The principles and practice of modern surgery

Formerly the surgical fevers were all grouped together, and a certain amount of febrile disturbance was looked for after any injury. But with the introduction of antiseptic methods and the healing of wounds by primary union, with absence of all septic phenomena, and the use of the clinical thermometer, it is noted that there is a certain rise of temperature more or less quickly after an operation or reception of a wound, with fever of mild grade, persisting for several hours or two or three days, and with other accompaniments. This phenomenon has been carefully studied, and so separated from the septic fevers as to deserve a distinct recognition under the names above given, of which the most common in this country is surgical fever.

As long as this fever is free from indications of septic character it is without significance and needs only symptomatic treatment. It begins usually within the first twenty-four or thirty-six hours, after which the temperature may rise, progressively or with a morning remission, to a height of 102° or possibly 103°. In children we are more likely to get extremes in this regard than in healthy adults. It will be followed by some disturbance of alimentary function, glazing or drying of the tongue, deficiency in urinary secretion, and subside generally spontaneously—invariably so if cathartics, diuretics, cool sponge baths, etc., are used. It is usually due to the retention of blood clot, ligatures, etc., or tissues which have been ligated and whose stumps remain; in all instances there is some foreign material to be removed. This means unusual phagocytic activity, perhaps temporary leukocytosis, with active metamorphosis of clot and other material, of all of which the elevated temperature is an accompaniment and expression. It is not unlikely that the antiseptic materials used may sometimes occasion this pyrexia.

Iodoform and carbolic acid are among the drugs in common use which are known to be irritating and capable of producing toxic symptoms. Often after the use of the latter the urine will be discolored and will furnish the clue to the fever. In young children particularly, and not infrequently in adults, mental disturbance, even active delirium, may characterize the case. This is not always to be explained by cerebral anemia due to loss of blood during the operation or accident, but is probably due to drug toxemia or to intoxication from materials furnished by the altered tissues.

Surgical fever of strict type may merge into a more or less continuous fever as the result of intestinal toxemia permitted by failure to evacuate the bowels, and this intestinal toxemia may be a predisposing cause of genuine septic infection. Consequently a surgical fever which does not disappear within two days is to be viewed with suspicion, especially if it does not subside after the administration of cathartics.

Some surgical fevers are accompanied by eruptions, a number of which may be due to drugs and some to intrinsic poisons. Thus carbolic acid and iodoform give rise occasionally to erythematous eruptions, and the concomitant administration of drugs like potassium iodide, quinine, antipyrine, and copaiba may produce urticarial or other manifestations. Again, it is known that certain toxins—produced, e. g., by the bacillus pyocyaneus—are capable of causing dilatation of the superficial vessels and various flushes or eruptions. To one of these, which dilates the capillaries, Bouchard has given the name of ectasine. Consequently it by no means follows that every eruption or rash following operations or injuries is of a specific character. On the other hand it seems to be established by numerous observers—among whom Paget is perhaps the most prominent—that surgical patients, particularly the young, are particularly liable to infection by scarlatina; and in the experience of Thomas Smith, of forty-three children whom he cut for stone, ten had scarlet fever. Therefore, in spite of the fact that a certain number of cases of eruption may have been mistaken for scarlet fever, it is undoubtedly true that in surgical and puerperal cases patients are more than usually liable to this invasion. The use of antitoxins or serums is also occasionally followed by intense urticaria.

The subject of surgical fever may then be epitomized as consisting of elevation of temperature with certain accompanying disturbances, which appear to be essentially due to the results of tissue metabolism, including also metabolism of blood clot, ligatures, etc. It is not a necessary nor conspicuous accompaniment of all surgical cases, and in some individuals, even after grave operations, it will scarcely be noted. It is more likely to be extreme in children than in adults. As a result of excessive loss of blood it may be postponed. It may be complicated and prolonged by any one of the auto-infections, particularly that already mentioned in the preceding chapter as intestinal toxemia, as a result of which septic infection may ensue, and that which was at first a legitimate surgical fever may thus become merged into a septic condition. In the absence of auto-infection, and with appropriate treatment, surgical fever should quickly subside until it becomes indistinguishable about the second or third day.

Proceeding then in the order of pathological complexities, the first of the surgical infectious fevers to be considered is sapremia.

SAPREMIA.

The term sapremia will be used here as indicating a condition which is often likened to an intoxication produced by a supposititious septic suppository. The term was first used by Duncan, and was largely confined to puerperal cases. Some of the most ideal cases of sapremia are those of puerperal origin.

In each of the three conditions comprised under the general term of septic infection it is not now a question of particular organisms, but of intoxication by products which are more or less common to at least several of them. In a general way, they are mainly due to the activity of the organisms already grouped as pyogenic. Those which produce pus are capable of causing septic infection. In addition to these, it is probable that certain of the saprophytes or ordinary putrefactive organisms may produce the same effect.

Symptoms.

—In sapremia the symptoms begin promptly, depend for their intensity upon the dosage of poison, and recede quickly as soon as the source of poisoning is removed or its activity subdued. An instance of the possible causes of sapremia will perhaps best illustrate its pathology. Take, for example, the act of delivery of the full-term fetus. At the completion of this operation there is left a fresh, bleeding wound of large area which is more or less exposed to putrefactive agencies. This is reduced with the contraction of the uterine walls to a comparatively small cavity containing more or less freshly coagulated blood. As long as this clot does not putrefy it is disintegrated inoffensively, to be discharged in large part with the lochia. If germs of putrefaction enter, either during the act of labor or afterward, and linger, putrefactive processes are set up in the clot with the prompt production of certain toxins and ptomains. There is here then a septic suppository with conditions favorable for absorption by the containing tissues. How quickly the poisoning may show itself, and how soon it may subside after removal of the putrefying clot, daily experience may tell.

