In nearly all cases, when the origin of the constitutional disease cannot be traced to the introduction of diseased fluid into the system through an open vein, it will be found that the part primarily injured has wanted the degree of vigour, requisite to establish and maintain healthy adhesive inflammation.
Upon another occasion,[31] I have endeavoured to show that, where lymph is effused around a poisoned wound, the virus will find its way less easily along the absorbent vessels, than when no such effusion has taken place; and that when, in such a wound, the effusion of lymph is checked or prevented, as by the administration of mercury, a larger proportion of cases will indicate an affection of the lymphatic system, than when the natural process has not been interfered with. There can be little doubt, that the same principle may be observed with regard to ordinary wounds. The number of cases in which the absorbents inflame, will be in inverse proportion to the number of those in which the original wounds are circumscribed by healthy adhesive inflammation. In Case xxvii, it is mentioned, that the surface of a muscle, implicated in the original lesion, was as cleanly dissected as if done with a scalpel, thus showing the total absence of any surrounding effusion of lymph. The absence of, or defect in, the process of adhesion may thus be associated with inflammation of the absorbents, as the want of "union by first intention" has been shown to be connected with inflammation of the veins (Section ii.)
The minuteness of the absorbent vessels, and the changes which their contents undergo in their glands, prevent any unhealthy fluids from being as readily recognised in them as in the veins. But when the progress of inflammation can be traced along these vessels from a wound, towards the centre of the circulation, marked, as it often is, at intervals, by the formation of abscesses, we cannot doubt that an irritating fluid has found its way along their canals: and when the constitutional symptoms, which arise at the same time, terminate in the formation of purulent deposits (as in Case [xxix]), we cannot but admit that the absorbent vessels are the direct means by which, in such cases, diseased secretions are poured into the blood, and the system becomes infected. It would, therefore, appear that there are two principal conditions, under which local disease may produce a general infection of the system by the direct introduction of vitiated fluids into the blood. The first of these is connected with defective union in injured veins; the second is associated with want of healthy adhesion in inflamed lymphatics.
The period of invasion of the attack differs in some degree in the different classes of cases, but it is generally marked with great precision: even when apparent recovery has been followed by a second attack, the occurrence has in each instance been accurately noted by the sudden appearance of constitutional symptoms (see Case [xxxvii]).
When one of the large veins has been originally affected, the period which elapses before symptoms of infection of the system manifest themselves, is comparatively short (Case [i]). In cases occurring after child-birth, it is usually longer, extending to the end of the second week. After surgical operations or accidents involving some portion of bone, the access of the disease will be marked by a rigor during the third or fourth week; and finally, when the absorbent system is primarily affected, the period of the occurrence of the constitutional symptoms may be much farther removed from that of the original injury (if any such existed), and is by no means so accurately defined.
At the time of the occurrence of the general disturbance of the system, the local injury or wound will generally put on an unhealthy appearance. The skin in the immediate neighbourhood will sometimes assume a dull brownish-red appearance, which will gradually fade into the colour of the surrounding parts. This symptom will usually commence near the termination of the vessels, which are derived from the same trunk as those which supply the injured part. When the original injury is complicated with a wound upon the surface of the body, it will usually become dry and glazed, and the blush upon the skin will commence in its neighbourhood, or a short distance from it, and will usually extend towards the centre of the circulation, without presenting any very defined margin: occasionally it will extend, in the form of erratic erysipelas, over a large part of the body.[32]
IX. The commencement of constitutional disease, after direct infection of the blood, is marked by a sudden change in the manner and appearance of the patient; a severe rigor is usually the most prominent symptom, and is followed by much febrile excitement, or by extreme depression; a very peculiar heat of skin (Case [xxii]) will sometimes be present, while, at other times, the surface will be covered by a profuse clammy perspiration. The rigor may be repeated at irregular intervals, but occasionally it will recur about the same hour for three or four days in succession (Case [xxxvii]); and in a few instances it will not be observed at all.
Great depression frequently accompanies even the first stages of this disease, indicated by a want of tone in the pulse, by an extremely listless manner, and sometimes by a tendency to syncope (Case [i]). The countenance becomes anxious, the tongue dry and brown in the centre, and red at the edges, or, in other instances, it presents a coating of a pasty yellowish-white colour; a dusky yellow hue frequently pervades the skin, and sometimes the conjunctivæ of the eyes. This may or may not depend upon an accompanying affection of the liver. The pulse varies much in frequency in different cases, and at different times in the same case: generally it is very rapid, especially when accompanied with much heat of skin.
The pain is sometimes severe, and may be referred exactly to the spot which subsequent examination shows to have been the seat of secondary inflammation; at other times it is not confined to any particular situation, but consists of general ill-defined feelings of short duration, and recurring at irregular intervals. The peculiarity of such sensations is best expressed by the terms applied to them by the patients themselves. "Catching pains all over", "soreness of the stomach", and "thrilling in the blood", not unfrequently accompany this disease.
Vomiting may occur, either as a symptom of constitutional disturbance, or as indicative of inflammation of an abdominal organ (Case [xxvi]). In the latter case, it is extremely obstinate, and the fluid ejected is generally of a green colour. Diarrhœa is a symptom of frequent occurrence, and appears to exercise a considerable influence on the course of the disease. Its appearance will not unfrequently be accompanied by relief of the other symptoms (Case [iii]); when it occurs, it is generally profuse, and little under the control of medicine, but, if checked, may be followed by a sudden change for the worse in the condition of the patient.