Library of Congress Subject Headings, 21st edition, 1998

Languages Used:

• English

LC Subject Headings:

• Surgery, Military -- Confederate States of America.
• Medicine, Military -- Confederate States of America.
• Military hospitals -- Confederate States of America.
• Confederate States of America -- Armed Forces -- Medical car
• United States -- History -- Civil War, 1861-1865 -- Medical care.

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AN
EPITOME
OF
PRACTICAL SURGERY,
FOR
FIELD AND HOSPITAL.

BY

EDWARD WARREN, M. D.
SURGEON GENERAL OF THE STATE OF NORTH CAROLINA, FORMERLY
PROFESSOR IN THE UNIVERSITY OF MARYLAND.

FRIST EDITION.

RICHMOND, VA.
WEST & JOHNSTON, 145, MAIN STREET.
1863.

Entered according to Act of Congress, in the year 1863, by
EDWARD WARREN, M. D.,
In the Clerk's Office of the District Court of the Confederate
States for the District of Pamlico, North Carolina. BROTHER & MARCOM PRINTERS, RALEIGH, N. C.

TO
LAFAYETTE GUILD
Surgeon C. S. A.
AND
JOSEPH P. LOGAN,
Surgeon P. A. C. S.
This work
IS MOST RESPECTFULLY AND AFFECTIONATELY
DEDICATED.

PREFACE.

        MUCH experience in Field and Hospital, has convinced me of the necessity for the publication of a work on Surgery, more elementary, practical and concise in its character than has hitherto appeared. I have therefore, devoted myself to the preparation of this volume, as a vade mecum for the Surgeons of the Confederate service, with the view of supplying the desideratum which exists in this regard.

        Little claim to originality, either as to principles or details, is advanced in these pages; but I have mainly endeavored to glean from fields of experience far richer and broader than my own, such views, facts, and deductions as are most worthy of diligent study and faithful preservation. The ablest authors on the various subjects discussed, have been freely consulted, and the intelligent reader will have no difficulty in discovering to what extent I am indebted to them for the substance matter of this volume. Wherever an issue has been made with standard authorities, it has been from an honest conviction of the absolute necessity for such a course, and from an earnest desire to advance the best interests of Surgical science.

        So far as the typographical execution of this book is concerned, I must urge in extenuation of its imperfections, that the best printers are in the service, and that those who remain behind are too young and inexperienced to do proper justice to any author. For this reason many errors will be found in this edition which shall be corrected in a subsequent one.

        For the invaluable statistical information contained in the Appendix, I am indebted to the courtesy of Surgeon Samuel Preston Moore, Surgeon General of the Confederate States, under whose intelligent scrutiny and able direction it was carefully collected by Surgeon Francis Sorrell, Inspector of Hospitals for the City of Richmond.

        Whatever the merits or defects of this unpretending work, it has been undertaken in a spirit of loyalty and humanity: and it is now issued with the hope of contributing something to a cause in which every sentiment of my bosom is most warmly enlisted.

        Should it be the means of saving a single life, of alleviating a pang of pain, or of inspiring one professional brother with a braver heart and a steadier hand in the hour of trial, my proudest aspiration will be more than realized.

INDEX

• Abscesses, 78
• Accidents after Amputations, 116
• Acupressure, 228
• Alteratives, 78
• Amputation, varieties of 81
• Amputation, primary, 81
• Amputation, secondary, 87
• Amputation, modes of, 104
• Amputation, of great toe, 137
• Amputation, of metatarsal joint 138
• Amputation, of metatarsal bones, 138
• Amputation, through tarsus, 139
• Amputation, at ankle joint, 140
• Amputation, of leg, 143
• Amputation, at knee joint, 144
• Amputation, of thigh, 146
• Amputation, at hip joint, 152
• Amputation, of fingers, 155
• Amputation, at wrist joint, 158
• Amputation, of fore arm, 159
• Amputation, at elbow joint, 160
• Amputation, of upper arm, 161
• Amputation, at shoulder joint, 162
• Anæmia from loss of blood, 209
• Antiplogistic regimen, 62
• Applications, cold and warm, 73
• Arteries, structure of, 239
• Arteries, compression of, 218
• Arteries, ligation of. 235

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  Page viii

• Arteria innominata, 266
• Anterial sedatives, 57
• Axillary artery, 268
• Barton's fracture, 376
• Blisters, 71
• Blood, changes in, 13
• Blood, condition of, 213
• Blood letting, 54
• Bones, excision of, 101
• Bones, reproduction of, 203
• Bones, fractures of, 340
• Brachial artery, 27
• Brainard's perforator, 348
• Cancer. 43
• Causes of Hemorrhage, 211
• Carpal bones, dislocation of, 323
• Carpal bones, fractures of, 379
• Carotid artery, 247
• Circular method of amputation, 104
• Colle's fracture. 376
• Comminuted fractures, 342
• Complicated fractures, 342
• Compound fractures, 342
• Compound fractures, of inferior maxillary, 363
• Compound fractures, of arm, 373
• Compound fractures, of hand, 378
• Compound fractures, of ribs, 366
• Compound fractures, of pelvis, 375
• Compound fractures, of thigh, 383
• Compound fractures, of leg 388
• Compound fractures, of foot, 301
• Compression of Arteries, 217
• Compression of brain, 351
• Concussion of brain, 351
• Corpuscles, red, 13
• Corpuscles, white, 13
• Depletory remedies, 54

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  Page ix

• Depression of bone, 339
• Disarticulation of fingers, 157
• Dislocations, 205
• Dislocations, of lower jaw, 308
• Dislocations of clavicle, 310
• Dislocations of acromion, 312
• Dislocations of shoulder joint, 313
• Dislocations of ulna, 318
• Dislocations of radius, 318
• Dislocations of wrist, 322
• Dislocations of thumb, 324
• Dislocations of thigh, 326
• Dislocations of patella, 333
• Dislocations of tibia, 333
• Dislocations of fibula, 336
• Dislocations of astragalus, 336
• Dislocations of calcaneum, 337
• Effects of gun-shot wounds, 356
• Erysipelas, 123
• Extension and counter extension, 304
• Fever, 26
• Fissures of bone, 369
• Flaps, length of, 109
• Flap amputations, 105
• Flexion of bones, 339
• Fractures, classification of, 328
• Fractures, of pelvis, 370
• Fractures, of humerus, 370
• Fractures, of ulna, 374
• Fractures, of clavicle, 366
• Fractures, of scapula. 653
• Fractures, of cranial bones, 350
• Fractures, of radius, 375
• Fractures, of ulna and radius, 376
• Fractures, of carpal bones, 379
• Fractures, of fingers, 378
• Fractures, of femur, 379

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  Page x

• Fractures of patella, 387
• Fractures of tibia, 380
• Fractures of fibula, 380
• Fractures of fibula and tibia, 370
• Fractures of bones of foot, 300
• Gangrene, 189
• Ginglymoid joints, 293
• Hemorrhage, 210
• Hemorrhagic fever, 208
• Hernia cerebri, 361
• Hospital gangrene, 120
• Inclined plane, 382
• Induration, 37
• Inflammation, 13-70
• Ligation of arteries, 226
• Ligation of arteria innominata, 246
• Ligation of common carotid, 247
• Ligation of exterior carotid, 250
• Ligation of thyroid. 252
• Ligation of lingual. 252
• Ligation of facial, 253
• Ligation of subclavian, 255
• Ligation of axillary, 268
• Ligation of brachial, 271
• Ligation of radial, 275
• Ligation of ulna, 278
• Ligation of common iliac, 356
• Ligation of external iliac, 264
• Ligation of internal iliac, 262
• Ligation of femoral 280
• Ligation of popliteal, 285
• Ligation of posterior tibial, 291
• Ligation of anterior, tibial, 287
• Ligation of dorsalis pedis, 389
• Ligation of peroneal, 289
• Ligatures, mediate and immediate, 226
• Litters, 345

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  Page xi

• Litter Corps, 344
• Lymph, absorption of, 36
• Malar bone, fractures of 263
• Median Basilic Vein, 274
• Mercury, 57
• Morphia--Endermic use of 305
• Nervous Sedatives, 89
• Opium, 59
• Organization of Lymph, 43
• Orbicular Joints, 298
• Oval method of Amputation, 106
• Palmar arch, 279
• Points for ligatures, 235
• Points of stagnation, 14
• Position in hemorrhage, 221
• Position in inflammation, 71
• Pullies compound, 328
• Pus, 40
• Pyæmia, 127
• Pyogenic membrane, 39
• Redness, 18
• Resections in general, 180
• Resection of meta: carp: phal: articulation, 180
• Resection of meta: carp. bones, 180
• Resection of wrist joint, 180
• Resection of radius, 181
• Resection of ulna, 182
• Resection of elbow joint, 183
• Resection of shoulder joint, 185
• Resection of clavicle, 190
• Resection of scapula, 190
• Resection of tarsus, 191
• Resection of ankle joint, 192
• Resection of knee joint, 192
• Resection of hip joint, 199
• Resolution, 36
• Revulsives, 77

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  Page xii

• Saline elements, 14
• Seton, 228
• Shock, 120
• Smith's ant: splint, 386
• Statistics, 392-400
• Stumps conical, 119
• Stumps neuralgia of, 120
• Structure of arteries, 239
• Swelling, 20
• Styptics, 236
• Suppuration, 139
• Tetanus, 131
• Tourniquets, 217
• Transformation of tissue, 45
• Trephining, 169
• Warm applications, 75
• Water dressings, 74
• Wounds of head, 356
• Wounds of face, 362
• Wounds of lungs, 368
• Wounds of arteries, 208
• Wounds of soft parts, generally, 357
• Wounds of bones, 356
• Wounds of entrance, 358
• Wounds of exit, 358
• Wounds from round balls, 357
• Wounds from conical balls, 358
• Wounds from swords, 352
• Ulna, 313
• Venesection in lung wounds, 368

ERRATA.

        Page 19, 12th line, last word, read "inflamed."

        Page 58, 9th line, next to last word, read "relieving."

        Page 132, 18th line, after principle, read "nerve."

        Page 146, 13th line, for "60," read "50 percent."

        Page 176, 31st line, for "only," read "generally."

        Page 252, 14th line, for "antrim," read "antrum."

        Page 285, 10th line, for "abductor," read "adductor,"

CHAPTER I.

INFLAMMATION.