Sapremia then is intoxication produced by absorption of the results of putrefaction of a contained material within a more or less closed cavity, whose walls are capable of absorption of noxious products as they form. As long as putrefaction is essentially limited to the contained mass, and does not spread to and involve the containing or surrounding tissues the case is one of sapremia. As soon as the process spreads from the containing tissues the case merges from one of sapremia into one of septicemia. That this may occur in any case without prompt intervention will be readily understood. Sometimes patients may die of sapremia, though rarely, and in such case ordinarily as the result of gross neglect. Once the septicemic process is begun, however, its spread cannot always be checked, and the case which one day is sapremic and redeemable may later become septicemic and practically lost.

The symptoms of sapremia are not essentially different from those common to septic infection, save that ordinarily they are, at least at first, milder. There are flushing of the face, dry tongue, mental disturbance, pyrexia, while usually all the symptoms are ushered in by a chill, which may have been preceded only by slight malaise. These are followed by nausea and vomiting, with headache, and often, later, by diarrhea or active purging. Later delirium may occur, possibly even fatal coma. On postmortem examination there are few changes revealed; alterations in the blood, a failure to coagulate, and some softening of the spleen and liver would probably be the only ones.

Treatment.

—The treatment should be prompt and the cause removed. In puerperal sapremia the uterus should be emptied, antiseptic douches given, irrigating as often as necessary to prevent offensive odor to the discharge, and combating general signs of poisoning by plainly indicated measures. Heart depression should be overcome by diffusible stimulants and hypodermic injections of strychnine in doses of ¹⁄₂₅ grain or more. The bowels should be unloaded by a mercurial followed by a saline cathartic; suppression of urine treated by venesection and hot-air baths or sweats; diuretics should also be prescribed, and fluids administered copiously. If the patient is restless, an opiate should be given; if delirious, necessary restraint should be resorted to.

Essentially the same measures should be pursued in a surgical wound or in a case of compound fracture, or any injury where retained material may be undergoing changes already alluded to. General measures should be the same. Purgatives are advisable in these cases.

Chronic Sapremia.

—Chronic sapremia is a better name for what used to be known as hectic fever. It is characterized by rapid, feeble pulse, a temperature but little elevated in the morning and rising to 102° or 103° in the latter part of the day, with profuse perspiration, or sometimes colliquative sweats that leave patients exhausted. There is usually a distinctive flushing of the cheeks. Emaciation is a marked feature in most instances. Hectic means simply habitual fever. It is met with particularly in tuberculous cases, whether of lungs or bones or joints, in empyema, psoas abscess, and most all chronic pyogenic infections. It is frequently followed by or associated with amyloid or waxy degeneration of the liver, kidneys, and spleen. This process commences in the walls of the bloodvessels and by its spread to the surrounding connective tissue leads to notable enlargement of these organs, with albuminuria, edema, ascites, and the usual associated phenomena.

Treatment.

—Treatment, in addition to that already indicated above, should be addressed to removal of the cause. In all instances it should comprise attention to elimination, digestion, nutrition, and fresh air. By such measures even distinct amyloid changes may be arrested, or possibly improved.

Cryptogenetic or Spontaneous Septicemia.

—Cryptogenetic or spontaneous septicemia is a term applied to those cases in which the port of entry of the germs is no longer visible—e. g., a hypodermic puncture—or cannot be positively determined. On careful study this may be found to consist of a small focus where pus is forming within narrow confines and under great pressure. Under these circumstances, as Kocher has shown, toxic virulence is rapidly augmented. This is doubtless one reason why the septic features of many cases of osteomyelitis and appendicitis are so pronounced.

SEPTICEMIA.

According to the views thus enunciated, the difference between sapremia and septicemia is not one of character as much as of location. In septicemia the putrefactive action is no longer confined to material enclosed by (yet not of) the tissues themselves, but has spread from this to the surrounding living cells, which are being attacked by bacterial enemies; in other words, we deal with infection of living tissues rather than with mere intoxication. This is a progressive invasion of tissues by continuity, with a constantly proceeding systemic intoxication by poisons produced in larger quantities. So rapid may this action be—as may be seen in malignant diphtheria—that the individual speedily succumbs before evidences of abscess or local gangrene appear. On the other hand, providing that the toxic action is less pronounced or the patient’s vitality more enduring,—i. e., his tissues more resistant—abscess, phlegmon, or local gangrene may result in the destruction of tissue being limited to the environs of the parts first involved. Bacteria are also found in the blood.

While septicemia then may be a direct continuance of an original sapremia, it is not intended to intimate that it may not originate de novo; that is, many cases may begin as a pronounced septicemia from a local infection. This is the case, for instance, with the majority of dissecting wounds, etc.

Symptoms.

—In septicemia there is a period of incubation, usually two or three days, often longer. If this follows an operation, the mild fever which would indicate the slumbering fire is usually regarded as surgical fever. But when this rises and is followed by prostration, with alimentary disturbance, loss of appetite, headache, etc., followed by typhoidal symptoms, the alarm is sounded and should be quickly heeded. Usually, but not always, there is a preliminary or premonitory chill, after which prostration will be more marked than before. The severity of the symptoms cannot be foretold from the size, location, or character of the wound. The character of the fever is essentially continued, usually with morning remissions. Gussenbauer has called attention to a class of cases in which subnormal temperature is caused by the absorption of ammonia compounds. To these he has given the name ammoniemia. This condition may be seen in connection with gangrenous hernia, and has even been mistaken for shock (Warren). (See also acetonemia, in previous chapter.)

