BIBLIOGRAPHICAL NOTICES.
Inflammation : its Symptoms, Causes, and Treatment philo-
sophically considered. By J. P. Batcheldek, M. D. New
York. 1848. Pamphlet, 8vo. pp. 66.
The object of this essay, and the motives which induced its
author to prepare and publish it, are thus unfolded by himself:
“ So much has been written on inflammation, that it may be
deemed quite superfluous to present to the medical public any ad-
ditional remarks ; but having seen no pathological views from
which the indications of cure, and the methodus medendi seemed
to flow as natural, regular and legitimate deductions, the writer
proposes for consideration a theory which he hopes may contribute
to remedy that defect.” And he adds, “ Whether the endeavor
will be crowned w7ith success, or the views presented meet with
any favor, other than a candid examination, is to him quite prob-
lematical.” p. 3.
We will endeavor to give a brief synopsis of the author’s views.
He considers that the proximate cause of inflammation—that
phenomenon, in the language of Parry—“ that phenomenon in the
body or part most immediately preceding the state which we call
disease, and without which previous phenomenon the disease is
not known to exist,” is “ a suspension of the normal resistance, a
relaxation, a yielding, a diminished action of the capillaries of the
part that admits, upon hydraulic principles, of the inflowing of
fluids by which they (the capillaries) are over distended. This
want of action, this non-resistance, continues until the distention
has proceeded so far as to excite actual resistance in the capil-
laries, and then, and not until then, can w7e,affirm the existence of
the disease. The action of the vessels is then increased. This
increased action” {contraction, the only mode of increased action
of which the capillaries are capable, as stated at page 16,) “ the
final end and natural consequence of which is, not only to prevent
the additional influx of fluids, but to force them out of the in-
flamed part, constitutes the true vis medicatrix natures ; for it
causes, or attempts to cause, and if successful does cause, the re-
flux of fluids into the general circulation, w’hich is equivalent to
an evacuation by art.” p. 17.
Thus, it will be perceived, inflammation is supposed by the
author to consist, at its outset, in a painful distention of the
capillaries, a condition of commencing, active, salutary resistance
to a preceding state of relaxation, its proximate cause.
The occurrence of this primary and essential state of relaxation
is thus explained: The blood which circulates in the capillaries
is regarded as their natural stimulus which prompts them to action
or resistance. When the vessels are healthy, and their contents
natural in quantity and quality, action and reaction are duly
balanced, and every function normally performed. And before
this equipoise can be subverted, and an anormal relaxation of the
capillaries induced, the author contends that a stronger impression
must be and is exerted upon a part, than that made by the fluids
on the inner surfaces of their containing vessels; in which event,
and in obedience to the axiom that the stronger effaces the
weaker impression, the vessels “cease their resistance, and yield-
ing, suffer themselves to be distended, over-distended, and stretched,
until they are excited to resist, and that painfully,” p. 14. The
agents by which this state of things is brought about constitute the
exciting causes of inflammation. They may be “ external agents
acting mechanically, chemically, or physically upon any part of
the body ; or causes affecting the whole system ; or the disease may
arise spontaneously,—that is, without any apparent cause.” The
first-mentioned class of causes operates directly by producing a
stronger impression on the surface upon which they act, than that
made by the blood upon the internal surface of the capillaries be-
neath this surface, and consequently and indirectly occasions a re-
laxation of these vessels; and since, naturally, the blood in the
capillaries is acted upon all over the system, at the same instant
and with an equable force, (the vis a tergo,if the resistance op-
posed to this force is weaker at one point than elsewhere, thither
will there be a greater afflux of blood. The second class, among
which the author considers cold and malaria, is supposed to
“ excite a general contraction of the capillaries throughout the
entire body, which is followed by a spontaneous relaxation com-
mensurate in extent and degree with the previous contraction ; if
under such circumstances any part or organ, from predisposition,
hereditary taint, disease, injury, age or sex, be weaker than the
rest of the system, its vessels having less power of resistance, will
yield and be over-extended, an effect which will be greatly en-
hanced by the increased energy with which the heart will act in
consequence of its own capillaries having, simultaneously with
those of the other organs, relaxed, and of course admitted more
arterial blood into its very textures, as well as into its cavities.”
