varied according to the particular circumstances of every case. It will generally be found, after this plan has been continued until the gums become slightly affected, that the constitutional symptoms and the signs of the local disease begin to subside; sometimes, indeed, this will take place without any evidence of the specific action of the mercury.

From what has been already said (p. 52, et seq.,) it must be apparent that when we have reason to apprehend that the inflammation is of a destructive rather than of a plastic character, the use of mercury, if not altogether laid aside, is to be diminished, and its effects upon the system, as well as upon the local disease, carefully watched. For the same reason we must use it more cautiously when the inflammation attacks a tissue in which it is likely to give rise to puriform effusion than when it affects those which ordinarily pour forth plastic lymph: thus in inflammations of the mucous surfaces it must not be used so freely as in those of the serous membranes, of the areolar tissue, or of the parenchymatous viscera. There are also certain states of the system in which there is a diminished power of throwing out plastic lymph, of which a remarkable instance is afforded in the tuberculous or scrofulous diathesis. As this want of power often depends, in great measure, upon the deficiency in the blood of fibrine and red corpuscles, especially the former, mercury is to be used with the greatest caution, since by its tendency to aggravate the constitutional fault it favours the unhealthy and destructive action which inflammation in such constitutions is pecularly apt to assume. In those also in whom there exists the condition of the blood already described under the term anæmia, there is an extreme susceptibility of the action of mercury, whether the anæmia be spontaneous, or whether it be the result of loss of blood, of other discharges, or of visceral disease; in such subjects not only is there the greatest danger of the inflammation assuming a destructive character under the influence of mercury, but also its specific effect upon the mouth and gums is apt to take place with the greatest violence, leading to excessive salivation, ulceration, sloughing, and necrosis of the jaw-bones; but even where there are no signs by which we might suspect the intolerance of mercury, we sometimes find furious salivation set up by very moderate doses, and sometimes when we do suspect this intolerance we are compelled to run the risk of its consequences rather than let an inflammation proceed uncontrolled which has resisted other means, or in which they would be inapplicable. A vast number of remedies have consequently been suggested for checking salivation; purging and blistering behind the ears are undoubtedly of service for this purpose, and the various astringent gargles are useful in ordinary cases, as those of alum, or what is better, of alum, bark, and myrrh; (6)*

the chloride of soda (7)* gargle is also to be recommended when there is a very offensive foetor. That of brandy with an equal quantity of water, recommended by Dr. Watson in his lectures, is perhaps the best of all where the flow of saliva is excessive, and the soreness of the gums very great. Very destructive sloughing, which sometimes ensues, will however be often best counteracted by bark and wine and the use of some stimulating application, such as the gargle of nitric acid. (8)†

In the latter stages of inflammation, when the time for general bleeding-for medicines which exert a sedative influence upon the circulation, and commonly, also, for mercury, has passed; though often whilst there still remains opportunity for the useful employment of local bleeding, there is frequently need for another class of remedies, differing in their effects from those which have been mentioned already, or rather opposed to them-viz., stimulants. These are in the main chiefly available for the attainment of the fourth object proposed in the treatment of inflammation-"Where one of the results of inflammation must ensue, the leading that process to a favourable termination."-The particular instances in which these results occur requiring such support will be specially noticed hereafter. They may perhaps be generally included in-"those cases in which a long process of absorption, ulceration, or granulation has to be gone through, and in which a certain strength of habit is necessary, that these processes may go on favourably."+

There are, indeed, other conditions of the system which have been already noticed as indicating a tendency to one of the modes of fatal termination of inflammation, viz.-by depression of the moving powers of the circulation,-in which the cautious but continued use of stimulants may be the only means by which the life of the patient can be preserved. There are cases again of inflammation of the mucous surfaces, or, of a specific character, in which there is an asthenic congestion of the minute vessels, where the inflammation subsides and the symptoms are relieved by remedies of this class.

We have hitherto made no special mention of the use of counterirritants in the treatment of inflammation, though they have been casually alluded to in speaking of metastasis, and one of the modes by which they act was noticed in connexion with bleeding under the term derivation. The object, then, of counter-irritation is to imitate this metastasis, and make it available for the purpose of cure, by transferring to the surface an inflammation which is going on in some deep-seated part or internal organ. It must, however, be

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remembered as a most important rule in practice, that this mode of relief cannot be attempted in every stage of the inflammation with equal chance of success, or safety to the patient. At the very commencement of an inflammation termed intercurrent, that is to say, supervening in the course of another disease, we often obtain a considerable mitigation of pain, and sometimes check the inflammation by the application of some substance capable of quickly exciting one which shall be superficial, and likely afterwards to subside speedily by spontaneous resolution. Beyond this, however, it is highly inexpedient to employ counter-irritation till a more advanced period— until, in fact, the fever has in some measure subsided, and the local inflammation is assuming a more chronic character, or is passing into a state more nearly approaching passive congestion, or has given rise to some of its characteristic exudations; for if it be employed too early, the additional inflammation excited by the counter-irritant accelerates the heart's action, and perhaps, too, increases the inflammatory condition of the blood, and may thereby aggravate the primary disease; but if it be done after the skin has become cooler and more moist, and the pulse less frequent and softer, it will generally happen that a great mitigation of the symptoms ensues, and in many forms of inflammatory effusion, as for instance into the pleura, there is no more effective measure towards its absorption than the application of a blister. In chronic inflammation, on the other hand, counter-irritation is almost always applicable.

