of course, is nothing but a kind of septic infection. Indeed, some speak of this "true septicemia" as "true septic infection," in contrast to "ordinary septicemia," which they call simply "septicemia."

CLASSIFICATION OF BACTERIA.

Give the usual method of classifying bacteria.

As we have seen, the second and third classes of bacteria are each of them pathogenic, and, as we have also seen, in each of these classes there are both specific and non-specific bacteria. Furthermore, it has been made clear that some specific bacteria cause local inflammation with or without the constitutional symptoms of inflammation, and that other specific bacteria (e. g. tetanus) cause only certain constitutional symptoms without any local ones. This has also been shown to be true for the non-specific bacteria as well. From this point of view, then, which differs only in the grouping of the bacteria of the second and third classes, we have the following usual method of classification :

From the foregoing it is clear how inflammations may be divided into the specific and non-specific varieties, already referred to under Classification of Inflammations.

Define mixed and secondary infection.

(a) Mixed Infection. This means that there are two processes, or even more, going on at the same time, and not only that, but that these processes probably began at the same time. For exam

ple, some cases of erysipelas begin to suppurate very soon; that is, a non-specific infection (pus) gets mixed in with a specific infection (erysipelas), or glanders may, and often does, present suppurating foci from the very beginning. When a marked interval of time occurs between the onset of the first disease and the supervention of the other, then we call it a case of (b) Secondary infection.

Any of the septic diseases, when pathogenic (specific or nonspecific) or non-pathogenic, may complicate each other. This explains the presence of pus or other discharges in a tubercular or syphilitic process; also in the same way is explained the presence of putrefaction in a part which was previously undergoing a suppurative or serous or hemorrhagic inflammation; and in like manner the fact is made clear how a tubercular inflammation may take place in tissues previously thickened and altered by non-specific productive inflammation, etc. etc. Gonorrhoea is perhaps the best example of pure mixed infection, for it practically always has pus and its microbes from the beginning in addition to its own gonococcus. Finally, it is to be remembered that all inflammations, medical as well as surgical, can be brought under this classification and are susceptible of mixed or secondary infection; that the putrefactive processes or "diseases" are always accompanied by more or less inflammation of one kind or another; and that very many inflammations may have an accompanying putrefactive or fermentative process, slight or severe as the case may be, especially those inflammations whose exudate is copious and has not free drainage. Hence "ordinary septicemia" may often be really mixture of septic infection and septic intoxication.

SPECIAL VARIETIES OF INFLAMMATION.

a

Under this heading will be discussed briefly, and in a general way only, each of the various kinds of inflammation already referred to. The above Table of Classification will be followed.

What are the non-specific inflammations?

They are those inflammations which are caused by the nonspecific pathogenic bacteria, and each one may be "exudative" or "productive."

What can you say as to non-specific productive inflammation?

This inflammation means simply an increase in the elements of the tissue-structure of the part affected and, in the viscera and various membranes, especially of their connective-tissue portions. (The purely pathological question as to whether, in such an inflammation, the cells or the intercellular substance or the fibres are increased or not, will not be discussed). It is common in the connective-tissue planes, in the female breast, in the joints, in the arteries, in the bones, and in the various viscera. Its symptoms vary according to its location. It may be primary, but it is generally secondary to one or other of the exudative inflammations. Its course is chronic as a rule, and its tendency is toward resolution after the subsidence of the primary inflammation.

What are the non-specific exudative inflammations?

