the whole  series of vessels  remain
unchanged  during an  ordinary attack of  acute inflammation?
Does the vital contractility of the capillaries enable them to with-
stand the increased quantity of blood thrown into them from the
larger arteries?  Or is there any probability that their tonic power
is ultimately overcome, and that they are incapable of withstanding
the augmented pressure from behind?   It is  no argument  because
the arteries leading to the seat of disease  are acting vigorously that
their delicate capillary terminations must be in the same state.' On
the contrary, we will presently show that the increased activity of 
THEORY OF INFLAMMATION.
25
the former leads,  sooner or later,  to a loss of power in the latter,
and a stagnation of the fluid within their canals.  No information
can evidently be derived from reasoning such as this ; for wherever
speculation usurps the place  of experiment and observation, we
only pursue the shadow and lose the substance.
  Again, we are told that a sense of throbbing experienced in some
cases,  as in  whitlow,  is  a proof of the increased activity of the
vessels.  This is, without  exception, the most  unfortunate argu-
ment that could have been  brought forward ; and, in place of being
a sign of an increased circulation through an inflamed part, it is an
obvious  mark of obstruction.   The phenomenon  arises from the
resistance the  blood meets with in its passage through the  smaller
vessels, and  may be  produced at any time by tying a ligature so
tight round a  finger as to obstruct the circulation.   Besides, as Dr.
Thomson has well observed, this throbbing or pulsatory motion
can afford no proof of the  force with  which  the artery contracts ;
for it  is caused  in  the dilatation of the artery, and  by a power
foreign to the artery itself.  Another circumstance, on which the
doctrine of increased action rests, is,  that if the artery leading to
an inflamed  part be divided, as  the digital  branch in whitlow, the
blood will be ejected to a greater distance and flow more impe-
tuously than from a vessel supplying a similar healthy part.
   We believe that every practical surgeon will acknowledge  the
truth of this  remark; but  although  an increased  activity in  the
larger arteries is  thereby distinctly shown,  it docs  not  follow that
those at the seat of disease are similarly affected, and our objections
here are the same as  those already offered.   It is no proof of the
state of the circulation through an inflamed part that it contains
more blood than one in a sound condition, for the contending parties
admit this point without dispute; nor  is it any evidence of either
one state or another, because the blood flows more freely when  an
 incision is  made; for were the vessels distended from whatever
 cause, the same  thing would result on their division.  A careful
 examination into  the venous circulation of an inflamed part, would
 prove a more powerful argument either for against the doctrine of
 an increased  action of the vessels.  During health, the powers by
 which the blood is kept in motion are  so exactly balanced, that no
 accumulation or congestion occurs in  any part of the body, and the
 quantity of fluid delivered  into the veins is precisely equal to that
 received by the arteries. Had we no better means therefore of judg-
 ing the question of an increased  or diminished activity of the ves-
 sel mio-ht be determined by the quantity of blood found returning
 from the veins of an inflamed  texture. If the  circulation through
 the capillaries was much accelerated, the amount of blood delivered
 into the veins should  be greater than  in health ;  but, on the other
 hand  if the extreme  arteries  are  relaxed, and the fluid stagnating
 within them, then the incipient veins immediately leading from the
 seat of disease should be comparatively empty.  Now the truth is,
 that in the earlier stages of  inflammation, the  circulation  is more 
 26            MORGAN'S PRINCIPLES OF SURGERY.

 rapid—the capillaries  are acting with increased vigour—the  flow
 of blood through the part is greater than in health—and  the quan-
 tity delivered into the veins is consequently augmented ; but, in the
 latter stages, from the  motionless state of the blood, as seen by the
 microscope, the  phenomena of  the  venous circulation must be
 directly reversed.  It is to be regretted  that we have no accurate
 account of the  condition of the veins leading from an inflamed part,
 and especially  during  the different stages of the  disorder,  nor did
 the idea of examination suggest itself  till we had nearly concluded
 our experiments on this subject.   When the hand is the seat of dis-
 ease, and a vein at the bend  of the arm  is  opened, the blood flows
 more freely than usual; but this, although  a proof that more blood
 is sent to the extremity, is  no testimony either of the state of the
 circulation through the inflamed part, or the plenitude of the veins
 communicating with the affected capillaries.  Where inflammation
 was limited, no difference in the state of the veins might be observed ;
 where the morbid action again  was more  extensive, the pressure
 from effusion would  have the effect of  interrupting the  return of
 the blood by one set of veins, and of causing greater distension of
 others.   All we contend for is, that there is no evidence  by which
 we can show that, during the existence  of  inflammation  in a part,
 a greater quantity of blood is continually delivered into the incipient
 veins, and by which a free and increased  circulation through the
 extreme arteries would be going on.
   No conclusion can be  drawn, as the  advocates for an  increased
 action  of the  vessels have supposed, from the circumstances of
 pressure on an  inflamed spot  causing  the redness to disappear, and
 a momentary paleness  to ensue.   This can only be  observed in an
 early stage, and where a superficial part as the  skin is affected.
 We can conceive that pressure would as easily remove the stagnant
 blood out of a dilated vessel as prevent its  influx ;  while, in either
case, the action  of the  larger arteries behind will speedily lead to
the restoration of the lost colour.   The  exciting causes of  inflam-
mation are all of them said to be of a stimulating nature, and there-
fore to prove increased activity of the vessels.  These do  not, in
general, remain long  in operation ; hence, whatever effect they may
at first exercise on the capillaries, must ultimately cease, leaving
no ground for the assertion, that one and the same state of action is
present throughout.   Moreover,  it would  be necessary  to know
 what amount of stimulus is required,  and for what  length of time
it must be applied ; for the exciting causes  differ so much in their
nature and intensity,  that, it is difficult to draw a line of distinction
between those which exalt  and those which depress  vital  action.
 Whoever takes  the trouble of looking into the phenomena of inflam-
mation as arising from a local exciting cause,  will  soon  perceive
the great changes which are induced, not only in the part  itself but
in the system at large; and  by which new modes  of action 'and
new pathological states are developed.  So  long only as the  respec-
tive balance between all the vessels is maintained, does no marked 
THEORY OF INFLAMMATION.
27
derangement occur  in the circulation ; and  as soon as that balance
is subverted, a new series of changes immediately begin.
  The doctrine of  increased action  of the vessels only implies a
greater  activity in  the circulation, by which more blood  shall be
transmitted  through a part in a given time; but during which,
according to the ordinary laws of the animal economy, there shall
be no accumulation or congestion.   We have several  reasons for
believing  that a state of increased action, by which more  blood is
passing through a  part, and where there is no stagnation, cannot
make up the whole  act of inflammation.   We have many instances
of local determinations of blood to  particular  parts, by which the
circulation  is  much increased ;  but which neither give rise  to
morbid  phenomena, nor  have been considered  as  any deviation
from  the state of health.  Did inflammation merely consist  in an
increased circulation of blood, it would certainly be a difficult mat-
ter for us to conceive  to what extent that should  be which, on the
one hand, led to  the most innocent results; and, on the  other, to
the most  serious and  destructive changes.  We have plenty of
evidence to  show that, while local determinations of blood may be
removed without farther  change either to  the  part itself or  to the
system at large—such states frequently precede morbid action, and
under all circumstances  are  favourable to its development; and
that where the exciting cause which produced the effect in  question
is allowed to remain, or acquires an increase in power, inflamma-
tion may be speedily manifested—nay,  more, we have abundant
reason to believe  that this is the way in which inflammation gener-
ally originates;  for after disordered action is present, we often find
it spontaneously ceasing on the physical cause being withdrawn,
and without any other  result than  merely accelerated circulation.
WTe observe with the miscroscope that an  increase in the natural
circulation  is amongst the  earliest effects  of  the application of a
stimulus—that the arteries contract with greater vigour,  and pro-
pel their  blood onwards  into the veins; but that although  more
blood is thus  passing through a part, yet  no more is contained at
one given time, and there are no signs of stagnation.   In the same
way we are informed that the period of incubation—if we may so
name the incipient stage of inflammation—may pass away, the
augmented  circulation decline, and  the  part assume its natural ap-
pearance ; while, if the exciting cause continues in operation, and
the morbid  action goes on to increase in severity, the healthy equi-
librium among the vessels  is subverted, the vis  a tergo increases,
the contractility of the extreme  branches is weakened, and a stag-
nation  of the  circulating fluid becomes  unavoidable.  The first
stao-e of inflammation consists in an increased velocity  of the  blood
through the vessels, which greatly resembles, and may arise out of,
that state to which we give the name of local  determination; but
such  falls vastly short of the phenomena to be observed during the
continuance of a morbid action far more complex in its nature. To
those who view the capillaries as inert tubes, destitute of all con- 
28
MORGAN'S PRINCIPLES OF SURGERY.
tractile  power, incable of exerting any change on their  relative
capacity, and without any control over the fluid which  circulates
through them, no other idea of inflammation, save that of increased
action" could well suggest itself; but as these vessels can, by direct
experiment, be shown to be susceptible of contraction and relaxa-
tion, such notions must, for many reasons, be erroneous.   We have
commented on  the ordinary proofs for an increased activity of the
vessels in an inflamed part, in order to point out what share of credit
the doctrine is entitled to receive.   Our objection is, that it has been
made too exclusive, and that those, its advocates, have remained  con-
tent with knowing only the first series of changes going forward.
   There is another class  of individuals who have given to inflam-
mation  a totally different  character.   They have  described the
vital energy of the capillaries as diminished, and the blood stagnant
in the relaxed  and dilated vessels.  It being granted that the ex-
treme arteries are the seat of disease, and  that, during its presence,
they are much dilated, as evinced by the turgidity of the colourless
branches, it has been  inferred, that increased dilatation and injection
with red blood could only  arise from  relaxation and debility, fol-
lowed  by an obstruction to the circulation.  Such  seems to have
been the opinion of  Vacca Berlinghieri of Pisa, who published a
treatise  at Florence in  1765,  wherein  he  has the merit of promul-
gating the doctrine of diminished action of the vessels in inflamma-
tion.  The same theory was afterwards embraced by Mr. Allen, a
lecturer on physiology at Edinburgh, and who was probably its
first advocate in this  country.  The difficulty of accounting for the
state of dilatation into which  the  capillaries are thrown, coupled
with an increase in their active power of contraction, has led to the
opinion that inflammation consists in relaxation and debility of the
minute  vessels.  Were the  arteries muscular, or at least endowed
with a power of contracting upon their contents, it  is argued  that.
they could not  be dilated, and at the same time assume an Increased
activity; because increased action  implies increased contraction,
which, instead of enlarging, must lessen  the diameter of a vessel.
When  the muscular fibres of the heart  or bladder contract, the
cavity of these organs is  lessened ; after the same manner the cir-
cular fibres of the intestines diminish their canal and assist in  pro-
pelling  the contents  onwards.  How then are we to conceive  that
the contractile power of an  artery is augmented, and by which the
blood is more rapidly transmitted, while the calibre  of the vessel is
plainly enlarged ?  According to the theory of diminished action,
the exciting causes,  although  they may be said to stimulate the
vessels,  do not produce increased activity of the capillaries.  They
may rouse  the action of the larger arteries leading to the inflamed
spot, and ultimately  quicken that of  the heart itself; but the effect
of this inverted order is only to propel an unusual quantity of blood
into the part, and especially into the colourless branches, and by
which their canals are obstructed.  The  stagnation thus created
proves that the smaller vessels, instead of having their action in' 
THEORY OF INFLAMMATION.
29
creased, are debilitated, and unable to carry forward their contents.
The curative influence of the loss  of blood  will be, to lessen  the
impetus of the circulation and the pressure from behind ; while the
topical application of cold or astringents will assist in the contrac-
tion of the arterial tunics, and thereby in the  expulsion of the stag-
nant fluid ;  and it is not a little curious, how plausible and natural
the explanation of remedial measures may be, according to either
method of reasoning.
   The abstract consideration of both theories involves the doctrine
of the vital contractility of the extreme branches—their independent
power of altering the distribution of the blood, and of accelerating
its motion.  Unless we  grant these, it will  be  impossible ever to
illustrate the nature of inflammatory action.  To ascertain the con-
dition of the blood vessels is, of course, the  first step towards the
completion of  our knowledge; although, as we have already re-
marked, the disease  in question  is made up of a series of  changes
exceedingly complex in their details.  It  has been ingeniously at-
tempted to resolve the local action of arteries, as seen in blushing,
&c, into a relaxation of their tunics, and by which an additional
effect would be given to the impulse of the  blood as  it is  emitted
from the heart.  " We have but to suppose that the usual resistance
of the vessels to the flow of blood is diminished by a relaxation of
their tunics—the final cause of which would be as obvious as the
physical cause which  determines it is  obscure."*   According to
this explanation, all determinations of blood, whether  natural or
morbid, towards particular parts, would be caused by the spontane-
ous relaxation of the coats of the arteries; and the heart, although
its action was  not increased, would, from a diminution of the usual
resistance, be enabled to transmit the blood in greater quantity.  If
 we  can once  reconcile ourselves to the  theory that the coats of
 vessels are in this relaxed condition, we  shall find  no difficulty in
 accounting for the  more copious draught of blood determined to
 particular parts ; and all doubts  as to the alleged inconsistency of
 an artery being in a state of increased activity, while, at the same
 time,  its calibre is enlarged, will be completely removed.  There are,
 however, various reasons for our not adopting the opinion, that the
 relaxation of the coats of arteries is a source  of local action.  First,
 the act of blushing  is so instantaneous, that,  did it arise from relaxa-
 rion of the capillary branches, it is extremely improbable that it
 should cease so suddenly as is observed; for  relaxation implies a
 quiescent condition of the vessels with slower motion of the blood.
 Secondly, the obstacles  to the circulation  of the blood are so numer-
 ous that the heart  is unable to carry it  on  independent of a tonic
 contractile power exerted by the minute vessels; and there being
 no appearance of congestion in organs to which larger quantities of
 blood are sent, but, on the contrary, evidence often  of an increased
 nutrition, as in the uterus during  pregnancy, we cannot  suppose
1 See Mayo's Outlines of Physiology. 
30
MORGAN'S PRINCIPLES OF SURGERY.
 that  the capillary  system is  in a relaxed and passive condition.
 Thirdly, in most of the local determinations which take place from
 natural causes, and in many cases of inflammation also, the  action
 of the heart is not increased ; and it is therefore impossible to believe
 that the impetus of the blood from the ventricle could acquire such
 additional  effect  from the  relaxation of the  arteries, as to pass
 through the extreme branches with the rapidity and in the quantity
 we witness.   Fourthly, the velocity of the blood through the capil-
 laries in the act of blushing is much greater than at the  source of
 the circulation, and consequently must depend on increased con-
 traction, and not on relaxation of the  vessels.  Fifthly, if local de-
 terminations arose from relaxation of the arterial tunics, the blood
 in the capillaries  should have an intermittent motion,  being  under
 the more immediate influence of the heart; but no such undulating
 movement can be perceived.   Sixthly, causes, such as fear, which
 weaken vital action, and should produce relaxation, are not followed
 by local  congestion but  the reverse;  while those which stimulate
 or excite, give rise to the phenomena we are now considering.
   For these reasons we are not inclined to  reeeive the hypothesis
 which ascribes local determinations to the relaxation of the vessels,
 and by which it has been said additional effect may be given to the
impulse from the  heart; and we adhere to the opinion that all such
irregularities are,  in the  first  instance, to be explained by an in-
creased action of  the arteries and the power which they possess of
altering the distribution of  the blood.  Neither can we admit, be-
 cause the extreme branches are dilated beyond their ordinary size,
 that they must necessarily  be in a  state  of relaxation or debility.
 Increased action, no doubt, implies increased contraction, and this
may be supposed  in turn to diminish  the diameter of the vessels,
and allow of less blood within their canals;  but there is evidence
to show that, within certain limits, arteries may be dilated so as to
accommodate  themselves  to  a greater quantity of blood, and yet
preserve their entire control over its motion.   The analogy borrow-
ed from the contraction of the fibrous structures is an argument, in
favour of this  opinion ; thus, the heart and bladder act  more power-
fully  when moderately distended, and the  intestines and uterus  in
like manner.   If we admit  that arteries are endowed with a vital
contractility by which their inner coat  is always kept in close con-
tact with the blood, then we must allow that, within  certain healthy
limits, they are also capable of  distension; for the circulating fluid
varies in quantity at different  periods, and it is only when  these
limits are exceeded, either by loss of tonicity in the vessels,  or by
the pressure of a greater column of blood than  they are able  to
sustain, that relaxation and debility ensue.    The microscopical
observations we are enabled to make on the early stages of in flam*
mation, point out to us most clearly that the minute branches have
their diameter enlarged and their action increased;  the hypothesis,
therefore,  of relaxation being a source of  local action in arteries
or inflammation being throughout  a  state of congestion, arising 
THEORY OF INFLAMMATION.
31
from the entrance of blood into enlarged and enfeebled capillaries,
is contrary both to reasoning and known facts.
  The first accurately detailed experiments concerning the state of
the vessels in inflammation were  made by Dr. Wilson Philip, who
came to the conclusion that the action of the capillaries was dimin-
ished, while that of the larger arteries, leading to the seat of disease,
was increased.   " Thus far,"  says he, " I cannot help thinking the
nature of inflammation appears sufficiently evident.   The  motion
of the blood is  retarded in the capillaries in consequence of the de-
bility induced in them; an unusual  obstacle is thus opposed to its
motion in the arteries preceding them in the course of the circula-
tion, which are thus excited to increased action."  He then proceeds
to enumerate  several  difficulties connected with  the subject  on
which his experiments have  thrown no light, and which  remain
unexplained to the  present day.   Such are the effects produced on
the  constitution by inflammation in  different  situations,  or the
manner  in which the disease spreads to contiguous  and  distant
parts—all of which are referable to the agency of the nervous sys-
tem.  He considers that the irritation of the nerves of the inflamed
part may excite the larger arteries of this part, or of distant parts,
or of the whole sanguiferous system; and  that it will, of  course,
be most apt to do so where the irritation excited by the inflamma-
tion is greatest, and consequently in the more important and vital
parts. "Nor is it a little in favour of the doctrine of a diminished
action of the vessels  being  the proximate cause of inflammation,
that its supporters have founded their views on actual observation;
while those who have entertained an opposite opinion have not, so
far as we are aware, made a single experiment to corroborate their
assertions.  We have the same objections to Dr. W. Philip's views
as to some others which have been  brought forward on the same
side—namely,  that  they  are  too limited, and do  not include an
account of the phenomena which are seen during the earlier stages.
   In order to ascertain the state  of the blood-vessels in inflamma-
tion,  Dr. Thomson instituted a number of experiments in  the au-
tumn of 1809,  the  results of which  were detailed in his valuable
lectures, published in 1813.   These trials were made on the web
of the frog's foot; and it  is to be  regretted they did not include  the
warm-blooded  animals, as it has been objected  that analogies  be-
tween the higher and  lower orders of animals  cannot be  deemed
conclusive.  These objections have been  done aWay with by ex-
periments since made on  a more  extensive scale, and which allow
us  to give full  weight  to the statements of Dr. Thomson.  This
gentleman applied Irritation  to the  small arteries  of  the web, by
means  of a  fine needle, strong  spirits  of wine,  and tincture of
orium  all of  which,  in  various instances, increased the  general
circulation.  Weak volatile alkali had the effect of inducing con-
traction  in the arteries  to  which  it  was applied,  followed by a
diminution in the velocity of the circulation through the capillary
vessels with which the contracting  artery communicated.   When 
32            morgan's principles of SURGERY.
the contraction was complete, a temporary stagnation was observed
in the capillaries  immediately communicating with the contracted
artery, and the corresponding veins were obviously diminished  in
size.  In  the  experiments with the ammonia, a  paleness, rather
than a redness, was produced; but this lasted only for a short time.
" These observations," says the learned  professor, " which I have
just related, prove undeniably, I conceive, the existence of irrita-
bility in the smaller or capillary vessels of cold-blooded animals;
and, consequently,  the possibility of irregular distributions of the
blood in particular parts of the body being produced, independenty
of the heart, by the vital, contractile, or  irritable power  inherent
in even the minutest branches of the arterial system."  The most
remarkable  effects, however,  resulted  from  the  application  of a
saturated  solution of common salt, and which  varied in  different
animals, and in the same animal under different circumstances.
These may generally  be stated  as—increased  velocity  of the
blood, with a sensible  enlargement  of the  arterial and venous
trunks, but after repeated application, followed by retarded capil-
lary circulation,  or  even by complete  stagnation—an apparent
increase of the circulation in the arteries  and veins, with a dimin-
ished velocity in the capillaries, seemingly arising  from want  of
power—most frequently diminished rapidity of the  circulation in
arteries, veins, and capillaries, the diameter  of each set of vessels
being enlarged, and the redness of a darker colour than that which
is accompanied with an increased capillary circulation.  In all the
experiments with the salt, the blood-vessels were  dilated, whether
the circulation  through the  capillaries was increased, diminished,
or altogether suspended.   Considering these effects—which lasted
for different periods of time, according to circumstances, especially
the weakness of the  animal and the frequency in  the repetition  of
the salt—as analogous to  inflammation, Dr. Thomson infers,  first,
that the velocity of the blood,  so far from  being always diminished
in inflamed vessels, is often  increased,  particularly  in the com-
mencement of inflammation;  and that this increase of velocity may
continue in the capillary vessels from the commencement to the
termination of that state.  This increased circulation occurs, he is
inclined to believe,  in a greater or  less degree, in that state which
has been denominated active inflammation.  Secondly, he considers
that a diminished velocity in the circulation through the  inflamed
capillary vessels may take place in the very commencement of in-
flammation, and  may continue during the existence  and  progress
of that state.  Thirdly, that  this  diminished  circulation  in the
inflamed capillary vessels takes place, however,  more frequently
during the progress than at the commencement of inflammation  in
healthy and strong persons;  and  that it is probably a state which
occurs in  those  inflammations which  have  been  denominated
passive.   This inference, he  thinks,  is warranted by the diminu-
tion of velocity  produced in  the  arterial branches by  repeated
applications of salt, or even in weaker animals by a single appli- 
THEORY of inflammation.
33
cation.   If these views of the circulation in inflamed vessels be
just, it  will  follow,  that  inflammation is sometimes attended by
an  increased, and at others by a diminished, velocity through the
capillaries of the inflamed part;  and,  consequently, that neither of
these two states  ought to be included in  the definition we give of
inflammation.  In a previous part of the same chapter, the author
states his belief that a diminished velocity of the blood in  the ca-
pillary branches is  by no means a necessary, constant, nor  even
the most common effect of incipient and moderate degrees of in-
flammation.
  Dr. Thomson has very generally been ranked amongst those who
support  the theory of  a  diminished action  of  the  vessels as the
proximate cause  of inflammation ; but how far this can be main-
tained,  we may  judge from the quotations now made from his
writings.  He considers that inflammation may consist in a state of
increased action of the vessels  throughout, and this more particu-
larly when the disease has assumed an  active  character.  Again,
that there may be from  the commencement to  the termination, a
diminished motion of the blood through the capillaries, and that this
occurs  more frequently  during the progress of inflammation in
healthy subjects, and in that form which  has been named passive.
It appears, however, extremely  illogical,  and even a contradiction
in terms, to argue that  acute inflammation, during its whole course,
should be attended  at  one time by an increased, and at another by
a diminished circulation through the capillaries ; or that two such
opposite states should make up  by  mere chance, one and the same
species  of morbid action.  We  can show, to a  demonstration, that
active inflammation is first a  state of increased, and then one of
diminished action  of  the vessels—that  at its  commencement the
velocity of the circulation is greater, but subsequently becomes less,
and nearly,  if  not  altogether  ceases;  and  that retardation, not
acceleration of the blood's motion, is  the most conspicuous pheno-
menon.   Neither has it  been  proved  that passive inflammation
alone consists of diminished or obstructed circulation through the
capillaries of an inflamed part,  although considering its being fre-
quently a termination of that which has been acute, the  apparently
slugo-ish condition of the vessels, and the effects of remedies, there
is reason to believe that the extreme branches are in a relaxed and
weakened condition.                            .
   Dr. Thomson has drawn his inferences  respecting the state of
the blood-vessels, exclusively from  the  appearances presented to
him in  the web of  the frog's foot by the application of salt.  This
appears to us the principal error committed, and accounts for the
opposite and contradictory conclusions  at which he arrived; for
had he made trial of other means to effect his purpose, he must have
witnessed very  different  results.  Common salt, for example, pro-
duces instant dilatation of the  small  vessels to which it is applied,
while oil of turpentine removes it by causing contraction; and it
would be as  unfair to  insist, from the use of the latter, that mflain-
   n                                              3mgn 
34
morgan's principles of surgery.
mation consisted of nothing but increased action, as it would be to
argue  the contrary, because  retardation  of the  blood's motion
generally  follows the application of the former.  It  is highly essen-
tial, in an investigation like this, that we should be aware that dif-
ferent agents  produce very different  effects; that some cause con-
traction of the vessels of momentary paleness followed by redness,
increased circulation, and ultimately  retardation ; others, dilatation
with quicker  and then slower motion of the blood ;  others, at once
complete stagnation ; and  others again, contraction and increased
activity without being  succeeded  by other changes.  Several of
these maybe made  to produce opposite effects according to the state
of intensity in which they are applied ;  and not unfrequently the
destruction of the arterial tunics has been mistaken for the influence
of stimuli  on  the vessels.   It must appear plain, therefore, how very
cautious we ought  to be in drawing conclusions from the effects of
agents between which  so  many wide differences exist;  and how
liable  we are  to be  deceived  by confining our view solely to the
appearances presented by  only one  or two.   And, while dwelling
on this point, we may observe, that by far the most accurate infor-
mation respecting the state of the vessels is derived from watching
the inflammation set up  in parts by severe mechanical irritation or
violence, as in this way  we are  free  from the deception attending
the application of peculiar substances.
  Dr. Hastings has more recently investigated the process of inflam-
mation experimentally, and entertains nearly the same views as Dr.
W. Philip.  He infers, from his researches, that inflammation con-
sists  in a weakened action  of  the  capillaries,  by  which  the
equilibrium between the larger and smaller  vessels is destroyed,
and the  latter become  distended.    With  respect to the opinion
advanced  by  Dr. Thomson, that increased action may form a part
of moderate or incipient inflammation, or in some varieties,  as the
acute, be present from beginning to end, Dr. Hastings replies, that
such a state is only that temporary  excitement  of the  capillaries
which precedes their debility, and which is inseparable from inflam-
mation.  " Certain stimuli," says he, " applied to living parts, pro-
duce an increased  velocity of the blood's motion, and a" contraction
of the vessels.  During  this state of excitement, the part affected is
so far from having any thing like the appearance of inflammation,
that the size  of the vessels is diminished and the part paler.   But
if the stimulus be  long  continued or increased in power, the small
vessels  which in  the natural state admit only of one  series  of
globules, become so dilated as to allow an accumulation of a much
less fluid and redder blood in them, which loses its globular ap-
pearance, and moves much more slowly than that which previously
passed through the vessels.  The part now appears inflamed.   If
the stimulus  be removed, the blood vessels do not soon regain their
original state ; time is necessary to allow them to recover their con-
tractile power, so as to  prevent the impetus with which the blood
is propelled by the heart and  larger  arteries from  keeping up the 
THEORY OF INFLAMMATION.
35
dilated state of the capillaries."  According to the same authority,
if the stimulus which produces the inflammation be of a very acrid
nature, debility of the vessels is  frequently induced without any
previous excitement; the blood in all the branches becomes very
red, circulates very  slowly, and in some  vessels  stagnates.   Dr.
Hastings rightly observed, that there was a temporary excitement
of the capillaries inseparable from the act  of inflammation, and he
erred in not allowing this excitement, as he is pleased  to call it, its
due  weight in the process.   Like others who have  adopted  the
theory of diminished action, he has  overlooked the important phe-
nomena which generally precede stagnation ; and has attributed the
whole chain of morbid  effects to that  debility of  the capillaries
which is seen in a later stage.   In  short, it  has  been too readily
assumed, that the extreme vessels must be at once in a relaxed and
enfeebled condition ; while  no allowance has been made for the
share they  at first take in the increased circulation.
  The hypothesis of diminished  action and slower motion of the
blood in the  capillaries  of an inflamed  part has been  the most
generally received, because its phenomena may be readily demon-
strated with the microscope ; while that of increased action of the
vessels with accelerated circulation has been rather inferred from
attendant circumstances.   In  the anxiety to support  a  favourite
notion, or  from some of the  most material  parts of the process
having escaped attention, the series of changes incidental to inflam-
mation have not been explained in connection, but separated and
given only in part by the upholders of each doctrine.   " Inflamma-
tion," according to the learned professor already quoted, " like every
other phenomenon occurring in animated  bodies, is to be regarded
not as a simple event, but as one  uniformly arising  from the com-
bined and  complicated operation  of powers, some of which  are
known, others at present unknown, to us.   Simple views, whether
of health or disease, however ingenious, can seldom be  just.   They
have their origin in the spirit of system, not in the careful study and
faithful enumeration of the complicated  circumstances which con-
cur in the production of all vital phenomena."
  There is another error which has been committed by experi-
menters on this subject—namely, that  of having confined their
attention exclusively to the state of the vessels and the influence of
stimuli over them, without having considered the manner in which
these stimuli act.   They  have overlooked entirely the sensibility of
the part on which they have been operating, and which modifies so
materially the effects that follow.  On this point, however, we con-
fess ourselves unprepared to enter.  We are unable  to trace the
influence which the nervous system has over the vascular, or rather
the reciprocal relation  existing between them;  and, therefore, we
cannot give a precise answer to  the  question—how far the  inter-
vention of nerves is necessary for  the production of inflammation ?
The application of  stimulants would  lead us  to think that the
earliest change produced is in  the sensibility of the part—a change
                                               mgn 3* 
36
MORGAN*S PRINCIPLES OF SURGERY.
on which all the subsequent phenomena seem to depend, and with-
out which, it is probable, they would never take place.  In confir-
mation of this, we observe the  rapidity with which inflammation
advances in structures highly  organised, compared with  others
where the organisation is less perfect;  and it  is only by reference
to the sensibility of a part, and its connection with the nervous sys-
tem, that we can explain the  constitutional effects of local inflam-
mation, and the great diversity we meet with in this respect.   How
far we may thus be enabled to account for the disease  when pro-
ceeding from sources which we cannot trace and hence said  to be
spontaneous, we do not pretend to determine—it is possible that the
order of occurrence is the same from an external as from an internal
cause; and the fact,  that  in  neither case does the morbid  action
yield till  the sensibility of the part has first been lowered, is a strong
proof of what we have stated.
  Let us now briefly glance at the phenomena of inflammation.
When mechanical violence, irritation, or stimulants are applied to
a part, the first change induced is  an alteration of its sensibility
denoted by the occurrence  of pain.   This, without  doubt the pre-
liminary  step in the process, is speedily followed by a change in the
circulation; the  capillaries  are  either  constricted  and  the part
becomes  pale, or there is an increase in the quantity  of blood and
the  part  appears  red.    The  difference observed  at first  in  the
colour and in the circulation, depends  on some variety in the  ex-
citing cause.   Thus, mechanical violence, irritation, and heat, have
the effect simply of increasing the circulation ; weak  ammonia, or
a moderate degree of  cold,  constricts  the vessels and produces
momentary paleness; while strong  alcohol accelerates the motion
of the blood, and then,  in  some cases, from the cold attending its
evaporation causes its coagulation.  It is impossible to divide acute
inflammation into regular stages, as Kaltenbrunner has attempted;
we believe it better for all practical purposes to consider the disease
as consisting in numerous changes progressively going  forward,
the most  conspicuous of which  can only be  described.  Provided
the source  of  local excitement  is removed, the immediate  effects
may cease—the contraction and paleness of  the vessels subside__
the circulation becomes tranquil—and the part assumes its natural
appearance.   Whatever visible difference exists among local  agents
on  their  first application to the  capillary vessels, we'observe that
their effects soon merge into each other by such insensible decrees
as to make the ultimate results nearly alike.  The interval of^time
which elapses between the immediate changes, and those which can
be  said  to constitute inflammation, is  various •  in some cases
scarcely  a  few seconds  elapse, while in others, several  hours will
intervene.   In the majority of instances  this depends  upon  the
severity and steady continuance  of  the exciting cause, partly also
on the sensibility of  the part affected, its importance in' the scale of
vitality, and the strength of the  constitution ;  for, in repeating the
same experiments on animals of the same class, whether warm or 
THEORY OF INFLAMMATION.
37
cold-blooded, we have seen that inflammation is set up with very
different degrees of celerity.
  Whatever  may  have been the immediate effect, of the stimulus
applied, we  next observe that the capillaries have  their diameter
enlarged;  the part, from  this  circumstance, appears redder and
slightly swollen—there is a distinct rise of temperature indicated by
the  thermometer, and the activity of the circulation  is much aug-
mented.   The process of inflammation has now commenced. The
irritation  quickly extends to  the larger arteries leading to  the in-
flamed spot, and we can easily see with the  naked eye that they
are acting with increased energy.  The balance among the differ-
ent vessels is as yet maintained—the blood is circulating briskly—
there are  no  signs of stagnation—the  veins  leading from the seat
of disease are distended, and  are carrying away the exact amount
delivered into them by the arteries.  It is quite an erroneous notion
that  the  capillaries  cannot be dilated so as to receive a  greater
quantity of blood, without supposing them, at the same time, to be
paralysed or their contents stagnant.   We have already remarked
that, if they are endowed with a contractile power, dilatation, within
certain limits, must be allowed to take place; and if ever any thing
was  made obvious to our senses, it is  what we now contend  for.
Were the vessels constricted, we would not -have a larger quantity
of blood transmitted through them within a given time; for when
this  is brought on by the application of diluted  ammonia, the part
turns pale—the circulation is diminished—and, finally, comes  to a
stand  when the constriction is complete.   In the early  dilated
condition of the capillaries,  we have the most convincing proof
that there is  no stagnation—the globules of blood are moving with
increased rapidity—the veins  leading from the inflamed spot are
equally distended—and the appearance presented to the eye is very
different from what is seen when the circulation is arrested. This,
then, is  properly  the state of increased action ; it is that which
succeeds  to the primary effects of the stimulus ; it is the first stage
of acute inflammation ; the earliest sign of morbid  vascular action.
  The phenomena now detailed vary  in intensity in different cases;
no change, however, in the structure of the part is yet induced; no
new  products are formed; but the healthy  functions of secretion
and nutrition are suspended.  It is  during this early period  that
we find those changes commencing in the mass of blood, the study
of which is of so much importance both in the investigation and
treatment of inflammation.  The violence and duration  of  this
stage are not alike in all cases.  In some, if  the local  cause  is
removed, the disease declines;  in others, once the morbid action is
set up, it continues to progress; and  in both, the period during
which the inflammation remains bears always a direct ratio to the
violence  with which it was established.  It is better marked  and
more vehement in a warm than in a  cold-blooded animal, as in the
mesentery of the rabbit compared with the web of the frogs foot—
a difference to be explained by the greater susceptibility and higher 
38
MORGAN'S PRINCIPLES OF SURGERY.
organisation of the parts in the one over those of the other.  This
stage of acute inflammation has of late received the name of active
congestion, in order to distinguish it from the changes which after-
wards  ensue.   Those by whom it has been thus named  have de-
scribed  the  circulation as either " much quickened, or slow and
embarrassed," and have attempted to separate it from what they are
pleased to consider as real inflammation.  But what name, we may
ask, could they have chosen worse fitted  to express their meaning,
than one which is made to comprehend two directly opposite states?
Why have they omitted  to confer, on the last stage where the cir-
culation  is arrested, the absurd title of passive congestion ? for in
either case the part is full of blood.   We should then have no more
occasion to  use the  vulgar  word inflammation; we should  only
have to speak of congestions.   But if the changes we have describ-
ed—and which are admitted by them to have taken place in the
part—be not characteristic of genuine inflammation, by what signs
are we to recognise it?   Have we yet to learn that redness, pain,
heat, and swelling, do not belong to inflammation, but are a part of
active congestion ; or, are we to  search for the symptoms of the
former in the stagnation of the blood and the formation of new pro-
ducts ?   Is not inflammation often  a state of disordered vascular
action, subsiding without leaving a single morbid  trace behind it?
or, are we now to give to such a case the more fashionable but
foolish title  of an active congestion ?   How  much we  have to
lament that new terms  should be employed to designate different
stages merely of the same morbid action.
  But  let us return to our subject.   The duration of the stage of
increased action depends upon the violence with which it is set up,
and  the strength of the part  in which  it resides.   Kaltenbrunner
has  satisfactorily shown that in tissues highly organised, and in
which the  circulation is rapid, as  the  mesentery  of  the rabbit,
inflammation is not  so  speedily developed as in  organs, like the
liver, where the motion of the blood  is  slower; but  that once it is
established,  it acquires a much greater intensity in the former than
in the latter.  At the commencement, and for  some time after in-
flammation  has begun, the circulation is equally supported by the
capillary vessels, the blood is moving more rapidly,  and double or
triple the quantity seems to be transmitted through the part.  Should
every source of local irritation be removed, we  find, in experiment-
ing on the lower animals, that the morbid action may cease.  The
resolution takes place in various ways.   In some, the action of the
larger arteries which lead to the seat of disease declines, the redness
disappears,  and along with  it the pain, heat, and swelling; in
others, the vessels relieve themselves by the exhalation of a limpid
or sanguineous fluid; or, if a mucous membrane has been  affected
by an increase in its natural secretion, and not unfrequently by a
discharge of blood.  In some instances we have succeeded in put-
ting an  end to the disorder, by compressing the vessels leading to
the inflamed spot, and keeping up the compression till the effects of 
THEORY OF INFLAMMATION.
39
the local irritation have subsided ;  in others, we have procured re-
solution by keeping the part immersed in cold water,-which causes
the vessels to contract, and restores the original paleness.
   In the majority of instances, in a warm-blooded animal, the local
symptoms become more intense; from the sympathy called forth,
the vis a. tergo increases, there is a gradual subversion of the phe-
nomena present, and a new and different series of morbid changes
arise.  Every thing conspires to exhaust the vital contractility re-
siding in the delicate capillaries,  and  to  paralyse their efforts to
carry on the circulation.  We will afterwards treat of the changes
induced  in the blood  by inflammation—suffice it at  present to re-
mark, that it loses much of its fluidity, and becomes more viscid ;
that, in the  minute vessels, its globular structure is  broken down,
and it appears like a red clotted mass, having a serous fluid effused
around it.  The increasing  viscidity  then of the blood, and the
more vehement action of the larger arteries behind,  tend, in parti-
cular, to destroy the tonicity of the extreme branches,  which become
still farther dilated, and lose their control over the fluid within
them.   The  loss of power, unless when  the  local excitement has
been  unusually severe, comes on gradually, and in different situa-
tions ; and it is easy for the eye to perceive the struggle made  to
maintain the circulation.  In  many of the extreme vessels the blood
is now at rest, and the points of stagnation may be distinguished by
their bright red colour.  These phenomena are most conspicuous
in the centre of the inflamed  spot, for  the circulation is still going
on about the circumference.
   The  stagnation of blood, and the formation of cylindrical clots
within  the  vessels—although at  first confined to  the capillary
branches—soon extend to the arteries in immediate communication
with  them.   As the  inflammatory  action increases, the  redness
assumes more of a livid appearance—the  points of  stagnation be-
come more numerous, the effusion of serum is greater, lymph  is
poured  out  into the cellular interstices, and  some of the over-dis-
tended vessels burst  and allow their contents to be extravasated.
Gendrin states that a section of an inflamed  part exhibits, in some
cases, towards the centre, an infiltration of pure blood surrounded
with a gelatinous fluid; in  others, a yellowish fluid  resembling
fibrin, and apparently made up of globules ; farther from the centre
of the inflamed spot, a reddish fluid containing a very few globules
is  found;  while  about the  circumference there  is  only  oedema.
When the part is observed changing from a bright into  a livid red,
and the surcharged vessels are bursting, the inflammation is then
at its greatest height;  the healthy functions of secretion and nutri-
tion were long before suspended,  depositions of lymph and serum
are forming  in all directions, and a  morbid change of tissue has
now commenced.  Kaltenbrunner remarks that he has observed, in
the mesentery of the rabbit, globules of blood bursting through the
sides of a vessel, and forcing a passage for themselves through the
cellular tissue  into another vessel; and  that  new canals are thuo 
40
MORGAN'S PRINCIPLES OF SURGERY.
formed by which the circulation is  kept up.  The bursting of the
vessels, and  the  consequent extravasation of blood, are seen in
every case where the local  action is severe;  but we doubt the
formation of  new channels for the circulation, by globules of blood
forcing their  way through the cellular interstices into other vessels,
and are rather disposed to look upon it as a microscopical error.
The rupture  of the vessels has been  attributed to disease of their
coats, induced by the inflammation  present;  but from the rapidity
with which this, in some cases, may  be effected, time is  scarcely
afforded for an ulcerative action to extend  through their tissue, and
the laceration seems to arise simply  from the pressure from behind.
Some idea may be formed of the obstruction in the capillaries when
inflammation is at its full  height, from the circumstance that pres-
sure with the finger will not then empty them of their blood.  In a
few instances, however, we have found that the coats of the larger
arteries, near the seat of disease, had lost their elasticity, and were
thickened from infiltration.  Should  the  inflammatory action be
rendered still more intense, and the part made  to lose its vitality,
the only other changes observed are, the colour passing from livid
red into black, the blood still farther decomposed, coagula filling up
the canals of the  arteries in the vicinity, together  with a great
decline of the vital powers, evinced by the enfeebled state of the
minute vessels, and the diminished force of the general circulation.
   AVhen  treating of the immediate  effects  arising from a local
stimulus, and of the first stage of inflammation, we remarked—that
these frequently subsided, provided  every source of  irritation was
removed ; but when the morbid action has gone  farther, we observe
that  little tendency is shown to  abate till  the congested vessels
relieve themselves by the effusion either of serum or lymph, or by
bursting and allowing  their  contents  to  escape.  The transition
from the state of increased action to  that of diminished motion, and
ultimately stagnation of the blood, generally takes place slowly, and
occupies some length of time; but when the local irritation is great,
the one may  succeed the  other so quickly that scarcely an appre-
ciable interval of time comes between them. After the inflammatory
action has subsided, the part always remains weak, and is so pre-
disposed to a renewal of the attack, that a  much less stimulus than
was at first employed will suffice to  rekindle it.
   In viewing the leading changes  going forward in parts labouring
under inflammation, it would be possible to enumerate, but certainly
not accurately to define, several intermediate stages; for we observe
increased action and stagnation co-existing in different parts of the
inflamed texture, and oppression  and languor of the capillaries a
considerable time previous to the circulation being entirely arrested.
We may farther briefly notice, that  the colour which the inflamed
part takes on is modified by the agents employed to excite the dis-
ease.   Thus, muriate of mercury gives to the vessels a brown tino-e;
diluted  ammonia,  or alcohol, produces a  scarlet red;  a saturated
solution of common salt renders the part  opaque, or, if employed 
             LOCAL SYMPTOMS OF INFLAMMATION.           41

