Sepsis

SEPSIS (sepsis, septicaemia), a general infectious disease defined by the body's specific reaction to constant or periodic infection of the blood with various microorganisms and their toxins, not accompanied by any specific processes either at the gates of infection (which usually remain in the background) or in the body as a whole. S. literally means blood putrefaction, i.e., the circulation in the blood of putrefactive bacteria or substances. In reality, S. is comparatively rarely blood putrefaction (sapremia), and in most cases, the causative agents are the most diverse and rarely putrefactive microbes. Among the causative agents of S. can be named almost all existing pathogenic microbes, such as: staphylococcus, streptococcus, pneumococcus, gonococcus, meningococcus, typhoid group bacteria, blue pus, anthrax, tubercle bacillus, etc. This circumstance in itself sets S. apart from other infectious diseases. Among other features of S. should be noted that this disease does not have definite clinical-anatomical cyclicity; for example, it lacks definite incubation periods. Being caused by the most diverse microorganisms, S. in its clinical course nevertheless remains rather uniform. Finally, even anatomically it does not stand out with any specific processes in terms of their quality, definite localization, as we see, for example, in dysentery, scarlet fever, etc. All these data place S. outside the number of typical infectious diseases. On the other hand, there are data that bring S. closer to ordinary infections. Thus, almost every infectious disease has at least a brief phase of bacteremia, i.e., infection of the blood; the concept of S. also usually includes the bacteremic factor. However, it would be a gross error to identify the concept of S. with the concept of bacteremia, at least because the latter can be observed in mild local diseases (acne, paronychia) and even in completely healthy people. The same should be said in relation to the phenomena of intoxication (toxemia)—both in S. and in other infectious diseases, intoxication can be the leading factor among general phenomena, and the acting toxins can be both products of bacterial breakdown from the local focus and products of breakdown of the body's own tissues. Thus, S., not being a typical infectious disease, at the same time cannot be understood in essence if separated from classical infections. Every S. presupposes a moment of penetration into the body of certain pathogenic bacteria. The site of penetration—the gates of S.—in most cases is more or less obvious (for example, injury, furuncle, otitis). Depending on the various gates of infection, one speaks of wound, otogenic, urogenic, odontogenic, umbilical, puerperal S., etc. Often, however, the local focus at the gates of infection is completely absent and develops only at a distance, and subsequently from this distant 'septic focus' the entire picture of S. develops. Finally, a third category of cases occurs when no local focus forms either at the gates of infection or at a distance, and the very mechanism of development of S. remains unclear (cryptogenetic S.). In those cases where there is a local focus at the site of infection penetration (for example, abscess, paronychia), the further course of the infection through the lymphatic or blood system can sometimes be clarified clinically and anatomically. Spread through lymphatic vessels is accompanied by pictures of their inflammation, i.e., lymphangitis. Lymphangitis is often easily recognized macroscopically by the presence of red painful strips running along the course of the vessels from the corresponding septic focus. Lymphangitis is usually accompanied by lymphadenitis, up to the purulent melting of the glands and the development of phlegmon around them. The spread of infection through the blood system usually occurs through the corresponding veins, and in some cases it is accompanied by thrombophlebitis, in other cases the lumen of the veins remains free and infectious agents are found either directly in smears from the vessel contents (for example, in the blood of umbilical vessels in the so-called umbilical S.) or in the vessel wall itself and its immediate periphery. Most often one has to observe purulent thrombophlebitis, i.e., purulent melting of the formed thrombi. The detection of these vascular changes has the significance that with a weakly expressed local septic focus they can clarify the location of the latter, i.e., the source of infection. Thus, by incising the parametrium and finding in it signs of lymphangitis or thrombophlebitis, one can conclude that the uterus is the gate of infection.—In a whole series of cases, especially when the course of infection through the vessels cannot be proven, doubt arises as to the very connection between the local process and the septic disease, all the more so that anatomical-histological evidence of the entry of infection may be absent even at the gates that are clinically beyond doubt, for example in some cases of postpartum, umbilical S. Finally, sometimes the dependence between a certain local process and S. is merely assumed without sufficient grounds. Often one speaks, for example, of angina-S., pyelitis-S., etc., and yet both angina and pyelitis themselves often arise in the course of existing S., being therefore symptoms of the latter, not the local conditions producing it. For the pathologist, and especially for the forensic expert, it is extremely important to remember this reverse dependence of the local on the general, in order not to make erroneous conclusions. Example: a pregnant woman shortly before childbirth became ill with severe otitis; the latter was operated on, thrombophlebitis of the sinuses developed and S., and during the latter childbirth occurred. On autopsy, it turned out that along with the picture of S. and its gates (ear, sinuses) there existed the classic picture of septic endometritis, simulating ordinary puerperal S. and undoubtedly arising during the otogenic S. as its consequence (see below). As for the septic 'foci at a distance', they can arise both through the lymphatic system (for example, in glands) and through the blood system, and both through venous and arterial. These include cases of S. developing from liver abscesses after former appendicitis, ulcerative colitis, cases of S. from non-traumatic osteomyelitis, from abscesses of unknown origin but undoubtedly hematogenous in spleen, paranephron, etc. S. without visible gates of entry of infection is called cryptogenetic. Such a diagnosis is always somewhat forced both for the pathologist and for the clinician, leaving the impression of insufficiently careful examination of the patient (or corpse). Defects in examination undoubtedly exist, but on the other hand, it can be stated that cryptogenetic S. has every right to exist. The very 'entry' of septic infection is not always exogenous: the doctrine of autoinfection, of the endogenous origin of pathogenic forms in the process of dissociation and 'mutation' of non-pathogenic microbes, and namely under the action of various external and internal factors on the latter, at present can no longer be disputed; on the other hand, even with exogenous infection, it is easy to imagine the passage of bacteria through one of the body's external barriers, for example the mucous membrane of the digestive, respiratory, urinary tract, without such passage being accompanied by obvious violations in structure. Finally, even definite but insignificant in volume violations may disappear by the time of examination of the case on the anatomical table in the process of regeneration, and then the entire disease will inevitably present itself to us as cryptogenetic, although in fact it is not. Thus, from the theoretical side, the disease S. can well be imagined without visible gates of infection and without any traces of its entry. Finally, and this is most important, we do not know all the main causes of even the vulgar forms of S. with obvious local processes and obvious ways of their spread. Indeed, why in one case the infection remains local or regional, in another case it gives a distant metastasis that remains a local suffering, in the third it spreads in the manner described above, and, reaching the general blood current, in one case it gives a typical, usually fatal S., and in another case, as it were, an innocent rudiment of the latter—bacteremia and some general phenomena, such as temperature, malaise, etc. In particular, what concerns the relationship of S. to bacteremia and the significance of the so-called general phenomena, here, on the one hand, it seems clear that S. is unthinkable without bacteremia and without general phenomena. On the other hand, as has been pointed out, it can be stated that neither bacteremia by itself, nor general phenomena as such, nor finally the combination of these two moments serve as proof of S., because otherwise the concept of S. as a qualitatively specific nosological unit would disappear, and a slightly indisposed carrier of a paronychia with lymphangitis and somewhat elevated temperature would find himself in the same group with the classic, usually fatal S. or pyemia.

Thus, it is by no means the same thing whether we have before us a typical S. or some local focus with a number of 'general' phenomena, even with bacteremia. What then is the criterion of sepsis? The most correct criterion to propose is the principle of complete independence of the general phenomena from the starting point, i.e., from the source of sepsis. It is a general disease with such general phenomena as are qualitatively different from the general phenomena that arise in various local and general afflictions. On the other hand, and this is most important, S. is such a general infectious process that has entirely lost its original dependence on the local focus. The enormous role of infection in S. is quite obvious, but at the same time it is clear that since S. can be associated with various microorganisms, it is determined not by any peculiarities of the infectant, but by peculiarities of the body's reaction itself. If the streptococcus, this most frequent cause of S., gives even more frequently abscesses, phlegmon, sometimes agranulocytic angina, erysipelas, disease of the newborn, sepsis lenta, and according to the testimony of very competent authors also acute rheumatism, scarlet fever, and some cases of acute leukemia, then this of course does not happen because there exist septic, phlegmonous, erysipelas-like, leukemic streptococci, etc., and not because in S. in particular we are dealing with some exceptional virulence of the microorganism. S. is above all a macrobiological problem, as is indeed the problem of any other infection. The occurrence of S. is sometimes associated with various conditions, pre-existing and arising in the life of both healthy and sick individuals. Among such conditions, age and physiological factors are important; in particular, the indication of a predisposition to S. in childhood and pre-senile age, in pregnant and menstruating women, in patients suffering from endocrine diseases, metabolic diseases, as well as infectious diseases; hence also the relative frequency of S. as a para-infectious disease, as an 'associated' infection, for example after typhoids, pneumonias, scarlet fever, etc. The pathological anatomy of S. lacks any special pictures either at the site of infection entry or in the body in general. This does not mean, however, that anatomic diagnosis of S. is impossible: the combination of changes, even though essentially vulgar, in various organs remains sufficiently characteristic. On the other hand, precisely the absence of special pictures characteristic of other infectious diseases indirectly emphasizes the septic nature of the affliction. It is customary to distinguish two main forms of S: septicemia and pyemia (or septicopyemia). Both forms in general give a very grave prognosis: a fatal outcome occurs in most cases, but still the most malignant form should be considered septicemia, both in the acuteness of its course and in its fatality. The following signs are common to one or the other form. On external examination, a yellowish discoloration of the skin and sclera ('xanthochromia') often strikes the eye, apparently based on phenomena of hemolysis. Often, rashes in the form of petechiae are noted on the skin, and the latter can be pinpoint, barely noticeable, or large in the form of polymorphic spots, stripes; in individual cases, red stripes reach large sizes (especially on the back), resembling whip lashes. In rarer cases, septic rashes have the character of diffuse erythemas or resemble measles, scarlet fever, and sometimes pustular rashes in chickenpox. In individual cases, the skin lesion has a completely unique character: such are, for example, the pictures of exfoliative dermatitis in children, papulonecrotic rashes in blue pus, tuberculous S. Microscopic examination of exanthemas as a rule reveals only hemorrhages of various sizes and depths in the skin, sometimes accompanied by necrobiotic changes in the epidermis and skin glands. In special forms of S. (meningococcal, blue pus, tuberculous), island-like inflammatory processes, cellular exudate, etc. are often found. It is interesting that wounds that served as the gateway for septic infection change their appearance from the moment sepsis sets in: they become peculiarly dry, their bottom is sometimes covered with a bran-like or continuous fibrinous coating ('septic wound'). This circumstance in itself testifies to the great importance of the general condition of the body and the severe disturbances of its metabolism for the course of local, in particular inflammatory and regenerative, processes. This same circumstance demonstrates to us how the local (wound), giving rise to the general (sepsis), in turn undergoes changes coming from this general. The spleen in most cases is noticeably enlarged (2-3 times, and sometimes more), is flabby, tears easily, and from its cut surface a large amount of pulp is scraped off. All these signs have long been the basis for the characterization of the so-called septic spleen. Sometimes, however, the typical flabbiness of the organ is absent, and the spleen differs little from an ordinary infectious one. On microscopic examination, the abundance, especially in the vessels, of the so-called 'formalin pigment' almost always strikes the eye, giving sections from a septic spleen a dirty, dusty appearance. The pulp is unevenly full of blood, from which sometimes the organ also looks macroscopically mottled, variegated, with more or less pronounced hemolytic phenomena on the part of erythrocytes. The pulp is relatively rich in polymorphonuclear leukocytes (septic leukocytosis of the spleen); in cases of more prolonged course, large amounts of myeloid elements and plasma cells are noted in it. Only in individual cases do purulent processes, the formation of abscesses with possible rupture of the capsule and peritonitis, occur. The lymphatic glands everywhere undergo slight enlargement (desquamative 'catarrh' of the sinuses, some myelosis of the pulp), most noticeable in the neck area, as well as in areas that are regional in relation to the local focus. Lymphoid tissue, such as: tonsils, the follicular apparatus of mucous membranes, Peyer's patches of the intestine, may also somewhat swell. In particular, it should be emphasized again the frequent swelling of the palatine tonsils, the enhanced desquamation of epithelium in their crypts, the appearance of leukocytes in the cavity of the latter, etc. The blood of septic corpses is mostly fluid, with early hemolytic processes. This leads to early imbibition of the intima of vessels, endocardium, and heart valves, which in the corpse take on a diffuse pink-red color. The respiratory system may not have special changes; only a pronounced tendency to develop pulmonary edema is noted, sometimes accompanied by scattered foci of pneumonia; the latter can have a hemorrhagic or purulent-hemorrhagic character. From the heart, more or less marked degenerative phenomena are noted: dilation of the cavities, often hemorrhages into the epicardium, under the endocardium, especially in the area of the posterior wall of the left ventricle. In the vast majority of cases, S. proceeds without endocarditis; in relatively rare cases, acute warty and ulcerous forms of the latter are observed. The well-known tendency of septic patients to thrombosis is explained mainly by changes in the blood itself. From the gastrointestinal tract, apart from the above-mentioned hyperplastic processes in the lymph apparatus, tonsils, nothing special is observed; sometimes, however, hemorrhages, as well as acute catarrhal or diphtheritic processes, arise in the ileum and large intestines, probably related to the excretion of septic principles by the intestinal mucosa. In the course of S., the development of cholecystitis, appendicitis, pancreatitis, embolic hepatitis is also possible. In the urinary system, pictures of degeneration of the renal epithelium, sometimes nephritic changes, catarrhal pyelitis are found. In women, S., like other infections, is often accompanied by acute apoplectic hemorrhages into the corpus luteum of the ovaries, as well as into the uterine cavity. Degenerative-necrobiotic phenomena in the lutein cells of the true corpus luteum are a common occurrence in puerperal forms of S. The well-known tendency to develop abortions and premature births in S. is known, and the possibility of subsequent hematogenous infection of the wound surface of the endometrium was mentioned above. From the endocrine organs, degenerative changes in the adrenal glands can be pointed out: swelling of the cortex, impoverishment of its cells with lipoids, phenomena of discomplexation, necrobiosis. In the medulla, as well as in the depths of the cortex, hemorrhages are observed, which sometimes lead to dissection of the organ and the formation of hematomas in it; the tendency of septic adrenal glands to early autolytic disintegration in the center of the organ is also known. The nervous system may remain without special changes, both macro- and microscopically. In some cases, edema of the soft membranes and brain substance is found; sometimes a large number of lymphoid-type cells are mixed with the edema fluid in the membranes; the desquamated endothelium and the whole picture resemble the so-called serous meningitis.

