sometimes takes place, and when it does not the advance of the ulceration is slower and its cicatrization more rapid than in the adult. Typhoid fever occurs most frequently from nine to fourteen years of age; it is less frequent from five to eight; and very unusual in the earlier years of childhood. MM. Rilliet and Barthez describe three forms of it, differing from each other in intensity; the first being very slight, the third very severe, the second intermediate in intensity between the other two. The symptoms of the first form, which they met with in 47 cases, are much the same as those which characterize what is ordinarily called infantile remittent fever in this country. Both this and the other forms, however, present some peculiarities in their symptoms, and run an unfavorable course more frequently than is the case with the remittent fever with which English writers are familiar; a difference probably owing in part to the unfavorable circumstances in which patients are placed in the Hôpital des Enfans at Paris. The writers enlarge on the diagnosis between remittent fever, meningitis, pneumonia, and enteritis; but conclude that when enteritis assumes a typhoid character its distinction from typhoid fever is almost impossible; though the appearances found after death are very different. The remarks on the treatment of the disease do not present anything new, except the recommendation of the sulphate of quinine in the ataxic and adynamic forms: but the whole essay will well repay a careful perusal.

DYSCRASIE.

Gangrenes. M. Becquerel* notices the connexion that often exists between pseudomembranous and gangrenous affections in childhood, and illustrates his remarks by the description of an epidemic which prevailed in the year 1841, at the Hôpital des Enfans. The two forms of disease presented close relations to each other; both causing to a great extent the same general symptoms, and one succeeding to or complicating the other. The epidemic croup of 1840, did not altogether cease at the close of that year, and again became epidemic in the ensuing year, and at the same time its complication with gangrenous affections began to occur. M. Becquerel observed seventeen cases of gangrenous angina, twenty cases of croup, and eighteen in which blistered surfaces became gangrenous.

Gangrene of the pharynx was usually preceded by pseudo-membranous augina. Sometimes it coincided with gangrene of blistered surfaces, or of other parts, and in these cases was only a repetition of the morbid process which existed elsewhere. In most cases of gangrene of the pharynx there existed a preternaturally liquid state of the blood, and the symptoms that existed during its progress were such as betokened a generally adynamic condition. It was frequently complicated with pulmonary apoplexy, occasionally with hemorrhage from the bowels. Pneumonia was an unusual complication. It was treated, unavailingly by local cauterization, and by general tonics. Croup occurred in twenty cases. It often succeeded to a pseudo-membranous angina, or came on as an idiopathic affection. It seldom followed the eruptive fevers. In addition to the ordinary symptoms of croup, phenomena indicative of disturbance of the nervous system often came on towards its close, and pneumonia was frequent. All the cases terminated fatally; tracheotomy having been practised nine times with

out success.

Gangrene of blistered surfaces took place in the course of very various diseases; but mostly of such as presented something of an adynamic character. It often came on in the course of measles. False membranes usually formed over the blistered surface; which next became gangrenous, but the patients died under symptoms of great exhaustion before the eschar became detached. Local treatment and general tonics invariably failed of success.

MM. Rilliet and Barthezt give a full description of the different forms of gangrene which occur in childhood, and regard them all, not as mere local maladies which subsequently react on the constitution, but as the result of a generally diseased state of the whole organism. M. Boudet‡ in the course of some remarks on gangrene of the lung in childhood, observes that spontaneous gangrenes in children, appear invariably to develop themselves under the influence of causes acting on the entire economy. He conceives the proximate cause of all these affections to be an altered state of the

• Gazette Médicale, Oct. 28 and Nov. 4, 11, 18, 1843. Archives Gén, de Médecine, Août et Sept. 1843.

Lib. cit., tome ii, p. 98.

blood, such as succeeds scurvy, measles, and scarlatina, and which is characterized during life by hemorrhage, purpurous spots, ecchymoses, &c. The lesion of the blood, consists in his opinion in a diminution of its fibrin, and an excess of alkali. This supposition, however, rests on but a slender basis; partly on the statement of MM. Andral and Gavarret, that the fibrin of the blood is diminished, and its fluidity increased in the exanthemata; partly on the result of his own investigations. He examined the blood carefully four times: twice it was entirely fluid in the heart and vessels, twice it was diffluent, and scarcely coagulated at all; and in the remaining cases, ten in number, it was much less firmly coagulated than natural.

