Dunglison's American Medical Library. 
AN OUTLINE 
OF 
INFLAMMATION AND ITS EFFECTS: 
BEING 
FIRST PRINCIPLES OF SURGERY. 
BY 
GEORGE T. MORGAN, A M. 
LECTURER ON SURGERY IN ABERDEEN. 
PHILADELPHIA 
PRINTED AND PUBLISHED BY A. WALDIE, 46 CARPENTER ST. 
1838. TO 
STUDENTS OP SURGERY, 
THIS WORK, 
INTENDED TO ASSIST THEM IN TIIEIR LABOURS, 
IS RESPECTFULLY DEDICATED 
RY 
THE AUTHOR. 
U INTRODUCTION. 
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, for 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. 
This apparent discrepancy, with 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 
great cavities of the body, from the application of cold to the surface, 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 abdomeni 
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 would 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 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 epitaph, we would lead 
the enquirer into this noble edifice and say— 
“ Si monumentum qusras, circumspice.” 
Such men as Hunter appear only once 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 the 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 great idea—the discovery 
and elucidation of nature’s laws. From the course of investigation 
which he pursued, he stepped at once out of the night of darkness 
into the full sunshine of knowledge. The difficulties 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 alone, he liberated many 
parts of surgery from the impurities by which they were disfigured. 
On the lofty elevation reared by his own labours, he 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 always 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. 
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 miffiit not be misunderstood on this intricate 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 ol 
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; 2 
Morgan’s principles of 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, and partly also from the cerebro-spinal 
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 
excreting 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 4 
Morgan’s principles op 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 exbalant 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. 
Pounded 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- 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 be 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 
rabhit, 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, even 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, arid 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 far 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 
to 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, &c. 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. 
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 licjuid 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 artery 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 contractility par defaut d'extension—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 
momentary 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 
change 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, litfe 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 feet; the internal area of the left 
ventricle being equal to 15 square inches ; these multiplied into 7i 
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 
Alienee 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 18 
Morgan’s principles of surgery. 
the neck, and is probably derived from the contact of the neighbour- 
ing1 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 Magendie’s experiment is correct, that the 
flow of blood through the large veins is affected by the vis a ter go 
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 foetus 
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; 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 ol 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 lias 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 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 body than in 
another. 
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 21 
THEORY OF INFLAMMATION. 
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 vence 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 intricate 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 
our acquaintance with the former more enlarged, our knowledge 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 
during life, 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. When 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 called 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 
pathology 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. We 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 first 
suggested 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 does 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 eilher 
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- 
sels might 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. fmm 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. AVe 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. 
We 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 
stage 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- 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 furgidity 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 Yacca 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 receive 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 inflam- 
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 OP 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 L809, 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 
opium, 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 hy 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 au 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 
sluggish 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 inflam- 
1 i O 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 (infrequently 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 OP 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 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 degrees 
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 frog’s 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. Wre 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 7 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, tfie 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 unfreqnently 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 thus 40 
Morgan’s principles op 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. 
When 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 tinge; 
diluted ammonia, or alcohol, produces a scarlet red; a saturated 
solution of common salt renders the part opaque, or, if employed 41 
LOCAL SYMPTOMS OF INFLAMMATION. 
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 
truly 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 lour 
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 viortis, a strong contraction 43 
LOCAL SYMPTOMS OF INFLAMMATION. 
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 of capil- 44 
morgan’s principles op 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 lew. 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 op 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 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. It 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 
having 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 
LOCAL SYMPTOMS OP INFLAMMATION. 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 Anger, 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, 
lasting 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; the 
invasion of acute disease may be so rapid as to admit of little 
change being effected on the features. 
The signs of distinction now given, enable us, on all occasions, 
to separate inflammatory from spasmodic pain ; and, were anything 
farther wanted to complete the diagnosis, it would be found in the 
amount of febrile disturbance in the system, and in the origin and 
progress of the two cases. It is principally in delicate females, the 
subjects of hysteria, that we meet with cases similating inflamma- 
tion ; in whom these affections often spring from some mental 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 fine, 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 OP 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°, while 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 when 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 proofs of 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 arm-pit will rise to 107°, nine 
degrees above the heat of the blood in the aorta, supposing it to 52 
Morgan’s principles of surgery. 
average 98°. Ill 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 in 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, 
thafheat 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 beinsr greater, the 
latent heat was set free wherever the change into venous was going 
on. 
