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cess of adhesive inflammation to the destructive one of suppuration, or ulceration, a change which calls imperatively for an alteration in our remedial measures.

The character and symptoms of the fever are also materially influenced by the age and constitution of the patient. Thus, in persons of advanced age, or of constitutions impaired by bad or intemperate living, the fever will often be of the low or typhoid type, and there will be almost from the first a brownish tongue, feeble compressible pulse, and generally prostrate condition of the system. Whereas in the younger and more robust we shall have a greater hardness of the pulse, with a dry tongue, and greater heat of surface; and these symptoms of active fever will often be observed to persist after the more urgent ones of the local disease have begun to subside.

The febrile symptoms are still further modified by the seat of the disease. Inflammation of the tonsils and of the serous and synovial membranes, is attended with a more active fever than that of the parenchymatous viscera, and inflammation of the latter than that of the mucous surfaces. Inflammations of the brain, of the pericardium, and of the intestines, produce remarkable modifications of the pulse, to be noticed hereafter.

In taking a review of the inflammatory process, it may be important for practical purposes to make a few observations upon the effects which it produces upon the living powers.

Now, as regards the part itself which is the seat of the inflammation, it may be remarked, that the term increased action, so freely used by writers upon this subject, must be taken in a very qualified or restricted sense, for though there is, while the inflammation lasts, an increased afflux or determination of blood to the part, there is no increase of the vital process of nutrition; on the contrary, so far from there being any hypertrophy or increased formation of the natural tissues of the inflamed part, we have an opposite tendency; the tissues waste, or become soft, relaxed, and weakened; they degenerate, and are lowered in functional power, or become absorbed; they die and are cast out from the system.

We perceive then that, as regards the part itself, the effect of inflammation is rather to depress than to exalt its vitality; and the same may perhaps be said of the attendant fever, upon the system at large; whilst this fever lasts the waste of the body often goes on with increased rapidity, and its nutrition being checked, its renewal is arrested until the inflammation has subsided.

As regards, however, the products of the inflammation, or the new matter which is generated in and around the inflamed part, we often have indeed an increase in bulk and weight; but as regards this new matter it should be remembered, that even when it becomes organized, no other tissues are ever produced but those which are lowest in the scale of vitality, viz., bone and areolar tissue; and that the effused lymph cannot assume even this degree of organization until the inflammation has subsided; whereas, if it be excessive, or very long continued, the organization is ultimately entirely frustrated.

The immediate or proximate causes of inflammation must be sought for in the disturbance of those conditions essential to healthy nutrition, of which we have seen inflammation to be a perversion, although it may be doubted if each, or even any of these is capable of singly producing inflammation. Thus changes in the blood-vessels affecting the free transit of blood through them, are capable of producing an imitation of some of the phenomena of inflammation, as in the effusion of liquor sanguinis, which sometimes assumes the form of inflammatory lymph, and undergoes partial organization; but, beyond this, we do not find that simple distention of the bloodvessels, as that produced by mechanical obstruction, is capable of alone producing the phenomena of inflammation.

Changed condition of the blood itself has undoubtedly a more certain tendency to produce inflammation, than has that of the bloodvessels; and it is highly probable that the majority of the so-called constitutional or idiopathic inflammations have their origin in the blood. This we know to be the case in the eruptive fevers, where the presence of a morbid matter may be proved by their communicability by inoculation; and though it may not have been actually demonstrated, there can be little doubt that the same is the case with rheumatism, gout, erysipelas, eczema, and similar affections generally called constitutional.

As regards the due influence of the nervous force, we have seen from instances already adduced that its disturbance may excite inflammation, and more will probably be mentioned hereafter; at the same time there is no reason for adopting the hypothesis that the phenomena of inflammation are brought about solely through the medium of nervous influences, since they may be excited in parts that have no nerves.

As the nutrition of a part is maintained by the mutual interaction of the blood and the tissues of that part, it must follow that an altered condition of the part itself must interfere with its healthy nutrition, and therefore we might expect, from analogy, that the phenomena of inflammation might arise from the same cause, the more so as we know that "it is the state of an injured part, or of its proper tissues, not of its nerves and vessels, which determines the process of reparation; and some of the processes of repair are so like those of inflammation, that they are commonly identified, and are, perhaps, not capable of even a refined distinction."*

*Paget, "Lectures on Inflammation."

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V.

SIGNS OF INFLAMMATION, AND OF DISEASE IN

GENERAL.

THE symptoms of inflammation require to be treated of in this place, although some of the remarks which we shall have occasion to make will be equally applicable to those of disease in general. They have been commonly described as local and general, but there exist some objections to this arrangement, inasmuch as the so-called local signs are often not seated in the part affected, but, on the contrary, manifest themselves in others remote from it; nor indeed are they always confined to any fixed part, since the derangement produced by the impaired function, consequent upon the disease of a vital organ, must be perceptible over the whole of the system. We therefore prefer to class them, as

I. Primary and local.

II. Secondary and sympathetic.
III. General and febrile.

(1). When the inflammation (or other disease) is seated in external parts, the local symptoms are so obvious as to require no description.