These comprise the serous, the fibrinous, and the sero-fibrinous; the catarrhal and croupous; the suppurative and purulent; the hemorrhagic. The first three may occur in joints, in the peritoneum, and in the pleura. Of these, the serous may be present in any part of the body, and is a very common affection of the connectivetissue planes. The catarrhal variety is met with frequently in the joints as a synovitis. It is also very often found involving the mucous membranes, and then there is more or less mucus mixed with the exudate. Croupous inflammation is almost always situated on mucous membrane. Suppuration, or suppurative inflammation, may attack any organ in the body, the connective-tissue planes being a very common site. It is usually acute, but may be chronic. Certain varieties of pleuritis or of synovitis are purulent. But, practically, these may be regarded as mild forms of suppuration. Hemorrhagic inflammation occurring by itself is extremely rare surgically, because it is usually associated with gangrene or death of the tissues which it invades. For this reason it is called gangrenous inflammation. As met with commonly it is essentially an inflammation of the connective-tissue planes, involving in its course muscles, blood-vessels, and nerves according to its extent and severity. The same gangrenous inflammation at times affects the lungs, and, of course, may affect any portion of the body.

Hemorrhagic inflammation without gangrene is met with at times in the peritoneum, pleura, and pericardium.

What are the special or local symptoms of these non-specific exudative inflammations?

They vary according to the location and the variety of each. Hence we will postpone the discussion of the symptoms, treatment, special pathology, etc. of each of these inflammations until we meet it as actually occurring in some definite part of the body, as in the connective-tissue planes, the bones, the joints, etc.

What are the specific inflammations?

They are those inflammations which are caused by the specific pathogenic bacteria, and, like the non-specific, each may be "exudative" or "productive."

What may be said as to the specific exudative inflammations?

For purposes of clearness it may be said that the actual varieties comprise the same list exactly as was given of the non-specific exudative inflammations, with the exception of the suppurative and purulent. But, strictly speaking, each one of these specific exudative inflammations, as a rule and as met with clinically, should be regarded as a case of mixed or secondary infection (which see). In other words, the inflammation originally is specific-i. e. caused by a specific microbe-but sooner or later there are added non-specific bacteria, which aggravate and extend the process. This mixed infection, however, may not in some cases take place. Give examples of specific exudative inflammations.

Specific serous inflammation occurs in the cellular layer and in and about the lymphatics of the skin as part of the lesion of erysipelas. Later on, suppuration may complicate the process. Specific fibrinous and sero-fibrinous inflammations are found in the serous and synovial membranes, in the former situations as part of the lesion of a tubercular peritonitis or pleuritis, and in the latter as partaking of the morbid condition of a tubercular, rheumatic, or gouty synovitis. Specific catarrhal inflammation is the essential lesion of gonorrhoeal synovitis, as is specific croupous inflammation of diphtheria. Specific hemorrhagic inflammation is seen, surgically, in connection with gangrene or death of tissue in a manner precisely similar to that of non-specific hemorrhagic inflammation, and for a similar reason should be called specific gangrenous inflammation.

This is met with in anthrax, and in the rather rare form of erysipelas known as erysipelas gangrenosum.

What are the specific productive inflammations?

There are several special varieties of these, thus presenting a contrast to non-specific productive inflammation, which is practically always one and the same process.

Give examples.

Tubercular, syphilitic, and actinomycotic inflammations; also leprosy. The first three are commonly spoken of as tuberculosis, syphilis, and actinomycosis respectively. These four inflammations are primarily diseases of connective tissue, and will be dealt with more fully in speaking of the inflammations of the connective-tissue planes. They may occur in any part of the body, are usually primary, are chronic in course, and are generally of an unfavorable prognosis, actinomycosis being an exception in this last regard.

What are the special or local symptoms of the specific inflammations?

The consideration of symptoms, together with the special pathology, treatment, etc., of each inflammation, will be taken up later in discussing, under their several headings, the various tissues as affected by these inflammations.

SEPTIC INFECTION.

The above, in a general way, finishes the inflammations from a local standpoint. But on referring to the Table of the Classification of Bacteria we observe that there are, in addition to the inflammations, still other morbid processes to be considered which are also due to bacteriological action.

What are these processes, other than inflammations, due to bacteriological action ?

They comprise two main classes-viz. 1, those due to pathogenic bacteria; 2, those due to saprogenic bacteria.

What are those due to the pathogenic bacteria ?

They may be subdivided as follows:

(a) Certain constitutional diseases occurring without appreciable local symptoms;