carefully to scrutinize all that relates to this morbid process, on the comprehension of which so much of sound theory and good practice depends. What inflammation really is we have great difficulty in gathering from Mr Paget's observations. A definition of it he purposely avoids, because he thinks we are not yet in a position to give one. He says:

"Just definitions cannot be made in any science till some of its broad and very sure principles have been established. Such principles we cannot boast to have yet attained in the study of pathology; and the attempts at precise definitions that have been made hitherto, seem to have led to confusion, or to false and narrow views of truth. Besides, to define inflammation is the less necessary, because, practically, we all know sufficiently well what the term implies we know the signs of the presence of the disease in all its chief forms; and, when we watch these signs in any external part, we see them so often followed by peculiar changes in the part, that we are justified in recognizing the changes as effects of inflammation, and in believing that, wherever we find them, the similar or corresponding signs of inflammation have preceded them."-P. 292.

This passage will certainly not bear criticism. It assumes that science is not yet sufficiently advanced to enable us to define inflammation, an assumption which, as we shall subsequently endeavour to show, is erroneous. Then, it is argued, a definition is unnecessary, because practically we know what the term implies; but if science is incapable of defining it, practically much unanimity as to its meaning cannot and does not exist? Lastly, it asserts that because external inflammations are so often followed by peculiar changes of the part, that therefore wherever we find these latter, we are warranted in believing that similar signs of inflammation preceded them. But is this true-do the signs of inflammation, (pain, heat, redness, and swelling), invariably precede internal, as they do external, inflammations? Are there no such diseases as latent pneumonias, without these signs, and true inflammations leading to suppuration of the liver, kidney, spleen, or brain, in which they have been all absent? Every physician can point to such cases, and hence the danger of the surgeon generalising on a morbid process, which is alike common to external and internal parts, from an observation of the latter alone. It is this surgical idea of inflammation which has hitherto reigned in pathology, an idea which, instead of looking to its essence, regards its occasional symptoms, and because the cardinal signs are very commonly present in external lesions, has led to the most deplorable mistakes in the detection of them when internal, and when such signs are absent.

Now, it has long been maintained in the Edinburgh school of medicine, and taught from the chair of the Institutes, that inflammation is the exudation of the liquor sanguinis. This is at once the definition and the essential phenomenon of the morbid proThose changes which precede it, if they stop short without producing it, do not constitute inflammation, while those which follow it are the true results of the process. Without directly alluding

cess.

to the labours and investigations of those who maintain this doctrine, although fully aware of their nature, Mr Paget observes of it :

"We may, indeed, say that stagnation of blood, or effusion of liquor sanguinis, or some exudation, or some degenerative change in the elements of the affected tissue, shall be the condition sine quâ non of inflammation; we may call whatever falls short of these, active congestion,'' irritation,' or by any other name; but, in reality, such distinctions are often impossible, and sometimes untrue; and, in study, the terms are convenient for the sake of brevity rather than of clearness."-P. 293.

Here, again, this paragraph deals more in assertion than in argument. Why are such distinctions often impossible?" To us they are always capable of being made with the utmost certainty, both in theory and in fact. How are they untrue? It cannot be denied that such exudations are poured out. When they are so, we have to do with inflammation; when they are not, we have no inflammation. With great deference to Mr Paget, such a doctrine not only appears consistent with all known facts, and is, therefore, true; but, while brief, is also clear to the comprehension, which Mr Paget's notions confessedly are not. For instance, he says:—

"The several parts of the inflammatory process are-increased fulness of the blood-vessels, with retarded movement of the blood; swelling; pain, or other morbid exalted sensation; increased heat; exudation of lymph from the bloodvessels; defective nutriment of the proper elements of the affected part. The first five are often spoken of as the signs of inflammation, the last two as its effects; but these terms have reference only to the former, being more transitory phenomena than the latter: they are all, when they concur, constituent parts of the disease; but the latter are less quickly recovered from than the former. "It would not be judicious, I think, to refuse to call that process inflammation, in which any one of the conditions just enumerated is absent or unobserved. Swelling, or pain, or, much oftener, increased heat, may be inappreciable in tissues that we may still rightly call inflamed, while the other evidences of the disease are present. The same may be said of increased or altered exudation from the blood-vessels. No such exudation is observed in the diseased cornea or articular cartilages; but it would be unreasonable, in the case of an inflamed eye, to say that the changes are due to inflammation in every part but the cornea; and to call the process leading to the ulceration or leucoma of the cornea by a name different from that which we give to the coincident and similarly excited process in the other tissues. So, during the inflammation of a joint, it would be, at the least, inconvenient, to say that all the tissues are inflamed except the softening or ulcerating cartilages. The progressive degeneration of tissue is, probably, never absent when the other parts of the inflammatory process exist; but, in quickly transitory cases, it is often inappreciable. The altered state of the circulation may be unobserved: but it is, probably, always present; for in the case of the parts that have no interstitial blood-vessels, inflammation may still be attended by enlargement of those of adjacent parts, on which their ordinary nutrition depends.