        DEFINITION.--Inflammation is a condition of altered nutrition in which a perversion of the Blood and Blood Vessels occurs, accompanied by increased vascularity, augmented sensibility, change in secretion, an exudation of Liquor Sanguinis, and a modification of structure and of function.

        CHANGES WHICH TAKE PLACE IN THE BLOOD.--The blood becomes thinner, as was first established by Hewson.

        The Red Corpuscles are increased in quantity in the early stages of inflammation, but are subsequently decreased as the disease advances. They also have a tendency to cluster together, by the cohesion of their flat surfaces.

        The White Corpuscles are largely increased in number, and, by adhering to the walls of the vessel, tend to arrest the circulation.

        The Liquor Sanguinis.--Andral and Gavarret have shown that Fibrin may be increased up as high as 6 per 1000--an augmentation which is manifestly due to the more rapid and complete metamorphosis which takes place in the tissues of the part. But by far the most remarkable and important fact which manifests itself in this regard, is the tendency to effusion which is developed as the disease advances. The Liquor Sanguinis escapes

from the vessel and disseminates itself through the surrounding tissues, either, to be subsequently re-absorbed, to organize, or to break down into purulent matter. This exudation, according to Virchow, is the essential element in the inflammatory process, giving character to it, and furnishing the most reliable index as to its pathology and treatment.

        The Saline Elements are somewhat below the normal standard, while the proportion of water is perceptibly increased.

        The Coagulation of inflammatory blood takes place more slowly, while the coagulum is harder, and smaller, and the quantity of serum greater than under ordinary circumstances. The upper surface of the coagulum is covored with a layer of yellow fibrinous matter, known as the buffy coat, and depressed in its centre in the form of a cup.

        The Buffy Coat, is regarded as an index and representative of the intensity of the inflammation, though the test is by no means infallible, in as much as the same phenomenon is manifested in Rheumatism, Pregnancy, and Plethora, in all their stages and conditions, without regard to the extent of the inflammatory process.

        Points of Stagnation may be found, upon a close examination of the inflammed tissue, at which the blood current appears to ebb and flow, until it is finally and permanently arrested. This stagnation usually occurs in those capillaries which are not directly located between arteries and veins, and results from adhesion of the Red Corpuscles and the consequent blocking up of the vessels by

the masses thus formed. It is at these points also, that the drawing away or exudation of Liquor Sanguinis usually commences,--facilitating the coallescence of the corpuscles, and indirectly contributing to the arrest of the blood current at the particular localities in question. Wherever this retardation of the circulation occurs, the white corpuscles may likewise be found in great quantities, either rolling slowly along the walls of the vessel or closely adhering to them.

CHANGES WHICH TAKE PLACE IN THE BLOOD VESSELS.

        --The arteries, capillaries and veins are usually contracted in the first instance, but are subsequently enlarged.

        The Arteries leading to the part are especially dilated, while their coats are relaxed, so that the pulsations within them are stronger and more perceptible.

        The vessels, in consequence of this dilatation, actually convey more blood to the inflammed part, than under ordinary circumstances, as has been repeatedly demonstrated.

        In consequences of the expansion of the smaller arteries and capillaries, red corpuscles are more freely admitted, so that the part becomes red, as if from the development of new vessels.

        The arteries are not only dilated, but become elongated, tortuous, and waving--increasing in length as well as in circumference, while small branches project from their walls, and fusiform dilatations of the whole diameter frequently present themselves.

        The distention of the arteries and capillaries before the point of obstruction, induces increased effusion of serum, lymph, and pus.

        The veins beyond the point of obstruction are empty; and, hence, there is increased absorption with softening &c.

        The circulation at the point of obstruction is arrested, so that there is a reduction or abolition of the vital properties; and consequently, either gangrene, ulceration or suppuration is developed.

        There is also increased circulation of the blood around the point of obstruction, causing exaltation of the vital properties; and, hence, spasm, pain, sympathetic irritations, increased secretion &c., are produced.

        CHANGES WHICH ARE INDUCED IN THE SYSTEM AT LARGE.--The excitement may extend to the heart and arteries, causing inflammatory fever.

        The whole mass of blood may undergo alterations by increase of fibrin, by diminution of the secretions, and by the retention in the circulation of their elements.

        Exhaustion ensues after excessive excitement, the effusion of serum or the formation and escape of pus.

        Depression, with partial irritation, not unfrequently supervenes in consequence of the presence of pus in the blood. Though the pus globules cannot be absorbed into the blood by reason of their size, in their normal state, yet certain modifications take place in them, under some circumstances, which do admit of their being taken into the circulation,--causing the development of

peculiar symptoms and the induction of fatal consequences.

        CAUSES OF INFLAMMATION.--The causes of inflammation may be divided into predisposing and exciting.

        Predisposing causes act both locally and generally. The general or constitutional predisposing causes are plethora; excess in food, or bodily exertion; exposure to miasmatic influences; disorders of the liver, skin and kidneys; great mental emotion; over stimulation; vascular and nervous depression &c.

        The local predisposing causes are, excessive use of the part; previous injury or disease; delicacy of organization &c.

        The exciting causes are, mechanical injury; chemical agencies; morbid poisons; and certain imponderable agencies, as heat, cold, galvanism &c.

        The causes of inflammation may produce their legitimate results either directly--that is to say, by irritating and inflamming the part with which they are in contact--or indirectly through the agency or instrumentality of nervous reflex action, as when cold applied to the feet causes inflammation of the lungs, bowels, or peritoneum.

        The causes of inflammation are common or specific,--the former being of constant occurrence, and affecting all constitutions equally,--the latter being peculiar in their origin, action and effects upon the human economy.

        SYMPTOMS OF INFLAMMATION.--The symptoms or signs by which inflammation is distinguished are local and general,--that is to say, connect themselves

both with the part affected and with the system at large.

        Local Symptoms.--The symptoms of inflammation which connect themselves with the part affected, are redness, pain, heat, swelling, alteration of structure and changes in function.

        Redness--This is owing to the primary production of a greater number of red corpuscles than usual; to the enlargement of the vessel, permitting red corpuscles to circulate more extensively through them; and to the presence in the part of an unusual amount of blood.

        Pain.--This is due to the tension of the nervous filaments directly involved; to the greater irritability of the whole nervous mass; and to the augmented susceptibilities of the sensorium. There are different varieties of pain. Thus, it is dull, obtuse, heavy or aching in congestions, and chronic inflammations, or in acute inflammations of parenchymatous, organs: it is gnawing or lacerating in rheumatis, gout, and periostitis: it is lancinating in scirrhus or in inflammations of the nerves: it is twisting, griping or spasmodic in dysentery, ileus, gastralgia, and obstruction of the intestines: it is burning as in cutitis, and erysipelas: it is sharp and cutting in inflammations of serous membranes: and it is oppressing in inflammations of the stomach, testicles, liver, and kidneys.

        Pain is not an invariable concomitant of inflammation. Thus it is absent when inflammation only ends in adhesion;--when the inflammatory action is indolent, as in scrofula; when both the mental and physical susceptibilities have been

destroyed, as by the abuse of spirituous liquors, opium and tobacco,--the exhibition of chloroform, or the existence of that peculiar morbid condition which is denominated insanity; when the nervous centres have lost their normal irritability or responsive power, in consequence of the absorption of some "blood poison," or the retention of the elements of the bile, urine, &c.; and, when the connexion between the brain and the affected part is destroyed, as by the destruction of the nervous filaments serving as their bond of union.

        Heat.--The amount of heat in an inflammed part, is never so great as the patient supposes, though it has been established by the experiments of Becquerel, and Breschet, that Celsus and Hunter were correct in regarding elevation of temperature as a characteristic of the inflammatory process. The temperature of the foci of inflammation is to be regarded as the expression of several distinct sources of heat, viz:

        1. From the blood which accumulates in an unusual quantity about the centre of irritation.

        2. From the increased metamorphosis of tissue which takes place in consequence of this accumulation of blood, and the attendant superabundance of those elements whereby the structures are renewed.

        3. From the more active metamorphosis of tissue which is induced by specific changes in the nervous status of the part.

        The blood is warmer than the subjacent tissues, and hence, there must be more heat at those points where this fluid accumulates. Again, as it is now

placed beyond question, that the source of the normal animal temperature is to be found in the chemical development of heat attendant on nutrient changes continually occurring in the tissues, it follows that, where there is an elevation of temperature, there must also be increased metamorphosis. Now, this increased metamorphosis becomes a matter of necessity when an unusual supply of pabulum is presented, as is the case where blood accumulates in tissues which have at once an appetite for it, and the power of appropriating it according to their necessities.

        And lastly, the experiments of Bernard and Sequard, have clearly established, that this appetite of the tissues, or in other words, their formative power, or metamorphic capability, can be increased or diminished according to the amount of nervous influence supplied to them. It follows therefore, that when there is an excess of pabulum--as must occur when the circulation is more rapid than usual, or there is an increase of blood in the part from any cause, and such a concurrent change in its nervous condition takes place as tends to stimulate its nutritrive power,--there must be a more rapid and complete metamorphosis, and a corresponding elevation of temperature.

        Swelling.--This is caused at first by the increased quantity of blood, and subsequently by the effusion of lymph, the pouring out of serum, or the formation of pus. The more dense the texture, the less there is of swelling, and vice versa.

        Alteration of Function.--Each tissue and every

organ has a certain part to perform in the economy, which is its contribution to the completeness and perfection of the organism. This is known as the function of the part. Thus the function of muscular tissue is to contract, and of glands to secrete. Now, a given tissue requires two things particularly, in order to secure the proper performance of its appropriate function, viz: the distribution to it of a certain amount--neither too much nor too little--of nervous influence; and the preservation of its structures in their normal condition. Inflammation, as previously shown, not only changes the nervous status of the part, but constitutes per se such a veritable perversion of its nutrition, as speedily induces a positive modification of its structure.

        It thus becomes plain, that inflammation, must, as a matter of necessity, materially interfered with the function of the part in which it has been produced, while all experience confirms the truth of this deduction.

        It is in this way that alteration of secretion ensues. Thus, secretion is usually diminished at the commencement of inflammation, suspended when it is at its acme, and increased at its close, if health be the termination. In the same manner, secretions may change their characters chemically, or become mixed with the products of inflammation, as blood, serum, epithelial cells, tube cast, lymph and pus.