weaker, it imparts a purple hue.  Some stimuli again are capable
of removing that stage  of  inflammation  where  the vessels are
relaxed and the circulation is impeded ;  others induce and increase
it.  Cold, nitrate of silver, and oil of turpentine, afford examples of
the former;  while muriate of soda causes instant dilatation of the
capillaries, and augments still farther their debility.  The effect of
an agent in removing the inflammation is often  temporary—the
disease ceasing for a  short interval, and again returning with re-
newed vigour; moreover, whenever a complete cessation is not
obtained, we almost invariably find that the morbid action is much
increased, and the part runs rapidly into a state of gangrene.
  We mean not to recur to the question, what is  the condition of
the blood vessels in inflammation?  If the phenomena, now so im-
perfectly related, be correct, they will furnish a sufficient  answer
to all such queries;  and it must strike every one, as it has done us,
that if the views entertained by the  contending parties had  been
amalgamated and reduced to a proper order, we should have had
ere now a  satisfactory termination  put to  this discussion.  It is
much to be regreted that some portion of the valuable time wasted
on this subject has not been given to matters of greater importance.
However desirable it  may be to have a precise acquaintance with
the nature of inflammatory action, what is it, after all, compared to
the diversified effects produced  by this disease in the  system of
many of which we are almost completely ignorant?   Theories are
truiy the soap-bubbles with which the grown-up children of science
amuse themselves; while the  idle crowd  dignify  these  learned
vagaries with the name of wisdom.
                       SECTION III.

             LOCAL SYMPTOMS OF INFLAMMATION.

  According to the artificial  distinction drawn between Medicine
and  Surgery, our attention should be  confined to inflammation
occuring only in an external  part; but the general remarks we
mean now to offer will be found applicable to the disease wherever
it may chance to have its seat.  The symptoms of inflammation
have  long  been  divided by pathologists into  two orders: those
arising in the part affected, hence named the local—and those aris-
ing in the system in consequence of the local  disturbance, named
the general or constitutional.   Each of these divisions will require
our separate consideration, and it  is important for the student to
bear them in remembrance.  We shall first treat of the local signs;
and, under  this head, discuss the changes observed during life, and
those remaining after death. 
42
morgan's principles of surgery.
  Redness, pain, heat, and swelling, occurring together in one part
of the body, denote the  presence  of inflammation.  These  four
symptoms—to which  some have added a sense of throbbing, and
to which  we  would  add disorder of function—were  originally
given by Celsus in  his definition of inflammation;  and, taken col-
lectively, they furnish  sufficient proofs of its existence.  Inflamma-
tion, however, is a morbid action which extends to every organised
tissue, causing such various results, and admitting of so many
modifications, according to the structure affected, that although the
symptoms now enumerated  serve to  describe it in  a general way,
they are by no means to be found in  every individual case.  Con-
sidered separately, indeed, there is  probably  not one them which
can  be said  to indicate the  disease, for they may all proceed from
opposite pathological states;  but viewed in  combination,  whether
the whole are present or not, they leave  us no room to doubt
respecting inflammation.
  The phenomenon which  chiefly attracts  our attention, when
inflammation is external,  is redness of the affected  part.   In order
to be considered morbid, the  redness  must not only be permanent,
but combined with some  other symptom, such as pain.   Redness,
considered in this  way,  is  the most constant, if not a  pathog-
nomonic, local sign  of inflammation ; one which can hardly ever
be absent while the disease is  present, and  which seems essential
to its constitution.   In internal inflammation, the redness of course
cannot be seen during life ; but we scarcely  conceive that where a
part is inflamed it can fail to be red.   There are some structures
in the body, the vessels of which are  so minute as not immediately
to admit of red blood  during inflammation ;  and much has of late
been  written, especially  by  some  of the French  pathologists, to
prove  that  redness does not  always accompany  inflammatory
action, and that a part may be seriously inflamed while it  remains
colourless.  This, we are told,  holds  true with respect to certain
transparent  tissues, as  the  arachnoid of the brain, the  cornea
lucida. or the membrane of the  vitreous humour.  The first effect
of inflammation on these is to produce opacity, which  therefore
becomes  a sign of  the disease; and, as a  general  rule, we may
state, that parts  which lose  their transparency have their texture
thickened and altered  before they are injected with vessels carrying
red blood.
   But the doctrine, that redness  does not  invariably accompany
inflammatory action,  has not been fairly  represented.   In  many
cases, where no doubt is left us of inflammation having  been the
cause of death, it often happens that  no traces of it are afterwards
to be found.  Properly  speaking,  inflammation is a state of dis-
ordered vascular action, which may  subside without leaving any
morbid effects behind it;  and it is no argument, therefore, that the
arachnoid, or other delicate membranes,  have not been  reddened
by inflammation, because this  is not to be  perceived after disso-
lution.  When a person  is in articulo mortis, a strong contraction 
LOCAL SYMPTOMS OF INFLAMMATION.
43
of the blood-vessels takes place, by which the arteries empty them-
selves  into the veins,  and on  which account  the  redness of an
inflamed part often  disappears.   Sometimes  the  redness  remains
for a few hours and then subsides.  We have seen the body of a
child  dying in an  early stage of variola,  uniformly red, and in a
few hours  turning  pale  and white.   It is a remarkable fact,  also,
that  in some  cases of  purulent ophthalmia, where  the vision  has
been impaired, the inflammation will cease, and the transparency
of the cornea be restored, immediately preceding death, from some
other source.  Before a part will  retain its red colour, it is neces-
sary that the inflammation shall have lasted such a  length of time,
and  been  so  acute, as  to cause  permanent enlargement of the
vessels, and stagnation of the fluid within them.  This is demon-
strated to us in our experiments on animals.   In  delicate  transpa-
rent membranes, it may likewise be remarked, that inflammation
always commences  in the adjoining cellular structure, which  is
rendered vascular by the injection of its minute vessels.   Where
opacity, therefore,  may  be the earliest sign  of inflammation, red-
ness is still present in some  adjoining tissue, and from this tissue
the disease spreads to the proper membrane, which subsequently
becomes thickened  and vascular.  We therefore  conclude,  that
redness  during life forms a  constant and essential part of local
inflammation.
   The redness is always greatest towards the centre of the inflamed
spot,  because, as we stated in treating of its phenomena, the disease
is most intense in  that situation ; from this  it spreads  and diffuses
itself till it becomes lost in the affected tissue.  The termination of
the redness is in general indistinct, and no line of demarcation can
be traced  between the inflamed  and  the  healthy  parts; at  other
times it is more abrupt, and we may observe distinctly where the
disease ends.  The colour varies from  a scarlet to a purple tint;
 and,  as the  part approaches to  gangrene, gradually changes into
 black ; a livid tinge is a sign of greater intensity than a bright red,
 and is always seen to increase  with the severity of the local dis-
 order.   The depth of colour depends principally on the vascularity
 of the texture affected ;  it is greatest where the organisation is
 highest, and for  the  obvious reason  that  the morbid  action is
 usually more intense.
   The redness of  inflammation is owing to  an increased quantity
 of blood being transmitted to the part, and  particularly to the dis-
 tension of the colourless capillaries.  If we look at the membrane
 of the conjunctiva, in the natural state, we observe that it is pale
 and transparent;  if we  examine  the same structure under inflam-
 mation, we  find that  it is minutely injected with  red vessels.   In
 every  instance where we  have  an  opportunity of watching the
 local  phenomena of inflammation,  it is  demonstrated to us, that
 not only those vessels which naturally carry red blood have  their
 diameters  sensibly enlarged, but  that  the  otherwise  invisible
 branches  take on a similar mode of action.   Both sets ot  capil- 
44
MORGAN'S PRINCIPLES OF SURGERY.
laries are, therefore, dilated;  and the distinction into  the coloured
and  colourless artery, the arteria  non rubra of  Haller, is lost
amidst the derangement of function created by  inflammation.
  When an incision is made into an inflamed  tissue, a more than
ordinary flow of blood  ensues;  and when  the  part is examined, it
appears more  vascular, its vessels turgid and increased in number.
To account for the increase of vascularity,  it was a favourite
notion with  some, that new vessels are  developed  either at the
commencement or during an early stage of the disorder.  The
difficulty of accounting for such  new formations,  in cases where
inflammation  is suddenly  induced,  renders  the  hypothesis un-
tenable.  If we irritate the skin mechanically, or with a rubefacient
substance, dip  the finger  in  boiling  water, or allow a foreign body
to remain within the eyelid, redness, pain, and heat, immediately
ensue, and the parts will go through all the changes consequent on
an attack of inflammation.   It is more correct in  recent cases  to
ascribe the increased vascularity to the injection of the colourless
arteries with red blood ;  and this is proved, first, by  the fact  of
transparent  parts,  as the  conjunctiva, becoming  instantly red
under inflammation ; and, secondly, by the experiment originally
made by Mr.  Hunter.  This individual froze and then thawed the
ear of a  rabbit;  by these means he brought on inflammation. He
next killed the animal and  injected both ears.   On dissection, the
inflamed ear was found to contain a great  number of vessels filled
with the colouring matter of the injection;   the  uninflamed ex-
hibited comparatively few.   This experiment,  confirmed since by
repeated  trials, proves the greater vascularity of an inflamed part,
and points out, at the same time, the manner in which that vascu-
larity is accomplished where  the  disease is  suddenly  induced.
When inflammatory action,  however, has continued long, we have
reason to believe that new vessels are developed; but of these and
their mode of formation we shall have occasion hereafter to speak.
  Mere redness, in consequence of an increased quantity of blood
being sent to a part, does not alone make up the act  of inflamma-
tion.   In blushing, the cheeks are rendered florid  from the  deter-
mination of  blood towards them; yet we know that, on the  cessa-
tion of the  mental  emotion, the redness  will quickly disappear.
Many similar  examples might be given.  It has been attempted  to
express the redness of inflammation by saying that it was preter-
natural ; but we do not find that even preternatural redness consti-
tutes inflammation.   The  changes induced  in the skin by the
exanthematous and other diseases afford the best illustration  of the
difference between preternatural redness  and inflammation.   In
scarlet fever or measles, the skin over the  whole body may be pre-
ternaturally red, yet it would be absurd to insist  that it was inflamed;
for inflammation taking place over such an extensive surface would
quickly extinguish life; besides, the better marked  and  more vivid
the eruption is, the constitutional effects are in general  less severe.
We make use of the phrase, increased vascular action or preterna- 
LOCAL SYMPTOMS OF INFLAMMATION.
45
tural redness, to express the condition of the skin in these cases,
although we often  apply the same terms when  speaking  of the
condition of an inflamed part.  In some instances, as small pox,  it
would appear that real inflammation is present, for the skin goes
through some of the changes incidental to that disease, and forms
purulent matter;  besides, here, the more extensive the affection  is
—constituting the principal difference between mild and confluent
small-pox—the greater is the danger to be apprehended.  Let us
compare, however, a  patient having measles or scarlet fever with
one labouring under erysipelas.  In the last, we have real inflam-
matory action of the skin and adjacent tissue, and much pain  is
experienced when the surface is pressed upon; the  system  suffers
severely although the affection  should be limited ; and, in short,
the termination of the disease, as well as the symptoms present, leave
us no room to doubt that the cutaneous texture is very differently
situated from what we  find it in either of the others.  We may,
therefore, have increased vascularity of a  part so as to constitute
preternatural redness, without inflammation being present.
   Again, we observe, from experiments on animals  and from some
other circumstances occurring in the human body, that increased
vascular action is often the first step towards the  establishment of
inflammation, and  that a renewal  or  continuance  of the exciting
cause will convert the one state into the other.  If we apply friction
to the  skin, we simply cause increased redness ;  but, if the friction
is too long continued, we bring on inflammation.   Should a foreign
body lodge in the conjunctiva, redness and turgescence of the ves-
sels ensue ;  if the extraneous substance is withdrawn, the increased
vascular action subsides—if allowed to remain,  inflammation fol-
lows.  Mr.  Hunter long since accurately observed, that such is the
way in which  inflammation generally  commences; and it would
 appear that we are often at a loss to distinguish between that kind
 of vascular  action which occurs in health, and that which leads to
 the formation of disease.  On the one hand, we find it existing in
 a preternatural degree, and for a length of time, without producing
 any bad effects; while, on  the other, the operation of the same
 cause speedily brings on disordered action.  Hence redness, as a
 part of inflammation, must not only be permanent before it can be
 considered morbid, but must be accompanied by some  of the other
 local symptoms of the disease.
   Lastly, more blood may be accumulated in a part, as in what  is
 termed congestion, without inflammation being present.  We have
 no wish to enter into any controversy on this subject; its importance
 and the  frequency of its occurrence have been grossly exaggerated;
 it seems to be  ill understood, and, consequently, much absurd rea-
 soning has  been adduced respecting  it;  and it has given rise to
 great confusion in practical medicine.  In the most  common accep-
 tation of the word congestion, we understand the  blood to be col-
 lected in the venous trunks, or in those branches of the capillaries
 which form the incipient  veins, and in this sense only we can 
46
MORGAN'S PRINCIPLES OF SURGERY.
comprehend its meaning; wherever the colourless arteries are dis-
tended with red blood under the circumstances we have mentioned,
we are entitled to consider the part as inflamed.  The phrase con-
gestion, however, too fashionable or mysterious to be lost sight of,
has been applied to  other states where blood is accumulated; and
coupled with  the adjective  active, has, as already mentioned, been
improperly made  to include the early stage of inflammation.
   The next local symptom which we shall consider, is pain.  When
irritation is applied to a local part, the  first change induced is in
the function  of the nerves, by which pain  is created and which
leads to increased vascular action and all the subsequent phenomena
of inflammation.   This is  the way in which the disease seems to
be established, and the nerves may so far be regarded as  the safe-
guards of the constitution, warning us of the presence of local mis-
chief, which might  and does make dangerous  inroads where the
sensibility  is  impaired.  It  is by means of this symptom that we
judge of the seat of internal inflammation ;  it is in general the oc-
currence of pain, and not of  redness, which first awakens the patient
to his condition ;  and although not an unequivocal, it is, neverthe-
less, one of our principal guides, by the presence or absence, or de-
gree of which, we judge of  the intensity of inflammatory action in
parts concealed from view.   In consequence of pain or uneasiness,
we are made aware of the existence of organs which, in the healthy
state, transmit no sensations ; and hence pain is a valuable sign, at
least, of derangement in the natural function of a part.
   Pain is not, however, a  symptom  of  inflammation only, for we
can show that it may be excruciating while inflammation is absent.
In various  forms of neuralgia, the pain may be so violent as to make
the sufferer cry aloud;  yet where opportunities have occurred of
examining  the nerves after  death, no  marks of inflammation have
been found, nor does the complaint yield  to depleting remedies.
The same thing is observed in many other nervous affections, and
the mere existence of pain in a part is not to  lead us to infer that it
must necessarily  be  inflamed.   Again,  the most fatal inflamma-
tion may be going forward where pain is wanting; and the disease,
attended with this peculiarity, is always of the most dangerous de-
scription.   In many cases of typhus, especially in advanced life, the
lungs maybe extensively inflamed without any other symptom than
cough  or a hurried respiration ; and it too frequently happens, from
the patient  being rendered incapable by the fever of expressing his
proper feelings, that the local disease is overlooked.  Inflammation
of the substance of the brain is sometimes marked by the same pecu-
liarity ; and singular as the statement appears, this organ, though
the source  of feeling to other parts, seems itself possessed of little
sensibility,  and, unless in its diseases we  had  other symptoms  to
guide us than mere pain, we should often be misled.  To point out
how far inflammation may  take place independent of pain, we may
mention the case of paralysis of the extremities, where blisters may
be applied or  burns inflicted without  the  consciousness  of the 
LOCAL SYMPTOMS OF INFLAMMATION.           47
individual.  Moreover, pain does not invariably point out the exact
seat of the disease.  Thus, in inflammation of the liver, pain is felt
at the  top of the right shoulder and down the arm; in hip-joint
affections, the chief uneasiness, at first, is at the knee ;  and hence a
wrong reference is often made to the locality of the disorder.
   The production of pain is chiefly regulated by the nature of the
tissue  in  which the inflammation resides;  and no  anatomical
knowledge would have enabled us  to say a priori where increased
sensibility would have been most exhibited. We should likely have
concluded that, in textures where nerves are plentifully distributed,
inflammation would have created the greatest pain ;  yet experience
teaches us that parts possessing only a moderate share of organisa-
tion, and even devoid of sensibility in the normal state, become un-
usually painful when inflamed.  Tt may be stated, as a general law,
that, in all dense tissues  or those least susceptible of swelling, the
greatest amount of pain is experienced ; and hence the reason why
bones or cartilages take the  lead of other structures more highly or-
ganised.   There is thus  often a wide difference  between containing
and contained parts.  When the substance of the brain is the seat
of the disorder, little or no complaint of pain is made ; the individual
for the most part is unconscious of his condition, and affected with
stupor or typhomania ; but should the  inflammation be in the mem-
branes, or should these subsequently participate, the pain  becomes
severe, accompanied with watchfulness and furious delirium. The
same law, with respect to pain, holds  true when the substance of
the liver or its serous covering is affected; yet in all cases, the dan-
ger is  proportionally greater, when inflammation is  seated  in  the
interior of an organ than in its investing membrane.
   The mucous or cellular tissue, above all others, furnishes  the
least amount of pain during inflammation.  Of the former, a very
familiar  example occurs in nasal catarrh.  Here the lining mem-
brane  is  inflamed and swollen, the person expresses his condition by
 saying that his  head is stuffed, a thin discharge succeeds which
 terminates the disease, but all along we have  no complaint of pain.
 In acute inflammation of the bronchial tubes, the morbid action is
 indicated more by the general febrile symptoms, the  hurried respi-
 ration, the  mucous rale  heard over the chest, and the discharge of
 sputa, than by any  uneasiness experienced by the  patient, and,
 which seldom amounts to  more than  a  sense  of constriction.   In
 inflammation, likewise, of the mucous membrane of the intestines,
 pain is but a secondary symptom; and, in either of the two  last
 cases, the comparison is striking, when the serous covering is the
 seat of disorder.  It is obvious that a mere  reference  to physical
 structure will never explain the  diversities we meet  with  in  this
 symptom, else parts possessing the fewest nervous  filaments  and
 havino-  the smallest share of organisation should  afford the least
 pain  &In all lax  structures, the  natural sensibility is but slightly
 exalted • while in dense organised tissues, it may reach the highest
 pitch    The degree of pain  varies from slight tenderness to the touch 
48
MORGAN'S PRINCIPLES OF SURGERY.
up to the most acute suffering, and depends on the nature of the
tissue affected, the intensity of the inflammation, and probably, also,
the idiosyncracy of the  individual.   Next to the particular seat of
the disease, the  severity of the local action has  undoubtedly the
greatest influence in creating pain ; but as no just, estimate can  be
formed of the intensity of inflammation in any two cases, no  accu-
rate comparison can be drawn.
  We need not discuss the question, What is pain ;  or in what does
it consist?   It appears to be made up of some mental change ; and
although originating in,  or kept up by, local disease, yet it is  solely
dependent for its production on a healthy state of the brain and the
continuity of the  nerves proceeding  therefrom.  In proof of this,
we may quote the absence of pain when the function of the brain is
disturbed ;  or the paralysis of the extremities, where inflammation
may be  induced  without the consciousness being awakened.  We
may farther observe, respecting the pain of inflammation,  that it
seems to consist in an exaltation of the common sensibility diffused
over the body; while that which is peculiar to parts, as rendering
them  instruments of sense, is lost or impaired.   During the preva-
lence of catarrh, the sensibility of the lining membrane of the nose
is  so great  that the minutest particles  floating  in the air  excite
sneezing; but the sense  of smell is for a time suspended.  And the
same  thing may be observed of other organs.
  It is  important to learn that pain, or a painful  condition of the
filaments of nerves, arises from more sources than one; hence pa-
thologists have laid down rules for distinguishing spurious or spas-
modic from inflammatory pain.  The word spasmodic is  ill chosen,
as conveying an idea of muscular contraction ; for although pain
may  arise  from the violent  spasmodic action of muscles, as in
tetanus, it more frequently exists as a peculiar affection of a nerve,
as in  neuralgia.  When  employed to denote that pain, arising from
other causes than inflammation, occurs in paroxysms or spasms,
the phrase  is  more  appropriate,  for this  is one  of the principal
marks of distinction.  Pain, resulting from local inflammation, may
be described as constant, though not  uniform in degree; that aris-
ing from other sources and commonly called spasmodic, is attended
with remarked remissions, and not unfrequently there is a complete
intermission between the paroxysms.  Constant tenderness to the
touch, therefore, with nearly a steady degree of pain, enables us to
distinguish inflammatory from spurious cases, where patients suffer
from  marked exacerbations, lasting for a short period, and then per-
haps  completely disappearing.  It may be laid down as a general
rule,  that inflammatory  pain is aggravated by pressure  or motion
or  whatever tends to disturb the actions of the affected  part, while
spasmodic  pain, on the  contrary, is generally relieved.   The most
prominent example of this is  afforded in enteritis and colic  which
may  readily be distinguished, independent of constitutional  symp-
toms, by the application of pressure alone.   We can easily explain
why  pressure  should aggravate the pain of inflammation, and why 
LOCAL SYMPTOMS OF INFLAMMATION.
49
it should relieve that arising from colic ;  but there are many cases
of spurious  pain, where  pressure operates in a way of which  we
know nothing, while there are others  in  which it  produces no
effect whatever.
  There has been  apparent exception made to the law now laid
down, and which, coming from high authorities, deserves consider-
ation.   It has  been stated  that, when an inflamed part is wholly
and gradually compressed, the pain  will  be  relieved ;  and that it is
only"because the pressure  is partial the pain  is aggravated.  To
ascertain, therefore, that  pain  arises from inflammation, we should
compress the part suddenly and partially, as gradual and  equable
pressure over  the  whole affords relief.   Our  success,  it  is said,
in such cases, depends  on emptying the vessels of the inflamed
structure completely of their blood; a circumstance which,  unless
a detached part, as  a toe  or a finger, was the seat of disease, we be-
lieve to be perfectly impossible.  Founded, however, on this prin-
ciple, Velpeau  and  others have suggested compression as a means
of cure in erysipelas ; but there are substantial reasons for declining
the  recommendation.  We must confess that  we have never yet
had the misfortune of meeting with a case,  where the mode merely
 of applying pressure rendered us in any  doubt as to its exact nature ;
and we look on the whole as an  ingenious quibble, more  fitted  to
 amuse than instruct.
   The kind of pain experienced  in inflammation varies according
 to the seat and intensity  of the disease ;  but it is very different at all
 times from  that which occurs in  spasmodic cases.  Sometimes it is
 acute,  at other  times dull;  sometimes it  is of a  lancinating  or
 burning nature, or of an itchy or prickling  kind ; frequently it
 is  a throbbing pain,  increased at each pulsation of the  vessels;
 and, in some of these  cases, as whitlow or cephalitis, aggravated,
 by a dependent posture.  Spasmodic pain, again, is often violent,
 lastino- a few seconds  and  then remitting; in neuralgia, it more
 resembles electrical shocks  than anything else to which it can  be
 compared ; occasionally, it is  of a stinging  description ; but it never
 consists of  the mixture  of pain and heat-the true burning pain of
 local inflammation.  In colic, the pain is described, in some in-
 stances, as  being of a cold nature, and  certainly it is very different
 from what is experienced in genuine enteritis.  Expression of coun-
 tenance is not of great value as a sign  of pain from inflammation
 and is only observed  in cases which have lasted a few days   e
 invasion of acute  disease may  be so  rapid as to admit  of  little
 change being effected on the features.
    Tlfe signs^of  distinction now given, enable us, on all occasions,
 to separate inflammatory from spasmodic pam ; and  were anything
 ferS?? wanted to  complete the diagnosis, it would be  found in the
  amount of febrile  disturbance in the system, and in the origin and
  nrTress of the two cases.  It is principally in dehcate females, the
  suS of hysteria, that we  meet with cases similating inflamma-
  ion   in whom these  affections often spring from some mental
      i  "J ™                                     mgn  4 
50
MORGAN'S PRINCIPLES OF SURGERY.
sympathy, and for the relief of which we  have often known the
most vigorous depletion imprudently put in force.  We ought to
recollect, however, that spasm  may induce, or  be followed by, in-
flammation ; and thus  these two states may be blended together.
In line, sudden remission of severe pain, without sufficient  cause,
should put us on our guard, either that the case is not one of in-
flammation ; or, if so, that some change of action has arisen.
  Lastly,  how are we  to account for pain  as a local symptom of
inflammation ?   The hypothesis has been started, that new nerves
are developed;  but pain is one of the earliest effects of a stimulus,
and there  is not time allowed for the new formation. Again, it has
been supposed that the extremities of the nerves  themselves were
inflamed;  but we have no proof of this on examination after death;
besides, were it true, the more  copiously then a part was  supplied
with nerves,  the greater should be the amount of pain.   In all
dense structures, as bones or fibrous membranes, where swelling is
most resisted, the pain, as we have said, is great compared to that
arising in parts which are lax and  readily admit of distension.
The mechanical  compression,  which  the minute branches  of the
nerves must suffer during inflammation, explains more satisfacto-
rily the origin of pain than any  other hypothesis that has been
brought forward.   The ramifications  of nerves accompany those of
arteries to their invisible terminations, and are enclosed with  them
in the same sheath;  hence the over-distension of the coats  of the
vessels and the pressure  from newly effused fluids, must cause
undue compression of the nervous twigs, and give rise to unnatural
sensations.  If, therefore, the pain  in  the first place proceeds from
over-distension of the coats of the  blood-vessels, and, secondly, is
increased  by the effusion of fluids into the part, it follows, that the
denser the structure, the  greater must be the pressure exerted on
the extremities of the nerves.   In this way only can we account
for the pain  accompanying inflammation in tissues having  but a
moderate  share  of organisation, and  displaying  little  or no sensi-
bility in the healthy state.  And, in  farther corroboration of this
view of the local cause, we may remark that, in certain inflamma-
tions, the  pain is much increased during the distension of the arte-
ries at each contraction of the ventricle; and, on which  account,
it has sometimes received the name of pulsatile.
  Heat, as a symptom of inflammation, is not in reality so great as
we might often  be led to  expect from the  feelings of the patient.
Mr. Hunter made numerous  experiments in order to determine
whether or not  any increase of temperature takes place.  Having
brought  on inflammation  in  the chest,  abdomen,  rectum, and
vagina of animals, he then introduced the  thermometer to ascer-
tain  the degree of heat,  and  he came to the conclusion, that it
seldom exceeded that of the blood as it issues from the left ventricle
of the heart.   In parts at a distance from the centre of the circula-
tion, the  temperature is  always lower; but Mr.  Hunter believed
that in them, it never reached  the natural standard during inflam- 
LOCAL SYMPTOMS OF INFLAMMATION.
51
mation.  He operated on a man in St. George's Hospital, for hydro-
cele, with a view to peform the radical cure.  The tunica vaginalis
being opened, he immediately introduced the ball of the thermome-
ter  by the side of the  testicle; the  mercury rose exactly  to 92°.
The cavity was filled with lint, dipped in salve, (an old method of
radically curing  hydrocele,) in order that it might be taken out at
will.  The next day, when  inflammation had come on, the dress-
ings were removed, the ball of the thermometer was introduced as
before, and the mercury now rose to 98f°;  but  even this was pro-
bably not equal to the heat of the blood, at the source of the circu-
lation in the same man.  This experiment, it is added, was repeat-
ed more than once, and with nearly the same results.
  In consequence of such high  authority, many have  adopted the
opinion that there is no rise of  temperature in inflammation ; but
whatever value we attach to Mr. Hunter's experiments, we cannot,
in the present day, coincide with the inferences which he drew
from them.  We believe that, were it possible to measure the degree
of heat, it would be found in almost every instance to be increased.
It is quite unreasonable, for example, to argue that  there is no
increased heat, because the  temperature of an inflamed part may
not exceed that of the  blood at the source of the circulation ; for if
it rises two or three degrees above that which is common to the
part, then we  contend  that the  heat is preternatural.  The rise of
temperature is best observed  in  the extremities, as they are at the
greatest distance from the heart's action ; but the same  thing would
be found, though in a  less degree, in  parts in the more immediate
vicinity  of the chest.   The standard heat of the blood  may  be
reckoned about  98°, varying from  96° to 100°, wnile that of the
inferior extremities is usually six or eight degress below.   When,
accordingly, inflammation takes place in  the latter, the heat may
scarcely average that in the chest or axilla, yet the natural tempera-
ture of the parts is elevated  several degrees;  and it  is from this
circumstance being overlooked,  that the opinion has gone abroad,
of the heat not being augmented during inflammation.
  From the warmth experienced wheii  the hand is  laid  over  an
inflamed part, and from the great complaint made of this symptom
in some cases, we might be led to expect that the rise of temperature
would be very considerable.  It is necessary to be aware, however,
how liable we are to be deceived by the hand, in judging of heat
or cold   If the  hand is cold when  applied, the inflamed part will
indicate a degree of heat not in  reality present; if warm, the tem-
perature may be considerably elevated  without our being able  to
detect it   It is better,  therefore, not to trust to the hand, but to use
a thermometer wherever it is practicable.   We have now so many
convincing proofsof the temperature of the body being  raised above
the natural standard, that no arguments to the  contrary can invali-
date them   In  common fever,  the  mercury in the thermometer
placed under the  tongue or in the armpit will rise to 10/ , time
decrees  above the  heat of the  blood in the aorta, supposing it to
  5                                            mgn 4* 
52           MORGAN'S PRINCIPLES OF SURGERY.
 average 98°.   In scarlet fever, we  have found the heat ranging
 from 100° to 112°.   It  has been  stated, by accoucheurs, that the
 uterus, during labour, will cause the  thermometer to rise as high as
 120°; and we observe in some spasmodic diseases, as tetanus, that
 the mercury will reach 106° and 107°.  In erysipelas of the lower
 extremities," we have  found the heat as high as 107°, and m one
 case 108°; and it is  not correct, as  Mr. Hunter supposed, that, in
 parts at a distance from the  heart's  action, the temperature never
 exceeds that of the blood at the source of the circulation.  It is only
 where inflammation  is  external that  the  degree  of heat can, of
 course, be measured, although we have little doubt that it would be
 found increased in most other cases ; and we must again  insist on
 our position that, wherever the temperature rises above that which
 is common to  a part  in health, whether that rise is greater or less
 than the natural standard, then preternatural heat is unquestionably
 indicated.
   We do not consider increased heat an unequivocal sign of inflam-
 mation.  Parts may be unusually warm where no morbid action of
 this  kind  prevails; and, again, a  sense of preternatural heat is
 frequently not complained of, where  intense inflammation is going
 on.  It is principally when inflammation affects the extremities,
 that"heat becomes a prominent symptom, as in these the circulation
 is more languid and the  temperature always lower.   In pleurisy,
 for example, pain is the most remarkable local symptom ; while, in
 whitlow or erysipelas of the leg and  foot, both pain and heat pre-
 dominate.   There are, however, a  few cases of internal  inflamma-
 tion, where increased heat  is present.   In  enteritis,  preternatural
 warmth is often experienced by the patient; and in phrenitis, it is
 perceptible when the hand is placed on the naked scalp.  Heat,
 therefore, is a valuable means of detecting inflammation of the brain
 in children, or in  those who may be incapable of expressing their
 proper feelings.
   We can offer no satisfactory explanation of heat  as a symptom
 of inflammation, without reference to  its production  over the body;
 and of this, we may at once confess that we know almost nothing.
 It was first supposed by Dr. Black—and the theory was supported
 by Crawford and others—that the formation of carbonic acid in the
 lungs was attended with an evolution of heat similar to what we
 observe results from the union of carbon and oxygen in ordinary
 combustion.   The heat was,  however,  rendered latent  in conse-
 quence of the greater capacity of the arterial blood for caloric; but
 was again given out, during the transition of the red  into venous
blood, in the general  circulation.  Dr. Adair Crawford estimated
 the specific caloric of arterial blood to exceed that of venous by
 14.5°, an amount  which has since been reduced by Dr. Davy to 1°.
 Nevertheless, the capacity of red blood for caloric being greater, the
latent heat was set free wherever the change into venous was o-oina
 on.                                                     h   b
   Such was the generally received theory till the experiments of 
LOCAL SYMPTOMS OF INFLAMMATION.
53
Sir B. Brodie were made  known, and  which have gone to prove
that the nervous system is concerned in the production of animal
heat.  After securing the vessels of the neck, Sir B.  Brodie killed
two rabbits by decapitation;  in  the one, artificial respiration was
kept  up—the other was  left untouched.   The  circulation  and
respiration went on perfectly  in the former, and yet it cooled more
rapidly—the thermometer standing at 97° in the rectum of the one,
and at 98° in that of the  other.  Sir  Everard Home divided the
nerves distributed to the growing  antler; its temperature  immedi-
ately  fell several degress, but  rose again in a few days higher than
that of the opposite horn.  The inference from these trials would
be, that animal heat does not depend on the changes induced in the
blood at the lungs.
   The experiments of Sir B. Brodie have been repeated and con-
tradicted by Legallois;  and Drs. Hastings and Philip have subse-
quently shown,^that the more rapid cooling of the first animal was
owing to too large an inflation of  the chest with  the cold air, and
that artificial respiration,  moderately  kept  up, retards  instead of
accelerating  this process.   There  are several circumstances which
point out the changes taking place in  the  blood, as  the principal
source of animal heat.   When  the main artery of a limb, as the
femoral, is surrounded with  a tight ligature, the temperature  occa-
sionally falls so low that we are obliged to have recourse to artificial
means to guard against it.  The farther a part is removed  from the
source of supply, the natural temperature is proportionally dimin-
ished ; hence that of the  lower extremities is always less than of
the upper.   In cases where  the blood is imperfectly artenahsed,
and a dark mixture is circulating through  the vessels,  as in some
malformations of the heart, the  natural heat of the surface is defi-
cient; and the same  thing may also  be observed in  asthma, when
the respiration is not sufficiently performed.   Dr. Wilson  Philip
applied the galvanic influence to the arterial blood of a rabbit im-
mediately on its  being  drawn ;  an evolution of heat amounting to
2° or 3°'took  place, and  in  the  meantime the  blood  acquired a
modena hue.   In venous blood, on the other hand, no rise of tem-
perature could be effected.  Dr. Davy has admitted that the specific
caloric of arterial blood exceeds that of venous at least by 1°, and,
it beincr apparent that this excess is discharged during the transition
of the"one into the other, it  may be  inferred  that, as this change
takes place in  the capillaries, it is there  where animal heat  is first
evolved.                                          .     .   .
   Admitting however, that the changes in the blood constitute a
source of animal heat, it is still doubtful in what manner the specific
caloric of the  arterial fluid  is acquired.  Dr. Crawford  supposed
that  the  carbonic  acid  of respired air was formed in the  lungs by
the direct combination of  the oxygen with the carbon of the  blood,
and that  the caloric, necessarily evolved by the combination of these
two elements, was absorbed,  and became latent in the arterial nuid.
 But there are strong reasons for thinking, that the formation  of the 
54           MORGAN'S PRINCIPLES OF SURGERY.
carbonic acid does not take place at the lungs, but that it exists
previously in the blood,  and is merely thrown off at these organs.
The theory, that the volume of oxygen which disappeared during
respiration was greater than that of the carbonic acid exhaled, was
at one  time overturned by the experiments of Allen and 1 epys,
which went to show that the two were exactly equal.  The more
recent researches of Edwards and Dulong  have proved,  that the
amount  of oxvgen  consumed is greater than that of the  carbonic
acid given  off;  and, consequently, it  has been  inferred,  that the
whole of the oxygen may as well be  absorbed into the blood as
part going to  the  formation of the  fixed air.   Dr. Edwards has
further proved that, in animals confined for various periods of time
in pure  hydrogen,  nearly as much carbonic acid is exhaled as  if
they were breathing pure air, and much more than could, by any
possibility,  have existed  in the lungs previous to immersion in the
inflammable gas.  It would appear,  from other  experiments, that
similar results are obtained when animals are made to breathe pure
azote; and, in the human subject also, the full quantity of carbonic
acid  has been  thrown  off, while the lungs were inflated with
nitrogen.
  These facts point out  that the carbonic acid of expired air is not
formed in the lungs, but  merely extricated at these organs from the
venous blood ;  and if this be true, then there would be no union of
oxygen  with carbon in the chest, and no caloric evolved to be ab-
sorbed by the arterial blood.   In whatever way the changes on the
circulating mass within  the lungs are  brought about, one thing is
evident,  that a volume  of oxygen  is consumed equal  to, if not
greater  than, the carbonic acid expired ; and whether this volume
of oxygen  combines in part with the  carbon of the blood to form
the fixed air, or passes wholly into the arterial fluid, in either case,
from  the condensation which ensues,  a rise of temperature must
follow.
  Dr. Edwards has likewise shown that, in young animals, less
oxygen  is consumed in respiration, and that they have a less faculty
of generating heat;  moreover,  he considers that this power is in-
creased  or diminished  by the quantity of oxygen  taken into the
lungs.  But, on the other  hand, it may be observed that, if the
power of generating animal heat depended solely on the consump-
tion of oxygen at the lungs, then it might be expected that frequent
inspirations would cause a great increase of temperature.   No such
effect, however, follows the attempts of the kind,  and we find the
only way of accomplishing this  is to accelerate the circulation, and
thereby indirectly create a necessity  for  fresh air.   In a patient  at
St. George's Hospital, with injury of the cervical  vertebrae, the heat
rose to 11° at a time when the respirations  did not exceed five or
six in a minute—a proof that the development  of heat is  not  in
proportion  to the consumption of oxygen.1
1 Medical Gazette, June, 1836. 
LOCAL SYMPTOMS OF INFLAMMATION.
55
  Dr. Wilson Philip admits that the action of the air  upon the
blood in the lungs is the principal source of animal heat, but con-
siders its extrication throughout the system as a sort of secretion,
in which the nervous system is directly concerned.  This opinion
derives  support  from his experiments, which show  the effect of
galvanism in causing an evolution of caloric and the transition of
the arterial  blood into venous.   Dr. Edwards believes that the
power of generating animal heat does not depend on any single
function, but that it is intimately connected with  respiration, cir-
culation, and secretion; and, moreover, that it cannot undergo any
sudden and permanent alteration in  health.  If we understood  the
influence which the nervous system has over the capillary circula-
tion, we should be better able to explain the phenomena in question.
There can be little doubt, however, that the process of secretion
and nutrition are intimately concerned in the production of heat
over the body, for whatever tends to disturb these,  has the effect of
altering, in some way or  other, the animal temperature.
   Chossat  has shown  that injuries  of the nervous system, which
lower the temperature, are identical with those which diminish the
functions of secretion  and nutrition.  In Sir B.  Brodie's experi-
ments, these functions were  necessarily suspended;  and we can
readily understand  why the inflation of the  lungs would then ac-
celerate the cooling of an animal.  It would appear, however, that
there are some injuries to the  nervous system, as those done to the
spinal cord, where a remarkable evolution of heat takes place ; and,
in  the case  already recorded,  the temperature reached  as high as
 111°.   It is probable  that a great  difference will  be observed, as
respects animal heat,  between cases where the functions of secre-
tion and nutrition are  completely arrested from the annihilation of
 the nervous influence, and those wherein they undergo some de-
 rangement in common with the vascular system. It is in this latter
 way that we would explain the temperature,  both in fever and in-
 flammation, being  so  many degrees above  the  natural standard;
 and by which we would  reconcile  also the statements of Dr. Hast-
 ings, who has seen the pulse  in fever at 45, and the heat of skin at
 105°'; and, in  hydrocephalus, the  former at 60 or 70, while the
 latter'was at 100°.                         .           .     .
    Ic has been argued,1 in proof of the heat in inflammation being
 dependent on the blood, that it never exceeds the standard acquired
 by that fluid in the aorta; but we have already shown that Mr.
 Hunter himself was deceived on this point.   In experimenting on
 animals, we observed  that, as soon as inflammation is  established,
 and every vital  function in the  part is deranged,  the  temperature
 then rises ; but it appears to us impossible to explain this increase
 by the state of the  circulation alone,  without taking into account
 the chances induced in  the nervous system, so far  at least, as the
 latter is connected with  the  functions of secretion  and nutrition.
1 Thomson's Lectures on Inflammation. 
56            MORGAN'S PRINCIPLES OF SURGERY.
The evidence on the production of animal heat is still conflicting;
and, until we are able to account satisfactorily for this vital process
in the state of health,  no just  explanation can be expected of its
increase or diminution  in disease.
  Swelling, although  usually enumerated among the local symp-
toms, ought rather to be regarded as an effect or product of inflam-
matory action.   It is chiefly seen when inflammation occurs in the
more external  parts, and can seldom be discovered when the dis-
ease is internal, till on examination after death.   Perhaps, the brain
is the only tissue which will not admit of swelling ; the contents of
the cranium cannot, properly  speaking, admit of increase; and
when  effusion of any kind takes place here,  some of the vessels
are unduly compressed, and we explain the symptoms which arise,
by supposing a portion  of the nervous matter to be deprived of its
supply of blood.  Lax  tissues, as the cellular or mucous, are those
in which  swelling most readily occurs.  Hence dense structures,
as bones or fibrous membranes, do not  become thickened till the
morbid action has been  some time present.  Swelling has frequently
the effect of relieving the inflamed vessels; at other times it aggra-
vates the local symptoms, by creating a feeling of tension, as when
the scalp is the seat of  disorder.
  Swelling, in the first place,  is caused by the greater distension of
the blood-vessels,  and  especially the colourless  capillaries.   The
conjunctiva, for instance, from  being smooth,  becomes turgid and
slightly elevated when  inflamed, and the inequality of surface thus
produced  imparts a sensation of a grain of sand or other foreign
body being within the eyelids.   After inflammation has been a short
time established, an effusion of fluid from the over-excited vessels
takes place.   The effusion consists either of serum tinged with the
colouring matter of the blood, or a mixture of serum and coagulat-
ing lymph.  When the  local action is intense, some of the distended
vessels burst, and blood is extravasated, so that the section of an
inflamed part occasionally exhibits blood, lymph,  and serum com-
bined.  Should the effused fluid consist principally of serum, the
swelling is soft, and disappears quickly after  the inflammation has
ceased; when much lymph is thrown out,  the part feels firm and
tense,  and the  hardness  remains for  some  length  of time.  In
general, the effusion  is  made up both of serum and lymph, and the
swelling is partly soft and  partly hard,  and  disappears sooner  in
one situation than in another.   The induration left after inflamma-
tory action is often a source of great inconvenience, and, from the
length of  time  required for the natural  absorption of the lymph,
causes much uneasiness in  the mind of  the patient.  Swelling,  in
inflammation,  may also be partly caused from the function of the
absorbents being interrupted  by the pressure  from  the newly de-
posited fluids.   Swelling, from  collection of blood or serum   must
not be mistaken for that arising  from inflammation.  Thus we may
have blood effused from a blow, or serum collected in the  cellular
membrane, as in cedema,  without any morbid action beino-  present- 
LOCAL SYMPTOMS OF INFLAMMATION.
57
but we know of no instance where lymph is poured out, unless as
a product of inflammation.   Swelling must, therefore, be combined
with other symptoms before it can be received as any evidence of
inflammatory action, and would,  as we  have already hinted, be
more properly included among its effects.
  The throbbing of an inflamed  part  arises from the obstruction
the blood  meets with in its  passage through the dilated  capillaries,
as is illustrated by the experiment of tying a ligature round a
finger.  It is  generally found where inflammation is limited in ex-
tent and violent in character,  and is  peculiar to some forms, as
whitlow  and cephalitis.  It may  be present from the commence-
ment, and gradually decline as the disease  abates.  When occur-
ring at a subsequent period,  from the  greater  intensity of the
inflammation, it often indicates that suppuration will  ensue.   The
local pain is  always increased at each  pulsation, and has hence
been denominated pulsatile; it is produced during the dilatation of
the vessels.   Where throbbing is met with, we commonly find that
it is much increased by postures which favour the flow of blood to
the part, and  prevent its free return by the veins.
  Another local symptom, and one which we hold in as high esti-
mation as any yet treated of, is functional derangement of the part
affected.   There is not, nor can  there be, any  organ in the body
which does not exhibit this when  attacked by inflammation ; hence
its importance in ascertaining disease.  The truth is self-evident,
that a disordered organ can never perform its functions rightly—
the coincidence therefore inseparable, of a disordered function imply-
ing a disordered organ.  Let us give a practical illustration of the
value of  this symptom.   In inflammation of the  substance of the
brain, neither redness or  swelling are visible, there may be no pre-
ternatural heat indicated when the hand is laid  on the scalp, and
the patient may be rendered incapable  of expressing his proper feel-
ings.  What other symptom, then, have we to point out the seat of
the local mischief, save the derangement manifested in some of the
natural functions  of the affected"organ ?  How  often, in cases of
typhus fever, should we be deceived as to the existence of fatal
inflammation in the lungs,  were it not for the hurried respiration,
the accidental cough, and  the  phenomena indicated  by the stetho-
scope? And in inflammation of the mucous membrane of the intes-
tines, are not the discharges from  the bowels the most conspicuous
local signs of the disorder? Derangement of function at once pro-
claims'the seat of disease ;  and there is no part which has an office
to fill in  the animal economy that can  be exempt from this law.
We are, of course, far from wishing to assert that functional  disor-
der is attributable to no other source than inflammation; we  wish
only to state  that, in combination with other evidence, it stands
invaluable as a local symptom.
  The alteration occasioned in the function  of parts  by inflamma-
tion is modified according  to the  violence and duration of the dis-
ease. The most common  effect is to suppress  or alter the  secre- 
58            MORGAN'S PRINCIPLES OF SURGERY.
tions, as when the kidney or liver is the seat of disorder ; in othe'
structures, as  the mucous,  the discharge is both  vitiated and
increased.  Suspension  of a natural secretion, however, is not an
invariable mark  of inflammation.   In suppression  of urine, when
other symptoms are wanting, we should not be justified in adopting
bold depleting measures.  Functional disorder, as a result of inflam-
mation, arises in two ways ; either  from the mere  violence of the
local action, which, as soon as subdued, leaves  the part again  fit for
its office ;  or from morbid change of structure, where, although the
inflammation may have ceased, the derangement of function remains
behind.  As a symptom of inflammation, therefore,  we have to con-
sider whether it is the immediate and transitory effect of disordered
action, or  whether  it springs from  some  permanent  alteration
induced in the natural structure; for our prognosis with respect to
its  future disappearance, in the two cases, is very different.  In
whichever of these ways disorder  of function is  caused, we find
that it is  a never-failing accompaniment  of  inflammatory action,
and therefore  a  useful guide  to the disease  when occupying an
internal part.
  Lastly, we shall briefly allude to the local signs remaining after
death.   We do not mean to detail, at present, the change of struc-
ture left by inflammation, but simply to enquire how far the symp-
toms now treated of correspond  with the  condition in  which we
find an inflamed  part.  This is a subject of great importance in a
medico-legal point of view, and one in  which serious mistakes are
liable to  be committed.  In making  post mortem examinations,
nothing appears more surprising than that no traces of derangement
can be seen in cases where we were  certain, from the  symptoms
during life, inflammatory action had  been going on ; and  again,
that we should meet  with evident marks of the disease where no
suspicion of its existence had previously been  entertained.   When
inflammation attacks an organ essential to life, as the heart, death
may ensue before time has been allowed for any change of tissue
to be effected.  Strictly speaking, inflammation is a state of disor-
dered action incompatible with that possessed  by a  part in  health;
and the tendency of which is, by long continuance only, to give
rise to  morbid  products.  It may so happen, therefore, that no ap-
parent alteration  is to be discovered, merely because the disease
has proved fatal before these changes could be brought about.
  Redness and swelling are the only local signs of recem  inflamma-
tion which are to be found after death ; the pain and heat, the sense
of throbbing, and the disorder of function, must have necessarily
ceased with life.   Redness, however, is not always  to be  observed ;
neither are we to  infer  from  its presence that inflammation had
taken place.  We are quite certain  that the redness of an inflamed
part may disappear after death, as  we witness when  the skin or
conjunctiva has been effected;  hence we are not to conclude, pro-
vided there was  good evidence to the contrary during life, that a
person may not have died of inflammation, simply because the part 
             LOCAL SYMPTOMS OF INFLAMMATION.           59

