symptom, indicating the state of the alimentary canal--not, however,
during the prodromal stage, but after the disease has progressed a few
days. It is then observed that the tongue has become peculiarly
smooth, dry, and often excessively red. This smoothness is caused by
the collapse of the papillæ, and the dryness by a diminished
secretion. The organ now frequently appears as if covered with a thin
layer of collodion which had been caused to dry on the surface, so as
to present a glazed look. Again, the tongue may be covered with brown
crusts and the teeth with sordes. These brown crusts and sordes are
usually seen in advanced cases, following the first condition
described. Much importance is attached to these brown crusts by many
experienced surgeons, and although there may be very marked
improvement in all other symptoms, still they insist on a very guarded
prognosis until the tongue has assumed a healthy appearance. Aphthæ on
various parts of the mouth and pharynx are frequently present in the
more chronic cases, but are usually absent in acute cases. Herpes of
the lips sometimes occurs in the commencement of the disease.
Vomiting is comparatively rare, but there is, even in the early
stages, a complete failure of the appetite, with great thirst.
Singultus is rarely present in genuine pyæmia, but frequently so in
septicæmia, and occasionally in septo-pyæmia. Diarrhoea is not so
frequent or the stools so copious in pyæmia as in septicæmia. Billroth
observed in one hundred and eighty cases of pyæmia thirty-two cases of
diarrhoea. It is impossible to determine whether those cases in which
the diarrhoea {976} occurred were pure or mixed pyæmia. The stools are
often of a pappy consistence, and passed involuntarily in bed. There
are, however, severe cases of pyæmia with high fever, and accompanied
by obstinate constipation.
Examination of the heart may, in rare cases, show the existence of
pericarditis, although usually the only indications of disease are the
too feeble sounds. Auscultation and percussion of the lungs may yield
unsatisfactory results when the metastatic abscesses are small and
scattered, for the same reason as in miliary tuberculosis. The large
deposits in the lungs are by these means readily determined. There may
be a sensation of suffocation, the pneumonic sputa, the friction sound
of pleurisy, or the signs of pleuritic effusion; and the existence of
these symptoms or signs would naturally aid in the diagnosis of
metastatic abscesses.
Enlargement of the liver and spleen may be determined before death,
and in connection with other symptoms would aid in diagnosing deposits
in these organs.
The urine in the first stage of this disease is scanty, high-colored,
contains a large amount of salts, and is of a high specific gravity.
Epithelial, fibrinous, and blood casts, and also albumen, are
occasionally found in it during the course of the disease. Billroth
mentions a case in which there was complete suppression, with uræmia.
In many cases of pyæmia suppuration of the joints, one after another,
takes place with great rapidity and with comparatively little pain,
but occasionally some swelling, redness, etc. are present. In most
cases these suppurations are easily diagnosed. Instead of suppuration
taking place in the joints, there are cases in which it occurs in the
cellular tissue; and I have recently seen a case where abscess after
abscess formed with such rapidity that within a single week the
patient was literally covered with abscesses from the crown of his
head to the soles of his feet.
Delirium generally exists during some stage of the disease, more
frequently the last, and is then mild in its character, although
active delirium has been observed in the first stage. Patients are
low-spirited and very apprehensive of death. The face at the beginning
of the attack may be flushed or pallid, but toward the end it always
becomes careworn and haggard. The breath occasionally has a sweetish
or purulent odor.
The changes in the wound are in some cases very marked, even in the
first stage of the disease. The suppuration, which has been previously
free and healthy, may be suddenly checked, the wound becoming dry. The
discharge, if it continues, becomes scanty, thin, ichorous, or
greenish. The granulations, if previously healthy, may soon slough.
These changes may not always appear in the first stage, but should
they not then take place they may be expected later in the disease.
