dysentery the colon constantly contracts and expels its contents; the stomach does likewise in gastritis; and the bladder acts similarly in cystitis. Spasmodic twitching of the eyelids occurs in conjunctivitis, and twitching of the muscles in fracture and after amputation.

Impairment of Special Function.-In inflammation of the eye, when an attempt is made to look at objects, the lids close spasmodically, and even a little light causes great pain and lachrymation (photophobia). In inflammation of the ear noises cause great suffering, and even when in a quiet room the patient has subjective buzzing and roaring sounds in his ears (tinnitus aurium). In coryza the sense of smell, in glossitis the sense of taste, in dermatitis the sense of touch, and in laryngitis the voice may be lost. In inflammation of the brain the mind is affected; in arthritis the joints can scarcely if at all be used; and in myositis it is difficult and painful to employ the muscles.

Derangement of Secretions.-In dermatitis the sweat is not thrown off; in hepatitis bile is not properly secreted; and in nephritis urea is not satisfactorily removed. The secretions may undergo important changes of composition. Pneumonia causes rusty sputum, and dysentery causes bloody mucus (Gross).

Derangement of Absorbents.—In the height of an inflammation the absorbents are blocked and clogged by coagulated fibrin, and they cannot perform their offices.

Constitutional symptoms of acute inflammation may be absent, and often are in moderate or limited inflammations; but in severe, extensive, or infective inflammations the symptom-group known as fever is certain to exist. This is known as symptomatic, sympathetic, or inflammatory fever, and it arises in non-septic cases from the absorption of aseptic pyrogenous exudate and in microbic inflammations from absorption of pyrogenous toxic products. In young and robust individuals an acute non-microbic inflammation causes a fever characterized by full, strong pulse, flushed face, coated tongue, dry skin, nausea, constipation, and possibly acute delirium. (the sthenic type of the older authors). In broken-down and exhausted individuals an ordinary inflammation, and in any individuals a bacterial inflammation may cause a fever with typhoid symptoms (the typhoid, asthenic, or adynamic type). In inflammatory conditions the leukocytes are markedly increased in number, the condition being spoken of as leukocytosis or transient leukocythemia. Blood plaques are also increased. The fibrin-ferment is obtained from the white cor

puscles; it is liberated as the corpuscles break up in the exudate, and acting on the liquor sanguinis forms fibrin. The absorption of fibrin-ferment many believe causes aseptic fever (page 88). Inflammatory blood contains an increased amount of albumin and salts. If a person with inflammatory fever is bled, the blood coagulates rapidly, the clot sinks, and there is found on the surface a cup-shaped coat, made up of liquor sanguinis and white cells, known as the "buffy coat," but this is not a sign of inflammation and occurs normally in the blood of the horse. The buffy coat forms when blood contains a great number of leukocytes, because these leukocytes sink more slowly than do the red corpuscles. Cupping occurs because the white corpuscles sink more slowly by the sides of the tube than far from the sides.

Treatment of Inflammation.-The first rule in treating an inflammation must be to remove the exciting cause. If this cause is a splinter in the part, take out the splinter; if it is a foreign body in the eye, remove the foreign body; if urine is extravasated, open and drain; take off pressure from a corn; pull out an ingrown nail, and remove irritants from an infected area by asepticizing. The rule, remove the cause, applies to a chronic as well as to an acute inflammation. If the cause of an inflammation was momentary in action (as a blow), we cannot remove it, for it has already ceased to exist. After removing the cause, endeavor to bring about a cure by local and constitutional treatment.

Local Treatment of Inflammation.-It must be remembered that the division of inflammation into stages is natural, and not artificial, and that a remedy which does good in one stage may do harm in another. Certain agents are suited to all stages of an inflammation, namely, rest and elevation.

Rest is of infinite importance, and is always indicated in acute inflammation. Its principles were first thoroughly studied by Hilton.' The means of securing rest differ with the structure or the part diseased. When rest is used, do not employ it too long. In cerebral concussion rest must be secured by quiet, by darkness, by the avoidance of stimulants and meat, by the application of ice to the head, and by the use of purgatives to prevent reflex disturbance and the circulation of poisons in the blood. In inflamed joints rest must be obtained by proper position, associated in many cases with the adjustment of splints or plaster, or the employment of extension.

In pleurisy partial rest can be secured by strapping the Lectures upon Rest and Pain.

affected side with adhesive plaster or by using a bandage or a binder to limit respiratory movements. In fractures Nature procures rest by her splints-the callus-and the surgeon procures rest by his splints-immovable dressings, or extension. In fractures of the ribs strap the chest on the injured side. In cancer of the rectum a colostomy secures rest for the damaged bowel. In enteritis opium gives rest to the bowel by stopping peristalsis. In cystitis rest is obtained by opium and belladonna, which paralyze the muscular fibres of the bladder. The use of the catheter gives rest to the bladder by removing urine. A cystotomy allows complete rest by permitting the bladder to suspend its function as a reservoir of urine. In vesical calculus rest is obtained by cutting or crushing the stone. In inflamed mucous membranes rest is secured (from the contact of irritants) by touching them with silver nitrate, which forms a protective coat of coagulated albumin. Opening an abscess gives its walls rest from tension. In inflammations of the eye light must be excluded to obtain complete rest, but tolerable satisfactory rest is given in some cases by the use of glasses of a peacock-blue tint. In aneurism the operation of ligation cuts off the blood-current and gives rest to the sac. In hernia the operation gives rest from pressure. Instances of the value of rest could indefinitely be multiplied.

