PATHOLOGY 401 way ; as infecting cells they might be the agents of much suppura tion, and, through their wandering propensities, of suppuration at discontinuous points. They would thus have a power in inflam mation analogous to that which has been claimed in a former sec tion for catarrhal and other epithelial cells of a mucous membrane (or of a gland) which had found their way into the supporting connective tissue. Among the things that determine the degree and course of an inflammation, besides the kind and extent of the injury, may be mentioned the florid or anaemic habit of body, the gouty habit, the alcoholic dyscrasia, the diabetic cachexia, the scrofulous inherited constitution, and the syphilitic taint. There are even cases where the predisposing cause is, as it were, strong enough to dispense with all but the slightest exciting cause ; where, accordingly, the inflam mation would be called idiopathic. But, however much the "crasis " of the blood or influence of the nerve -force may determine the degree and kind of inflammation, it is clear that the stagnation of the blood, the incontinence of the vessel-walls, the exudation, and the suppuration may all follow an injury where the crasis and the general nervous control are perfectly normal. The significance of micro -organisms in the inflamed area must be judged from the same point of view ; all the events of inflammation may happen without them, but they may help to determine the kind and extent of the inflammatory eil ects. * 15. INFECTIVENESS. One of the most dreaded results of a wound, or an inflammation from other causes, happily rarer in modern surgical practice than in former times, is pyaemia, septic aemia, or purulent infection. About a week, more or less, after the injury, the patient has a shivering fit followed by a perspiration ; he may feel comparatively comfortable for a time, but there soon begin to be grave symptoms of constitutional disturbance. He becomes uneasy, has pains in the limbs, a weak and quick pulse, fever, loss of appetite and thirst, a dry and brown tongue, a somewhat jaundiced skin, and sometimes diarrhoea. The shivering fit returns at intervals followed by the sweating, the tem perature rising to a great height and falling rapidly to a corresponding degree. Death usually ensues, sometimes not for two, three, or four weeks, being preceded by mut tering delirium and unconsciousness. A curious symptom accompanying these phenomena is the sweetish odour of the breath. Meanwhile the wound, where there is one, will have ceased to discharge pus freely, becoming dry and brownish and yielding only a thin ichor ; at a dis tance from the wound one or more joints may become swollen and painful, or an abscess may form at one or more points under the skin, or there may be pustules and discoloured patches on the skin. Vund- In the examination after death the secondary abscesses may be ii ction. very various in their seat, oftenest perhaps in the lungs, under certain circumstances in the liver, or in one or more joints, or in the substance of the heart, or at the back of one or both wrists. The parotid glands are peculiarly liable to diffuse secondary in flammation. In a class of cases called septicremic for distinction, no secondary inflammations or products of inflammation can be discovered anywhere ; in these cases the periodical shivering fits are not marked, although there may be profuse sweatings from time to time. In another class of cases, to which Paget has called special attention, the course of the disease is very protracted, being marked by relapses from time to time ; and the chances of recovery are found to be in proportion to the chronicity. In the pathology of these cases attention has always been fixed on the state of the veins leading from the wounded part, and of the blood in them. The old doctrine was that the veins secreted pus from their walls, which was carried into the blood - stream. This pre-microscopic opinion has given way to the modern doctrine of thrombosis and infective embolisms elaborated by Virehow. Not only the veins leading from an external wound, but the veins of the uterus after delivery, and other internal veins under various circumstances, may become lined by a layer of coagulum, or even blocked in their entire lumen ; the coagulum undergoes puriform (although not purulent) degeneration ; pieces of it, or molecular 1 See Paget, Sury. Path.; Simon, "Inflammation," in Holmes s Sijst. of Surg. , vol. i., 2d ed. ; Sanderson, ib., vol. v. ; Cohnlieim, X eue Untersuclmnyen iiber die Entziindung, Berlin, 1872 ; Strieker, Dories, uber ally, und exper. Patholor/ie, Vienna, 1878-83, and in Aslmrst s Internal. Encycl. of Surg., vol. i., Fliilad. audLond., 1882; Van Buren, ibid. particles of it, get washed off, carried into the blood-stream, and lodged as emboia in the small vessels of a terminal vascular area of the lungs or other organ or part, where an unhealthy form of inflammation arises secondarily. These events will become more intelligible by reference to a particular case. A woman undergoes an operation for internal piles saccular dilatations of the inferior haanorrhoidal veins. The haemorrhoids had been ligatured, and for some reason there ensues an altogether