SYMPTOMS OF SEPTICÆMIA.--These are commonly developed within
twenty-four hours after the receipt of an injury or the performance of
a surgical operation, and they may be sketched as follows: Frequent
pulse; tongue, lips, and throat dry; skin hot and the temperature of
the body high. The patient replies accurately to questions, but with
some hesitation. He is much inclined to sleep, has entirely failed to
take nourishment, drinks frequently when aroused from his lethargic
condition, and has vomited everything taken into his stomach since the
receipt of the injury or the performance of the operation. If {977}
the dressings are now removed from the wound, the foul odor of
putrefaction greets the attendants. In cases of amputation-wounds
considerable discoloration of the flaps may be observed, the edges
being blackened. Above these blackened edges the integument is
reddened and slightly oedematous. The wound having been closed with
sutures, which are now removed, there escapes a few drachms--possibly
ounces--of highly offensive fluid, the decomposed remains of blood,
etc. A further examination of the flaps on their inner surfaces show
that their capillary circulation has ceased. The tissues, instead of
presenting a life-like appearance, are now of a very dark color and
occasionally mottled with dull grayish spots, although the movements
of the ligature at the point where it embraces the femoral artery, for
example, show that the blood still rushes against the artificial
boundary.
Let us now leave our patient, without further comment, for the next
forty-eight hours, when we will resume the examination. We now find
the same dryness of the mouth that was previously noticed; the pulse
is more frequent, and has become very feeble; he complains of much
thirst, has vomited frequently, and has taken very little nourishment,
and that only at the earnest solicitations of the attendants. The
temperature is higher than at the former examination, and has been
steadily increasing; in the morning it is lower, however, than in the
evening of the same day. The patient is lethargic, and is suffering
with a profuse diarrhoea. The odor of the stools is highly offensive;
they are properly described as rice-water evacuations. The abdomen is
tympanitic; the body bathed in perspiration; the respirations rapid;
the urine scanty, high-colored, and contains albumen. The examination
of the stump shows that gangrene has extended rapidly, involving not
only the flap, but a portion of the adjacent tissues. The stench
arising from the wound is almost stifling. The decomposing fluids are
continually forming. That portion of the thigh not already gangrenous
is now very oedematous, and the integument covering it is much
discolored, being of a dark, icteric, or reddened hue.
We now allow twenty-four hours to elapse, and then make our final
examination. The patient's tongue is more moist; the body still bathed
in perspiration; the eyes dull; the conjunctivæ icteric, and the same
hue extends to the body, though in a less marked degree; the pulse has
become very frequent, feeble, and not easily counted; the temperature
is below normal. Singultus is now present, and has been so during the
last twenty-four hours. Bronchial symptoms, combined with marked
oedema of the right lung, have appeared; the diarrhoea continues the
same; the gangrene is still extending.
It must be admitted that the report here offered shows only the
symptoms that are found in a single class of cases. The symptoms vary
greatly in different cases, but they are especially marked in the
acute sepsis mentioned by Massanneuve under the head of _gangrène
foudroyante_. In these cases there appears, immediately after the
receipt of an injury, enormous oedema about the wound, which extends
rapidly in every possible direction, followed by the death of the
patient within a few hours unless prompt measures are adopted. The
puncture of the cellular tissue or of the blood-vessels involved in
the oedema prior to the death of the patient gives rise to the escape
of a highly offensive gas. Roser mentions a case of this disease in
which he promptly amputated {978} the limb of the patient through the
healthy parts, without even waiting for the administration of an
anæsthetic, and his patient recovered.
The symptoms of septicæmia must necessarily depend greatly on the
condition of the patient and the amount of septic material introduced,
but it is not deemed necessary to dwell longer on this subject.
DIAGNOSIS.--It is thought that a brief presentation of the
etiological, pathological, and semiological differences may be
advantageous to busy physicians who desire to obtain, with the least
expenditure of time, an accurate knowledge of the chief points of
distinction between these morbid conditions. This effort at
differentiation is merely intended to place the most important
characteristics in marked contrast; and consequently it should be
remembered that it is not our intention to give here the complete
etiology, pathology, or semiology of either of these morbid states,
but only their essential differences. Furthermore, it is thought that
the following arrangement will facilitate the object which we desire
to accomplish:
ETIOLOGY.
