of the chest, the use of diuretics, strychnin, digitalis, and, it may be, artificial respiration. See that drainage of the wound is free, if an external wound exists, and thoroughly immobilize the damaged part. In order to prevent fat-embolism after a severe injury insist on rest. Massage used early after some injuries is dangerous, as it may force fluid-fat into the vessels. When a severe contusion gives rise to a large cavity filled with blood Groubé advises incision, to lessen the danger of fat-embolism.'

X. SEPTICEMIA AND PYEMIA.

Septicemia, or sepsis, is a febrile malady due to the introduction into the blood of septic organisms or their products. There is no one special causative organism, and any microbe which produces inflammatory and febrile products may cause it. Either streptococci or staphylococci may be present. Septicemia arises by absorption of septic matter by the lymphatics. Clinically we make two forms of septicemia: (1) sapremia, septic or putrid intoxication; and (2) septic infection, true or progressive septicemia. In these conditions. the area of infection is usually discovered by the surgeon, but when it is not located the case is called by the Germans cryptogenetic septicemia.

Sapremia, or septic intoxication, is due to the absorption of poisonous ptomaïns from a putrefying area. The bacteria rarely enter the blood, but their toxins do, and, as these toxins are active poisons, the condition is comparable to poisoning by successive alkaloidal injections, the symptoms and prognosis depending upon the dose. Even if some of the organisms enter the blood, they do not multiply in this fluid. Slight symptoms and recovery follow a small dose; grave symptoms and death follow a large one. The poison does not multiply in the blood, and a drop of the blood of a person laboring under putrid intoxication will not produce the disease when introduced into the blood of a well person; in other words, the disease is not infective. Sapremia results from the absorption of putrid matter from considerable areas which are under high pressure. It may follow labor where putrid fluid is retained in the womb, or follow amputation where decomposing blood-clot or wound-fluid is pent up within the flaps. In this condition there always exist a considerable absorbing surface and a large amount of dead matter which has become putrid. Roswell Park points out that 1 Rev. de Chir., July, 1895.

2 Treatise on Surgery by American Authors.

sapremia arises from putrefaction of a blood-clot or from wound-fluids which are retained like foreign bodies in the tissues, and does not arise from putrefaction of the tissues themselves. He speaks of the condition as due to the absorption of poison from a "putrid suppository." We use the term putrefaction because this is the usual change, but any fermentative organism may cause the disorder. Sapremia is a malignant form of surgical fever, and its existence means an ill-drained wound, and a fermenting and probably putrid collection of blood-clot or wound-fluid.

Symptoms.-In twenty-four hours or more after labor, after an injury, or after an operation, there is a chill followed by high temperature, gastric disturbance, dry tongue, weak, rapid pulse, great prostration, muscular twitching, restlessness, headache, often delirium, diarrhea, foulness of wound, often drying up of wound-discharge, diminution or suppression of urine, and a strong tendency to congestion of various organs. Blood-examination shows leukocytosis. Great clevation of temperature precedes death.

Treatment. The treatment is to at once drain and asepticize the putrid area and give enormous doses of alcohol. Strychnin and digitalis are useful. Purge the patient, and favor diaphoresis, using in some cases the hot bath. Establish the action of the kidneys; allay vomiting by champagne, cracked ice, calomel, cocain, or carbolic acid with bismuth. Give food every three hours. Feed on milk, milk and limewater, liquid beef-peptonoids, and other concentrated foods. Use quinin in stimulant doses. Antipyretics are useless. Watch for any visceral congestion, and treat it at once. The use of saline fluid by hypodermoclysis or venous transfusion dilutes the poison and stimulates the heart, skin, and kidneys to activity.

Septic infection, or true septicemia, is a true infective process. In sapremia the blood contains toxins of fermentative organisms, but not the organisms themselves. In septic infection the blood contains both pyogenic toxins and multiplying pyogenic organisms. In sapremia the causative condition is putrid material lodged like a foreign body in the tissues. In septic infection the tissues themselves are suppurating, and both bacteria and toxins are being absorbed by the lymphatics. Of course, septic infection may be associated with septic intoxication or may follow it. In suppurative fever the tissues suppurate, but only the pyogenic toxins are absorbed, and not the pyogenic organisms. In septic infection both the pyogenic bacteria and toxins enter the blood, and

the bacteria multiply in the blood and produce continually increasing amounts of poison. The symptoms of sapremia 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 septicemia, 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, and is commonly punctured or lacerated.