        Alterations in Structure.--These take place in consequence of the alteration in the nutrition of the part. The various tissues of the body are differently

affected by the inflammatory process, as will be shown hereafter, but there are certain changes common to all of them, which may be mentioned here. The weight is usually increased, unless apoplexy be produced: hardness is diminished,--that is, there is less of cohesion in the part, because of the effusions which infiltrate its tissues. In chronic inflammations the opposite of this is frequently the case, inasmuch as the effused lymph organizes, or the whole limb may become shrunken: Transparency is destroyed. Polish is impaired materially: and alterations may take place in all the physical properties pertaining to the tissue.

        General or Constitutional Symptoms.--The most promenent and important of these is fever. Fever and inflammation are processes that many confound with each other, though they are really distinct. They may alternate or be intercurrent; and on the other hand, their characters and phenomena may be so blended as to render it a matter of impossibility to draw a line of demarcation between them, and even to necessitate the use of a mixed term to define the resulting condition. It is in this way that the expression Inflammatory Fever has obtained a place in the vocabulary of medicine; and yet, whatever may be the analogy between them, or however undoubted the fact of their simultaneous existance at certain times, it is impossible to deny that they differ in their essential nature, and that they are totally distinct processes.

        Points of Resemblance between Fever and Inflammation.--The following characteristics distinguish both of them:

• 1. An elevation of the animal temperature, such as can be distinguished and measured by the thermometer.
• 2. An acceleration of tissue metamorphosis of a decided and appreciable character.
• 3. An increased rapidity of the circulation and definite changes in the nervous system, as have already been referred to, and as will be more fully explained hereafter.

        Points of Difference between Fever and Inflammation.

• 1. Inflammation is usually of local origin, whilst fever is generally of systemic origin, and in its course involves the whole organism.
• 2. In Inflammation, the attending heat, acceleration of metamorphosis, excitement of circulation and change of nervous status is localized; while in fever these conditions are produced generally and simultaneously throughout the system.
• 3. In Inflamation metamorphosis is induced in the tissues even to the extent of their disorganization. In Fever, the nutrient local changes, though accompanied by interstitial absorption, progress, both in tissues and organs, without material interference with their functions.
• 4. Inflammation usually results as the effect of some mechanical, or chemical cause, acting upon the animal structures, and can be produced at will. Fever, on the other hand, is produced by causes which can be neither explained nor controlled.

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  Page 24

• 5. The Inflammatory process can be checked, controlled or modified by the employment of proper therapeutical agents; while, of most fevers, it may be asserted, that they are self-limited, and that any attempt to cut them short must result in failure as a matter of necessity.

        In this connexion, Lyons,*

        * A Treatise on Fever &c., by Robert D. Lyons, K.C.C.D.D. Blanchard & Lea, Philadelphia, 1861. To this admirable work, we are indebted to many for the above views.

        Circumstances under which fever is not readily produced.

        1. When the Inflammatory process limits itself simply to the repair of tissues, Fever is not one of its attending phenomena.

        2. When it is circumscribed, that is, when, but a small portion of the animal structure is involved, Fever is not ordinarily developed.

        3. When it occurs in tissues of an inferior degree of vital organization, the system does not respond to the local impression, and that reaction,

which we denominate febrile excitement, is not produced.

        Thus, an inflammation of the skin, cellular tissue &c., does not produce fever so readily as inflammation of the parenchyma of the lungs, of the pleura, or of the synovial membranes.

        4. When it occurs in persons whose constitutions are neither above the standard of health, nor below--neither plethoric nor anæmic--, fever is not readily produced.

        Circumstances under which Fever is readily produced.

• 1. When the Inflammatory process assumes a greater degree of violence than is necessary for the repair of tissues, and threatens the disorganization of the part.
• 2. When it involves a considerable portion of the animal structures.
• 3. When it affects tissues which possess a high degree of organization. Instances in explanation of this point were given under the last head, though if additional proof be wanting, reference can be made to the facility with which Fever is developed in connexion with Inflammation of the delicate coats of the eye, of the nerves and of the internal tunics of the blood vessels.
• 4. When it attacks parts which have numerous and important nervous connexions with the system at large. In this way fever is developed either directly, or indirectly by what is known as nervous reflex action. Thus Inflammations of the brain, spinal cord, and stomach readily and rapidly produce an impression upon the whole system, which expresses itself in febrile-excitment.

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  Page 26

• 5. When it occurs in persons whose constitutions possess an unusual degree of susceptibility to local impressions and general influences of a morbid character.
• 6. When it is developed in those whose nervous systems are particularly irritable because of the existence of plethora, or of anæmia, though in the one instance the fever assumes a sthenic character whilst in the other, it is of a low grade.
• 7. When it exists in connexion with an epidemic of fever, the development of malarial poison, or those debilitating influences which are the prolific sources of typhoids, and typhus, such as infest crowded camps, ill-ventilated Hospitals, and the confined Burden Cars in which soldiers are so frequently transported.

        Definition of Fever.--It is a matter of the first importance to understand the exact meaning of the word Fever, to comprehend the precise pathological conditions which are included in and expressed by that most significant term.

        From the days of Celsus to the present time, the Profession has sought eagerly for a proper definition of Fever; but it is generally agreed, that Cullin's description embodies the most correct enumeration of its essential phenomena. It is as follows: "after a preliminary stage of languor, weakness, and defective appetite, there occur acceleration of the pulse, increased heat, great debility of the limbs, and disturbance of most of the functions, without primary local disease."

        Phenomena of Fever.--EssentialP henomena.--Galen long since declared that the essence of fever

consists in a calor proeter naturam, and the most recondite researches and scientific analyses have succeeded in discovering no element that is more characteristic, constant and important than the elevation of tranperature which invariably accompanies the febrile paroxysm. That there is such an elevation has been decided by the experiments of De Haen, who found, that even in the algid states of fever, there was, in the internal parts, a manifest increase of temperature, in some cases to the extent of 2°, 3° and even 4°, and that the slightest febrile conditions are attended with an increase of heat, which is likewise in some instances the only observable phenomenon whatever.

        The chief source of the increased temperature in Fever is to be sought in an exaggeration of those causes which operate in the production of heat in the normal state of the system. It is now universally admitted, that the source of the normal temperature is to be found in the chemical development of heat, which results from the nutrient processes invariably occurring in the various structures of the organism. It follows therefore, that the elevation of temperature which characterizes the febrile condition, is the result and the exponent of an accelerated metamorphosis in the tissues. It must be remarked, in this connexion, that there is not only an increased consumption of the natural pabulum which the blood supplies to tissues, but that the actual constituent elements of the body themselves are appropriated and removed by the increased metamorphic activity induced in the

structures generally. Thus the fluids, the muscles, the adipose tissue, the glands and even the bones themselves waste away during the progress of a febrile attack, particularly if it be of long duration, or of great intensity.

        As the normal nutrition of the tissues bears a direct ratio to the amount of blood distributed to them,--since it is the source of their pabulum, it follows that the accelerated metamorphosis which characterizes the Febrile paroxysm, must be accompanied by an increased activity of the circulation. It is well known that however induced, an augmentation of the force and the rapidity of the circulation presents itself among the earliest concomitants of a large majority of febrile attacks. So invariable is this association, in fact, that alterations in the Pulse are universally regarded as an essential element of that peculiar condition which we denominate fever.

        Metamorphosis, though depending to a great degree upon the amount of pabulum supplied by an increased circulation, or an accumulation of blood from any cause, is also, to a certain extent, influenced and controlled by the nervous system, since, as before remarked, it has the power of increasing the appetite of the ultimate elements, and of thus inducing a larger consumption of those materials upon which they feed.

        It has been shown by Bernard, Sequard,--Weber, Virchow and others, that the nervous system exercises a direct and most potent control over the circulation. Thus, Bernard has demonstrated that the section of the sympathetic nerve

in the neck is followed by a rapid increase of temperature in the corresponding side. Brown Sequard has cut the sympathetic filaments distributed to the ear of a Rabbit, and found, that there was not only an increase of temperature in it, but that the blood was warmer on leaving, than when it entered the part. Weber has shown, that irritation of the Vagi nerves causes an arrest of the heart's action; and it has been known for a long period, that after section of these nerves, an immediate and decided acceleration of the pulse takes place. Similar experiments have been made by Ludwig, Valkman, Fowelin, and Traube, and with like results; whilst Virchow has investigated the subject still farther, and with such success as to induce him to build upon the facts eliminated, the whole superstructure of his febrile pathology. For these reasons, it is now regarded as an established fact, that certain parts of the nervous system preside over the general and local circulations, and that all changes in them, depend upon and represent certain complimentary and precedent alterations in the nervous status of the organism. Virchow, who may be regarded as the great pathological pioneer of the 19th century, believes that these abberations affect primarily the regulator or moderator functions of the nerves, and that the nerves which play this important part in the economy are the Vagi and Sympathetic, having, in all probability, their centre, especially the former, in the Medulla Oblongata.

        The essential phenomena of Fever may therefore be thus summed up:

• 1. Increased heat, produced by--
• 2. Increased metamorphosis, produced by--
• 3. Acceleration of circulation, produced by--
• 4. An irritation of the regulator nerves, especially the Sympathetic and Vagi, whose centres are in the Medulla Oblongata.

        Non essential phenomena of Fever.--Fever may be accompanied by pain especially of the the head and loins; a sense of heaviness or general lassitude; deficiency of either secretion, or of all of them; dryness of skin; thirst; nausia; scanty and high colored urine; delirium; constipation; jactation; &c. Some one of these symptoms is always present in connexion with inflammatory action, but they constantly vary, and, on that account may be regarded as non essential phenomena.

        Varieties of Fever.--Fevers may be divided, with reference to the causes producing them, into two great varieties, viz: Idiopathic and Symptomatic.

• 1. Idiopathic Fevers.--These are produced by causes of an inappreciable character, either developed within or without the organism, and acting upon the nervous system directly or indirectly through the agency of the blood. Typhoid, and Typhus are types of this class of Fever.
• 2. Symptomatic Fevers are produced by some injury or disease of a particular portion of the organism. They are, in fact, nothing more or less than the system's response to an impression made by a disturbing agency, upon some one of its parts--the general manifestation of a special

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  pathological disturbance. It is with Fevers of this discription that the Surgeon has specially to deal, and they must therefore be particularly considered in this connexion.