Or, if the cause thus acting be extensive and powerful, and
applied to the surface, the vessels of some internal organ, in obedi-
ence to the law propounded, may relax and suffer themselves to be
over-distended to the development of inflammation, p. 15. Thirdly,
there may be no apparent cause, and yet in consequence of “great
weakness, or readiness in the capillaries of some part to relax and
yield to the distending influence of the fluid which they contain,”
the same phenomenon may be induced, p. 15.
The author easily explains the symptoms which are considered
as denotive of inflammation,—“ redness,swelling, pain and heat.”
“1st. Redness arises from an increased determination and admission
of blood into the vessels of an inflamed part, and particularly such
as in a state of health circulate colorless fluids.” He regards this
as an essential symptom, and he thinks that, although it some-
times exists without inflammation, the latter cannot exist when it
is absent; and further, that by the degree of the redness present,
the stage, rapidity and violence of the disease may be pretty accu-
rately distinguished, p. 3.	2d. The tumefaction or swelling he
ascribes to two causes,—to the presence in the vessels of an
unusual amount of blood, “ proportioned to the diminution of their
resistance and the intensity of the vis a tergo ; and also, and
chiefly, to the effusion of serum, albumen and coagulable lymph.”
p. 4. Concerning this latter cause of the swelling, the author
thus reasons. “ How does this effusion take place, and by what
law is it governed or regulated ? We come to the principle. If
from any cause the capillaries be suddenly or violently distended,
or over-distended, and consequently prompted to act violently, or
inordinately, as in inflammation, the pores, like the sphincter of
the bladder, or of the anus, similarly circumstanced, act or resist
no less violently or inordinately, and consequently suffer no fluid
to escape ; and this we conceive to be the precise state of the
vessels and pores in the early stage of that disease, and is analo-
gous to that of the vessels on the surface during the hot stage of
an intermittent, in -which the skin is dry.
“ At this period there is no other swelling than that occasioned
by the distended state of the vessels of the part. There is no effu-
sion of serum, none of fibrin. There is mere congestion; the
vessels over-distended, the pores constricted and resistant. How
then, we repeat, is the effusion produced ? The principle is this,
that rest shall succeed to action. This law results from necessity,
and is consequently universal, reaching and controlling all vital
movements ; hence, vascular contraction is followed by the spon-
taneous relaxation to which we have alluded, and which, gene-
rally, is in proportion to the previous contraction. Therefore, in
obedience to this law, the pore, or sphincter, as the case may be,
which has been for some time resisting powerfully and completely
the inordinate action of the vessel or viscus, and of course pre-
venting the transmission of the fluids by W’hich the latter (the
vessel or viscus) wrere distended, now in its turn foregoes its re-
sistance, relaxes and allows the effusion of serum or fibrin to take
place into the inflamed part, or perspirable matter over the whole
surface, as in the sweating stage of an intermittent, (or the escape
of its contained fluid from the containing viscus, Rev.) In these
cases the overdistended vessels are relieved. The final end of this
effusion is to empty the vessels; in other words, to cure the dis-
ease. This is the method of nature, and also of art—a fact of
which the practitioner should never lose sight.
“ If this want of equilibrium between the vessels and pores con-
tinues but for a short time, and the effusion be but slight, reso-
lution is said to have taken place, which is one of the terminations
of inflammation mentioned by systematic writers ; but with all due
deference, we are disposed to consider the effusion by which the
vessels are emptied and relieved as the only legitimate termination
of that disease—if indeed W’e except gangrene. If the state of
distention continue several days, the effusion may be considerable
and of a mixed character, as serum, albumen, coagulable lymph,
or even blood. It constitutes the principal cause of the swelling.