Symptoms.-The type of this condition is met with in puerperal septicemia or in an infected 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. When the remission begins there is a copious sweat. The pulse is small, weak, very frequent, and compressible. The tongue is dry and brown with a red tip. The vomiting is frequent, and diarrhea 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. Visceral congestions occur. The spleen is enlarged, ecchymoses and petechiæ are noted, secretions dry up, urinary secretion is scanty or is suppressed, and the wound becomes dry and brown. Bloodexamination detects disintegration of red globules, and marked leukocytosis. When a wound inaugurates septicemia, red lines of lymphangitis are seen about it and there is enlargement of related lymphatic glands. No thrombi or emboli exist in septicemia. The prognosis is bad, and in some malignant cases death occurs within twenty-four hours.

The treatment is the same as for septic intoxication. Antistreptococcic serum is employed by some surgeons, but the value of this method is as yet doubtful.

Pyemia. Pyemia is a condition in which metastatic abscesses arise as a result of the existence of septic thrombophlebitis, the disease being characterized by fever of an intermittent type and by recurring chills. It is not actually due to free pus in the blood, but to the passage into the blood of clots infected by streptococci and staphylococci. If an area of infection leads to thrombophlebitis, lymphatic absorption of toxins or organisms is apt to be occurring at

the same time. Hence in many cases septicemia exists with pyemia.

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 runs up in the lumen of a vein, and the apex of the purulent clot softens, a portion of it is broken off by the blood-stream and 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 lodgement form embolic, secondary, or metastatic abscesses. Wounds of the superficial parts and bones produce pyemic infarctions and metastatic abscesses of the lungs. When these infarctions break into fragments particles may return to the heart and lodge, or may be sent out through the arterial system to form other foci in distant organs. Infected areas connected with the portal circulation (intestinal injuries or suppurating piles) produce abscess of the liver. Malignant endocarditis is called "arterial pyemia," 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 pyemia is a misnomer. Some primary focus of infection must exist (often in the middle ear).

Symptoms. The wound becomes dry, brown, and offensive. A severe and prolonged chill or a succession of chills ushers in the disease; high fever follows, and drenching sweats occur. The chills recur every other day, every day, or oftener. After the sweat the temperature falls and may become nearly normal. The temperature often oscillates violently. The general symptoms of vomiting, wasting, etc., resemble those of septicemia. In some cases the mind remains clear, in many the delirium is purely nocturnal. The skin becomes jaundiced, and a profound adynamic state is rapidly established. The blood shows disintegration of red corpuscles and leukocytosis. The spleen is enlarged. The lodgement of emboli produces symptoms whose nature depends upon the organ involved. Lodgement in the lungs causes shortness of breath and cough, with slight physical signs. Lodgement in the pleura or pericardium gives pronounced physical evidence. Lodgement 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 pyemia always look for a wound,

and if this does not exist, remember that the infection may arise from gonorrhea, osteomyelitis, suppuration in the middle ear, or abscess of the prostate. Chronic pyemia may last for months; acute pyemia may prove fatal in three days. The complications are joint-suppuration, bronchopneumonia, pleuritis, endocarditis, pericarditis, peritonitis, pyelitis, venous thrombosis, and abscesses.

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

XI. ERYSIPELAS (ST. ANTHONY'S FIRE).

Erysipelas is an acute, contagious, spreading capillary lymphangitis due to the streptococcus of erysipelas, which grows and multiplies in the smaller lymph-channels of the skin and its subcutaneous cellular layers and of serous and mucous membranes. The disease is characterized by a rapidly spreading dermatitis, by a remittent fever due to absorption of toxins, and by a tendency to recur. It is always due to a wound. Idiopathic erysipelas is due to a small wound which escapes notice. The involved area 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, as they believe the streptococcus is not 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 debilitated and broken-down (as alcoholics and sufferers from Bright's disease). The disease may become endemic in special places or localities. The poison of erysipelas will produce puerperal fever in a lying-in woman. The streptococcus was first obtained in pure cultures by Fehleisen (Tillmann's Principles of Surgery). This organism is widely diffused. The question of identity with the streptococcus pyogenes is discussed on p. 38.

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