When we wish to relieve the pain of an inflammation not attended with much effusion-when, in fact, the nerves seem principally involved-such counter-irritants as produce a considerable effect upon the sentient nerves are to be preferred; e. g., what are commonly termed rubefacients: when, again, we wish to restrain or remove inflammatory exudation, a counter-irritant causing considerable effusion under the cuticle is to be preferred, the vesication being afterwards healed as speedily as possible, and the vesicatory repeated after a short interval in the same or a neighbouring part. When again we wish to check suppuration and ulceration of a chronic character going on in an internal part, those counter-irritants will be best fitted for our purpose which keep up a discharge of puriform matter. If there is chronic inflammation, producing the slow effusion of lymph or serum, or some perversion of nutrition, as in the cases of chronic inflammation with thickening of serous or fibrous structures, or chronic changes in parenchymatous viscera (e. g., the earliest stages of phthisis pulmonalis,) the best mode of counterirritation consists in the repeated or continuous application of substances which stimulate the nerves and vessels without producing any great vesication. When, indeed, such change is suspected to be going on with great activity, counter-irritation of such a nature as to produce a considerable puriform discharge is sometimes serviceable, as setons and issues; not so much on account of the discharge itself, as the revulsive action of the hyperemia accompanying that discharge.

VII.

TYPHOUS, SCROFULOUS, AND TUBERCULOUS

DEPOSITS.

CLOSELY connected with the subject of inflammation, and generally the result of one of the varieties of that process, are certain morbid products which show a very low degree of organization throughout their whole progress. These constitute a class of pseudo-plasmata of Vögel and other authors, which, in their molecular structure, as well as in the concomitant local phenomena, are closely allied to ulceration. It is characteristic of this class of deposits that they do not commonly remain local, but appear simultaneously on several parts of the body, owing probably to the same cause which gave rise to the first pseudo-plasma becoming repeated in its vicinity or in a distant part of the body. It is to this disposition in the morbid action to repeat itself, rather than to any essential difficulty in the healing of the cavities and ulcers, caused by these depositions, that the extensive destruction, which they often produce, is mainly to be attributed.

These deposits are described by Vögel under the names of-I. The typhous deposit,-II. The scrofulous deposit,-III. Tubercle, a classification which is here adopted as most convenient for the purposes of practical medicine.

"The period which elapses between the deposition and the softening of these deposits, or epigeneses, is very different in individual cases; it may vary from a few days or weeks to several months. In general the softening extends to the enclosed normal tissues, and the united product opens for itself a passage and is discharged externally. An ulcer is thus formed: this either spreads by the continuance of the original process (new deposition with softening) in the surrounding parts until it terminates in death, or the ulcer heals by cicatrization, whilst the loss of substance is repaired by permanently-organized epigeneses. In other cases the softened mass does not become discharged, but is gradually resorbed, and the loss of substance is repaired by a similar cicatrization to that which occurs in the preceding case. Sometimes the reparation is interrupted by the deposition, instead of softening, becoming converted into an earthy or cretaceous mass, and thus forming a concretion."*

I. In most cases of that variety of fever to be described hereafter either as typhus or typhoid, pathological deposits take place in different parts of the body, most frequently in the intestinal canal immediately underneath the mucous membrane, and above all, in Peyer's glands near the termination of the ileum, more rarely in the spleen, in the lungs, and in the trachea. These formations consist, at the

* Vögel's Pathological Anatomy, by Day, p. 271.

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commencement, of yellowish or whitish masses, of different degrees of consistence, deposited amongst the normal tissues, which, together with those tissues, undergo the process of softening and ulceration above described, and either heal by cicatrization or continue until the death of the patient.

These deposits consist-1, of an amorphous stroma or floor to the ulcer; 2, of minute moleculer granules, sometimes interspersed with fat globules; 3, of imperfect cells or cytoblasts. These three elements are present in very uncertain proportions, the granules, however, being generally in excess. When softening takes place the amorphous matter disappears, leaving the granules and cells suspended in a fluid; the softening mass frequently containing unsoftened particles of considerable size, which become isolated by the disorganization of the surrounding parts, and are thus discharged as agglomerate masses.*

II. The scrofulous deposits occur in that state of the system commonly known as the scrofulous diathesis, or scrofulosis, and in their elementary composition bear an exact resemblance to the preceding; the only difference being their mode of deposition, which takes place much more slowly and under a different condition of the system. They exhibit, however, great variations in their anatomical structure, being sometimes dense and firm, sometimes lardaceous, and sometimes soft and friable. Like the typhous matter, they consist of an amorphous stroma, granular matter, and imperfect cells or cytoblasts. Softening does not, however, always ensue in scrofulous deposits, but, in many, the calcareous deposition becomes predominant, and the result is an earthy concretion.†

III. The most important, however, of this class of deposits is tubercle. This word was at one time very indiscriminately applied, but more lately it has been endeavoured to restrict it to certain pathological exudations, the result of a specific morbid tendency termed tuberculosis; though perhaps sufficient care has not been taken to establish the proposition that tuberculosis is always the cause and not the effect of tubercles.

Tubercles are described by Dr. Carswell as consisting of a pale yellow or yellowish-grey, opaque unorganized substance, and there is much truth in this description, with the exception of the term unorganized. The fact is, that tubercles are unorganizable, that is to say, incapable of any higher degree of organization, but they are not on that account unorganized.

Tuberculous matter is composed of different elements occuring in different proportions, but corresponding essentially with those of the typhous or scrofulous matter already described; these are, 1, a transparent, amorphous, vitreous stroma, occurring in large masses, and closely resembling coagulated fibrine; 2, minute molecular granules, occuring in masses of a brownish colour; some of these appear to be modified protein compounds, others consist of fat, and some of calcareous salts; 3, imperfectly-developed cells and cytoblasts, with or

Vögel, opus citat.

† Ibid.