We are, however, ready to admit that want of absorption and the
generation of new vessels tend in some degree to augment the
tumefaction ; and here it is proper to remark that the formation of
new vessels is often exceedingly rapid, which, with the secretion
of pus, has been reckoned among the causes of swelling.” pp. 5, 6.
The third symptom, Pain, the author says, “ in all cases, with-
out a single exception, as we believe, arises from one of two
causes—an over-constricted, or an over-distended state of the
vessels.” And again, “ it may be laid down as an axiom in physi-
ology and pathology, that whatever diminishes the influx of red
blood into a part, or forces it out, produces a corresponding dimi-
nution of its susceptibility of impression.” p. 8. And the reverse,
he also contends, is true—that the sensibility of a part is propor-
tionally exalted by increments in the amount of red blood sent to
it. The author’s remarks upon the true signification of the pain
suffered, and the specific character of pain which appertains to
each particular tissue, are, we think, very just, generally.
The fourth symptom, increased heat, he does not regard as
essential, or as particularly important. The inference drawn by
him, from his premises and reasoning, is, “that this fourth symp-
tom of inflammation is seldom present unless the skin, or mucous
membrane in its immediate vicinity, is involved, and that it always
indicates an over-distended state of the capillaries of the part, and
gives intimation that changes are going on in the tegumentary
structures, which interfere with their functions, or threaten their
integrity.” pp. 12, 13.
The plan of treatment recommended by the author does not
differ, generally, from that pursued by physicians of judgment and
experience. This branch of the subject is examined under two
main points of view:—1st, the conditions upon which the over-
distention of the capillaries are maintained; 2d, the mode of re-
lieving this over-distention. The first depends upon the constant
antagonism, as the author supposes, which exists between the
vis a tergo and the “ pores ” of the capillaries, and the morbid
predominance of resistance of the latter over the former, so that
the fluid in the vessels is not permitted to escape. The second—
the method of obviating this condition—consists in lessening “ the
vis a tergo so as to restore the equilibrium between the vessels and
the pores;” in diminishing “the effect of the fluids impinging
against the inner surfaces of the capillaries, which excites them
to inordinate action, and disturbs the harmony of function between
the vessels and the pores;” and lastly, in counteracting the results
of the disease. To secure these ends the whole antiphlogistic
regimen and treatment is advised in full force—comprising strict
attention to diet and hygienic conditions, general and local bleed-
ing, the free use of emetics and cathartics, of arterial and nervous
sedatives, the ordinary topical applications, and rest of the whole
body, or of the affected part, in the proper position.
After having thus discussed the subject of inflammation, and its
treatment, the author devotes the remaining pages, 47—66, of his
pamphlet to the consideration of the commonly-called “ termina-
tions ” of the disease, viz., Resolution, Adhesion, Suppuration and
Ulceration—he himself, however, admitting of “ but one legiti-
mate termination, i. e., by depletion,” by which he means the
removal of the fluids from the vessels of the inflamed parts, either
by their spontaneous contraction, or by the assistance of
art. pp. 17, 47.
It would be foreign to our purpose, at present, to enter into a
discussion of the subject of inflammation, further than the bearing
of this pamphlet upon it requires. We have given the author’s
tract a careful perusal, and have derived pleasure from it; but we
think that it is amenable to some strong objections, and we shall
state them in that spirit of candor and respectful consideration
which the author himself invites.
It is well known that there are now two chief theories with
regard to the condition of vital action in the capillaries of an in-
flamed part. Both admitting that these vessels are increased in
diameter, in order to accommodate the augmented supply of blood
which they are acknowledged to contain, one theory supposes that
this dilatation is the result of an increased action of the capillaries,
under the influence of the organic nerves , while the other contends
that these vessels are in a debilitated condition, and that their
enlargement is the result of a passive relaxation. The author of
the treatise under examination adopts the latter view. He as-
sumes, without examination, that the only mode in which increased
action can be manifested in a capillary is a diminution of its
calibre, and that, consequently, the first theory must be wrong.