In the substance of the brain, in addition to degenerative changes in the ganglion cells (tigrolysis), inflammatory foci are described, representing foci of proliferation of neuroglia (septic focal encephalitis), sometimes these are ordinary pyoembolic foci. - The serous membranes (pleura, peritoneum, pericardium) often bear ecchymoses, and in some cases inflammatory changes are found; however, such changes are more often associated with the pyemic variety of S. (see below). Turning to the differentiation of the above-mentioned varieties of S, it should be noted that the main difference between them is the phenomenon of more or less widespread focal suppuration. This phenomenon is absent in pure forms of septicemia; it is mandatory for pyemia. Thus, pyemia is a variety of S, characterized by a universal, at any rate fairly widespread, purulent reaction of tissues at the sites of deposition of the corresponding causative agents. Small, e.g., miliary, and large infarct-like abscesses, more rarely diffuse purulent infiltrates, may be observed in the brain (purulent focal encephalitis and diffuse meningitis), in the lungs (of the type of beginning infarcts), in the kidneys (of the type of purulent embolic nephritis), in the spleen, skin, thyroid gland, in the walls of arteries, in the myocardium, prostate, etc. Simultaneously, there may be purulent effusions in the joints, serous cavities, e.g., purulent pleurisy, peritonitis, pericarditis (pyemic polyserositis). Occasionally, embolic phlegmons are noted, e.g., of the larynx, subcutaneous tissue, mediastinum, etc. From the side of the infection gate, for pyemia, pictures of purulent thrombophlebitis are especially characteristic; hence the very concept of pyemia as 'pyemia'. There are special varieties of S, distinguished not only by clinical-anatomical, but also, for example, hematological features. Thus, a significant number of cases of acute leukemia, acute pseudoleukemia, acute hemorrhagic aleukia, agranulocytosis should probably be classified as septicemia. The attribution of these acute 'leukoses' to the general group of S. has its grounds: 1) these diseases proceed under the banner of general acute infections and are almost always fatal; 2) streptococci, pneumococci are the most constant finding in them; 3) the leukemic or leukemoid factor, as well as the aleukic, agranulocytic factors, are not entirely foreign to the pictures of ordinary septicemia; it is well known that S. can proceed with a sharp leukocytosis in the presence of a strong shift to the left; it can also proceed with lymphocytosis, as well as leukopenically and neutropenically. As for the hematopoietic organs, the phenomena of acute myelosis, e.g., in the lymph glands, spleen, liver, are by no means an exception for S., and on the other hand, pictures of an 'indifferent' bone marrow and even the presence of degenerative, destructive changes in it can be observed in all acute infections, including S. Finally, it is important to bear in mind fundamentally that qualitative and quantitative fluctuations of white blood cells are in themselves insufficient to assert special diseases, in particular special 'blood diseases', all the more so since the mechanisms of leukocytoses, aleukic shifts, thrombopenic phenomena, etc., can come into play in connection with diseases of the most diverse nature, especially in infections and in particular in S. Individual cases of chronic S. may proceed with pernicious-anemic symptoms; however, even in these cases, the color index usually remains <1. Certain acute skin and muscle ailments should probably also be included among the varieties of S., such as dermatomyositis, polymyositis, some cases of exfoliative dermatitis of newborns. In newborns, S. may proceed under the guise of Buly's disease or Winkel's disease. As has been indicated, in S. there is no definite causative agent; the most frequent is the streptococcus - over 65% of all cases of S. It gives the largest number of clinical-anatomical variants; apparently all varieties of S. can be headed by streptococcal infection. The most acute or fulminating forms of sepsis are most often associated with the streptococcus. Streptococcal S. is the most common parainfection, i.e., a sequential or final suffering in various other diseases; thus, it can arise during the course of abdominal, typhus fever, tuberculosis of the lungs, pneumonia, as a complication of various ulcerative and neoplastic processes, bedsores, etc. - Pneumococcal S. covers about 15-20% of all cases. It is often complicated by purulent (or seropurulent) meningitides, pneumonias. There are indications of the sequential development of cholecystitis and appendicitis, as well as of the involvement of heart valves with lush thrombotic deposits on them (endocarditis polyposa). - Coli-sepsis covers about 10% of cases, most often this is so-called urosepsis, i.e., the picture is headed by catarrhal processes from the side of the bladder, renal pelvis; sometimes the source of S. is so-called ascending nephritis. A significant part of cases of kidney stone disease also ends in colisepsis; often the gates of infection are ailments of the intestine, bile ducts, peritoneum, endometrium. It more often proceeds as septicemia, more rarely as pyemia. - Staphylococcal S. (about 5%) is predominantly pyosepsis, i.e., pyemia. In contrast to streptococcal varieties, this S. usually gives many embolic local foci; a special tendency to thrombophlebitis is noted. In general, it is considered one of the relatively benign and longer-lasting varieties of S. The main mass of cases of recovery of septic patients falls on staphylococcal S. The starting point is often furuncles, osteomyelitis, mechanical catarrhs of the bladder, e.g., those arising during catheterization. Among the rarer bacteriological varieties, gas S. (Bac. phlegmonae emphysematosis, bacilli of gas edema, Bac. perfringens, etc.) should be noted, observed especially often in wartime conditions; it develops, e.g., after gas gangrene or gas edema, as well as postoperatively, or spontaneously, e.g., in cholecystitis, endometritis. It is characterized by the rapid development of gas bubbles in the vascular system (which apparently begins already in the agonal period) and the early onset of sharp postmortem changes: hemolysis, swelling of the gas of the face, neck, abdomen. The liver, spleen, kidneys of such corpses often have the appearance of honeycombs or foam (Schaumleber - of German authors). Sometimes metastatic development of gas gangrenous foci is observed, especially in the soft tissues of the shoulder and lumbar belt (glutaeus). - Pseudomonas S. (Bac. pyocyaneus) is a rare phenomenon; it most often proceeds as septicopyemia and arises on the basis of chronic otitis, as well as in various exhausting purulent processes, such as: abscesses of the lung, empyemas, etc. The purulent exudate, both in the primary sources and in the metastatic foci, looks bright blue-green. The formation of purulo-necrotic foci on the skin and in internal organs, e.g., in the kidneys, gastro-intestinal tract, - so-called ecthyma gangraenosum with an abundance of causative agents in the necrotized vascular walls, is also characteristic; an extremely sharp hyperemia of the surrounding vessels (stasis of blood) is also characteristic. - Gonococcal S. (gonosepsis), despite the frequency of gonorrheal infection, is rare. It arises either in the acute period of gonorrhea or against the background of old local processes (prostatitis, urethritis, vesiculitis). For gonosepsis, ulcerative endocarditis (especially of the pulmonary and aortic valves), as well as the involvement of joints (gonorrheal monoarthritis), tendon sheaths, kidneys (nephritis) are fairly characteristic. It is also often accompanied by rashes on the skin of various kinds (urticaria, papules, vesicles, petechiae, etc.). - Meningococcal, typhoid, anthrax, tuberculous S. - see the respective infections. The determination of the causative agent of S. is carried out by the usual methods of bacteriological examination of the corpse. It is best to use blood from the cubital vein, cutting it after preliminary sterilization of the cubital bend. The corresponding exudates, pus from metastatic abscesses, pulp of the spleen can also be examined. It should be borne in mind that the mere finding of bacteria, e.g., the bacillus coli, even streptococcus, in the blood of a corpse is not proof of S.; such findings (in the order of agonal invasion) are possible in various diseases without them being a manifestation of S. In particular, streptococcus is found in the blood in approximately 25-30% of all corpses and to a certain degree independently of the disease that led to death. In other words, the diagnosis of S. should be based primarily on clinical-anatomical or purely anatomical data. It should also be borne in mind that in unmistakable S., the seeding of the blood of the corpse may turn out to be sterile even when using special media, anaerobic growing conditions, etc. This is explained either by the rapid plasmolysis of bacteria or by the actual absence of them in the blood at the moment of cardiac arrest.