        The essential elements of all fevers are identical, while their non-essential phenomena constantly vary. Heat; inceased metamorphosis; acceleration of the circulation; and nervous disturbance are the invariable phenomena which distinguish and characterize febrile action. Fever, then, regarded as a pathological entity--a distinct unit, made up of the peculiar morbid conditions just mentioned--is always the same so far as its essential nature is concerned. It is true that the degree of heat, the extent of the metamorphosis, the rapidity of the circulation, and the amount of nervous disturbance are exceedingly variable; but it is equally certain that the mode, order and history of their development are precisely the same under every variety of circumstances. It is therefore a misnomer to denominate fever per se as inflammatory, irritative, &c.; and, hence, the usual classification adopted by writers on this subject, is manifestly unphilosophical because it has no foundation in positive pathological fact.

        Fever, however, may associate itself with the Inflammation of a healthy system, or with the Inflammation of a debilitated, impoverished cachectie system.

        The first is known as Pyrexia, or true Surgical fever, and is of a sthenic character. Its symptoms are a hot and dry skin; a full, bounding and frequent pulse; the diminution or arrest of

the secretions; acidity and high color of the urine; constipation of the bowels; coating of the tongue with a white fur; thirst; languor, heat and pain of head. A disposition is always manifested in this connexion, to remit or intermit, or in other words, the fever is not of a continuous character.

        Its abatement is followed by the subsidence of all the symptoms mentioned above:--by a free perspiration;--by abundant discharge of urine abounding in lithates;--by a natural movement of the bowels, or it may be diarrhoea;--by cleansing of the tongue, abatement in the frequency and force of the pulse;--by subsidence of thirst and a general feeling of relief on the part of the patient.

        The second which is of a decided asthenic character, presents itself under three forms, viz: Typhoid Fever, Irritative or Nervous Fever, and Hectic Fever.

        The true Asthenic or Typhoid Fever occurs principally in persons whose constitutions are enervated by exposure, privation, irregularity of life, grief, or long residence in a vitiated atmosphere.

        Symptoms.--The period of depression is marked and much prolonged. The reaction is not of a very active character; there is a disposition to heaviness, stupor, and delirium; the pulse is feeble but quick and frequent; the skin is sometimes moderately hot, then again is particularly dry and burning, and occasionally covered with an abundant perspiration; the cheeks are flushed, and the eyes bright and starring, while the tongue is red, dry and sometimes cracked in its centre.

        The abatement of the fever is characterized by a gradual disappearance of all the symptoms; but

the patient remains weak and debilitated for months, and the return to health is invariably slow and uncertain.

        Should the disease take an unfavorable turn, the pulse grows more feeble and frequent, the tongue dryer and more cracked, the skin cold and mottled; while hiccup, subsultus, dyspnoea or coma comes on and death closes the scene by claiming its victim.

        There is always a tendency to visceral complications in connexion with this affection, which not unfrequently decide the fate of the patient. The fever is usually continuous and pathologists locate the especial seat of the disease in the Sympathetic system.

        Irritative Fever is a variety of the asthenic form though not of so specific a type as the last. The nervous system is especially concerned; and the affection presents itself in connexion with the systems of those whose mental powers have been over taxed, or whose vital energies have been destroyed by excessive venery, indulgence in drink, constant intellectual labor, &c.

        The symptoms which distinguish Irritative fever are a dry and red tongue; a sharp, small, but frequent pulse; subsultus; restlessness and delirium, which soon give place to signs of debility, with coma and cerebral irritation, sudden exacerbations, unequal and irregular remissions; rapid and important changes are also frequent concomitants of this form of disease.

        Hectic Fever, is also a variety of the asthenic form, and generally presents itself in conjunction with some organic, serious disease, excessive discharge of

any secretion, but more particularly with the formation of abcesses and the production of pus. Emaciation; debility; clear and red tongue; disposition to diarrhoea and profuse perspiration; a frequent and small pulse; slight chills followed by burning of the hands and feet, with a circumscribed flush upon the cheek, indicating derangement of the capillary circulation, are the symptoms which characterize this form of fever.

        Hectic is but too frequently the harbinger of a speedy death; and yet, it is really astonishing to observe with what rapidity and completeness many patients recover even after the development of its most characteristic and unfavorable symptomps.

        It not unfrequently has the effect also of producing an exhileration of the spirits,--elevating them to such an extent as to preclude all fear of the fatal catastrophy of which it is the sad precursor.

        TERMINATIONS OF INFLAMMATION.--Inflammation may terminate either in the repair of the part; in its return to health; in the modification of its function and structure; or in its death.

        Repair of the part.--A part whose continuity has been broken or destroyed may be repaired, after the development of Inflammation, either by the immediate organization of the Effused Lymph, or by its more slow and gradual conversion into a structure identical with that of the subjacent tissues or similar to it.

        When the repair is immediate, it is called union by the "First Intention," and when more tardy--

being accompanied by the formation of healthy pus, granulation, &c., it is denominated union by the "Second Intention."

        Restoration of the Part to health.--Inflammation may be developed in a part, which has suffered no solution of continuity, under the influence either of some Local or General cause, and, after the manifestation of all the characteristic symptoms, of that process, leave it in its original condition. This is accomplished by the reabsorption of the effused Plasma, either in its nascent state, or after it has been changed into blastema and fibro-cellular tissue. The absorption of the Lymph in its liquid state is denominated Resolution, and is the most favorable termination or effect of Inflammation. Nature, in many cases, labors to make way with effused Lymph in such a manner as will prove least injurious to the surrounding parts as well as to the organism; and, hence, the work of reabsorption is commenced, under its watchful and intelligent guidance, to be perfected or not according to the circumstances of the case. Each petholigical step is then carefully and successfully retraced. The attraction between the Globules and the walls of the vessel, loses its intensity; the stasis of Blood disappears; the Heat, Pain and Swelling abate; and the part assumes its normal status, both as regards function and organization. It sometimes happens, however, that all of these steps are taken suddenly and simultaneously, or occur so rapidly as to be inappreciable. This is styled Delitescence.

        Metastasis is the sudden translation of Inflammation

from one point to another. This, in a majority of cases, may be regarded as a phenomenon of Nervous Reflex Action--a principle which plays a most important role both in the Physiological and Pathological processes of the organism.

        Resolution is the natural, legitimate and most favorable conclusion of the Inflammatory process--a result towards which the efforts of the Practitioner should be invariably directed as the most effectual method of preventing disastrous consequences.

        The Absorption of Lymph after its conversion into blastema and fibro-cellular tissue, does not occur to any considerable extent during the height of the inflammation by which it has been produced. There must always be a marked reduction of the morbid action before the absorbent vessels can be forced to take hold of it; but when this point has been once reached the process often goes on with great rapidity. When the Lymph has become completely organized, absorption is, of course, still more difficult, and not unfrequently impossible.

        It is more than probable that Lymph even in a liquid state, is not absorbed until it has been dissolved in the fluids of the affected parts, when it is brought more readily under the influence of the absorbent vessels.

        Modification of the structure and functions of the Part. Inflammation may also leave the Part modified both as regards function and structure. This modification is due to the influence of certain products of the Inflammatory Process, which should

be briefly considered, in connexion with this mode of development, and the nature of the effects produced by them.

        The effects or products of Inflammatory Action, which play this important part in the economy are: Induration, Hypertrophy, Atrophy, Effusion of Serum, Formation of Pus, Organization of the effused Lymph, or Transformation of Tissue.

        Induration. When the effused lymph is not absorbed it organizes, either forming a sort of internal cicatrix which is harder than the surrounding tissues or increasing the density of the part by augmenting the amount of plastic material within it.

        Softening. This results either from the infiltration of effused liquids, or disintegration of the substance of the textures themselves, by which their consistence is diminished.

        Hypertrophy. It has been previously shown that the Inflammatory Process not only increases the amount of Blood--the pabulum sent to a given tissue--but also stimulates the appetite of the part, so as to render its nutrition more active and complete. It thus happens, not unfrequently, that tissues, and whole organs are permanently enlarged, as a consequence of Inflammation.--Hypertrophy is essentially a local disease.

        Atrophy. Though atrophy is the opposite of Hypertrophy it is not an unusal effect of Inflammation. Nutrition is made up of two elements, which though entirely distinct, the one from the other, are absolutely essential to the perfection of the process. Cell destruction as well as Cell elaboration--the breaking down and the building up of

tissue, occur simultainously throughout the whole organism. The term metamorphosis includes both of these processes; and in the normal condition of the system presupposes a perfect equilibrium between them. Under the influence of Inflammation this equilibrium is lost, so that cells may be too readily produced, or too rapidly destroyed. In the one instance Hypertrophy is produced and in the other Atrophy is the result.

        Effusion of Serum.--Congestion or the accumulation of Blood in the part affected, constitutes one of the distinguishing features of Inflammation. It is, in fact, an essential element of that process. The vessels thus become filled with an unusual quantity of the circulatory fluid, which distends their coats, and facilitates the pouring out, or the exosmosis of the watery portion of the Blood into subjacent cavities or neighbouring tissues. It is in this way that fluxes are produced and dropsies occur, materially altering the structure of tissues and organs, and interfering with their peculiar functions. All the tissues do not present the same tendency to the effusion of serum in connexion with Inflammatory action. The structures which supply it in greatest abundance are the cellular and serous, the secernent vessels of which are extremely active even when the disease itself is comparatively mild. The mucous membrane of the alimentary canal, particularly that of the Colon and Rectum is frequently the source of large effusions of serum, as is seen in diarrhoea and Cholera Infantum.

        The appearance of the serum is usually limpid,

though it may be changed by admixture with the secretions, Lymph or Pus. The effusion of Serum is always a phenomenon of Osmosis, while it is controlled by the laws which govern that process, and is dependent upon that principle alike for its production and its cure.

        Suppuration or the formation of Pus. The idea was long entertained that Pus was a veritable secretion, poured out from the vessels under certain abnormal circumstances, and subject to all the laws which control the products of secerning organs generally. The researches and arguments or Gulliver, Mandt and Addison have demonstrated the incorrectness of this opinion; and it is now generally agreed among Pathologists, that Pus Corpuscles are modifications of the Exudation Cells, and that suppuration is nothing more nor less than the breaking down or degeneration of the Lymph poured out in connexion with the inflammatory process.