Without attempting to decide positively between these two view’s,
we incline to adopt the first, believing that it is based upon more
tenable ground, and that it affords a more easy and rational ex-
planation of the phenomena of inflammation. We think that
increased action of the capillaries, the result of increased organic
nervous influence, is not only compatible with, but productive of
expansion of these tubes; the phenomena of blushing and other
local determinations of blood, under similar causes, and the con-
dition of the capillaries in hyper-nutrition, render it more than
probable that a similar condition of the vessels exists in inflam-
mation. This active expansion may continue, or it may, at
length, be changed, from exhaustion of nervous force, into a state
of passive dilatation. This seems to us a more probable suppo-
sition, and more analogous to w’hat we generally see of the effect
of long-continued exercise of all organs, especially of hollow
organs, than that the capillaries should, after long resistance to
the distending power of the affluent blood, and after being “ dis-
tended, and over-distended” thereby, be capable of active, sustained
contraction so as to expel the blood from their interior, (p. 17.)
And it renders unnecessary the assistance of such an influence as
that which Dr. Batchelder invokes in the explanation of the
occurrence of distention of the capillaries,—the action of an
impression upon some part stronger than that made by the blood
upon the inner surface of these canals, (p. 14.) The idea of the
existence of such an influence or action is entirely groundless; for
it supposes, of necessity, that the circulation of the blood in the
capillaries is assisted by the elastic resistance of these vessels to
the blood, “ which is their natural stimulus, and prompts them to
action.” Now the most enlightened physiologists of the present
day contend, that the contraction of the heart and the elasticity of
the arteries are the forces which propel the blood through, the
capillaries, and that the latter exert no mechanical action upon it;
that the motion of the fluid is equable, not pulsatory, as would be
the case if the capillaries reacted upon the blood which filled
them.
The capillaries possess a degree of elasticity, and a capability
of accommodating their calibre to the amount of fluid which they
contain; but this is a very different property from the contractility
which responds to a stimulus, as that of the heart, which causes it
to act upon and expel the blood from its cavities.
We dissent, also, from the author’s views with respect to the
structure of the capillaries. He regards them as being possessed
of “pores” which, if we were to be guided by his mode of speak-
ing and reasoning concerning them, are distinct and visible outlets.
The walls of the capillaries partake, undoubtedly, of the general
porosity of all membranous textures ; but their pores are not
visible, and still less are they, by any stretch of fancy, to be
assimilated or likened to the sphinctered orifices of the bladder,
uterus, rectum, and stomach, as is attempted by the author; (p.
19, et seq.) consequently, all the reasoning based upon this
falsely assumed similarity of structure and function must pass for
nothing.
The author has entirely neglected to notice the affinity which
inflammation excites between the walls of the capillaries and the
modified fluid which they contain, and the effect which this must
have upon the circulation in the inflamed part.
The account of the symptoms of inflammation embraces no
mention of altered functions of the tissue or organ involved, and
the explanation of the symptoms is insufficient and faulty. Thus
the pain of the disease is ascribed to stretching of the nervous
fibrils, in consequence of the swelling of the part, and to over-
distention or over-contraction of the capillaries, and is said to be
closely proportioned to the amount of red blood circulating in
them. The vital changes, of which the nerves of the part are the
subjects, are not alluded to. The temperature, too, of an inflamed
part is affected by other circumstances than the amount of arterial
blood, and does often rise higher than that of the blood in the
heart, in consequence of increased vital action occurring in the
diseased structure itself. (Copland, and others.)
