If it disagrees, it should be boiled and mixed with lime-water, or to each dose an equal amount of Vichy or soda-water may be added. Peptonized milk is a valuable agent. One part of milk, 2 parts of cream, and 2 parts of lime-water make a nutritious and digestible mixture. Milk punch is largely used. Whey may be used when plain milk cannot be taken. Eggs are highly nutritious, but are apt to disturb the stomach; they may be given as egg-nog, or simply soft-boiled, or the yolk can be beaten up in a cup of tea. When con

siderable nausea exists the yolk of an egg may be added to 3j of lemon-juice and 3ij of sugar, the glass being filled with carbonated water. Beef tea is certainly a stimulant, but its food-powers are questionable. It is prepared by cutting up one pound of lean beef, adding to it a quart of water, and then simmering, but not boiling, down to a pint, finally filtering and skimming the liquid. The dose is a wineglassful seasoned to taste. Meat-juice, obtained by squeezing partly cooked meat with a lemon-squeezer, is also highly nutritious. Liquid-beef peptonoids are both agreeable and nutritious; they are given in doses of 3ss to 3j. Clam-juice is palatable and digestible. When nothing else will stay on the stomach koumiss will often be retained. This fermented milk is nutritious, stimulant, and very useful. Coffee is a valuable stimulant in febrile conditions. If the stomach retains no food, the patient must be fed entirely by the rectum. If the stomach rejects most of the food swallowed, mouthfeeding must be supplemented by nutritive rectal enemata. When the sufferer feels able to eat a little, any good soup, strained and skimmed, should be ordered. As the patient gets better he may be fed on sweetbreads, chops, etc., until he gradually reaches ordinary diet.

Ventilation and Cleanliness.-The ventilation of the apartment is of the greatest importance. Every day the windows. should be opened widely for a time, the patient of course being protected. When the windows are open the air of a room can be quickly changed by swinging the door to and fro. A constant access of fresh air must be secured, and the temperature kept at about 68°. The sick man must be cleaned and be sponged off with alcohol and water every day if high fever exists. It is important that the bed-clothing be clean and that the sheet be unwrinkled, as otherwise bed-sores may form.

Chronic Inflammation.-This condition progresses slowly and does not produce symptoms of severity either in the part or the body at large.

Causes.-Blood diseases, as rheumatism and gout; infective diseases, as tuberculosis and syphilis; retained pus in an ill-drained abscess; blockage of the duct of a gland; foreign body in part; flow of an irritant secretion (as saliva from a fistula); repeated identical traumatisms of an occupation, etc. W. Watson Cheyne tells us it is not due to the ordinary pyogenic organisms (see Cheyne's article in Treves' System of Surgery).

Tissue-changes-Practically the same as in acute inflammation, but take place far less rapidly. It is maintained by Cheyne and others that typical granulation-tissue does not form, the tissues of the part being replaced by fibrous tissue. The amount of fibrous tissue produced is relatively very great. This tissue may cause permanent thickening, or may contract, and thus diminish the size of a part. Contraction is very considerable in cirrhosis of the liver and in interstitial nephritis.

Symptoms.-Pain varying in intensity and character; tenderness; great swelling, which in some cases is followed by shrinking, and is usually indurated or brawny; sometimes heat, rarely discoloration unless the skin is itself inflamed. There are no constitutional symptoms attributable purely to the inflammation. If there are such symptoms, they are due to the disease which induced the inflammation or to interference with the function of an organ because of the fibrous mass. (For treatment of chronic inflammation see articles upon special regions and particular structures.)

IV. REPAIR.

Repair is an active process by which destroyed tissues are replaced, and it is due to increased nutritive activity, rather than to inflammation. Inflammation may occur, or we may be obliged to induce it when the blood-supply is scanty or the exudation deficient; but certain it is that an aseptic wound heals without many of the evidences of inflammation.

If pus

Healing by First Intention.-A wound may heal by "first intention." This mode of healing, which is known as "primary union," occurs without suppuration, and is observed in the healing of an aseptic wound. forms, primary union will not take place. If an incised wound is asepticized, the hemorrhage arrested, and the edges brought into nice apposition, slight swelling arises, but no discoloration appears. Lymph and leukocytes are exuded from the vessels, fibrin forms in this lymph, and the edges

of the wound are stuck together by a natural cement. In extensive wounds the exudation is in excess, and much of it must be drained away, for its retention will cause tension and inflammation, and the exudate furnishes a favorable soil for the growth of pus organisms. The exudation is converted into embryonic tissue by multiplication of its own cells and multiplication of tissue-cells. Embryonic tissue consists of small round or oval cells held together by a jelly-like intercellular substance. In a few days some spindle-shaped cells can be found, and also large cells with one or more nuclei (epithelioid cells). Prolongations of embryonic tissue are raised up by capillary loops, which prolongations fuse with one another end to end, or fuse with other capillary loops, are hollowed out and become endothelial tubes or capillaries. By vascularization embryonic tissue becomes granulation-tissue. Granulation-tissue becomes fibrous tissue, and the new fibrous tissue contracts to a great degree (Figs. 25, 26). The final step in healing is

contraction of the fibrous tissue and the covering of the surface with epithelium, which springs from the epithelial cells upon the edges. This final process is called "cicatrization," and consists in contraction of the wound and skimming over with epithelium. The "immediate union" of some writers never occurs. This term means the union of microscopical parts to their counterparts without any effort at repair. A first union is effected always by fibrin, and next by embryonic tissue. A wound healing by first intention exhibits no evidence of inflammation. There is some slight tenderness, but no actual pain. A certain amount of swelling arises because of exudation of fluid from the blood, and the coagulation of this fluid makes the wound-edges hard. Venous obstruction leads in some cases to a considerable fluid swelling.