        When Lymph is not converted into tissue, or false membranes--because of the blight impressed upon the formative power of the contiguous structures by the Inflammatory action--or fails to organize even into cacoplastic products, a peculiar depreciation takes place in it whereby the corpuscles of the Plastic mass are transformed into Pus Cells, the Blastema degenerates into liquor puris, and Purulent matter takes the place of the more highly organized effusion.

        When Pus is formed upon a free surface, it is styled a Purulent secretion; and when elaborated within the structure of a part, it is called an Abscess.

Nature usually makes an effort to retain the Pus thus formed within limited bounds, by depositing around it an external boundary of consolidated Lymph, known as the Pyogenic Membrane. This does not secrete Pus as was supposed by Delpech and many others, but is simply the boundary line between the abnormal product and the intact tissues. When this Membrane is absent, it may be regarded as indicative of a want of tone in the system, and as such furnishes a valuable hint to the Surgeon as regards prognosis and treatment. In the above remarks concerning this Pyogenic Membrane, the production of Pus in connexion with abscesses, is only referred to. This fluid is elaborated along the track of wounds extending through tissues of all grades and varieties, with so much rapidity and in such large quanties, as to preclude, even in the most vigorous constitutions, the formation of a protecting membrane, and is, hence, found diffused, in many instances, throughout the subjacent structures.

        When Pus is opaque, thick, smooth, slightly glutinous, of a yellowish white color, with a greenish tinge, a faint odour and a alkaline reaction, it is said to be healthy or laudable; when mixed and tinged with blood it is sanious; when thin watery and acrid, ichorous; when it contains cheesy looking flakes, curdy; and when diluted with mucus or serum, muco-pus or suro-pus.

        It consists, when laudable, of corpuscles, floating in a homogeneous fluid, styled "liquor puris." These corpuscles are modifications of the exudation-cells, and are composed of a semi-transparent

cell-wall, with two or three nuclei, of large quantities of granular matter, of particles of fibrin, and of disintegrated exudation cells. A multitude of changes, however, may occur in it, altering its composition, and changing its character, which can be detected by the microscope. When the suppurative process has once been set up, it may continue for an indeffinite period, becoming, as it were, the fixed secretion of the part. From mucous membranes particularly, it has been known to last for years.

        The symptoms which indicate that Pus is about to be formed, are; a more throbbing pain, a greater swelling and tension of the part, and a red, glazed and shining appearance of the skin, though it is sometimes elaborated without the development of any antecedent local sign.

        The symptoms which indicate that Pus has been formed are: the disappearance of the ordinary signs of inflammation; the occurrence of chills or rigors; alternations of heat and cold; abatement of the intensity of the fever, and its assumption, in some instances, of an intermittent character; softening and perhaps quickening of the pulse; and fluctuation in the part, with enlargement also when the fluid is diffused throughout its tissues.

        The symptoms which indicate that Pus is escaping from the system in too great a quantity, are: emaciation and loss of strength, a quick, small and compressible pulse; a coated and dry tongue with red tips and edges; flushed cheeks; dilated pupils; profuse sweating; copious purging; large

discharges of urine, filled with red deposits; great debility; hypocratic countenance; husky voice; insomnia, &c. There is usually an exacerbation towards evening, and the actions upon the bowels, skin and kidneys alternate with each other, until the patient dies from sheer exhaustion.

        The tendency to suppuration is increased by the following circumstances, viz:

• 1. Peculiar conditions of the Patient's system. Thus, in conditions of debility from any cause which diminishes the vital powers, as bad food, impure air, cachectic states of the organism, scrofula, &c.
• 2. Specific character of the Inflammatory process. Thus, in Gonorrhoea and Purulent Opthalmia, Pus is more readily eliminated than under ordinary circumstances.
• 3. Locality of the Inflammation. Mucous membranes more readily suppurate than serons, &c.; cellular tissues more rapidly than muscular, &c.; Inflammatory surfaces when exposed to atmospheric air supurate more readily and freely than others.
• 4. The state of the part affected. All parts of the system are not invariably in the same condition of health. Thus the nerves running to a particular part may have been divided by some previous accident, or some affection peculiar or confined to it may have lowered the tone of its vital powers, &c. In this way Inflammations which some portions of the body would readily resist, terminate elsewhere in suppuration.

        The Plastic matter thus destroyed is the food of

the tissues involved in the Inflammatory action--the pabulum upon which they depend for the preservation of such properties as are essential to the integrity of their structure and the perfection of their functions.

        Again, the purulent fluid by desseminating itself throughout the tissues, or by pressing upon them, so changes the normal status of the part as to disqualify it, either partially or completely, for the performance of its proper offices.

        Of the fatal consequences which connect themselves with the presence of Pus in the blood, it is unnecessary to speak in detail here, in as much as they will be more fully discussed in another connexion. It is sufficient to say that the Purulent elements, when thus absorbed or developed, so paralyze the nervous centres and blight the tissues of the organs generally, as to interfere with the action of all the component parts of the organism--suspending nutrition, aborting or altering secretion, robbing the muscles of their tone and power, destroying "nervous influence," and inducing a complete revolution in the whole system.

        Organization. The Plastic Lymph effused in connexion with the Inflammatory process may either Organize or break down into Pus. The term organization includes the conversion of the effusion into tissue, taking its character from the subjacent structures; the development of false membranes: and the formation of certain heteromorphous products, as Tubercle, Cancer, &c. Plastic Lymph possesses an inherent capacity for organization. As soon as it is effused, this tendency manifests

itself by the formation of cells and nuclei in great numbers, which connect themselves with each other, and gradually spread out into fibres lying for the most part in parallel lines, and profusely inlaid with granules. Vessels soon show themselves, which are the result either of a new epigenesis, or the contributions of the neighboring structures, the latter being the more common source of supply. Nerves and absorbents, finally appear, but whether they are supplied by the surrounding tissues, or are spontaneously developed from the effused matter, has not been determined by Pathologists. In this manner the effused Lymph either assumes the characters and functions of the tissues with which it is in contact, or forms false membranes. When, however, there is a deficiency of nervous influence in the part or system, a want of plasticity in the effusion itself, or a deficiency of vital power in contiguous tissues, the same attempt at organization is made, but the issue is an aborption, and a product results, of an inferior degree of organization, and lower in the scale of vital endowment, to which the term heteromorphus has been applied. It is in this way that Tubercle and other similar growths are developed, as the effects of Inflammation, complicating the termination of that process, and inducing eventually the most serious consequences to the system.

        Inflammation may terminate, leaving behind the higher products thus formed in a state of complete organization, and materially modifying the structure and functions of the part in which they have been developed. An organ, as the Liver or Spleen,

which has been hypertrophied, by the organization of Lymph effused into its structure, does not preserve its original status either physically or functionally, and is, hence, modified to an appreciable extent by the precedent morbid action. So likewise, False Membranes, by agglutinating the Intestines, binding together the Costal and Pulmonary Pleura, constricting or contracting the Urethra, &c., &c., materially interfere with the legitimate functions of these parts, and produce disastrous consequences in the economy.

        Transformation of Tissues. Each tissue posses the power of appropriating certain elements supplied by the Blood, and of converting them into its own substance. In order that this "formative power" may be legitimately exercised, it is necessary that the structures remain in a condition of health, that the ordinary supply of nervous influence and of proper pabulum be supplied them, and that their normal Physiological status continue intact. The Inflammatory Process interferes with the supply of nervous influence, and destroys the responsive power of the tissues without necessarily depriving them of the elements which constitute their proper food. Instead of converting plastic Lymph into their own substance, they simply impress it with a sufficiency of vital force to insure its organization into tissues of a lower grade, and, hence a spcies of degeneration, or transformation ensues--the original elements of the structures concerned being consumed by the destructive Metamorphosis which takes place in them, in common with all the tissues of the

organism. The whole process may be thus summed up:

• 1. Inflammatory action causing a diminution of nervous influence in a given tissue, together with a loss of susceptibility to this influence, and an abatement of its energy.
• 2. The constant destruction of the original elements of this tissue, in obedience to the general law of metamorphosis which applies to the whole organism.
• 3. The organization of Plastic Lymph, and its conversion into a tissue of inferior vital endowment.
• 4. The entire substitution of this inferior tissue for the original one, and the consequent modification of the part both as regards "structure and function."

        The most common instances of this degeneration or transformation, are the cellular, mucous, cutaneous, fibrous, calcareous and fatty.

        The Fatty degeneration is the most usual universal and important of all, since there is hardly any organ or tissue of the body in which it may not occur. It has been observed in the Lungs, Placenta, Cartilages, Bones, Cornea, Lens, Arteries, Heart, Kidneys, and Liver--particularly of drunkards--, and constitutes one of the most important products with which the Pathologiest has to deal.

        It is important to remember that the various tissues possess different degrees of vitality, some being much more highly organized than others; and, hence requiring dissimalar conditions for the full exercise of that power by which plastic Lymph

is converted or transformed into their substance. The products now under consideration, differ from the cacoplastic deposits, referred to in another connexion, in being more highly organized, and in the fact of their requiring the exercise of a greater degree of vital energy on the part of the affected tissues in order to insure their development.

        All the facts in regard to the organization of the effusion incident to the Inflammatory process may be thus arranged:

• 1. Inflammation--
• 2. Effusion of Plastic Lymph--

        Organizing completely, and forming False Membranes, or being converted into the Elements of subjacent tissue.

        Organizing incompletely and forming tissues of inferior vital endowment to those affected by the inflammatory action.

        Organizing less completely, and forming Heteromorphous products generally.

        Not organizing at all, but breaking down into Pus.

        Death of the Part.--Inflammation causes the death of the part, in which it occurs in two ways, not materially differing from each other in their essential nature.

        These processes, which are at once the effects of the Inflammatory process, and the instrumentalities by which it accomplishes its work of destruction, are Ulceration and Gangrene.

        Ulceration.--In atrophy the form and structure of the part remain, while the breaking down and

absorption of its elements take place with unusual rapidity--more rapidly, in fact, than they can be reproduced. It sometimes occurs that this power of Inflammation localizes itself, and so completely annihilates the equilibrium between the waste and repair--cell-destruction and cell-elaboration--of a tissue, within certain prescribed limits, as to insure the entire suspension of that Physiological process by which the structure is built up, and to stimulate, to an unusual degree, that destructive metamorphosis by which it is broken down. There results, consequently, a possitive disorganization of the part thus affected, with an actual loss of its substance--forming what is familiarly known as an ulcer.