In septicemia from infection of a visible portion of the body there are usually seen evidences of lymphangitis and perilymphangitis of septic character. These will be evidenced by tender and purplish lines, extending subcutaneously along the course of the known lymphatics or in connection with the more prominent subcutaneous veins. The lymph nodes, into which these visible vessels as well as the deeper ones empty, become enlarged and tender; the whole lymphatic system participates; the spleen in aggravated cases becomes notably enlarged, and even the bone-marrow more or less involved. Diarrhea is commonly an early but controllable symptom. A hematogenous icterus of mild degree is another frequent accompaniment. The conjunctiva becomes discolored and the skin slightly so. Should the blood be examined marked leukocytosis will be noted, and should cultures be made from it, in many instances at least, the organisms at fault can be detected and recovered from it. The vigor of the heart muscle is seriously impaired; the pulse becomes rapid and weak. In scarcely any form of septic infection is this more prominent than in diphtheria; and microscopic examination shows the rapid disintegration of the cells of the heart muscle, as well as those of other parts of the body, even to the almost complete molecular disintegration of the nuclei. Erythematoid, pustular, and even hemorrhagic eruptions are met with upon the skin, some of which are probably to be explained by thrombosis of the dermal capillaries. Certain complications are not infrequent, among which inflammations of the pericardium and endocardium—e. g., ulcerative endocarditis—are frequent. As the case becomes aggravated the temperature rises irregularly; the hot, dry skin becomes cold and clammy; prostration and indifference more marked; diarrhea more colliquative; icterus more pronounced; urine more reduced in quantity or suppressed; and these symptoms are succeeded by indifference, mental apathy, stupor or delirium, and finally death, the patients being comatose and collapsed.

While these are the general indications of septicemia, the wound or site of injury has undergone changes which are also characteristic. They comprise the edema and redness of wound margins, which may be seen even in sapremia, followed by increasing tumefaction, escape of foul-smelling discharge, and finally by sloughing and gangrene of the parts involved. On microscopic examination the capillaries are filled with infective thrombi and vessel walls infiltrated with microörganisms, which abound also in the lymph spaces. Bacterial infection can be traced in microscopic sections from the infected area, from the point in the neighborhood of the wound where microbes infest the tissues to points remote from it, where they are sparsely found, if at all. The same evidences of infection may be traced along the lymphatic vessels, and often the veins.

Postmortem Evidences.

—The postmortem evidences of septicemia are indicative on first sight: the blood is of the consistency of tar and does not coagulate; evidences of putrefaction are plain to sight and smell; the serous membranes, particularly the pia mater, are often extravasated; the muscles are discolored and of a darker hue than natural, edema of the lung is frequent; the intestines reveal a gastro-intestinal catarrh, the duodenum and rectum showing punctate hemorrhages; the spleen is darkened, enlarged, and softened; the liver shows similar signs, less marked, and at times an emphysematous condition due to putrefactive gases. Cultures can be made from the fluids and tissues of organs thus affected. It is also of importance to emphasize that such material is powerfully and often fatally infectious; some of the worst forms of dissecting wounds and instances of fatal infection have come from carelessness in making these postmortem examinations.

So far as concerns the character of the wound, which is most likely to be followed by septicemia, there is but little to be said. Wounds made by infected tools, the butcher’s knife, the anatomist’s scalpel, etc., are the most dangerous. All forms of phlegmonous erysipelas, many cases of gangrene following frostbite, nearly all instances of traumatic gangrene, most cases of carbuncle, and, in fact, all similar lesions, are likely to be followed by septicemia. The so-called spontaneous cases have an equally infectious origin, though one which is concealed. In unrecognized instances of appendicitis, for instance, and in many other conditions, although the path of infection may not be easily traced, it is, nevertheless, always present, and can be found if diligent search is made. The nasal cavity, the tonsils, the teeth, the middle ear, the deep urethra, and the rectum are often overlooked as offering possibilities for septic infection which may follow this general type.

Treatment.

—This should be both local and general. Local treatment should consist in complete and absolute removal of the active cause. This comprises the reopening of wounds, evacuation of clot, cutting or scraping away of sloughs and gangrenous tissue, with cauterization of the exposed living tissue, in order that absorption may be prevented, and will often include amputation or extirpation of a part. For tissues which are not too completely riddled by disease, and lost beyond possibility of redemption, continuous immersion in hot water offers the best possible prospect. By it putrefaction seems checked, the separation of dead from living tissues is accelerated, relief of pain or discomfort is afforded, and disinfection of material which is foul and infectious is guaranteed. An excellent local application is the mixture of resorcin 5 parts, ichthyol 10 parts, ung. hydrarg. 40 parts, and lanolin 45 parts, already mentioned in Chapter IV, or the application of brewers’ yeast. (See chapter on Ulcers.) Of great value also will be found the silver ointment of Credé (Unguentum Credé). This permits of absorption of silver through the unbroken skin (as in the case of ung. hydrarg.), and the dissemination throughout the system of the antiseptic virtues of the silver itself. To ensure its greatest efficiency this ointment should be thoroughly rubbed in, especially over parts which are not too tender. Many cases of septic infection promptly yield under the influence of the argentine preparations which Credé has lately introduced.

In suitable cases also the subcutaneous injections of antistreptococcic serum will be followed by beneficial effects. The earlier the injection is given the better the prospect of benefit. Evidence is strongly in favor of this serum as a prophylactic measure, especially before operations, when septic pneumonia or other septic accidents are feared.