M. Huguier relates a case of that rare occurrence, spontaneous gangrene of the surface in a child aged 74 years. The previous history of the patient was unknown, beyond his own statement, that two months before he had had a very violent cold. When received into the Charité, the tips of all the fingers of the left hand were black, and those of the right hand had begun to show a darkish colour. All the toes of the left foot were quite black, the middle toe had dropped off, and the tips of the toes of the right foot were also black. There was neither pain nor redness in the course of the arteries, nor were they less yielding and elastic than natural. The child was bled twice, and took opium during his stay in the hospital; the duration of which, as well as many other points of importance in the case, are not stated. He left the hospital well, having lost all the toes of both feet, the fingers of the left hand, and the whole of the right hand, as also the skiu at the tip of the nose, at the prominence of the cheekbones, the chin, and the edges of the ears.

Tubercle and scrofula. MM. Rilliet and Barthez† contend earnestly for the identity of the tuberculous and scrofulous diseases; and they assert, that having examined the bodies of a large number of scrofulous children at the Hôpital St. Louis, they met with no instance in which tubercular deposits did not exist in some part or other. They regard many affections, usually termed scrofulous, such as ophthalmia, caries, eczema, &c., as being of a secondary nature, accidentally complicating the original scrofulous, or tuberculous habit, but not essentially scrofulous in their nature. They propose to banish the name, scrofula, from medical nomenclature, as being vague, and likely to mislead, and to substitute for it the term tuberculization. M. Bredow, of St. Petersburgh, takes a similar view of the identity of the two diseases; he proposes, however, to retain the word scrofula, to designate tuberculous disorganization of the lymphatic glands, and to employ the name, tubercle and tuberculous disease for the same affection existing in other organs. The interesting researches of MM. Rilliet and Barthez into the anatomy of tubercle, belong properly to the domain of pathological anatomy. They have directed their attention to some other points, however, which may with propriety be mentioned here. The extreme frequency of tuberculous disease in childhood appears from the fact, that it existed in a more or less advanced state, in some part or other, in 314 out of 525 children, of whom they made a post-mortem examination. With reference to the influence of sex and age on its production, they find that it is most frequent from 6 to 10 years of age, then from 11 to 15, next from 2 to 5, and lastly from 1 to 2; and they support this statement as well as their other assertions by statistical data. The female sex is, on the whole, more liable to it than the male, though this liability is not the same at all ages, for from 1 to 2 years of age more cases are met with in the male; from 3 to 5 there is a slight excess among females, and from 6 to 10 the two sexes seem equally liable to the disease, but from 11 to 15, that is to say, at the time when puberty approaches, female children suffer much more from it than males. It appears, too, that tuberculous deposit is most frequently met with only in a slight degree from 3 years of age to 5; that a moderately abundant deposit is oftenest found from 1 to 2, and next in frequency from 3 to 5; and that very abundant deposit is much oftener discovered from 6 to 15, than from 1 to 5 years of age. Children under 1 year old, did not come

under their notice.

They give an interesting table of the comparative frequency of tuberculous deposit in different organs in 314 children between the ages 1 and 15:

Clinique des Hôpitaux des Enfans, Dec. 1842.
Ueber die Scrofelsucht, 8vo; Berlin, 1843.

XXXIV-XVII.

Lib. cit., tome iii, pp. 1-163.

18

The work of M. Bredow* is an extremely well-executed compendium on the subject of scrofula, and contains many valuable practical suggestions derived from his extensive experience as physician to the Imperial Manufactory of Alexandrowsk, near St. Petersburgh.

