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the blood contains toxines, but not organisms. In septic infection the blood contains both toxines and organisms, the bacteria multiplying in it. The symptoms of sapræmia depend on the dose. In septic infection only a small number of organisms may get into the blood, but they multiply enormously. The pus microbes cause true septicæmia, and reach the blood chiefly through the lymphatics, but to some degree by penetrating the walls of vessels. A drop of blood from a man with septic infection will reproduce the disease when injected into the blood of an animal; hence it is a true infective disease. The wound in such cases is often small.

Symptoms.-The type of this condition is met with in puerperal septicemia or a poisoned wound. It begins, in from four to seven days after labor or an injury, with a chill, which is followed by fever, at first moderate, but soon becoming high. The fever presents morning remissions and evening exacerbations, and may occasionally show an intermission. The pulse is small, weak, very frequent, and compressible. The tongue is dry and brown with a red tip. The vomiting is frequent, and diarrhoea is the rule. Delirium alternates with stupor, and coma is usual before death. Prostration is very great. Toward the end the face often becomes Hippocratic (p. 79). Congestions occur. Ecchymoses and petechiæ are noted, secretions dry up, urinary secretion is scanty or is suppressed, and the wound becomes dry and brown. Blood-examination detects disintegration of red globules. When a wound inaugurates septicæmia, red lines of lymphangitis are seen about it and there is enlargement of related lymphatic glands. No thrombi or emboli exist in septicæmia. The prognosis is bad, and death may occur within twenty-four hours. The treatment is the same as for septic intoxication.

Pyæmia.-Pyæmia, which is septicemia plus metastatic abscesses, is characterized by fever of an intermittent type

and by recurring chills. It is not due to pus in the blood, but to the taking up of clots infected by streptococci and staphylococci.

In an area of suppuration there are coagulation necrosis, thrombosis, and septic inflammation of the adjacent vessels, and the thrombi are infected. A vessel-thrombus reaches up to the first collateral branch, and the apex of the purulent clot is broken off by the blood-stream from that branch and is carried as an embolus into the circulation. Many of these poisonous emboli enter into the blood and lodge in some vessels which are too small to transmit them, and at their points of lodgment form embolic, secondary, or metastatic abscesses. Wounds of the superficial parts and bones produce pyæmic infarctions or metastatic abscesses of the lungs. When these infarctions break into fragments particles may return to the heart and lodge there, or may be sent out through the arterial system to form another focus in the kidneys. Infected areas connected with the portal circulation (intestinal injuries or suppurating piles) produce abscess of the liver. Malignant endocarditis is called "arterial pyæmia," and is due to endocardial embolic infection. In this disorder infected emboli lodge in the kidneys, the spleen, the alimentary tract, the brain, or the skin (Osler). Idiopathic pyæmia is a misnomer. Some primary focus of infection must exist (often in the ear).

Symptoms.-The wound becomes dry, brown, and offensive. A severe and prolonged chill or a succession of chills usher in the disease; high fever follows, and a drenching sweat. These chills recur every other day, every day, or oftener. After the sweat the temperature falls and may become nearly normal. The general symptoms of vomiting, wasting, etc. resemble those of septicemia. The skin becomes jaundiced, and a profound adynamic state is rapidly established. The spleen is enlarged. The lodgment of em

boli produces symptoms whose nature depends upon the organ involved. Lodgment in the lungs causes shortness of breath and cough with slight physical signs. Lodgment in the pleura or pericardium gives pronounced physical evidence. Lodgment in the spleen produces severe pain and great enlargement. The parotid gland not unusually suppurates (as in the case of President Garfield).

In a suspected case of pyæmia always look for a wound, and if this does not exist, remember that the infection can arise from gonorrhoea, osteo-myelitis, suppuration of the middle ear, or abscess of the prostate. Chronic pyæmia may last for months; acute pyæmia may prove fatal in three days. The complications are joint-suppuration, bronchopneumonia, pleuritis, endocarditis, pericarditis, peritonitis, venous thrombosis, and abscesses.

Treatment is the same as for septicæmia. Open, drain, and asepticize any wound and any accessible secondary abscess.