unusual course of events. In a few days the patient has symptoms of pyamiia, and death follows in a fortnight. At the examination the inferior mesenteric vein, all the way up from its ligatured inferior luemorrhoidal branch to where it joins the splenic on its way to the liver, is found much dilated, lying along the left side of the lumbar vertebrae as thick as the little finger, of a greyish appearance externally, and filled with greyish puriform detritus. In the liver, to which this vein conducts, there are a number of in flammatory centres, some of them merely dark -red or livid circular areas, others of them purulent centres or true pyamiic abscesses. In this case the wall of the ligatured vein had taken on some action which had affected the clot formed naturally within it ; instead of the clot organizing, it had become a semi-iluid mass of puriform. detritus ; it had extended by continuity far up the main trunk of the inferior mesenteric vein, the puriform softening follow ing it ; particles or larger pieces of this unnatural clot had passed into the portal vein, and had become impacted in certain capillary territories of the liver, where they had infected the elements of the part (probably the connective tissue exclusively) to take oil an inflammatory and suppurative action. It is questioned by some whether there may not be a class of Infective pyaemic and septicaemia cases in which no thrombosis (with puriform throru- softening of the thrombus) of peripheral veins occurs ; but it can- bosis. not be doubted that this kind of thrombosis, and the discharge of particles or pieces of the thrombus into the general circulation, are very general accompaniments of pyremia and septicaemia, puer peral and other. The interest centres in the state of the vein-wall, which causes the blood to clot within it, where it would not other wise have clotted, and causes the clot to undergo a puriform degeneration, or to acquire an infective power. The state of the primary wound must be held answerable in general for all the secondary events, from the thrombosis onwards. In the wound the ordinary products of inflammation cease to be formed, and, instead of them, there is an ichorous foul -smelling discharge, or a dry and semi-gangrenous condition of the parts ; whatever this action may be, it communicates itself to the walls of the vessels, and the throm bosis (with detachment of the puriform particles) follows. There are certain well-understood circumstances in which wounds take on such an action : the crowding of a number of cases of suppurating wounds in a limited space without adequate attention to the removal of the putrid discharges from the wounds, great nervous prostration of the subjects of wounds, the coexistence of kidney-disease, and such-like constitutional states personal to the case. The situation of the wound or exposed surface comes also into account ; thus injuries of the bones (as in compound fractures), and especially injuries of the cranial bones, arc more liable to take the pyaemic direction. Above all, the surface of the uterus after delivery, or contused wounds of the labia, or other lacerations, will take on an unhealthy action, either from the circumstances of the patient, or owing to a very minute quantity of infective substance (cadaveric or other) having reached it from without, or from the putrescence of portions of retained placenta. The liabilities of child-bed are increased by the circumstance that the blood in the puerperal condition is unusually liable to clot in the veins, even when their walls are in good condition, and also by the fact that the venous sinuses of the uterus after delivery are such as to afford opportunities for stagnation of the blood in them (unless the vigor ous contraction of the organ have practically obliterated them), in which respect they resemble the venous sinuses of the dura mater. Experimental Septicaemia. The injection of small quantities of Experi- putrid substance into the circulation in animals, such as the dog, mental produces symptoms of septic poisoning corresponding somewhat to septic- the symptoms as observed in practice. In this experimental septic- aemia. aemia, as well as in the septic processes of man, there are many facts to show that bacteria are concerned. How these micro-organ isms are concerned is another and much more difficult question. According to one view the lowered vitality of the tissues in a certain class of injuries, or in the injuries of a certain class of subjects, gives these ubiquitous organisms their opportunity. In this view the organisms initiate nothing ; they are incidental to the morbid state of the tissues, and their presence in large numbers is rather the index of the liability to septic infection than the cause of any septic infection that may occur. The most extreme claim made for these organisms in purulent and septicsemic infection (as well as in erysipelas, ulcerative endocarditis, and diphtheria) is that their physiological activity (if not even their mechanical presence) determines the nature of the morbid process, including the tissue- changes, the type of constitutional disturbance, and, in general, the development, course, and termination of the infection. In judging XVIII. 51