Sepsis by no means implies the permanent presence of bacteria in the blood, let alone their multiplication in it, so that periods of sterile blood are always possible. The presence of bacteria in the blood at the time of death is usually accompanied by their significant multiplication subsequently, sometimes by the development of entire colonies along the course of the capillaries of various organs. The postmortem nature of the development of such colonies is indicated by the absence of a reaction from the surrounding tissues. Depending on the point of origin, the following categories of septic diseases are distinguished. Therapeutic S., i.e., S. associated with so-called internal diseases. This also includes cryptogenic S. The majority of therapeutic cases fall on para-infectious S., especially after scarlet fever, typhus, pneumonia, erysipelas, etc. An intermediate link here is often some purulent process, e.g., retropharyngeal abscess, phlegmon of the neck, lung abscess, parotitis, bedsore, etc. To this same group belongs anginous S., e.g., with the development of a peritonsillar abscess. Surgical S. encompasses a group of so-called surgical diseases and all postoperative cases. This will include wartime field S., associated with gunshot wounds and other similar injuries; S. associated with burns of the body, with swallowing or aspiration of foreign bodies that traumatize mucous membranes (e.g., dental prostheses); S. associated with profession, e.g., in doctors after injuries during operations, during autopsies. A prominent place is occupied by cases of S. associated with furuncles, especially of the face, with carbuncles, gangrene, especially in diabetics. In the strict sense of the word, surgical are cases of S. after various operative interventions; here the intermediate moment is usually either a phlegmon in the field of operation or purulent inflammation of one or another serous cavity. The category of surgical S. also includes urological S. (urosepsis), otogenic, oral (in particular odontogenic) and finally obstetric-gynecological (in particular and mainly puerperal). Urosepsis is observed predominantly in chronic cases of kidney stone disease, in purulent cystitis, pyelonephritis. Sepsis, however, often ends through bladder-kidney complications in cases of prostate hypertrophy, urethral strictures. Among the causative agents of urosepsis, as indicated, besides streptococcus, the bacillus coli (E. coli) is particularly important. From the anatomical side, thrombophlebitis of the pelvic cellular tissue (e.g., the area of the paraprostatic venous plexus) is quite characteristic, sometimes extending into the inferior vena cava. Otogenic S. represents one of the most frequent groups of S. in general: among fatal complications of inflammation of the middle, inner ear and mastoid process it occupies 55-60%, and as a cause of death in the general prosectorial material (Moscow, 1925-1927) it covers about 1.5% of all autopsies. For trephined cases (in mastoiditis), purulent and ichorous thrombophlebitis of the sinuses of the dura mater are very characteristic, often extending into the jugular vein; multiple abscesses in the lungs are also usually observed. The question of oral, in particular odontogenic, S. is particularly persistently raised by American authors under the guise of the doctrine of 'focal infection.' They point to the importance of various chronic ailments in the area of the tonsils, paranasal sinuses, especially the teeth, and moreover not only with obviously pathological processes, such as: pulpitis, apical granulomas, paradentitis, but also relatively harmless ones, e.g., devitalized, filled teeth. This local infection can supposedly give various metastases, causing clinical pictures of stomach ulcer, cholecystitis, appendicitis, sepsis, acute rheumatism, as well as a number of nervous and mental diseases. This doctrine and in particular the considerations put forward about the elective localization of infection (introduction into an animal of microbes obtained from a local focus in a person suffering from stomach ulcer, pancreatitis, nephritis, etc., supposedly gives the animal the same ailments) have not gained great prevalence and sufficient confirmation on the European continent; the very possibility of sinusogenic, odontogenic, and tonsillogenic septicemias is of course not disputed by anyone. Odontogenic cases of S. most often arise from purulent inflammations of the so-called paradentium, complicated by periostitis and osteomyelitis of the jaws. The local process often takes on a gangrenous-ichorous character due to the penetration of mixed oral infection into the wound, especially fusospirochetal. Gynecological S. is almost entirely exhausted by the corresponding complications of abortions and births (sepsis post abortum, sepsis post partum). A smaller part is made up of other cases: salpingitis, disintegrating cancers of the uterus (especially after intensive irradiations), etc. According to the materials of Moscow prosectories for 1923-27, the total number of cases of obstetric-gynecological S. amounts to over 52% of all fatal diseases of the female sexual sphere and about 6.5% of all deceased adult women. With regard to puerperal S., the following varieties should be kept in mind: 1) S. beginning before the onset of labor, 2) arising during the act of labor (s. intra partum), 3) arising in the postpartum period (s. post partum), 4) eclamptiform, 5) fulminant. The fourth and fifth varieties can be related to various stages of the act of labor. The practice of pathologists and obstetricians persistently indicates that this distinction (especially the first, second, and third) is not only possible but also vitally necessary in the majority of cases, since it resolves questions of a socio-legal nature in terms of clarifying, e.g., the role of the attending physician in septic contamination. Thus, the discovery immediately after birth of an old decidual endometritis against the background of acute septic phenomena can serve as proof of S. that began sub or ante partum, i.e., before labor. Naturally, clinical data also play a very important role here (onset of fever, etc.). The differentiation of eclamptiform S. (from eclampsia as such) requires analysis not only of clinical but also of patho-anatomical data; it is indisputable, however, that cases of typical eclampsis with subsequent sepsis are encountered. Fulminant S. (within 12-24 hours) often gives no special anatomical points of support for diagnosis; here bacteriological control of the corpse, in particular of the blood of the uterine veins, is of great help. Sepsis of newborns. Most often, umbilical S. is meant, associated with inflammation of the umbilical vessels. The anatomical diagnosis is usually not difficult and is based on the presence of purulent thrombophlebitis or thromboarteritis of the umbilical vein or arteries. Sometimes, however, thrombotic phenomena do not develop and the corresponding diagnosis is made on the basis of the general pictures of S. and on finding bacteria, usually streptococci, in the liquid blood of the umbilical vessels. Cryptogenic S. is observed not infrequently, in any case more often than in children (or adults) in general. In newborns, S. sometimes proceeds with symptoms of melena, i.e., in the presence of diffuse hemorrhages into the gastrointestinal tract: the anatomical pictures are negative in this case; sometimes the development of multiple hemorrhagic erosions of the stomach is observed. It is very probable that the so-called disease of Buly and disease of Winkel should be attributed to the manifestations of S. in newborns. The questions of the theory of S. undoubtedly have great importance for clarifying certain practical aspects associated with the so-called septic contamination. By the latter is meant those complications of S. that arise after accidental or intentional, e.g., operative, wounds, after obstetric aid, extraction of a tooth, etc. There can be no doubt that every wound with access to the wound from an external non-sterile environment creates a certain, albeit minimal, danger of septic infection of the wound and general contamination. The same danger can also be presented by wound surfaces that arise in a physiological order, for example the surface of the postpartum uterus, the end of the cut umbilical cord, etc.; in particular with regard to the postpartum uterus, the initially established view of the sterility of its surface has undergone significant changes in the opposite direction in recent years. Even greater danger is presented by injuries of non-sterile or diseased tissues containing (sometimes for years) the so-called latent infection, remaining for example in adhesions after a former process; this includes almost all cavity operations, resections, anastomoses, etc., as well as operations on teeth, especially in the area of the periodontium, including extraction of diseased teeth. All these manipulations, performed even with sterile hands and instruments, but in non-sterile tissues, give a certain percentage of 'unfortunate cases,' which naturally arouse in public opinion and in the organs of prosecutorial supervision suspicion of one or another carelessness on the part of the physician. From all of the above it follows that in deciding questions of septic contamination, sufficient objectivity and CAUTION must always be observed.

I. Davydovsky. Clinic. Symptomatology and course. Local manifestations in S. can be both severe and mild. They are not given decisive importance for the diagnosis of S. The diagnosis is made on the basis of symptoms not directly related to the septic focus itself. It is impossible to draw a precise line between local coccal disease and S. The diagnosis and prognosis are made on the basis of clinical examination and evaluation of the patient's condition. It is not surprising that under such conditions, at the patient's bedside, the diagnosis of S is often found to be arbitrary, when, for example, two physicians, without arguing about the nature of the disease, name it differently, with one speaking of S and the other of endometritis. The signs on which the decision to speak of S is based are numerous and varied. Fever should be considered an essential symptom. Fever in S. does not have a characteristic course, similar to typhoid or in lobar pneumonia. The duration of the disease varies extremely: from several days to a year or more. The onset of the febrile state in most cases is gradual. However, it is not uncommon for the onset of S. in some purulent process to be considered the moment of appearance of a septic chill. During and immediately before the chill, it is especially easy to find microbes in the blood. Therefore, it is generally believed that the chill corresponds to the massive entry of bacteria from the focus into the blood. Undoubtedly, however, bacteria enter the blood without causing this symptom. Elevated temperature is also observed in periods when there are no bacteria in the blood, depending only on the absorption of bacterial metabolic products and tissue breakdown. The height of the febrile temperature varies and is not characteristic of the septic state. If the temperature is high, it often has a remittent character with large fluctuations during the day, especially when chills are present. The nature of the temperature curve depends not only on the type of infection but also on the location of the septic focus (focus in veins or lymphatic vessels), as well as on the reactivity of the patient. In collapse and severe general exhaustion, the temperature may drop despite the increasing general severity of the disease. As in other cases of high temperature, we also have here increased metabolism and enhanced tissue breakdown, manifested by increased nitrogen excretion and clinically by weight loss and muscle weakness. In the urine, a diazo reaction is sometimes noted. Conclusions about the nature of the infection based on the temperature curve must be made with great caution. Nevertheless, to a certain extent, remittent temperature movements are characteristic of streptococcal infection, which does not exclude the possibility of other curve forms. Staphylococci, on the contrary, rarely cause severe chills and remissions, more often the temperature is high and fluctuations are small. The curve has a strongly remittent character also in S. caused by B. coli; a remittent type of fever is observed in the rare in adults infection by B. pyocyaneus. Pneumococcus gives a high temperature, sometimes interrupted by strongly expressed remissions. The skin in septic diseases may show no deviations from normal. Depending on the fever, the septic patient sometimes reddens somewhat. More common and much more typical for S. is general pallor. It depends on the resulting anemia and exhaustion, but also on changes in vascular filling as a result of septic poisoning with a completely sufficient content of Hb in the blood. Pallor sharply increases during chills. Against the general pallor, local hyperemia with a cyanotic tint may be expressed on the face. Generally, a certain bluishness of the skin is often observed in septic patients. Increased sweating and associated miliaria crystallina are often noted. In cases of exhausting prolonged disease, on the contrary, the skin becomes dry and peels. The subcutaneous tissue in low-lying areas may swell at the same time. Various erythemas, some completely unique, some of the scarlet fever type, or measles-like, are also observed in S. Symptoms resembling erythema nodosum and urticaria are also encountered. Finally, on the skin, changes in blood vessels dependent on S. are often found. They also occur partly from intoxication. But here bacterial emboli, which cause various pustular eruptions, are often also of importance. All cases with hemorrhages from blood vessels of the skin, petechiae and larger hemorrhagic rashes should always be considered highly suspicious for S. Large hemorrhages are usually a late symptom of S. Any hemorrhatic rashes appear predominantly on the skin of the extremities, especially on the inner side of the forearms and shins. As a consequence of damage to blood vessels, the Rumpel-Leede phenomenon is also observed. On the lips and face in S., herpes sometimes appears. Finally, in the subcutaneous tissue and partly in the skin itself, the appearance of abscesses is sometimes noted. Each of the described symptoms is not characteristic of any particular infection, nevertheless, for some causative agents, favorite symptoms have been noted. Thus, herpes is especially abundant in S. caused by the bacillus coli. In septic infection by B. pyocyaneus, small and larger bubbles filled with hemorrhagic exudate appear on the skin, under which tissue necrosis is found. The staphylococcus, which generally metastasizes more often than other cocci, also gives purulent emboli in the skin and subcutaneous tissue. On the contrary, B. coli practically does not give metastases to the skin. Hemorrhagic phenomena in the skin are not specific for any coccus. The nervous system. The patient's psyche is not always affected by the septic process. Especially in not very acute course, complete clarity and mental equilibrium can be maintained for a long time. However, even the consciousness of the severity of the diagnosis is hard to bear for a febrile patient. The influence of the septic principle brings the patient into a state of depression strongly resembling the state of a typhoid patient. General indifference is sometimes interrupted by periods of excitement during chills. The febrile state manifests itself in other cases with excitement, prolonged and violent delirium. Judgments about the severity of S., often expressed only on the basis of febrile and mental symptoms, may prove to be very erroneous. In this area more than anywhere else, the individuality of the patient has importance. True psychoses are observed in predisposed individuals and are rare. At the same time, in many patients, complete loss of consciousness of the severity of their condition and a feeling of general well-being are observed. The patient complains of nothing, finds everything wonderful, makes plans for the future, and dies a few hours later. Such euphoria is especially characteristic of S. and in fever is always suspicious for S., provided the possibility of tuberculosis is excluded. Headaches and nuchal rigidity, which appear very frequently in S., as well as other symptoms, lead one to think of inflammation of the meninges or their irritation. It is impossible to separate meningitis from meningism on the basis of clinical symptoms. Examination of the cerebrospinal fluid in meningitis shows the presence of leukocytes, protein, and causative agents of meningitis. Clinically, the question of whether the patient has meningitis or meningism is often decided before the bacteriological analysis of the cerebrospinal fluid arrives, which in some cases gives a negative answer in terms of bacterial growth despite clinically obvious meningitis. There is a unique connection between meningitis and S. Meningism or meningitis phenomena may appear as a symptom of general septic spread of infection. But S. and meningitis are often parallel consequences of one process. Inflammation of the middle ear, causing through thrombosis of the sinuses and nearby large veins general septic disease, at the same time, due to direct proximity, extends to the meninges. Meningeal phenomena may appear in all kinds of infection, but the meninges are especially often and severely affected in pneumococcal infection. The reason for this is undoubtedly not only that the pneumococcus often affects the middle ear, but that there is a natural predisposition of the meninges to pneumococcal infection: pneumococcal meningitis is observed without middle ear involvement and often pneumococcal S. proceeds with the clinical picture of meningitis. This tendency to infection of the brain membranes is even more pronounced in meningococcal S., which proceeds as meningitis with septic phenomena, sometimes weakly expressed. Localized foci and abscesses in the nervous system are also observed in S. They develop in both the brain and spinal cord, but not often. Finally, rarely in endocarditis lenta, embolic aneurysms and rupture of cerebral arteries with all consequences can be seen. Sense organs. In S., the ear and eye participate in the general picture differently. The eye is rarely a source of S., but characteristic septic changes sometimes appear in the eye. On the contrary, the ear, as a manifestation of any typical septic signs, is of little interest, but the middle ear is very often a source of S. This does not exclude that in some cases the middle ear is affected metastatically.

