The ptomaïnes of the erysipelas streptococci often exert a favorable effect on neoplasms, causing destruction of tumor-cells. Cases of cure of sarcoma, carcinoma, lupus, lipoma, and keloid have been reported. This effect may be produced either by an attack of erysipelas, accidentally or purposely induced, or by subcutaneous injections of the filtered or sterilized cultures of the streptococci into or near the tumor. Attacks of erysipelas in patients suffering from diphtheria have often exerted a beneficial effect on that disease.

Complications are most commonly due to an added infection by pus microbes. There may be suppurative cellulitis or suppurative thrombo-pyelitis. Metastatic abscesses in the viscera may occur, especially in the brain and lungs. There may be septic inflammation of serous membranes, meningitis being the most important, due usually to infection through the sheaths of blood-vessels or nerves from the face. There may be ulcerative endocarditis or pericarditis. Pleurisy is not uncommon with erysipelas of the chest-wall. Pneumonia and nephritis are infrequent.

cases.

The prognosis is usually good except in debilitated subjects. The disease is usually fatal only by its complications. Treatment.-Prophylactic.—The patient should not be attended by those who have to do with puerperal or surgical The attendants must carefully protect any abrasions on their own persons, and must cleanse the hands frequently with an antiseptic solution. In hospitals the patient must be isolated and the ward and bedding be disinfected carefully. sary.

In private practice rigid isolation is not so neces

General treatment consists in careful nursing and feeding and in controlling annoying or threatening symptoms on general principles. Stimulants may be given freely in cases. with enfeebled heart-action, and in these cases the admin

istration of camphor in doses of gr. i-ij every hour, as recommended by Pirogoff, has been found serviceable. As a routine treatment tincture of the chloride of iron is frequently given in large doses (3ss in glycerin and water every two to three hours), but it does not seem to exert any specific effect, and its efficacy is doubtful.

Local treatment is to be resorted to in all cases, not only to relieve the local symptoms, but also to check further advance of the disease. Hueter recommends the injection of a 2 per cent. solution of carbolic acid under the healthy skin near the advancing border. Injections of weak solutions of bichloride or biniodide of mercury may be employed in like manner. Kraske recommends multiple scarification of the skin in advance of the lesion, with subsequent moist sublimate dressings. Painting the advancing margin twice a day with a 10 per cent. solution of carbolic acid in alcohol is a simple measure, and the result is often brilliant. The spread of the disease may at times. be checked by compression of the healthy skin at the periphery by adhesive straps.

To relieve the burning and itching, applications of cold water, of solutions of acetate of alumina, or of weak carbolized or sublimate solutions may be employed, but hot applications are generally more grateful and seem to exert a beneficial effect upon the disease itself. Hot lead-andopium solution or any of the above-mentioned solutions may be employed. Ichthyol in ointment or in collodion, though recommended, is not of much service.

Abscesses and suppurations are to be treated without delay on general surgical principles.

PYÆMIA.

Definition.-Pyæmia is a septic disease characterized by repeated chills, a remittent or intermittent temperature, and

metastatic abscesses in various parts of the body, due to emboli infected by the microbes of pus.

Etiology.-Pyæmia can result only from suppuration in some part of the body, the microbes of suppuration (streptococcus pyogenes and the forms of staphylococci) being necessary for its development. There must always be, in the neighborhood of the focus of suppuration, an inflammation of a vein due to the invasion of its wall by the microorganisms. This phlebitis is regularly followed by the formation of a clot in the interior of the vein; into this clot the pus microbes make their way, as the result of which the clot becomes softened and breaks down, so that small pieces containing the microbes are swept into the general circulation until they enter some vessel too small to allow their passage. Here they will become lodged, and as the nutrition of the part suffers from the cutting off of its blood-supply by the emboli, the most favorable conditions are afforded for the development of metastatic foci of suppuration.

The infecting emboli, to get into the arterial circulation, must first pass through the lungs, which act as filters. Hence the lungs are most frequently affected. If the emboli enter the arterial circulation, they may cause abscesses in any part of the body. This is the case also in malignant endocarditis, in which disease vegetations from the diseased valves containing micro-organisms become detached, are swept into the arteries, and produce metastatic abscesses in whatever part of the body they happen to lodge. The term "arterial pyæmia" is often used to designate these cases.

Should the primary focus of suppuration occur in the district of the portal vein, multiple abscesses of the liver are produced, and there may be also suppurative pylephlebitis.

In some cases the primary suppurative focus is so slight as to be overlooked. The term "idiopathic pyæmia" is

used to designate these cases. Osteomyelitis, gonorrhoea, and prostatic abscess are the conditions most frequently overlooked.

Symptoms. The symptoms of septicemia, and possibly the local symptoms of thrombosis of a vein near the suppurating wound, may precede the actual symptoms of the disease.

The onset is marked by a chill, which is repeated at regular or irregular intervals throughout the disease. The temperature rises rapidly during and after the chill to 103° to 105° F., and runs an intermittent or remittent course, its fall being accompanied by profuse sweating. There may be vomiting and diarrhoea. The pulse becomes rapid and feeble, and there is rapid emaciation. Delirium is infrequent, the mind usually being clear throughout the disease. The breath has a peculiar sweetish odor. There may be a septic erythema which is transitory. The face may be pale or there may be developed a moderate jaundice, usually of hæmatogenous origin. The spleen is usually large, and it may be painful and tender. There may be albumin and blood in the urine.

The symptoms of the metastatic abscesses depend upon their number, size, and locality. Abscesses in the lungs usually give rise to cough and dyspnoea.

Any of the serous membranes of the body may become secondarily affected, and septic involvement of the joints (pyæmic rheumatism) is common.

The prognosis is always grave. Almost all patients die in a few weeks. In rarer cases the disease may be protracted for months.

Diagnosis. The three conditions with which this disease is apt to be confounded are malaria, typhoid fever, and acute miliary tuberculosis.

In malaria the chills, fever, and sweating occur with more

regular periodicity, are checked by quinine, and in the blood the plasmodium malariæ can be found.

A careful review of the case, the occurrence of spots and abdominal symptoms, and the course of the disease distinguish it from typhoid fever.

In acute miliary tuberculosis the symptoms are more those of septicæmia: there are usually evidences of tubercular foci, and bacilli are usually present in the sputum.

Treatment consists in the aseptic treatment of all wounds, the early evacuation of abscesses if possible, and supporting the strength of the patient by feeding, nursing, and the administration of alcoholic stimulants in full doses. Quinine in large doses may be found of temporary benefit in controlling the fever, but it is of no actual service in modifying the disease itself.

SEPTICEMIA.

Definition and Synonym.-Septicemia is the train of symptoms resulting from the introduction into the circulation of septic micro-organisms or their ptomaïnes. Synonym: Sepsis.

Septicæmia occurs in two distinct forms:

1." Septic intoxication is caused by the absorption of a pre-formed ferment or toxine which produces the maximum effect as soon as it reaches the circulation, and the symptoms subside with the arrest of further supply and the elimination of the septic material from the circulation.

2. "Septic infection, on the contrary, occurs in consequence of the introduction into the circulation of living micro-organisms which multiply with great rapidity in the blood-a circumstance which imparts to this form of septicamia its progressive character" (Senn).

Clinical Forms.-I. FERMENTATION FEVER (Resorption fever, Aseptic fever, or After-fever) is that form of septic in