Another measure of great utility in selected cases is the intravenous infusion of a solution of Credé’s soluble silver, made with 1 gram of silver in 1000 Cc. of sterilized water at a temperature of 105° to 110°. In cases of profound toxemia a small amount of blood may be withdrawn (50 to 400 Cc.), for reasons stated in Chapter VI. No hesitation need be felt in introducing 500 Cc. or even 1000 Cc. of this solution. It is the ideal way of bringing a powerful non-toxic antiseptic into immediate contact with pathogenic microbes.

There have been recent suggestions as to the intravenous injection of very dilute formalin solution, in order to take advantage of its remarkable germicidal activity; it has been employed in a few cases, especially of puerperal sepsis, with success, 1 Cc. of standard formalin solution is mixed with 800 Cc. of sterilized salt solution. It has been shown that if 50 Cc. of this is thrown into the veins of an average adult it will form with the 5000 Cc. of blood a mixture of 1 to 200,000, in which strength it may be expected to prove an efficient bactericidal agent. Indeed, a smaller amount or a weaker preparation would probably suffice. Barrows has reported success following two infusions, two days apart, of first 500 Cc., then 750 Cc. of a 1 to 5000 formalin solution. Still, these injections may be followed by cramps in the arms, cardiac discomfort or distress, and blood (or blood cells) in the urine. It would probably be well to limit this use of formalin to those cases at least in which the presence of cocci in the blood can be demonstrated by culture or other method.

An excellent method in the local treatment of parts which admit of it (hands and feet) is their exposure to dry hot air in the Kelly heater or some similar apparatus. Hot air will be borne at a temperature of 210° to 220°, which may be destructive to germs while still tolerable for a short time by the tissues. Clinton, of Buffalo, with whom this method is original, reports that the temperature within the tissues thus treated is raised to about 107°, which is above the thermal death point of the ordinary pyogenic organisms, and that this method gives better results than any other of treatment of septic infection of those parts which can be subjected to it.

The general treatment of septicemia is, in the main, stimulant and tonic. Fever is not to be treated with arterial sedatives nor often with antipyretics. It is a symptom of poisoning, and its too prompt suppression prevents both the recognition of the intoxication and the measure of its degree. Pyrexia then is best combated with cool sponge baths and stimulant measures of a general character. The principal reliance must be upon nutrition and stimulants. Assimilation may be impaired when gastro-intestinal catarrh is as prominent a feature as it is in many of these cases. Consequently the simplest and most assimilable food, often that which is predigested, should be administered. Milk, eggs, beef peptonoids, and fruits are among the most appropriate. The best stimulants and tonics are alcohol and strychnine. Strychnine is preferably administered hypodermically in doses of ¹⁄₂₅ grain from two to four times a day. Heart depression is best combated by this measure, or by quinine in large doses, while digitalis and atropine may be added. For internal use alcohol is, par excellence, the remedy. This is administered in doses only to be measured by their effect. In fact, the administration of alcohol in these cases is a matter of effect, and not of dosage. Aside from these measures the intestinal antiseptics should be administered, among these being corrosive sublimate, ¹⁄₁₀₀ grain, every three or four hours, salol in large doses, bismuth salicylate, or naphthalin—any or all of these in connection with powdered charcoal. Intestinal pain and frequency of stool can be more or less controlled by opium, while disinfection of the alimentary canal is only to be accomplished by the above remedies, in connection with flushing of the colon with saturated boric acid solution or something of that kind. Pain is to be controlled by morphine administered subcutaneously.

No special attention need be given to the so-called septicopyemia. It represents a mixed condition of septic intoxication, local infection, and destruction, with metastatic abscess, and is a term appropriately applied to cases which combine the significant features of each type.

PYEMIA.

The derivation of the term pyemia, which came into general use in 1828, is misleading. Although septic fever always accompanies suppuration, it is not certain that pus as such circulates in the blood, as the term pyemia implies, the error having arisen originally from mistaking the contents of breaking-down thrombi for pus from ordinary sources. While a recognition of the etiology of the disease is new, the disease itself has been recognized for many centuries.

Pyemia is only met with in connection with suppuration, as far as known, never without it. In those cases which appear to be free from suppuration pus will be found. Pyemia may be described as septicemia plus thrombotic and embolic accidents, which lead to distribution of infectious material to all parts of the body. This distribution is made by the bloodvessels, although to some extent the lymphatics undoubtedly participate. When pyogenic organisms reach bloodvessel walls they tend to set up a mycotic phlebitis, which, by virtue of the coagulating blood, becomes soon what is known as thrombophlebitis. Infection proceeding through the vessel walls, the endothelial lining is loosened, while to these rotting spots leukocytes adhere and coalesce into a more or less homogeneous mass. This so-called white thrombus becomes also infected with bacteria; portions of it, loosened and dislodged, are carried by the returning blood stream to the right side of the heart, whence they are distributed through the lungs. Dislodgement may be made by mere force of the blood stream, or may be assisted by movements of the part or handling of the same. These particles of thrombi are loaded with the infectious organisms which began the disease, and wherever one settles a reproduction of the original thrombophlebitis is rapidly produced. In this way numerous infected thrombi are formed within the vessels of the lungs, which, again, loosen, and are now swept into the left side of the heart, whence they are distributed with arterial blood in all directions. While it is true that they are equably distributed, it is also positive that certain tissues seem more capable of lodging and being attacked by the contained organisms than are others. When it is once appreciated that each particle of infected clot is capable of setting up, either in the lungs or in the other tissues, upon the second distribution, other abscess formations analogous in etiology to that from which came the first disturbance, then the fundamental idea of metastatic abscess is fully impressed. The term metastasis may be regarded as synonymous with transportation, and metastatic abscesses are those produced by transportation of infected particles from one part of the body to another. Wherever they lodge similar trouble will result. Contiguous minute metastatic abscesses quickly coalesce, and in this way large collections of pus are formed. The blood also contains organisms not attached to thrombi, and from the blood of the pyemic patient cultures can at almost any time be made. Until this is done it will be virtually impossible to incriminate any particular organism as the one at fault. Thrombo-arteritis is the equivalent in the arteries of thrombophlebitis in the veins, and is accompanied by the same detachment of endothelium, adhesion of leukocytes, etc. Whenever such a lesion occurs in artery or vein, coagulation necrosis takes place and suppuration occurs around it. The metastatic abscess is thus the result of breaking down of this affected tissue, and is often called miliary abscess. Particles of infective thrombi cling also to the valves of the heart and a septic endocarditis may result.