Finally, in severe general condition of a septic patient, the middle ear can also become infected from the nasopharynx, as with any other infection, regardless of whether there is a septic primary process in the nasopharynx or not. Vision is almost never affected by septic disease. Metastatic abscesses in the tissue of the eyelids and behind the eye appear rarely. Metastases in the conjunctiva of the sclera have been described, but they are not common. Petechiae, which so characteristically appear on the skin in S., may also be found on the conjunctiva of the lower eyelid. They are observed mainly in sepsis lenta and appear periodically. In the center of the petechia, a small white necrotic area is visible with a magnifying glass. These petechiae, which result from emboli, are of great importance for the diagnosis of endocarditis lenta. Changes in the fundus of the eye are very characteristic for S.: 1) hemorrhages of varying size in the retina; 2) small white spots that arise from characteristic changes in the nerve fibers of the retina (Roth's spots). Both symptoms have little effect on the patient's visual ability and, with favorable course of the disease, may subsequently disappear. Much more serious is the metastatic lesion of the eye by a septic embolus—panophthalmitis, leading to loss of the eye. Cardiovascular system. The general severe condition and high fever in septic patients are often associated with a sharp drop in blood pressure and even collapse. Periods of temperature rise and shaking chills especially affect the pulse and blood pressure. The vascular system plays a large role in S., both as a pathway for spreading infection and through which septic poisoning of any part of the macroorganism occurs. The introduction of bacteria can involve a number of organs, which, depending on the virulence of the bacteria and their characteristics, show one or another form of manifestation of S. Anaerobic pathogens from the abdominal cavity first enter the right heart and often give secondary suppurations in the lungs. Emboli from deposits on the heart valves in endocarditis are carried mainly into the arteries of the greater circulation. Arteries and veins in individual cases of S. can also be the location of a primary septic focus. The heart is affected first and suffers in its function. The pulse weakens and becomes frequent. In streptococcal infection, wherever the focus is located, the pulse is especially frequent. If the septic focus is located on the heart valves, this gives acute septic endocarditis. Such localization of the process can occur in any case of S., but often endocarditis stands out so much against the background of all other manifestations that one no longer speaks of S., but of septic endocarditis. Strepto- and staphylococci affect the endocardium more easily than other bacteria, followed by diplococci and sometimes gonococci. The disease with acute endocarditis manifests itself extraordinarily violently and ends in the death of the patient after a few weeks. A special type of streptococcus—Streptococcus viridans—often affects the valves and gives a picture of chronic, prolonged S.—sepsis lenta (endocarditis lenta) (see Endocarditis). Veins participate no less, but rather much more than arteries, in the picture of S. The slow, uniform, non-pulsating flow of blood in the veins predisposes them to thrombosis, especially when the seriously ill patient is at rest. Infection entering the blood from within, and inflammatory foci and their bacteria in close proximity to the vein from without, contribute to the formation of thrombotic deposits, which are a suitable place for the multiplication of microorganisms and the formation of a septic intravascular focus. Thrombi develop and sometimes spread over a great distance. Bones, joints, muscles. Joint phenomena during S. are observed very often. In most cases, these are insignificant pains that disturb the patient relatively little. Sometimes the joints are affected more severely. Effusions may appear in them. The picture of the disease then resembles severe rheumatism, or the joints—one or several—may become suppurative. Gonococci and pneumococci affect the joints most frequently, and the gonococcus especially often affects the large joints of the lower extremities. General emaciation and weakening of the muscles in S. develop rapidly. Noticeable weakness of the muscles and pain on touch and pressure are observed. The pain undoubtedly occurs partly from the periosteal phenomena observed in S. at the sites of muscle attachment. Bones are also affected more deeply by foci of osteomyelitis. The phenomena of osteomyelitis can reveal and maintain the picture of S. Osteomyelitis can develop with various pathogens of S. and secondarily later, when the diagnosis has already been established and it has also been established that the initial septic focus is not osteomyelitis (staphylococcus). Digestive tract. The tongue in acute forms of S. is sometimes extremely dry and coated. The developing toxic emaciation is contributed to by loss of appetite. Among the phenomena of digestive disorders, septic constipation and diarrhea should be mentioned. While constipation is a common phenomenon in any fever, septic diarrhea is especially typical for S. These diarrhea, appearing with the most careful diet, are usually accompanied by bloating, are difficult to treat, and greatly exhaust the patient. It is difficult to give them any anatomical basis. Petechiae, which appear in such abundance on the skin, also appear in abundance on the mucous membranes, without giving clinical symptoms. The liver during S. is often affected. Like any other harmful influences, the liver reacts to bacterial poisoning by swelling and jaundice. Due to swelling, the organ becomes sensitive to pressure and becomes accessible to palpation. Jaundice, besides the yellowing of the sclera and skin, also gives yellowing of the blood plasma. In the serum, a direct Himans reaction can be obtained, in urine all phenomena characteristic of hepatic jaundice. Undoubtedly, however, hemolytic processes in S. also play a role and, if not entirely causing, then to a certain extent increase the hepatic jaundice. There are also studies that establish that in gas S., the breakdown of red blood cells and the decomposition of Hb cause hematinic coloring of the coverings and blood plasma. Such an observation has not been made in any other diseases except for gas gynecological S. Emboli to the liver cause solitary or multiple abscesses, which are difficult to recognize. The infection causing them varies. Due to the proximity of the intestine, the liver is often infected by the bacillus coli. Multiple abscesses can be caused by staphylococci. Spleen. During the patient's life, an enlarged spleen is observed very often and confirms the diagnosis of S. But since the spleen belongs to the number of organs whose enlargement easily escapes the investigator, the absence of a large spleen cannot be given decisive diagnostic significance. The consistency of the organ in rapid swelling is soft, which increases the difficulties of palpation; in more prolonged cases, the spleen is dense (sepsis lenta). Emboli of septic thrombi sometimes give infarcts and abscesses in the spleen. Blood. The condition of the blood in S. changes. All types of sepsis with prolonged course lead to a decreased content of red blood cells and a fall in Hb. Patients with streptococcus are especially easily anemic. The color index decreases and the anemia is of a secondary nature. The number of white blood cells in S. is not always significantly increased. A large leukocytosis is characteristic not so much of S. as of the appearance of a purulent focus. A shift in the leukocyte formula to the left is also observed. This sign is perhaps more subtle than leukocytosis. In recent years, in some forms of S., the appearance in the blood of huge cells, so-called histiocytes, has been described. Presumably these cells originate either from the endothelium at the site of a finger prick or from internal organs—the liver and spleen. The blood picture is not always easy to interpret for or against sepsis. To this day, many authors consider that cases of acute leukemia represent a special form of S. Such a view is sufficiently unfounded, and one should be all the more cautious about this point of view that even if in acute leukemia unmistakable signs of S. could be discovered, this S. would be permissible to consider as having joined the main disease. The relationship of acute leukemia to S. should for the present be considered unclear. Doubt about the diagnosis sometimes arises in cases of severe anemia with remittent fever. If the number of leukocytes and other clinical phenomena do not definitely decide the question for or against pernicious anemia, clarity is usually brought about by liver treatment. It is more difficult to get out of the difficulty if before us is an anemic patient with signs of secondary anemia, slight fever, and a systolic murmur. Here the question arises, are we dealing with sepsis lenta or is it some other secondary anemia accompanied by fever, which, as is known, is often observed. Enlargement of the spleen speaks more for S., but it can sometimes occur with prolonged anemia, can be caused by some other cause (malaria). The diagnosis needs to be coordinated with the anamnesis (rheumatism, blood loss) and the course of the disease.

Petechiae on the conjunctiva of the lower eyelid with a yellowish dot in the center indicate sepsis lenta, a very low color index rather argues against it. A positive blood culture with growth of Streptococcus viridans clarifies the question of S. definitively. The morphology of blood is usually quite indeterminate in these cases. Respiratory organs. The respiratory tract is rarely the source of septic processes. Metastases of the introduced infection give abscesses that follow the pattern of severe pneumonias, and gangrenous foci. Embolic phenomena caused by anaerobes are most often observed in the lungs, where foci with foul-smelling decay form. Effusive, serous and slightly bloody pleurisy also sometimes accompany septic processes. Urinary and sexual organs. The sexual organs of women are very often the place from which S begins, but they can also be the place of manifestation of septic general disease. To a much lesser extent, this applies to male sexual organs. While a huge number of various causative agents have been isolated from gynecological septic foci, the localization of septic foci in male sexual organs is observed much less frequently and the nature of the microbes isolated from them is much less diverse. The usual causative agents here are staphylococci that have penetrated in connection with unsuccessful catheterization, and gonococci from deep urethritis and prostatitis. The urinary sphere with its large cavities is easily infected. Infection from here often generalizes and from a local b-ny S develops. The characteristic picture often observed in septic processes that began from the bladder and renal pelvis is also partly due to the products of urine fermentation. Urogenic S. is in most cases caused by the bacillus coli. Septic embolism in the kidney area is more often localized in the paranephrium. The parenchyma itself in S. in most cases responds, as to any infection, with albuminuria, often also with focal nephritis phenomena (hematuria, cylindruria). In the renal parenchyma in septic processes, multiple abscesses often develop. The bacteria causing S., especially the staphylococcus, are often excreted by the kidneys. Classification of sepsises. According to the principle that is accepted for other infectious diseases, within the general concept of S., it would be necessary to delineate separate species according to the microorganism causing the disease; however, the clinical picture of S. originating from different causative agents is largely similar, and the clinic would gain little from such a classification. Recognition of individual cases according to such a scheme, which would be etiologically correct, would also encounter great technical difficulties in isolating the causative agents and determining them, which would make it practically little applicable. To carry out the bacteriological-etiological principle, based on clinical signs, is far from always possible due to the absence of specific symptoms and their combinations. The overwhelming majority of S. are caused by streptococci. The place of their introduction is difficult to establish in most cases. Metastases do not always occur. The septic focus is located mainly inside and around large veins. The course is often stormy with large fluctuations in temperature. Sometimes, however, the streptococcus also causes a prolonged disease (sepsis lenta). Staphylococcal S. is observed somewhat less frequently. Multiple abscesses and metastases are almost always present. They appear in large numbers in muscles, even in the heart muscle. Both streptococcus and staphylococcus give endocarditis and meningitis. Staphylococci are excreted with urine. Joint lesions (purulent and serous) are more characteristic of streptococcal S. Pneumococcal S. is observed as a complication of pneumonias, less often generalization occurs from other sources. For pneumococcal S., secondary localization on the meninges, as well as on the heart valves, is characteristic, joints are less often affected. Meningococcal S. usually originates from the nasopharynx, is accompanied by petechiae, joint phenomena, and sometimes heart lesions, which are also combined with meningeal phenomena. In most cases, cerebral symptoms are the first clinical manifestation of S., predominate in the entire picture of the disease, and from them the general spread goes. Gonococcal S. belongs to the rarer forms. Its main feature lies in its ability to affect joints and endocardium. Other sites of lesion for this S. are atypical. Generalization occurs from the urethra and is often maintained from there. Septic diseases caused by B. ruosa-neus are characteristic of childhood, accompanied by hemorrhagic pustular eruption, after which necroses and small ulcers remain. Pyocyanotic lesions of the middle ear, heart valves, pleura, etc. have been observed. The bacillus coli, which abundantly inhabits the intestine of a healthy person, is also a cause of S. Postpartum, urinary and intestinal S. are often caused by this microorganism. A feature of colibacillary S. is the extremely rare metastasis of foci. Herpes is often observed in this case and S. proceeds with chills and sharp fluctuations in temperature. The course is relatively favorable. There are also cases of simultaneous septic lesion by different types of microorganisms. Special mention is deserved by typhoid and tuberculous S. In septic lesion by typhoid bacteria, the picture of the disease corresponds to S., not typhus, typhoid bacteria can be found in the blood, while the characteristic changes for typhus in the intestine are not observed. Such typhoid S. was found not only in adults, but also in newborns, whose infection occurred through the placental route. A number of clinicians describe the picture of S. caused by tubercle bacilli, in the blood of these patients an enormous number of Koch's bacilli are found, while at the same time specific tubercles, as in miliary tbc, cannot be found anywhere. The portals of entry, the place of introduction of the microorganism, are very diverse. According to Schottmüller, to a certain degree the portals of infection can be associated with certain microorganisms. 1) The skin and its injuries are often the place of entry for staphylo- and streptococci; 2) the mucous membranes of the mouth and pharynx admit streptococci and pneumococci; 3) the nose and accessory cavities are frequent sources of pneumo- and streptococcal S.; 4) the middle ear is predisposed to the introduction of streptococci, pneumococci and anaerobic bacteria; 5) the bronchi and lungs are permeable to pneumococci and streptococci, rarely to staphylococci; 6) the intestine and bile ducts are infected by B. coli and anaerobes; 7) the urinary tract is the place of introduction of B. coli; 8) the female genital sphere is infected by streptococci, staphylococci, B. coli and numerous anaerobes. The place through which the infection entered the body of the patient_gvery often subsequently loses its clinical significance. All interest is concentrated on the resulting septic focus, from which S. is subsequently maintained. Most S. begin with a certain local inflammatory process, from which the disease spreads further. This local process can be extremely insignificant and not give reason to suspect that from here such a heavy suffering as S. has spread. However, the anatomical arrangement of the stages of spread of infection, the location of septic foci allow to quite definitely indicate the area of introduction, where the portals of entry themselves are discovered in the form of obviously infected damage to the skin or mucous membranes. Cases where the portals of entry remain unexplained are not frequent. Much that is considered cryptogenetic S., upon careful questioning of the patient, does not deserve this name, as the anamnesis indicates that a long time ago the patient had some phenomena that can be recognized with great probability as the source of sepsis. In addition to bacteria entering from outside, self-infection can also be observed. In the mouth, intestine and sexual organs, bacteria are constantly present in abundance, which can cause septic disease. In addition to this constant carriage, the possibility of unusual carriage of bacteria without any clinical manifestations from the mucous membranes (B. typh. et paratyphi, coli, Löffler) and even of tissues--the so-called "dormant" infection (staphylo- and streptococci) has also been established. Thus there is no lack of bacteria for infection of the macroorganism, only suitable conditions are needed to give them the opportunity to spread. It is also possible that sometimes for still unclarified reasons the pathogenic power, virulence of bacteria increases. Undoubtedly in many cases we also observe a decrease in the resistance of the macroorganism to infection. This is evident from the fact that a large number of S. occur secondarily, after some disease. Every seriously ill patient (after typhus for example) from minor skin injuries, from bedsores, etc., is infected much more easily than a person not weakened by a previous disease. Moments favorable to infection can be not only general but also local. These include all traumatic S., where the tissue is weakened by trauma and the paths are widely open for the mass entry of bacteria.

