398 PATHOLOGY tendons, and aponeuroses, so in the heart they are in the peri cardium and in the more fibrous parts of the endocardium. But they are sometimes in the cardiac muscular tissue itself, the mus cular substance of the heart being peculiar. Chorea The association with chorea may now be noticed. Chorea is not and a disorder of heat-regulation, and it is not due to chill ; it is a rheuma- disorderly habit of some nervous centre or centres whereby the tic fever, ordinary work of muscles is made irregular, and it is due to some feebleness in, rather than to injury of, the nervous mechanism. The considerable liability of choreic subjects to rheumatic fever, the actual endocarditis that they suffer from even if they have never had rheumatic fever, the occasionally observed choreic movements of the muscles in the course of true rheumatic fever in adults, the occurrence of chorea as a sequel of rheumatic fever all these associated things go to show that the disordered nerve- centre is the same in both diseases, and that the discharge of its force may pass readily from one path to another. It may either set free muscular heat without muscular work, excessive in degree and attended by unique pain in the joints ; or it may spend itself in those gratuitous displays of muscular work which amount to chorea. Herpes The foregoing diseases have been regarded as errors of the heat- in febrile regulating nervous mechanism. In rheumatic fever we have seen attacks, that there is a singular relationship to a truly nervous disorder, namely, chorea. It remains to mention another implication of the nervous system which several of them have in common, namely, an herpetic eruption about the corners of the mouth. Herpes is now accepted as an affair of certain cutaneous nerve-areas ; and in malarial fever, pneumonia, and acute attacks of quinsy due to chill there are very apt to be eruptions of herpes labialis. Why the labial region should be involved is not obvious: 1 14. INFLAMMATION. The inflammations may be regarded as an empirically made-up group of disordered states which have somewhat in common. Although inflammation is certainly a provisional category, there has always been a tendency to overcrowd it with newly-described morbid conditions, rather than to empty it of its temporary occupants. Whenever patho- logists have become impatient to say the last word about the endless perplexities of disease the class of inflamma tions has become unusually full ; this happened in the period of Broussais, when even the specific infections were placed therein, as gastro-enteritis and the like ; and the frequent resort to the termination itis in more recent pathology may be taken as an evidence of a correspond ing habit of mind. Thus there is much fairness in the bold criticism of Andral : "Recu dans le langage, sans qu aucune idee precise lui ait jamais ete attachee, sous le triple rapport des symptomes qui 1 annoncent, des lesions qui la caracterisent, et de sa nature intime, 1 expression inflammation est devenue une expression tellement vague, son interpretation est tellement arbitraire, qu elle a reellement perdu toute valeur ; elle est comme une vieille monnaie sans empreinte, qui doit etre mise hors de cours, car elle ne causerait qu erreur et confusion." It is at least the duty of pathology to reduce the congeries of inflammations to as small a bulk as possible, to follow up the analysis of the inflammations one after another until they are reduced to the scientific position of errors of the respective structures and functions. Inflamma tions, indeed, are best regarded as an ever -diminishing residue ; there is always the residue, because the correlated structural and functional aspects of the life of the tissues cannot be stated with equal clearness for all of them. It is the great binding tissue of the body that gives occasion for this nosological residue ; the connective tissue is the one tissue about whose dual life of structure and function there is a difficulty. We shall appreciate its unique posi tion best by comparing it with so direct a modification of 1 See Senator, Untersuch. uber den falerhaflen Process, Berlin, 1873 (abstract and criticism by Sanderson, in Rep. Med. Off. Privy Council, 1875) ; C. F. Oldham, What is Malaria, and why is it mast intense in Hot Climates? Lond. , 1871 ; C l. Bernard, Lemons sur la Chaleur aninvile, Paris, 1876 ; Morehead, Clinical Researches on Diseases in India, 2 vols., Lond., 1856 ; Jas. Johnson, Influence of Tropical Climates, 4th ed. , Lond., 1827. itself as fat-tissue. But even these phlegmasire are capable of some further analysis in the direction of disordered structure and function if we have regard to the functions of the embryonic mesoblast, and to the " memories " of the same that the common binding tissue never quite