Elevation partly restores circulatory equilibrium. A felon is less painful when the hand is held up in a sling than when it is dependent. A congestive headache is worse during recumbency. A gouty inflammation in the great toe is more painful with the foot lowered than when it is raised. A toothache becomes worse on lying down.

Relaxation is in reality a form of rest, and consists in placing the part in an easy position. In synovitis of the knee semiflexion of the knee-joint lessens the pain. In muscular inflammations relaxation relieves the pain.

Certain agents are suited to the stage of vascular engorgement, increased arterial tension, and beginning effusion. These agents are—(1) local bleeding or depletion; (2) cutting off the blood-supply; and (3) cold.

Local bleeding or depletion is the abstraction of blood from the inflamed area. This abstraction relieves circulatory retardation and causes the blood to move rapidly onward; the corpuscles clinging to the vessel-walls are washed away, the capillaries shrink to their natural size, and the exudate is absorbed. In other words, local blood-letting increases the rate of the circulation, though not its force.

The methods of bleeding locally are-(a) puncture; (b) scarification; (c) leeching; and (d) cupping.

Puncture is recommended in inflammation, not only because it abstracts blood locally, but also because it gives an exit to effusion under fibrous membranes. It is very useful in relieving tension-for instance, in epididymitis. It is performed with a tenotome and with aseptic precautions. If numerous punctures are made, the procedure is termed "multiple puncture." This is very useful when applied to the inflamed area around a leg-ulcer. The late Prof. Joseph Pancoast was very fond of employing multiple punctures, designating the operation "the antiphlogistic touch of the therapeutic knife."

Scarification or Incision.-By means of scarification we bleed locally, evacuate exudates, and relieve tension. One cut or many cuts may be made, and these cuts may be deep or may not even go entirely through the skin, according to circumstances. Multiple incision is very useful applied to inflamed ulcers, ulcers in danger of gangrene, and to almost any condition of great tension.

Leeching-Leeches must not be applied to a region plentifully endowed with loose cellular tissue, as great swelling and discoloration are sure to ensue. These regions are the prepuce, labia majora, scrotum, and eyelids. Leeches should never be applied to the face (because of the scar), near specific scars or inflammations, nor over a superficial artery, vein, or nerve. A leech is best applied at the periphery of an inflammation and between an inflammation and the heart. To leech at the inflammatory focus only aggravates the case. Before applying leeches, wash the part and shave it if hairy. If the leeches will not bite, smear the part with milk or with a little blood. In using a leech, place it on the skin under a glass tube or an inverted wine-glass. Never pull off a leech: let it drop off; and if it refuses to do so, sprinkle it with salt. After removing a leech, employ warm fomentations if continued bleeding is desired. Sometimes the bleeding persists, but this may be arrested by styptic cotton and pressure. Leeching leaves permanent triangular The Swedish leech, which is preferred to the American, draws from four to six drachms. Leeching has both a constitutional and a local effect. It is at the present time used comparatively rarely, but it is employed by some surgeons over the spermatic cord in epididymitis, on the temple in ocular inflammation, and over the right iliac region in mild cases of appendicitis.

Cupping: Wet Cups.-In wet cupping apply a cup for a moment, remove it, incise or puncture the skin, and apply the cup again to draw the requisite amount of blood. Baron Heurteloup devised an instrument (Fig. 22) in which the incision is made by a scarifier. The blood is drawn by a pump, the tube being placed upon the cut area and the withdrawal of the piston creating a vacuum. This instrument is known as the "artificial leech." Wet cupping is of value in pleuritis, pericarditis, and nephritis.

Cutting off the Blood-supply.-Onderdonk, of New York, in 1813 recommended ligation of the main artery of a limb for the cure of inflammation in important structures supplied by the vessel. The procedure was warmly advocated by Campbell, of Georgia, for the treatment of gunshot-wounds

of joints. This plan of treatment is now not to be considered for a moment; antisepsis furnishes us with a safer and more certain plan. Vanzetti, of Padua, advocates digital pressure to cut off the blood-supply to an inflamed part.

Cold is a very powerful and an extremely useful agent. It constringes the vessels, prevents migration of corpuscles, favors the absorption of exudate, retards cell-proliferation, and relieves pain, swelling, and tension. Cold must not be applied to the old or to the feeble, as it may induce gangrene. It is harmful in advanced inflammations or severe congestions (as strangulated hernia). There are two forms of cold, the dry and the wet.

Wet Cold.-To apply wet cold, the part is wrapped in wet linen or muslin and laid upon a rubber sheet folded like a trough and emptying into a bucket. A vessel filled with cold water is placed upon a higher level than the bed. A wet lamp-wick is now taken, one end is inserted into the water of the vessel, and the other end is laid upon the part.