"The conclusion, then, may be, that in what may be regarded as wellmarked or typical examples of inflammation, all the characters I have enumerated are present as concurrent parts of the disease; but that the same name should not be refused to diseases in which any one of these parts is absent or unobserved, especially when its absence may be explained, as in the case of inflamed cartilages, by some peculiarity of tissue or other condition of the disease. I think it would not be right to call any process inflammation

in which there is neither an exudation of lymph (i. e. of material capable of such developments or degenerations as I have described), nor a deterioration of the proper tissue of the affected part-even though the other characters of the disease might be present. But, really, whatever rule of nomenclature be adopted, we may expect to meet with many cases in which we shall doubt what name to give to the processes which we watch, or of which we see the results. There is neither here, nor in any other part of pathology, anything like the unity, or circumscription, of species by which the zoologist, whose nomenclature pathologists are prone to imitate, is justified in attaching to each specific name the idea of several constant and unalterable characters in the beings to which it is assigned."-Pp. 428-430.

Hence, according to Mr Paget's views, nothing definite can be introduced into the pathology of inflammation. All is confusion. But, fortunately, the reason of this is apparent from the above passage. The obstacle to Mr Paget's clearness of perception in this matter consists in the fact that he is confounding morbid processes widely different, and this, as we shall attempt to show, in direct opposition to his own careful observations. To talk of inflammation, of non-vascular textures, such as of cartilage or of the cornea, is, according to the doctrine we are defending, evidently absurd. If exudation be the essential phenomenon of inflammation, then the softenings, abrasions, and ulcerations of the cartilage and cornea are either not inflammatory, or, if they be, they constitute an argument opposed to the correctness of our generalization. The latter is the view of Mr Paget. Now, the following are the changes observed in diseased cartilage, altogether independent of the penetration of lymph, as admirably observed by Dr Redfern, and recorded in the pages of this Journal. We quote from the condensed account of Mr Paget:

"These changes consist, essentially, in the enlargement of the cartilage-cells, with increase of the nuclei, or of peculiar corpuscles contained in them, or with fatty degeneration of their contents, and fading, or similar degeneration of their nuclei. The hyaline intercellular substance at the same time splits-up, and softens into a gelatinous and finely molecular and dotted substance, or else is gradually transformed, in the less acute cases, into a more or less fibrous tissue. The enlarged cartilage-cells on the surface are released, and may discharge their contents on the surface of the ulcer; and the intercellular substance is gradually disintegrated and similarly discharged, or, whatever part of it remains, is transformed into fibrous tissue, and becomes the scar by which the ulceration is, in a measure, healed.

Lastly, in the cornea, a series of observations on the effects of inflammation, purposely excited in it by various stimuli, have shown that the changes in it are not due to any free exudation of lymph in it, but to alteration in its proper constituent textures. They consist, chiefly, in swelling and enlargement of its corpuscles, the appearance of minute fatty molecules in them, and the increase and enlargement of their nuclei. The intercellular substance becomes, at the same time, turbid, more opaque, denser, more fibrous, and, sometimes, finely granulated; and in some cases fatty molecules appear in it. The changes thus produced in the cornea are not essentially different from those that follow its idiopathic inflammations; and, as Virchow concludes, they are extremely like those of the arcus senilis."-Pp. 415, 416.

Now the processes here described in non-vascular textures, namely, the enlargement and endogenous multiplication of the normal cells

of the part, and their fatty degeneration, with fibrous alteration of the intercellular substance, are in no way analogous to the increased fulness of the blood-vessels with retarded movement of blood,-exudation of lymph,-new development of cells, and defective nutrition of the proper elements of the affected part observed in vascular tissues. This is obviously because there are no blood-vessels in the part, and no blood; there is no exudation; no development of new cells; and, so far from nutrition being defective in the proper elements of the affected part, it is evidently increased, the proper cells of the tissue assuming augmented powers of development. The broad distinctions separating cartilaginous ulcerations and their mode of healing, from inflammatory ulcers, are thus laid down by Dr Redfern :"Articular cartilage contains no blood-vessels, consequently ulceration and other changes of structure confined to it are never complicated by inflammatory exudations, pus, etc., and can be examined very satisfactorily; ulceration in tissues containing blood-vessels is almost always complicated with inflammation, and the ejected particles of the tissues having undergone a very complete degeneration, and become mixed with a mass of structures formed in the inflammatory exudation, also degenerate, are, therefore, very difficult to recognise. Ulceration or other disease confined to articular cartilage has in no single instance been shown to be productive of pain, no doubt for the very simple reason, that these structures contain no nerves ; in other textures, ulceration is often attended with very severe pain from implication of the nerves ramified in their substance.