X. ERYSIPELAS (ST. ANTHONY'S FIRE). Erysipelas is an acute, contagious, capillary lymphangitis due to the streptococcus of erysipelas, which grows and multiplies in the smaller lymph-channels of the skin and of serous and mucous membranes. It is characterized by a remittent fever and a tendency to recur. It is always due to a wound. Idiopathic erysipelas is due to a small wound which escapes notice. It may or may not suppurate. Suppuration, some say, does not require a mixed infection, as the streptococcus is identical with the streptococcus pyogenes (Osler, Koch); others think suppuration does require mixed infection, the streptococcus not being pyogenic. Erysipelas is most common in the spring and fall, and is most usually met with among those who are crowded into dark, dirty, and ill-ventilated quarters; it attacks by preference the debil

itated and broken-down (as alcoholics and sufferers from Bright's disease). The poison of erysipelas will produce puerperal fever in a lying-in woman.

Forms of Erysipelas.-Ambulant, erratic, migratory, or wandering erysipelas is a form which tends to spread widely over the body, leaving one part and going to another. Bullous erysipelas is attended by the formation of bullæ. In diffused erysipelas the borders of the inflammation gradually merge into healthy skin. Erythematous erysipelas involves the skin superficially. Metastatic erysipelas appears in various parts of the body. Puerperal erysipelas begins in the genitals of lying-in women, producing puerperal fever. Erysipelas simplex is ordinarily cutaneous. Erysipelas neonatorum begins in the unhealed navel of a new-born child and spreads from this point. Typhoid erysipelas occurs with profound adynamia. Universal erysipelas involves the entire body. Phlegmonous erysipelas involves the skin and subcutaneous tissues, with suppuration, and often with gangrene. Edematous erysipelas is a variety of phlegmonous erysipelas with enormous subcutaneous œdema. Lymphatic erysipelas is characterized by rose-red lines of lymphangitis. Venous erysipelas is marked by the dark color of venous congestion. Mucous erysipelas involves a mucous membrane. Black tongue is erysipelas of the fauces. Clinical Forms.-The clinical forms are cutaneous erysipelas, cellulo-cutaneous or phlegmonous, and cellulitis.

Cutaneous erysipelas is ushered in by a chill which is followed by fever and sweat. Any wound which exists becomes dry and unhealthy, and its edges redden and swell. This combination of redness and swelling extends, and its area is sharply defined from the healthy skin. In the hyperæmic area vesicles or bullæ form, and oedema affects the subcutaneous tissues, producing great swelling in regions where they are lax (as in the eyelids). The anatomically

related lymphatic glands become large and tender, and between them and a wound are seen the red lines of inflamed lymphatic vessels. Erysipelas spreads at its periphery and fades at its point of origin. When spreading stops the swelling and redness gradually abate, and after they disappear desquamation takes place. Cutaneous erysipelas rarely suppurates, but may do so. The fever is remittent, and usually

terminates in four or five days by crisis.

In strong subjects the symptoms are usually slight. In the old, debilitated, or alcoholic the symptoms are typhoid, delirium comes on, and death is apt to occur. Possible complications are meningitis, pneumonia, septicæmia, endocarditis, and albuminuria. Erysipelas neonatorum is generally fatal.

Treatment.-Isolate the patient and asepticize any wound. Cases of cutaneous erysipelas tend to get well without treatment. If a person is debilitated, stimulate freely. Tincture of chloride of iron and quinine are usually administered. Nutritious food is important. For sleeplessness or delirium use chloral or the bromides; for high temperature, cold sponging and antipyretics. To prevent spreading, inject the healthy skin near the blush with a 2 per cent. carbolic solution or with gr. of corrosive sublimate. Locally, paint the inflamed area with equal parts of iodine and alcohol and apply lead-water and laudanum. If an extremity be involved, bandage it. Another good treatment is a 50 per cent. ichthyol ointment with lanolin. Some use iced-water cloths. Others apply borated talc or salicylated starch. Ringer advised painting every three hours with a mixture composed of gr. xxx of tannic acid, gr. xxx of camphor, and giv of ether. Da Costa recommends pilocarpine.

Cellulo-cutaneous or phlegmonous erysipelas is characterized by high temperature (104°-106°), the rapid onset of grave prostration, irregular chills, sweats, and a strong tendency to delirium. The parts are not so red as in the pre

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