PYÆMIA. | SEPTICÆMIA.
1. Pyæmia generally commences | 1. Septicæmia generally commences
with the putrefaction in an | with the putrefaction in an
open wound of the secondary | open wound of the primary
wound-fluids--pus, etc.--in | wound-fluids--blood, serum,
which there are developed | etc.--in which there are
globular bacteria, which enter| developed rod bacteria, which
the blood and certain tissues | enter the blood and certain
of the body, where they | tissues of the body, where
multiply and produce | they multiply and produce
constitutional disturbances. | constitutional disturbances.
2. Pyæmia is commonly preceded by| 2. Septicæmia is commonly a
some local inflammatory | primary wound-complication,
wound-complication, such as | which is generally developed
suppurative periostitis, | within forty-eight hours after
osteo-myelitis, etc., and is | the receipt of the injury.
rarely developed before the |
end of the second week after |
the receipt of the injury. |
PATHOLOGY.
1. Increased coagulability of the| 1. Diminished coagulability of
blood. | the blood.
2. There are metastatic abscesses| 2. Complete absence of purulent
in various parts of the body, | or ichorous deposits in all
especially in the lungs, | cases of unmixed septicæmia.
liver, and kidneys: serous | Post-mortem appearances may be
cavities frequently contain | completely negative, with the
sero-purulent deposits; | exception of the condition of
similar deposits are often | the blood, although there is
found in the joints; abscesses| often some oedema of the
in the cellular tissue; and | lungs.
also abundant evidence of the |
existence during the life of |
the patient of pyæmic endo- |
and pericarditis. |
SEMIOLOGY.
1. Pyæmia commonly commences with| 1. Septicæmia commonly commences
a chill. | without a chill.
2. Fever variable, but rarely | 2. Fever steadily increases, but
entirely intermits. | is lower in the morning.
3. Sudden and great changes in | 3. The temperature is high at the
temperature, followed by | beginning of the disease,
profuse perspiration. | increases until near the fatal
| termination, when it falls
| below the normal. The skin is
| moist, but without profuse
| sweatings. {979}
4. Pulse variable; toward the | 4. Pulse rapid, and gradually
fatal end rapid, feeble, and | increases in frequency toward
irregular. | the fatal end.
5. Facies at the beginning | 5. Facies expressive of a dull,
flushed or pallid, toward the | listless condition throughout
end careworn. | the whole course of the
| disease.
6. Tongue smooth, dry, and | 6. Tongue, lips, and throat dry
excessively red, later | at the commencement, toward
brown-coated, and even the | the end moist. Thirst is
teeth coated with sordes. | marked.
7. Diarrhoea with stools of a | 7. Rice-water evacuations, very
pappy consistence. | offensive; obstinate vomiting.
8. Epistaxis. | 8. Epistaxis rarely occurs.
9. Mild delirium toward the fatal| 9. A lethargic condition from the
end. | beginning, increasing toward
| the fatal end.
10. Aphthæ in the mouth and |10. Icteric hue of conjunctivæ;
throat, sudamina, vesicles, | singultus often present.
pustules, and purpuric |
patches. |
The differences in the local manifestations occurring in and around
the wound, during the progress of these diseases, may be summed up as
follows:
At the commencement of this | The odor of putrefaction is
disease the suppuration is | commonly very marked within
commonly checked, the wound | twenty-four hours after the
becoming dry, and if a discharge | receipt of the injury, the
continues, it becomes scanty, | integument slightly reddened
thin, ichorous, greenish, etc. | about the wound, and the
The granulations, when previously| surrounding parts somewhat
healthy, soon slough, and venous | oedematous. The wound-tissues
oozing sometimes takes place. | soon assume a dark-brown color,
There occasionally appears in the| and are occasionally mottled
later stages of this disease | with dull grayish spots, while
around the wound a reddish | the edges of the wound are at
erythematous blush, which soon | the same time blackened,
extends over the whole limb. | although the movements of the
| ligature, when arteries have
| been tied, show us that the
| blood still rushes against its
| artificial boundary.
