which is the site of a suppurative inflammation may collect in pockets and recesses and become putrefied. Or a focus of inflammation (suppurative or serous) may open spontaneously or be incised, and the discharge will have a bad odor, due to decomposition caused by the saprophytes. In both of these instances there are supposed to be no constitutional symptoms present. Retained bloodclots may also putrefy.

What are the processes due to saprogenic bacteria and accompanied by constitutional symptoms?

These are all known as varieties of septic intoxication, and will be at once taken up in detail.

What is septic intoxication?

Septic intoxication is an abnormal condition of the general system manifested by certain symptoms, and due to the absorption, by the vital centres of the body, of the ptomaïnes of the saprogenic bacteria. And these ptomaïnes, as has already been stated, are taken into the blood from the wound or other point of putrefaction or fermentation, wherever that may be.

What are the two main varieties of septic intoxication ? Fermentation fever and sapræmia. The former is also called aseptic fever or primary wound-fever.

Describe fermentation fever.

This is the mildest form of septic intoxication. It occurs at times with wounds that have been made during an operation, and which have received the most careful aseptic treatment. It is rarely met with under other circumstances, except occasionally in simple fractures. There are no symptoms other than fever and a corresponding rise in the pulse rate. The fever comes on a few hours after the completion of the operation, runs rather high (102° F. on an average), and disappears at the end of forty-eight hours, and the patient feels perfectly well in the mean time.

What is the condition of the wound?

It is that of all wounds which are healing by primary union. There is no inflammation present.

What are the causes of fermentation fever?

Although the wound is healing by primary union, there is still enough exudation and molecular necrotic tissue present in and on the opposed surfaces to form a focus for a mild fermentative action

of certain saprophytic bacteria which have gained access to the spot. And it is to the absorption of certain ferments, notably fibrin-ferment, which are the results of this fermentative action, that this fermentation fever is due.

What is the treatment?

There is no treatment for the fever itself, save watching for a day or two for the symptoms of septicemia. The wound should be left alone. A mild purge may be given. Preventative measures consist in careful stoppage of all hemorrhage at the time of the closing of the wound, for the reason that bloody discharge, if retained, is a very favorable medium for the action of these sapròphytes.

What is sapræmia ?

Sapræmia is that form of septic intoxication in which there are marked constitutional symptoms and a more or less severe local putrefactive process.

What are the general symptoms of sapræmia ?

They are practically those of septicemia. A differential diagnosis based on symptoms alone could not be made. If the case is severe, then all the symptoms are present; if less severe, then some may be present and others not, etc., just as in the case of septicæmia.

Mention some of the local putrefactive processes which cause sapræmia.

Any gangrenous inflammation, such as noma, anthrax, acute spreading traumatic gangrene, malignant oedema, etc. In these cases we really have a mixture of septicemia and sapræmia, because, locally, we have both an inflammation and a putrefactive process. Again, psoas abscesses frequently, if not always, have a foul odor; hence showing the presence of saprophytes. Here we have an instance of a suppurative inflammation combined with putrefaction of its exudate, and in like manner the general symptoms of psoas abscess are really due to both septicemia and sapræmia. Examples of pure sapræmia are never met with, for the reason that, clinically, all foci of putrefaction have more or less inflammation of the surrounding tissues, and of course it is doubtful how much the bacteria of this inflammation contribute to cause the constitutional symptoms. However, there are cases in which we can disregard this accompanying inflammation, and practically call

them sapræmia. Examples: A hæmatoma is sometimes conjoined with severe general symptoms. On opening the swelling the retained blood is found to be decomposed and possessing a very bad odor. Similarly, certain forms of "puerperal fever" are due to decomposed fragments of placenta and blood-clots remaining in the uterine cavity. To conclude: The only positive way of making a clinical diagnosis of sapræmia is by the sense of smell. The amount of bad odor in any given focus determines the degree of putrefaction. If the odor is very bad and the inflammation slight, it is sapræmia; if with a bad odor there is present considerable inflammation, the case is one of sapræmia and septicemia combined; and if the odor is slight or absent and the amount of inflammation considerable, then the constitutional symptoms are to be regarded as due to septicemia alone. Pyæmia, of course, may be similarly complicated with sapræmia.

What is intestinal toxæmia?

It is that form of sapræmia in which the focus of putrefaction is located in a mass of decomposing fæces, and from which the ptomaïnes are absorbed into the system through the intestinal mucous membrane. Marked general symptoms may thus be produced. Hence the importance of having the bowels well cleared, and of always inquiring into their condition whenever the patient's temperature rises.

