and the type of the constitutional disturbance. In an ordinary case of simple inflammation, beyond a brisk purge, subsequent regulation of the bowels and secretions by salines, and restricting the diet, no special constitutional treatment is required. But when the fever is high, the patient young and vigorous, and the pulse rapid, full and strong-in short, where the fever is of the sthenic type, antiphlogistic or lowering treatment should be adopted. Where, on the other hand, the patient is weakly or old, or broken down in constitution, and the fever of a low or asthenic type, a stimulating plan of treatment will be required. Antiphlogistic treatment may be considered under the heads of diet, drugs and general blood-letting.

The diet should be restricted to milk, weak beef-tea, barleywater, arrowroot, and the like.

Drugs.-Purgatives determine the flow of blood to the intestines, and so relieve the inflamed part. They are not, however, generally employed except as a brisk purge at the onset of the inflammation, and in gonorrhoea and orchitis, in which they are of considerable benefit. In inflammations of the intestine and peritoneum they should not, as a rule, be used at all. Diaphoretics and diuretics relieve the distended vessels, the former by determining the flow of blood to the skin, the latter to the kidneys. They are not often employed in surgical inflammations. Aconite in small doses frequently repeated is believed to reduce the frequency and force of the heart's action, and is much praised by some. Antimony was formerly much employed, and is still used in inflamed testicle. Mercury in combination with opium was once in much favor, and was thought to have a controlling action on the inflammation. It is seldom given at the present day, except in syphilitic inflammation and as a purgative at the commencement of other inflammations. Opium, however, is frequently used to relieve pain, and it also seems to have some action in controlling the inflammation. It may be given by the mouth, or in the form of morphia as a subcutaneous injection. Quinine, salicylic acid and antipyrin are sometimes employed when the temperature is high, as is colchicum in gout, potash in rheumatism, perchloride of iron in erysipelas, and hyoscyamus and chloral when there is want of sleep.

Bleeding is not often employed in modern surgery, but it is at times beneficial in very acute inflammations in young and plethoric subjects. During twenty years' experience of hospital work I have seldom seen it used, although formerly it was in constant vogue. The blood may be taken from one of the veins of the arm, or from an artery, as the temporal.

The stimulating plan of treatment may be considered under the head of diet, drugs and stimulants. The diet should consist of essence of beef, milk, eggs, milk-puddings, oysters, turtle soup, and of white fish and minced chops if solid food can be retained. Of drugs, ammonia and bark or quinine and iron will generally be found of most service; while stimulants in the form of brandy, the brandy-and-egg mixture, port wine, champagne, or any other that the patient has been accustomed to take, should be given in divided and measured doses at stated intervals. Stimulants increase the force of the heart's action, and so drive the blood through the inflamed part, and maintain the circulation till the crisis has been tided over. The indications for their use are a feeble and frequent pulse, a high temperature, a dry and brown tongue, and general signs of prostration.

CHRONIC INFLAMMATION.

The pathological process in chronic inflammation is essentially the same as in acute; but the dilated vessels appear to lose their tone, and remain dilated for longer periods, and the escape of leucocytes is continuous. Further it appears possible that the inflammatory exudation, which contains less fibrin-forming material and albumen, is formed in part by the original tissue cells as well as by escaped leucocytes. Like the acute it may terminate in resolution, suppuration and ulceration, but it is much more likely to produce chronic thickening of the tissues, from the accumulation in them of the cellular elements, or terminate in caseation or even calcification.

The causes of chronic inflammation are similar to those of the acute, but they appear to act with less intensity and for longer periods. Among the predisposing causes must be especially mentioned passive congestion, struma, rheumatism, gout and syphilis. The exciting causes are often very slight, and may be altogether overlooked; while secondary causes which may keep up the inflammation for an almost indefinite time frequently come into play. Thus in chronic joint-disease, though the cause may be but a trivial injury in a rheumatic subject, continual movement and tension due to the distention of the synovial membrane may keep up the inflammation for months or years. The presence of miliary tubercle is a frequent cause.

Symptoms.-These are also local and constitutional. Of the local signs the redness may be absent, or, if present, of a dusky hue; while the part is often discolored from pigmentation due to the disintegration of the colored corpuscles. The pain is less severe than in the acute, often of a dull, aching character, and increased on pressure and sometimes worse at night.

The

part may be slightly hotter than natural, but at times no increased heat is apparent. The swelling is always a marked sign. Constitutional symptoms may be altogether absent; generally, however, the patient's health is feeble or below par, or he is strumous, or he has gouty, rheumatic, or syphilitic symptoms. At times there may be some fever when an important organ is affected.

Treatment. The indications are: to remove the cause and all secondary sources of irritation; to promote the absorption of the inflammation products; and to re-establish the normal nutrition of the damaged tissues. For this purpose constitutional as well as local means should be employed. Thus: we should endeavor to improve the general health by a careful dietary and the regulation of the secretions; while stimulants and tonics should be given where indicated. In the strumous, cod-liver oil, in the syphilitic, mercury or iodide of potassium, in the gouty, colchicum, and in the rheumatic, the salts of potash or guaiacum, are especially indicated; while residence at the sea, or at some spa suitable to the diathesis, or a sea voyage should be enjoined. Locally, the means at our command, besides rest of the part, are: 1, counter-irritation by blisters, tincture of iodine, and stimulating liniments; 2, friction with mercurial ointment, the oleate of mercury or ointments of iodide of lead or cadmium, or by shampooing, massage, etc.; 3, pressure by means of carefully applied bandages, Scott's dressing, or Martin's bandage, or the ammoniacum and mercury plaster; 4, the formation of setons or issues; and 5, the application of the actual cautery. Where suppuration threatens, as in chronic inflammation of lymphatic glands, sulphide of calcium may be of service to promote the rapid breaking down of the caseating mass. It should be given in doses of to grain.