docs not afterwards appear red.  In order that the redness be per-
manent, the inflammation  must have reached that stage where the
vessels are dilated and have lost their contractile power, and where
the blood  is stagnant and  cannot  be urged forward  by pressure.
In such a case, we have  generally other signs of the disease, as
effusion of serum or lymph.  Should the inflammation terminate
fatally, before these changes in the state of the minute vessels have
taken place,  then  the redness disappears in consequence  of the
general contraction  occurring  throughout the whole of the arterial
system at  the moment of dissolution.
   Neither is mere redness any proof of a part having been inflamed.
Dr. John  Davy1 first showed, and his observations have since been
confirmed  by Andral. that  the  colouring matter of the blood  may
transude so as to impinge  the neighbouring solids and redden their
contents.   Unless a body  is examined  within twenty-four hours
after death, in warm climates  where decomposition proceeds more
rapidly, Dr. Davy considers it  impossible to discriminate between
the  redness of  inflammation  and  that  caused  by  transudation.
During life, the colouring matter of the  blood does not even tinge
the lining membrane of the vessels along which it moves;  but
after death, and especially when decomposition has commenced,
the solids  loose their cohesion, become  soft and porous,'and allow
the blood  to transude throifgh their substance.   The period at
which the examination is made, is, therefore, a matter of great im-
portance,  in all cases.
   The transudation of blood through the solids is much influenced
by the manner in which death has happened.  Thus, where it has
arisen  suddenly, as from  lightning, drowning, or  suspension, the
tendency  of the blood to transude "is much increased.  In some of
these the  contractility of the arteries is instantaneously destroyed,
and these vessels, as well  as the veins, remain full of blood ; in all
of them the greater fluidity of the blood allows it  to ooze more
readily through the tissues, and thus accelerate decomposition.
   Position has also  a remarkable effect in causing redness, by allow-
ing the blood to gravitate towards the most depending parts. Thus,
in'"bodies  lying in the ordinary way, the most prominent points on
which they rest, as  the  back part of the scalp, the shoulders, and
nates, are reddened.  The posterior portions  of the  lungs, for the
same reason, usually contain a considerable quantity of blood ;  and
were we to set this down  as a sign of  inflammation, we should be
guilty of  a gross error.   Notwithstanding the influence of gravita-
tion, there is a tendency to congestion in all internal organs, arising
from the inability of the heart and arteries, during the last acts of
life to transmit 'the blood to  the surface of  the body. It a  part
which is naturally  pale be placed in such a position as to favour
the oravitation of the blood, and then examined at the end of three
or four days it will be found to iiave assumed a bright  red.  Rigot
1 Medico-Chirurgical Transactions, Vol.' X. 
60           MORGAN'S PRINCIPLES OF SURGERY.

and Trousseau state that, in many cases where they had suspended
a piece of intestine, the blood not only gravitated to its lower parts,
but transuded through the mucous coat.  In this way blood may be
extravasated, and mistaken for the effects of external violence ; in
the former case, however, it is always fluid, while, in the latter, it
is generally coagulated.
  Any obstruction  to the free return of the blood to  the right side
of the heart, or to its circulation through the lungs, will cause red-
ness and congestion in parts independent of inflammation.   How
often do we observe blood  effused under the inner membrane of
the stomach from this  cause, and  which has been set down as
evidence of other disease?   The mucous  lining of the intestines
frequently exhibits  red  patches  throughout  different parts of its
course; and even  blood will collect within  the  canal, where no
inflammation was present, but where some obstacle to the free cir-
culation through the lungs had existed.  There are, therefore, four
circumstances "to be taken  into account in judging of redness in
the dead body.   These are—the period at which the examination
is  made, and the probability of transudation—the mode of death,
whether sudden  or gradual—the position  in  which the body has
been laid—and  the presence of any mechanical obstruction to the
circulation.  Whenever we observe  that redness is not confined to
one spot, but is exhibited  in different places  remote  from  each
other, we may rest assured  that it arises from  some of the causes
now mentioned; on the other hand, where it appears solitary, and
no other marks of congestion or  transudation are present, there is a
probability of its being the result of  inflammation, and we must be
cautious as to the opinion we mean to deliver.
  The  most unequivocal proof of redness being a sign of inflam-
mation is, where it is found united with some of the  common pro-
ducts of the disease.  Effusion of serum or blood would not entitle
us to come to any immediate conclusion, because they often  arise
from other causes; but when,  along with the redness,  we  find
lymph, or flakes of lymph mixed with a serous fluid, we may then
be  satisfied  that  inflammation  had been present.   Coagulating
lymph is thus a certain test  of inflammation ; and  we know of no
instance where it can otherwise  be formed.   It may happen, never-
theless,  that time has not been allowed for  lymph  to  be thrown
out, and still the other evidence  may be so clear, that it can hardly
be set aside.  If, for example, we are confident, from  the symptoms
during life, that a certain organ was inflamed ; if, on examination
after death, redness, more or less intense, remains, and which can-
not be washed out  like a piece of blood-stained membrane • and if
due attention has been  paid to  position, the chance of mechanical
obstruction,  and the probability of  transudation—we may safely
enough infer that inflammation  had  been present.  In fine when-
ever we are attempting  to  ascertain that inflammatory act'ion has
been the cause of death, we ought  carefully to contrast the pre-
vious symptoms with  the  appearances seen on  dissection, and 
      CONSTITUTIONAL EFFECTS OF LOCAL INFLAMMATION.   61

these latter again with the changes going forward in the body
before and after vitality has ceased.   Unless this is done, it will be
impossible  to arrive at the  truth; and, in legal medicine, errors,
involving the life of a  human  being, are,  from want of necessary
precautions, not tin frequently committed.
                        SECTION IV.

      CONSTITUTIONAL EFFECTS OF LOCAL INFLAMMATION.

   We come, in the next place, to treat of the general or consti-
tutional effects, commonly  denominated  the  symptomatic  fever.
While inflammation often proves fatal, by altering or suspending
the functions of parts essential to life, much of the danger to be
apprehended arises from  the febrile disturbance  to which we are
about to direct our attention.  The importance of this subject, in a
practical point of view, is thus apparent; while, to the theoretical
pathologist, it has afforded  much scope for interesting investiga-
tion.   It is not  our duty to enter at length  into all the curious
details involved in its discussion; but we shall endeavour to give
such a sketch as to render  the matter intelligible, as far as is sub-
servient to our present purpose.
   Of the  history of fever, a very brief outline will suffice.   Two
theories have been brought forward to explain the nature of febrile
action—the one ascribing the whole to a morbid  change in the
composition of  the  fluids—the other, to  some modification in the
state of the solids; and from these have sprung the doctrines of the
humoral and the nervous pathology.   The ancients, nearly igno-
rant of the structure of the  body, and  still less acquainted with its
functions, ascribed the origin of fever to some  change in the con-
dition of the fluids.   The greater bulk of these,  compared to the
solids, and the manifest derangement of all the  secretions observed
during a paroxysm of fever,  tended to confirm them  in this opinion.
The blood, from its  high  importance, was the fluid to which their
attention  was chiefly  directed;  but  its  composition, like many
others, was then unknown. If a redundant portion of bile made
its escape into  the vessels,  or if the blood became charged  with
phlegm or  other viscid matter, fever ensued,  and remained till
some alteration  was again  effected.   Hippocrates  advanced  the
opinion, supported afterwards by Galen and his followers, that the
system was impregnated  with  some  noxious  substance, exciting
certain movements and  commotions which constituted a paroxysm
of fever.   He supposed that nature exerted all her powers to accom-
plish its expulsion ; and, according to the length of  time required,
so was the disease of shorter or  longer duration.   The struggle
which nature made to relieve herself, caused the ebullition or con- 
62
MORGAN'S PRINCIPLES OF SURGERY.
 coction;  and the more obstinate the resistance from the foreign
 power, the  more violent  was  the  fever  which  ensued.   The
 changes more especially taking  place during the  progress of the
 exanthemata appear  to  strengthen the conjecture  of Hippocrates,
 that some morbid agent has been  received into the system, and it is
 afterwards eliminated.   The doctrine was well received, and very
 generally adopted for many ages; and however unsatisfactorily it
 may account for all  the phenomena of fever, there is much truth
 in  the  assertion that a morbific poison has  been  applied.  The
 chemical doctrines of  Paracelsus and Van Helmont,  which set forth
 that the fluids possessed at one  time an alkaline,  and at another,
 acid properties, and  that an effervescence  took place, producing
 fever, rendered the humoral pathology still more imposing.  Boer-
 haave, dissatisfied with the opinion of Hippocrates, that there was
 a change in the composition of the blood, applied his mechanical
 theory of an  error loci to explain  the cause of fever.  Towards the
 close of his life,  and  with a candour  not often  seen among those
 belonging to our profession, this illustrious man acknowledged the
 insufficiency of his views,  and  partly adopted  the  doctrine of  the
 nervous pathology, which had by this time been brought forward.
  So far the fluids had  been regarded of paramount, importance,
 and to their modifications were  all  diseases to be traced.   But few
 theories in medical science, founded  on  conjecture rather than on
 close observation and experiment, have  been  destined to survive;
 and the humoral  pathology, in all its pride, gradually bent before
 the more refined hypothesis of the solidists.  In  contemplating  the
 fluctuation in opinion and estimation  to which the  doctrine of"  the
 fluids has been subjected—for several  hundred years the idol of its
 party, then neglected  and  despised (for such  was the rancour of
 controversy), and now again rising into repute—we have a memor-
 able instance of the imperfection  and  instability of  all human rea-
 soning.   In a published lecture  on typhus,  Dr. Clanny  has  en-
 deavoured to show that  a cessation of sanguification is the  ostensi-
 ble proximate cause of the fever; but such a theory is at variance
 both with the manner  in which the disease often makes its invasion,
 and likewise with its decline.  He considers, however, that  \\\a,
 solids are first affected, and  that the important changes taking place
 in  the blood are  established through  them.  Dr. Stevens,  on  the
other hand, believes the derangement in the  circulating mass to
 form the first link in the chain of  morbid phenomena.   In opening
 the heart, in cases of yellow fever, he found a fluid as thin as water
and as black as  ink;  and, in all  parts of the body, the distinction
between arterial and venous blood  was lost.   According to him  the
blood undergoes a regular series of changes, first becoming thinner
and losing  its saline principles, then turning black,  and havino- its
vitality so destroyed as to be incapable of supporting the action of
the heart.   He farther considers that the aerhl poisons, from which
all  pestilential diseases  proceed, are carried with the atmospheric
air into the lungs, mingle there with the blood, and being circulated 
      CONSTITUTIONAL EFFECTS OF LOCAL INFLAMMATION.   63

over the body, cause subsequent morbid action of the solids.   The
fact of the composition of the blood being altered in fever, and
many other diseases, will be acknowledged by every practitioner of
the present day, whatever value he may feel inclined to attach to it;
the difficulty is in accounting  for the order of occurrence, whether
such changes  precede or are acquired during the  progress of the
affection ;  as, in the one case, they would be the cause, in the other,
only the consequence of an aberration from the state of health.
  Andral is of opinion that the morbid alteration in the circulating
mass takes the precedence.  We  find him stating—" The fever,
termed  inflammatory,  seems often to arise from no other source
than the blood being  too rich in fibrin; in like  manner, an im-
poverished state of the blood, whether accidental or  natural, is often
connected with mucous fevers, and with those characterised  by a
sudden sinking of the vital powers; and that the source and primary
seat of typhus fevers, properly so called, is the blood, inasmuch as
they are caused by the introduction of deleterious substances,  such
as animal  or vegetable effluvia into that  fluid."  Whatever be the
order of occurrence observed, it is certain that, in fever which par-
takes of an inflammatory character, the  blood contains at first a
larger proportion of  fibrin, and forms  a  firmer coagulum; while,
during the progress  of the case, or in one accompanied from the
beginning by evident marks of prostration, there is  a diminution in
the quantity of fibrin, and  the clot is soft and loose.   We are in-
clined to adopt the views of Andral  with respect, at least, to the
inflammatory variety of fever; for we have many  opportunities of
observing  this condition of the blood, in persons  in  the  habit of
having venesection performed once or twice a year, and who, unless
some evacuation or other is  practised, become often the subjects of
local inflammation.   If we regard the morbid  alterations in the
composition of the blood as the primary source of fevers, we can
easily explain the subsequent derangement in the functions of
organs, and the vitiation of the different secretions during their con-
tinuance.  A want of facts prevents us from arriving at any accurate
conclusion; the subject is yet in its infancy; and while the humoral
pathology  will, we trust, emerge from the obscurity and redicule
thrown over it by its bigoted opponents, we, at the same time, hope that
its due share in the constitution of disease may only be assigned to it.
  In opposition to the  doctrine of the humoral pathologists came
that  of  the solidists, first  introduced and promulgated by Stahl.
He supposed that there existed a salutary  agent, the vis medicatrix,
which, on  perceiving  any  injury done to the body,  immediately
exerted  itself to counteract it.  Reckoning this point established,
he concluded that fever consisted of a tonicus spasmus of the dif-
ferent nerves, to overcome which there was a struggle of the vires
medicatrices, and which excited  those commotions in the system
constituting the disease.  So  imposing was this new theory, that
even Boerhaave become reconciled to it, although he considered
the change as merely mechanical, and not consisting of any different 
64           MORGAN'S PRINCIPLES OF SURGERY.
state of the living solid.   By others, however, it was condemned,
and said to be both unintelligible and  without proof,  Hoffmann
afterwards adopted  and refined  the  views entertained  by Stahl.
The patient investigations of Hoffmann  and the results  of  his
inquiries were forgotten, till again revived by Cullen.   Like both
his predecessors,  Cullen believed  in the operation of a vis medica-
trix natural; and, as Hoffmann had done,  he gave to every part of
the body its due share of this salutary power.  Thus armed, he
gave forth to the world his ingenious  theory of fever, one which
professes, in some respects, to give a more natural explanation than
any other before or since  offered, and which, if now falling into
neglect, cannot be said to  be  dying  away  before a model of more
stately structure.
  The  most unmerited censure  has been heaped on  Cullen  for
having made use of the phrase vis medicalrix naturae; but he was
not the inventor of this tutelar deity, as many have ignorantly sup-
posed ;  it had descended  from Stahl,- nor did Cullen  receive it
without limitation, for  he  justly  considered it as throwing an  ob-
scurity over all  our reasoning.   By the vis medicatrix was only
meant the reaction of the system, or the efforts made by nature to
restore the several functions of the body, when they have been inter-
rupted or disturbed by some noxious power ; and, used in this
sense, it was also  the language of Hippocrates.   Although  the
phrase has been laid  aside by modern writers, they acknowledge
the same principle when they refer certain effects to the reaction of
the system ;  and whoever, in the ordinary course of his experience,
has had occasion to observe the  human body in its opposite states
of health and disease, must have recognised the attempts  made to
regain the one, and to provide against the ravages committed by the
other.   We cannot, it is true, explain  the means by which nature
endeavours to accomplish these ends, anymore than we can explain
how life itself is  maintained;  we witness the results only, the steps
by which they are effected remain hidden.   Again,  where nature is
unable to accomplish her work, or when the reaction of the system
is so violent as to threaten destruction to life, the interference of art
becomes necessary; in the former case, we endeavour to promote
her efforts;  in the  latter, to  preserve them within proper bounds.
To this power,  then,  of  self-preservation, whether we choose to
know it by the title of  vis medicatrix, or by that of reaction of the
system, do we ascribe  many of the changes occurring within the
animal economy, both from  the application  of remedies  and the
attacks of disease; and it was only to express this original  law
of our constitution that Cullen sanctioned the use of a phrase about
which he has been  so ungenerous.'y reviled.
   It was a leading feature in the theory of Cullen—and he borrow-
ed the idea from Boerhaave—that one stage of fever was the cause
of another, and  that the different stages should therefore follow in
regular order.   As the cold stage occurs first, and gives rise to the
warm,  it was conceived  that, provided the  cause of the former 
         CONSTITUTIONAL EFFECTS OF INFLAMMATION.       65

could be discovered, the nature of a paroxysm would be easily ex-
plained.   From the weakness of pulse, the general coldness of the
limbs, the languor, uneasiness, deranged sensations, and impaired
animal functions, Cullen inferred  that the causes of fever operated
by diminishing the energy of the brain, and thereby enfeebling the
action of the heart.  He attempted to prove that contagion, mias-
mata, cold or fear, induced debility; that any cause which brought
on  this would  renew a fever after convalesence; and, from such
premises,  he concluded  that fever essentially  consists  of three
states—one of debility, another of cold, and a third of heat.  These
constituted the general phenomena of a paroxysm ; and as, accord-
ing to his supposition, a regular succession was observed,  the
debility was the primum mobile, creating the cold stage, and this,
in its turn, the  warm.  The  Herculean task still remained unfin-
ished.   How does the cold  stage arise out of debility ?   Here the
theory is imperfect: and we are  merely referred to that general law
of the animal economy, by which all  noxious  powers are obviated
or expelled.   Observing that derangement and suppression of the
secretions continued till the sweating stage set  in, Cullen imagined
that a spasm of the extreme vessels had taken place.  He supposed
that the spasm formed  during the cold stage proved a stimulus to
the heart and arteries, whereby their action was increased ; and, in
order that debility might not be presumed incapable  of producing
these effects, he attributed the cause of the spasm  to  the vis medi-
catrix.  The extreme vessels were every where in  a state of de-
bility, and this  formed an important part of the proximate cause of
fever.  The debility of the capillaries extended  from those on the
surface to those of the stomach, and caused the anorexia and vom-
iting frequently witnessed during the cold stage : it arose out of a
diminished energy of the brain, from whence ensued the delirium
and imperfect sensations formerly alluded to.  This state, however,
was transient;  increased  action of the heart and arteries followed,
and by which  the energy of the brain was restored; the spasm of
the extreme vessels was  removed, and diaphoresis ended the pa-
roxysm.
  The complex theory of Cullen would require a volume to un-
ravel  it; and, even were  the task accomplished,  we should find
that we  had not  advanced a single  step towards explaining the
nature of fever.   It was  an essential position  that  the  different
stages should succeed each other  in regular  order; and, if we can
show that this  is not  always the case, the chain  of reasoning is at
once broken and destroyed.   Now it  often happens that  in  inter-
mittents which  have become irregular, the order of occurrence is
reversed;  and,  in  other instances, as in  the  variety  described by
Cains,  diaphoresis has accompanied the fever throughout.   The
idea that spasm of the extreme vessels occurs during the cold stage
of fever, and proves an irritation  to the heart and  arteries, is sup-
ported  by no evidence, whatever; and, again, the supposition that
the increased circulation restores the energy of the brain, and thus
       12—b                                    5 mgn 
66            MORGAN'S PRINCIPLES OF SURGERY.