What is the treatment of sapræmia?

Local and general, and on exactly the same lines as already laid down for that of septicemia. There is a point to be noticed in this connection-viz. other things being equal, the constitutional symptoms of sapræmia subside much more quickly after thorough drainage of the point of local disturbance than do those of septicæmia. The reason is that the ptomaïnes, being manufactured only on the spot, are carried off, and thus the system is relieved of the infection; while in septicemia, it will be remembered, the pathogenic bacteria form their leucomaïnes not only on the spot, but also in the system at large. Hence a longer time is required for elimination, and recovery.

DISEASES OF THE CONNECTIVE-TISSUE PLANES.

What are the inflammations of the connective-tissue planes? They comprise two main divisions, specific and non-specific. Of the specific inflammations we have erysipelas, anthrax, glanders, tuberculosis, syphilis, actinomycosis, myxedema, and leprosy. The non-specific are serous, suppurative, and gangrenous inflammations. The non-specific group will be considered first.

Describe suppurative inflammation of the connective-tissue planes. This occurs in one of two ways-viz. diffuse and circumscribed. If the former is present, the process is called simply suppurative cellulitis; if the latter, the term abscess is used. Hence an abscess is really a circumscribed suppurative cellulitis. An abscess may be acute or chronic.

The above of course refers to "idiopathic" suppurative cellulitis, or that variety which occurs without any visible traumatism. Suppuration occurring in wounds is the same process. In fact, a wound which is suppurating may be regarded as an abscess with the incision already made.

What is the pathology of an acute abscess?

As a result of any one of the "original" causes of inflammation already discussed, one or more of the varieties of the staphylococci set up a focus of suppurative inflammation in a given region of the connective-tissue planes. This process continues, more and more pus accumulates, and the "abscess" enlarges in the direction of least resistance. Accompanying this process is, of course, actual destruction of the elements of the original connective tissue, or a "destructive inflammation," and this occupies an area immediately surrounding the pus. Beyond this is still another zone of connective tissue which is more or less thickened, and which, as the pus accumulates, in its turn breaks down or becomes the seat of a "destructive inflammation." This thickened zone means merely that a "productive" inflammation has taken place, and it constitutes the so-called "wall" of the abscess. The inner portion of this zone, before it breaks down, is changed into granulation tissue. This is the name given to connective tissue in the adult when its structure is the same as that of connective tissue in the embryo. In the process of repair (which see) there is, speaking in a general way only, first, loss of tissue; secondly, granulation tissue;

and, lastly, fully-formed tissue. Conversely, in the process of destruction we have first normal tissue, which, after becoming somewhat thickened, is changed to granulation tissue, which in its turn is destroyed.

Finally, if left to itself the pus reaches the skin, which in like manner becomes first thickened and then destroyed; the pus escapes, and the abscess is said to have "opened spontaneously."

What is the pathology of a chronic abscess?

Occasionally a regular non-specific abscess is met with which is chronic; that is, certain symptoms are absent which are found accompanying an acute abscess. The pathology of such an abscess is the same as that already given.

Usually, however, a chronic abscess is an example of "mixed infection;" that is, suppurative inflammation has been added to or set up in a focus of a preceding specific inflammation, which, in the great majority of cases, is tubercular, but may be syphilitic. In such abscesses the process differs from the foregoing only in the following respects: If the original inflammation is tubercular, then the "thickened zone" is largely made up of, and infiltrated by, tubercular tissue, and the surface of this zone, which is in contact with the pus, is covered by a layer of this same tubercular tissue, often called "gray-granulation" tissue. This layer may be quite thick, and if so constitutes the " pyogenic membrane " of some authors. Furthermore, the pus contains the detritus of this layer as it breaks down, together with the tubercle bacilli.

If the original inflammation is syphilitic, the new tissue is naturally that due to the influence of the syphilitic virus, but the “pyogenic membrane" is much less marked.

Of course a tubercular or syphilitic focus may be infected by acute suppuration.

Finally, after opening such a chronic abscess, almost always there will be found a sinus leading from its cavity to either an area of tubercular bone-inflammation or one or more tubercular lymphatic glands.

What are the symptoms of an acute abscess?

Pain, swelling, heat, and redness of the skin, tenderness, fluctuation, and impaired function of the part in which the abscess is situated. If the abscess is deeply placed, fluctuation may not be detected. The other symptoms of course vary in degree and severity.