Finally, both conditions may be observed simultaneously (sepsis in diseases of the urinary tract, sepsis in ulcerated neoplasms, postpartum sepsis). As for the location of septic foci, it must be remembered that for the formation of entry gates, a favorable factor is primarily the direct proximity to places rich in bacteria. Since the septic focus comes into contact with vessels, mainly venous, areas where plexuses of such vessels are located are particularly suited for the formation of a septic focus. Therefore, the veins of the small pelvis, associated with female genital organs, which are always rich in bacteria, or located near the prostate gland, as well as the hemorrhoidal plexuses, accessible to contamination by the intestinal flora, so easily become the site of septic foci. Also dangerous are all areas related to the venous cranial sinuses - the hairy part of the head, the occipital region, the upper lip, the paranasal sinuses, the ear, and the nasopharynx. The large branches of the portal vein are also dangerous, which in appendicitis and other abdominal inflammations can give rise to pylephlebitis. Foci in the heart itself in endocarditis are also known. The lymphatic system can also be the localization of a septic focus. The inflammatory process along the lymphatic vessels spreads according to the type of erysipelas or phlegmon, or metastasizes, giving rise to a new focus. In the end, the bacteria here also enter the bloodstream. Everywhere there are large accumulations of areolar tissue - the scrotum, pelvic cellular tissue, the perirenal area, the occiput, the neck - a septic focus can form and maintain general contamination. A focal lesion of bone tissue and individual cavities (peritoneum, joints) has special significance for sepsis, where the development of the infectious agent occurs under particularly favorable conditions. Depending on what the septic process began with and where the septic focus is located, one speaks of gynecological, urological, otogenic, etc., sepses. The course of sepsis can be very acute and end in the death of the patient in one or several days. In contrast to this, cases of prolonged chronic sepsis are also known. The most convincing example of a chronic septic process must be considered endocarditis lenta. Here all the main signs are present - a focus, septic symptoms, and bacteria in the blood. The concept of chronic sepsis has been expanded by some authors. It is pointed out that in many parts of the body, especially in the tonsils, around the roots of teeth, in the paranasal sinuses, as well as in various lymph glands, bile ducts, etc., inflammatory changes can develop without noticeable local symptoms, which cause distant septic phenomena, sometimes very severe. Fever, general exhaustion, anemia, neuralgic pains, focal nephritis, etc. - all these symptoms can be observed in cases of chronic sepsis. The main danger lies in the fact that the infection located in such a focus, under certain circumstances, can infect some other organ, just as is observed in the case of ordinary severe sepsis. Theoretically, the concept of chronic sepsis differs from the concept of dormant infection by the presence of all kinds of clinical symptoms, whereas a 'dormant' infection usually does not manifest until it gives an outbreak. For some time, the existence of chronic septic foci was given exaggerated importance. - All types of sepsis should always be considered a serious disease. Statistics show that among the most common severe types of sepsis, streptococcal and staphylococcal sepsis are particularly dangerous. Other types of sepsis - pneumococcal and sepsis from B. coli - are characterized by a somewhat milder course. Endocarditis lenta allows recovery only as an exception. The treatment of sepsis presents great difficulties and in most cases does not give favorable results. At present, in the treatment of sepsis, attention is focused mainly on the septic focus. If this focus is found, the first task is to eliminate it or, by ligation of the veins, delay the entry of the septic agent into the general circulation. For example, the rapid improvement of the most severe condition of a patient after amputation of a limb with a septic focus can serve as the best proof of the importance of the focus for the general picture of sepsis. Unfortunately, the location and multiplicity of the focus usually do not allow for radical removal of the infection. To this must be added that the focus is often poorly demarcated from healthy tissues. Nevertheless, in the treatment of sepsis, it is first necessary to think about local treatment. However, this is greatly hampered by the fact that for any surgical treatment, a prerequisite is the sufficient reactive forces of the patient's body. Therefore, in addition to local treatment, it is necessary to think about using all possible measures to raise the general strength of the patient. Questions of rational nutrition should be regulated accordingly. The same must be said about rational care for patients, attention to oral hygiene, the position of the patient in bed, etc. Wounds, injuries, scratches, and bedsores: in a septic patient are especially dangerous. Nutrition should not be too abundant, especially in fats, which are often poorly tolerated by febrile patients. The former viewpoint on the benefit of alcohol for a septic patient is not justified in any way. Emptying of the bowels should be as regular as possible. Periodic administration of laxatives is sometimes accompanied by a favorable effect. Great attention should be paid to the condition of the heart and blood pressure. Caffeine, camphor, and strychnine usually give a better effect than digitalis, which is of little effect in septic processes. Whereas in endocarditis lenta, the use of digitalis, despite the absence of any signs of decompensation, sometimes has a good effect on the general condition. The general well-being of a septic patient with high temperature usually improves significantly from warm rubdowns. To increase diuresis and maintain it in sufficient quantity, abundant drinking should be given. Infusions of salt or glucose solutions, sometimes recommended for septic patients, should be used with special attention to the rules of asepsis. Sometimes after infusion, definite improvement occurs. Septic nephritides, if present, require care according to general rules. The possibility of the appearance of septic pneumonias forces turning the patient more often and not allowing him to lie in one position for a long time. Unfortunately, all these general therapeutic measures have little effect on the main suffering. The situation is no better with disinfectant agents. Neither sublimate, nor silver nitrate, nor Rivanol, nor trypanflavin or colloidal metals, administered intravenously, have a certain effect on the septic process. They are constantly tested and their application remains unconvincing. Therapia sterilisans magna in the field of sepsis so far gives no results. The situation is no better with the use of serum treatments. None of the sera recommended to this day has stood the test of clinics, and all of them continue to be used to this day solely for lack of better treatment means.

E. Fromholdt. Surgical sepsis encompasses the most significant group of cases of S. that develop after injuries, surgical interventions, or complications of diseases that are usually subject to surgical treatment (the group of so-called surgical or related diseases). This includes cases of S. that develop after injuries (wounds) from street, industrial, agricultural, military-field; cases of S. complicating the course of all types of local inflammatory processes, such as: furuncles, carbuncles, phlegmons, abscesses, etc.; S. in persons who in the course of their work come into contact with infectious (virulent) material, for example surgeons, pathologists, etc. as a result of injury during operations, autopsies; cases of S. arising after various surgical interventions, etc. To this category should also be included cases of S. having their source in a focus in the oral cavity (oral S.), in the urinary organs (urosepsis), in the ear (otogenic S.), in the female genital organs (gynecological S.), especially in pregnant women or parturients (obstetric S.). The main feature of surgical S. is the presence of a primary wound or purulent focus that is the object of surgical intervention. The other factors determining S., such as a certain clinical picture, bacteremia, are common to all groups of S. (including surgical). ^ Lexer divides all cases of S. into: 1) general purulent infection with metastases and 2) general purulent infection without metastases. General purulent infection with metastases (pyohaemia-pyemia) develops by bacteria from some purulent focus in the body entering the bloodstream and subsequently settling in the tissues or organs and forming metastatic abscesses; general purulent infection without metastases (septicaemia-septicemia) - in the common room 'infection of the blood' - develops when bacteria and their toxins penetrate into the bloodstream and subsequent intoxication of the body, and in most cases it does not come to metastases. Such a division is quite sufficient for clinical purposes and allows one to distinguish between both groups of S. at the patient's bedside not only on the basis of the absence or presence of metastases, but especially on the basis of the different picture of the disease. Between these two forms of general purulent infection there are transitions, and in the literature (Baumgarten and others) they are usually designated by the term 'septicopyemia'. The first form of S. proceeds as a normergic inflammatory process, the second as a hyperergic one. Division of S. can also be carried out on the basis of accounting for the gates of entry, such as: 1) wound S. (after trauma), 2) 'inflammatory' (phlegmon, abscess, osteomyelitis, etc.), 3) postoperative, 4) cryptogenic (only the form with metastases can be attributed to surgical S.). At present, surgeons mostly have to deal with the 1st and 2nd groups, much less frequently with the 3rd and 4th groups. Surgical S. does not have its own constant causative agent, but can be caused by any of the pyogenic microbes (see above). In the overwhelming majority of cases, the primary infectious focus coincides with the gates of infection, i.e. at the site of introduction of the causative agent and the infectious focus develops (wound sepsis, postoperative, postpartum sepsis, etc.); in other cases, the local infectious focus at the gates of infection may be absent, but develop at some distance and from this distant focus S. develops, for example osteomyelitis-sepsis. With generalization of the process, the character and direction of the process can change depending on the ratio of reactive properties of the body and peculiarities of the infectious agent or in the direction of normergic state (then pyemia develops), or in the direction of hyperergia (purulent infection without metastases), or allergy (fulminant S., abortive, etc.). A significant role in the development of S. is played by anat.-physiol. conditions of spread of the process. In this, it is necessary to take into account: 1) the size of the primary focus, 2) the site of introduction of infection, 3) anat.-physiol. conditions of blood circulation and 4) locus minoris resistentiae. 1. There is a certain parallelism between the size of the primary focus and the frequency of generalization of the process. Thus, it is known that large wound surfaces, especially those resulting from military-field injuries, represent a special danger in terms of the development of S. Similar data exist also in relation to inflammatory processes. Kaufmann notes that S. is observed in 25% in single forms of furuncle and in 75% in widespread ones. 2. As for the site of introduction of infection and the paths of its spread, it is necessary to note that, according to Felsenthal, every organ and every part of the body can become a focus of sepsis. According to the data presented in the work by Schultze, the most frequent gates of entry of general infection are the skin and traumatic injuries of the extremities (open fractures, etc.). A significant role is played by the paths of spread of infection from the primary focus: hematogenous, lymphogenous, canalicular or combined. Spread of infection by the lymphogenous path gives fewer cases of generalization of the process than the hematogenous; infection, being in the bed of lymphatic vessels, can easily be retained in lymphatic glands, where it is fixed and neutralized by the reticulo-endothelial system of the nodes. A significant role is played by the richness of a given area with blood or lymphatic vessels and the speed of blood flow. 3. Anatomophysiological conditions of blood circulation play a significant role primarily in that arteries carrying a larger amount of blood contain more bacteria (spleen, liver); with a smaller amount of blood, fewer bacteria (parotis, pancreas). With arteries of the same caliber, the one that branches off obliquely from the main trunk carries more blood, and the one that branches off perpendicularly from the trunk carries less. The character of the branching of arteries in organs cannot be left without attention; thus, terminal arteries are the site of settlement of infection (brain, kidneys, heart, lungs). According to Schultze, for the spread of infection and the character of the changes that occur, the form of the capillaries and their connection with the reticulo-endothelial system play a significant role. On the basis of experimental work with intravenous injection of rat cadavers, Schultze divides internal organs into 3 groups: 1) organs with wide capillaries in the closest connection with the reticulo-endothelial system (liver, spleen, bone marrow, lymphatic nodes); 2) organs having not wide, sometimes tortuous capillaries, intimately connected with the reticulo-endothelial system (lungs, kidneys, skin); 3) organs with narrow, elongated capillaries in insignificant connection with the reticulo-endothelial system (periosteum, muscles). This division, taking into account the character of the capillaries and their connection with the reticulo-endothelial system, should help to resolve the question of the selectivity of organ damage in general infection and the development of metastases in S. Thus, the wider the capillaries, the more bacteria are brought by the blood; the closer the connection with the reticulo-endothelial system, the more such an organ is involved in the process; on the other hand, the more intimate the connection with the reticulo-endothelial system, the faster the process of transition of bacteria into the cells of the reticulo-endothelium and cleansing of the bloodstream from them. Thus, we should expect in S. the greatest damage to organs of the 1st and 2nd groups. And indeed it is known that in S. most often affected are liver, spleen, bone marrow, lungs, kidneys, etc., i.e. organs of the 1st and 2nd groups. Schultze, arranging his clinical material according to the frequency of damage to one or another organ, showed that the most frequently affected are spleen (in 1st place), then liver, then kidneys, lungs, lymphatic glands, endocardium, etc. It is also necessary to note that organs rich in reticulo-endothelial system, quickly cleansing themselves from infection, most often have parenchymatous, not purulent, lesions. Thus, for example, the spleen and liver are organs most often involved in the septic process and at the same time the most quickly cleansed from infection. 4. The role of 'Locus minoris resistentiae' in the development of foci (metastases) is well known to clinicians. Often a certain part of the human body, having been traumatized, in the presence of purulent infection in the body becomes the site of settlement of bacteria and development of a metastatic focus. With trauma, one deals with necrotic and necrobiotic processes at the site of injury with rupture of blood and lymphatic vessels and entry of blood and lymph into the area of injury; thus all favorable conditions are created for bacteria to enter this part of the body and develop rapidly against the background of the necrotic process. When analyzing the pathogenesis of S., it is of course necessary to take into account the virulence of the infection. As for the virulence of the causative agents, according to Donath and SaxPy, it is understood as: 1) the rate of growth and 2) the toxicity of the causative agents.