The possibility of so-called spontaneous or idiopathic pyemia is occasionally discussed. This means a pyemia whose cause is concealed. The explanation will be found sometimes in an acute infectious osteomyelitis, sometimes in ulcerative endocarditis, or inflamed appendix or other portion of the peritoneal cavity. Again, it may proceed from middle-ear disease, in which there is so little discharge as scarcely to attract attention. Thus causes which predispose to suppuration (see Chapter III) come into play here, and the influence of exposure, fatigue, starvation, etc., is not to be ignored in furnishing an explanation for the so-called idiopathic cases.

In the majority of instances, however, pyemia follows surgical operations and injuries, among which are compound fractures, deep injuries with small superficial evidence thereof, compound injuries of the skull, and injuries by which veins are exposed. Inasmuch as the typical pyemic manifestations require a certain length of time for their development, the onset of this disease is more delayed than in the case of septicemia. While the case may be manifestly one of septic infection of unrecognizable type, the characteristic indications of pyemia seldom appear in less than ten days, and frequently not for several days longer.

Symptoms.

—The symptoms of pyemia do not essentially differ from those of other septic infections. The principal difference is in the frequency of chill and range of temperature. Chills are more common at the inception of the condition, and more frequent throughout its continuance than in other septic conditions. The chill may be slight or assume the proportions of a rigor, and each chill is followed by colliquative sweat and exhaustion. In other words, chills which are infrequent in septicemia are common in pyemia. There is reason to believe that with each fresh distribution of emboli we have one or more chills as the objective evidence thereof. Distinctive also of pyemia is the temperature curve, which much resembles that of intermittent fever, without the regularity of change characteristic of malarial fevers. It is without regular remissions, and has been referred to as irregularly intermittent. The first rise is abrupt and usually excessive, while with each fresh chill or series of chills similar abrupt alterations will be noted. These occur so frequently and fluctuate so irregularly that in order to note them accurately the temperature should be taken at least every two hours. The temperature seldom drops to normal.

As the lungs fill with the first crop of infected emboli, and the first series of metastatic abscesses form there, there is more or less dyspnea and sense of oppression; there may be also pulmonary complications—pleurisy, bronchitis, etc., even pulmonary edema. Frequently there is expectoration of frothy and discolored sputum; occasionally there is blood in the sputum. A peculiar sweetish odor of the breath has been noted by many observers in this disease, and is supposed to be idiopathic and characteristic. (See acetonemia in previous chapter.) With the dispersion of the second crop of emboli from the lungs there is apt to be icterus, with evidence of metastatic abscess in the liver, and collection of pus as the result of coalescence of small abscesses. The sensorium is not so affected in pyemia as in septicemia, and in the former disease patients are more likely to be alert and active in mind. General hyperesthesia and restlessness are common. Colliquative sweats are also a feature of pyemia. There is the same liability to eruptions, etc., which may mislead or complicate the diagnosis. A dermatitis is seen sometimes in pyemia, the lesions assuming a papular or pustular form, due to local infections of the skin. Purpuric spots are also seen, and vesication is not infrequent. Within the mouth sordes collect upon the teeth or gums; the tongue becomes dry and brown and heavily coated. Diarrhea is less common in pyemia. The urine is usually scanty and high colored, containing solids in excess; albumin is sometimes found therein, as well as peptone. The presence of peptone in the urine is probably an indication of the breaking down of pus corpuscles in various parts of the tissues.

A significant objective evidence of pyemia is met with in the metastatic collections of pus within the joints, which occur relatively early, and which, if multiple, may lead to a correct diagnosis. One of the earliest joints to be involved is the sternoclavicular, although none of the joints are free from the possibility of invasion. The articular serous membranes seem to have the property of carrying and holding the infective thrombi better than any other tissue in the body. The pyarthrosis of pyemia is for the most part painless, yet implies loss of function of the affected joints. The distention of these is usually evident to the eye, the fluctuation pronounced, tenderness not extreme, but the swollen part merges into tissues which are edematous and reddened. When pain in the limb is extreme, it is usually because of metastatic abscess within the bone-marrow cavity. In other words, we now have a metastatic osteomyelitis.

In all cases of pyemia prostration is marked, yet the pulse is seldom weak, at least until toward the close of life. As cases progress from bad to worse subsultus tendinum is often noted.

The appearance of the wound or site of operation does not differ essentially from that already described under Septicemia. There is usually, however, less discharge, granulations are smoother and dryer, and if tissues are gangrenous they are not as wet and nauseous as in the other case. Evidences of thrombophlebitis and lymphangitis will proceed from the wound toward the body, as in other instances of septic infection.

Prognosis.