During the first twenty-four hours after a wound begins to heal by first intention the discharge is most plentiful, but after this period it becomes very scanty and soon ceases entirely, and can be much diminished in quantity in the first. day by the application of pressure. In a large wound we notice a profuse flow of bloody serum. Warren says that after a hip-joint amputation over a pint flows out during the first twenty-four hours. In a large wound special methods to secure drainage are required. In a small wound drainage is obtained between the stitches. The use of irritant germicides in a wound greatly increases the amount of discharge and renders drainage necessary in even a small wound for the first twenty-four hours. In an aseptic wound, as a rule, one-half of the stitches are removed on the fifth or sixth day and the remainder on the eighth day, but for two weeks more the wound should be rested and supported, as the new tissue is not very resistant to infection. Aseptic fever always arises when much exudation is given out, and is due to the absorption of aseptic pyrogenous material (p. 87).

Healing by Second Intention.--In a wound whose edges cannot be approximated a great gap has to be filled, and this is accomplished by granulation. This process is known as "healing by granulation" or "second intention." In an hour or so after the infliction of such a wound (it may be in less time) the raw surface is covered with a thin glazed layer of coagulated blood and exudate. This glaze is fibrin, which soon becomes filled with leukocytes; underneath this fibrin-coat cell-proliferation is proceeding and embryonic tissue is forming. The wound-discharge is at first thin and red, but in a few days becomes purulent and so profuse as to wash away the discolored fibrin-coat. Granulations are now disclosed, the embryonic tissue being lifted up in countless points by capillary loops. When these loops approach the surface contraction begins in the fibrous tissue in the depth of the damaged area, which contraction brings the edges of the wound nearer together and gradually cuts off by pressure the excessive blood-supply which is no longer needed. When the granulations reach the surface, epithelium in a thin bluish film grows from the epithelial cells at the edge. and covers the ulcer. Cicatrization is contraction plus skinning over with epithelium. Epithelium can only spring from the wound-edges, unless there be some epithelial structural remains in the wound, such as an undestroyed papilla, a sweat-duct, or a hair-follicle. If the granulations rise above the surface, constituting exuberant granulations

or proud flesh, they must be cut off or burned away before epithelium will grow over the wound. Pale edematous granulations are usual in tuberculous processes, and if they form pressure must be applied. The contraction of cicatrization results from the conversion of granulation-tissue into fibrous tissue (Figs. 25, 26). Contraction is so great after some wounds as to cause terrible deformities. This is notably the case after burns, whose scars or cicatrices contain much elastic tissue. Coagulation-necrosis of a superficial layer of granulation-tissue produces a diphtheritic membrane or aplastic lymph. This coagulation-necrosis depends on capillary closure or lack of capillary development, the embryonic tissue dying for want of nutriment. Ulcers heal by second intention.

Healing by Third Intention.-This consists in the union of two granulating surfaces, and is seen in the union of collapsed abscess-walls. The surgeon occasionally seeks to obtain union by third intention by approximating two granulating surfaces. In subcutaneous wounds, if aseptic, healing occurs without suppuration. First a blood-clot fills the wound, exudation occurs, and embryonic tissue forms in the walls of the cavity, embryonic tissue is converted into granulationtissue, the new granulation-tissue grows into the clot, which is broken up and absorbed, and fibrous organization and contraction of the new tissue take place. If suppuration occurs, an abscess forms. Healing under an aseptic blood-clot is healing "by first intention." The fibrous tissue of a scar arises from granulation-tissue, which itself arose from embryonic tissue. The multiplication of connective-tissue cells may be by direct, but it is usually by indirect, division.

Cell-division.-Direct cell-division consists in division of the nucleus followed by division of the entire cell.

Indirect cell-division, or karyokinesis, shows remarkable changes in the neucleus. The membrane of the nucleus disappears; the nuclear network becomes first close and then more open, and the cells become round, if not so before. The network of the nucleus, now consisting of one long fiber, takes the shape of a rosette; next it takes a starform-the aster stage; two sets of V's next form-the equatorial stage; an equatorial line appears and widens, and each set of V's retreats toward a pole. Thus two new nuclei are formed, each polar V passing in inverse order through the previous changes of shape, and the protoplasm of the original cell collecting about each nucleus (Fig. 27).

In non-vascular tissues, such as cornea or cartilage, the