Since a number of authors (Schottmuller, Schmitz and others) deny the possibility of bacteria multiplying in the circulating blood, according to their view the issue is not about the rapidity of microbe reproduction, but about the quantity of them entering the blood from the septic focus. - Pathological anatomy G. - see above. We proceed to describe the picture of both groups of S., dwelling in detail on the clinical data. We emphasize that the picture of S. is not unambiguous and is never characterized solely by the type of pathogen, especially in terms of course, formation of metastases, disruption of organ vital activity, etc. Thus, staphylococcal infection, entering the blood in large quantities and in a state of high virulence, can proceed with the picture of fatal poisoning, without metastases. On the other hand, streptococcal infection, entering the body in a low-virulence state and in small quantities, can proceed very chronically with absence of toxic phenomena and with metastases in the heart valves, large joints, etc. - General purulent infection with metastases can proceed acutely, subacutely and chronically; therefore the clinical picture will differ depending on the nature of the process. The source of this group of infection is often purulent processes in the skin, subcutaneous and intermuscular loose connective tissue, ulcerative processes of the skin and mucous membranes, lesions of bones, joints, serous membranes, etc. Often the source of this form of S. is the inflammatory process in the oral cavity (teeth), pharynx (angina), accessory nasal cavities, middle ear, area of the anal opening (paraproctitis), mucous membrane of the uterus (after abortion, childbirth), pyelitis, etc. Particular inclination toward the development of this group of infections is shown by purulent diseases of the vessels joining the infectious focus, especially veins, cerebral sinuses (thrombophlebitis). Examples can be the well-known clinical cases of pyemia resulting from lesions of the middle ear and thrombosis of sinus transversus et v. jugularis, postpartum pyemias on the basis of thrombophlebitis of the pelvic veins, pyemias in appendicitis or after appendectomy (lesion of mesenteric vessels), pyemias after carbuncles and furuncles, especially on the face (thrombophlebitis of v. facialis), etc. For the clinical picture of general pyogenic infection with metastases, severe general phenomena, a peculiar course of fever, strong shaking chills, and development of metastases are characteristic. Patients are in a serious condition, their skin is dry, shiny, facial features are sunken. Usually there is a depressed state of the nervous system; in severe cases - decreased consciousness, loss of it, delirium; sometimes shortly before death patients fall into a state of euphoria. In chronic cases of pyemia, yellowish discoloration of the sclera and skin (mainly hematogenous jaundice) often appears. This jaundice depends on the breakdown of red blood cells, on disease of the liver (parenchymal changes or metastatic processes) and finally may depend on catarrh of the mucous membrane of the duodenum with disruption of bile outflow. In severe cases of pyemia, skin rashes (exanthemas) are observed, appearing either as a result of toxic changes in the walls of capillaries or as a result of metastatic lesions of the skin. Fever in pyemia has an irregular course, sharply remittent character with daily fluctuations within 3-4° (increase in t° in the evening, sharp decrease in the morning to normal or even below it) or intermittent character, i.e., after an increase in t° there is a decrease to normal or even below for an indefinite time, only to subsequently rise again to high figures. This type of infection usually begins with a strong shaking chill, which b. or m. often repeats, sometimes with intervals of several days, sometimes even several times a day. Measurement of t° immediately after the chill usually reveals an increase to 40-41°. The phenomenon of chill and temperature increase indicates the fact of entry of a new infectious agent into the bloodstream. Decrease in t°, disappearance of chills indicate either absence of infectious agent in the blood or disruption of the function of heat-producing and temperature-regulating apparatuses, which sometimes occurs before death. The fever can take the character of febris continua if strong and continuous absorption of bacteria and their toxins occurs from primary or metastatic purulent foci. In such patients besides chills, sometimes profuse sweats are noted, so that it is necessary to change linen several times a day. After the decrease in t° in these patients, symptoms of severe weakness are often noted. According to data by authors (Buzello and others), the type of pathogen also exerts some influence on the character of the temperature curve. Thus, for streptococcal infection, intermittent fever, changing to constant fever, is more characteristic. For staphylococcal and pneumococcal infection, the remittent type of fever is more common. For infection with the bacillus coli or gonococcus, a sharply intermittent type of curve is found. Buzello recommends in patients with S. simultaneous measurement of t° in the axillary fossae and in rectum. This has significant prognostic interest, since in the beginning signs of cardiac weakness, a difference between t° in the axillary fossa and in rectum of 2-3 or more degrees is found due to insufficiency of the work of the cardiac muscle and disruption of blood circulation. The next important symptom is the small and frequent pulse. Increase in pulse rate often disproportionately precedes the t° and reaches 120-140 beats per minute. Increase in pulse rate is obviously dependent on irritation of the n. accelerantes by toxins or high t°. Uneven, easily compressible and small pulse indicates toxic damage to the cardiac muscle. During the disease, endocarditic murmurs sometimes appear; here the issue may be about passing systolic murmurs appearing as a result of dilation of the heart, or they become permanent and then the matter obviously concerns an added metastatic ulcerative endocarditis; most often the mitral valve is affected. In convalescents, slowing of the pulse may appear, which is a symptom of fatigue of the severely overloaded heart. Sharp changes also occur on the part of the blood. According to Schottmuller, S. does not give a definite picture of the blood. 'The type of pathogen, the influence of toxin on the blood-forming organs, metastatic foci, the state of the blood-forming apparatus and individual predisposition of the body do not make it possible to fit the changes in blood into one definite formula for S.' A significant decrease in the number of erythrocytes and decrease in Hb content (to 30%) is noted. On the basis of intoxication, massive breakdown of erythrocytes is noted, which manifests itself as hemoglobinemia and hemoglobinuria. At the beginning of the disease, hyperleukocytosis (up to 20,000) is mostly noted, which according to clinicians is a favorable sign. On the basis of path.-anat. research by E. F. Müller, the first place of settlement of bacteria from the blood is the bone marrow of the vertebrae. In connection with this, the function of a considerable part of the leukopoietic system is disrupted and reactive transformation of the fatty bone marrow of the long tubular bones into functioning red bone marrow develops. This phenomenon is accompanied by strong leukocytosis. Neutrophilic leukocytes and young forms come especially to the fore. If in the further course of the process the bone marrow of the long tubular bones is also affected by the infectious process, leukopenia may occur. In a series of acute cases, as well as shortly before death, normal leukocytosis or leukopenia may be observed. On the part of the lungs, symptoms of bronchitis or bronchopneumonia are noted, often little detectable. A severe complication is metastatic lung abscesses, especially occurring in staphylococcal infection. Accelerated and difficult breathing, cyanosis of the lips in the absence of initial path. pulmonary data are serious indications of development of foci in the lungs; subsequently serofibrinous or purulent pleuritis may join. On the part of the urine, usually slight albuminuria is established; the amount of urine is decreased, while the amount of urea and nitrogen-containing substances increases. Multiple abscesses of the kidney cortex often observed on the autopsy table in cases of pyemia are usually not clinically detected. Sometimes noted bacteriuria in the absence of purulent metastases in the kidneys serves as a sign of severe toxic damage to the kidneys. Often during the disease, symptoms of cystitis join. Changes on the part of the gastro-intestinal tract: absence or weak appetite, nausea, sometimes vomiting (of toxic nature), dry and coated tongue. Diarrheas appearing during the disease greatly exhaust patients; they depend on metastatic lesion of the mucous membrane of the gastro-intestinal tract or on excretion through the intestinal mucous membrane of toxic products of infection; diarrhea can also develop as a result of amyloidosis of the intestine, occurring in the prolonged course of pyemia. The liver in a number of cases is markedly enlarged, especially due to stagnant phenomena. The spleen enlarges (septic spleen), but due to its flabbiness is not clearly palpable; its palpation is usually painful.

Enlargement of the spleen occurs due to hyperplasia of the pulp and intensified destruction of red blood cells taking place in the spleen itself. The most frequent localization of metastatic abscesses is the subcutaneous and intermuscular loose connective tissue. The number of such metastatic abscesses can be considerable; in the literature there are indications of cases where surgeons had to open up to 100 such abscesses. It should be noted the predisposition to metastases in the loose connective tissue under the pectoralis major muscle, the gluteal region, and the paranephric region. Metastases are also observed in the lungs, kidneys, muscles, serous membranes, joints, eyes, etc. Metastases in the lungs are clinically accompanied by the appearance of shortness of breath, cough, expectoration of sputum, etc.; the development of pulmonary infarcts is expressed in the sudden appearance of shortness of breath, bloody sputum, and decline in cardiac activity. Metastases in the kidneys proceed covertly or with the phenomena of severe acute nephritis. Foci in the muscles develop either in the order of limited abscesses or in the form of a widespread inflammatory process. In various joints, a serous or purulent synovitis develops, either more acutely or subacutely, which in severe cases can pass into general inflammation of the joint (arthritis) with destruction of the ligamentous apparatus and articular cartilage. From the side of the eyes, hemorrhages or necrosis of the retina, clouding or suppuration of the vitreous body, iridochorioiditis or general purulent inflammation of the eyeball are observed very frequently. Particularly severe are metastatic ophthalmias, developing due to infectious emboli entering the retinal capillaries and leading to suppurative processes and loss of vision. Authors (Schmitz and others) indicate that when examining the fundus of the eye of patients with S., one can discover 'spots' which Roth considers to be metastases. Otitis media can also develop metastatically, which leads to impairment of hearing. As for the question of the nature of metastases in one or another type of microbes (their organotropism), staphylococci affect primarily the kidneys, the juvenile bone marrow, the liver, and small joints (especially the interphalangeal and sternoclavicular joint); streptococci—the large joints, the periosteum, the pregnant uterus, the endocardium (especially the heart valves), etc.; pneumococci—the meninges; the bacillus coli leads primarily to metastatic suppurations in the peritoneum, the wall of the urinary bladder, the renal and hepatic passages, etc. In most cases, pyemia has an acute course (10-15 days), more rarely chronic (2-5 months), sometimes even more. The prognosis in pyemia is always serious. General purulent infection without metastases. The main, characteristic feature of general purulent infection without metastases is the flooding of the blood and the entire organism with bacterial poisons and bacteria and the general intoxication of the organism. It sometimes occurs after the most insignificant injuries, such as: after pricks with a pin, needle, scratches, cuts, etc.; in these cases, already a few hours after the injury, there appear a shaking chill, high fever, and severe general condition (e.g., cases of S. in pathoanatomists or in surgeons during purulent or purulent-necrotic operations). In other cases, the onset is less acute, and the patient already has a more or less long-standing inflammatory process (e.g., paronychia, carbuncle, phlegmon, osteomyelitis, etc.), which is complicated by general infection. In these cases, the phenomena of the general reaction of the given disease pass gradually, for the most part without a shaking chill, into the picture of general infection. The clinical phenomena described in metastasizing infection are partly repeated here as well, but they have a more pronounced and acute character. A very severe general condition, prostration, general weakness, restlessness, pulling pains in the extremities are noted. The skin is dry and hot to the touch; skin exanthemas, petechial or pustular rashes appear. The nature of the rash differs somewhat depending on the type of infection. Thus, for streptococcal infection, erythemas are characteristic, partly resembling scarlet fever or erysipelas; in staphylococcal lesions, there is often a rash similar to acne or various pustules. The temperature is constantly highly elevated (up to 40° and more); morning and evening fluctuations usually do not exceed 0.5-1°; before death in collapse, the temperature may fall below normal. This type of infection is quite often accompanied by 'bloody' diarrhea. From changes in the blood composition, a sharp decrease in erythrocytes and the amount of hemoglobin is noted; at the same time, there is a sharp thinning of the blood due to great loss of protein (Grawitz). A significant leukocytosis is mostly not observed; in some cases, leukopenia is noted. Due to toxic and bacterial damage to the vessel walls, hemorrhages occur in the skin, serous membranes, conjunctiva, retina, bone marrow, etc. Characteristic changes are noted in the wound surfaces that served as the source of general infection. The wound surface becomes dry and is covered with a dirty coating due to superficial necrosis of the tissue and a fibrinous coating containing bacteria; the discharge of pus and further granulation of the wound cease. The duration of the disease is usually very short. In the most severe cases, death already occurs after 1-2 days (fulminating S.); sometimes after energetically conducted treatment, improvement occurs, which is usually followed by deterioration. The prognosis for the disease is very threatening, especially in acute cases, although in a number of cases recovery is achieved. The diagnosis of S. is made on the basis of the clinical picture and bacteriological examination of the blood. Bacteriological examination of the blood must be carried out systematically during the septic process both for the purpose of diagnosis and for the purpose of controlling treatment. The fact of finding bacteria once without a corresponding clinical picture does not yet indicate a general purulent process, since at the present time it is well known that with almost any local purulent process (furuncle, carbuncle, phlegmon, mastitis, osteomyelitis and others), bacteria can be found in the blood from time to time. Examination of the blood for bacteria (by seeding on nutrient media or inoculation of animals) must establish the type of bacteria and their approximate number. For seeding on nutrient media (under aerobic and anaerobic conditions), blood in the amount of 5-10 cm³ is taken from the subcutaneous vein of the elbow in adults or from the v. saphena magna (or one of its branches) in children. In addition to seeding, it is also recommended to make inoculations of animals (e.g., white mice). On average, after a day, it is possible to determine the type of the growing microbe; for the bacillus coli, this period is reduced to 10-12 hours. In general purulent infection with metastases, blood cultures must be taken immediately after a chill; in general purulent infection without metastases, the time of seeding is indifferent. For topodiagnosis of the septic focus in cases where it cannot be found, Friedemann proposed a test based on the fact that blood taken closer to the septic focus contains a larger number of microbes than blood taken from a distant site. If one portion of blood is taken directly at the focus and another from a distant area, then upon bacteriological examination, a greater difference in the number of bacteria is obtained. Differential diagnosis must first be carried out with miliary tuberculosis and typhoid fever (see the respective articles); more rarely with cerebrospinal meningitis, acute articular rheumatism, malaria, etc. Of the various types of S. close to surgical, first of all, postpartum S. (puerperal S.) must be mentioned (see below). Cases of sepsis of otogenic origin were well known to old clinicians; works indicating a connection between disease of the temporal bone and sepsis date from the beginning of the last century. The process develops in such a way that the middle ear becomes diseased, from which it spreads to the cells of the mastoid process, to the wall of the transverse sinus, namely to its sigmoid process. A purulent thrombophlebitis arises, which subsequently becomes a source of general infection. Otogenic S. does not always go through sinus thrombosis. The process can generalize without thrombophlebitis (Kerner's osteophlebitic pyemia); in addition, the infection can directly pass to the meninges and subsequently spread throughout the body. Clinically, otogenic S. proceeds in the same way as other types of S. What is characteristic for this type of S. is the appearance of metastases in the subcutaneous tissue, muscles, joints. Prognosis: in the preoperative period, the prognosis was very poor and reached 90% mortality (Mygind, Uchermann); after the application of surgical intervention, the prognosis radically changed and gives 50-60% recovery. Oral S.—the problem of it has been raised and developed to a significant extent by American authors. A number of cases of S. in the absence of a clearly expressed primary septic focus and with the presence of one or another foci in the oral cavity belong to the category of oral S. In the problem of oral S., a special role is assigned to pulpless teeth.

