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pulmonary tuberculosis. Modern pathology teaches that erysipelas is due to the entrance into the organism of toxic agents that produce inflammatory conditions of the skin through an open wound; hence this disease is liable to occur in the puerperal state. It has sometimes resulted from a small crack in the skin at the angle of the nose or at the mouth, or from a scratch upon the face; from the piercing of the ears for earrings or from the ulceration about a carious tooth. In some instances the point of entrance of the specific agent can not be found.

Exciting Cause.-This disease is due to the streptococcus erysipelatos of Fehleisen. (For a description of the germ see p. 101.) Since the discovery of this germ the division into idiopathic erysipelas must be entirely abandoned.

It has not been shown to be transmissible by the air, having occurred without obvious traumatism, abrasions, or inoculations, and may enter the organism by the respiratory surfaces. Most cases occur in the spring of the year. Occasionally, a house epidemic has occurred.

Pathology. When the specific germ gains entrance into the tissues, it produces the phenomena of severe inflammation. These changes may extend to the subcutaneous tissues. Occasionally, the inflammatory changes will go on to the point of suppuration. The inflammatory process is usually circumscribed. Postmortem appearance will reveal, besides the local lesion, evidences of granular degeneration of the internal organs, such as the heart, kidney, and liver. These changes

are, as a rule, produced by the toxins, the organism rarely gaining access to the blood-corpuscles. In such an event suppurative changes are produced. A marked leukocytosis of an inflammatory character is present.

Period of Incubation.-From three to seven days; in artificial inoculation, from fifteen to sixty hours.

Symptoms.-The disease usually begins with a chill, which may be mild or severe, and is followed by the development of the eruption. With this there are usually gastric distress and some febrile reaction (the temperature not being characteristic), with the signs of an irritative, itchy, swollen skin at the point at which the eruption begins. There are heat, tension, and burning in the part. The eruption shows a decided elevation with a distinct prominent margin, red and puffy in the center. It is irregularly circumscribed, and there is an abrupt descent to the level of the surrounding skin. The

involved area is discolored, of a bright crimson color, and glossy in appearance.

The skin is hot and tender, but firm and smooth. For two or three days the area extends uniformly but irregularly; the margins, however, being always abrupt, well-defined, and circumscribed. In mild cases, after two or three days the eruption may become stationary and the process undergo resolution, with a remission in the fever, desquamation of the inflamed area, subsidence of the edema, and the color changing from a bright red to a bluish purple or light brown. The desquamation occurs in scaly masses. In mild cases the eruption may show no tendency to spread, but may remain where it first appeared, involving the whole face or side of the scalp, and terminating in recovery in from two to three weeks. In the severer cases the inflammation spreads over wider surfaces and invades the adjacent skin, leaving the portions in the center pale and red and undergoing desquamation.

If bullæ are formed, serum is thrown out under the epidermis, or if the inflammation has been severe, true blisters occur. The fluid in such cases is limpid, of a straw color, and may be purulent. As resolution takes place crusts are formed that gradually break down. In malignant cases areas of gangrene form, the skin repairing by sloughing and cicatrization. If the erysipelas travels over a considerable area, disappearing at one point and appearing at another, it is known as "erysipelas ambulans," or "wandering erysipelas." This is much more serious, and the affection is likely to terminate fatally, although the process may be prolonged over a series of weeks.

In severe cases in which the affection appears upon the face the eyes are closed, the lips project, the ears are shapeless and cushiony, the nose is deformed, the cheeks encroaching upon it, and secretions may collect at the corners of the eyes, mouth, or nose. The whole face is painfully distorted and deformed. The tongue is coated with a yellowish fur, becoming dry and glazed and of a reddish hue. In severe cases marked nervous symptoms develop, delirium, coma, subsultus tendinum, and carphology, and the temperature may rise to 106° F. or higher.

In fatal cases hemorrhages take place in the blebs upon the skin, and gangrene makes its appearance. This may occur in infants, in the aged, in those subject to chronic alcoholism, and in cachectic individuals.

The disease commonly starts from the point of the ear, tip

of the nose, from a point of vaccination, or from ulcers upon the lower extremities. The bowels are usually constipated. The urine has the character of febrile urine, and even in mild cases true albuminuria occurs early in the course of the dis

ease.

Surgical Erysipelas.-Surgical erysipelas rarely occurs in these days of antiseptic methods.

Complications and Sequels.-Complications and sequels are not numerous. Albuminuria occurs in serious cases, and always when the temperature is high. Uremia has occasionally been noted. After erysipelas of the scalp there is alopecia, and seborrhoea sicca may occur, which gives rise to permanent baldness. Abscess occurs, and lymphangitis has been noted. Arthritis may result from the extension from the skin to the joint tissues. Peritonitis and malignant endocarditis. have been seen as sequels.

Diagnosis.-Depends upon the occurrence of the eruption with well-defined margin, showing tendency to spread, occurrence of fever, and constitutional symptoms.