removes the constriction of the capillaries, is alike without founda-
tion.   There is  probably  much truth,  however, in the statement
that the causes of fever operate first and most strongly upon the
nervous system; but we never find  that the derangement of func-
tion so created is repaired  by the hot  stage, as Cullen wished to
impress.  Notwithstanding its ingenuity, when applied to explain
the nature of fever, the theory is deficient;  it has done good, by
serving to connect  in a more regular manner the different symp-
toms ;  and it has done evil, by leading the mind astray to the use
of means calculated to remove the supposed  spasm of the vessels.
  From the celebrity of the  author, these views of  the  nature of
fever were very generally received until they were exposed  by
Brown, at first the friend  and afterwards the inveterate enemy of
Cullen.  The Brunonian  doctrine  attracted  much attention  from
its  professed simplicity, and a long time elapsed ere  the principles
on which it was founded were acknowledged to be false.  Man was
now represented to be a mere passive machine, endowed with a
certain portion of life, and capable of being acted upon by external
agents.   The natural period  of life was thus fixed ;  every animal
received a certain share, which, if not too rapidly exhausted, would
continue for a certain length  of time.   The phenomena by which
life was to be exhibited resided in an uniform indivisible property
termed excitability, of itself incapable of producing life, and requir-
ing for this purpose to be acted upon by stimuli.   The quantity of
excitability allotted was more or less quickly exhausted by the ap-
plication of stimuli.  Should the stimuli be  in excess, the excita-
bility was impaired; if deficient it accumulated ; a certain portion,
however, was necessary for life, for, if totally withdrawn, our exist-
ence ceased.  Health  was attained only when the stimuli and ex-
citability bore a certain relation to each other; but this balance was
often subverted, and  then disease  commenced.  The Brunonian
classification of diseases was  into sthenic and asthenic;  the former
being of one kind  only, the  latter  comprising cases wherein the
excitability was either  exhausted  or  morbidly  increased.  The
treatment was  obvious—to employ means either to lessen  or to
rouse the excitability.  The diseases of increased excitement, how-
ever, were few, compared  with those where debility  was manifest,
and to the latter, therefore, the Brunonians devoted their principal
attention.
  According to these views,  the due performance of  every healthy
function was  constantly exhausting the excitability originally be-
stowed upon us; nay, the very processes of digestion  and assimi-
lation, which are supposed by sober-thinking  people  to  preserve
life, must have been daily cutting short our career.  The supposi-
tion, that man is a mere machine, endowed with a certain measure
of excitability which gradually diminishes and cannot be resupplied,
is at variance with all the natural  phenomena of sleep, nutrition,
fatigue, and muscular exertion ; and, consequently, the superstruc-
ture raised on such a foundation must be weak and indefensible. 
CONSTITUTIONAL EFFECTS OF INFLAMMATION.
67
The theory of Brown lingered longer in other countries than in
his own. It was carried into Italy by Rasori, one of its most strenu-
ous supporters.  A few years afterwards, the petechial fever break-
ing out at Genoa, gave the disciple an opportunity of following out
his favourite treatment, but many of his patients perished.  Rasori
next tried a controstimulant plan, by which the loss of human life
was much diminished; convinced, then, of his error, he discarded
for ever the Brunonian principles.   This proved a decisive blow to
what may, without any hesitation,  be named  the most pernicious
theory ever invented for selfish motives.
   Another class of the solidists has assigned to fever a local seat in
the body.  Marcus and  Clutterbuck consider  inflammation of the
brain to be the cause of fever, and  accordingly direct their atten-
tion principally to the state of this organ.   Pain in the head is the
symptom during life  which has led to this opinion ; but we are
not warranted, where the nervous system is so much deranged, in
considering pain as always proceeding from inflammation, and we
think experience freely justifies us in making this assertion.  Other
pathologists, again, consider  lesions of the intestinal canal as  the
essential cause of fever.  Amongst the  most conspicuous of this
class stands Broussais, who thinks that the  influence of such a
doctrine over the population would  be even more  favourable than
vaccination.  The same views have been supported by Petit, Serres,
Bretonneau, and Louis, the latter of whom has given an  elaborate
account of the different lesions occurring in  fever, and  confirms
the dissections previously made by Bretonneau, that the primary
source of disease  is  in the mucous  glands of  the lower  portion of
the ilium and the caelum.  Agreeably to the  French pathologists,
every species of fever proceeds from a gastro-enterite, and which
may give rise to other  symptoms during its progress from  bad to
worse.  Such lesions would seem  to be more frequently met with
in some  countries than  in  others, arising apparently from local
causes, as indeed the effects of fever vary at all times according to
climate, season, and particular type which may  be prevailing.  While
we willino-ly admit the frequent complication of fever with inflam-
matory action, and the urgent necessity that exists  for watching the
 invasion of the latter, we would be understood as plainly to deny
 that fever was dependent on local disease.  It is, no doubt, true that
 inflammation of particular organs will co-exist with or supervene
 on an attack of fever;  but it is equally true  that fever  may arise
 and go through its whole course without  any such  local derange-
 ment'  We  shall afterwards assign reasons for our belief.  In the
 meantime we may observe that both theories have done good, by
 puttiiio- us on our guard against these local attacks, and  leading to
 a more successful line of treatment; but no better argument against
 the exclusiveness of such views could be given, than the  difference
 existincr among their supporters as to the proper seat of disease.
   Ao-am fever has been regarded  as an  essential disease not de-
 pendent on any local  affection, but frequently complicated  with such,. 
68
MORGAN'S PRINCIPLES OF SURGERY.
 and which constitutes the greater source of danger.  To this class
 of reasoners the name of essentialists has accordingly been given.
 Fordyce, in our own country, considers fever "as a general disease
 which affects the whole  system, the head, the trunk  of the body,
 and  the extremities:  the circulating, absorbing and  nervous sys-
 tems;  the skin, the muscular fibres, and the  membranes; the body
 and likewise  the mind."  Pinel  of France so  far  takes  the same
 view, but  he  has evidently become a localist, when he  assigns a
 seat for the different varieties, as  the inflammatory in the  organs of
 circulation—the bilious in the mucous membrane of the small intes-
 tines,  &c.   For our own  part,  we  think  that all attempts to refer
 fever to an affection of one  individual organ or system are both
 fruitless and erroneous ; and that, when sober reasoning comes to
 be substituted for the erratic  excursions of the imagination, the
 fluids  as well  as the  solids  will  be allowed to participate in the
 general derangement.   Whether the primary  source  of common
 fever consists  in a morbific poison applied to the blood in the lungs,
 and by which  the nervous  and other systems  are subsequently
 affected, or whether the changes in the latter take precedence of the
 changes in the  circulating masp, we do  not  pretend to determine;
 but we hold that the records of established cases coincide with daily
 experience  in  proving the worst  varieties to  occur  without the co-
 existence  or supervention of local  disease.  It  is  by reference to
 the great book of nature, the same through a thousand editions, that
 this practical point must be determined ; and  it is to the interpre-
 tation  of her work that the life  of the physician  should be steadily
 devoted.
   In attempting to define disease, the object to be  kept in view is
 to give an enumeration of those symptoms which are deemed essen-
 tial to  its existence, and without the manifestation of which it could
 not be said to have occurred.   In regard  to objects of  natural his-
 tory, where each individual has its  progenitor exactly  the same as
 itself, the business of defining  is  precise and limited.   In the science
 of medicine, far greater latitude must be allowed,  for there we can-
 not classify diseases according to  their real nature, but only  by the
 symptoms to which they give  rise ; and when the greater number of
 these are observed, the particular  morbid  state is then inferred to
 be present.   Boerhaave attempted to reduce the phenomena of fever
 to shivering, increased frequency of pulse and heat; but  this attempt
 at generalisation fails,  for many diseases which we consider febrile
 not only want these, but  are attended by opposite symptoms  and
several others would require  therefore to enter  into the definition
 The concourse and succession  of symptoms  are briefly given by
 Cullen  m  these  words-"post horrorem, pulsvs frequens, calor
major, phires functiones lesa, viribus prcesertim artuum irnmi-
nutis.'  These he illustrates  at greater length  in that part of his
Practice of Physic which treats  of fevers ;  and, although sometimes
defective, his descriptions of disease  indicate a close observance of
nature, and are well worthy of the attention of the medical student 
        CONSTITUTIONAL EFFECTS OF INFLAMMATION.       C9

  Some degree of languor and a sense  of debility usually usher in
febrile affections—premonitory signs, be it  remarked, which are far
more generally seen in what is termed idiopathic than in  sympto-
matic fever.  These  feelings are succeeded or accompanied  by  a
coldness over the body, and  shivering  to a  greater or less extent.
The sense of cold then gradually subsides, and a preternatural heat
is  next  experienced  by the patient.   During  these changes the
plures functiones lesm manifest themselves in some form or other.
The pulse, at first small and quick, rises in fulness and strength,
the natural secretions are suspended or altered, and the functions of
the nervous system impaired.  After a while the increased circula-
tion abates, the preternatural heat diminishes, and a solution of the
fever takes place in the way of some critical evacuation, commonly
as perspiration, diarrhoea, or hemorrhage.
   Such may be considered as a brief statement of what takes place
to a greater  or less  extent  in  febrile  affections ; and  it  is  to be
regretted  that  we have  no  more concise way of expressing our
knowledge of their existence.   We have seen enough to satisfy ns
that the word fever does not convey a simple idea,  but is employed
rather to denote a certain assemblage  or succession  of symptoms
which cannot  be  comprehended under any single term.   It is  a
remarkable circumstance, also, in the history of these diseases, that,
although  we cannot  state precisely by what symptoms  they are
known  to exist, to the eye of the experienced  practitioner, a fever
patient  presents an object which is immediately  recognised.  In
short, we are perfectly familiar with the appearances of fever, and
can give to it without farther examination its  proper name ;  yet it,
is with  considerable difficulty we can assign a reason for our belief
   The  whole course of the symptoms, from the commencement  of
the rigours to the  close of the critical  evacuation,  is  termed  a
paroxysm.  Sometimes the fever consists of a single paroxysm;
sometimes of a number of distinct paroxysms, with complete  inter-
missions between them; sometimes of a protracted paroxysm with
only very slight remissions and  corresponding  exacerbations.  On
the occurrence of these is founded the division of fevers into  inter-
mittent, remittent, and continued.   It will likewise facilitate our
description, to  remark that the  phenomena  of continued fever pre-
sent varieties which give rise  to a  subdivision of it into sthenic  or
inflammatory, and asthenic  or typhoid.   The nature of the  affec-
tions so designated need not be explained till we proceed further  in
our investigation; all that we wish at present to be understood  is,
that these varieties depend  upon certain  peculiarities  in  the pre-
dominant symptoms—that the general character of the inflammatory
or sthenic is an exaltation of the powers of  life—while the typhoid
or asthenic  is recognised  by  marks of  debility, depression,  or
diminution of  strength.   We shall form, also, a better idea of the
subject under discussion, by considering  the symptoms as  they
relate to the different functions or systems which  are deranged.
We do not enter into the question, in  what order are the various 
70
MORGAN'S PRINCIPLES OF SURGERY.
functions affected? and do the successive functional derangements
stand to each other in the relation of  cause and effect?  We are
merely desirous of taking a view of the phenomena occurring in
fever.
  Symptoms indicating derangement  of the nervous system are,
then, among the earliest that appear in febrile diseases, but our pre-
sent knowledge does not enable us to  say on what this functional
derangement depends, nor is  it likely that we shall  ever arrive at
any accurate  conclusion on  this subject.   Of all the changes
observed in  fever, those happening in  the  nervous system are the
most difficult to comprehend,  or  to which we can refer,  with least
certainty, the proper symptoms which spring from them.  A degree
of confusion of thought, a want of intellectual energy, certain inde-
scribable sensations with a feeling of horripilatio (for we have no
English term so expressive) over the body, constitute the first symp-
toms complained of by the patient.  The most prominent  change
referable to the nervous system—and one generally met with in all
diseases entitled to the name of febrile—is a feeling  of listlessness
or an uneasy sensation quite peculiar to this state.  No description,
to use the language of Dr. Southwood Smith, can convey any idea
of it to one who has not felt it, and to him who has, the word fever
recalls that  feeling  so  instantaneously  and  so  vividly,  that most
unprofessional persons  conceive  that it  is this very feeling which
constitutes the essence of the disease.  It is much more distressing
than pain ; the mere restlessness  which accompanies  and forms so
large a part of it,  any one would gladly  exchange for intense pain.
In all diseases it is this which makes the sufferer on  his midnight
pillow  exclaim,  "O! that it were morning!"  and,  in the  day,
" would that it were night!"  To  this feeling, also, we may  add the
pain experienced in the back and limbs.  The headache so generally
present in fever is commonly a symptom merely of the general ner-
vous derangement, although at other times dependent on dangerous
inflammatory action  within the  cranium.   The sensorial  powers
are  always affected ;  and  we have every variety present, from slight
confusion of thought to delirium or complete aberration of the mental
faculties.
  In the inflammatory or sthenic form of fever, the nervous symp-
toms are less prevalent; while in the typhoid or asthenic, they con-
stitute the most prominent feature.  So much is this the  case  that
the  latter  variety  is not unfrequently denominated nervous fever.
The delirium observed  in fever  usually appears under two forms
—the delirium ferox or vehement species—and the delirium mite
typhomania, or low muttering ; the first accompanying the sthenic^
the  second, the asthenic type.   It is from this symptom of asthenic
fever that the word typhus is originally derived, TV<pot, literally
meaning stupor.  The functions of the nervous system in reference
to the muscular  powers  of the body,  are likewise'remarkably
affected.   Cullen has noticed this fact, in his definition of the pros-
tration of strength, by the expression " viribus artuum prcesertim 
         CONSTITUTIONAL EFFECTS OF INFLAMMATION.      71

imminutis ;" and, as a symptom of fever, it holds a very prominent
place in the  more severe forms of typhus.  In connection with this
symptom, also, we have the tremour  of the tongue and limbs, and
the subsultus tendinum.   In the inflammatory fever, the  pre-
monitory signs depending on derangement of the nervous system
are much less  distinctly marked,  indeed often entirely wanting;
there is a preternatural exaltation of the powers of the system, and
the muscular energy appears for a time to be increased.
  The next  system affected, and that probably, too, in the order of
occurrence, is the circulating.  A preternatural frequency of pulse
is one of the most prominent symptoms of fever.  We have already
hinted  that this is not always  nor  necessarily present, as there are
cases  which, from  the  other  signs, must be  regarded as febrile,
where the pulse is either  not accelerated  or is slower than natural.
In that form of fever,  the description of which we have  more par-
ticularly in view, the pulse is almost always  preternaturally quick.
Quickness of pulse, it will  be recollected, is, to a certain extent,
only a relative term, and bears reference  to the  usual number of
pulsations in the individual when in health.  For example, in  a
young person the pulse may be  habitually from eighty to eighty-
five in a minute ; but, in an  old  person, whose  natural standard
does not exceed  sixty or  sixty-five, this would be regarded as an
increased acceleration-.  Reference must  also be made to the idio-
syncracy of  the individual.   In  speaking of the pulse, we  may
observe that not only  the number but likewise the character of the
pulsations must be carefully noted.   In the commencement of fever,
or in what is called the cold stage, the pulse  is weak, quick, and
generally irregular.   As this stage subsides, and  the  warm ap-
proaches, the pulse acquires a fuller, harder, and more bounding
character, and may continue so till  a solution of the fever takes
place.   The pulse, however, is not always full and strong, it some-
times continues weak or becomes so, and this is one of the distinctive
marks between fever of an inflammatory or of a typhoid type.  The
sthenic variety is usually characterised by a full, hard, or bounding
pulse; the asthenic, on the  other  hand,  exhibits  the  small, weak,
although sometimes sharp pulse.  It is not our business to discuss
the varieties of the pulse or their  causes, we shall merely observe
that we measure its strength or weakness by the quantity of blood
circulating  through the vessel, and  the greater or less pressure
required to  suspend the pulsation.  Both these conditions, again,
may be coupled with,  or occur without, that peculiar state—difficult
to express in words, but easily remembered when once felt—to
which the terms sharpness, hardness, or wiriness have been applied.
   Connected with  the derangement occurring in the circulating
system, we  may notice  the difference of temperature observed in
fever.   As there is reason to  believe1  that the generation of heat
is chiefly dependent  on the function  of the  circulation and the
1 See Local Symptoms—Animal Heat. 
72           MORGAN'S PRINCIPLES OF SURGERY.
changes going forward in  the  mass of blood, it is natural enough
to expect,  that  an alteration in the animal temperature will be
effected.  A good deal of variety exists in this symptom; but, even
even at the highest,  the absolute temperature is not so great as we
might be led, from the feelings of the patient, to expect.  In order
to measure the degree of heat, the thermometer should be applied
to the  arm-pit,  or under the tongue, and, when the observation  is
made in this way, it will be seldom  found  to exceed  107° F.  In
some species of fevers, as the exanthemata, the heat will be as high
as 112°; but, in common fever, the rise of temperature seldom goes
beyond 7°, assuming  100° as the natural standard.
  Amongst the derangements, also, exhibited  by the circulating
system, we  ought to mention the regular  distributions of blood
which  so frequently  take place, and which have been  described by
pathologists under the name of determinations.  These, in common
fever, are  observed to occur in some of the great cavities of the
body, and demand particular  attention, both from the symptoms
immediately arising  from  them, as well as the  tendency to inflam-
matory action  thereby induced.   Probably  nothing is so common,
during the progress of fever, as irregular supplies of blood to dif-
ferent organs, and nothing we know of predisposes more to  local
complications; but such determinations are met with principally in
idiopathic  fever, and not  in that variety connected  with inflam-
mation.
  The most important change, in  the system we are now speaking
of, remains to  be  noticed—the alteration in  the character and pro-
perties in  the  circulating mass, so conspicuously seen  in sthenic
or inflammatory fever.  In point of importance, we may look upon
the derangement  in the  blood  and its circulation as paramount;
and by many we should not be thought to err, were we to attribute
to them all the other changes which arise  in fever.  When  blood,
drawn during  inflammation, has coagulated, its surface, instead  of
presenting  the  usual florid or scarlet hue, is found covered with a
white,  opaque, adhesive  matter,  strongly  resembling coagulated
albumen.   To this appearance has been given  the  name  of the
buffy coat, the crusta coriacea of some authors.  The immediate
cause of this change is the precipitation of the  red globules to the
bottom of  the  vessel, and  by which the fibrin or lymph above is
deprived of its  colouring matter.   When the surface  of the
coagulum is rendered hollow or concave, the blood is then said  to
be  cupped ;  and in addition  to  this,  we often  find  its  edges
puckered or fringed.
   The buffy coat of the blood varies in thickness from a line  to
one or two inches, supposing the fluid to have been received into a
common tea-cup.  The coagulum, when divided from above down-
wards, resembles  nearly the section of an egg, with the small end
of the oval placed uppermost.  It is much more dense and  firm
than  the  coagulum  of  ordinary  blood, the density and cupped
appearance being usually  in proportion to the  intensity of the 
CONSTITUTIONAL EFFECTS OF INFLAMMATION.
73
inflammatory action, and the strength of the constitution.  These
phenomena are more conspicuous in some cases than others, and
particularly where  lymph  has not been effused  as  a  product of
inflammation.   In consequence of the unusual firmness with which
the particles of the buffy coat cohere, the serum is more effectua ly
squeezed out; hence the coagulum appears proportionally smaller
from the quantity  of serous  fluid  with which it is surrounded.
There is, however,  no increase in the quantity of serum;  there is
only a  more complete contraction of  the  clot.   When  blood  is
slightly buffed, or, as  it has bsen termed, sizy, the serum appears
less in  quantity from being detained  within  the mass,  while  in
reality it is increased.                           ,     .  .
   When the coao-ulum of inflamed blood  is examined, it is  touncl
to  consist of  pure  fibrin,  containing a small quantity of serum.
 The late Mr. Thackrah1 considers the buffy  coat as a network ot
 fibrin, enclosing a portion of serum, and has shown experimentally
 that it is made up of 18 per cent, of dry solid fibrin, 2b per cent ot
 dry solid matter from the  serum, and 56 per cent, of water.   1 he
 dry solid matter to which he refers is albumen, always  found in
 much greater quantity in  the serum of inflamed than in that ot
 healthy blood.  No two analyses of the buffy  coat will be found to
 ao-ree • for the proportions of  the blood in diseases vary in different
 individuals, and in the same individual  at different times, in tne
 same way  as  they do in a state of health.  It has been supposed
 that only venous blood, when drawn, puts on the  buffy appearance,
 and this has  been  assigned as a reason why, in  certain  cases  the
 crusta coriacea is wanting; but Dr. Tweedie has seen blood taken
 from the temporal  artery buffed  and cupped  in two separate
 instances;  one where the  patient laboured under inflammation of
 the chest the other where  the cerebrum was affected during fever ,
 and the same thing has been  observed by Gendrin, and by the late

 D^rmS,ficSlbU^ which the blood  seems  m undergo in
  inflammatory fever,  consists in an increase  ot  ts  fibrin and the
  aniZl mattL contained in the serum.  Gendrin  has very minutely
  detTed die appearances presented by the blood  under the different
  van^ of Xilnotionfand the -lative  proportions which  he

  crassamentum and  the serum bear Xo/^^r^tt^ne^
  inflammation the buffy coat is firm and elastic, of great  thickness,
  ^ndch cupped ■  the whole of the serum is nearly  squeezed out,
  ad ipoint of volume, the clot appears to this  fluid  as one to one
  ana in Pomi                   ltl some caseSj the  proportion of
  sen,n,' I  .«s\Zr.h.Tr.^.men..™, the latter  adhenngto  ■he
  seium ib  ic                form of a truncated cone.   tiom the
  finTZ me ion o   the  oagnTl, however, the serum generally
  i™ s n o e  ab ndaIlt lha„1t really is, and, in sneh eases, appears
  usua IV co ourless and free of red matter, even m the lower part of
» See his excellent Essay on the Blood. 
74            MORGAN'S PRINCIPLES OF SURGERY.

the cup.  In less vehement inflammation, the buffy coat is cylin-
drical in shape, does  not  extend so deeply, and is not so strongly
cupped;  while the serum equals twice the volume of coagulum.
In subacute inflammation, the blood presents  the  sizy appearance
merely; the buffy coat extends only one or two lines in depth, and
is  of "less density and slightly ovoid; the serum, which at least
equals twice the volume of conguIum, is viscid and  limpid  above,
but reddish at the bottom of the vessel, from the precipitation of
the coloured  globules.  These phenomena are varied according to
the seat and intensity of the inflammatory action, and many other
modifications might, no doubt, be described.
  The change effected in  the circulating  fluid has been a subject
of keen discussion among pathologists.  The immediate cause of
it is a more complete  separation of the serum, and a precipitation
of the red globules, leaving the colourless  fibrin contracted into a
firm dense  mass; the remote cause is involved in much obscurity.
The coloured  particles being found to be specifically heavier than
the other ingredients of the blood; and it having  been observed that
the time, in general, required by buffed blood to coagulate exceeds
that of healthy, it naturally occurred  that the appearance in ques-
tion  depended on  the mechanical  separation of  the red globules
merely from their greater density,  just as sand and water separate
after being agitated together.   The circumstance of slower coagu-
lation, we may simply remark, is not  found to be an uniform ante-
cedent to the  formation of the buffy coat; neither does it appear,
even  were  it  so,  to   afford  a sufficient explanation of the other
phenomena accompanying the process.   Gendrin maintains that
coagulation commences sooner, and is more speedily completed in
inflamed than  in healthy blood, and with a rapidity proportional to
the quantity of the buffy coat.  The  same thing  has been amply
proved by  Dr. Stokes,1  and may be witnessed by any one in the
ordinary routine of practice.   It has been also imagined that the
colouring matter,  as  well  as the serum, are squeezed  out, by the
fibrin contracting and cohering with greater force than in health ;
but this is stating  the effect without assigning the cause.
  It is scarcely possible  to give any  explanation of the formation
of the buffy coat till the cause of coagulation  in healthy blood has
been first agreed upon.  The fluidity of the blood while circulating
in the vessels, and its  coagulation or  spontaneous separation when
withdrawn from  the  body,  are  circumstances which cannot be
explained by any chemical or mechanical agency;  and, perhaps,
we commit the least error by regarding them as ultimate  facts in
the  animal economy.  Neither heat or  cold, rest or agitation,
although all exerting an influence  over the time in which coao-ula-
tion  takes  place,  have any other  share in the process whatever.
Nor,  as  Sir  Charles Scudamore2 has attempted to  show  does
coagulation depend on the escape of carbonic acid.  If we surround
1 Pathological Observations.
Essay on the Blood. 
CONSTITUTIONAL EFFECTS OF INFLAMMATION.
75
a portion of blood with an  atmosphere of carbonic acid, its upper
surface is merely prevented  from assuming a florid colour;  we do
not, in the slightest degree, retard coagulation.  If we place blood
in the receiver of an air-pump, and exhaust the air, by  which the
escape of  carbonic acid would be  abundantly favoured, we do not
cause more speedy coagulation.  We have also sufficient chemical
authority  for denying that carbonic acid makes its escape in such
quantity as to  account either for the  celerity or tardiness with
which the separation takes place.
   Mr.  Thnckrah has concluded,  from  his own  experiments and
those of  Sir  Astley Cooper, that the  coagulation  of blood,  under
ordinary circumstances, depends principally on its separation from
the living vessels; and that its remaining fluid, in cases of sudden
death,  where the nervous  energy over the body is destroyed, arises
from its  vitality not being  extinguished.  In such instances,  the
blood remains fluid for several  hours, and then slowly coagulates
after being removed.   There  is a natural tendency in the fibrin to
coagulate, and which is prevented, no  doubt, by its motion in the
vessels; but that a certain vital relation between these is established,
is apparent  from the fact  that blood coagulates speedily in a dead
vessel, while it  remains fluid for some hours when enclosed be-
tween two  ligatures in the living body.  It was these, and such
like phenomena, which led  Hunter to speak of the life of the blood,
understanding  the word life to imply a series of changes, unlike
those which take place in unorganised matter.  In the same man-
ner, we may state, that there  is a  vital relation subsisting between
the fibrin and the colouring matter, and which undergoes alteration
in disease.   We cannot attribute the formation of the buffy  coat to
any of the circumstances attending  ordinary coagulation ; neither
can we ascribe it to the fibrin  being thinner, as has been presumed;
for we find that, when  the  separation  has taken  place,  the mass is
unusually firm, and coheres with greater strength,  There seems,
 indeed, to be a repulsion exerted between the colouring portion and
the fibrin, or, at least, there is an  unusal tendency to separation in
 those cases where the buff appears.   Two circumstances observed
 during the process of coagulation, lead to this conclusion, and we
 may give them  in the  words of Dr. Alison.1   » First, the formation
 of the buffv coat (though  no doubt favoured or rendered more com-
 plete by  slow coagulation,) is often observed in  cases where the
 coagulation  is more rapid than usual; and the colouring matter is
 eveu observed to retire from the surface of the fluid, in such cases,
 before any coagulation has commenced.  Secondly, the separation
 of the fihrin from the  colouring matter, in such  cases, takes place
 in films of  blood so thin  as not to admit of a stratum of the  one
 beino- laid above the other ; they separate from each other laterally,
 and'the  films  acquire a speckled or  mottled appearance equally
 characteristic of the state of the blood as the buffy coat itself.'
1 Outlines of Physiology. 
76            morgan's principles of surgery.

  Admitting, which we freely do, our inability to explain the man-
ner in  which  the buffy coat is  formed,  it  becomes an  interesting
question  how  to  account for its presence.  This is a point still
uninvestigated by pathologists.   Mr. Thackrah represents the fibrin,
which  in a state of health goes to  repair  the muscular and other
fibrinous tissues, to  be increased from more extensive  formations,
and especially from the occurrence of adhesive inflammation.   To
this we reply, that, in  cases where lymph  is thrown freely out on
the surface "of membranes, as  in inflammatory affections of  the
pleura  or peritoneum,  the buffy coat  is less firm and  copious than
in those where no albuminous matter is secreted, as in rheumatism.
It might hence be inferred that the presence of the buffy coat in the
blood was to be ascribed to the suspension of the process of nutri-
tion, rather than to any increased formation of fibrin.  But, although
the density and abundance of the buffy coat may be augmented, in
cases where no fibrin  is thrown out as an effect of acute inflamma-
tion, as in rheumatism, and lessened in others where this  takes
place, as  on the surface  of serous tissues, there are several facts
which  lead us to the belief, that this change in the blood  precedes
any suspension of the process of nutrition, and  is effected by some
vital action of the coats of the vessels. In  individuals of sanguine-
ous  plethora,  as  proved by the observations  of Ratier and Bel-
homme, and in persons in the habit of being bled, we have seen the
inflammatory appearances assumed by the  blood, although no local
action had been established; and it is  this change in the composition
of the mass which, in  these instances, so  frequently leads to disease.
It is well  known, also, that, during  the period of pregnancy, the
buffy coat is exhibited in the blood, and  here the process  of nutri-
tion  is  certainly not suspended.  Again, the sudden transitions in
the mass of blood, show that the vessels  have some power in  modi-
fying the composition of that fluid.   We thus observe that, during
blood-letting, where the stream is equable and every other circum-
stance  favourable, the first cup contains more fibrin than the second,
and the second than  the third; and this  change is  usually com-
mensurate with the amendment of the patient.   Rapidity of coagu-
lation,  as Mr. Thackrah  has observed, is in the inverse  ratio of the
quantity of blood left in  the vessels; for of quantities,  drawn suc-
cessively under the same circumstances  and from the same indivi-
dual, those taken last coagulate in  the  shortest time.  The short
period in which coagulation takes place  being generally considered
unfavourable to the development of the  buffy coat, rnio-ht be pre-
sumed sufficient to explain the difference between the first and last
cups of blood drawn in inflammation.  We may remark however
that rapidity of coagulation is  chiefly exhibited in animals losing
large quantities of blood, or in  those perishing from hemorrhage
and  does not apply to cases of ordinary blood-lettino- in the human
subject.  We  have, moreover, direct testimony1  that buffed  blood

    1 See Gendiin's Treatise, and Stakes' Pathological Observations. 
constitutional effects of inflammation.
77
coagulates in less time  than healthy ;  and to this we may add the
fact that the quantity  of fibrin in the second or third vessel, as
".ompared to the first,'is diminished—showing a real change in the
amount of the solid contents.
  Mr. Thackrah has further represented  the phenomenon of the
buffy coat  to  be commonly, though  not  always, connected with
rapidity of circulation, and has inferred that, wherever  there is a
sudden acceleration of the circulation, there will be an equally sud-
den production of size.   The blood of the horse thus occasionally
exhibits the buffy coat immediately after a  hard gallop, as, in such
a case, the contractions of  the heart are very rapid.   But there are
many cases of inflammation, and especially of the substance of the
brain, where the buffy coat is  very dense  and  constant, and where
the pulse falls even  below the natural standard; and, as has been
ably observed, it would be requisite, first, to establish the proposition
that, when the heart contracts one hundred and twenty times in a
minute,  it  expels  from its chambers the same quantity of blood
which it does when it contracts only sixty or seventy times.  There
is, indeed, no ground for believing that, at each of the numerous
sudden contractions, the heart throws out the same amount of blood
 as it does in its more tardy and natural mode of acting;  but, on the
 contrary, there is reason to believe  that  it expels a much smaller
 measure, and it might be shown that, though  the  heart contracts
 with preternatural frequency, the blood in reality moves much more
 slowly than  natural.1  It is  by no  means, however, proved  that
 accelerated or  slower motion of the blood is  connected with the
 phenomenon of the buffy coat; and  it seems probable, as far as we
 can iudo-e, that it can  take place  during the presence or absence ot
 either  B\Ve  are  inclined to  attribute the formation of the buffy
 coat to some vital action of the coats of the vessels.   We think the
 sudden transitions in the  mass of blood are best explained by the
 increase or loss of vital power in the vessels and over the system at
 laru-e • first, because these changes vary with the state of  the con-
 stitution as to strength  or otherwise; secondly,  because  they are
 best seen where debility becomes manifest, and not where bleeding
 is borne well; and, thirdly, because, as Gendrin  has found, blood
 drawn in  recovery induced by syncope, has not only lost its inflam-
 matory character, but the clot is also softer.
    The changes  thus effected  in  the circulating  mass appear to
  const  ,to  a lecessary and essential part of the process of inflam-
  mation whch, when complete, may be described as made up of a
  Scil  'rotate both of the solids and  fluids.  But although we have
  £'ld that, in  individuals of plethoric habit, the buffy coat is occa-
  sio ,\mv exhibited, and seems, when present, often to lead to  local
   o plicXns, there are reasons for  believing  that the changes  in-
  du ed  in the blood are, in general, only secondary, and caused by
  me previous  morbid incited action of the vessels. Of these the

    i See Review of Thackrah in Edinburgh Medical and  Surgical Journal,
  July, 1835. 
78           morgan's principles of surgery.

following may be adduced.—First, there are many cases where the
buffy coat  is wanting, and others where it only appears to a slight
extent compared to the local symptoms.  Secondly, when the pro-
cess of inflammation in the transparent parts  of an animal is
watched with the microscope, the earliest changes seen consist in
an increased action of the vessels; and it is not till the local disor-
der has lasted for some time and reached a certain stage, that the
alteration in the mass of blood takes place.  Thirdly, if inflamma-
tion depended on the changes induced previously in the blood, and
not on  the incited  action of the vessels, it should  commence and
continue so long as  the former state remained ; whereas the general
rule is, that it  subsides  as  soon as relief is given  to the  local dis-
order.  Fourthly, in many cases inflammatory action declines spon-
taneously after it has been  fairly established, as we witness in ex-
periments on  animals, and  in the greater  number of  these the
alteration in the mass of blood has not commenced.  Fifthly, inflam-
mation is often the result of violence done to a part, and wherein it
is  clearly shown, by the symptoms which ensue, that the buffy coat
follows  the  incited action of the vessels.  Sixthly,  inflammation
arises in habits the very opposite to  the sanguineous, and where
there  is  rather a deficiency than an excess of fibrin in the blood;
moreover, the buffy coat is  found,  as we  shall presently see,  in
cases  where  no particular local  disorder is present ; and from
which cause it has been too hastily set down as no indication of
inflammation.  For these reasons we view, with the exception we
have  mentioned, the formation of the buffy coat as consequent to
the change of action in the vessels ; and we farther consider it as a
strong proof of the vital relation subsisting between the latter and
the mass of blood.
   There are  several contingent circumstances which  have an
influence over the formation  of the buffy coat in blood drawn from
the body, and which require,  therefore, to be  taken into account
before judging of it as a sign of inflammatory fever ;  these, how-
ever,  are so  uniformly  adverted  to, in all elementary works on
physiology, that it is needless to discuss them  here at  any length.
Thus, the buffy coat is  best exhibited when the blood is received
into a vessel of ordinary depth, as a tea-cup, and  then  allowed to
remain  at rest till  the coagulation is  complete;  when blood is col-
lected in a broad flat vessel, or kept in a state of agitation for some
minutes after it is  drawn, no separation of the colouring matter
takes  place, even although intense inflammation should be present.
The greater the rapidity with which the blood  flows from the ori-
fice in the vein, and the less the distance which  it has to fall  into
the receiving vessel, favour the formation of the buffy coat; on the
contrary, when the blood trickles slowly from the arm, or is allowed
to fall from a height of three or four feet, no buffy  appearance will
be indicated.  The size of the opening  made in the vein, and the
rapidity with which the  blood flows,  frequently cause  one cup to
be more buffed than the others;  and, when the last cup has  this 
constitutional effects of inflammation.
79
appearance and not the  first, it will be generally found owing to
the blood having trickled away at the commencement.  The degree
of temperature maintained during coagulation is likewise worthy of
notice;  thus, extreme cold, as seen  by surrounding the blood with
a frigorific mixture, prevents the formation of the buffy coat.  The
addition of certain substances, as caustic  potash, prevents  also the
separation of the colouring matter;  but these can never operate in
an accidental way.
   Peculiar states of the constitution give rise to the same alteration
in  the mass of blood  as is observed in inflammation.   Thus, it is
found in pregnancy, in sanguineous plethora, and  in  individuals
under  the  influence of mercury; it has  been  seen also  in scurvy,
and in hysteria where the circulation is rapid.   Neither is  the den-
sity or abundance of the  buffy coat any indication of the danger to
be apprehended ; because, as already stated, it  is more conspicuous
in inflammation of  some fibrinous tissues, as in rheumatism, than
where the substance of organs is the seat of disease; and  because,
in other cases, it is either wanting, or out of all proportion to  the
existing symptoms.  These considerations, while they deter us from
regarding  the  buffy coat as a positive indication either of the pre-
sence or intensity of inflammation, point  out, at the  same time, the
impropriety of abstaining from repeated  blood-letting, where other
circumstances combine "to render it  necessary.  On  these points
 more  ingenuity than sound  reasoning  has been displayed;  for
where due attention is paid to the influence of adventitious causes,
 we must  be permitted humbly to say, that our own  experience has
 led us to look on the buffy coat as a valuable,  though  certainly not
 an unequivocal, sign of  inflammation.
    Now, this condition of the blood is only observed in fever of the
 inflammatory or sthenic type, and contrasted with it, we  have the
 appearances presented in the opposite  form of the disease.   In
 typhoid or asthenic fever, complicated with  local inflammation, the
 blood either remains  natural, or,  when it has coagulated, resembles
 a mass of dark red jelly.  In  some of these cases,  as the fever
 assumes more of the sthenic variety, the  blood shows a tendency to
 form the buffy coat, a fact which, we think, forcibly points out the
 vital relation subsisting between the  vessels  and the fluid which
 moves within them.  In extreme instances of typhod fever, without
 any apparent  local complication, blood, when imprudently drawn,
 shows little tendency to coagulate, and seems almost destitute  of
 fibrin ; when coagulation has taken place, the mass is soft and of a
 greenish  or slightly yellowish  hue, the serum is turbid, and the
 whole  has a dissolved appearance, with  an unusual disposition to
 putrescency.                                               ,  .
    We have taken a brief survey of the  derangement  observed  in
 the two great systems—the nervous and  the circulating.  The
 other functions of  the body, dependent, as physiology demonstrates
 to us  on one or both of these, are likewise affected; and it is neces-
 sary that we should run over the principal of them shortly.  Tne 
80 "          morgan's principles of surgery.