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 or. 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 arterialised, 
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 being 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 wit!) the carbon ol the blood, 
and that the caloric, necessarily evolved by the combination o( these 
two elements, was absorbed, and became latent in the arterial fluid. 
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 Pep.ys, 
which went to show that the two were exactly equal. The more 
recent researches of Edwards and Dulong have proved, that the 
amount of oxygen 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 
lu ngs. 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 
J 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 suspendedand 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°. 
It 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 cf the circulation alone, without taking into account 
the changes 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 conflicting1; 
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 
genera], 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 oedema, without any morbid action being present; LOCAL SYMPTOMS OP 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 other 
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 recent 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 
does 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 Atidral. 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 through 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. If a part 
which is naturally pale be placed in such a position as to favour 
the gravitation of the blood, and then examined at the end of three 
or four days it will be found to have 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 
lympli 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 lympli 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 action 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 unfrequently committed. 
SECTION IY. 
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 the 
solids are first affected, and that the important changes taking plac« 
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 having its 
vitality so destroyed as to be incapable of supporting the action of 
the heart. He farther considers that the aerial 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 naturae.; 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 medicatrix naturce; 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 ungenerously 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 pritmim 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 1 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 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 lever, 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 pioved 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 coelum. 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 willingly 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 
putting 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 
existing among their supporters as to the proper seat of disease. 
Again, 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 lias 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 mass, 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 he 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; blit 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 in these words—“post horrorem, pulsus frequens, color 
major, plures functiones lescc, viribus prcesertim artuum immi- 
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. 
69 
Some degree of languor and a sense of debility usually usher in 
febrile affections—premonitory signs, be it remarked, which are for 
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 functioned lesce 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 us 
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 (he 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 Ur. 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, “0! 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, Tt,pof, 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 prtesertim 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 ot 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. 
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 effectually 
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 been termed, sizy, the serum appears 
less in quantity from being detained within the mass, while in 
reality it is increased. 
When the coagulum of inflamed blood is examined, it is found 
to consist of pure fibrin, containing a small quantity of serum. 
The late Mr. Thackrah1 considers the huffy coat as a network of 
fibrin, enclosing a portion of serum, and has shown experimentally 
that it is made up of 18 per cent, of dry solid fibrin, 26 per cent, of 
dry solid matter from the serum, and 56 per cent, of water. The 
dry solid matter to which he refers is albumen, always found in 
much greater quantity in the serum of inflamed than in that of 
healthy blood. No two analyses of the buffy coat will be found to 
agree; for the proportions of the blood in diseases vary in different 
individuals, and in the same individual at different times, in the 
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 
Dr. Gordon, of Edinburgh. 
The modification, then, which the blood seems to undergo in 
inflammatory fever, consists in an increase of its fibrin and the 
animal matter contained in the serum. Gendrin has very minutely 
detailed the appearances presented by the blood under the different 
varieties of inflammation, and the relative proportions which the 
crassamentum and the serum bear to each other. In very acute 
inflammation, the buffy coat is firm and elastic, of great thickness, 
and much cupped ; the whole of the serum is nearly squeezed out, 
and in point of volume, the clot appears to this fluid as one to one 
and a half and sometimes two. In some cases, the proportion of 
serum is less than the crassamentum, the latter adhering to the 
bottom of the vessel in the form of a truncated cone. From the 
firm contraction of the coagulum, however, the serum generally 
seems more abundant than it really is, and, in such cases, appears 
usually colourless and free of red matter, even in the lower part of 
1 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 coagulum, 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 coagula- 
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. 
2 Essay on the Blood. CONSTITUTIONAL EFFECTS OF I NFL A JIM AT I ON. 
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. Thackrah 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 huffy 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 buffy 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 
even observed to retire from the surface of the fluid, in such cases, 
before any coagulation has commenced. Secondly, the separation 
of the fibrin 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 
being 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 huffy coat itself.0 
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 huffy 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- 
hornme, 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, might 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-letting in the human 
subject. We have, moreover, direct testimony1 that buffed blood 
1 See Gendlin’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 
compared 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 
huffy 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 he 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 judge, that it can take place during the presence or absence of 
either. We 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 
large ; 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 
constitute a necessary and essential part of the process of inflam- 
mation, which, when complete, may be described as made up of a 
peculiar state both of the solids and fluids. But although we have 
stated that, in individuals of plethoric habit, the buffy coat is occa- 
sionally exhibited, and seems, when present, often to lead to local 
complications, there are reasons for believing that the changes in- 
duced in the blood are, in general, only secondary, and caused by 
the previous morbid incited action of the vessels. Of these the 
1 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 
huffy 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 m 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 bufly 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 butfy 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 butfy 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 butfy 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 butfy 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. The 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 diarrhma 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 
tono-ue 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 vitiated, 
bein<r sometimes increased, at other times diminished. The respi- 
ratory function is usually disordered ; the breathing is either quick CONSTITUTIONAL EFFECTS OF INFLAMMATION. 