Prognosis. In simple uncomplicated cases occurring in those in previous good health, prognosis is favorable.

Prognosis should be regarded as serious when erysipelas occurs as a complication of any other malady or from surgical accidents or in the puerperal state. It is always serious in cachectics and in alcoholics.

Treatment.-Prophylaxis is that of the infectious diseases in general. In hospitals erysipelas is isolated and treated in separate wards, as the disease is mildly contagious. Treatment should be directed to the alleviation of the principal symptoms. Free purgation is useless and unsafe, but gentle laxatives at the onset are of advantage.

Water, especially cold water, should be liberally administered to the patient, and cold spongings, especially if the temperature is high, are of distinct advantage.

For the eruption the best treatment consists of iced cloths, frequently renewed, kept over the eruption. An ointment of ichthyol and lanolin is also used for this purpose, but this is smeary and the benefit derived is questionable. Collodion may be painted over the eruption with good result. There is no specific treatment.

Tincture of chlorid of iron in full doses is the general method of treating erysipelas. It is, however, questionable whether any good has been obtained from its use. In severe

cases the hypodermic use of pilocarpin, as first advised by Da Costa, is of distinct benefit, if cautiously used. The physiologic effect of pilocarpin should be obtained, but a stimulant should be administered at the same time, on account of the depressing effects of the pilocarpin on the circulation. When nervous symptoms become prominent, or in the aged or cachectic, bold stimulation is necessary. Alcohol is best for this purpose. If the pain be severe, the hypodermic injection of morphin should be resorted to. Systematic and liberal administration of nourishment must be insisted upon in severe cases. Antistreptococcic serum may be beneficial, and may be resorted to, especially in malignant cases.

FEVERS WITH MARKED LOCAL MANIFESTATIONS.

CROUPOUS PNEUMONIA.

Definition. An acute, infectious, febrile disease, with a characteristic local pulmonary lesion and marked constitutional symptoms.

Synonyms. Lung fever; lobar pneumonia; fibrinous pneumonia; pleuropneumonia; pneumonitis.

Etiology. Predisposing Cause.-Climate is a predisposing cause, pneumonia being more prevalent in warmer than in colder climates. It may occur at any season of the year, but especially in the winter and early spring. Nine-tenths of the cases of pneumonia of the aged occur between November and May. Sudden changes in the temperature have greater influence on the production of pneumonia than prolonged steady cold weather. Damp weather and rainy seasons do not predispose.

It occurs at all ages, and is the most fatal of all diseases after sixty. The male sex suffers to a greater extent than the female, probably due to exposure and occupation. Depressing influences, both physical and mental, are said to be predisposing causes. Previous disease is important, as pneumonia

is often the terminal event in the cachectic and alcoholic individual. It is a common sequel in acute diseases, such as the malarial and other infectious fevers.

Exciting Cause. The specific organism is the diplococcus pneumoniæ. (For a description see p. 103.) Other organisms

have been found associated with croupous pneumonia, such as Klebs-Löffler bacillus, staphylococcus, bacillus typhosus, bacillus coli communis, and bacillus of influenza. It is only within the last decade that pneumonia has been widely recognized as an infectious disease, up to that time having been regarded generally as a local inflammation of the lungs.

Period of Incubation.-Period of incubation is unknown. Pathology. This form of inflammation of the lungs affects most generally.a lobe, or more than a lobe, sometimes affecting the entire lung; hence the name, lobar pneumonia. The most frequent site of attack is, first, the right base; next, the left base; both bases and the apices less frequently. The condition is a process of acute inflammation, the stages gradually merging one into the other, and, for the purpose of clearness in description, the stages are defined separately.

The pathology of croupous pneumonia is divided into three stages: first, engorgement; second, consolidation; third, resolution. The infectious irritant lodges in the lung, and produces its effects in the air vesicles. The introduction of the infection is imported into the lung through the respiratory tract. The diplococcus of pneumonia being in many instances. normal in the saliva, the mode of infection is, therefore, easily traced when the system is in such a condition as to favor the growth of this organism.

In the stage of congestion the blood-vessels are found dilated, the lung becomes red, and when the affected area is placed in water, it floats at a deeper level than normal tissue. Microscopically, it will be found that in the stage of engorgement the blood-vessels are dilated, but little or no exudate is noticed in the air vesicles.

The epithelium lining the air vesicles becomes granular, swells, and is shed of its basement membrane. Gradually, the exudate forms in the air vesicles, giving rise to the stage of consolidation, the first part of which is termed red hepatization, so called because it resembles liver structure. In this stage

the affected area is completely consolidated, and when placed in water, it sinks. There will be complete absence of crepitation. Microscopically, it will be found that the exudate in the air vesicles is composed of a large amount of fibrin, leukocytes, red blood-cells, and a few epithelial cells. The specific microorganism is found in this exudate. The blood-vessels are still dilated and tortuous. This exudate, as a rule, contracts somewhat, and probably by the force of gravitation seeks the de

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