—Prognosis is usually bad. While recovery may follow where metastatic infiltration has not been too general, the ordinary case of pyemia will die within twelve to fourteen days after diagnosis. Sometimes the entire process is much slower, and isolated cases occur which can be designated as so-called chronic pyemia, which differs but little from the acute form. A case of pyemia should not fail of recognition because there is no evidence of infection from without. A fatal case of pyemia has been known to occur from a suppurating soft corn which was not discovered during life; also from peridental abscess, etc., which had been overlooked. Death is the result of tissue destruction and septic intoxication.

Postmortem Appearances.

—In the vessels these consist essentially of thrombosis, examples of which may be seen, for instance, in the cranial sinuses and in the large veins. Aside from these, with the enlargement and softening of the spleen, the liver, and lymphatic structures, already described under Septicemia, the principal objective evidences consist in the discovery of metastatic abscesses in many or all parts of the body. As stated above, there is no tissue or organ in which they may not be found. The mechanism of their production has been already described. Infarcts may also be met with, in the kidneys especially, the liver and spleen as well, and indicate areas already cut off from blood supply by thrombo-arteritis, in which abscess formation would have occurred had time been given. In the liver large abscesses may be found; joint cavities may be filled with pus; the lungs are usually the site of innumerable small abscesses. The other postmortem changes commonly noted are not difficult of explanation, but are not so characteristic or pathognomonic as to call for further mention. In a joint which has become filled with pus there usually has been loosening of the cartilage and more or less disorganization of all the joint structures, which appear to have undergone rapid ulcerative destruction and putrefaction.

Treatment.

—Treatment of pyemia is in large degree unsatisfactory. That which used to be the terror of surgeons in the pre-antiseptic era is now, thanks to Lister and others, almost abolished. Pyemia is a rare disease in modern surgical practice. Its possibility should be borne constantly in mind, however, and the necessity for careful antiseptic or for a rigid aseptic technique is in large degree based upon fear of pyemic consequences.

When once established, the disease is to be treated on lines nearly similar to those laid down for septicemia, including resort to the ichthyol or silver ointments, and to intravenous infusion of silver solution. (See p. 89.) Amputation or extirpation of the part from which infection has first proceeded may be of avail. Among the most successful measures for surgical treatment of this disease is to expose the infected area, open the involved veins, and either excise them or scrape them out and disinfect them. This treatment has been successful in cases of cranial infection following middle-ear disease, etc. (See chapter on Cranial Surgery.)

Disinfection of the infected area and immersion in hot water should be practised. Metastatic abscesses should be opened and drained, and every accessible collection of pus evacuated, either by the knife or aspirator needle—e. g., in the liver.

The medicinal treatment is practically the same as in septicemia, while the surgeon’s mainstays are alcohol and strychnine. These, with cathartics and intestinal antiseptics, will practically sum up the drug treatment, the surgeon meantime not neglecting the matter of nutrition, crowding it in every assimilable form.

ERYSIPELAS.

Erysipelas is an acute infectious disease characterized by its tendency to involve the skin and cellular structures, to extend along the lymphatic vessels, to involve wounds and injuries under certain conditions, accompanied by more or less fever of septic type, leading frequently to septic disturbances of profoundest character, yet tending in the majority of instances to spontaneous recovery. It has been observed probably from prehistoric times, but has not found a proper description nor appreciation until perhaps within the past century. It occurs in so-called traumatic and idiopathic form—which latter means that the site of infection is not discovered—and also in a virulent and contagious type, which leads to the appearance of a number of cases over a large territory; it often appears in the epidemic form. On account of the reddening of the skin it goes by the name of the rose among the German laity. It may assume the type of an infectious dermatitis, subsiding without suppuration, or a similar lesion of exposed mucous membrane may be noted, or, occasionally, its virulence seeming greater, its lesions are met with in more deeply seated parts, accompanied by suppuration or even gangrene, and it is then called phlegmonous. In a small proportion of cases the infectious organism appears to be transported from one part of the body to another, and thus we have metastatic expressions of this disease. The most common examples of this are seen in erysipelatous meningitis after erysipelas of the face or scalp, and erysipelatous peritonitis after the disease has manifested itself on the truncal surface. It is of a type which makes itself almost interchangeable with puerperal fever; and when epidemics of erysipelas have involved certain states or areas, it has been noted also that nearly every obstetrical case developed puerperal septicemia.

Etiology.

—There is more than passing interest connected with this last statement. It is now definitely established that the infectious organism is a streptococcus which is allied to, if not identical with, the streptococcus pyogenes, the ordinary pyogenic organism of this form. This specific organism has been separated, studied, and its role assigned by Fehleisen, and the organism is frequently called Fehleisen’s coccus. Preserving always its morphological characteristics, it acts, as do many other pathogenic organisms, within wide limits in virulence. Cultivated from some cases, it scarcely seems infectious, while from others it is fatal.

Pathology.

—The disease manifests a tendency to travel via lymphatic routes. As long as it is confined to the skin and superficial tissues it has the appearance of an acute dermatitis. When it migrates deeper it generally leads to suppuration, another reason for believing that the streptococci of erysipelas and of pus production are the same. In the affected and infected area the minute lymphatics will be found crowded with the cocci, which are seen much less often in the small bloodvessels; also in the tissues beyond the apparently infected area they may be found dispersed less freely. The bacterial activity seems most active along the advancing border of the superficial lesion. Here the phenomena of hyperemia and phagocytosis are most active. Even in the vesicles that are characteristic of the disease the organisms may be found.

The discharges from this region are infectious, and caution should be observed in dressing such cases. A finger pricked by a pin from a dressing may subject the individual to loss of life. The dressings containing the discharges should be burned immediately.