loses. The earliest and most fundamental notions about inflam mation, and those which pertain to the residue above spoken of, were derived from the external parts of the body when injured by blows, wounds, scalds, the lodg ment of foreign bodies, and such-like palpable irritations. Along with simple inflamed wounds were taken cases of erysipelas, a disease which has now become the sole heir of the original Greek name for inflammation, namely, phlegmon. It will be convenient to begin with a brief reference to erysipelas. Erysipelas. Besides phlegmonous erysipelas, or diffuse inflam- Erysi- mation and suppuration of the cutaneous and subcutaneous con- pelas. nective tissues, there is a common form consisting of redness, swelling, pain, and heat of the surface only, and stopping short of suppuration. This condition often follows a wound, especially in the, region of the scalp or face ; it may occur also when there is no obvious wound, although there will probably have been a catarrhal state of the nearest mucous membrane. Fever or constitutional dis turbance usually precedes the inflammation twenty-four hours or less, and in this respect erysipelas is comparable to the effects of chill already treated of. Wounds received in a drunken brawl are especially apt to become erysipelatous ; also the wounds of those suffering from kidney-disease or liver-disease. Erysipelas is most apt to occur in cold weather with east winds, or in cold and damp weather. One attack predisposes to others. It often arises spon taneously or autochthonously, but it is perhaps equally often induced by contagion and inoculation from pre-existing cases. Of its origin do now from time to time there need be no question ; thus, it has been observed in a single individual of a ship s com pany at sea off Cape Horn. The redness and swelling advance with a well-marked border from the wound or other starting-point until they have invaded, it may be, a large cutaneous area. There is exuded plasma in the spaces of the connective tissue, and there are also nuclear cells (leucocytes) in the lymphatic spaces and vessels, and in the tissue generally. An increase of the colourless cells in the blood is also described. Since attention has been called to the presence of minute living organisms in disease there have not been wanting authentic descriptions of micrococci in the lymphatic spaces of the advancing margin in erysipelas, although they are said to be absent in the older areas of the inflammation, and during the stage of subsidence generally. In phlegmonous erysipelas the connective tissues to a consider- Plileg- able depth beneath the skin are soaked in serous fluid, which be- inonoii comes turbid, like thin pus ; at a later stage the lines of pus extend erysi- in all directions along the tracts of binding tissue, fragments of the pelas. latter being found as detached shreds in the larger purulent centres. The skin, usually of a limb, may thus become involved over a large area and to a great depth, considerable pieces of tissue falling at once into a state of slough. The temperature is often as high as 105, and delirium, with other symptoms of nervous disorganization, is common. Death from failure of the heart is probable. This dis ease is the most extreme form of phlegmon, by far the most formid able inflammation that exists. It is usually the sequel of a wound, but not invariably. Chilliness and all the other symptoms of com mencing fever precede the local phlegmon, so that the condition is comparable to those errors in the regulation of the animal heat, previously mentioned, in which the incidence falls upon a peripheral part. That it is itself a local effect of general temperature disorder cannot be maintained, inasmuch as there is usually nothing in the antecedent circumstances to implicate directly the heat-regulating centre. However, it is not the extent of the local injury that serves to account for the inflammation, but the habit of body of the patient, especially the drinking habit. It is not an overtaxed heat-regulating centre that is implicated, but a nervous system overtaxed in more general respects. A peripheral injury, not necessarily a severe one, tells in an unusual way upon the unstable centres, just as in tetanus ; and the outgoing response falls in a peculiar way or with a peculiar force upon the wounded part, pro ducing phlegmon there and fever generally. Whether the rise of the body -temperature is mainly due to over -combustion within the injured area is open to discussion. The connective tissue as a source of heat has not hitherto come into our consideration ; if it is to be regarded as a member of the heat-producing executive, under the central nervous control, its membership is at least not important except when the redness, swelling, heat, and pain of inflammation arc present.