SUPPURATION AND ABSCESS.

We have already seen that under some circumstances the inflammatory process may terminate in the softening and breaking down of the inflamed tissues, death of the infiltrating leucocytes, and formation of pus, suppuration being then said to be established. This process, whether it occur, 1, in the substance of the tissues or organs or, 2, on the free surface of the skin, a mucous or a serous membrane, is practically the same. In the former situation it is spoken of as circumscribed, or as diffuse suppuration, according as it is limited in extent or the reverse; in the latter situation it is known as purulent exudation or catarrh, or as ulceration, according as the process merely involves the superficial layers of the epithelium, or extends through

to the deeper parts. We will first deal with the circumscribed variety of suppuration or abscess, as this is the most familiar example to surgeons.

CIRCUMSCRIBED SUPPURATION OR ABSCESS.-An abscess may be defined as a circumscribed collection of pus, the result of inflammation. It may be acute or chronic.

Acute Abscess.-The formation of an abscess may perhaps best be studied as it occurs in the superficial tissues. We have already seen that an inflamed part is hot, red, swollen, and painful. If the inflammation ends in suppuration, the swelling which was more or less diffuse becomes circumscribed and pronounced, the redness localized and more intense, the pain assumes a throbbing character, and a distinct chill or rigor is generally experienced. On pressing lightly with the fingers on the inflamed part a sensation of fluid beneath the skin is felt, and fluctuation is said to be present. If left to nature, the abscess makes its way in the direction of least resistance, i. e., generally toward the free surface of the skin, or, if more deeply seated, toward a mucous canal, serous cavity, or the interior of a joint. Continuing to take a superficial abscess as our example, one part of the inflamed area becomes more prominent than the rest, and the skin over it red and glazed. The abscess is said to point. The skin will shortly ulcerate or slough, and bursting of the abscess with discharge of the pus will ensue. On the evacuation of the pus either naturally as above, or through an incision artificially made, the walls fall more or less together, and the cavity is gradually filled up by granulations till finally only a scar remains. The minute changes concerned in this process are briefly as follows: The leucocytes which have escaped from the vessels in the way already described aggregate at the focus of inflammation; the tissues, in part from the pressure of the leucocytes, in part from the original injury, and in part from lack of nourishment consequent on the thrombosis of the vessels, undergo softening and liquefaction, and together with the leucocytes die and form pus. The accompanying wood-cut (Fig. 2) illustrates diagrammatically the appearance that would be presented by a section through an abscess and the surrounding tissues. In the centre is the abscess cavity; around this in the upper half of the diagram are zones representing the inflammatory changes in various stages of progress. When an abscess enlarges it is simply by the extension of the inflammatory process from zone to zone. The central cavity increases by the successive degeneration of the small round cells, which fall into the cavity and become pus-corpuscles, while what was formerly the zone of thrombosis is now converted by the aggregation of

FIG. 2.

the leucocytes into the zone of small round cells, the zone of dilated vessels and retarded flow into the zone of thrombosis, and so on to the circumference. Such at least occurs when an abscess spreads uniformly in all directions. Usually, however, it makes its way in the direction of least resistance, these changes then occurring chiefly at that part. If an abscess is not opened the tension keeps up the inflammation, but when the pus is evacuated the circulation in the vessels around resumes its normal state. Delicate loops of capillaries grow in among the small round cells surrounding the abscess cavity, thus forming a wall. of granulation tissue.

The granulation tissue is

developed into fibrous

tissue which in its turn

contracts, obliterating

the blood-vessels, and is

Vessels dilated with i
Vessels dilated with relan

converted into dense cic

atricial tissue. In the

lower half of the dia- Diagrammatic representation of the minute changes in

gram are zones representing the various

the formation and healing of an abscess. The upper half shows abscess enlarging; the lower half abscess healing.

changes in the process of healing. Thus, the abscess cavity becomes gradually filled up by the granulation tissue, the zone of granulation tissue converted into the zone of vascular fibrous tissue, and this again into the zone of cicatricial tissue, and so on till the healing process is complete.

Characters of Pus.-Pus from an acute abscess in an otherwise healthy person is called healthy or laudable. It is a thick, creamy, opaque, yellowish-white, slightly alkaline fluid, with a faintish smell and saltish taste, and a specific gravity of about 1030. If a drop is examined under the microscope it is found to consist of a fluid (the liquor puris) and corpuscles (pus-cells). The greater number of these corpuscles are globular, slightly granular, measure of an inch in diameter, and contain two or three nuclei which are made more evident on the addition of acetic acid to clear up the granular matter. Among them may be seen other corpuscles indistinguishable from leucocytes, and exhibiting, when examined on a warm stage, amoeboid move