81 
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 tire 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, increased 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 might be able, at this period, to state more freely the fol- 
lowing1 fact, namely, that certain inflammations are accompanied 
by sthenic, and others by asthenic fever. Of the former kind are, 
inflammatory affections of the serous and fibrous tissues ; of the lat- 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 which 
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 state, 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, 
ivhereby pain is produced, and that from this increased sensibility CONSTITUTIONAL EFFECTS OF INFLAMMATION. 
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 adequate reason for assuming that the fever is 
the cause of 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 primario,” 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 Icedentia” 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. 
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 part; 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 creating an ulcer in an opposite part of the face, or the pain 
felt at the right 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, &c. 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 original law 
in our constitution. 
From the regularity with which these cirqumstances 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 high, 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. 
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. Abercombie,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 was 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 
if, are ro-used; 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, 
1 On the Diseases of the Brain and Spinal Cord. 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 
sympathy 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 tear 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 schir- 
rlious tumour. These, 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 seyere 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 
fihrin 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 high, 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. 
Again, we have instances where the nervous system seems to 
predominate without any deranged state of the blood, and where 
the cause principally operates on this system, as some of the 
animal poisons, or injuries in individuals of a peculiar nervous 
temperament. In habits of this kind, the puncture of a clean 
needle in the hand will be followed by inflammation of the ab- 
sorbents and glands in the ann-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 the 
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 serious 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 acquires 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 in 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 On 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 accpiires 
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 surgeon must weigh well in his own mind; 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. Abernethy.1 “ A man between forty and fifty years of 
age 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 might do well. Granulations were produced from the 
periosteum and whole surface of the wound, and as those which 
filled 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 subsided. 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 progress 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 buflfy 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 circuinstance, 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 pleura. 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 prse- 
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 THE PROCESS OF INFLAMMATION. 
95 
the restlessness ceases; and a low 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- 
ing 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. 
Phlegmon (from <s>\tyu, to burn,) was deemed healthy, because it 
showed little disposition to spread; and when matter was formed, 
the fluid was found to be confined within a sac or cyst. Erysipelas, 
again, 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 part. To this source are to be traced the erroneous notions yet 
entertained by many respecting erysipelas, and also the singular 
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 to 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 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 OP 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 
are 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 Morgan’s principles of surgery. 
98 
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 hypercumia, 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 VI. 
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 apply 
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 
that the cause has ceased to operate. These objections to the word 
termination show a wonderful degree of ingenuity turned to little 
purpose; for, as few will be liable to mistake our meaning when 
we say that inflammation has ended in suppuration as in mortifica- 
tion, and we shall accordingly continue to employ the phrase in the 
manner now explained. 
The most frequent and natural termination of inflammation is 
that by resolution. Here the morbid action disappears, and the 
healthy function of the part is sooner or later restored. With the 
exception of mortification, this is certainly the only other instance 
where all traces of morbid action are removed; and hence the 
reason, as we have remarked, of the other changes having been 
regarded as effects. The French pathologists have applied the 
term delitescence (from delitesco, to abscond) to cases in which 
inflammation suddenly disappears; but, in some of these, the dis- 
ease has only shifted its seat from one part to another; and such 
instances cannot, strictlv SDeakinsr, be included under the head of 100 
Morgan’s principles of surgery. 
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 moving 
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 OP 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 hjrs 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 increase of vascular action ; while 
adhesion of a mucous membrane is only effected by the most 
intense inflammation. We have already adverted to the fact that, 
where much lymph is thrown out during inflammation, as in some 
cases of serous membfanes, less fibrin will be found in the blood 
drawn from a vein ; but this, although accounting for a deficiency 
in the huffy 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 
tinged with the colouring matter of the blood, or mixed with por- 
tions of lymph ; or should the inflammation be violent, with flakes 
of purulent matter. We have already hinted that, in the great 
majority of cases, there is an exhalation of serum with little 
lymph, or even an extravasation of blood; but where the effusion 
is trifling, 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.—gangrene 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 hrain 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 new 
and solid product, different entirely from the natural structure of 
which the part is made up. 