The path of infection is usually through a wound, and as soon as discovered a case of erysipelas should be separated from all surgical cases, or if the erysipelatous patient cannot be isolated, he should be removed from proximity of other wounded individuals.

Erysipelas which follows injury, however slight, is termed traumatic. The terms “idiopathic” or “spontaneous” should be restricted to those cases in which the path of infection is not discovered.

Symptoms.

—With the exception of the local appearances, they are essentially the same in both of the above-mentioned forms. The characteristic feature of the disease is a dermatitis with its peculiar roseate hue, which it is impossible to describe in words. In tint it differs slightly from that noted in certain cases of erythema. It is, however, accompanied by an infiltration of the structures of the skin, so that the area which is reddened is at the same time elevated above the surrounding surface. Its edges are often irregular. As exudate takes the place of blood in the tissues, the red tint merges into a yellow. At this time there is more induration of the skin and tendency to pit on pressure. Vesication of this involved area is now frequent, the vesicles often coalescing and forming large blebs and bullæ, which fill with serum that may become discolored or purulent. When exposed to the air, unless the tissues become gangrenous, this serum usually evaporates and forms scabs. This disturbance of the skin is always followed after a number of days by desquamation. This infectious dermatitis shows a constant tendency to spread in all directions. Its most characteristic appearances are limited to the margin of the enlarging zone, while in its centre there may be evidences of recession of the disease. If it commences in the vicinity of a wound it will probably spread in all directions from it. Beginning in the face, it usually spreads upward; in the trunk, in all directions; if on the extremities it tends to migrate toward the trunk. Wandering erysipelas is a term often applied to these phenomena. The metastatic expressions of the disease have been described.

When this affection attacks a recent wound the local appearances are not essentially distinct from those mentioned under Septicemia. The wound margins separate to a greater or less extent, the surfaces slough, and a characteristic seropurulent discharge occurs. Granulating surfaces usually become glazed—often covered with a membrane resembling that of diphtheria; deep sloughs may occur, undermining of wound edges, even hemorrhages from destruction of vessel walls. In rare instances, however, under the influence of the microbic stimulation granulations proceed faster than normal.

Whether the disease proceeds from an injury or not, the constitutional symptoms vary but little. There is usually a period of malaise with nausea, followed by alimentary disturbance, coating of the tongue, elevation of temperature, sometimes with occurrence of chill. Complaint of pain or unpleasant sensation will lead to examination of the area involved, when the above symptoms will be noted, with evidences of lymphangitis and enlargement of lymph nodes. When chill occurs it is followed by pyrexia. Temperature fluctuates, with a tendency to assume the remittent type. When the disease subsides spontaneously it is by a gradual process of betterment and subsidence of temperature. In other instances the constitutional symptoms assume more or less of the septicemic or typhoid type, and it is seen that the patient’s condition is practically one of mild septicemia, which often proves fatal.

When the disease assumes the phlegmonous type the constitutional symptoms become more and more typhoidal and the septicemia becomes most pronounced. Locally exudation goes on to the point of threatening, even of actual, gangrene, unless tension is relieved by incisions. Pain is usually intense, partly because of confined exudates beneath resisting structures. More or less rapidly the local and constitutional signs of pus formation are noted, and unless these are observed and acted upon early there will not only be suppuration, but more or less actual gangrene, so that not only pus, but sloughs of tissue will be discharged through the incision, or will, when this is delayed, make their escape by death of overlying textures.

In all phlegmonous cases there is practically coincidence of septicemia, already described, and of the local appearances above noted. In proportion to the extent of the lesion in these phlegmonous cases, and failure to afford relief, will be the opportunity for septic intoxication.

The mucous membrane does not always escape, and even in the nose, the pharynx, the vagina, and the rectum a distinctive erysipelatous lesion may be found. The disease may travel from the pharynx through the nose and involve the face, or through the Eustachian tube to the ear and thence to the scalp, or vice versa. Erysipelatous laryngitis is to be feared on account of edema of the glottis, which would soon be fatal unless overcome by intubation or tracheotomy. An infectious exudation into the lungs is also known to follow erysipelas, and has been considered an erysipelatous pneumonia. The cellular tissue of the orbits may also be involved, when abscesses will occur, which should be opened early; the parotid and other salivary glands may become involved, usually in suppuration.

Many cases are accompanied by much gastric irritation, which it is difficult to explain. Ulcers are sometimes found in the intestines, as after burns. These usually give rise to bloody diarrhea. The cerebral symptoms may be simply those of delirium from irritation or of meningitis from infection. Strange phenomena have followed the disease in certain instances—cessation of neuralgic and of vague, unexplainable pain, improvement in deranged mental condition, spontaneous disappearance of tumors, etc. Advantage has been taken of this last in the treatment of these cases. (See Cancer.)

It is quite likely that some of the worst forms of phlegmonous erysipelas are due to mixed infection. To inject the bacillus prodigiosus together with the streptococcus of erysipelas will greatly enhance the virulence of the latter, so that reaction may proceed even to gangrene.

Postmortem Appearances.

—These are not distinctive, but are a combination of local evidences of suppuration and gangrene, with the deterioration of the blood, the softening of the spleen, etc., which are characteristic of septic poisoning. Only in the skin, and then under microscopic examination, can any pathognomonic appearance be discovered. This will consist in the crowding of the lymphatic vessels and connective-tissue spaces with cocci, in the evidences of rapid cell proliferation, in the quantity of exudate, in vesication, sloughs, etc.

Diagnosis.

—Diagnosis of erysipelas should be made mainly from various forms of erythema, from certain drug eruptions, and from other forms of septic infection which do not assume the clinical type of erysipelas. The gastric symptoms of this disease are sometimes produced by certain poisonous foods or the distress which is produced by medicines, such as quinine, antipyrine, etc.