Rickets. Dr. Elsässert opposes the commonly received opinion, that this disease does not occur during infantile life; and describes a peculiar affection of the skull in early infancy, which he believes to be the result of rickets. It consists in softening of the cranial bones, attended with increase of vascularity and alteration of their texture, which becomes spongy, rough, and porous, owing to a diminution of their earthy constituents, and disintegration of their tissue. Under the microscope the canaliculi of the bones are seen to be dilated, and communicate freely with each other; -conditions that have been observed to follow from the action of rickets on other bones. To this affection he gives the name of craniotabes, or the soft occiput, from that yielding of the bones under pressure which constitutes one of its most striking symptoms. A great part of infantile life being spent in the recumbent posture, the softened and yielding occiput has to support the pressure of the contents of the cranium for many hours daily. This circumstance would of itself produce some unpleasant effects, which are aggravated by the tendency of the pulsation of the brain, within the cranium, and the pressure of the pillow on which the infant reposes, without the cranium, to attenuate the softened bone at those places where the convolutions of the brain are most prominent. Sometimes the bony matter is completely absorbed in various places, the holes in the skull being closed merely by the dura mater and pericardium. This condition is not the result of originally defective ossification, for it is not met with in the fœtus; and, moreover, the situation of the openings in the skull does not correspond with those which would be produced by any suspension of the process of ossification. It is not found either immediately after birth, but begins about the third month, or somewhat later; and the circumstance that the attenuated and perforated spots are found only at the occiput or the occipital end of the parietal bones, though the whole cranium is softer than natural, proves that it is the result of pressure exerted in the way already described. It is but natural that, the protecting case of the brain being thus weakened and thinned, the organ itself should suffer from various external agents. Accordingly, cerebral irritation and congestion are produced, and show themselves in convulsive seizures of various kinds, and frequently in attacks closely resembling laryngismus stridulus. So far, too, is the affection from being one of slight moment, that half of those who are affected by it die; while its occurrence is so frequent that Dr. Elsässer has met with it forty times, in the course of five years' practice, in a small country town. The appropriate treatment consists in the employment of tonics, among which iron bears the chief place; and in the adoption of various precautions to prevent or, at least, to diminish pressure on the occiput. [Notwithstanding Dr. Elsässer's assertion to the contrary, a suspicion may be entertained that he has been misled as to the frequency of this affection; or that endemic causes or some local peculiarities have tended to render it very prevalent in the town where he practises. For the last six months, since his work came under the notice of the writer of this Report, he has carefully examined the heads of infants who came under his care at the Infirmary for Children, and has very rarely found any such yielding of the bones as Dr. Elsässer frequently met with, except just in the neighbourhood of the anterior fontanelle. Laryngismus stridulus, too, has not come under the writer's notice more than two or three times a year, during the past five years, notwithstanding the large number of children who are brought to the Institution.]

• Ueber die Scrofelsucht, 8vo; Berlin, 1843.

+ Der weiche Hinterkopf, etc, 8vo; Stuttgart und Tübingen, 1843. Review contains a more extended analysis of Dr. Elsässer's observations.

The present Number of this

REPORT ON THE PRESENT STATE OF KNOWLEDGE OF THE NATURE OF INFLAMMATION.

BY T. WHARTON JONES, F.R.S.

Lecturer on Anatomy, Physiology, and Pathology at the Charing-Cross Hospital; Corresponding Member of the Imperial and Royal Society of Physicians and Surgeons of Vienna, &c. &c.

WHEN a part of the body, visible externally, is the seat of inflammation, the observer perceives it to be preternaturally red, swollen, and preternaturally hot; the patient, moreover, says that he feels it hot and painful. The conditions on which these symptoms depend are, on the whole, sufficiently obvious; but the nature of the process which leads to them-in other words THE THEORY OF INFLAMMATION is very obscure, and has always been, and still is, an object of much debate and inquiry with pathologists.

As it is microscopical parts which are immediately concerned in the inflammatory process, it is only since pathologists became acquainted, by means of the microscope, with those parts and their mode of action, that any real advance has been made in the inquiry. The parts referred to are principally the corpuscles of the blood and the capillary vessels. In entering, therefore, on the task of reporting on the theory of inflammation, it will be useful to premise the following points regarding the blood and its circulation in the capillaries in the healthy state:

I. BLOOD IN THE HEALTHY STATE.

§ 1. In human blood, after being drawn, the red corpuscles aggregate together like coins in rolls. This aggregation takes place in the course of half a minute or so after the blood is drawn, when the blood is in a healthy state, with its plasma of ordinary thickness; when, on the contrary, the blood is not in the healthy state, but has a more inspissated plasma, the aggregation of the red corpuscles is so rapid that it is found to have already taken place by the time the blood can be transferred to the microscope and examined.

§ 2. The admixture of certain reagents with the blood influences the aggregation. Some promote it, others prevent it; those which promote it, if anything, give rise to endosmose rather than to exosmose; among those which prevent it are found as well such as give rise to exosmose as those which give rise to endosmose. It appears to be viscidity of the fluid (a certain proportion of salts being at the same time dissolved in it,) in which they are suspended, which especially promotes, though is not the cause of, the tendency to the aggregation of the red corpuscles.