organs  connected with  the function of digestion are prominently
disordered in  all febrile diseases.  The tongue is furred, and the
appearance of this organ is  generally characteristic of the type of
the fever.  In the inflammatory variety, the tongue is covered with
a yellowish or whitish fur, principally occupying the sides, middle,
and back part of the organ ; in the typhoid  form, the tongue is dry
and glazed, often enveloped in a thick dark crust, and the lips and
teeth  covered  with black  sordes.  As  the  febrile disturbance de-
clines, the  fur or crust on the tongue separates, leaving the organ
again in its natural  state.  The condition of the tongue is  often
erroneously considered as an index to that of the stomach, and for
this no  other reason  is  assigned than  the respondence sometimes
observed between them.   The tongue has no more particular con-
nection  with the stomach  than with  any other part of the alimen-
tary canal, and this merely because it is lined  by a continuation of
the same mucous membrane.   If the state of the tongue was an
index at ail times to that of the stomach, every disorder of the one
should affect the other;  but there are many instances where this is
wanting.  Emetics have no effect in disordering the tongue, neither
in many dyspeptic cases, is there any  alteration in this organ.  The
tongue,  on the other hand, is frequently furred in diseases in which
the stomach is not implicated, or in which  its function may be only
impaired in common with that of other organs.  Furred  tongue is
generally the  sign of febrile  disturbance in the system  in which
derangement the stomach likewise partakes, for the desire of food is
wanting, and the digestion impaired  ; but  the fever is the cause of
the disorder in  the one organ as well  as in the other.   This is  a
point of great practical importance,  as leading to a  more rational
method of treatment,  and especially in cases of dyspepsia, where
patients are made to swallow  tonic and bitter remedies without dis-
crimination.
   The  functions of  the intestinal canal are  always deranged in
fever, the secretions are vitiated, constipation or diarrhsea is present,
or alternates with each other.   We abstain from saying  any thing
farther  here, as to the frequent  existence  of inflammatory disease
within the abdomen, or  ulceration of the mucous membrane as the
cause of fever, because such  is confined to  the idiopathic variety,
and does not occur in that form which it is our business  at present
to  investigate.    The different secretions  and excretions  are all
more, or less  altered.   The  urine is diminished in quantity and
high  coloured, and  deposits a  lateritious  sediment as  the  fever
declines.   The perspiration  is suspended, and  the skin is hot and
dry.  To the same deranged  state of the mucous membrane of the
tongue  and fauces we ascribe the thirst which  harasses the patient,
and forms so distressing a part of his disease ; and we observe that,
as the  tongue becomes hard and dry, so is  the desire  for  drink
generally increased.   The secretion  from the liver is also vitiat< d,
being sometimes increased, at other times  diminished.  The respi-
ratory function is usually disordered ; the breathing is either quick 
constitutional effects of inflammation.
SI
or slow and laborious, and frequently, from accidental complication,
we have  cough.   The more frequent inspirations and expirations,
when independent of local  inflammatory action within the chest,
are simply owing to the increased rapidity of the circulation creating
a necessity for fresh  air.  All these derangements in  the nervous
and circulating systems, and in the functions dependent on them,
as the  secernent, digestive, and respiratory, are to  be  found, more
or less, in every case of fever.  It is not necessary that they should
be all present with the same degree of severity, for this varies in
individual cases, and according,"too, with the type or variety of the
fever;  but, making every  allowance for these shades of difference,
more easily  remarked than  explained,  we consider the febrile con-
dition  denoted by the disturbance in the healthy functions we have
now pointed out.   Were  we treating of continued fever as a part
of the practice of physic, we would detail more  minutely its dif-
ferent  forms ; we would speak of the  various morbid appearances
discovered after death ; we  would enter into the reasonings about
its various causes ; we would describe its different stages or periods,
as that of invasion, formation, and decline ; and we would discuss
the  doctrine of  crisis  or  critical  days.   But all this, however
interesting and necessary  to be known, is quite foreign to our pre-
sent purpose, and  we accordingly proceed to state the c onnection
between  fever and local inflammation.
   When considering the local symptoms of inflammation we stated
that their severity depended on  several causes, as  the intensity of
the morbid  action, the structure  affected, and  the  idiosyncracy of
the patient.  Now, should these symptoms occur to any extent, or
should inflammation be  established with any marked degree of
severity, we find that, in  a  short time, the phenomena of fever are
observed.   If the local disturbance is moderate, the  only  striking
febrile symptoms may be  heat of skin,  quick pulse, increat-ed thirst,
and furred  tongue.  The degree of fever is usually proportioned to
the severity of the local affection, but it is  likewise.materially modi-
fied, as we  shall  presently see, according  to  the structure and  im-
portance of the part which  appears to  be the seat of disease.  This
is a valuable pathological fact, as frequently the only satisfactory
proof of the existence  of  inflammation, which, from being internal,
cannot be seen, is the  concomitance of well-marked febrile symp-
toms with disordered function.  We accordingly find  that Cullen
has commenced his definition of the phlegmasia, or inflammations,
with "febris synocha," that is, inflammatory fever; but the defini-
tion is incorrect,  in as far as the variety of fever understood by the
term synocha, only occurs in  certain cases.
   We have endeavoured, as  we went along, to point  out  the  dis-
 tinction  of febrile diseases into inflammatory and typhoid,  in order
 that we  mi^ht  be able, at  this period,  to state  more freely the fol-
 lowing  fact! namely, that certain inflammations are  accompanied
by stlfenic, and others by asthenic fever   Ot the  former kind are,
 inflammatory affections of the serous aud fiurous tissues; of the lat-
   12_c                                        mZn 6 
82            morgan's principles of surgery.
ter, those of the cellular, mucous, and cutaneous.  This appears to
us a very extraordinary circumstance, and one  concerning w,»c«j
no just explanation can be given; it  is, at present, to  be  regarded
as an ultimate fact in pathology—an original law  of our constitution,
to which we must attend particularly when investigating morbid
action.  Of the necessity or  importance  of watching the constitu-
tional symptoms induced by  inflammation, we may slate, that these
as frequently prove fatal as  the local disease itself; and  the  fatal
event is to be attributed to the depressing effect produced on the
heart, or, in less ambiguous terms, to the strongly-marked typhoid
character of the fever."   Acute inflammation  of  the intestines may
thus prove destructive within three or four days, and that of the  peri-
condium and heart, in less than twelve hours from the commence-
ment of the attack, and. in either, before any change of structure or
local cause of death has ensued ;  hence, inflammation may be fatal,
merely from the effects  it is capable of producing in the system.
Many other instances might be given, but it is needless to multiply
examples of what a very little attention to the phenomena of disease
will soon render familiar.
  By what law, then, or in what way does  febrile action arise in
the  constitution from the presence of local inflammation? It being
universally admitted that inflammation  has a tendency to spread
from one part to another, and especially to textures of  a  nature
similar to that in which the action commenced, it has been inferred,
that the morbid condition of the blood-vessels is propagated along
their tunics, until the whole  of the circulating system is ultimately
involved.   There are,  however, strong  reasons for believing that
the nervous system is very much concerned in producing the phe-
nomena in question ; and the following  arguments may be stated
in confirmation of this  opinion :—First, febrile action is peculiar to
organised  beings with nervous systems;  the diseases of vegetables
are purely local.   Secondly, we find the fever to  be  more particu-
larly developed-and more readily induced in  individuals in whom
the nervous system is known from  other circumstances to be most
prominently susceptible ;  hence, we observe different degrees of
constitutional disturbance following the  same amount of local in-
flammation  in  different habits.   Thirdly, the  suddenness of the
febrile attack is more like the effect of some nervous sympathy than
the  gradual spreading of disease ;  moreover,  we have  all  parts
simultaneously affected, and not those first that are contiguous to
the inflamed organ.  Fourthly, the  degree  of the fever is not pro-
portioned to the degree of the inflammation without reference to the
part inflamed ;  some structures cause more  constitutional disturb-
ance than others, although the intensity of the inflammatory action
is equal or even less, and these we find to be connected to the rest
of  the  system  by the  greater number of sympathies.  Lastly, in
inducing inflammation for the purpose of experiment, we observe
that the first action of  a stimulus is on the nerves of the local part,
whereby pain is produced, and that from this increased sensibility 
constitutional effects of inflammation.
83
all the other  phenomena seem to ensue.  It  appears, indeed, that
the fact of febrile symptoms being established, identifies itself with
many others, both in  physiology and pathology, which are said to
be sympathetic ;  and  this is  the most  satisfactory explanation we
can offer of their  mode of origin.
   In considering the nature of the febrile action set up in the con-
stitution by inflammation, the question  has  been agitated, Whether
the fever is the cause, the concomitant, or the consequence of the
local disease? The occurrence of febrile symptoms in some cases,
as in measles, scarlatina,  or the other exanthemata, previous to any
local affection, is no adequrte reason for assuming that the fever is
the cause ol the  inflammation ; for  these eruptive complaints are
different in their origin, nature, and  progress, from ordinary inflam-
matory diseases.   Again,  the frequent observation of marks of
inflammation, in  persons dying of fever, has  led some pathologists
to conclude that  this latter affection never occurs without an ante-
cedent, whether we can  trace it or not; and, to a doctrine of this
kind, as formerly stated,  we  find attached names  of the highest
respectability, such as  Clutterbuck  in  this  country, and Broussais
in France, each of whom has fixed  upon a different region of the
body as the seat of disorder.
   The assemblage of symptoms manifested in the system from the
presence of  inflammation, we  in general denominate the  sympto-
matic fever—in contra-distinction to that which  arises without any
cognisable antecedent or local affection, in  the language of Cullen
 " sine morbo locali pri?nario," and  which  has hence been named
idiopathic.  It has been said  that the word  symptomatic or sympa-
 thetic, as used to point  out  the fever created by inflammation, is
 misapplied, in as far as it is doubtful whether  the local disease gives
 rise to the constitutional disturbance, or whether the latter does not
 take  the precedence of the former.  Nay,  farther, Dr. Southwood
 Smith refuses to apply the term fever, even qualified by the word
 symptomatic, to the constitutional symptoms in such cases ; because
 he considers that there only  can exist  idiopathic fevers, and that to
 denote both by  the  same name is giving rise  to a  confusion of
 terms.  " Febrile diseases," says he,1 "are commonly divided into
 idiopathic and symptomatic, a division which is  liable to the fun-
 damental objection that  the diseases included in the second section
 are not fevers, but inflammations.  There are no fevers but idiopathic
 fevers "  He adds, that  the order in which the symptoms appear,
 and even the phenomena themselves, are different; and that there-
 fore, " to call both by the same name  can  only produce confusion
 and misconception."
    There are certainly  many circumstances connected with  idio-
 pathic and symptomatic fevers, which point  out a remarkable dif-
 ference between them, and which cannot be denied by the boldest
 opposer of this doctrine; yet the difference does not seem to depend

                        1 Treatise on Fever.
                                                 mgn 6* 
84            morgan's principles of surgery.
so much on the symptoms present in either case, as on the nature
and operation of the cause from which they more immediately pro-
ceed.  If there is a point in practical medicine about which we are
satisfied, it is that of the frequent existence of idiopathic fever with-
out any local complication ; and we shall  just allude to a few cir-
cumstances which entitle us to consider fever as arising from other
causes than inflammation.  First, there  is the occurrence of fatal
cases of  fever without  our being able to  detect any local cause.
Secondly, nervous symptoms are often present to a much greater
and more alarming extent than  we ever see in fever which is evi-
dently symptomatic.   Thirdly,  we find  in idiopathic fever a ten-
dency to a spontaneous termination, and which  is rarely observed
in inflammation.  Fourthly, when inflammation  does occur  at an
early period in  idiopathic  fever, we  find  that, although the local
affection has been subdued, the febrile symptoms continue, and pur-
sue a regular and  determinate course.   Fifthly, in cases where
inflammation has preceded the febrile attack, or where the latter
has been a consequence merely  of the  former, we observe that, on
the removal of the local cause, the fever speedily subsides.   Sixthly,
idiopathic fever often exists for a length  of time  without any local
disturbance being manifested, when, all at once towards its decline,
from some accidental circumstance, as exposure  to cold or the im-
prudent exhibition of stimulating food or drink,  inflammation will
arise in some local part, and the previous  symptoms then undergo
a corresponding  change.  Seventhly, the  effect  of the "juvantia
and loedentia" shows a remarkable and striking difference between
idiopathic and symptomatic fevers.  We witness, for  example, the
great  efficacy of  venesection, and the injurious effects of stimuli in
active local inflammation with fever; and  that, on the other  hand,
whenever the coexistence of inflammation with idiopathic fever
demands the use of  the lancet, one-half the evacuation will be suf-
ficient to subdue  it.  Moreover,  in common fever, the most decided
benefit is often derived from wine and other stimulants, even where
inflammatory action is going on  ; and, in some cases, it appears that
the only indication we have it  in our power to fulfil is to prevent
the pulse from sinking.
  For these reasons we conceive ourselves warranted in assuming
the doctrine that idiopathic fever does exist; and, farther, that it
may begin and terminate without any local affection being percep-
tible either at the commencement, or during any part, of its course.
Neither do we refuse to apply the term fever, qualified by the word
symptomatic, to  the effects produced by inflammation in  the con-
stitution.  There cannot be a doubt that  these  effects are febrile,
and the order of succession plainly points out that they are sympto-
matic of the local disease.  In all such cases we observe that,  while
the primary cause remains, the  fever continues; when  increased,
abated, or removed, the latter undergoes  a corresponding change;
and, in short, without the one  we are justified in saying  that the
other would not  have been present.  The argument of Dr. South- 
constitutional effects of inflammation.      85
wood Smith  has never, so far we know, been supported by any
respectable authority; it  is contrary to  every species of evidence
we possess, and a refinement, at  least, which the present state of
medical science will not permit us to appreciate.
   The symptomatic fever arising from local inflammation, particu-
larly that modification of it caused by local injuries,  has often been
described under the title of irritative—a phrase still more used when
the constitutional symptoms are of a typhoid kind.   The term irri-
tative, as applied to any variety of febrile disease, is objectionable,
because it does not point out the leading condition of the system, as
to whether the reaction is of the sthenic or asthenic order, and be-
cause it likewise involves an hypothesis respecting the origin of the
symptoms; when meant also to express the constitutional sympathy
occasioned by local injuries, it is equally objectionable, for, of what-
ever character that may be, whether inflammatory or typhoid, or a
combination of both, it is nothing more or less than  febrile disturb-
ance.  We do not mean  these observations to apply to the phrase
irritation used in a local sense, but only when meant to signify any
species or type of fever.   For instance, a decayed  tooth creating
ulcers about the cheeks, lips, or throat, or worms in  the alimentary
canal producing violent itching at the  nose  and grinding of the
teeth during sleep, are examples  of irritation arising from causes
which act locally, and are incapable or rather not sufficiently great
to excite the phenomena of fever; but these are very different from
the serious effects set up in the constitution, and which require and
ought to be more explicitly defined.
   Mr.  Hunter  first made use of the terms  universal and partial
sympathy to  express what we have considered under the head of
symptomatic fever and local irritation.  By the universal sympathy
is meant, when  the whole constitution sympathises with some sen-
sation or action of a pant; by  the partial, on  the other hand, when
one or more  parts sympathise with some local sensation or action.
These two states, the universal  and partial sympathy, may be
easily distinguished from each other  by the circumstance, that the
former is an  affection of the whole constitution, while the latter is
merely the sympathising of one local part with another.   Partial
sympathy was further divided by Mr. Hunter into three different
kinds—the  remote,  the  contiguous, and the  continuous.   The
remote sympathy is, where  there appears no visible connection of
parts to account for the peculiar effects which result;  as a decayed
tooth creatine an ulcer in an opposite part of the face, or the pain
felt at the rio-ht shoulder and down the arm in inflammation of the
liver   The'contiguous sympathy has been defined as that arising
from the contact of separate parts; thus those which are internal
often sympathise with those which are external, as  the  brain with
the scalp the  testicles with  the scrotum, <fcc.   The continuous
partial sympathy is  generally more extensive than either of the
others • here there is no interruption of texture, and the  morbid
action extends from a point or centre to any distance beyond.  The 
86            morgan's principles of surgery.
spreading of inflammation along  the surface  of  membranes or
the skin in erysipelas, affords the best illustration of this  form
of sympathetic  disease.  Such was Mr. Hunter's arrangement of
the phenomena of  sympathy, to which  many objections  might
now be offered.  In the present state  of our physiological know-
ledge, we can have little conception of this important process;  it
extends to the  condition of the mind as well  as  to  that of the
body, and involves some of the most mysterious laws of the nervous
system.
  The symptomatic fever from local inflammation varies, according
to the intensity of the disease, its seat, and the  habits or idiosyn-
cracy of the  patient.  It accords with what we should naturally
expect—that  the  more severe the inflammatory action,  the  more
intimately will the constitution sympathise with the part which  is
suffering.   There is a reciprocity of action existing among all the
functions of the animal economy, which, though unperceived, seems
necessary to  maintain  the balance of health;  and which, when
subverted or  disturbed, creates, as pathology teaches  us, more or
less extensive sympathy, according to the degree of derangement
prevailing.  Should an organ be affected with acute inflammation,
the local and  constitutional symptoms are better marked than when
the disease is  of a milder character; and  we accordingly find that
the presence  or absence, or degree of disturbance  in  the general
system,  is a diagnostic mark of  the intensity of  the morbid action.
We uniformly observe, however, that  the constitutional symptoms
bear a constant reference  to the structure and  importance of the
part affected;  and  hence inflammation  causes varieties  in the
symptomatic fever, according as it occupies different tissues.  The
serous, mucous, and fibrous structures give each of them origin to
a different  train of constitutional symptoms.   When  serous mem-
branes are the seat of acute inflammation, the fever is of the inflam-
matory or sthenic type; when mucous membranes are  affected, the
fever is  more  of the typhoid or asthenic order;  in inflammation of
some fibrous  tissues, as those placed  around the joints, the local
disease is not  only peculiar, in as far as it translates itself from one
part to another, but the symptomatic fever is remarkable for being
often accompanied  by diaphoresis throughout.   The remarkable
fact of  inflammation causing different varieties of constitutional
disturbance has never been satisfactorily explained; and it is best
for  us to express our ignorance, by referring it  to an  ori<nnal law
in our constitution.
  From the regularity with which these circumstances are observed,
a great dissimilarity  in the constitutional effects  prevails, when
inflammation is seated in  a containing and  in a  contained part.
Thus, the  symptoms are different when  the serous covering and
the proper tissue of the liver  are affected.   When  the membranes
of the brain  are  inflamed, the  symptomatic fever  runs hio-h the
pulse is quick and  bounding, there is a distressing sense of pain,
and generally wild delirium'.   On the other hand^when the sub' 
         CONSTITUTIONAL EFFECTS OF INFLAMMATION.      £7

stance of the organ is the seat of disorder, the patient complains of
a sense of weight  rather than actual pain ; he often appears over-
come, feels drowsy and inclined much to sleep, and, in very young
subjects, there is a conspicuous falling  down or half closed state of
the upper eyelid.   Nay, more, we often observe that there is a con-
siderable discrepancy in the constitutional symptoms when inflam-
mation attacks  different  portions  of  the same  organ.  This is
remarkably the case with respect to the brain, where the  pulse will,
in some  cases, fall below the natural standard.  This subject has
been well illustrated by  Dr. Abercornbie,1  with all that perspicuity,
candour, and adherence to truth, which become so distinguished a
medical  philosopher; and  to his writings, therefore, we may refer
for further illustration.
   Mr. Hunter v. as inclined to attribute the remarkable diversity in
the constitutional effects of local inflammation to the connection of
the viscera with the stomach.  " All the parts," says he,  " that may
be called vital, do  not produce the same effects upon the constitu-
tion ; and the difference seems to  arise from the difference in their
connections with the stomach.  It is to be observed that vital parts
may be divided into two, one of which is  in itself immediately con-
nected with life, as the stomach—the other, where life only depends
upon  its action and use;  the heart, lungs, and brain are to be
considered  in this last  light, therefore they  have a considerable
sympathising affection with the stomach, the symptoms are rather
depressing, the pulse is quick  and small, and  the blood  is not
pushed into the smaller vessels."   In the present day we are rather
disposed to reverse  the statement made by Mr. Hunter respecting
the organs on which life more immediately depends, and  to consider
the stomach as only indirectly contributing to its support; neither
does it appear, in  many cases where the constitutional disturbance
is unusually severe, that the part has any particular sympathy with
this viscus.  In those cases where the local morbid action does not
of itself induce death, by causing change of structure or some other
dangerous product as effusion, and where the constitutional affection
seems alone to have brought about the fatal event, we are inclined
to attribute the extinction of life to the depressing influence exerted
 on the nervous system; and it is farther remarkable that, where
this peculiar termination  to inflammation is found, the parts are
 chiefly supplied with branches from the sympathetic ganglions.
 When inflammation has  commenced in any structure  not very
 essential to life, but with  such violence as to  affect the actions of
 life, the symptomatic inflammatory fever, and not the typhoid, is
 usually present;  the great depression of the vital powers does not
 so rapidly follow; the  actions of  the part, as Mr. Hunter expresses
 it, are roused ; and the effects on  the constitution are  not such as
 to impede the functions of the vital organs.
   The varieties in the symtomatic fever,  arising in different habits,

            » On the Diseases of the Brain and Spinal Cord. 
                'i
 88           morgan's principles of surgery.

 cannot be accurately ascertained; because  it would  be  necessary,
 first, to have a precise  knowledge of the extent and severity of the
 local mischief—circumstances which can  never be compared but in
 a very general way.   We  may state, however, that the  fever does
 not  vary so.much in type as  in degree.  Thus, inflammation of  a
 mucous membrane in any kind of subject is accompanied by asthenic
 symptoms, that of a serous by sthenic;  although the amount of
 sympatic manifested in the.constitution will vary in different cases.
 Acute inflammation, generally speaking, proves more severe, runs
 its course sooner, and requires more vigorous means to subdue it in
 sanguineous or plethoric individuals than in those of an opposite
 habit.  Yet, in enfeebled subjects, as  those recovering  from pro-
 tracted fever,  we often find that inflammation, brought  on  by im-
 prudent  exposure to cold, proves exceedingly obstinate to remove;
 and  in fact these cases, from  the  fear of employing sufficiently
 active measures, and the tendency which the disease has to terminate
 in effusion, prove, without  exception, the most hazardous we meet
 with.  In conclusion, we may infer, from what we  have  laid down
 respecting the modifications arising  in the constitution  from local
 inflammation,  that, where the disease does not impede the functions
 of any vital organ, we have, in such a case, most  to fear from the
 severity, extent,  and mode of termination of the morbid action
 itself.  On the other hand, it may be remarked that, although much
 danger is to be apprehended from the local effects of  inflammation
 when occurring in organs immediately concerned in the production
 of life, we  have, in such cases also, to  encounter the  hazard from
 the constitutional disturbance arising out of the depressing influence
 exerted on the nervous system.
   But, to the  surgeon, by far the most important  and interesting
 modifications of the symptomatic fever from inflammation, are those
 arising after the reception of severe injuries, and to which we may
 very shortly direct our attention.  We shall  here suppose that there
 is no tendency to any diseased action  independent of what  may
 originate  in consequence  of the accident,  for, where a peculiar
 susceptibility is lurking in  the constitution, we frequently observe
 that  the parts take on a similar mode of action.  Thus, in a person
 of scrofulous  habit, an injury to a joint may ultimately lead to
 serious mischief, and from  a  cause which at  first seemed trifling;
 or, in a female in rather advanced life, and where hereditary predis-
 position exists, a  blow on  the breast will be followed by a scir-
 rhous tumour.   Those, however, are to be reckoned rather among
 the remote effects of accidents;  and it is only to the immediate
 symptoms arising in  the system that we wish at present  to confine
 our observations.   It is, perhaps, a trite remark, but  it  is  equally
 true  as trite, that no two individuals are possessed of  constitutions
 exactly similar, and that, therefore, remarkable differences will be
exhibited when they become the subjects of disease.  When  accord-
 ingly, a local injury has been such as  to give rise to symptomatic
fever, we observe  that the phenomena are varied according to the 
CONSTITUTIONAL EFFECTS OF INFLAMMATION.
89
particular habit of the patient, and  it is of the highest importance
for the surgeon to ascertain immediately what this may be.  Before
proceeding to the performance  of any capital operation, the first
thing done is to enquire into the general health and habit of body;
and," when persons  become the subjects  of severe accidents, the
inquiry is equally essential, for, without such information, an error
may be committed at the outset which is afterwards irremediable.
   The  different effects consequent on the infliction of severe in-
juries, result from the state  either of the vascular  or nervous
systems.   The  influence of  the blood on the  vital  functions  is
proved  by the fact,  that the  vigour and activity of animal life
depend principally on the condition of the circulating fluid ; and,
according  to the qualities of the mass, when inflammation sets in
after severe injuries, are the subsequent constitutional phenomena
in a great measure regulated.   The quantity of blood in the living
body is continually varying, according  to the  waste  and  supply
kept up in the system ;  the state of health is that in which  the two
are most nicely adjusted, for a preponderance on either side creates
disease.  The composition of the mass, however, exhibits the most
striking changes, and those to which our observations  must be con-
fined, as we can form no estimate of the quantity of blood in circu-
lation.   In health, the crassamentum bears always a due  relation
to the  serum, there  is an abundance of fibrin  and  of colouring
matter, coagulation takes, place in the usual manner, and the upper
surface of The clot is of a florid red.  In such  a case, the symp-
tomatic fever arising after an injury would, in all probability, be of
the inflammatory or"sthenic type, commencing and going  through
its stages in a regular and determinate form, not marked by  extreme
violence unless"where the local cause was inordinate, and  the con-
stitution  having  sufficient  powers to withstand  the  subsequent
depressing process.    Where  the blood becomes redundant with
fibrin  and colouring  matter,  with a great  increase in the albu-
minous portion of the serum, and these changes coupled with a
full habit of body, there is a strong tendency manifested to disease.
 In such a subject, the symptomatic fever, after a trifling injury,
 will run hi<rh, and  the subsequent prostration  is equally  remark-
 able   Contrast either of these with a case where the blood, when
 drawn, is seen  deficient in fibrin, scarcely  coagulating, or, if so,
the  crassamentum pale and the serum preponderating;  where the
 nervous system  is  in  an exhausted or irritable state, and,  along
 with the vitiated condition of all the fluids,  giving  origin to the
 most destructive and pernicious form of fever.
   Ao-ain  we have  instances where the nervous system  seems to
 predominate witho.it any deranged state of the blood, and where
 the cause principally operates on  this  system,  as  some of  the
 animafpoisons, or  injuries in individuals of a peculiar  nervous
 tenmcrnment.   In  habits of  this  kind,  the  puncture of  a clean
 nPPdle in the hand will be followed by inflammation  of the ab-
 sorbents and glands in the arm-pit,  and  with violent  symptomatic 
90
morgan's principles of surgery.
fever;  while  frequently, after the person seems well, both the local
and  constitutional disturbance will be renewed on any accidental
derangement  of  the  general  health.  There is, however, a wide
difference between the resources of the constitution in  this merely
nervous temperament, and that where the nervous system is mor-
bidly exhausted by excess of stimuli and an impoverished  con-
dition of the  blood, although  both  have been included under the
familiar title of irritable.  The former  is principally met with in
females, or in those of a delicate or susceptible frame, but otherwise
in good health;  the  latter is found in  the  constitution of the
habitual drunkard.
  As Mr. Travers1  has  remarked,  "it  is scarcely  necessary to
illustrate the influence of an  irritable temperament upon the con-
sequences of  casual injury or disease.  Practically, we all know it
well.   We say, such a person would be a bad  subject for a com-
pound fracture; and whoever has  had opportunities of watching
several subjects of compound fractures  under treatment at one and
the same time, well knows the import of this phrase, and that .lie
greatest degree of mischief is often accompanied by the least con-
stitutional disturbance, and for this reason is soonest and  most  per-
fectly restored.   The first few hours will  enable an experienced
observer to determine whether  the subject of a se.ious  injury or
operation  will do  well or otherwise.   How vastly different in dif-
ferent individuals  is  the  inconvenience  attending such minor de-
rangements  as a boil, an enlarged gland, a whitlow,  or a simple
inflammation of the eye /  In some, the constitution seems ignorant
of the affair, and the individual  pursues his ordinary avocations.
In others, the whole system sympathises—the spirits  are ruffled,
the  nights are  restless,  the appetite fails, the  pulse acqni.es an
undue bound, and the white tongue, the creeping chilliness, and
slight erratic  pains of symptomatic  fever are present.   It would be
of the highest importance for the surgeon, were he able to tell the
constitution of a patient  who has met with a severe  accident,  and
be able at once to  decide what will, in all probability, be the result
of it.  No doubt it is of material consequence that the local injury
should  be well,considered,  and that the greater is the mischief
done to the surrounding soft parts, or the more important these are
to the animal economy, the more severely may we expect the  con-
stitution to   suffer.  Yet a good  constitution  will  bear up  and
triumph over a  multitude of  difficulties,  while  a bad  constitution
would not be able to support itself under one half the evil."
   We may illustrate  the modifications in the  symptomatic  fever
arising from injuries, by reference to a case which often occurs in
practice.  An individual iu sound  health gets a compound fracture
of the leg;  the  bones may be protruding, and require  the integu-
ments to  be  divided or  the saw to be  applied, before they can be
brought into  apposition.  The man is put to bed, perhaps cold and
1 Oa Constitutional Irritation. 
CONSTITUTIONAL EFFECTS OF INFLAMMATION.
91
in a state of collapse from the injury; but after a few hours, the
skin gets  warmer, the circulation revives, and  the pulse  at the
wrist  becomes stronger.  Next day there is pain  in the back and
loins,  with general uneasiness, a full and bounding pulse, the skin
hot, the urine scanty and high-coloured, headache, want of sleep,
thirst, furred tongue, and,  in  short, all the regular symptoms  of
inflammatory  fever.   After  a  lapse of four or five days, during
which the fever has been  kept in  moderation, the general symp-
toms begin to subside, the pain in the head and loins  disappears,
the secretions are restored, the tongue  becomes clean, and the sleep
is natural.  The injured parts,  the inflammation  of  which had
brought on the constitutional disturbance, undergo a corresponding
change; purulent matter is secreted,  and soon after granulations
arise,  by which the chasm between the ends of the bones will  be
filled  up, and a permanent union of the osseous structure ultimately
attained.
   It  not  unfrequently  happens  that,  during the  treatment, and
while every thing is  going on  well, diarrhoea will set in, or  hemor-
rhage ensue from the separation of a  slough ;  and that,  in the
course of  a single day, all our prospects of a cure seem at an end.
The  purulent discharge from the wound  is exchanged for a thin
sanious secretion, the granulations disappear, the surface acquires
a dusky hue, tending to mortification, and  the chasm between the
ends of the bones is as  great as at first.  Along with these local
changes,  we find  that the constitutional symptoms acquire a new
character; the inflammatory fever is  exchanged for one of a more
typhoid type, the patient  gets  restless,  the tongue is furred, the
appetite gone, the pulse sinks at the wrist, and gradual  exhaustion,
with  low delirium,  succeeds.  Yet, even here, the prospect is not
so dark as may be anticipated.  A good  constitution will bear  up
under a combination of evils, and may have met with such a severe
shock that,  until  the exciting cause is removed, no chance  for
recovery  is afforded.  This is a practical  point, however,  which
the suro-eon must weigh well  in his own mine ;  the circumstances
under which he  is  called upon to  act, are of the most trying
 description ; there is little time for delay ; but the remedy useful in
 one case,  would in another be utterly hopeless.
    To show what adverse fortune a good constitution will  support
 itself under  we shall quote an instructive case from the writings of
 the late Mr. Abemethy.1  " A man between forty and fifty years m
 aae had a compound fracture of his leg, in which a considerable
 portion of the tibia  was knocked out, so that the upper and lower
 portions of the  bone lay about an inch apart.  As  the  limb could
 be kept steady  in a proper position, hopes were entertained that
 the case  mi*ht do  well.  Granulations were produced from  the
 nerio>teum and whole surface of the wound,  and  as those which
 rilled the space  between  the  broken  ends of the bones nearly
1 Lectures on Surgery. 
92            morgan's principles of surgery.
coalesced, there was every reason to suppose  that the event would
be favourable.  At the end of seven  weeks,  however, the patient
was seized with a violent complaint in his bowels, when the granu-
lations disappeared, leaving the chasm between the ends of  the
bones as great as at first.   In his now reduced state of health, the
granulations did not grow again, or they reappeared but in  a trivial
degree; and as his health declined, the wound fell into the state
which has already been  described, and produced irritative fever.
The wound then sloughed, and the anterior tibial artery was laid
open, in consequence of which he suddenly lost so much blood
that he fainted and seemed dead, for nothing  that  was tried could
arouse him; and in this state I amputated his thigh, tied the prin-
cipal vessels, and closed the stump.  He was laid in bed, still com-
pletely unconscious.   Volatile salts were applied  to his nose, and
the warming-pan was passed repeatedly over his  body; at length
he gave signs of returning sensation, the circulation was renewed,
and warmth was restored.  He was, of course, extremely reduced;
but the same kind of febrile excitement with delirium still continued
for three days, when it sudsided.   The wound, when opened, was
found flabby, and for some time produced little or  no  discharge;
the soft parts retracted,  and, although there had at  first been a
superfluous quantity both of muscle and integument, the bone pro-
truded ; eventually, however, the man  did well."   In  some cases,
the patient will rally,  and the limb may be preserved; while in
others, the resources of the system are exhausted, and,  unless the
local source of disorder be removed, there is no prospect of survival.
It thus happens that, in a compound fracture wherin there was at
first a chance of saving the limb, amputation becomes afterwards
necessary—the constitution  being  incapable of  supporting  the
actions  essential  to  recovery.   Such  may  be the prooress of a
serious injury in a person of a sound habit of body.
   There are two principal morbid varieties of constitution in which
local injuries produce peculiar and extraordinary effects.  The one
is that of general plethora, attributable to over-repletion of the vas-
cular system; the other  arises from an impoverished state of the
blood, coupled, in the worst species of cases,  with a disturbed  con-
dition of the  nervous system.   We shall only select the extremes
of these for examples, as it would be impossible to detail, within a
brief space, the various combinations to be met with.  Fortunately,
Such cases are easily recognised at the bedside, and their treatment
must be regulated according to existing symptoms.
   A plethoric state of the system, amounting to what, in common
language, is termed a full or bloated habit, is engendered by over-
repletion  or defective secretion, and not unfrequently by a combi-
nation of both.  There  is a greater tendency  to make blood in
some individuals than in others, and in the same individual at one
time than at another: when this has gone beyond a certain point
it ceases to be healthy, and brings the subject of it to the very brink
of disease.  When blood is  drawn, it exhibits the buffy coat on 
         constitutional effects of inflammation.      93

coagulation ;  the fibrin is increased in quantity, and likewise the
animal matter  contained in  the serum.   Such a state is far from
that of health ;  there is a want of that tone which characterises the
sound  condition of the body; the muscular fibre, instead of being
firm and rigid,  is soft and loose; and the secretions  are generally
deranged.  In  the expressive language of Mr. Hunter, the indivi-
dual is living above  par.  In disease, the most violent action is set
up; but  there  is an incapability of supporting it. and exhaustion
speedily  follows.  The full-bloated habit is  principally confined to
those who live high and take little exercise, or those who eat freely
and use  large quantities of malt liquors.  Such people are easily
distinguished from the rest of mankind.  They do  not eat and
drink for the sake of living,  but they live  for the sake of eating
and drinking.   To use the language of Prior, who has not  inaptly
described them,

           " They eat, and drink, and sleep; what then?
             Why, sleep, and drink, and eat again."