"The healing of ulcers in articular cartilages, and in tissues freely supplied with blood-vessels, differs in this remarkable particular, that in the former, the fibrous cicatrix is invariably made up of the changed substance of a portion of the cartilage not subjected to the process of ejection, and in the latter, the cicatrix as constantly results from the development of the inflammatory exudation. This difference admits of the following explanation :-In the case of the ulcer affecting no texture but that of cartilage, there is no other matter from which a cicatrix can be produced than the actual cartilage tissue remaining; and it may be remarked, that cartilage is a very simple cellular texture, and that the greater number of the tissues are originally formed from cells, that the cells of cartilage have a natural tendency to transformation into fibre, as is shown in the development of fibro-cartilage, and that the inter-cellular substance shows as remarkable a disposition to produce the same result in its diseased state. In the ulceration of tissues supplied freely with blood-vessels the reverse maintains; for the degeneration and destruction of the tissue actually involved is so complete, that this can in no way assist in the formation of the cicatrix; and there is, therefore, nothing left in this instance but the inflammatory exudation from which that substance can be formed."-Dr Redfern in MONTHLY JOURNAL, vol. xiii., pp. 212, 213.

The two processes, then, of inflammatory ulceration, and the ulceration in non-vascular parts, are widely different, and it is the confounding them together which constitutes the difficulty with Mr Paget, a difficulty that is at once got rid of by maintaining what we conceive to be the more correct view, namely, that these forms of anormal nutrition, in non-vascular parts, are not inflammation at all. But it may be asked, if not inflammatory, what are they? Surely, it is urged by Mr Paget, the abrasions and ulcerations in cartilage and in the cornea are strictly analogous to ulcerations in vascular

NEW SERIES.-NO. XLIX. JANUARY 1854.

G

parts. To this we say, by no means; the one is dependent, as shown by Dr Redfern, on increased development of the normal cells of the texture; the other is produced as the result of an exudation. Now there is another non-vascular texture where identically the same process is observable, where ulcerations occur, and are, in like manner, dependent on increased development of the normal cells of the part-we allude to the epithelial or epidermic structure. Let any of our readers study the accurate account given by Mr Paget of the structure comprehended in this ulceration, commencing p. 434 of the second volume, and it will be made apparent that we have here to do with a multiplication of epidermic and epithelial cells; that is, of the proper texture of the part. Hence the processes carried on in cartilage on the one hand, and in epithelium on the other, are strictly analogous, and yet Mr Paget labours to prove and other cancer. In our opi

that the one is inflammathe?

nion, he has here madecal fundamental pathological error, separating lesions strictly allied, and extending the meanings of both inflammation and cancer, order that they may embrace diseases which ought to be carefully distinguished from both those morbid processes. In consequence, his notions of cancer are as faulty as his views of inflammation. While most of the pathologists in Europe are carefully drawing distinctions between what is and what is not cancer, and showing the importance of their labours by clearing away the discrepancies attached to those much abused words, malignant and benignant, Mr Paget once again endeavours to mix them together under the terms malignant fibrous tumours, myeloid tumours, epithelial cancer, melanoid cancer, osteoid cancer, villous cancer, etc. etc. With great deference, we are of opinion that pathological science will be more benefited by limiting the terms inflammation and cancer to the essential and invariable phenomena of those morbid processes, than by continuing to confound, under new names, all kinds of different lesions together, in order to meet arbitrary notions of symptoms on the one hand, or of what is called malignancy on the other.

The second volume, however, containing the author's views on what he calls innocent and malignant tumours, will constitute the subject of a second notice in our next number.

Asiatic Cholera; its Symptoms, Pathology, and Treatment; with which is Embodied its Morbid Anatomy, General and Minute. Translated from a paper by Drs Reinhardt and Leubeuscher. By RICHARD BARWELL, Fellow of the Royal College of Surgeons, etc., etc. Small 8vo. London. 1853. Pp. 219.

We have read this book with great satisfaction, and can recommend it to our readers as a very useful contribution to medical literature