Ryvkind, when examining the question of the pathological anatomy of dental septic foci, notes that as sources of odontogenic septic processes, chronic marginal and apical paradentitis are usually considered, which represent foci predominantly of productive inflammation. When examining their role in the development of sepsis, Ryvkind notes that 'apical foci, arising as a result of infection penetrating into periapical tissues from the root canal, are those areas that can serve as primary foci in chronic sepsis.' He does not attribute importance to marginal foci, since they are open foci and thus there are no conditions for the absorption of inflammatory products. Treatment of S. Numerous methods of treating S. have been proposed; the fact that there are a large number of them speaks to the absence of reliable methods of treatment that could displace all others. The main rule for treating S. is strict individualization depending on the nature of the infection and the condition of the patient. All methods of treating S. must be divided into: a) general (symptomatic) treatment, b) surgical, c) specific methods of treatment. All these methods of treatment are not in contradiction with each other, but mutually complement. Patients with general infection should be provided with careful care and the best possible conditions for rest and sleep. It is necessary to pay the most serious attention to the condition of a number of organs and systems that suffer most in S. Early strengthening of the heart's strength (without waiting for cardiac weakness) should be carried out in the form of daily intramuscular injection of 5-10 cm³ of camphor (1-2 times a day), and in case of cardiac dysfunction, intravenous or subcutaneous administration of Digalen or Coffeini natri-benz is recommended. The activity of the heart must be carefully monitored and after the septic process, since even after recovery of the patient, early cardiac strain can lead to various serious complications (acute cardiac decompensation, etc.). Fever does not require special therapeutic interventions; antipyretics in this case only worsen the heart's work and conceal the true state of affairs. If with a prolonged high temperature threatening phenomena from the side of consciousness occur, then cold wraps or baths with 'cool' temperature are recommended. The patient is carefully seated in a bath with a temperature of 32° (on average) and with constant monitoring of the pulse, the bath is brought within 10 minutes to a temperature of 25°. Prevention of pulmonary complications should be carried out in the form of daily breathing exercises, provided there is wide access to clean air. In case of threatening stagnation in the pulmonary circulation, small bloodlettings (50-100 cm³) are recommended; these bloodlettings also help to remove toxins from the circulating blood. Nutrition has enormous importance in the treatment of S., and it represents a difficult task, since the digestive and absorptive capacity of the gastrointestinal tract in such patients is sharply impaired. According to Bondy, patients with general infection need 1,500-2,000 calories per day. Here liquid, most digestible substances should predominate, in which the main nutrients should be contained in concentrated form (milk, eggs, butter, sugar, etc.). A number of authors (Veliaminov, Buzello, etc.) recommend wine or cognac to such patients as substances that stimulate appetite, improve mood, provide the patient with a certain amount of calories, etc. Patients with general infection, due to high temperature, frequent sweating, etc., excrete significant amounts of fluid and appear to be very dehydrated, which sharply worsens their general condition. Therefore, abundant introduction of fluids here is urgently necessary. Such patients should drink as much as possible; in addition, the introduction of physiological solution by drop enemas is desirable. In case of diarrhea, one has to resort to subcutaneous or intravenous infusions. With intravenous infusion, a small amount of fluid (500-1000 cm³) should be administered, since otherwise collapse from overload of the right half of the heart may occur. The introduction of fluid into the patient's body raises the tissue turgor, dilutes toxins and promotes diuresis. For insomnia, veronal, luminal, bromural are indicated. Chloral hydrate has a good effect in the form of enemas-10-15 cm³ of a 10% solution in the evening. As for the surgical treatment of S, there is no unanimity on this issue. A number of authors (Schottmuller, Lexer, Martens, Fraenkel, Sultan, etc.) recommend radical, possibly early, operative measures in the form of wide opening of the purulent focus and its drainage, sometimes removal or enucleation of the primarily affected organ (for example, kidney). In a number of cases of acutely occurring general infection without metastases, one has to resort to urgent amputation or exarticulation when it is necessary to remove the focus of infection as quickly as possible, threatening the inevitable death of the patient. A number of authors (Rufanov, Ul'iki and others) adhere to a more conservative point of view regarding surgical measures in S, recommending as sparing measures as possible and refraining from early operations in a number of cases. Ul'iki, for example, says: 'The outcome of surgical treatment can be fatal if the operation is performed too early, for example, when a finger is injured, when there is still no barrier, etc. Undoubtedly, a certain percentage of mortality falls on the early incision.' In a number of cases, to prevent the carrying of infection from thrombosed, infected veins, it is recommended to ligate the draining veins, for example, the internal jugular vein in case of facial carbuncle and thrombophlebitis of the anterior facial vein, or in case of disease of the sinus transversus after purulent inflammation of the middle ear, v. saphenae magnae in thrombophlebitis of its branches, veins of the small pelvis in puerperal S., etc. Under specific methods of treatment of general infection, measures are understood that are directed at the direct destruction of bacteria or at achieving the quickest immunity to them. However, until recently, all urgent attempts to obtain such radical specific means remained without due success. For S., the introduction of alkalis is recommended, to which staphylococcus is especially sensitive. Thus, according to Vorschutz, daily introduction of 10-20 g of Natri bicarbonici in milk is recommended. Buzello offers intravenous administration of a 40% solution of urotropine in Ringer's solution. This solution must be administered in a heated to 37° form in an amount of 10 cm³ daily 1-2 times. Sometimes after 6-8 injections, irritation of the bladder may occur, which quickly passes after stopping the injections. Buzello saw a good effect from these injections. Attempts at therapiae sterilisans magna in general infection have not yet given obvious success. Especially many attempts have been made with preparations of colloidal silver (Collargol, Electrargol, etc.). Collargol is used in the form of ointments, enemas, intravenous injections; thus, for intravenous injections, a 2% solution of it is used in an amount of 2-10 cm³; for enemas, a 1-2% solution is used in an amount of 90-100 cm³. Hume recommended administering intravenously a solution of Arg. nitrici 0.1 per 1,000.0 in an amount of 300 to 1,000 g for sepsis. Calcium therapy in S. should be especially emphasized. In a number of cases, a good effect has been obtained from this method of treatment in general infections (Petrov, Chistyakov, etc.). At present, intravenous infusion of a 10% solution of calcium chloride in an amount of 10 cm³ daily is used; there are proposals for intravenous infusions of a 1% solution of calcium chloride in an amount of 200-400 cm³; it is also possible to administer per clysmam in the form of a 10% solution. Attempts at active immunization in S. have mostly ended unsuccessfully. At present, observations are being made with passive immunization. A polyvalent serum prepared from various human strains of streptococcus has been prepared, which in a number of cases gives a satisfactory result. The serum is administered subcutaneously into the area of the thigh or chest in 50 cm³ or more until improvement in clinical manifestations. For general infection, intravenous infusion of normal human serum in an amount of 150-200 cm³ in 800 cm³ of physiological solution with the addition at the end of the infusion of 30-40 cm³ of polyvalent anti-streptococcal serum is also recommended. For the treatment of general infection, Wright proposed transfusion of immunized human blood; there are a number of reports (Kramarenko and others) of favorable results of this method of treatment.-Regarding the question of blood transfusion in general purulent infection, there are conflicting data. Spasokukotsky believes that in a number of cases blood transfusion gives a good effect, and illustrates this with his material, where out of 92 patients with S., recovery was achieved in 34.3% of cases. Richard Lewisohn writes: 'In chronic sepsis, transfusion improves the condition, while in acute cases it can accelerate a fatal outcome.' A number of authors (Sokolov and others) consider blood transfusion in acutely occurring general infection useless, since the transfused erythrocytes die immediately.'

The main fight against S. should be directed toward prevention. Correct and timely treatment of local inflammatory processes, complete asepsis during clean operations, and preventive measures in the treatment of wounds, burns, ulcers, etc., are the main preventive measures in the fight against sepsis.