Not unfrequently, a trifling circumstance, such as would  hardly
have  been  perceived by a good constitution, is followed  by the
most serious consequences.   Thus we have  seen a fretful chilblain
over the heel  giving  rise  to inflammation, spreading in patches
throughout  the limb, and ending in a succession of large sloughs,
under which the patient  speedily  sank ; or a splinter of wood
driven under the nail of a finger, creating  such violent constitu-
tional  disturbance as to terminate fatally within a few days from
the commencement.   Nothing, therefore, is  more characteristic of
this habit than the  amount  of reaction, compared with the nature
of the cause which may have induced it.
   When a serious injury, as a compound fracture, occurs  in this
state of the constitution, symptomatic fever of the most violent and
dangerous description is set up.   There  is at first great excitement
of the whole vascular system, followed by a corresponding degree
of depression;  there is a disposition to  action,  without sufficient
strength  to  maintain it; and, from the rapidity  with which  these
changes  succeed each other, the  struggle is often short.   Within
forty-eight hours after the receipt of the injury, inflammatory fever
of the most vehement kind is present.  The tongue is dry, brown,
and deeply furred; the urine  high  coloured,  and  its secretion
nearly suspended ; the skin burning hot, and the face flushed ; the
thirst incessant;  headache throughout, the day, followed by furious
delirium requiring restraint throughout the  night; the respiration
hurried,  and the breath offensive; the belly  costive, and the
evacuations of the colour and consistence of pitch ; great  general
restlessness,  with incessant  groaning;  and a full and  labouring
pulse.  If  immediate  relief be not  afforded, by bold and  decided
treatment, the  scene quickly changes into one of an opposite cha-
racter marked  by apparent  debility and failure of the powers of
life.  The wild delirium settles into one more calm, and of longer 
94            morgan's principles of surgery.

duration ; the face  becomes livid; the lips and teeth covered with
a black sordes; the breathing stertorous; the skin bedewed with a
clammy sweat; the extremities cold;  the pulse at the wrist flag-
ging, irregular or intermitting, rapid and  feeble; profound coma
winds up "the tragedy, and the individual dies  oppressed.  On dis-
section, we have found the veins of the brain distended;  effusion
of serum between different  parts  of the arachnoid covering,  and
into the ventricles; the  substance  of the hemispheres  slightly
softened, and presenting numerous red points when cut across; in
some cases the lungs gorged with blood, and an increased quantity
of fluid contained within  the pluura.   Nothing, at the commence-
ment,  will suffice  but  free, general,  and  local  depletion,  with
purgatives; and we  have, by  these means, known consciousness
restored, after an unfavourable prognosis had been passed.
  But by far  the worst kind of constitution we meet with,  and one
where the  least hope of saving life may  be  entertained, is that
where the blood  is impoverished,  and the nervous system in an
irritable and  morbidly-exhausted  state.  This  is  found  in  the
drunkard who consumes large quantities of ardent spirits, gets no
regular meals, or  whose food is not of the most nutritious descrip-
tion.  This sort of individual, as Mr. Hunter would have expressed
it, is far below par;  he possesses no resources within  himself,  and
sinks under the slightest affliction.   If a rigid system of abstinence
is pursued, the constitution is speedily unhinged ; and we have
seen,  from  this cause, a simple fracture of the leg, or a  trifling
rheumatic affection of the joints, prove fatal. Those who are great
eaters or great drinkers are equally bad subjects for  accidents or
operations ; and it is almost impossible to declare which is the more
dangerous of the two.
  When a person, much addicted  to the use of ardent spirits,  has
received such a severe  injury as a compound fracture, we often
observe that the symptoms from the commencement are of a pecu-
liar cast.  The state of collapse immediately following the receipt
of the mischief is long in subsiding; there is little  tendency to
reaction; and the nervous system seems exhausted by the shock
which it has experienced.  Next day, low typhoid fever is  present;
there is slight heat of skin, with general restlessness ;  the stomach
is irritable, and frequently much  uneasiness is felt about the prae-
cordia; the tongue  becomes dry,  and  covered with a deep brown
fur; the pulse is  rapid  and  feeble; the patient has been in a state
of wakefulness throughout the night, or slept disturbedly for short
intervals; and the intellect is slightly confused.  These symptoms
continue to progress.  Hour after hour the prostration of strength
increases; the hand  gets  tremulous, and the mind wanders  from
object to object.   If we  can engage the patient's attention, he will,
perhaps, answer  us  correctly, then  break out into some foolish
exclamation,  or address some strange objects  which  he imagines
are dancing around him.  Ultimately, the whole frame is agitated;
the tongue cannot be protruded; the pulse dies away at the wrist; 
varieties in tiii: process of inflammation.
95
the restlessness ceases; and alow muttering delirium, ending in
coma, succeeds.   During  the prevalence of these typhoid symp-
toms, there is generally a determination of blood towards the head;
the face is flushed, and the temporal arteries are beating violently;
and, when  the brain  is examined after death, marks of subacute
inflammatory action, with  increased effusion, are found.
  In the worst variety of cases, the dismal train of symptoms now
described arises and terminates within two or three days from the
receipt of the  injury ;  in others, some little time will  elapse before
the constitution  breaks up  and low  fever sets in.  The one  is
unmanageable from  the commencement; the other has, perhaps,
become so  from the want of proper precautions.  Both, however,
form  a complete  contrast  to the over-plethoric habit.   In the
former, there is  an absolute want of  power, a direct  debility ; the
blood is deficient  in  fibrin,  and the nervous system  is exhausted.
When this class of persons are the unfortunate subjects of accidents,
depleting measures, if necessary, must be sparingly employed ;  for
we have seen general bleeding followed by the most fearful effects.
The nervous system seems, in the first place, to suffer from its cus-
tomary stimuli being abruptly withdrawn;  and hence,  while local
means are used to subdue any dangerous inflammatory action that
may be going on  within the cranium, opiates and stimulants must
be given, in divided doses, to support the action of the heart.  Few
cases are better calculated to draw forth the  skill and judgment of
the medical practitioner than these, although it must be confessed
that they but too  seldom reach a favourable termination.
                        SECTION V.

        varieties in the process of inflammation.

  These may be considered under two heads—either as appertain-
ina to the morbid action itself; or, as connected with some specific
cause residing within  the constitution.  Inflammation is, therefore,
common or specific.   Of the former, the most ancient division was
into phlegmonous and  erysipelatous, or healthy and unhealthy; a
division which, even in  the present day, is not entirely laid aside.
Phlecrmon (from O^*, to burn,) was deemed healthy, because it
shovved little disposition to spread ;  and when matter was formed,
the fluid was found to be confined within a sac or  cyst.  Erysipelas,
ao-ain  was reckoned  unhealthy,  because  no limitation could be
placed to its spreading over all the body;  and when suppuration
followed the matter was diffused  throughout the cellular tissue of
the p-irt'  To this source are to be traced the erroneous notions yet
entertained by many  respecting erysipelas, and also thesmgular
idea  that inflammation  of the skin differs  from  all  others, not 
96           morgan's principles of surgery.

merely in its seat, but in its nature.   Whatever opinions  may be
held respecting phlegmon and erysipelas, these terms express neither
the duration or intensity of the inflammation ; we now consider the
former as occurring in the cellular  membrane which  constitutes
the basis of the different organs and textures throughout the body,
while the latter is restricted"™ the skin  and subjacent tissues.  On
the grounds, therefore, of involving an hypothesis as to the nature
of the morbid action—which seems at variance with the truth, and
resides only in the imagination ; and as denoting neither the degree
or length of time during which the affection has lasted—the division
of inflammation into phlegmonous  and  erysipelatous,  or  healthy
and unhealthy, should be rejected.
   The process  of inflammation, in some cases, is  violent, and its
progress equally rapid ; in others, it is  languid, and remains with
occasional remissions and exacerbations for any length of time ;
hence it has been  described  as  either" acute or chronic.   No fixed
period has been given by which we may determine when inflamma-
tion comes under  the one or the other  of these heads.  When the
disease begins  and terminates  within three  or four days, we say
that it has been acute ;  when continuing for several  days, it is reck-
oned of a chronic character.   These  terms are, however, employed
not merely to signify the duration of  inflammation,  but likewise to
denote the difference  in  its  symptoms and  progress.   When we
make mention  of an acute inflammation, we mean one which passes
rapidly through its different stages ; which terminates speedily in
some manner or other; and in  which both the local and constitu-
tional symptoms have been severe.  When, on the  other hand, we
speak of a chronic inflammation, we understand one  which has
remained some length of time, perhaps, unchanged in its character;
in which neither the general nor local disturbance is well marked,
but  which leads,  ultimately, to permanent disorganisation of the
affected part.   The phrase  acute only expresses the  nature or
character of the process itself, without any reference to time ; while
that of chronic, (from xe°vo^  time,)  without implying  the kind
of morbid action  present, signifies merely that it must  have been
of some  duration.  In the proper sense, indeed, in which these
terms should  be used, practitioners greatly err;  for  we  are in
the daily habit of employing them to  designate more  the  degree
than the duration of inflammation.   In no"  two  individual cases,
however, is  the severity of the  local  and constitutional symptoms
alike.  Inflammation does not consist of two states only, an acute
and a chronic;  between these extremes many shades of difference
might be  recognised ; and, accordingly, to express some of these
modifications, the  phrase subacute has been introduced.  It is quite
impossible to distinguish by mere names, all the various degrees of
a morbid action, which, at one  time, assumes an indolent and at
another, a most violent character, and of the intensity of which the
best criterion is the general and local  disturbance.
   In order to avoid any misconception  arising  from the use of the 
VARIETIES IN THE PROCESS OF INFLAMMATION.
97
terms acute and chronic, those of active and passive have been in-
troduced ;  but the latter, in the sense in which  they are ordinarily
employed, are nearly equally objectionable.  In many cases which
afe considered chronic, the inflammatory action is by no means of
a passive or indolent character, but, on the contrary,~of an active
nature, and requiring vigorous means for its removal; while, in
others of an apparently active description, it is in reality passive,
and does not admit of the same resolute treatment.  We have fre-
quent examples of the former in rheumatism, where, although the
disease may have continued so long as to merit the name of chronic,
it is, nevertheless, of an active  character,  and may demand the use
of the lancet for its removal;  while instances of the latter are  occa-
sionally furnished in subjects debilitated from fever or other causes,
where inflammation may be acute as  regards  its duration, but has
more of a passive than an active disposition.  True, in the majority
of cases, the terms acute and  chronic correspond exactly with  those
of active and passive—most acute inflammations being of an active
kind, while chronic partake of the passive order ; nevertheless, the
exceptions to the rule are so  numerous, that, where we wish  to ex-
press the degree as well  as the duration of the disease, we would,
on some occasions, require to make use of both phrases at the same
time.
   It is a matter of doubt, also, how far we are justified in speaking
of inflammation being altogether passive, for more or less action is
continually going forward, and the morbid parts are not observed
to be in that state of rest which the term passive would imply.  In
organs  where  this  form of  inflammation has been long present,
changes in their bulk  and  structure have been gradually taking
place—showing that the inflamed vessels  are not in a state of total
inactivity.  In acute inflammation, the action  of the vessels is said
to be increased, while, in the chronic form, it  is diminished ; and
this,  we  are generally told, constitutes  the principal  difference
between these opposite varieties.   It was  one of the conclusions at
 which Dr. Thomson arrived, when watching the process of inflam-
 mation in  the web of the  frog's foot, and it has been referred to as
 an ultimate fact in pathology.  This is one among many points in
 practical medicine, which, "from having remained undisturbed, has
 been invariably assumed as true.   We do not  mean to assert that,
 in numerous cases of chronic and  lingering inflammation, the ves-
 sels are not in a state  of debility and relaxation, because both the
 appearances they present and the  effects of certain remedies pro-
 claim them to be so; but we mean to be  understood that this does
 not hold true in every instance.   Neither does acute inflammation
 alone consist, as such notions would seem to inculcate, of increased
 action throughout; for soon after  it  is established, and  if its phe-
 nomena are at all well  marked, we find that the minute vessels are
 paralysed, and  the fluid  is stagnant within them.   In short,  in
 chronic inflammation we have no  reason to believe that the capil-
 laries are  in such a state of debility, or the circulation through them
        12-d                                   mSn 7 
98            morgan's principles of surgery.

so much interrupted, as towards the termination  of the  disease in
parts which have suffered more severely; while, again,  the fact of
the chronic form being often the result of that which has been acute,
and of the latter arising at any time out of the former—the facility
of change from the one  to the other being very great—inclines us
to consider them as the same process, differing rather in intensity
than in any supposed increase of activity or debility in the vessels
themselves.
  We need not, however, have recourse to abstruse reasoning, in
order to distinguish between acute  and chronic inflammation;
neither would any minute changes in the vessels at the seat of dis-
ease enable us, without more obvious  means, to establish the dif-
ference.  Acute inflammation may be  generally described as either
advancing or declining ; seldom  or never stationary ; running its
course quickly; ending in resolution  or mortification, or  forming
some new product.   It  is especially recognised by the  severity of
its local and  constitutional symptoms;  the  part either  speedily
recovers its former condition, or experiences a serious alteration in
structure, and the symptomatic  fever  undergoes a corresponding
change.  Although more violent in its  character, acute inflamma-
tion is, nevertheless, far more tractable  and  readily removed than
that which assumes an indolent and determined character; neither
do we observe, during  the presence of the former, that increase of
size  and change in  the conformation of organs, so conspicuously
seen during the maintenance of the latter.  No difference is appar-
ently manifested between parts which become the seat of disease in
the way of giving rise  to one variety rather than  another; for, as
far as we have been able to remark, acute or chronic inflammation
may arise in every organised tissue in the body.
  To avoid any confusion respecting congestion and inflammation,
Andral  has substituted for  these the term hyperemia, which sig-
nifies an excessive quantity of blood in a part;  but this cannot
remove a difficulty which consists not alone in words, and we think
it better to  retain those, the use  of which custom  has long sanc-
tioned.  Inflammation has also been described as tonic or atonic—
sthenic or  asthenic—latent—sympathetic—continued, as in  that
we daily meet with—intermittent, as in some forms of ophthalmia
—and remittent,  as said to occur  occasionally  in children ;  but,
with the exception of those which are latent and sympathetic, the
rest have either no foundation in  nature, or  occur so seldom as to
be  unworthy  of any separate notice.   Inflammation has. farther,
been supposed to vary according to some peculiar states of the con-
stitution, as the scrofulous, the syphilitic, the gouty, and the rheu-
matic.  In such cases, the disease  has been represented  as of a
specific character, although the difference is not presumed to depend
so much on the process itself, as  on the habit of body in which  it
appears.  In  the scrofulous subject, inflammatory action  is  often
modified, and gives rise to some  peculiar changes, which, during
our progress, we mean to consider; in others, as the syphilitic the 
TERMINATIONS OF INFLAMMATION.
99
difference is only ideal, but has been the fertile source of the per-
nicious treatment followed out  in  numerous  cases; the remainder
do not properly come within the scope of our investigations.
                       SECTION YI.

             TERMINATIONS  OF INFLAMMATION.

  We proceed briefly to detail some of the modes by which inflam-
mation terminates.   These may be described  under the  heads  of
resolution, adhesion, effusion, suppuration, ulceration, mortification,
and hardening and softening of tissues.  Of late, much quibbling
has arisen as to the propriety of applying the phrase termination to
some of the changes  induced by local inflammation, and which, it
is contended, ought  to  be regarded as  so many effects or conse-
quences   If we understand, by the word termination, that the mor-
bid action  has completely ceased, then we should use  it in too
extended a sense ; for, with the exception of resolution and morti-
fication, we have no other instance where the previous inflammation
does not still accompany, in  a less degree  perhaps, the  particular
change which has ensued.  Thus, where purulent matter is formed
as a product of inflammation, we know that the latter has abated in
intensity, but not yet subsided ; and the same may be  observed in
some of the other effects which ensue.   When the word termination
is employed to signify that the local disease has undergone  some
alteration, or that°some new change has taken place in the part, we
apprehend that about as little error is committed as when we app y
the term effect to  denote the  same thing; for, even in a strictly
physical sense, where we make use of the latter, we often presume
Siat he cause has ceased to operate.  These objections to the word
 term nadon show a  wonderful  degree of ingenuity turned to little
 puZe  for, as few will  be  liable to mistake our  meaning when
 we saythaiinflammation has ended in  suppuration as  in mortifica-
 fion and we shall accordingly continue to employ the phrase in the





 where m traces of morbid action  are  removed;  and hence the
 where all traces 01            f  h   t,    changes  having been 
100           MORGAN'S PRINCIPLES OF SUROERY.

resolution.  Were we  to  understand,  however, under  this head,
that  there was a complete cessation of every morbid alteration in
the solids, and a restoration of the natural powers and functions of
a  part,  there  would be many cases  which would  be excluded,
although  the  inflammation had, without doubt, been subdued.
Where  the disease has  been acute, and lasted for even a moderate
time,  it invariably gives rise  to effusion of serum  or  lymph, or
blood may be extravasated from some of the ruptured vessels ;  and
when we succeed, in such cases, in  putting an  end to the incited
action,  we can scarcely say that a "complete resolution has been
brought about.  Neither, where inflammation has been  intense, do
we find that the part or organ in which it has been seated  regains
its lost function suddenly, but in the most gradual manner, remain-
ing, in fact, weak, and  liable to a renewal of the disturbance from
the slightest exciting cause.   Provided, however, the effusion into
the tissue of the part is trifling, it  is soon removed  by  absorption
after the undue action which led to  it has ceased ;  nor is there any
necessity,  or  would it  be  possible,  at  all times, to separate such
cases  from those wherein  the inflammation has been  previously
subdued.
  The termination by resolution is attended with different results,
according to the structure which  has  been  affected.   Thus, in
serous membranes, further effusion is checked, and what is already
thrown  out absorded ; from mucous surfaces, the discharge is for a
time both  increased and altered in character.  The changes going
forward at the seat of disease during resolution, are—the  diminished
action of the larger  arteries leading to the inflamed spot, and the
gradual decline of the vis  a  tergo—the contraction of the  over-
distended  capillaries—the  propulsion  or  removal of  the  red blood
from  the  colourless  arteries into  the veins—and  the re-establish-
ment  of the natural circulation.  While  these  phenomena are
taking  place,  the  local and constitutional symptoms  abate; the
pain,  heat, and redness, disappear; the pulse falls to near the usual
standard; the thirst and heat of skin subside; and the secretions
are restored.
   In  resolution effected by natural causes, we have almost  inva-
riably observed in the mesentery of the rabbit, that the first step in
the process  was the cessation of the  undue action  of the larger
arteries leading to the inflamed spot, by which the impetus of the
blood's motion is lessened, and by which, also, the weakened capil-
laries are enabled to contract and regain their tonicity so  as to
carry on the circulation.  A considerable interval of time elapses
before the whole of the morbid phenomena subside, and the part
assumes its former appearance;  in some places,  we observe the
vessels  dilated and the  blood at rest;  in others, the fluid is movino-
slowly  forwards;  while  in  others,  the  healthy balance seems
restored.  When a stimulant, as turpentine or a solution of nitrate
of silver, is applied to the inflamed part, it causes a sudden contrac-
tion of the vessels and a paleness; the impetus of the larger arteries 
TERMINATIONS OF INFLAMMATION.
101
however, remains unchecked;  and, unless the  contraction is per-
manently kept up, the capillaries are afterwards farther weakened
by the increase in the general circulation arising from the stimulus
employed.  The phenomena thus observed in  the lower  animals,
correspond with what we frequently witness in the human subject
from  the untimely application of stimulants  to  parts labouring
under active inflammation, and where means  have  not first been
made use of to lessen the circulation.  They likewise point out the
advantage of keeping the system in a state of tranquillity  after the
morbid action  has abated,  from  the facility with which, at this
period, the latter may be renewed.
   When  two  inflamed  surfaces  are brought together, and kept in
apposition for a certain  period of  time, an intimate  union is esta-
blished between them; they are then said to adhere,  and this is the
meaning of the termination by adhesion.  The uniting medium is
lymph, which  subsequently becomes organised—constituting the
process  by  which recent  incised wounds  are generally healed.
The  fibrinous  portion  of the blood is thrown out more or less
 readily,  according to the structure attacked or the necessity for its
 separation.  Thus it is effused on  the surface of  a wound or  a
 serous tissue, under a slight inorease of  vascular  action ;  while
 adhesion of a mucous membrane  is only effected by  the most
 intense  inflammation.   Wre have already adverted to the fact that,
 where much lymph is thrown out during inflammation, as in some
 cases of serous membranes, less fibrin will be found in the blood
 drawn from a vein ; but this,  although accounting for a deficiency
 in the buffy coat where the local inflammation may be  severe,  is
 inadequate  to explain the cause of its formation.  The lymph thus
 effused,  and constituting a living bond of union between two oppo-
 site surfaces,  has been supposed  to vary  in  its nature from that
 ordinarily found in the blood; the circumstance, however, to which
 we have just  alluded, shows the intimate connection subsisting
 between them.  Mr. Hunter has  treated of these phenomena under
 the title of " the  adhesive  inflammation;" and certainly  wherever
 such changes  are going on, more or less of inflammatory action is
 always present.                                     .
    When the exhalant vessels of  a part labouring under imflamma-
 tion throw out a quantity of serous fluid, and by which the local
 action may probably be diminished, we understand  the termination
 by effusion to have taken place.   In some cases, the exhalation has
 the effect of relieving completely the inflamed vessels;  in others,
 the  relief is only partial, and the  incited action is still kept up.
 The effused  fluid seldom  consists of pure serum;   frequently it is
 tino-ed  with the  colouring matter of the blood, or mixed with por-
 tions of Ivmph :  or should the inflammation be violent, with flakes
 of puriem  matter.   We  have  already hinted that, in  the great
 maiority of cases,  there is an  exhalation of serum with a little
 S  or  even an extravasation of blood; but where the  effusion
  s Sng  and incapable of producing bad effects, we still consider 
102           MORGAN'S PRINCIPLES OF SURGERY.
the disease to have ended in resolution.  The termination by effu-
sion principally takes place  when a serous or cellular tissue  is
affected; and in the former, the degree of danger is to be estimated
by the quantity poured out and the  seat of  extravasation.  When
effusion is the result of acute inflammation  within the cranium or
chest,  the case is attended with the most imminent danger—the
patient dying of asphyxia, commencing either at the brain or lungs;
when  occurring in  a more chronic  form in the abdomen,  it gives
rise to a variety of  ascites; in  an external  part it merely  creates
oedema, and pain or inconvenience from over-distension.
  When the local and constitutional  symptoms have  been  severe,
followed by rigours  or shivering, the pain of the inflamed part gra-
dually remitting, and fluctuation becoming perceptible, the  process
of suppuration  has  then ensued.   The formation  of purulent
matter is frequently preceded by. a throbbing  pulsation at the seat
of disease, and takes  place with more or less facility in different
structures.   The  previous   morbid  action, though lessened  in
severity, still remains  for some  time, and Mr. Hunter accordingly
called it the "suppurative inflammation."
  When a portion of  the inflamed structure is removed by  its own
absorbents, and leaves an abraded surface from which a discharge
is  furnished,  the  phenomena of ulceration  are then established.
The removal of parts of  the  animal  body by ulcerative  absorption
must  be carefully distinguished  from that  gradual  absorption of
structure caused by tumours  or foreign bodies making their way
to the external  surface; the  former  is accompanied  by pain, heat,
redness,  and  secretion ; the latter is unattended by  either.  Mr.
Hunter was of opinion that the ulcerative inflammation was  often
substituted to prevent a part from perishing;  the morbid action is,
however, less severe than that  by which the vitality is destroyed,
and seems to occur very readily in certain textures, as skin, carti-
lages, and mucous membranes.
   When the  severity of the local symptoms suddenly remits, the
inflammatory fever is exchanged for one of a  typhoid character, and
the part observed to  be passing from a livid to a dark colour, and
losing its vital heat, mortification is  rapidly advancing.   The pro-
cess has been usually divided  into  two  stages, viz.—o-an^rene or
incipient mortification,  and sphacelus or complete  death of the
part;  and, with the  exception of resolution,  it is the only other
instance wherein the local  inflammation completely disappears.
Mortification may occur independent of inflammation, as in some
peculiar states of the constitution, or from the continued application
of intense cold ; as a termination of this disease, it takes place  more
readily in some individuals, and in  some textures, than in others.
We  forbear entering at greater  length on the more ordinary effects
of inflammation, as it  will be  necessary to revert to them at a future
period.
   Softening, or loss of cohesion, is a common  effect of inflamma-
tion ; and, in tracing  the progress of the disease in  different  parts 
TERMINATIONS OF INFLAMMATION.
103
of the  body, we shall have occasion to mention this as of frequent
occurrence.   Softening is more particularly  observed  in  some
tissues or organs than in others, as in mucous  or  cellular mem-
brane,  and in" the substance of the brain.  It is generally caused by
effusion of a serous fluid between the  laminae of a structure, but at
other times  consists in a direct loss of cohesion in the proper fibre
of which a part is  made  up.   Softening  is more  frequently  the
result of acute than chronic inflammation, and was first described
in the  brain and spinal marrow  by  the French pathologists under
the title of ramolissement.  The loss of cohesion varies in different
parts, according to their structure and the diseased action present;
thus, the substance of the brain may  be  reduced from its natural
firmness to a semi-fluid  mass resembling thin custard.  Softening
of this organ, however,  may take place from other causes, as ossifi-
cation of its vessels;  and, in  some  cases where  the  affection  is
extensive, it has been doubted whether it was really the conse-
quence of inflammatory action.
   Induration is the very opposite of that to which we have alluded,
 and is occasionally the effect of inflammation.  It more frequently
 arises  from the chronic than the acute form of the  disease, and is
 caused in various ways, according as the one or the other of these has
 been present.  In acute inflammation, the induration proceeds from
 the effusion of lymph and a highly albuminous serum into the in-
 terstices, and between  the laminae, of the tissue;  when resulting
 from  the chronic variety, there is frequently a deposition of a nevv
 and solid product, different entirely  from the natural structure of
 which the part is made up.
   Induration commonly occurs in the  cellular membrane,  or m
 parts  abounding with  it,  as the lungs; and in soft organs, as the
 brain  or liver.  It  is sometimes accompanied with increase of the
 part affected, constituting hypertrophy; at other times, with wast-
 ing of the  natural structure,  giving rise to atrophy.   Induration
 with hypertrophy may be caused either by a superabundant deposit
 of the nutritive matter which  enters into the composition of the
 part or by the formation of new products, as particularly seen dur-
 ing iono--continued chronic inflammation.  The degree of hardening
 deoends principally on the nature and density of the superadded
 matter, as  frequently little change  arises in the primary texture
 itself.   When the new deposit is such as is met with in other parts
 of the body, it is named an analogous transformation ; when differ-
 ent from any known natural  structure, a non-analogious transfor-
 mation  From the induration caused  in parts by inflammation,
 scirrhus has been looked upon by some as one of its terminations ;
 but true or malignant scirrhus is  a specific disease arising from
 hereditary  disposition, and quite independent of common  inflam-
 matory action   In  consequence of  the new matter deposited into
 me Sluktr  interstices of parts, we find their colour altered, and
   hoir bulk and weight much  increased;  and, in this  way, chronic
 inflammation may give rise to a great variety of effects.  In some 
104           MORGAN'S PRINCIPLES OF SURGERY.

instances, both softening and hardening are combined, occupying
different  portions of the same texture. " Finally, in estimating the
changes arising from inflammation, it is always requisite to compare
them with the consistence of the tissue in the healthy state, together
with its density at various ages.
                       SECTION  VII.

   PROGRESS OF INFLAMMATION IN  DIFFERENT STRUCTURES.

  There is no organised structure in  the animal economy in which
the phenomena of inflammation may  not be observed ; and, in this
respect, the disease differs  from all others we are acquainted with.
The human body is made up of different tissues, in each of which,
inflammation gives rise to a peculiar  train of morbid changes; and
we must, therefore, be prepared to meet with various effects, accord-
ing to the seat of disease.   The attention of medical men was first
drawn towards this  subject by Dr.  Carmichael Smith, in 1788 j1
and subsequently, in  France, by Pinel and Bichat.  It is not our
intention to enter minutely into many parts of this investigation;
but the great importance of studying it may be estimated from the
space latterly devoted to it in the  writings of  many distinguished
pathologists.
  Cellular Membrane.—The cellular or reticular  membrane,  so
extensively diffused  throughout the  body,  and constituting  the
basis of all  other parts, is the most common seat of inflammation.
The cellular tissue has been  generally considered as giving origin
to phlegmonous or  healthy inflammation; but experience teaches
us  that it  is equally involved  in  an erysipelatous or unhealthy
action.   In acute inflammation the reticular  membrane  loses
its elasticity, and  is easily  broken  down;  the cells are filled with
a gelatinous reddish-coloured fluid, an in some places with pure
blood;  the minute vessels  are distended, and a yellow serurn is
effused  around the inflamed  spot.    The morbid action may ter-
minate in resolution, effusion of lymph or serum, formation of matter,
or mortification and sloughing.   Primary  ulceration never occurs
as an effect of inflammation in the cellular tissue.
  When acute  inflammation  originates in the cellular membrane,
and ends in suppuration, the fibres become soft and loose;  the pus
is confined within a cyst formed of the condensed cells, and varies
in its character according to  the seat of disease; but when the in-
flammatory action spreads  from  the  skin to the reticular texture
beneath, adhesions are often  imperfectly formed, and the purulent
fluid undulates through the membranous cells. The different effects
 hus observed from suppuration, in the same texture, are principally
attributable to the circumstances under which it takes place.   In
'London Medical Communications.  Vol. II. 
         INFLAMMATION IN DIFFERENT STRUCTURES.      105

the one case, the inflammation is circumscribed, lymph is copiously
thrown out so as to form a boundary to the abscess, and the accom-
panying fever is usually of a sthenic type; in the other, the morbid
action is more extensive, often violent,  and occurring in an un-
healthy habit, while the symptomatic fever is generally of a typhoid
description.   We have examples of the death or sloughing of the
cellular tissue in erysipelas,  bile, carbuncle, hospital gangrene, and
malignant pustule ; in some of these, the membranous fibres separate,
and come away in masses like wet tow; they originate either in a de-
praved state of the general health, or from inoculation with an animal
poison, and are accompanied invariably with low typhoid fever.
  When  the adipose tissue is inflamed, the fat is broken down and
mixed with lymph, serum, or  extravasated blood;  and, should
suppuration ensue, the fat is absorbed, and purulent matter deposited
in the cells it previously occupied.  In parts abounding with adi-
pose substance,  and where  the pus is deep-seated, as in the neigh-
bourhood  of the rectum, the  fluid is generally  foetid, and the
constitutional  symptoms of  a st.ongly-marked typhoid character.
When chronic inflammation attacks the cellular tissue, the fibres
are thickened, and  the cells  filled with an albumino-gelatinous
fluid;  the part thus acquires an  increased hardness and density,
loses its natural elasticity, and, on being cut into, presents a grayish
or spotted red  appearance.  Such, at  least, is the condition of the
cellular membrane in what is named skin-bound  disease.
  Arteries.—The  arterial tissue is not so readily inflamed as has
been supposed. The subject has only of late years attracted notice;
but there  is  reason  to think that,  like  every other new doctrine in
medical science, a  degree of importance has been attached  to it of
which it is  unworthy.  Although the capillary branches are the
proper seat of inflammation, the larger arteries do not often exhibit
the same phenomena.   Both acute and chronic inflammation have
been  described as occurring in the arterial texture.  The internal
membrane which lines the  vessels resembles closely, in structure
as well as function, the serous tissues;  and, when inflamed,  under-
goes changes  analogous to  what is found in these.  The adhesive
form  is that generalfy  seen in the tunics of arteries, from whatever
cause the inflammation proceeds ;  there is increased vascularity at
the spot  affected ;  the vasa vasorum are more numerous and dis-
tinct ;  and  the middle  coat is softened.   On more minute examina-
tion, the smooth polished appearance of the inner tunic is observed
to be  lost, and the  membrane itself thrown into folds.
  We must be careful not to mistake colouring of the internal tunic
from imbibition after death,  for the effects of disease; and we are
persuaded that many errors  have arisen in this way.  Mere redness
of the lining membrane of an artery is no proof that inflammation
had existedrbecause this takes plate frequently from transudation,
and particularly, as we stated, in cases of sudden  death, or where
there had been  any obstacle to the free circulation of the blood.
When the  redness occurs in  numerous  places  throughout the 
106           MORGAN'S PRINCIPLES OF SURGERY.
vessels, unaccompanied by any other signs of disease, we may rest
assured that it is merely the effect of transudation; when, on  the
contrary, it is confined to one part of the. vessel, along with it we
observe the  nutritious arteries  to  be  enlarged, the surface of  the
inner membrane opaque and easily scraped off, with  tumefaction
and effusion of lymph, we are warranted in concluding that inflam-
matory action  had been present.
  The most common  effect of acute inflammation in arteries is
softening of their tunics, effusion of lymph in the connecting tissue
betweenthem, and on  the surface of the internal membrane—the
latter likewise loses its transparency  and is  thrown  into  folds.
When the  local action is  severe,  purulent matter  may be effused
between the coats or secreted from the inner membrane, and mingle
with the circulating fluid;  the vessel is increased in bulk from the
infiltration,  and so softened that  laceration  readily takes place.
Portions  of the artery will sometimes die and slough  away, and
then  hemorrhage ensues;  more commonly, however, the inflam-
mation gives rise to effusion of lymph, by which the tunics  are
agglutinated, and  the  canal of the  vessel rendered  impervious.
Whatever some modern pathologists may say to the contrary, acute
arteritis is a rare affection; it takes place  to a certain extent when
an artery is wounded  or surrounded with a tight ligature, but its
spontaneous occurrence in a large trunk is seldom seen ; and, when
occurring in those which are  deep-seated, there  are no signs by
which we could  detect it during life.   The idea of acute inflam-
mation occurring universally throughout the arterial system is so
absurd as scarcely to  merit notice; and  we are  confident that, in
many other instances, the effects produced by transudation have
been mistaken for disease.
  Chronic  arteritis is said to be  of more frequent occurrence than
acute.  It  is principally confined  to  the larger vessels, causing a
deep  brown tint of their tissue,  with softening  and rugosity of the
lining membrane.  Long-continued  chronic  inflammation  gives
rise to ulceration of the serous tunic, which  may extend through
the whole thickness of the  artery, and induce fatal  hemorrhage; we
have a preparation where a minute opening was thus formed in the
aorta within the pericardium, and led to instant dissolution, by the
filling of this cyst with blood.  Ulceration not unfrequently takes
place in the lining membrane of the heart, as Laennec described.
  Nothing  is  more common in the larger arteries than to find
morbid deposits of a calcareous, cartilaginous, or osseous substance,
within their tunics; occurring in patches of greater or less extent
and occasionally extending for some distance throughout the entire
circle of the vessel. This degeneration has been considered as the
effect of chronic inflammation, and chiefly for the  reason that dark
brown spots are observed in  the neighbourhood.  They often occur
in parts of the vessel distant from each other, and unconnected with
any other morbid appearance. They seem rather nevv deposits  into
the  substance of the  middle tunic, or between it and the inner 
INFLAMMATION IN DIFFERENT STRUCTURES.
membrane—for  the  latter  may be scraped off entire; the same
phenomena take place in other tissues; and hence they may, with
as great probability,  be  the cause, as the  consequence, of chronic
inflammation.  In whatever  way they originate, when ocurring
partially in an artery they are a frequent source of aneurism; the
diseased portion  of  the  vessel is  incapable of yielding  with the
neighbouring sound one to  the  impulse  of the circulation, and,
being once rent, the  blood insinuates itself through the opening, and
distends the outer runic  into an elastic swelling.   They are like-
wise of great importance to the surgeon in considering  the  cure of
this disease by operation.
   Veins.—-The lining membrane of the veins is very susceptible of
inflammation, and the disease  gives rise to the most fatal effects.
Phlebitis  never originates spontaneously, but is the result  of acci-
dents or operations,  or some other cause in which  the vessels are
directly concerned.   It thus follows venesection at the  bend of the
arm, or the division  or tying of veins after amputation,  or for varix ;
it is a frequent though unsuspected cause  of death after lithotomy;
it gives origin to one of the  varieties of puerperal  fever; and pro-
duces also phlegmasia dolens, the pathology of which  was so long
misunderstood.   We have seldom known it succeed  after severe
injuries or operations in individuals of sound constitution; but, in
an irritable or exhausted subject, especially where the  suppuration
is  profuse,  it not  unfrequently  supervenes.   The  first distinct
account of inflammation in veins was  published by Mr. Hunter in
 1793;  but notwithstanding,  the disease, till of late years, attracted
 little notice.                                                ,
    Acute  phlebitis usually commences  within a few days from the
 application  of the local cause; and in some cases proceeds with
 such rapidity as to resemble  the  introduction of a specific poison
 within the body, over which medical treatment has no control. At
 other times, a wound will be  in  a  healing  condition and no un-
 usual  suppuration  present, and  the  disease  will advance  more
 slowly but steadily  to a fatal termination.  In deep-seated veins the
 local si^ns are often so obscure as to escape observation during life,
 and  thS  constitutional  effects  have  been attributed to another
 source; hence phlebitis ought always to be suspected, where violent
 typhoid symptoms ensue after wounds or operations without suffi-