Prognosis.

—The majority of instances of idiopathic erysipelas run a certain limited course, although the eruption may spread to almost any distance upon the body. When the disease attacks surgical cases, and especially when it involves wound areas, the prognosis is not so good. When the disease assumes an epidemic type and involves cases of all kinds, it will be found to have a virulence that may make it a most serious affair. In proportion to the extent to which it assumes the phlegmonous type it will be found locally, if not generally, destructive. The ordinary case of facial erysipelas will recover with almost any treatment. Nevertheless meningitis may develop, and even a mild case is to be treated with care and caution.

Treatment.

—Danger comes from two sources—septic intoxication and local phlegmons or gangrenous destruction. Each is therefore to be combated. Treatment should consist of isolation. There is no specific internal treatment for this disease. Tincture of iron, which was long vaunted as such, has proved unsatisfactory, and is of benefit only as a supporting measure in a limited class of cases. Constitutional measures should be employed: First, for the purpose of maintaining free excretion by bowels and kidneys; second, for the purpose of supporting and maintaining strength; third, for tonic and stimulant measures in prostrated and debilitated patients; and, fourth, for the purpose of combating intestinal sepsis or intoxication from any other source. The robust patients with this disease need no particular tonic. The aged, the enfeebled, the dissipated, the prostrated individuals, and the confirmed alcoholics are those who need vigorous stimulation, partly by alcohol and quinine, and partly by strychnine, preferably given hypodermically, and by the other diffusible stimulants by which they may be kept alive. Pilocarpine, given subcutaneously and pushed to the physiological limit, has been praised by some. If along with prostration there occur restlessness and delirium, then anodynes and hypnotics are serviceable, and should be administered to meet the indication—morphine hypodermically and any of the agents which produce sleep are now most beneficial. Finally, if there is any drug which can be administered in doses sufficient to saturate the system with an antiseptic which shall at the same time not prove fatal because of toxicity, this is the ideal medicament for constitutional use only. Such a drug is not known, but it will be well to give some near approach to it internally, as by administering corrosive sublimate, salol, naphthalin, or something else of this character in doses as large as can be tolerated.

Should patients become violent it may be necessary to resort to mechanical restraint—a strait-jacket, a restraining sheet, a camisole, etc.

Nourishment must be kept up by the administration of the easily assimilable and predigested foods.

Locally the number of remedies that have been resorted to is legion. In a mild case of spontaneous erysipelas—i. e., where no infection can be traced—it will sometimes be sufficient to put on a soothing application, like a lead-and-opium wash. It often gives relief to have the part protected from air contact, which may be done by a soothing ointment or by dusting the part with a powder, such as bismuth oleate or subnitrate, zinc oxide, etc., these being rubbed up with powdered starch; or by a film of rubber tissue or of oiled silk. Brewers’ yeast applied on compresses and covered with oiled silk is efficacious.

Even before the bacterial origin of the disease was accepted it had been suggested to use antiseptic applications, either in watery solution or combined with oil or some unguent; this is now the ideal method of local treatment, the difficulty being only to find that which shall be efficacious as an antiseptic, yet not injurious in other ways. Compresses wrung in solutions of various antiseptics are often serviceable. The following preparation has given satisfaction: Resorcin (or naphthalin) 5, ichthyol 5, mercurial ointment 40, lanolin 50. The proportions of these ingredients may be varied, and the amount of ichthyol sometimes increased, especially when the skin is not too tender. The affected parts are anointed with this, and then covered with oiled silk or other impermeable material, simply to prevent its absorption by the dressings; the parts are then enveloped in a light dressing and bandaged. Credé’s silver ointment has also proved useful. As the disease becomes mitigated the ointment may be reduced with simple lard, and discontinued when local signs have disappeared. Absorption of any of these preparations may be hastened by scratches over the affected area with the sharp point of a knife.

Treatment of threatening phlegmon, or phlegmonous erysipelas, must be more radical, and consists of free incision down to the depth of the deepest tissues involved. In treating dissecting and other septic wounds of the fingers incision should be made to the tendon sheaths, even to the bone. It is only by such radical measures that worse disaster may be avoided. Some aggravated local cases are treated by a series of deep incisions with the use of the curette, the surface after careful clearing being kept buried under an antiseptic solution (silver lactate 1 to 500) or ointment.

RELATION OF LYMPH NODES AND GRANULATION TISSUE TO INFECTION.

In connection with erysipelas and the role of the lymphatics, it is advisable to consider the relation and behavior of the lymph nodes and granulation tissue to infecting agents. Depending on the virulence of the infectious material, the site of infection, and the variety of the microbe will be its arrival in these protective filters. Then follows a series of cycles of maximum and minimum activity in the nodes, during the former the bacteria almost disappearing. The more pathogenic the microörganism the more certain the destruction of the lymph node, or perhaps of the individual. The well-known enlargement of the nodes is due almost solely to an increase in their lymphoid elements. Halban, who demonstrated these cyclic variations in the contents of the lymph nodes, is inclined to insist on an intimate relation between them and the temperature variations noted in cases of septic infection.

When granulations are present the lymph sacs are closed, as by a sanitary cordon. Unless this tissue is broken they are proof against ordinary infection. It is well known that erysipelas will appear about an old wound or sinus that has been rudely probed. Even virulent organisms spread upon healthy granulating surfaces fail to infect. Strong carbolic and other toxic agents can be used in and about such granulating cavities with an exemption from poisoning that otherwise would produce dangerous effects.