$3. In the newly-drawn blood of the frog a sort of aggregation of the red corpuscles is also observed; but instead of having their surfaces fully applied to each other, and being raised up on edge, as in human blood, the red corpuscles, for the most part, lie flat, and merely partially overlap each other, like the coins of a roll which has been thrown loosely down. The admixture of mucilage of gum with a little common salt in solution, which, in human blood, much augments though in an irregular and confused manner, the aggregation of the red corpuscles, has comparatively little effect on the blood of the frog. Henle states that white of egg causes the red corpuscles of frog's blood to aggregate into heaps; but this does not appear to be to any greater amount than when mucilage of gum, with a little salt in solution, is the reagent employed.

$4. Though the red corpuscles of the blood of the frog have less disposition to aggregate than those of human blood, the colourless corpuscles appear to have more. § 5. The red corpuscles of the blood of the frog, as seen circulating within the vessels of the web, do not show the nucleus, or that very indistinctly; but when examined after being drawn from the body, the presence of the nucleus is sufficiently evident. The immediate cause of this difference appears to be, that in the former case the red corpuscles are more distended, in the latter more collapsed. For the reason that they are more collapsed after being drawn, the red corpuscles also appear redder. This change in the red corpuscles is coincident with the occurrence of the tendency to aggregate.

11. CAPILLARY CIRCULATION IN THE HEALTHY STATE.

§ 6. As the capillary circulation cannot be observed in the human body, reference is made to observations on the web of the frog's foot for what is necessary to be said on the subject, as a preliminary to inquiries into the action of the blood and of the capillaries in inflammation. In pursuing these latter inquiries, recourse must also be still had to observations on the web of the frog's foot. And it was in reference to this necessity to have recourse to observations on the frog, that the above remarks regarding its blood in comparison with that of man were made.

§ 7. When the circulation in the web of the hind foot of a frog is carefully observed under the microscope, the colourless corpuscles of the blood are seen, espe cially if the velocity of the stream be diminished by pressure on the limb, for example, accumulated on the inner surface of the walls of the vessels, along which they slide or roll over and over very slowly in comparison with the red corpuscles which occupy the axis of the stream, and move directly onwards.

$8. From these differences in the position, and in the mode and rapidity of progression of the two kinds of corpuscles of the blood, it would appear that there exists some sort of attraction between the colourless corpuscles and the walls of the vessels, but an absence of attraction, if not a repulsion, between the red corpuscles and these walls, as also between the red and colourless corpuscles.

§ 9. Though the red corpuscles keep together in the axis of the stream, there is not apparent among them any tendency to aggregate, like what is observed when the blood is drawn from the body.

§ 10. Through the very smallest capillaries, besides plasma and a few colourless corpuscles one after the other, a red corpuscle is only now and then observed to pass a circumstance which is to be explained, not by the too great size of the red corpuscles, (for they can readily accommodate themselves to vessels of a diameter less than their own,) but by a reference to the circumstance of an absence of attraction or the existence of a positive repulsion between the red corpuscles and the walls of the vessels. The plasma and colourless corpuscles, by virtue of their attraction for the walls of the vessels, readily enter very small ones, but when a red corpuscle would enter, it comes within the sphere of the repulsion of the walls of the vessels, and is as it were warded off. And when it does happen that a red corpuscle enters one of the smallest capillaries, it appears to be only by being actually forced in by accidental pressure from behind.

III. PHENOMENA ATTENDING THE FIRST STEPS of the INFLAMMATORY PROCESS, VISIBLE BY THE MICROSCOPE.

§ 11. To proceed now with the inquiry into the nature of the inflammatory process.

If the web of the frog's hind foot, displayed under the microscope, be irritated, mechanically or chemically, an opportunity is obtained of witnessing what is microscopically observable of the first steps of the traumatic inflammatory process which is excited.

§ 12. Very soon, then, after the web of the frog's foot, thus displayed under the microscope, has been mechanically or chemically irritated, accumulation and stagnation of the blood in the capillaries, including the terminations of the arteries and radicles of the veins of the part, is observed to take place; but amidst the obstructed vessels a few here and there may still be seen pervious, and through them the stream of blood is very rapid. The accumulation and stagnation of the blood in the small vessels is always preceded by a retardation of its flow-this retardation of the flow of blood, having or not having been preceded by the opposite condition of an accelerated flow.

§ 13. The acceleration, when it does occur, and the retardation of the flow of blood are coincident with changes in the width of the vessels-the former with constriction, the latter with dilatation. Omitting from further consideration the accelerated flow of blood, and the constricted state of the vessels with which it is coincident, as not constant, let the behaviour of the blood during the retardation of its flow and at the time of its stagnation be inquired into.