It is when there exists deep-seated inflammation, more especially in any of the great cavities of the body, that there often arises considerable difficulty not only in determing its seat but in ascertaining its existence; and this difficulty constitutes one of those problems the solution of which is the special province of the practice of medicine. I. The primary and local signs of inflammation consist in the alterations in the sensibility and physical condition of the part, and in derangement of its functions. II. The secondary consist in derangement of the sensations or functions of remote parts. III. The general and febrile are the inflammatory, irritative, and hectic fevers already described. It is to the first of these that our attention is directed by the definition of internal inflammation given by Cullen, viz., "fever with fixed pain in some internal part, and deranged functions in some external organ." Now as regards the pain, though it is almost always the first symptom to which our attention is directed, and often one of the most urgent; yet it is perhaps the most fallacious of the signs of inflammation, for not only does it vary very greatly according to the structure of the part inflamed, independently of the intensity of the inflammation, but besides this, we may have severe pain without inflammation, and inflammation, of an intense and dangerous character, without pain. Thus pain is severe in inflammation of the serous membranes (with the exception, perhaps, of the pericardium and lining membrane of the heart and arteries); less so in inflammation of the mucuous membranes; and so slight, or so frequently altogether absent, in inflammations of the paren

chymata of the viscera as to render it possible that when present it is dependent upon the implication of some membranous stricture in the inflammation. The pain also resulting from slight inflammation of the walls of the great cavities, as well as neuralgic pains, independent of any inflammation, may often equal in intensity that arising from the most acute.

There is, however, another modification in the sensations of the part, from which we may, where it is applicable, often learn as much or even more than from pain, and that is tenderness. It is very true that there may be an exalted sensibility, especially of the surface, without any inflammation, as in the case of the tenderness of the integuments in the early stages of continued fever, and of that which sometimes accompanies neuralgic pains in irritable subjects; it may also be present as a peripheral manifestation of some inflammation or irritation of the nervous centres, the brain, and the spinal cord. Still, where it is possible to apply pressure to a deep-seated part, as in the case of the abdominal viscera, the tenderness so detected may, in connection with other symptoms, be a great help to us in determining the existence or seat of the disease, and afterwards in esti mating its progress. This is particularly applicable to inflammation of the mucous membrane of the intestines, where the pain complained of may be very slight, although upon cautious and deep-applied pressure there may often be found to be considerable tenderness: the same holds good also in some degree in inflammation of the liver, kidneys, and bladder. In inflammation of the peritoneum it affords great assistance in determining its extent and progress. Care, however, should always be used that, in making pressure to ascertain the presence or absence of this symptom, we do not inflict injury upon parts rendered more than usually susceptible of it by disease.

There is, again, another way in which this tenderness manifests itself, and that is in the impediment it causes to the movement of parts connected with the seat of the inflammation, or the pain which it causes by their being brought into certain positions relatively to it. Thus, when the larynx is inflamed, we have often difficulty in deglutition or swallowing; when the pleura, a deep inspiration or cough causes pain; and the same is the case in inflammation of the peritoneum, owing to the tenderness of the inflamed membrane being excited by the descent of the diaphragm, the respiration being at the same time rendered thoracic; this latter symptom is also not uncommonly present, from a similar cause, in inflammation of the pericardium.

In addition, the signs which may be derived from the feelings of the patient are those presented to the senses of the observer; and where these can be applied, which, owing to comparatively recent improvements in the art of diagnosis, they now can be to a much greater extent than formerly, they become of more importance than the preceding. The most obvious instances of change in the sensible properties of a part, are the redness, heat, and swelling which may be seen or felt in parts which are immediately accessible to the sight or touch. But it is not only by the senses of sight and feeling that

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we are enabled to detect changes in the size or consistency of internal parts; the sense of hearing will be found most materially to aid us, and that too in parts situate within the bony walls of the chest, and consequently inaccessible to the touch. Thus, when the lungs are rendered more dense from the plastic effusion of inflammation, the sound elicited by striking the surface overlying the inflamed part will be duller than it would have been in health; a similar result, though from a different cause, is produced when inflammation of the pleura has given rise to effusion into the cavity of that membrane; and even in the abdomen, where we can in some measure apply the sense of touch, the variations in the resonance will greatly aid us in detecting enlargements and effusions, whether inflammatory

or otherwise.

But besides this, the senses of the observer may be applied to detect the alterations which are produced by inflammation in the sensible phenomena which accompany the action of those parts. Thus, not only do inflammations of the heart and large arteries make the pulsations violent and irregular, but the sounds accompanying them are greatly altered from what they are in health. Again, in inflammations of the lungs, air-passages, or pleura, not only is the respiration quickened, and in some cases rendered painful, but the sounds which accompany breathing, coughing, or speaking, as heard by listening on the surface of the chest, are essentially different, as one or other of these structures is affected, and according to the extent and stage of the inflammation.

Another sign of disease, and one which is, perhaps, of greater importance than any of the preceding, is the impaired or perverted function of the part or organ. Inflammation of the nervous centres may give rise to disturbances in the intellectual, sensorial, or voluntary functions, consisting of delirium, excessive sensibility, loss of sensation, increased mobility or spasm, and loss of voluntary motion. In inflammation of the lungs we may have not only the hurried and altered respiration before alluded to, but also a defect in the special function of those organs, namely, the decarbonization of the blood; hence the dusky hue of pneumonia. When the liver or the kidneys are inflamed, we may have suppression or diminution in the secretion of bile or urine; or, in the latter case, the presence of some of the ingredients of the blood in the secretion. Or the disturbance of the function of the part, the læsa partis functio, may evince itself in an alteration or perversion of its automatic movements, as, in vomiting from inflammation of the stomach, and in constipation or diarrhoea, according to the tissue involved, in inflammation of the bowels.

It must, however, be remembered, that, in the case of several organs, the integrity of the whole of which is not essential to the due performance of their functions, those functions may be carried on notwithstanding the inflammation of a considerable portion. Thus there may be, and not unfrequently is, considerable inflammation of the lungs without any perceptible embarrassment of the breathing, especially when the whole quantity of blood is reduced by long-continued disease, and therefore the quantity requiring to be arterialized