To the views expressed as to the treatment of inflammation, we
have nothing particularly to object, excepting that they are chiefly
or wholly applicable to the sthenic form of the affection; indeed,
throughout the Essay, asthenic inflammation is very imperfectly,
if at all, considered. In speaking of general bloodletting the
author alludes to syncope, which, he says, “ consists in a universal
and extreme contraction of the capillaries;” and that he considers
this to be an active condition, is obvious from the following sen-
tence: “ Now this violent and universal contraction of the capil-
laries must be followed by a spontaneous relaxation, or the patient
will die.” CPP- 26.) How there can be such an active force
in a condition characterised by such complete prostration of all
energy as is syncope, we do not comprehend. Nor do we under-
stand how the author can promulgate such an idea as this: “for
an obvious reason we should be in no hurry to remove the syncope ;
as a general rule, the longer it continues, and the more slowly it
goes off, the better.” (p. 33.) We should rather inculcate the
necessity of a speedy restoration, under the impression that the
longer the syncope continued the greater the danger that it would
be irrecoverable, and that, (if it be permitted us to perpetrate “ a
bull,”) if the patient should recover, it would only be to find him-
self—dead.
The author’s remarks concerning the organization of effused
plastic matter, the mode of formation of new vessels, and the
object of their formation, appear to us to be very erroneous. He
says, p. 6, “the effused fluids, if too great in quantity to be
absorbed, will remain an incumberance, greatly interfering with,
or wholly suspending, the function of the organ ; therefore, to get
rid of them, the suppurative process is instituted by nature in the
simplest manner possible; to wit, by the formation of new vessels
and consequent organization of the effused lymph. The secretion
of pus, then, is the final end of the formation of new vessels. How
are they formed ? On this point we shall hazard a conjecture,
which, like the theory promulgated in this paper, was framed
many years ago:—that a globule of blood escapes from a vessel,
probably the same which furnished the lymph, through which it
(the globule) makes its way, and thus forms a channel along which
other globules, following close and in rapid succession, continue
to move, until the track becomes a vessel; similarly occurring
results take place on every side ; globules after globules escaping
from other vessels, pass in all directions, till channel runs into
channel, and globule joins globule, when they will move in that
direction in which they are most forcibly impelled by the vis a
tergo which continues to urge them along, until the channels are
converted into living vessels, temporary or permanent, according
to subsequent circumstances.”
We do not wish to deny the author’s claim to originality of
theory, as regards his explanation of the manner in which new
vessels are formed in the effused fibrin, although we have before
seen the same view expressed by other writers. We cannot, how-
ever, think that it is correct. A globule of blood can only escape
from a capillary vessel through a rupture of the wall of the latter;
and, even admitting that such a rupture does occur, and that a
globule is forced by the vis a tergo through the rent, across the
coagulated fibrin, which seems to us improbable, how is it sup-
posed to find its wmy to a venous channel ? We grant that the
blood globule is a living cell, endowed with W’onderful properties,
physical and vital, and that nature is exhaustless in her resources
and in her means of accomplishing her ends ; but we can scarcely
think that she would expend her energies in the mode advocated
by the author. Let the reader imagine the curious and amusing
spectacle presented by an indefinite number of ejected blood-discs
careering “ hither and yon,” across an intervening septum of
plasma, in search of refuge and shelter upon the opposite side ; it
will remind him of some of Milton’s Wanderers in Chaos,—
“Embryos and Idiots, Eremites and Friars
White, black and grey, with all their trumpery.”
We would rather embrace the views of Schwann, Vogel,
Carpenter and some others, which suppose that vessels are formed
in exuded fibrin in the same manner as in the original tissues in
primary development; yet even here we acknowledge the difficulty
of explaining the mode by which the new vessels unite and innos-
culate wuth those of the pre-existing surface or surfaces. Or we
would still rather adopt the explanation of Mr. Kiernan and Mr.