V. Shlapobersky. Postpartum sepsis differs from therapeutic and surgical sepsis, on the one hand, by the greater lability of the patient's organism, weakened by birth trauma and blood loss during childbirth, and on the other hand, by the fact that the extensive birth wound and enhanced absorption from the postpartum uterus create particularly favorable conditions for the widespread spread of infection through the network of numerous blood and lymphatic vessels of the small pelvis. Therefore, the prognosis for postpartum S. is generally more unfavorable, and the fight against infection is less successful than in therapeutic and surgical S. The obstetric history is of great importance, as it gives indications of the possible source of infection, for example, in S. after an illegal abortion or childbirth with the participation of midwives, there is a greater chance of exogenous infection; after dry, prolonged or operative deliveries (especially after manipulation of the placenta) in a maternity hospital, the infection is more often endogenous-vaginal; in acute angina and influenza in the puerperal woman, in most cases, there is extragenital (hematogenous) infection. The diagnosis of postpartum S. is based on the analysis of the entire clinical picture of the disease, its statics and dynamics, and on the bacteriological identification of the causative agents of infection (see above). The most characteristic clinical manifestations of postpartum S. include the general condition of the patient, the temperature and pulse curves, chills, symptoms of metastatic lesions in various organs, as well as signs of functional disorders of vital organs. The general appearance of the patient in most cases indicates a severe illness. Jaundice of the skin and sclera is observed with severe infection by hemolytic microbes (aerobic and anaerobic). The temperature and pulse curves characterize different forms of postpartum S; thus, the acute stage of septicemia is characterized by a high temperature (up to 40-41°) with a critical drop in favorable outcomes. Septicopyemia gives a very broken curve with sharp (2-5°) daily fluctuations and periodic (over several days) decreases and increases in the general wave, which signal temporary lulls in the process followed by intensifications of the aggressiveness of microbes and the formation of new foci of infection." The pulse curve usually corresponds to the temperature curve; a divergence of these curves indicates a weakening of cardiac function and serves as a poor prognosis (crux mortis). Chills signal an active reaction of the body to the massive entry of microbes and toxins into the blood. Repeated chills are especially typical for thrombophlebitis in large veins with secondary metastases. In favorable outcomes of septicopyemia, a gradual weakening and cessation of chills are observed with a slow lytic drop in the temperature curve. The diagnosis and even more so the prognosis can be established in each individual case only after a certain observation of the course of the disease, taking into account all the data of the statics and dynamics of the clinical picture. Aids for clarifying diagnosis and prognosis are Foshier's fixation abscess, the erythrocyte sedimentation reaction, and to a lesser extent, the intracutaneous reaction of Bezredka. When making a prognosis, one should also take into account the greater or lesser resistance to infection of various constitutional types of women. The most unfavorable prognosis is given by the acute hematolymphogenous S. In extensive thrombophlebitis and multiple metastases, the prognosis is made with great caution both with regard to the preservation of the patient's life and to the restoration of her health, because these lesions, even in cases with favorable outcomes of postpartum S., often lead to prolonged, and sometimes permanent, occupational disability of the woman. Postpartum S. must be differentiated mainly from other acute infectious diseases in puerperal women and parturients. Streptococcal infections (angina, scarlet fever), as well as measles, show such a strong tendency to transition to postpartum S. that they are difficult to differentiate. The diagnosis of postpartum S. from erysipelas and diphtheria presents difficulties only in cases where the primary focus is located in the genital area and can cause general infection through the uterus. Other acute infectious diseases—typhus and typhoid fever, pneumonia, as well as malaria—are recognized without particular difficulty by the absence of the complex of characteristic manifestations of postpartum S. and by specific blood reactions.-Prevention of postpartum S. reduces to the prevention of postpartum diseases in general (see Postpartum period). For the treatment of postpartum S., a great many methods and the most diverse medications have been proposed, most of which prove to be of little effectiveness. Intrauterine manipulations are indicated only in cases of profuse bleeding due to incomplete emptying of the uterus; in all other cases, local therapy must be strictly conservative to avoid injury to the infected uterus. The methods of general treatment of postpartum S. are divided into: 1) specific therapy, 2) surgical, and 3) symptomatic (see above). Surgical methods of treatment of postpartum S. include excision of the uterus, ligation of thrombosed veins, and opening of purulent foci. Most authors speak out against excision of the uterus, considering its removal as the primary focus of infection irrational in general infection, and in local intrauterine—inadequate and too radical. Ligation of thrombosed veins, according to Trendelenburg, is still in the stage of lively discussion and needs further clarification of indications and contraindications. The main practical difficulties are the timely and accurate diagnosis of thrombophlebitis and the choice of the proper moment for intervention. Surgical evacuation and drainage of purulent foci (peritonitis, pleurisy, phlegmon, etc.) are undoubtedly indicated in postpartum S, but play only an auxiliary role, as they eliminate the secondary consequences of general infection without having a decisive effect on the main process. The experience of the postpartum infectious clinic of the Moscow Oblast Scientific Research Institute of Maternity and Infancy shows that the most effective method of treating postpartum S. lies in the combined use of a 40% solution of urotropin intravenously or the Rosen method together with antitoxic sera, then in the abundant administration of a 10% solution of glucose (subcutaneously or in drip enemas), in maximum immobilization of the patient, well-organized care, in stimulation of the heart, as well as in timely surgical interventions in the formation of purulent accumulations. S. Sazonov. Sepsis in children is distinguished by a number of features, which are determined by the peculiarities of reactivity and the state of the tissues of the child's organism, as well as the place of penetration of infection, different from what we have in adults. S. in children is characterized above all by the high frequency of these diseases, the rapidity of development of the process, the involvement of the gastrointestinal tract, the tendency of the organism to bleeding, and finally the absence of intermediate phases of the spread of the septic process (inflammation of lymphatic vessels and glands). The younger the child, the more these features manifest themselves, and they are most clearly expressed in the neonatal period (see Newborn), when S. also occurs relatively more frequently. A child can become infected in the uterine period with a similar disease of the mother or even only with a local process (angina, for example) in her. Usually children are born dead in these cases, sometimes even macerated. Infection of the child during childbirth occurs much more frequently and happens when microbes from contaminated waters enter the respiratory tract [nose, nasopharynx, lungs (Fischl)] or the digestive tract, from where microbes penetrate through the undamaged intestinal wall due to its increased permeability compared to older age (Czerny, Moser). Microbes found in contaminated (bad-smelling) waters or often in so-called dry births can infect children through the skin with even the slightest damage to it, and here precisely, due to the low reactivity of tissues, lymphatic vessels and glands do not give an inflammatory reaction, and infection directly penetrates the blood. Finally, microbes from contaminated waters can penetrate through the remnant of the umbilical cord when it is cut. In the former pre-aseptic era, the umbilical wound most often served as the gateway for infection, followed by arteritis and phlebitis of the umbilical vessels, but now with proper care of the navel, infection more often penetrates through other places, namely: the oral cavity (Bednar's aphthae), the stomach and intestines (feeding with milk containing pathogenic microbes); often the source of S. is the nasal cavity and nasopharynx, from where microbes penetrate into the middle ear, and purulent otitis already serves as a focus for S. Acute S. originates from the urinary organs. Essentially, any violation of the integrity of the skin or mucous membranes can be the site of introduction of infection, and the absence of regional enlargement of lymphatic glands gives no indication of the site of infection, so that it is sometimes impossible to find the source of infection. Particularly dangerous is sepsis in maternity institutions, where it can take on an epidemic character, apparently with a gradual increase in the virulence of the microbe.

Symptomatology of S. in newborn children is extremely diverse and variable, differing in the early period by the scarcity of symptoms. Septic components at the beginning of the disease consist not in local changes, which occur significantly later (and often do not occur at all), but in general phenomena of toxemia, which is confirmed by autopsy showing the picture of degeneration of parenchymal organs. Lethargy, slow movements, weak cry, sometimes alternating with temporary excitement and restlessness; grayish skin with a cyanotic tint of pale mucous membranes, sclerema, scleredema, catastrophically falling weight and noticeable emaciation constitute the habitus septicus of the child. The disappearance of appetite, refusal of food in a child who previously took the breast well is considered the earliest sign (Speransky). Almost always there is an increase in temperature, although in weakened and premature infants S. can occur with a low temperature. In any case, the fever is very irregular, sometimes being only an initial or terminal symptom. Characteristic is the absence of typical chills and sweats in adults. Enlargement of the spleen is not an obligatory symptom, more often there is enlargement of the liver. Changes in the blood consist mainly in a significant decrease in the number of red blood cells and hemoglobin and more or less significant leukocytosis, although in severe cases leukopenia is also encountered with the existing neutrophil shift. The entire blood picture usually corresponds to a sharply expressed acidothic condition of the body. In pyemic forms and in children of the first weeks of life there are corresponding changes in the blood. From the side of the urine, phenomena of nephrosis are usually found, as well as often nephrosis-nephritis and pyuria, which make it possible to assume purulent foci in the kidneys. The nervous system in S. gives various phenomena of excitement or drowsiness, toxic convulsions and vomiting, and various symptoms of encephalitis and encephalomeningitis in metastatic forms. The most striking changes are found in children on the skin. Most often there is more or less pronounced jaundice, sometimes taking a severe form (icterus gravis), associated with deep parenchymal liver damage and increased breakdown of red blood cells. Even in mild cases, there is always a yellowish tint of the sclera. Characteristic of S. in children are skin edemas, occurring in various parts of the body in the form of limited erythematous swellings of the skin, which disappear relatively quickly, appearing in another place. Furthermore, various kinds of rashes are often found, differing in their polymorphism, often taking a gyrate form (erythema gyratum), sometimes becoming purulent (vesicles, pemphigus-like blisters and skin necrosis). The erysipelas that often appears during S. is not an independent disease, but only one of the symptoms of S. in early childhood. A feature of childhood S. is the frequent occurrence of skin hemorrhages of the most diverse character, from small petechiae to huge bruises, caused both by the increased permeability of the vascular wall in early childhood and by deep changes in the blood under the influence of hemolytic bacteria (hemorrhagic and hemoglobinemic forms of S.) (see Winkel's disease and Buly's disease). In pyemic forms, purulent processes are observed in the subcutaneous tissue in the form of separate, isolated abscesses, most often associated with sweat glands, and large phlegmons (see Pyoderma), in which tissue melting and gangrenous decay sometimes occur with a speed resembling nomas. The arising multiple epiphyseal osteomyelitis with corresponding joint swelling, periarticular abscesses and finally purulent arthritis complete and finish the picture of septicopyemia in children. Internal organs are rarely affected and even more rarely are these lesions diagnosed during life, but cases ending in death give pictures of abscessing pneumonias and nephritis, sometimes purulent metastases of the spleen, brain, etc. Purulent peritonitis is most often associated with S. of umbilical origin. Thus, the clinical manifestations of S. in early childhood differ greatly and can manifest themselves both in anergic forms in processes of rapid and particularly malignant course of a toxic nature, and in normergic or hyperergic forms giving pictures of pyemia or septicopyemia. The first forms are more often encountered when the septic process begins immediately after birth. The second forms are S. of the first weeks and months of life, when the child's organism is already more reactive. Finally, in children of the first years of life we encounter septic processes arising from one (or several) foci that developed during the period of dysergy of the organism with a significant decrease in nutrition (atrophy, hypotrophy of the second degree), in which processes arise under the influence of one or another microbes constituting the permanent flora of the cavities (microbes de sortie). The purulent inflammations developing at this time become a focus for the general septic process. Particularly often in early age, septic processes of otogenic origin are encountered. This also includes cases of S. arising from latent, dormant infection (Solovov), which in early childhood is most often the purulent melting of the physiological thrombus of the umbilical vein (slow S. of early childhood). According to the course, the following are also distinguished: 1) rapidly developing forms (22-68 hours), 2) acute forms (pulmonary, meningeal, typhoid), 3) subacute and 4) cachectic forms (Tagunov and Tsymbal). S. in older children differs little from S. in adults, most often arising in connection with acute infectious diseases (scarlet fever, cerebrospinal meningitis, streptococcal angina, etc.). The diagnosis during the period of pyemic phenomena presents no difficulties, but the initial period of toxemia without local phenomena is always difficult, only the combination of the above-mentioned signs makes it possible to make a diagnosis. In any prolonged febrile state without local phenomena, one must think of S., especially in early childhood. Blood culture does not decide the issue. The prognosis in S. is always serious and the worse the younger the child, the closer to birth the septic process developed in him, and the more it proceeds with the character of toxemia. Septic processes proceed severely in premature infants, in children with congenital syphilis. Prevention of S. in newborns is based on proper conduct of childbirth and careful attention to the child (strict indications for obstetric operations threatening injury to the child), on careful aseptic care of the umbilical remnant and the wound after the umbilical cord falls off (see Newborn) and general care of the child and its feeding. When a number of cases of S. appear in a maternity hospital, it is necessary to carefully review all procedures performed with the child, the premises, linen, dressing material, etc. Sometimes it is necessary to close the institution for a certain time for disinfection and ventilation. Treatment of S. in children, as in adults, at present presents a difficult task. Attention should be centered on eliminating the septic focus and on the reactivity of the organism. In this sense, disinfectants should apparently take a back seat, since it is impossible to act bactericidally on microbes in tissues. Where there is an accessible to surgical intervention focus (otitis, arthritis, abscess, phlegmon, etc.), it should be opened, even if it seems to have lost its original significance. To increase the reactivity of the organism, means are proposed whose action consists mainly in stimulating the activity of the reticulo-endothelial system. Sero- and vaccine therapy, as well as non-specific protein therapy, do not give definite results. Greater success is achieved by the use of hemotherapy, which should be carried out under the control of blood tests of the child (see Hemotherapy). The best donor is the child's mother, especially in those cases when she has recently had a postpartum illness and one can think that the child's S. was caused by the same agent. Then the blood or serum of the mother acts specifically, as it contains antibodies against the very strain of microbe that caused the child's S. Blood is administered intramuscularly every 1-2 days and even daily. According to some authors, doses are 10-30 cm⁵ or 50 cm³ according to others. The total amount is from 100 to 300 g for the entire course of treatment. American authors recommended intraperitoneal infusion of blood, as well as bloodletting followed by intravenous transfusion of blood. In any case, hemotherapy gives a significant reduction in mortality from S. in early childhood (from 90% to 27% according to Tagunov and Tsymbal).