        It is in this way, that ulcers are originally developed, as the result of Inflammatory action, while the particular features which give them character, are impressed upon them by extraneous circumstances. Ulceration is therefore the local, circumscribed destruction of a tissue,--a veritable dissolution in miniature. The several distinct pathological acts concerned in the development of an ulcer may be thus enumerated:

• 1. An Inflammation which localizes itself.
• 2. A suspension within circumscribed boundaries of that process by which the tissue repairs itself.
• 3. An unnatural, morbid, excessive exercise of that process by which the waste--cell-distruction-of the part is accomplished.
• 4. A consequent solution of continuity, and the presence as effete, extraneous matter of certain

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  portions of the tissue which have not been so readily or rapidly absorbed.

        In support of this view of the subject it is only necessary to mention that the debris of the wasted tissue cannot be found either in the Pus which, subsequently fills the ulcer, or in the Blood itself--a fact which demonstrates that their disappearance is due to an exaggeration of the Physiological process by which the destruction of tissue occurs throughout the whole organism--or in other words that they disappear in obedience to the ordinary law of cell-destruction and absorption enforced with extraordinary energy and effect, through the agency of the Inflammatory Process.

        For the different varieties of ulcers, with their symptoms, treatment, &c., the reader is referred to the standard works on Surgery.

        Gangrene.--Gangrene may be considered as a partial death--the death of one part of the body while the other parts are alive. It may result from the violence of the Inflammation; from an arrest of the Circulation; and from deterioration of the elements of the Blood.

        The expression "violence" is used relatively in this connexion--to convey the idea of an Inflammation not intrinsically great, but still too excessive for the part to bear without serious detriment. The same amount of vitality does not reside in all systems, nor is it distributed in equal proportion to the tissues and members of a particular organism. When Inflammation is developed in a tissue or member, the vital force of which has been lowered, and whose "formative-power" is lost, a peculiar

modification of structure occurs, to which the term mortification is applied. In a word, the tissues not being supplied with their normal amount of vitality because of its consumption by the Inflammatory Process, and having, therefore, lost the power of appropriating the pabulum necessary for their support, die, as a matter of necessity, while the other portions of the body remain intact. Atrophy indicates that the "formative-power" of the tissues has been diminished, while a sufficiency of vitality remains to preserve their external form and internal organization; ulceration shows that this same power has been lost within circumscribed limits, and that molecular death has been the result; while Gangrene illustrates the fact that this ability to "appropriate and transform," has been entirely destroyed, even to the extent of entire tissues and members, with such a diminution of vitality as precludes the preservation of their organization, and permits the operation of ordinary chemical affinities.

        The circulation may be arrested by the congestion of a part, and by the pressure of effused Lymph, Serum or Pus. In this way the tissues are deprived of their proper food, and really die of starvation.

        The blood may be so altered by Inflammation, particularly of a specific character, as to afford no pabulum to the tissues, and to prove the occasion of their death. Thus the Inflammatory action associated with Small Pox, Scarlatina, Erysipelas, Pyæmia, Hospital-Gangrene, Glanders, and other diseases of a specific nature, terminates not unfrequently

in the mortification of some part or member of the human frame.

        In some instances the dead portion is dissolved away at its circumference by an exudation from the living parts, and is thus separated or sloughed from them; while, if the dead portion be extensive, separation will not be effected before decomposition takes place, and, hence, we have what are known as Gangrene and Sphacelus.

        Gangrene may be regarded as the state which precedes and terminates in Sphacelus,--a condition in which there is great diminution, but not a total destruction of the powers of life,--the blood still circulating through the larger vessels,--the nerves retaining some portion of their sensibility, and the part being not yet beyond the recuperative point.

        By Sphacelus is meant the positive and irrevocable death of the part,--the loss of its organization, the destruction of its component elements, the suspension of its vital laws, and its complete surrender to chemical principles and affinities.

        Gangrene has also been divided into the humid, dry, constitutional and local. But it is not our purpose to consider these varieties in detail, in as much as the same principles are concerned in their development, and similar laws apply to their treatment. When mortification is about to manifest itself as a result of Inflammation, the redness assumes a darker hue; heat and pain abate; and there is a general amelioration of all the symptoms save the swelling which generally increases

in consequence of the effusion of Sanguinolent Serum.

        When Gangrene terminates in Sphacelus the hue of part becomes dark and dirty--the tissues grow flaccid and cold, while crepitation manifests itself on pressure, and a most offensive odour is evolved.

        When the progress of the Gangrenous process is arrested, healthy circulation is developed up to the margin of the diseased portion, while a bright red line--the line of demarcation--indicates the establishment of adhesive Inflammation, and shows that the living parts are to be separated from the dead by a spontaneous effort of nature. This line of demarcation extends to the entire depth of the Gangrene, totally and completely surrounds it, and by a process of interstitial ulceration, removes the dead part, without hemorrhage or other serious inconvenience, leaving a granulating and healthy surface behind, which undergoes cicatrization without much difficulty or delay.

        In some instances however, as when Patients have been subjected for a protracted period to the influence of debilitating agencies, the blood does not coagulate in the vessels and hemorrhage of a fatal character occurs.

TREATMENT OF INFLAMMATION.

        --As the phenomena of Inflammation connect themselves both with the Part affected and with the System at large, it is plain, that the remedies employed in its treatment must be of a Local and a General character. This constitutes the first and most important classification of the remedial agents at the command of

the Surgeon in his contest with this dangerous, and often defiant malady, though more minute subdivisions may be necessitated by an accurate and elaborate investigation of the subject. From the account which has been given, of the symptoms, products and terminations of Inflammation, in the preceding pages of this work, it is plain, that the Remedies employed in its management, should be used with reference to the following Indications:

• 1. To control the response made by the system at large to the local disturbance--i. e. to control the adventitious,--non-essential phenomena of Inflammation.
• 2. To control the Heat, Pain, congestion, &c.--the essential phenomena of Inflammation.
• 3. To limit the effusions incident to the Process--i. e. to confine the Inflammatory Action within Physiological grounds by securing simply the repair of tissues.
• 4. To promote the re-absorption of the effusion and to restore the tissues to health--i. e. to insure Resolution.
• 5. To prevent modifications in the structure and functions of tissues and organs--
• 6. To prevent the death of the part affected, either molecularly, by ulceration, or entirely by Gangrene.

        All General and Local Remedies, used in the treatment of Inflammation, act either by controlling the phenomena, limiting the effects, or modifying the terminations of the Inflammatory process.

        General Remedies.--Inflammation may be associated

with a system in a condition of vigor, or of debility, and is sthenic or asthenic according to the circumstances of the case. When connected with a healthy and vigorous system, it is usually characterized by such symptoms of Inflammatory Fever,--as were referred to under the head of Sthenic Fever, and when developed in connexion with an impoverished and debilitated system, the resulting Febrile action is of a Typhoid character. These facts necessitate a division of the constitutional agents employed in the treatment of Inflammation into Depletory and Stimulant Remedies.

        Depletory Remedies.--Among the most prominent agents which belong to this class are Blood-Letting, Mercury, Depressants, Cathartics, Emetics, Diuretics, and Diaphoretics, Nervous Sedatives, Agents which control the Capillary circulation and the Anti-philogistic Regimen.

        Blood-Letting.--Without entering into the merits of the great Blood Letting controversy, which has so divided the Medical world, it will be sufficient for present purposes, to mention the circumstances, &c., under which, according to the instructions of the ablest masters, and the teachings of a sound therapy, the Lancet may be employed in the treatment of Inflammations.

• 1. Blood Letting should never be resorted to save in Inflammation which connects itself with a constitution which is strong and healthy,--that for instance of a vigorous, athletic man.
• 2. When Inflammation, is associated with Plethora

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  --a full habit, and an unusual supply of red blood.

• 3. In Inflammations which produce an excessive disturbance in the system at large, accompanied by a full pulse, hot skin, flushed face, and the usual evidences of Inflammatory Fever.
• 4. In Inflammations of some internal organ, which manifests itself by symptoms of great depression such as small pulse, cool skin, clammy perspiration--in a constitution healthy and vigorous up to the moment of the attack.
• 5. In all Inflammations of a high grade, when no tendency to Typhoidism exists, and the Patient can be subjected subsequently to proper treatment

        The ends which may be accomplished by Blood-letting are:

• 1. To lessen the amount of blood when it is too great, and to reduce its quality when abnormally rich or stimulant, and thus, to relieve Irritation and Inflammation.
• 2. To lessen the action, of the Heart and Arteries, to restrain the momentum of the circulating fluid, and consequently to diminish Heat, to abate Pain, to prevent effusion, to equalize the circulation, to obviate local determinations, to relieve spasm and nervous irritation, and to arouse the susceptibility of the various organs, rendered insensible by the congestion of the Nervous Centres.
• 3. To promote absorption, and to increase the action of other remedies.
• 4. To arrest Hemorhage by inducing scyncope, and favoring the formation clots, by which the

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  Vessels are blocked up, and the escape of Blood Prevented.

        It cannot be denied however that there are multitudes of cases, particularly in connexion with the Surgery of Camps, and Hospitals, in which Blood-letting would not be beneficial, but positively injurious. But as a pure anti-phlogistic when the grade of the Inflammation is high and the attendant conditions are such as to admit of its proper application, the Lancet has no rival, particularly if employed before the exudation of Plastic Lymph, or the development of those phenomena which indicate that the acme of the disease has been passed. This can be readily understood, when it is remembered, that in Inflammation, with each pulsation of the Heart an unusual amount of Blood is sent to the affected part, which serves to keep up and to increase the already excited irritation; that the Blood itself is far more stimulant than in health; that the momentum of the circulating fluid, is greatly increased; and that nervous irritation exists far beyond the natural limit,--morbid conditions which Blood-letting ameliorates and removes upon the principles already enunciated.

        The employment of the Lancet is based upon the supposition, that, though the nervous centres possess the inherent power of generating a sufficiency of vitality or nervous force, they are prevented from so doing by the presence and pressure of an unusual quantity of depraved Blood, and that the proper performance of their functions can be facilitated by the removal of this pressure, and

the supply of a better material for their consumption.