 C'WlleTthTvein is examined after death, the lining membrane is
 found  intensely  red, and, along with the  outer  tunic, so much
   h ckened as tomake the vessel  feel like a hard impervious cord,
  md resembles an artery in appearance.  The tissue  in which  he
 vein I?  imbedded  is likewise unusually vascular, being infiltrated
  with a reddish serum, much softened, and in some cases of a dark-
 brown or  black colour.   The  canal of the  vein is  filled with
 h Zh either loose or adhering  to the inner tunic, and obstructing
   be nassao-e; there are deposits,  also, of purulent matter sometimes
 m copious as to distend the vessel.  The pus is frequently confined 
108          morgan's principles of surgery.
 by the lymph forming boundaries to it both above and below, and
 in which case a chain of little abscesses occurs throughout  the
 course of the vein.  The inflammation may be limited to  a small
 portion of the tunics, or spread upwards  and downwards through-
 out a great extent of the vessel.  In venesection at the bend of the
 elbow, or in wounds of the femoral vein  at  the groin, the disease
 may proceed towards the fingers or toes, or in the opposite direction
 towards the heart, or, what is more common, in both  ways at  the
 same time.
   Mr. Hunter has stated that death takes place as soon as the in-
 flammation reaches the lining membrane of the auricle, but in very
 few instances does the local mischief extend so far; while the fact
 —of the disease sometimes taking an opposite direction, and of its
 proving fatal where only a few inches of a vein are inflamed—ren-
 ders it obvious that some other cause of dissolution must  prevail.
 Mr. Arrnott1 has remarked that the point at which the inflammation
 of a vein ceases is either where the vessel sends off or is  joined by
 another branch.   Thus, where a trunk is concerned, the boundary
 is  the entrance of a  branch; and where a branch is  affected, the
 boundary is its junction with a trunk.  He does not mean  to infer
 from  this, that the spreading of the inflammation must necessarily
 be arrested, but merely to remark that, where it does cease, there is
 commonly found another current of blood.  His observations have
 led him to the conclusion that the fatal indisposition is to be traced
 to  the entrance of pus  or some other product into the circulation;
 but this, although it may simply induce death in some cases, fails
in  doing so  in others, and the bad effects, as we shall immediately
see, are often referable to the complications of other organs.  The
 chance  of purulent matter being  mingled with the blood is much
greater where large than small veins about a wound are  affected.
   The constitutional  effects resulting from inflammation of veins
vary according to the extent of the local disease, but may all be
considered as of the typhoid or adynamic order. At the elbow joint,
while the affection is limited,  the febrile disorder is moderate; while
the local symptoms are well-marked by the pain in the wound and
along the track of the vessel, which is hard and  knotted, and by the
swelling of the limb.  When  the inflammation is greater, and puru-
lent matter has formed, the secondary effects in  the constitution are
materially altered ; and where the local changes are concealed from
 view as in some of the  deep-seated veins, and  there is nothino- to
 indicate the  disease externally, the febrile  disorder has  been mis-
 taken for malignant typhus alone.   There is at first great  anxiety
 of countenance and  depression of spirits, an irritable state of the
 stomach, and a distressing feeling of general uneasiness without
 the patient being able to refer  his symptoms  to  any particular
 source.   To these succeed heat of skin, and thirst,  with  a pulse
 ranging from 100 to 160 in the minute, and a hurried and anxious
1 Medico-Chirurgical Transactions. Vol. XV. 
INFLAMMATION IN DIFFERENT STRUCTURES.
109
respiration.   The sensorial powers are soon affected; there is inco-
herence, with either low muttering, stupor, or occasional attacks of
violent  delirium, followed by exhaustion and a  partial return to
consciousness.  Before death, and as the disease progresses, all these
symptoms are fearfully increased; not unfrequently the skin turns
yellow, leading to the  belief that the patient is jaundiced; the fea-
tures sink, the pulse gets rapid and thready, the tongue is of a dark
brown, and the teeth are covered with a black sordes, tremours of the
muscles of the  face and extremities follow, and  the patient lapses
into a state of fatal coma.  Acute phlebitis, although a most dan-
gerous, is not invariably  a fatal disease; when recovery does take
place, we find that  the canal of the vein is rendered impervious by
the effused lymph,  and that the vessel subsequently degenerates into
a round ligamentous-looking substance.
   In many cases of phlebitis, secondary abscesses occur in  distant
parts of the body.  The late Mr. Rose of St George's Hospital pub-
 lished a paper on  the purulent  depositions found in some of the
 viscera after severe injuries or operations, without, however, being
 able to explain  correctly  from what source they  proceeded.  Such
 cases have been described under the title of sympathetic inflamma-
 tion ; but they are  all referable to inflammation of the veins,  and the
 admixture of  purulent matter  with the blood in circulation.   In
 some, the eyes are the seat of purulent ophthalmia, the  lids  become
 red and swollen, pus  is effused into  the interior of the globe, and
 the cornea is rendered opaque  and  finally bursts.   In others, the
 fleshy substance of the thigh, or the joints of the  knee or elbow, are
 the seat of mischief;  and, on laying open the cavities of the latter,
 we find a mixture of pus and other fluids, and the cartilages stript
 from the articulating ends of the bones.  More frequently some in-
 ternal organ, as the brain, lungs, liver, or spleen, is softened and in
  a state of partial  gangrene,  and in some part  of its  substance is
  found a cavity filled with fetid  purulent matter.  Sometimes the
  functions of organs in which pus is deposited are little affected, from
  the abscess  occurring near their outer surface; and in  this  way we
  may not be able to tell before death what internal part  is  particu-
  larly deranged.  There  is no texture in the body in which this de-
  structive secondary mischief may not  ensue, and which  is often
  the unseen, and, therefore, the unsuspected cause of death in phle-

   1 Two explanations have been  offered respecting the formation of
  secondary abscesses-either, that they are caused by the pus being
  simply carried to that part and deposited there or that the  purulent
  fluid  bein* mixed with the blood, acts as a local  source of irrita-
  tion on the capillaries  of the part, and  excites inflammation and
  suppuration.   The reasons given in support of the former might be
  _!.that secondary abscesses do  not always  follow the  formation of
  nurulent matter  in  a vein-that pus may be received  apparently
  into  he circulation, as  in the  natural  absorption of a common  ab-
  scess without being followed  by any such disastrous  effects-and 
 110          morgan's principles of surgery.

 that, were secondary abscesses dependent on pus merely circulating
 with the blood, they ought not to be so often solitary, but appear in
 several parts of the body at one and  the same time.  On  the other
 hand, in favour of the latter opinion it may be alleged—that the
 quantity of fluid found in a secondary abscess is often greater than
 could,  by any possibility, have been separated from the blood at the
 part, for a large internal collection will be found  where the local
 suppuration in the vein is trifling—that there is not simply a depo-
 sition of purulent fluid, but evident marks of  violent inflammation,
 followed by disorganisation of the texture which happens to be af-
 fected—and that in some parts, as the eyeball, the changes which
 result are obviously not depending on the mere lodgment of puru-
 lent fluid, but on the destructive action caused in all probability by
 its presence.
  Chronic phlebitis produces a deep-brown colour and thickening of
 the tunics; lymph is poured out, and the canal of the vessel is closed
 up. Sometimes ulceration of the coats takes place, and fatal hemor-
 rage ensues, of which we have seen several examples in the superfi-
 cial veins;  but more frequently ulceration of veins is caused by an
extension of this process from the tissue  in which they are placed.
  Nerves.—If we except  some of the changes  going on in  the brain
 and spinal marrow, the investigation  of  which would be foreign to
our present purpose, we may at once confess that we know nothing
of the  progress of inflammation in  the nervous  structure.  We
should expect that, where nerves  were inflamed,  their sensibility
would be much increased and excruciating pain produced; but we
have evidence for believing that nerves are not so often themselves
the seat of disease, as that they are secondarily affected by disease
in their neighbourhood.   When, for example, inflammation is es-
tablished in a part, we have not  yet been able positively to decide,
 whether the pain  which is experienced  arises from the extremities
of the nerves being directly involved  in the affection, or  from the
pressure they sustain by the local distension, although the evidence
is unquestionably in favour of the latter supposition." We can state,
however, with confidence, from various phenomena observed in the
living body, that a painful condition of a nerve may occur without
any signs of local inflammation, and that the occurrence of pain is
dependent on the healthy function of the brain and on an uninter-
 rupted supply of nervous influence  from  that organ.1   In some
 cases of neuralgia, where  opportunities  have  been^afforded of ex-
 amining the state of the affected nerve after death, it has been stated
 that the neuromatous sheath was  thickened, and  the nerve itself
enlarged; but in others, no deviation  from the normal state could
 be perceived. In many of these we  find that the real seat of disease
 is at the connection of the particular nerve with the brain, although
 pain is experienced in a distant branch ;  while, in all instances, the
 inconstancy of the  affection, the often-disturbed state of the general
1 See Local Symptoms—Pain. 
inflammation in different structures.
Ill
health, and the nature of the remedies which  afford relief, show
that inflammation is not the cause of the disorder.
  When nerves are partially divided, the  injured portions will  be
occasionally found red and swollen, and  the  irritation from which
has been supposed,  in some  cases,  to account for the  invasion of
tetanus.   Mr. Liston1  has related  an  instance, where, during  an
attack of  tetanus from injury to the hand and wrist,  amputation
was performed, and in which the median nerve was found partially
divided, red and swollen ;  and  we have seen  the same thing in the
communicating tibial, from a pebble shot  into the calf of the leg.
Yet, although these may account for such a train of symptoms in
some cases, they will not in  all—as evinced by. the  lapse of time
after the injury, and the healing condition of the wound.   When
either of the cutaneous nerves, from taking  a more superficial
course, is wounded in venesection at the  head of the arm, slight
neuralgic symptoms will remain for long after; but no other  bad
effects,~as far as we have seen, ever result from the injury.   When
nerves are completely cut  across, as in amputation,  their  extremi-
ties sometimes expand into a substance resembling nerve,  giving
rise to  the most painful  sensations, and preventing the slightest
pressure being made on the  face of the stump.  The newly-formed
matter is firm and white, and varies both in figure and size;  it is
intimately connected with the extremity of the parent nerve, which
is indurated  and enlarged, and has been supposed to be the result
of chronic inflammation.  Mr. Langstaff has shown, however, that
 the painful condition of some  stumps is owing to the  extremity of
 a nerve getting involved in the  hardened cicatrix; and to prevent
 which, as nerves do not retract  like  muscular parts but  hang out
 at the wound, he recommends a portion of  them to be cut away.
 The small tubercle developed in the course of a nerve, and produc-
 tive of such  extraordinary pain when  handled, may  likewise be
 owino- to some species of chronic inflammation ;  but our imperfect
 acquaintance with the pathology of the nerves prevents  us from
 arriving at any accurate conclusion on this  and many other points
 wherein  they are concerned.               . ,   ,  .   ^   j
    Lymphatics.-The lymphatic  vessels,  with their  glands,  are
 often affected with inflammation;  and, when  we consider  their
 number  and the function which  they have to  perform, we  need
 not wonder  that such should be the case.   Those  placed  superfi-
 cially  are more frequently affected than those  which are deeper
 seated.   Inflammation of the lymphatics is generally to be  attri-
 buted to the absorption of some fluid, as pus, or a poison  of animal
 orio-in ■  in  susceptible constitutions, the disease will arise,   also,
 from the slightest irritation, as the prick of a dean needle   It is
 rare  however, that inflammation of the absorbing vessels follows
 ordinary wounds; for, where it appears after blood-letting  we find
 that there is always suppuration  around the opening made in the
1 Elements of Surgery. 
 112          morgan's principles of surgery.

 vein, and* to the absorption of some of the matter from which  the
 affection is to be ascribed.  In  such instances  the inflammation
 spreads upwards and downwards, or  towards the termination and
 commencement of the absorbing system.   When  the superficial
 lymphatics are inflamed, they form  red lines  running under  the
 skin, feel like a piece of whip-cord to  the finger, and may be traced
 as far as the glands in which they terminate.  On dissection, their
 coats are found red and thickened, their canals filled with an adhe-
 sive matter, and the cellular tissue in which  they  are imbedded
 infiltrated with a serous fluid.  The absorbents of the uterus and
 the receptacle for the chyle have  been seen filled with  a purulent
 fluid ; and the researches of Tonnelle and Duplay in France, and
 of Dr. Lee in this country, have proved that inflammation of this
 system  of vessels and  of the thoracic duct occurs in puerperal
 women, and  gives rise to as disastrous consequences as  uterine
phlebitis.
  The glands may be the seat of acute inflammation without  the
absorbing vessels participating in the  morbid action, of which  the
syphilitic bubo forms a familiar example.   In such  instances,  the
local symptoms are strongly marked,  and the constitution  sympa-
thises or not according to the extent  of the mischief.   The  affec-
tion may be limited  to  one gland, or extended  to several.  The
great swelling which occasionally ensues arises from  the infiltra-
tion into the surrounding cellular membrane,  for  the ganglions
themselves are but little enlarged.  The  effused fluid  consists of
serum and lymph ; and, from the large quantity of the latter some-
times deposited, the part remains  indurated long  after the  inflam-
matory action  has disappeared.   On  examination of an inflamed
gland, we find it increased in size, of a spongy consistence, of a
red or nearly violet hue, and exhibiting  a number of similarly
coloured spots  when cut across.  Mercurial  injections  may be
made to pass  through  the convoluted absorbents  of  which  the
ganglion consists; and from which it would appear that the canals
of these vessels  are still pervious.  Acute  inflammation of a lym-
phatic gland  may end  in resolution ; very frequently it runs into
suppuration, and particularly after the absorption of certain sub-
stances.  The purulent fluid is  chiefly deposited in  the inflamed
cellular  tissue surrounding the  gland  ; for when a large opening is
made into the seat of the disease, or the parts slough  extensively,
 the ganglions  may be  seen of a dirty ash colour,  and nearly of
 their natural size.  In other cases, the pus is effused into the centre
 of these bodies, when the glandular structure is absorbed, leaving
 only the cellular envelope,  which forms  a bag or cyst  for  the
 matter.  Where the local action  is severe,  occurring particularly
 in a bad habit of body, or one in which mercury  has* been unspar-
 ingly administered, great destruction of the  cellular tissue, and
 sloughing of the integuments arise, accompanied with rapid pros-
 tration and general sinking of the vital powers.
  The lymphatic glands are frequently the  seat of chronic inflam- 
inflammation in different structures.      113
mation, occurring either primarily or as the remains of that which
had been more acute, but had not proceeded to suppuration.  The
parts are swollen, stiff, and hard ; and, in the groin  or arm-pit, the
disease is a source of much inconvenience.  The cellular tissue is
filled with lymph,  which  forms  a  dense  capsule to the inflamed
gland ; and the latter, on being cut into, presents a brownish struc-
ture, intersected by numerous  blood-vessels.  This variety is often
met with as a primary symptom of syphilis.   The induration  may
remain for a great length of time before it disappears; or a more
acute attack of inflammation supervening, suppuration ensues, and
the disease is  thus got rid of.
   An important modification of chronic inflammation  in the lym-
phatic glands occurs in  individuals of a strumous or scrofulous
constitution.   The frequency with  which this form of disease is
observed, has  led some to adopt the opinion that scrofula  had its
seat in the  absorbing system; but it is more  correct to say  that
this system partakes only in common with other  parts, and expe-
rience has now amply demonstrated that,  with  the  exception  pro-
bably of the muscular, there is no texture  or organ which may not,
occasionally, be the seat of this variety of  morbid action.  It is not
our duty to  enter on the  general pathology of scrofula, but merely
to detail its effects in certain  structures ; we cannot  define what
this state is, we can  only point out its general character, and the
habit of body in which it is manifested ; for its hereditary descent,
and  other inherent features, show it to originate from a peculiarity
of constitution which is received at  birth, and which has the power
of modifying disease arising from ordinary exciting causes.  The
most remarkable circumstance connected with scrofulous  affections,
and  one which is peculiarly characteristic of their nature,  is their
remaining indolent  for a length of time  at their commencement,
and afterwards  assuming  a more  active  character, during which
they run  into suppuration  or  ulceration.   Healthy inflammation,
however, may not only  arise  in  scrofulous subjects, but may co-
exist with scrofulous disease ;  neither are we warranted  in calling
every  indolent or protracted disease by the name of scrofula.
   The absorbent glands most frequently affected with scrofula are,
first, those about the neck and jaw; secondly, those found between
the folds of the  mesentery; more rarely,  those at the groin ; and
still more rarely,  those  placed internally.  It  has been a question
whether scrofulous  action in  a gland occurs primarily, or whether
it does not proceed from disease in  the neighbourhood in which its
absorbing  vessels arise.   When the glands about the neck  are
affected the exciting cause is, in  general, cold, or local irritation,
as from dentition;  when  those  of the mesentery  are the seat ot
scrofulous  inflammation, the  enlargement may  proceed, in  some
instances from disease of the mucous membrane of the  intestines,
or the absorption of vitiated chyle; but there  are others m which
its occurrence seems spontaneous, or, at least,  there is no local
source to which we can with  propriety refer it.
        12—e                                   mSn 8 
114          morgan's principles of surgery.
  Scrofulous inflammation of a gland is peculiar to childhood, and
seldom met with after puberty; but we have seen disease of  these
bodies strongly resembling it, and  which we attributed to vacci-
nation.   Within two  or  three weeks after the application of the
vaccine lymph, the diseased  action  commences; glandular swell-
ings arise  in the groin, arm-pit, and neck, proceeding to suppura-
tion;  ulceration occurs  over  the joints  of  the fingers and  toes,
extending  to the  bones,  and  causing caries;  accompanied  with
general emaciation and a cachectic  state of the  system.   In one
child, at the age of four years, the growth had stopped  at the end
of the tenth month, while the disease continued to progress.  The
situation and extent of the local mischief—the period of its  inva-
sion,  usually within  a short  period after  vaccination—and the
absence of  any marks of scrofula in the parents or other children,
can leave little doubt,  in an unprejudiced mind, as to the nature of
the cause;  nor can we hesitate to  deny that the introduction of
vaccine lymph may not, under certain circumstances,  act as an
animal poison.
  Scrofulous inflammation may be confined to one gland, or spread
from one to another, till it affects the whole group in  the  vicinity.
In scrofulous inflammation, the gland itself is slowly enlarged, of a
dusky brown colour, and more vascular;  when  cut into,  a  peculiar
gray-coloured substance  like  mortar is seen deposited in  different
parts of the tissue, forming the proper scrofulous tubercle to the
softening and future changes of which the subsequent disorganisa-
tion is  to  be attributed.  The  local  symptoms  are  swelling;
increased heat, perceptible on  examination of the hand ;  more or
less pain on pressure; and with an absence of constitutional fever.
The general health, however, in most cases,  is  disturbed;  the  skin
feels harsh  and dry;  the  tongue  covered with a brown  fur; the
breath fetid; the evacuations from the bowels  unnatural;  and the
appetite depraved.
  If the inflammatory action  is  not  repressed, the swelling  con-
tinues to augment, the body of the  gland is uniformly enlarged,
and  the  tumour  acquires a doughy  feel, which   is  gradually
exchanged  for  one of fluctuation.   The  skin over  the swelling
often  takes on a livid  tint; and, if an  incision is now  made into
the gland, a thin fluid, mixed with a peculiar curd-like  substance,
is discharged.  If no  artificial opening has been made, the skin at
one part turns  darker, next it is thinned and  ulcerates, and  then
the contents of the abscess are evacuated.  In general, the ulcera-
tion extends a considerable way over the gland, and the integu-
ments are  so loose and detached that a probe may be  insinuated
around and beneath  them.  After  the matter is discharged, the
cellular tissue which formed a capsule to the ganglion remains as
a cyst, and secretes a thin whitish fluid;  the skin retains its red or
pink  appearance,  and un untractable and  unseemly sore is left
behind.  Sometimes  the  abscess bursts  in several  places   and
bridles of diseased skin cross the surface of the ulcer in  different 
inflammation in different structures.
113
directions, from beneath which the discharge oozes.   An  ulcer
thus  formed  shows  no disposition to granulate,  but remains
stationary, and secretes a thin glairy fluid ;  the skin around retains
its red colour; and, should cicatrisation take place, the integuments
are so much puckered  and drawn together that considerable de-
formity results.  In some instances, the  glandular  swelling con-
tinues indolent; the skin does not change its colour;  no  uneasiness
is experienced from  handling the parts;  and,  after a time, the
enlargement subsides.   On  the other hand, whenever the tumour
turns painful, begins to soften, and the skin over  it puts on a  dusky
red appearance, we may be assured that imperfect suppuration will
follow. Scrofulous inflammation never terminates in mortification,
but  often in ulceration.  It is, in  fact, a chronic disease, modified
by a peculiar habit of body, and is often remarkable for its indo-
lence at one time and its sudden activity at another.  The changes
arising in the lymphatic glands from scrofula,  especially in those
about the neck in females, are of great importance to the surgeon,
 both from the frequency of their occurrence, and  the deformity
 resulting from unskilful treatment.                            .
   Serous Membrane.—Under this head we include the arachnoid
 of the brain, the pleura and pericardium  in  the chest,  the  perito-
 neum in the  abdomen, and  the  tunica vaginalis of  the testicle.
 These membranes, in  the  natujal  state,  are thin,  shining, semi-
 transparent, lubricated  by a fine fluid  on  their  inner surface, and
 connected to the subjacent parts  by cellular tissue ; when affected
 with  inflammation, they lose their brilliancy  and transparency,
 become opaque and thickened, and numerous vessels, carrying the
 coloured portion of the blood, ramify  throughout their structure.
 In studying the effects  of inflammation in this class  of membranes,
 it is necessary to pay particular attention  to the cellular tissue by
 which they are connected to the subjacent parts.  It is  in this con-
  necting tissue the first  indications of inflammation are to be found,
  and to which the morbid appearances are  confined, should  the dis-
  ease prove fatal within a few hours after its invasion   It varies in
  quantity in different situations, and even in different  parts of  the
  same cavity;  in some, loos,e and  abundant, as  between the arach-
  noid and pia mater; in others, more dense and  sparing, as between
  SormerPand the aura mater.   This  variety in the distribution of
   heSla? tissue modifies  the  effects of inflammation in serous
  membranes, and is a point to  which the attention of the patholog.st

  Sh°TUnde c^retJmtroVlcute inflammation in a serous membrane
  is denoted by the infiltration and injection of its  subcellular tissue
  with red veLls.  As  the morbid action goes on  the infiltration
  mcreases-  the serous fluid penetrates between  the layers of  the
   eroiis membrane itself, and  causes increased  thickness, with loss
  of transparency.  The opacity, at least at first,  is not owing, as  has
  been Sally supposed, to the natural exhalation from the surface
  o ethegnembrLe naving ceased,  but to the fluid effused between its 
116           morgan's principles of surgery.

layers and into the connecting cellular tissue.   These changes are
best  seen by dissecting off the membrane, and placing it between
the eye and the light.  As  the  morbid action  spreads from the
adherent to the free surface of the membrane, red vessels appear in
solitary parts, forming lines which coalesce, and leaving the inter-
vening  portions of the tissue opaque and thickened.   When the
inflammation  is  very intense, some of the vessels  occasionally
burst, by which  blood is  poured out, and which has  been  erro-
neously imagined to be a secretion.  There are some serous mem-
branes,  as the arachnoid,  which seldom  admit of being injected
with red blood, and others  in which  the redness is not permanent;
so that  the  most obvious  signs  of inflammation,  in this class of
structures where the disease  has terminated early, are  their milk-
white appearance,  loss of transparency, increased thickness, and
infiltration of a serous fluid into the subcellular tissue.
  Inflammation  may  thus begin and  end without  any further
changes; but, in general,  as soon as the  disease reaches the free
surface of the membrane, the natural exhalation is suspended, and
new  products of different kinds are formed.  These may consist of
a serous fluid of different colours  of lymph, or of purulent matter;
and one or all  may occur together in the same case.   When the
inflammation is  moderate, the  effused fluid  is either clear and
limpid, or slightly lemon-coloured; it is made up of water, holding
a small quantity of albumen in solution, and from which its slightly
alkaline property is probably derived.  When  the morbid action is
more acute,  the  surface of the  membrane is coated over with  a
soft plastic substance, susceptible of spontaneous coagulation, and
found, on analysis, to be fibrin mixed with a small quantity of an
albuminous  fluid.  As the thinner  part is absorbed,  the effused
substance becomes more adhesive, but may readily be scraped off,
so as to  leave the surface of the membrane smooth beneath.  This
lymph or  fibrin—known  by the name of adventitous.  false, or
pseudo-membrane—is afterwards  penetrated by blood-vessels, and
unites the opposite surfaces of the tissue on which it is effused.
  The period within which the false membrane is organised seems
to vary  extremely.   In some cases, vessels  have been discovered in
less than twelve hours from the  supposed effusion; in others, no
vascularity could be detected after a lapse of several months.  It
is not improbable, that much  of  this discrepancy depends on the
unsuccessful  manner  in which the  examination" has been made;
for the vessels in the clot of blood have been successfully injected
both by Mr.  Hunter and Sir  Everard Home.   The vascularity is
first  indicated by a number of red dots, resembling the  "puncium
saliens" in the vitellary membrane of the chick, which run together
and form lines, communicating frequently, and traversing the niem-
brane in various directions.   These red  lines are soon observed
to be the rudiments of the  future vessels through which the blood
regularly circulates, and which increase in number as the organisa-
tion  becomes more complete.   It  is still undetermined, however in 
          inflammation in different structures.      117

what manner the newly-formed membrane acquires its vascularity;
whether the vessels shoot into the effused lymph from those of the
serous  membrane beneath;  or, whether they are not first formed
in the  lymph by an independent vitality inherent  in itself.  The
former is  the  opinion generally entertained, and is supported by
the recent microscopical researches of Gendrin ;  the latter has been
insisted on  by Laennec, who  considers that portions of effused
fibrin perform the functions of secretion, absorption, and nutrition,
before  any trace  of vessels  can be discovered.  In whichever of
these two ways the vascularity is first effected, we observe that,
after its completion, nerves  and absorbents supply the new forma-
tion ; next succeed those changes by which the false membrane
resembles the tissue on which  it had been  thrown out, becomes
itself susceptible  of taking on  the process  of inflammation, and
gives origin in turn to similar exudations.
   Where lymph is effused on the surface of a serous membrane by
inflammation, we frequently find that other  fluids are poured out
along with it; but,  in some rare instances, the exudation of  fibrin
takes place alone.   Very frequently masses or shreds of the lymph
are detached, and seen floating  in the other fluids which  are pre-
sent.   In such cases, the serum is generally, turbid, or has a  slight
sanguineous admixture, yields on examination more albumen, and
shows  stronger alkaline properties.  When the inflammatory  ac-
tion is  greater,  and has continued for several  days,  the serum
becomes highly alkaline, acquires a greenish or yellowish colour,
and often contains a considerable quantity of pus, which falls to the
bottom, and gives out an offensive smell.   In the most acute form
of the disease, mortification ensues, and, in some cases, with  great
rapidity.  Primary ulceration of a serous tissue never occurs  as an
effect of acute inflammation.
   Serous  membranes are very liable to be affected  by  chronic
inflammation, and in them the disease gives rise to different results.
It is during its long continuance that we find the opposite surfaces
of these tissues so" firmly connected ; as the arachnoid  lining the
dura mater  to that covering the upper  surface of the brain, the
pleura pulmoualis to the pleura  costalis, and  the peritoneum to the
intestines.  From the lymph which is thrown out becoming organ-
ised, and in its turn giving origin to fresh exudations, the original
membrane always appears much thickened; the subserous tissue
is filled with coagulated  albumen, and the vessels have a dull red
or brownish appearance.   When the adventitious and subcellular
tissues  are macerated and then carefully dissected  off, the proper
membrane will be found opaque, and of its natural thickness.  The
most extensive adhesions are in this way formed, especially in the
chest and abdomen; and in the former often without any complaint
of pain, or the individual being aware of the existence of the dis-
ease  False membranes, thus originating, are frequently extremely
firm, and yield to the knife with "as much difficulty as a piece of
cartilage. 
118           morgan's principles of surgery.

  In chronic inflammation of a serous structure, adhesions may
exist with or without the presence of other fluids.   In some  cases,
particularly when the peritoneum is affected, tubercles form on the
inner surface  of the membrane, and  which may suppurate and
burst into the general cavity.  Chronic inflammation may cause
increased secretion from the exhalent surface of a serous membrane,
and give rise to a form of dropsy.  All the three great cavities are
liable to this variety of disease.  Purulent  matter  may also  be
poured out by a serous tissue, under long-continued passive inflam-
mation.  This is more especially met with in the chest, where it
has received the name of empyema; and where the  fluid collects
in such quantities as  to fill the cavities of the pleura, without any
ulceration or breach of surface.   In these cases we have generally
found the membrane  thickened and opaque, and its interior rough,
and  having a  granulated appearance.   The  amount of  either
serous  or purulent fluids, effused during chronic inflammation of a
serous  texture,  is so various that no  general estimate can even be
given; in the brain  it cannot exceed a few ounces, while in the
chest or abdomen it may weigh several pounds.
  The  local  and  constitutional symptoms  are  probably  better
marked during acute inflammation of a serous  membrane than in
any other texture of the  body, and usually correspond to the inten-
sity of the morbid action and the strength of  the patient's constitu-
tion.   The effect on the system, however, varies with the particular
seat  of disease.  Thus,  in the head or chest, the pulse is full and
bounding, and the symptomatic fever of the sthenic type; while in
the abdomen the former  is small and wiry, and there is apparently
great depression of the vital powers.  This discrepancy can only
be ascribed to the nerves with which the peritoneal  membrane is
so freely supplied, and  which are derived from  the ganglions of
the great sympathetic ;  in all such  cases, too, the pulse becomes
rounder and softer after  free depletion.
  Mucous Membrane.—This tissue lines all  the different outlets
of the body,  and  is extremely liable to become inflamed.   When
we consider  the extent of surface over which this membrane is
diffused, and the numerous sources of irritation  to which it is ex-
posed, from external as well as internal impressions, we need no
longer wonder at its  being so  frequently the seat of disease.   Thus
we have a mucous tissue lining the eyelids, nose, mouth and throat;
the  trachea, to its minutest subdivisions; the oesophagus, stomach,
and the whole of  the intestinal canal;  the ducts  and pelvis of the
kidney;  the ureter,  bladder  and urethra;  and in the female, the
uterus and vagina.  The mucous membrane is far more extensive
than the  external  covering of the body to which, in  so many re-
spects, it is allied; nay, it has even  been calculated  that the lining
of the bronchia?,  if  unfolded, would exceed by several times, the
square surface of  the skin; and hence the free channel opened up
for the absorption of  the various atmospheric  poisons.
   In its natural state, the mucous membrane  is pale;  but  imme- 
inflammation in different structures.      119
diately on inflammation taking place, it  becomes injected with red
vessels.  Its structure is so much more lax than that of a serous
membrane, that, red blood at once circulates through it;  hence red-
ness is the earliest sign of incited vascular action.  In post mortem
examinations,  particularly of the abdomen, we must be  careful not
to mistake redness of the mucous membrane from other causes, for
that arising from inflammation; the former is evanescent; the latter
is unaffected  by pressure or position, and does not disappear after
maceration or drying.  The  brightness of the colour varies with
the acuteness  of the  inflammation; in the most vehement species,
the membrane is of a scarlet tinge.  Immediately after the  morbid
action has commenced, the submucous cellular tissue is injected
and infiltrated with  a reddish  serum, which,  along with  the in-
creased vascularity of the membrane itself,  gives rise to swelling.
In some cases,  the tumefaction thus created is the cause of very
formidable symptoms—as in ophthalmia, to protrusion of the con-
junctiva and elongation or the eyelids;  or in laryngitis, to narrow-
ing of the glottis and impending suffocation.
   Derangement of function is  also one of the first indications of
inflammation  in the  mucous membrane.  Its natural  secretion in
 health  consists  of animal  mucus,  held in  solution by a  watery
 fluid ; unlike that from a serous tissue, it is readily discharged from
 the system;   hence its examination becomes valuable where the
 actual disease of the  membrane  is concealed from view.  The first
 effect of inflammation is to increase  the secretion and convert it
 into a thin, transparent, or brownish-coloured fluid, possessing, with
 the exception of  that from the alimentary  canal  which  always
 remains acid, slight  alkaline properties.   These changes  are best
 exhibited by dipping a piece of turmeric or litmus paper in  the dis-
 charged fluid.  Frequently, the secretion  is  rendered more acrid
 fronfan increase in the quantity of soda, excoriating the parts oyer
 which it flows, and also coagulating,  when thrown  into boiling
 water, from the albumen it  contains.   Sometimes, at this  stage,
 the secretion is tinged with  blood, or  some  of the over-distended
 vessels burst, and pure blood is discharged; and if the latter is in
 any quantity, it usually has  the effect of relieving the local com-
 plaint.  As the inflammation increases, the secretion diminishes,
 and  is sometimes  completely suspended when the disease is at its
 climax- in other cases, the discharge, though diminished in quan-
 tity, continues  during the whole period.   As the inflammation
 beo-ins to  decline, the secretion returns, altered, however, in cha-
 racter*  being a mixture of transparent mucus and yellow pus, or,
 as it has  been  named, puriform-mucus.  The  proportions of pus
 and  mucus may be pretty  accurately ascertained  by the viscidity
 of the discharge,  and by the common test  of throwing part of it
 into water.   If mucus abounds, the fluid is tenacious,  ropy, and
 floats on the surface  of the water ; if pus predominates, the secretion
 is less viscid, and  it  sinks  to the bottom of the vessel.  When the
 inflammation has been very acute, the secretion is principally pun- 
120          morgan's principles of surgery.
form; and, as the disease declines, the mucus again becomes more
copious.   In all cases, the increased discharge has the effect of
relieving the congested state of the membrane.
  Where  puriform matter  is furnished by a mucous membrane, no
ulceration, under ordinary circumstances, is  present; there is a
mere alteration in the mode of secretion, as is proved by the return
to mucus as the disease declines, and by no breach of surface being
descernible on examination.   It may be  stated, as a general law,
that mucous tissue  shows a greater disposition to run  into suppu-
rative inflammation; serous, on the contrary, is more prone to take
on the adhesive mode of action.  This is  a provident arrangement
in nature; for,  had the phenomena been reversed, we should have
had, in the one case, outlets obstructed; and, in the other, secondary
effects proving  almost invariably fatal.   When, by the violence of
the local action, false membrane is thrown out on a mucous surface,
we generally find that a fluid is  effused  between them, by which
their adhesion is prevented  and the effused  lymph may be dis-
charged.   We have examples of this in croup, where  the false
membrane is coughed  up;  and occasionally, in virulent gonorhoea,
where shreds of lymph, resembling  the  urethra  in shape, come
away with the urine.  In the experiments  recorded by Mr. Hunter,
it required the  most violent means to induce the adhesive inflam-
mation in  a mucous structure.  In some instances, the  mucous
membrane is found in  a state of mortification; it is then easily lace-
rated and detached, and gives out a fetid smell—from both which
signs we  are  enabled  to distinguish it from congestion or extrava-
sation of blood info the subcellular tissue.
  The general effect of acute inflammation, in a mucous membrane,
is to render it soft, pulpy, and easily scraped off from the adjoining
tissue.  The disease usually commences  in distinct patches, occu-
pying only a small  extent of surface and leaving the intervening
portion free;  sometimes the inflamed spots run together, and the
affection  spreads rapidly along the membrane.  In what has been
described by Bretonneau, under the name  of diptherite, the inflam-
mation first appears  in the  fauces, but quickly extends upwards into
the nasal fossae, and downwards into the trachea and bronchias, and
proves fatal within  a few  hours after its commencement.  Suppu-
ration frequently occurs in the mucous follicles when the membrane
lining the mouth and throat has been inflamed, as in certain forms
of fever;  and these abscesses have been long known under the title
of aphthse. Pustules are said likewise to be found in the intestinal
canal, when the skin is the seat of small-pox.
  Chronic inflammation of a mucous membrane occurs in solitary
spots of a brownish colour, leaving the intermediate portions of the
tissue free and of the natural appearance.   In this form of disease.
the membrane is sometimes  softened, pale and thin, as we have
found in  bronchitis; more  generally, it is indurated and thickened
and its vascularity is distinctly increased.   In cases of long stand-
ing, the induration  and thickening arise from effusion of an albu- 
inflammation in different structures.      121
minous fluid among the interstices of the membrane and into the
subjacent tissue; the parts are firm to the touch, and cut with the
knife  like cartilage, as in old permanent stricture of the urethra.
The secretion from the membrane consists of a viscid, ropy mucus,
with or without admixture of purulent matter—the quantity of the
latter  varying generally with the degree of inflammation present.
A  small extent of membrane will sometimes furnish  a copious
mucous discharge.  In catarrh of the bladder, the vessel containing
the urine will be half filled with mucus, so tenacious as not to fall
out when the vessel is inverted.  In such cases, the system speedily
sympathises with the local disorder, and the  general health breaks
up.
   Ulceration is a frequent effect both of acute and chronic inflam-
mation in a mucous membrane, and occurs with greater facility  in
some  situations than in others.  Its most frequent seat  is in the
intestines, and next in the  urinary organs;  while,  with the excep-
tion of the  nostrils, throat and larynx, the rest of the  respiratory
apparatus may be considered exempt.  The ulcers assume different
characters,  and vary in depth, extent and number.   When the
ulcerative action is acute, a considerable portion of the membranous
surface may appear abraded; or the ulcers may be small, distinct,
and with irregular edges.   The ulceration may be confined to the
mucous  membrane or  extend to the  neighbouring tissue; in the
intestinal canal, the muscular and peritoneal coverings are thus
penetrated, and the fascal matter escapes into the general cavity of
the peritoneum.  The perforating ulcer in the intestinal canal  is
more  frequently the result of acute than chronic inflammation, and
will generally be found to occupy the last portion of the ileum and
the beginning of the colon.  In chronic inflammation, the ulcera-
tion is mpre"sluggish; the edges of the sores are better defined,
being  tumid or Inverted from the thickening of  the  subcellular
tissue.  Although ulceration of a mucous  membrane is in many
cases  a formidable occurrence, we have not, with few exceptions,
any distinct proof at what period it may have taken place.  The
appearance  of pus in the discharge is no indication of such a
change, because it is a peculiar property of these  tissues to have
their'secretion for a time  altered, and converted into one of a puru-
lent character.   In inflammation of the mucous lining of the intes-
tines,  where there is a sudden increase of pain with great distension
of the abdomen, a feeble pulse, and rapidly-approaching dissolution,
we have reason to fear that an ulcer has penetrated the coats of the
viscera, and allowed some portion of fasces to  escape.  In catarrh
of the bladder, again when ulceration has occurred, the sufferings
are much augmented from the urine  coming in contact  with the
abraded surface.
   When mucous membranes are inflamed, their natural sensibility
is  only slightly increased; the pain, even in the most acute form, is
trifling- compared with that  arising from a serous tissue, and  i3
o-enerally of a dull and prickling character.   We endeavoured  to 
122          morgan's principles of surgery.
explain this difference when treating of pain as a local symptom.
The increased sensibility of mucous textures appears likewise to be
principally called forth, when any of the fluids which wash over
them in their natural state come in contact with them when in-
flamed. This symptom, independent  of all  others, is valuable to
the medical practitioner, as showing him that some portion  of the
membrane is in a morbidly irritable condition.  When the mucous
coat in the lower part of the intestines is inflamed, pain, tenesmus,
and griping, are present before an evacuation, after which a corres-
ponding feeling of relief is experienced. Should the bladder  be the
seat of disease,  there is frequent desire  to  empty it, and  great
uneasiness while the urine  is collecting;  in  gonorrhoea, the pain,
from the urine passing over the  inflamed surface, is often extreme.
The fever accompanying  inflammation of a mucous  membrane
partakes more or less of the typhoid character; nor in any form we
meet with, do we find the well-marked sthenic variety which  occurs
during a similar state of a serous tissue.
  Fibrous  Tissues.—Under this general head, the anatomist in-
cludes the fascia? about the joints, those binding down the muscles
in particular situations, as  in the fore-arm or thigh, tendons, liga-
ments, periosteum and aponeuroses of all kinds; but whatever may
be their natural structure, pathology teaches us that many of them
are at least distinct, as they relate to disease.•  Inflammation, either
acute or chronic, of the fibrous  tissue  around the joints, or  of the
aponeurotic expansions covering certain muscles, as those  of the
back, constitutes true rheumatism—an affection peculiar both in its
nature and treatment. However violent or long continued the local
action may be, we rarely or never find that it proceeds to suppura-
tion; the most ordinary effect is an effusion  of lymph, with  thick-
ening and rigidity of the tissue, and  by which the motions of a
joint  may be much impaired.   The  disease seldom attacks the
muscular  fibre; and when  muscles  are  in  this way made to
participate, their affection is entirely  secondary.   Rheumatic  in-
flammation is remarkable for its tendency to recur in some form or
other; and, in certain constitutions, its attacks are apparently much
influenced by the temperature of the weather.  It often assumes an
erratic form, leaving its original seat, and wandering from joint to
joint, till it travels over the different articulations of the body.  In
some cases, the inflammation translates itself to an internal part of
similar structure, as the membranes of the brain, but more generally
the pericardium or pleura; and  it is not uncommon to find both
the external and internal affection existing at the same time.  Such
cases have been described as a metastasis, or translation of the dis-
ease; and  in connection with chronic rheumatism, we have seen the
surface of the  heart studded with small nodules of lymph,  firmly
imbedded  in  the substance of the membrane, and givino- to it a
rough and granulated appearance.
   Rheumatic inflammation of  a joint is  marked by redness and
slight  swelling; the  pain is aggravated during the  night  or on 
          inflammation in different structures.      123