Travers, formed from observing that “ inflamed capillaries become
varicose, and at points project in pouches and diverticula, and
stretch into loops. If these give way, argues Dr. Williams, the
blood would be injected into the lymph; and if something of
channels wTere previously formed by the arrangement of the fibrils
of the latter, or the elongation and communication of cells, it is
quite conceivable that a current would be effected by the vis a
tergo through several openings, and that a return of the blood
would take place by a reversal of the weaker currents.” (Wil-
liams'1 Prine., p. 252.) But no such rupture is necessary,—the
blood being conveyed through channels formed by “ out-growths”
from the original vessels.—{Travers—Inflam, and the Healing
Process; also, Paget, Sect. 4th, London Med. Gaz.—July 13th,
1849.)
However formed, “the final end” of their production is,
we conceive, the organization of the effused fibrin, not “ the se-
cretion of pus,” as Dr. Batchelder contends.
With reference to this latter point he says, p. 52, “ Suppuration
has been usually considered one of the terminations of inflam-
mation ; but the intermediate links between inflammation and
suppuration seem to have been overlooked, viz., the effusion of
coagulable lymph, and the formation of new vessels, which, with
a single exception, (in the inflammation of mucous membranes,
and this only an apparent exception,) always precede the secretion
of pus. These new vessels which secrete the pus, with the paren-
chyma which connects them together, compose the granulations,
which, being piled one upon another, fill the cavity, and consti-
tute what is technically called “ union by the second intention.”
Although we sometimes speak of “laudable pus,” the formation
of matter is never the product of healthy action. It may be modi-
fied by the part affected, the state of the constitution, the cause
and character of the disease.” And again, (p. 53, note,) “ we
remarked that, if the effusion of coagulable lymph was so large in
quantity as to prevent the new, or primitive, vessels, which shoot
into it, from innosculating with one another, they immediately
commence secreting pus, which is deemed to be “ altered blood ;”
and that the alteration of the blood, so as to constitute it pus, is
the function of the new vessels, but they answer a secondary pro-
cess, viz., the organization of the lymph;—their peculiar, appro-
priate and primary function is, we repeat, the secretion of pus.
All that is required is, an investment of fibrin about new vessels,
or the old ones elongated, in order to enable them to perform this
function.” Again, (p. 7,) “ the primitive vessels, if elongated
into the adventitious lymph, will secrete pus. But the business,
so far as an abscess is concerned, is probably done chiefly by the
newly-formed vessels, which are little other than imperfectly
animalized tubes, that can exert no other than a mere altering
influence upon the blood, which it converts into pus.”
We think that there are many inaccuracies in these and other
passages, in which the author expresses his views on the nature
of pus, and the mode of its formation. In the first place, we object
to the idea that the blood-vessels perform the part of secreting
organs under any circumstances; they have a single office, that of
conveying blood, and hence are, at best, merely accessories to the
process of suppuration, as of nutrition and secretion; these complex
actions are the results of the operation of agents and influences
external to the vessels upon the fluid which the latter have con-
veyed to the tissues—the centres of nutritive and secretory life.
Neither can pus be considered as “ altered blood.” It is the
result of a special organization of exuded fibrin, “ an organization
on which the character of pus is dependent, and which distin-
guishes it from other morbid products.” (FogeZ.) It is essential
to the formation of pus, says this distinguished pathologist, first,
that a fluid shall be secreted or separated from the blood, to serve
as a cytoblastema, and this fluid is fibrin, as it exists in the liquor
sanguinis, or in coagulated blood; this plasma may be of a healthy
character, or more or less abnormal, it may be fluid or solid ;
secondly, it is necessary that the pus-corpuscles be formed in and
from this pabulum, owing, probably, to a tendency possessed by
the exudation itself to develop organized products. “ The uses of
the formation of pus to the organism consist in this, that by its
means exudations which were originally fluid, and would have
become solid, are prevented from coagulating ; and those already
coagulated again become fluid, and thus the conditions requisite
for their removal are effected.”—(See also the fourth lecture of
Mr. Paget.)	F. W. S.