        Arterial Sedatives.--Veratrum Veride, Digitalis, Aconite, Tartar-Emetic, &c., produce the same effects as Blood-letting, though in a less marked degree, by the impression which they make upon the circulation. Under their action, the skin relaxes, the pulse softens, the tongue grows moist, secretions are restored, nervous irritation abates, and everything indicates the restoration of the circulation to its normal equilibrium, and the abatement of the Inflammatory symptoms. Their employment is particularly adapted to the cure of Inflammations of an acute character, in young and robust subjects, whose systems require to be rapidly impressed in order to stay the march of the disease. In Inflammations of the Respiratory Organs their beneficial effects are so particularly marked that they have almost entirely superseded the use of the Lancet.

        These agents are not spoliative. They do not deprive the system of its blood, and thus rob the tissues of their food. Their depressing effects are consequently far more transient than those produced by the Lancet; and, hence there is not the same difficulties to be apprehended in building the system up--in giving it tone and recuperative power--attendant upon their administration, as upon the employment of Blood-letting--a most important circumstance in these times of Typhoid tendencies, and low grades of Fever generally.

        Mercury.--This Drug not only controls the

symptoms of Inflammation, but limits its effects, and modifies its terminations.

        It controls Inflammation by rendering the Blood less irritable; by diminishing the momentum of the circulation; and by promoting the secretions, and by acting as a depletant and a deobstruant.

        It limits the effects of Inflammation by robbing the Blood of its Plasticity, and thus precludes extensive effusions; and, by releaving local congestion, accomplishes the same end.

        It modifies the terminations of Inflammation by liquifying the effused lymph and facilitating its absorption--thus promoting resolution, or "termination in health;" by promoting absorption, and obviating induration; by destroying false membranes,"--thus preventing modifications in the "structure and functions of tissues;" and controlling ulceration by altering the condition of granulating surfaces.

        Rules for the administration of Mercury:

• 1. Administer it in the form of Calomel, Blue Mass, or Mercury with Chalk.
• 2. When from the violence of the Inflammation, a prompt and powerful impression is required, Calomel should be given in large and frequently repeated doses.
• 3. When the Disease is less violent, and the organ not important to life, Blue Mass or Mercury with Chalk may be given in smaller doses.
• 4. To make Mercury more Purgative combine with it finely powdered White Sugar, and give it upon the Tongue.
• 5. To prevent it from running off the Bowels,

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  combine with each dose a small quantity of Opium.

• 6. Never administer Mercury without endeavoring to ascertain if the Patient possess any Idiosyncrasy in regard to it.
• 7. Do not administer Mercury in any form to persons of a strumous habit, to the very aged or infirm, to those who have been much enervated by the depressing influences of bad clothing, crowded and ill-ventilated tents, and improper food, or to the consumptive.
• 8. Never produce Salivation designedly, or in other words, suspend the medicine so soon as a free secretion from the Salivary Glands shows that the system is saturated with it. Chlorate of Potassa, administered in large and frequently repeated doses, is the best remedy for Salivation.

        Cathartics, Diaphoretics and Diuretics are administered for their depleting, derivitive or revulsive effects.

        Nervous Sedatives. Although the part played by the Nerves in Inflammation is not thoroughly understood, yet the following facts may be regarded as established:

• 1. The primary morbid impression is made upon the nerves, from which it is reflected to the Capillary Vessels, and hence irritation and subsequently congestion are the primary phenomena of the process.
• 2. The nervous centres, responding to the perturbation, thus induced in the economy, participate in the irritation, and hence, the circulation and the secretions, together with the nutritive process are disturbed.

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• 3. Inflammation is as much a product or concomitant of nervous irritation, as of vascular disturbance.

        It has been shown, that when the Opthalmic branch of the fifth pair is divided in the Cranial Cavity of a Rabbit at the Varolian bridge, Inflammation is developed in the surface of the eye, and that, when the nerve is cut in such a way as to divide the Ganglion of Gasser, the Inflammation is more violent and deeply seated. It has also been demonstrated that when the Pneumogastic Nerves are cut high up in the neck, the Lungs become engorged with Blood and present many of the phenomena of Acute Inflammation, while the stomach becomes also envolved to the extent of an arrest of its secretion. So likewise when the Brachial Plexus is tied, the integuments and finally the deep structures of the Limb become inflamed in a very high degree. These and a multitude of kindred facts which modern Physiology has established, demonstrate that the role performed by the nerves in the development and continuance of the Inflammatory Process is one of the greatest importance.

        The Therapeutical action of Sedatives is to diminish the injection of the nervous centres, to relieve the irritability of the whole nervous mass, and thus, indirectly to restrain the action of the Heart, to disgorge the Capillaries, and to regulate the action of the secreting organs.

        From this plain statement in regard to the condition of the nerves in Inflammation, and the therapeutical action of Sedatives, it is made

apparent that this class of remedies is peculiarly indicated in the treatment of that morbid process.

        The agent which stands at the head of this list is Opium, with its different preparations, as the Salts of Morphia, Laudanum, and Dover's Powder, though Stramonium, Hyosciamus, Indian Hemp, &c., may also be employed. This remedy is particularly indicated when the Inflammatory Process is accompanied by violent pain, a symptom which may complicate the morbid action to a considerable degree, even to endangering the patient's life. Rules for the administration of Opium.

• 1. Precede the exhibition of the Opiate, by Bleeding or Purgation, particularly when there is Plethora, Foecal distention, Disorder of Secretion, &c.,
• 2. Administer it in large doses--say from two to four grains of Opium within every twelve or twenty-four hours.
• 3. Give the Opiate at night, so that rest and quiet may be secured to the patient.
• 4. Remember, that under the influence of Pain the System acquires a greater tolerance for the Opiate.
• 5. If the skin be dry, combine with the Drug some Diaphoretic or use Dover's Powder.
• 6. When Inflammation occurs in structures which are likely to be put in motion by the normal processes of the economy, as the Peritoneum, the Pleura, the Alimentary Canal, &c., Opium may be freely used, not only for the purpose of controlling the Inflammation already existing, but to keep the part at rest and thus indirectly to prevent the

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  farther development of it,--by serving as a veritable splint to the affected structure.

        Agents which contract the Capillaries. In those cases where the local disturbance is excessive, accompanied by great Heat, Pain Congestion, and Swelling, it becomes a matter of importance to act upon the Capillaries in such a manner as to limit the amount of Blood in them. The remedies by which this end can be most readily attained are Ergot, Belladonna, and the Muriated Tincture of Iron,--agents which by diminishing the calibre of the Vessels, reduce the local hyperæmia, and relieve the unfavorable symptoms incident to it. Theoreically these Remedies, from their known theraputical properties, would seem to be particularly indicated in the treatment of that variety of Inflammation refered to; but as yet the utility of their administration has not been subjected to that practical test which the Profession demands as the essential condition of its faith and confidence.

        It must not be supposed however, that these agents act particularly upon the diseased part, for it is only by the impression made upon the organism in its totality that the engorged Capillaries are incidentally contracted, and the congestion relieved.

        They are certainly worthy of a thorough and impartial trial, and as such are recommended to the Profession.

        Antiphlogistic Regimen. Under this head are included the diet of the Patient, and certain other circumstances and conditions by which he may be

surrounded. During the height of the Inflammation, when the functions are interrupted, the secretions deranged, and the Blood filled with stimulating elements, great care should be observed in the regulation of the diet. Food is usually loathed, under these circumstances, and when injested in solid form, serves only as an additional source of irritation to the system. When the acme of the affection has passed, mild and easily digested food should be administered in a liquid form, beginning with gruel, arrow root, &c., and gradually and cautiously advancing to other more nutritive articles. The drink should be cooling and demulcent. The question of diet in connexion with the Inflammatory Process, is an important and delicate one. Care should be taken to run neither into the extreme of over stimulation nor of too great abstinence; but the Surgeon should remember that there is danger to be apprehended alike from an excessive supply of pabulum to the already infected Blood, and from the debility which necessarily and in some instances, rapidly ensues from the destructive metamorphosis incident to Inflammatory action.

        It is also a matter of the first importance to secure perfect tranquility of mind and repose of body, as well as a proper amount of healthful sleep.

        So, also, recovery and comfort are both promoted by a regular temperature, free ventilation, cleanliness of body, words of encouragement and kindness, clean and comfortable bedding, the presence of friends and relatives, the assurance of

victory, confidence in the skill and humanity of the Surgeon, and a multitude of similar circumstances which will readily suggest themselves to the Physician.

        Stimulants.--This class of remedies is indicated:

• 1. When the morbid action has been originally developed in connexion with a depraved and debilitated system.
• 2. When the strength of the system has been exhausted by the Inflammation itself or some of its products, as when Hectic is developed in consequence of the excessive discharge of Pus, &c.

        The principle upon which stimulants are exhibited, in this connexion, may be thus explained.

        The Nervous Centres, which are the great fountains of vitality,--the sources from which flow out the influences which give tone to the muscles, action to the secerning organs, life and power to the whole organism, become debilitated from the absence of those conditions which are essential to the health of the system, such, for instance, as pure and proper food, cleanliness of person, appropriate clothing, contentment of mind, and other similar circumstances. The Blood, at the same time, is impoverished, losing its red globules, augmenting in watery elements, and becoming more irritable and less stimulant to the tissues through which it circulates. The development of Inflammation, finds a system in which these changes have occurred, in but a poor condition to resist its invasion, and to prevent the induction of its most

unfavorable consequences. The great centres, from their preternatural irritability, respond immediately and violently to the local impression,--so excessively in fact, as speedily to exhaust themselves, and to lose the power of supplying that influence upon which the integrity of the Organism so much depends. The tissues generally being thus deprived of the stimulus from the Nervous System, are incapable of appropriating their necessary pabulum. The secerning Organs having lost their guiding and controlling principle fail in the performance of their legitimate functions. The chief motive power of the circulation being weakened or destroyed the Heart beats wildly, the arteries contract irregularly, the Capillaries engorge themselves with blood, and the circulating fluid is vitiated to a still greater 'degree under the constantly increasing demands for its vitalizing principles, the retention of the checked Secretions, the development of Inflammatory products, the waste of exhausted tissue, and the expenditure of its Carbo-Hygronous elements in the work of Calorification. In this emergency, the only means of preventing speedy disorganization,--the complete overwhelming of the system by the violence of the disease, is to supply it with strength. The exhausted fountains must be replenished, the wasted stream restored, the motive power of the paralyzed machinery supplied anew, or the Patient surrendered to the embrace of death. Stimulants, therefore become a necessity, so absolute and imperative, that to fail in their employment is to assume the responsibility of a fatal result.