Induration commonly occurs in the cellular membrane, or in 
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 long-continued chronic inflammation. The degree of hardening 
depends 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-analog ions 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 
the cellular interstices of parts, we find their colour altered, and 
their 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 ;l 
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 serum 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. Yol. 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 strongly-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 generally 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 existed, because this takes place 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 oft’, 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 
between them, 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 new deposits into 
the substance of the middle tunic, or between it and the inner INFLAMMATION IN DIFFERENT STRUCTURES. 
107 
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 tunic 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 dolcns, 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 unfrequeritly 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 signs are often so obscure as to escape observation during life, 
and the 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- 
cient local cause. 
When the vein is examined after death, the lining membrane is 
found intensely red, and, along with the outer tunic, so much 
thickened as to make the vessel feel like a hard impervious cord, 
and resembles an artery in appearance. The tissue in which the 
vein is 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 
lymph, either loose or adhering to the inner tunic, and obstructing 
the passage; there are deposits, also, of purulent matter, sometimes 
so 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 nothing 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 
‘ Medico-Chirurgical Transactions. Yol. 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- 
bitis. 
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, being 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 
purulent matter in a vein—that pus may be received apparently 
into the 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 oiten 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 neurifematous 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. 
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 
owing 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. 
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 
origin; in susceptible constitutions, the disease will arise, also, 
from the slightest irritation, as the prick of a clean 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 absorbing1 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 of 
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 in which 
its occurrence seems spontaneous, or, at least, there is no local 
source to which we can with propriety refer it. 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. 
115 
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. Scrotulous 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 natural 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, loose and abundant, as between the arach- 
noid and pia mater; in others, more dense and sparing, as between 
the former and the dura mater. This variety in the distribution of 
the cellular tissue modifies the effects of inflammation in serous 
membranes, and is a point to which the attention of the pathologist 
should be strongly directed. 
The commencement of acute inflammation in a serous membrane 
is denoted by the infiltration and injection of its subcellular tissue 
with red vessels. As the morbid action goes on, the infiltration 
increases; the serous fluid penetrates between the layers of the 
serous membrane itself, and causes increased thickness, with loss 
of transparency. The opacity, at least at first, is not owing, as has 
been generally supposed, to the natural exhalation from the surface 
of the membrane having 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 “punctum 
saliens” in the vitellary membrane of the chick, which run together 
and form lines, communicating frequently, and traversing the mem- 
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 ot 
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 bronchise, 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 
from an increase in the quantity of soda, excoriating the parts over 
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 
begins 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 puri- 120 
Morgan’s principles op 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 gonorhcea, 
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 into 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 fossee, 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 aphthae. 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 df 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 faecal 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 more 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 m 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 faeces 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 is 
generally 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 fascim 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 of 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 And 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 giving 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, nnd 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 purposely cut away, its place is supplied 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 orisfinal 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’s principles op 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 excitement, 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 on Diseases of the Joints. INFLAMMATION IN DIFFERENT STRUCTURES. 
125 
brane, 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 tie 
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 
being 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 of 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 
of a natural cure are nearly precluded. Ulceration of the 
■cartilages forms one of the varieties of white swelling; and, though 
nore 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 vertebra?, 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 has attacked 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 and 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, 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 
beeu 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 the 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 
which is at all times more liable to lose its vitality. When acute 
inflammation, followed by suppuration and ulcerative absorption, 
takes place 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- 
sess sufficient powers to repair the breach which has been made; 
granulations spring up from the osseous structure, and unite with 
those from the surrounding parts in filling up the chasm. In other 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 of 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 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. Yenereal 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, aftef 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 
by a process of ulceration or ulcerative absorption; but neither 
ought 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 op 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 becomes 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 
vertebrae, 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 11s 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 atfections 
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 
given 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. W'hen 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 
out in another. 
As long as the affection is confined to the head of the bone, 
there is only a deep-seated pain complained of, with stiffness on 
moving the joint; but, when the cartilages are involved and puru- 
lent matter is formed within the articulation, the local suffering is 
severe, and hectic fever, in its most aggravated form, sets in. 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 commencement; 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. Even 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. 
THE END.