motion, and in some cases by preternatural heat, and in others by
exposure to cold.   During the symptomatic fever consequent on an
acute attack* the  functions of the  brain never  suffer;  there  is
usually a moist state of the  skin  and tongue from the commence-
ment;  the blood is buffed out of  all proportion to the exigency of
the case, and remains so throughout.   Inflammation, again, of such
fibrous  tissues as those of the forearm or thigh,  and  which may
ensue spontaneously or after wounds,  manifests no disposition  to
change its seat; the local as well as the constitutional symptoms
run high;  the swelling and tension are very great, and suppuration
generally follows.   In the worst cases, mortification succeeds;  the
membrane changes to  an ash colour, loses its vitality, and sloughs
away in shreds.   Ulceration never occurs as a primary  effect of
inflammation in fibrous textures.
   Muscular Fibre.—Muscles are rarely the primary  seat of in-
flammation ; and, considering their great abundance in the body, it
is a fortunate provision.  They are sometimes secondarily affected
by the disease spreading to  them  from their coverings, as we
observe in  rheumatism and enteritis.   One  of the most curious
effects from inflammation is a motionless state of the muscle;  the
fibres are paralysed, and no irritation of the nerve supplying them,
or even the application of galvanism, will cause  their contraction.
We have an example of  this in  enteritis, when the inflammation
spreads from the serous to the muscular covering of the intestines;
obstinate constipation is then present, and all attempts to  relieve it
by purgatives are both fruitless and improper.
   When muscles  are injured by  external violence,  by the sharp
fragment of a fractured bone, or, in the lower animals, by a power-
ful stimulus, we have then an opportunity of watching the effects
resulting from inflammation.  There is first an increased influx of
blood, by  which  the  muscular fibres are rendered of  a deeper
colour,  and the cellular tissue is injected;  next follows an effusion
of serum and lymph, agglutinating the  substance of the  muscle and
increasing  its  bulk.   Some of the  over-distended vessels burst,
blood  is effused amongst the cellular interstices, and the proper
muscular fibre is  softened.   If the inflammatory action  is more
violent, in  addition to other fluids, pus is deposited  in  different
parts of the muscular structure,  which  now loses its  cohesion so
completely  as to lacerate  in all directions on the slightest touch.
Should mortification  ensue, the fibres turn black or green, readily
tear,  and slough  away in  detached shreds.   When a portion of
muscle is thus lost or "purPoselv cut awaY> its Place is suPPned by
an adhesive matter of great strength, which serves  as a bond of
union  between the separate  ends, but which never assumes the
appearance or action  of  the original  fibre.   Ulceration never
occurs  as a primary effect of inflammation in muscular fibre;  and,
when muscles are engaged in this process, as we observe in the
heart, extremities, &.c, it is from the  ulcerative  action spreading
from 'an adjoining tissue, and involving them in its progress.  The 
' 124          morgan'^ principles of surgery.

 tendons of muscles, though exhibiting neither sensibility or vascu-
 larity in the normal state, are, nevertheless, susceptible, of becoming
 inflamed.  Under this process they are slightly reddened, lose their
 glistening appearance,  and assume a dull or dead white ;  their
 cohesion  is so far destroyed as to make them plastic to the touch;
 their vitality  is readily extinguished, and they always separate at
 their connection  with the muscular  fibre.
   Synovial Membrane.—The synovial, like the serous membranes,
 form shut sacs, have a shining or polished appearance on their inner
 surface, and secrete a glairy albuminous fluid which lubricates the
joints.  They are subject to  inflammation of an acute or chronic
 form;  and those  which line the knee or ankle, either from extent
 or having the thinnest covering, are the most frequently attacked.
 Acute inflammation usually commences in one spot, but quickly
 spreads over the rest of the membrane;  the cellular tissue on the
 outside of the joint is infiltrated with serum; the capsule itself
 becomes highly vascular ; an  increased quantity of synovial fluid,
 of a less albuminous quality than occurs in health, is poured out;
 and from all which there arises considerable local swelling.   If the
 inflammation  is  violent or long-continued, coagulable lymph may
 be  effused into the cavity of the joint;  the synovial membrane
 may, from the same cause, be thickened, and  its opposite surfaces
 made to adhere; but these effects  are  not so common  as in the
 serous tissues. In some cases, under great local excitemeut, puru-
 lent matter is  secreted, forming an abscess within the capsule, and
 making its way out by one or more ulcerated openings.  Sir B.
 Brodie1 considers that suppuration  rarely takes place from a syno-
 vial membrane, independent of ulceration; but, although this holds
 true as respects  chronic diseases, pus is frequently  effused  during
 acute inflammation, without any breach of surface.  The constitu-
 tional symptoms, from active inflammation of a large joint, as the
 knee, are often  exceedingly severe, the fever being principally of
 the sthenic type; when purulent matter forms, delirium and coma
 ensue, and, should the patient survive, the inflammatory is suc-
 ceeded by fever of a hectic character.
   Chronic inflammation of a synovial membrane  is of common
 occurrence, and has long been described under the absurd title of
 rheumatic white swelling.  The disease is at first confined  to one
 part of the membrane, and slowly spreads  throughout the tissue;
 there is an increased collection of synovia  in  the joint, but which
 is afterwards  absorbed if the inflammation  subsides.  In cases of
 long standing, the synovial membrane becomes thickened, its inner
 surface deeply coated with coagulating lymph, and the shape of
 the joint considerably altered; eventually, suppuration takes place,
 the capsule ulcerates in one or more places, and the  articular carti-
 lages are absorbed.  Where ulceration of the  cartilages,  however,
 is observed in combination with inflammation of the synovial mem-
1 Treatise oa Diseases of the Joints. 
inflammation in different structures.      125
fcrane, it more frequently happens  that the former has been the
primary or leading affection—the latter only supervening on the
formation of an  abscess within the joint.  Inflammation of the
synovial membrane is not so  common  in  young persons  as in
adults, a circumstance which assists us in distinguishing its  more
chronic forms from some other diseases incidental to joints.
   Lastly, the synovial membrane is subject to a peculiar change of
structure, by which  its natural organisation is  completely effaced.
The capsule assumes a reddish brown colour, and is converted into
a pulpy substance, varying from a fourth to half an inch in  thick-
ness.   The disease generally involves the entire membrane, and
remains indolent for a length  of time; the cellular tissue on the
outside is infiltrated, and there  is much stiffness and immobility of
the joint.   As the disease progresses, abscesses form in various
situations; the articular cartilages disappear; the ends of the  bones
become carious ; and, unless the joint is removed, the patient wastes
under the accompanying hectic fever.  This change in the  struc-
ture of the  synovial membrane has been supposed by some to be
independent of inflammation, but it is more probably the result of
this species of morbid action  in a scrofulous  constitution.   The
knee is almost the invariable seat of the affection ;  it takes place in
early life, and cannot be arrested by any means we  are yet pos-
sessed of.
   Cartilage.—This structure  is neither  very  liable to become in-
flamed, or  capable of long withstanding the  irritation from disease.
When inflammation spreads  from a synovial membrane to the car-
tilage beneath, the  latter first becomes vascular, then swollen and
of a spongy consistence, and, lastly, ulcerates at one or more points.
 Ulceration of the cartilage  of a joint may either follow from disease
in its neighbourhood, or it may arise as a primary affection, and
while the other parts making up the  articulation are  sound. Pri-
 mary ulceration of an articular cartilage  seems, in the  majority of
 cases, to be independent of inflammation;  but is generally preceded
 by a soft and spongy state of its structure.  Mr. Key of Guy's Hos-
 pital has endeavoured to show that the absorption of articular car-
 tilage is caused by the synovial membrane, some portion of which,
 if the joint be carefully opened, will  be found  of a fringed appear-
 ance  and lying in  contact with the abraded surface; but, besides
 the proofs  that cartilages possess absorbents as well as blood-vessels,
 we find them ulcerated in situations where  no synovial membrane
 is opposed to them, as where the absorption commences  on the side
 next the bone.
    Ulceration, or rather ulcerative absorption of an  articulating car-
 tilage will go on for a length of time without any purulent  matter
 beino- effused into  the joint, and even when the ends of the bones
 have'been rendered carious.   The formation of pus, in  such cases,
 seems to be principally dependent on the inflammation of  the sy-
 novial membrane.   The  disease  is attended  with pain  from the
 commencement, especially on the ends pf the articulating bones 
 126          morgan's principles of surgery.

 being rubbed against each other, while the joint retains its size and
 shape.  As the ulceration extends, the heads of the bones and the
 synovial membrane become  affected; abscesses form  within  and
 without the joint and open in various places, and secondary dislo-
 cation may ensue.   While the ulceration is confined principally to
 the cartilages, and  matter is  not formed within the  joint, there is
 every chance of the ends of the bones throwing out granulations,
 and the limb  becoming anchylosed;  but, where the  disease has
 spread  to the  synovial membrane, and suppuration followed, the
 hopes of a natural  cure are  nearly precluded.   Ulceration of the
 cartilages forms one of the varieties of while swelling; and, though
 more frequently met with at the knee, is not confined to any articu-
 lation.  It is a disease peculiar to early life, and seems immediately
 connected with a scrofulous habit; there is no attempt ever made to
 regain the lost structure, and  hectic fever attends throughout.
  Periosteum and  Bone.—The pathology of the osseous system is
 not well understood, and  we are ignorant of  the manner in which
 many of the changes incidental to its structurue are accomplished.
 Bones do not,  as  was once supposed,  consist of laminae or plates
 united together by narrow processes, but are simply made up of a
 reticular tissue, into the cells of which the proper ossific matter is
 deposited.  They are furnished with vessels, nerves,  and absorb-
 ents, by which they are organised and have bestowed on them the
 properties of other textures; they are, therefore, like the soft parts,
 capable of taking on diseased action and repairing injuries inflicted
 on their substance.  The diseases of bones are only remarkable for
their duration and the obstinacy with which they yield to remedial
 means,  peculiarities which are easily explained by a reference to
 their structure.
  In studying the diseases of bones, there are some points in their
 natural history deserving  of  being carefully remembered; one of
the principal of which is,  the difference  of arrangement observed
 amongst the osseous particles.  Thus, some bones, as those compo-
 sing the extremities, have a dense solid wall of osseous matter en-
 closing a canal within, which is filled with  a spongy or reticular
texture, and in which the membrane ramifies that secretes the mar-
 row.  In these long  cylindrical  bones, the  compact structure is
greatest in the centre; while,  towards  their extremities, which are
expanded to afford a larger surface  for articulation, the density of
the external wall gradually decreases, and the interior is filled with
large cells,  or,  as  it is frequently named,  a cancellated tissue.  In
 another class, again, as the vertebras, or the small bones of the ankle
 and wrist, the spongy structure is accumulated, there is  merely a
thin solid plate of bone externally, and in these respects, they are
made to resemble the ends of the long bones.   In the broad flat
bones, as those of the head or pelvis, the compact substance is of
 moderate thickness, forming two layers or walls,  between which the
spongy  texture is enclosed.   These varieties in the arrangement of
the osseous particles have long been pointed out by the anatomist 
inflammation in different structures.      127
and they are equally worthy of attention from the pathologist, in as
far as they are frequently connected with different kinds of diseased
action.
  The bones are closely invested, except on their articular surface,
with a strong  dense membrane, named the periosteum, the func-
tions of which, in some of their diseases, have given rise to much
discussion.  It varies in thickness  according to the age of the indi-
vidual and the vascularity of the  bone which it covers; its outer
surface is rough, and united to the common cellular tissue; its inner
surface is smooth, and connected to the bone by prolongations which
line the canals transmitting the nutritous vessels.  The arteries of
bone are of  two orders—those  which are derived from the larger
vessels in the  neighbourhood, and  those which come from the peri-
osteum.   The former enter by the large foramina  seen  in bones,
run into the interior, and are distributed to  the membrane which
furnishes the marrow;  the latter,  which are small and numerous,
pass inwards through the minute pores visible to the naked eye on
the surface  of the compact tissue, and are  considered as the proper
nutritious arteries of the osseous structure.  Between the two orders
of vessels, and in the dense substance of the bone, an intimate com-
munication  is kept up—an anatomical fact which, if properly con-
sidered,  enables us to explain the  re-adhesion of the periosteum in
cases where it has been stripped off and again laid down ; and why
the surface  of the bone may not perish but throw out granulations,
where its investing membrane has been detached.  The vascularity
of bones, as well known, is greater in youth than in adult age, a
circumstance which likewise explains several points in their patho-
logy.  The presence of lymphatics in the  osseous  structure  is
proved by the absorption  going forward in certain diseases, and by
 the common experiment of feeding an animal on madder; while the
 existence of nerves, besides  being capable  of demonstration,  is
 plainly indicated by the  pain experienced during an  attack of in-
 flammation.  In studying the diseases of bones, therefore, we must
 particularly keep in recollection the difference in the distribution of
 the osseous particles; their being invested with a fibrous membrane
 without, and lined by a medullary one within; and the nature and
 mode of their vascular supply.
   Bones, with their investing  membrane, may be the seat of either
 acute or'chronic inflammation. The former frequently arises spon-
 taneously or from external injury; the latter is often connected  with
 a cachectic state of the system, induced by scrofula, the previous ex-
 istence of the venereal disease, or the unsparing use of mercury.
 From the unyielding nature of the structure, and the great resist-
 ance offered to the distension of the vessels or effusion of any kind,
 the most excruciating pain is  experienced in the acute form of the
 disease ; while, in  the chronic variety, and especially that connected
 with syphilis, the pain is observed to remit during the day and in-
 crease towards night.  Acute inflammation of the osseous structure
 is always accompanied by severe constitutional disturbance, and by 
 128          morgan's principles of surgery.

 considerable hardness and tumefaction  over the seat of disease.  It
 is most frequently met with in the superficial bones, as those of the
 leg or cranium; but those which are  well protected by soft parts,
 as the thigh, are nearly equally liable to be affected.  In some cases,
 acute inflammation hasattacked at once almost all the bones of the
 body, and proved rapidly fatal from the febrile disturbance which
 ensued.
   The periosteum is more liable to be inflamed than the bone itself,
 and may exist as a distinct disease without the bone participating.
 In such a case, the inflammation  is usually more active and more
 rapidly developed.  From  an intimate connection,  however, sub-
 sisting by blood-vessels  between the  periosteum and the outer sur-
 face of the bone, the inflammation soon spreads from the one to the
 other, although either for a time may remain distinct.   When the
 parts are examined, the blood-vessels of the affected bone  appear
 numerous and enlarged from their distension  with red  blood, the
 osseous structure is looser and more cancellated, and the foramina,
 for transmitting the small arteries, larger and more distinct.   The
 bone lies imbedded in an effusion of lymph aud serum, poured out
 from the inner surface of the periosteum, which  membrane is also
 thickened and  more vascular. The inflammatory action  is fre-
 quently communicated to the  cellular tissue external to the  perios-
 teum, lymph and other fluids are copiously deposited, and the limb,
 from this cause, is much swollen  and  indurated.   When a super-
 ficial bone, as the tibia, is thus affected, the integuments generally
 share in the morbid action, they become red and glistening, and the
 case is apt to be mistaken, by a careless observer, for one of phleg-
 monous erysipelas.  When acute  inflammation takes  place in the
 interior or medullary texture  of a bone, the pain is deeper seated,
 there is  much less external swelling, the  medullary membrane is
 thickened, and the bone itself enlarged.  From  the free vascular
 communication between the vessels of the compact tissue and those
 supplying the medullary cavity, the disease usually extends through
 the osseous substance and then involves the periosteum.
  Acute inflammation may be limited to a small portion of a bone,
 with its periosteal covering, or it may extend from one articulating
 extremity to another.   The disease terminates  either in resolution,
effusion of lymph, formation of matter, or death of the osseous sub-
stance.  When a bone is the seat of violent inflammation, it rarely
happens that a complete termination  by  resolution ensues • the
morbid action spreads rapidly to the  periosteum, and more or less
lymph and serum are poured out.  The lymph effused  beneath the
periosteum  remains and becomes  organised, ossification next com-
mences at different  points  and gradually extends throughout the
newly-deposited substance, and by which the figure of  the original
bone is destroyed.  While  the process of ossification is going for-
ward, the outer surface of the old bone is removed, but the absorp-
tion never takes place to such an  extent as to  restore  the former
appearance of the limb.   Such cases have been sometimes described 
INFLAMMATION IN DIFFERENT STRUCTURES.
129
under exostosis f but improperly, for they are always the result of in-
flammatory action, and do not, in" the least, resemble  that slow
growth of bone upon  bone to which the term exostosis  should be
strictly limited. This termination of acute inflammation is, therefore,
readily known by the alteration in the size and figure of the bone.
  Suppuration frequently follows incited vascular action of a bone,
either where the disease is external,  and has involved the perios-
teum, or where it originates in the medullary or cancellated tissue.
The formation of matter  in all these situations is attended with
severe constitutional  sufferings, proceeding, of course,  from  the
unyielding  nature of the  textures in which the pus is deposited.
When collected between the periosteum and bone, fluctuation  can
be so distinctly felt that no error need be committed; yet we have
known the effusion of lymph mistaken for it, and useless and pain-
ful. incisions  made  into  the swelling.  When secreted into  the
medullary cavity, there is  no local symptom to warn us of  its oc-
currence; the matter is too strongly protected to be felt externally,
and  often we are  not  aware  of its presence till on amputation or
examination of the bone after  death.  When suppuration  again
occurs in  the cancellated tissue, there is deep-seated pain; the bone
becomes enlarged and the periosteum thickened; the reticular cells
are broken down from the purulent fluid undulating through them;
the external compact shell  is absorbed; and then the absces breaks,
leaving a deep  chasm from which the discharge oozes out.  This
variety is common in the ends of the long bones, the lower jaw,
and the cranium; it  has  received the name of spinaventosa, and
been frequently, though erroneously, reckoned of a malignant cha-
racter.  The compact shell of bone  is with difficulty removed by
nature, and the purulent collection often gravitates in all directions.
We have an example of this after injuries to Ihe head, where pus
is deposited in  the diploe, and the abscess has not been opened by
perforating the outer  table of the cranium.  In  such  a case, the
fluid may^pervade nearly the whole of the concellated structure of
the  bones, bursting by numerous small openings beneath the peri-
cranium  on the outside,  and over  the dura mater on the inside;
and the skull, when macerated and dried, presenting the appearance
 of a sieve.                           .     „     ,   ,         ..
   Suppuration, either  on the external surface of  a bone  in its
 medullary cavity or its cancellated tissue, is, as might be expected
 more common than in its compact substance, which does not admit
 of such a change till opened out by the previous inflammation, and
 winch  is at all times more liable  to lose its vitality.   When acute
 inflammation, followed by suppuration and ulcerative  absorption,
  aLs pTace in bone, more especially where the disease has been the
 result of violence and is confined to  the external surface, we gene-
 rally observe that the constitution and the local parts together pos-
 ses/sufficient powers to  repair the breach which has been  made;
 eradiations spring  up from the osseous structure and unite  with
 fhose"from the surrounding parts  in  filling up the chasm. In other
        ^2__f                                    mgn J 
130           MORGAN'S PRINCIPLES OF SURGERY.

cases, particularly where the cancellated ends of long bones  are
affected,  the disease, though originating in the way we have men-
tioned, gets into  an indolent state, secretes  an unhealthy sanious
fluid, and reparation  is obtained with the utmost difficulty, either
by nature or art.   During the suppurative inflammation ot a bone,
the symptomatic  fever always runs high, and is similar to what
attends the formation of matter in the soft parts; while, after this
stage is over, and the disease acquires a lingering character, hectic
supervenes, under which and the local discharge the general health
may completely break up.
  Violent inflammation  of the osseous structure,  whether originat-
ing spontaneously or  from external  injury,  is frequently followed
by a loss  of vitality.  The word necrosis, from vtHou, to destroy, is
employed to denote the  death of a bone, and is used in  the same
sense as  the  term mortification  applied to  the soft parts.  It has
been justly doubted whether so vehement inflammatory action as
that which occasions  the death of  laxer tissues ever takes place in
bones.    Although  organised like  other parts of the body,  yet
organisation is of a low order ; the natural powers inherent in bone
are weak, and any excess of action  which causes obstruction  to the
circulation through the  minute vessels is likely to end in the death
of the texture itself.   Hence the  reason why the  least vascular
portion of the bone, or its compact tissue, is the most disposed to
perish, and why necrosis is more frequent in the shafts than in the
extremities of the long  bones—in  the flat than in the round ones.
As a general law, therefore, it might be stated that, from acute in-
flammation, the dense osseous structure is more subject to necrosis,
and the cancellated or spongy portion to suppuration.  During the
different  stages of necrosis, or  the separation of the old  bone and
the formation of the new, there arise some of the most curious and
interesting phenomena which can occur within the animal economy;
but we will return to this subject at a future period.
   While suppuration and necrosis  are to be traced to acute inflam-
mation in a bone, interstitial deposition and ulceration are the com-
mon results of a more  chronic form of disease.  It is during the
continuance of this latter state that we find bones becoming gradu-
ally enlarged, there being an increased deposition, not merely on
their surface,  but,  in many cases, throughout every part of their
parietes.   The inflammation and  swelling may be confined to a
small space, or affect a large portion of the bone, producing an un-
yielding  and incompressible tumour accompanied by a steady and
sometimes gnawing pain, and leaving, after the inflammation has
ceased, more or less permanent disfiguration.   When the disease is
limited,  it frequently appears as a  secondary symptom of syphilis,
and is then named a node. In such cases, the bones which lie nearest
the surface are the most  liable to suffer, as those of the shins elbows
and head; and, not unfrequently, different swellings exist on these
at the same time.  We have generally observed that the venereal
node commences in  the periosteum; this membrane becomes in- 
INFLAMMATION IN DIFFERENT STRUCTURES.
131
flamed and thickened; the disease then spreads to the outer surface
of the compact  tissue, and lymph is effused, which is'ultimately
organised and converted into bone.  Venereal nodes, however, are
of two  kinds—the one occasioned by acute inflammation, which
may  end in suppuration; the other,  the result of  slow chronic
action,  followed by effusion of lymph and subsequent formation of
new  bone.  In  either  case, they occur on  the  superficies of the
dense bones which are least protected by soft parts; and seem, as
we have said, to originate in the periosteum.
   Chronic inflammation,  with  enlargement, may occur  in any of
the bones of the body,  new ossific matter being deposited through-
out  every part  of their  substance,  and by which the medullary
canals and  cancellated textures are  completely  obliterated.   This
form of disease is also often described as exostosis ; and no distinct
boundary can, in many instances, be drawn between them.   Were
the term exostosis restricted to the exuberant growth  of bone on
the surface of bone, it would be easy to draw a line of distinction
between it and chronic inflammation, which first causes an effusion
of lymph; but when, according to Boyer, it is also  made to com-
prehend the enlargement of a part or of the whole  of a bone,  it
must be confessed that all chance of distinction is lost.  Chronic
inflammation just acts on bones as it does on soft parts, in the way
of causing enlargement of their substance ; neither do the former
more than the latter ever  regain their original size, after the undue
action has ceased.  Chronic inflammation of the periosteum some-
times occurs alone, and is liable to be mistaken for an affection of
the bone; this membrane will  even  have ossific deposits along its
inner surface, while the bone beneath remains perfectly free from
disease.
   Chronic inflammation,  as it is seen  in bones, admits of several
modifications, arising from the state of the constitution  as well as
the nature of the  local  action.  We have briefly alluded to two of
these under the  heads of enlargement of bones and venereal nodes,
and another has been described under the name of  caries.   This
 word is derived from %£»^, signifying to  abrade, and is best ex-
 pressed in  English by the word rottenness.   No definition has
 been given which accurately  describes  this condition of a  bone,
 yet the phrase caries has  been  in use for many centuries.  It has
 been generally employed  to signify ulceration of a bone, but there
 are several varieties of ulceration which ought not and  cannot be
 comprehended under it.   For example, there is a healthy kind of
 ulceration in bone, resulting from active inflammation which has
 ended  in suppuration, where granulations spring  up  from-the
 osseous structure,  and the resources  of the constitution are ade-
 quate to repair the breach.  This state is  not  to be mistaken for
 caries   Again, a portion of dead bone is separated from  the living
 bv a process of  ulceration or ulcerative absorption;  but  neither
 ouo-ht the term caries to be applied  to this  condition of  the  parts.
 We  would define caries  to be an unhealthy species of ulceration 
132          MORGAN'S PRINCIPLES OF SURGERY.

occurring in the spongy or cancellated tissue  of a bone, preceded
by chronic inflammatory action, showing little or no disposition to
heal, often arising from no evident cause,  and  for the most part
taking place at an early period of life.  To this definition it might
be objected  that caries is occasionally the consequence of acute
inflammation,  as in  some cases where purulent matter has  been
formed in the  ends of  long bones;  yet it may be replied that, in
such, the disease first beco'mes chronic, and the granulations fall
away before the state of caries succeeds.
  Caries is  confined to the spongy or cancellated osseous tissue,
and is therefore generally met with in  the  round bones, as the
vertebras, those of the  wrist or ankle, or the heads of the bones
composing the extremities.  It never occurs in  the dense external
wall, as  the tables of the cranium or the shafts  of the cylindrical
bones,  unless  previously expanded and opened out  by chronic
inflammation; and even  then, it  has been  considered as a sort of
pseudo-caries,  because  it  differs  from the original in being more
easily corrected.   The  fact of caries only occurring  in the loose
portion of a bone,  is of importance in enabling us to separate it
from necrosis  or death of a bone, an affection with which it was
long confounded.   The distinction  between these, in  one point of
view, is simple.  In caries, the  vital principle is still adherent;  in
necrosis, it is extinct.  The two are, however, sometimes combined,
as we observe  in the  heads of the long bones, and in some of those
of the face when arising from syphilis.  The absorption of a bone
from pressure, as from an aneurismal  tumour, or an  abscess, has
likewise  been  mistaken for caries;  but, in such cases, there is
simply a removal of the  osseous particles without any ulcerative   .
action, and as  soon as the pressure ceases the absorption stops.
  Whenever  we  have an opportunity  of watching a case  of
genuine caries from the commencement, we invariably find that it
is made up of two or three distinct stages, namely, one of chronic
inflammation—another of secretion of pus—and a third of ulcera-
tion.  The  spongy substance of the bone is, in the  first place,
affected with inflammation; then purulent matter is effused; and
this  finally  makes its way to the  surface  by causing  ulcerative
absorption of  the external compact shell—the periosteum, and the
integuments covering them.   The early stage of caries is attended
with considerable constitutional disorder; as soon as the confined
pus is discharged, the irritation subsides;  hectic fever subsequently
ensues, under  which and the secretion from the  bone, unless the
disease  is removed  by nature or  art, the  patient's  strength  is
gradually undermined.   We will treat more fully of caries when
we come to the subject  of ulceration.
  Another modification of chronic inflammation in bone  occurs
in individuals of  a  scrofulous  constitution.   Here  the disease
originates in the articular extremities of the long bones, and in the
spongy texture of the bones  of the carpus and tarsus;  and gives
rise to such formidable  disease of the joint as to  have received the 
INFLAMMATION IN DIFFERENT STRUCTURES.
133
name of the scrofulous white swelling.   Like all other affections
connected with  scrofula, it is incidental to young subjects; some-
times commencing in different parts  of the body at the same time,
or in succession, and often complicated with enlarged mesenteric
glands, tubercles in the lungs, and other signs of a  cachectic dia-
thesis.  When  the  bones  are examined  in an  early stage of the
complaint, the cancelli are found filled with a transparent fluid, the
earthy matter is partially removed,  and  there is increased vascu-
larity.  As the disease advances, the transparent fluid  is removed,
and  a yellow cheesy-looking substance,  resembling what is met
with in the absorbent glands, is deposited in its place; so little phos-
phate of lime now remains behind, that the bone may be cut with a
knife; and when macerated and dried, it is light and easily crushed.
There  is no enlargement  or increase  in  the  thickness  of the
diseased bone, the cells  are merely filled  with the peculiar  scrofu-
lous deposit, while the proper osseous particles are removed. When
the inflammation reaches the articular surface of the bone, vessels
carrying  red blood  are  prolonged into the cartilage; and this
structure, being incapable of resisting diseased action any length of
time, is absorbed.   The ulceration of the articular  cartilage  com-
mences in distinct points  on the  side next  the  bone, and spreads
through its  substance  till it  reaches the synovial  membrane re-
flected over it;  thus the disease of the bone is communicated to the
joint.                                               . •*
   While  these changes are going on internally, the tissue on the
outside of the  articulation becomes diseased.  The cellular sub-
stance is thickened and loses its cohesion; a serous  fluid and after-
wards coagulating lymph are deposited between the  capsule and the
 fascia which surrounds it;  hence  the swelling,  at first  soft and
 elastic, is succeeded by a firm colourless enlargement  of the  joint.
 The distension  and subsequent induration of the soft parts have
 <riven rise to the opinion that the heads of the bones  were enlarged;
 but when the other tissues are dissected away, such change is rarely
 if ever observed. As the disease advances abscesses form both within
 and  without the articulation, making their way to  the  surface  by
 circuitous routes,  and  discharging a  thin  pus, mixed with the
 coagulated  flaky substance met with in scrofulous cases.  When a
 probe is  introduced through any of these openings  it  is brought
 into contact with  the diseased bone;  and,  frequently, portions of
 the latter are detached, creating great irritation  before they are dis-
 charged  In some cases the purulent collections are confined to the
 cellular tissue,  and have no communication with the  cavity of  the
 joint—the ulcerated openings healing up in  one part and  breaking

 ^A^long  as  the  affection is confined  to the head  of the bone,
 thpre is  only a deep-seated  pain  complained of,  with stiffness  on
 movin- the joint;  but, when the cartilages are involved ancLpuru-
 lpni rmuter  is  formed  within the  articulation, the local suffering is
 severe and hectic fever, in its most aggravated  form, sets m.  The 
134
MORGAN'S PRINCIPLES OF SURGERY.
 progress of the disease varies extremely in different cases. In some,
 the morbid changes advance rapidly, abscesses appear quickly, and
 the articulating apparatus is destroyed within  a few months  from
 the oommencement; in others, years will elapse after the joint has
*been affected, and yet no suppuration may ensue.  The effusion of
 pus into the interior is a circumstance of great importance in all
 diseases involving a joint.   FiVen under the  most unfavourable
 circumstances, when the parts are kept in a state of absolute rest,
 the cavities of the abscesses may contract, the sinuses heal  up, the
 ends of the denuded bones throw out granulations, and the  patient
 escape with a stiff or anchylosed  joint.   The chance of a  natural
 cure, however, is much less  where the bones are affected by scrofu-
 lous  inflammation, than where their articulating extremities are
 rendered carious by disease  extending to  them from the neighbour-
 ing structures;  and this  hope is  still farther lessened—from the
 tendency the inflammation has to spread—where the joints of the
 wrist or ankle are affected, than where those of a less complicated
 description, as the knee or elbow, are the seat of disorder.
   The  popular phrase white  swelling, therefore, has been indefi-
 nitely applied to several chronic affections of the joints;  as where
 the disease has commenced  in inflammation or  disorganisation of
 the synovial  membrane—in ulceration  of  the cartilages—or in
 scrofulous  deposits in the loose  osseous tissue.  However much
 blended together these morbid changes may seem when a joint has
 been amputated and laid open, careful observation has proved  that
 the affection usually begins  in one particular tissue, and spreads by
 long continuance to  the neighbouring  and external parts.   We
 hence find that  the joint takes on different forms of swelling, and
 the case is attended with different symptoms, according as  the one
 or the other structure is primarily affected;  and that, of however
 little practical utility such knowledge in a late stage may be, yet
 we can tell with tolerable  certainty  at the  commencement, what
 part of the articular apparatus is diseased, and how far there  may
 be any  hope of the morbid changes being arrested.
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