        A simple illustration will elucidate the whole subject. The system may be likened to a Fortress, the Inflammation to the attacking Party,--the first resisting the assault, the latter striving to reduce the Work. Now, it is plain that a successful resistance can be ensured in two ways:--either by weakening the attacking Party, or by strengthening the Fortress. By Depletants, we diminish the number and power of the assailants, and thus ensure the safety of the Garrison. By stimulants, we strengthen the weakened Work, victual and encourage its defenders, and secure the repulse of the attacking Party. The one plan prevents fatal consequences by abating the force and intensity of the Inflammation, while the other accomplishes the same end by strengthening the sinking and overpowered system.

        A large majority of army Patients present symptoms of debility in connexion with the progress of all Inflammatory affections, and the exhibition of stimulants and tonics is consequently demanded as a general thing in the treatment of their diseases. This is the general rule, but it must be borne in mind that it has its exceptions, and is not of universal application, as some teach and many believe. Many affections which assume a Typhoid type during their progress and thus necessitate a resort to sustaining remedies, may be "cut short" by the timely employment of active measures; while it is possible to stimulate too excessively even in diseases which primarily and unequivocally demand that plan of treatment. It should never be forgotten that debility is as surely

and speedily produced by surfeiting the Nervous Centres with too great an abundance of the rich food which alcoholic Preparations supply, and by over taxing their generating properties by excessive and protracted stimulation, as by any other possible means, and that Carbon and Hydrogen, whilst subserving valuable purposes in the economy, are not the elements from which the most important structures of the organism gather their vitality or power.

        In exemplification of the truth of these observations, it is only necessary to refer to the recorded experience of Dr. Gualla, Surgeon in chief of the military Hospitals at Brescia, in regard to the treatment of the wounded after the battle of Solferino. He declares that the Italian soldiers who fought upon their own soil, in their native climate, in their full vigor and health, and not exhausted by long marches, or injured by unusual food, recovered rapidly from their wounds, though subjected universally to an Antiphlogistic treatment; while the French soldiers, who were weakened by the dangerous and protracted march over Mount Cenis, suffered greatly and died in large numbers, though treated on opposite principles. The greater suffering and mortality of the latter, he ascribes to the fact that they were allowed too rich a diet, and stimulated to an unreasonable extent, notwithstanding their previous debility. It is much to be apprehended, that under the extravagant teachings of Todd, Bennet, and others of their School, the death blow of many an unfortunate victim has been given in the excessive potations administered

for his comfort or relief. The Surgeon should enter upon the discharge of his most responsible task with an honest determination to discard all bias and prejudice in regard to particular modes of treatment, and with "in medio tutissimus ibis" as his rule, should only depart from it after a thorough individualization of each particular case, and an accurate knowledge of all the surrounding circumstances.

        Stimulants and tonics have been spoken of indiscriminately, for the reason that the one is so administered as to secure permanency of impression and the other employed in such a manner as to ensure rapidity of action, thus approximating them therapeutically, and making them subserve the same ends in the economy. The Remedies of this class in general use, are Alcoholic Liquors of all kinds, Wines, preparations of Ammonia, Sulphate of Quinia, and Tinctura Muriatici Ferri, &c.

        The alcoholic liquors stand at the head of the list, in as much as they can be more conveniently obtained and administered; as their effects upon the system are prompt and decided; as they are better borne by the stomachs of most men; and as they are more palitable and agreeable to a large majority of Patients.

        Rules for the administration of alcoholic stimulants--

• 1. Examine well into the present condition and previous habits of the Patient before administering them.
• 2. Commence with small quantities--say half an ounce, and gradually increase the dose according to the necessities of the case.

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• 3. Administer at such intervals as will ensure a prompt, continuous and equable impression upon the system.
• 4. Watch the condition of the stomach, carefully, lest an irritiation of that organ be developed, thereby interfering with the absorption of the stimulant and adding to the burdens of the laboring system.
• 5. Examine the Pupil frequently, noticing whether it be contracted or dilated abnormally and discontinuing the Remedy from the fear of cerebral Inflammation in the one instance or a excessive congestion in the other.
• 6. Attend strictly to the circulation, continuing the medicine, if the Heart beats more slowly under its influence, or continues at its original rate, and rejecting the stimulant when its pulsations are excessively increased in frequency and force.
• 7. If Coma be produced, Delirium increased, or sleep prevented, change the treatment.
• 8. If the Tongue grow red and cracked, the mouth dry, deglutition difficult, and the voice husky, stimulants are contra-indicated and should be abandoned.
• 9. If the Kidneys or Skin--particularly the latter--be too much acted on, thereby debilitating the Patient, stimulate carefully.
• 10. If the Heat, Pain, and congestion of the part increase, or the wound looks redder, fails to suppurate, or discharges Pus too freely, the remedy should be discontinued.
• 11. On the other hand, when none of the accidents

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  just mentioned present themselves, and the attendant phenomena assume an opposite character, the Surgeon should not be alarmed at the quantity of the stimulant employed, but being guided alone by its effects, and observing the progress of the case with the most intelligent scrutiny, he should push his advantage until the system has secured an entire mastery of the Disease.

        In regard to the particular preparation of Alcohol which should be employed, the fancy of the Patient, or the convenience of the Surgeon may be consulted when good Liquors are within reach. Whiskey is usually preferred, because when pure(?) it is more acceptable and less irritating to the stomach; while French Brandy also has its champions. In the present condition of the Country, Apple Brandy is the purest, most palatable, and least difficult to procure, since distillation from grain has been prohibited; while experience has convinced the Author, that as a pure stimulant it stands unequaled.

        The manner in which the other Remedies referred to under this head, are employed will be more fully considered in various connexions.

        Local Remedies.--These are either preventive or curative, according to the end for which they are employed. The most prominent and important among them are Rest, Position, Local Depletion, Revulsives, Cold and Warm Applications, Topical Alteratives, and Compression.

        Rest.--The importance of steady and persistent rest, can readily be understood, when it is remembered that the least exercise of the part necessitates

the flow to it of large amount of blood and nervous influence Where Rest cannot be secured by the Patient's own efforts, Splints may be employed, or Opium used for the purpose of temporarily paralyzing the muscular fibres of the affected structures. It is well not to continue this treatment long, lest anchylosis, permanent immobility, &c., be the consequence.

        Position.--In Inflammation the vessels are filled with an unusual amount of Blood, which is still controlled by the laws of gravity,--accumulating in a dependent part, and vice versa. This is true for the other fluids as Serum, Lymph and Pus which are developed in connexion with the process of the morbid action. So likewise position may increase the pain of the affected part, by causing muscular pressure upon it. For these reasons, the part should be kept in an elevated position, and so arranged as to relax its muscles, while the comfort of the Patient should likewise be consulted as far as practicable.

        Local Depletion.--This is accomplished by means of Scarifications, Punctures, Leeches, Cups, and Drainage. The Blood may be taken directly from the part by local bleedings, or robbed of its serum by Blisters. These remedies also exercise an indirect control through the agency of nervous reflex action, or by their general sedative effects upon the system at large. Blisters should always be employed with caution particularly in the earlier stages of Inflammation, lest they add to the irritation of the diseased structure, and thus prove an injury rather than a benefit to

the Patient. Punctures are employed for the purpose of relieving the suffering tissues of the Serum or Pus which may have been poured out in them. The artificial evacuation of Pus may be accomplished either directly by the Knife, by Caustic--though the latter is seldom attempted--or, by what is known as Drainage.

        Rules for opening Abscesses.--1. Take care in introducing the Bistoury not to interfere with any important nerve, to open a large vessel, or to penetrate one of the large cavities of the Body.

        2. Make the opening great enough to ensure a free vent of the pent up fluid. It is far better that the opening should be too large than too small.

        3. Assist the evacuation if necessary, by the hand or finger, used however, with the greatest gentleness.

        4. Prevent the incision from healing by "First Intention," by inserting a small tent made of old linen, well oiled, and interposed between the edges of the wound.

        5. Employ the "warm water dressing" or an Emollient Cataplasm(?)for the purpose of promoting the discharge of the fluid, after the bleeding has ceased, but be careful not to continue it for too long a period lest too much relaxation ensue.

        6. Approximate the sides of large abscesses by means of compresses.

        7. Make the opening, if possible, so that gravitation will promote the escape of the purulent matter, but if this cannot be effected, try a counteropening. A current of water passed from one opening to the other is frequently of great advantage.

        8. If arteries be divided in the operation, ligate them.

        Chaissaignac has proposed to relieve abscesses of their contents by a system of "Drainage," which is, in fact, but a revival of the old doctrine of the Seton. He plunges a Trocar lined with a Canula through the abscess and out again through the integument; then withdrawing the Trocar, he passes through the Canula, which remains behind, a tube of India Rubber, perforated with holes for the escape of the matter, and ties the two ends together. In this way the escape of Pus and Serum is facilitated, and a collapse of the parts secured, while the introduction of atmospheric air--an agent which promotes suppuration while it decomposes Pus--is entirely prevented.

        Cold and Warm Applications.--This class embraces everything from the "Cold water dressing" to the "Medicated Poultice." Though Cold Water has been used in the treatment of Inflammation from the earliest times, the experience of Ambrose Pare has mainly contributed to the elevation of the remedy to its proper position in the estimation of Military Surgeons. It has perhaps been more universally employed, in the War which is now being waged by the Confederacy than in any other previous struggle, and with results, which when properly tabulated, will astonish the world. To Surgeon J. J. Chisolm, Professor of Surgery in the Medical College of South-Carolina, and Author of the best "Manual of Military Surgery" that has been published in any language, we are indebted for the just appreciation in which this invaluable

mode of treatment is held, at the present time. If he had done nothing more than inculcate, in that able work, his most scientific and rational views in regard to the Cold Water treatment of wounds, he would deserve the lasting gratitude of the Profession and of the Public.

        Truly it may be said, the days of Cerates, Ointments, and Cataplasm has passed,--having been swept to oblivion by the copious streams of Cold Water, with which an enlightened Surgery has comforted and relieved the mutilated victims of a thousand Battle Fields.

        The advantages of "Cold Water Dressings" in all stages of Inflammation, as