TREATMENT.--It must be admitted that the management of either pyæmia
or septicæmia, when fully developed, is always unsatisfactory, and
generally unsuccessful; consequently, the success which has attended
the use of the prophylactic measures employed in connection with the
treatment of wounds during the last ten years has given much
satisfaction to the medical profession. The committee of the London
Pathological Society reports as follows on this subject: "The
accumulation of septic matter in the uterus after labor, in contact
with the raw surface left by the separation of the placenta, would
also present the conditions favorable to acute septic intoxication. In
the present day, when the necessity of thorough drainage of wounds is
so thoroughly understood, and the means at the surgeon's command for
carrying it out are so efficient, it can only be under peculiar
circumstances that a sufficient quantity of putrid serum or pus to
yield the fatal dose of the septic poison is allowed to accumulate in
the wound. Moreover, the antiseptic treatment of wounds, now so
largely adopted, by preventing decomposition of course renders septic
intoxication impossible. Ovariotomy would seem to furnish conditions
most favorable to septic intoxication, and a large proportion of the
deaths occurring in the first forty-eight hours {980} have always been
attributed to it. The proportion of fatal cases from this cause has,
however, of late been greatly diminished by drainage, and more
especially by the employment of the antiseptic treatment."[42]
[Footnote 42: _Trans. Path. Soc. of London_, vol. xxx. p. 15.]
We cannot repeat too frequently or too emphatically the fact that the
treatment of pyæmia and septicæmia, when fully developed, is almost
invariably unsuccessful, and that consequently he who desires to save
the greatest number of lives must make every exertion and use all
available means to prevent their development--a task which fortunately
has now been brought within the scope of possibility in the large
majority of cases. Every surgeon will readily admit that, were it
possible to secure union by first intention in all cases of wounds,
then it would be impossible for either septicæmia or pyæmia to occur
in surgical practice. Therefore, it follows that the character of the
wound, the method of operation, the surroundings of the patient, the
character of the treatment, become proper points to consider in this
division of the subject. The character of the wound and its relations
to pyæmia and septicæmia have already been briefly referred to under
the etiology of these diseases. The various methods of operating, with
their respective advantages and disadvantages, are of course not
suitable topics for discussion in this work.
The surroundings of the patient form a subject of vast importance in a
prophylactic view, and should never be lost sight of in the
construction of hospitals. I desire here to express my firm conviction
that surgical pyæmia is essentially and almost wholly a hospital
disease. The question of surroundings for the patient presents to my
mind the following demands as a sine quâ non for obtaining the best
possible results in surgery: (1) Absolute cleanliness. This demand
should be strictly enforced in regard to the wound, the patient's
body, the bedding, and everything else, including nurses and
instruments. (2) Absolute purity of the atmosphere. (3) Moderate and
equable temperature, containing a proper amount of moisture. (4)
Proper quantity of nutritious and easily digestible food, with
suitable drinks, etc. (5) Cheerful and pleasant surroundings,
especially in companions, nurses, and other attendants. It may be
objected to these conditions that they can never be obtained. I must
confess that perfection in every detail cannot always be attained, but
I am thoroughly convinced that he who makes a determined effort in
this direction will succeed far better than that person who is
constantly looking about for some excuse for negligence.
The question of treatment brings up the entire subject of antiseptics.
The favorite remedies of this class are carbolic and salicylic acids,
permanganate of potassium, chloride of zinc, bichloride of mercury,
and liquor sodæ chlorinatæ. There is no doubt that good results may be
obtained with any of these remedies. The surgeon should never forget
that he uses medicines merely as agents to enable him to accomplish
certain objects; and, keeping this in mind, he need very seldom fail
with his antiseptic when the object is to prevent putrefaction in an
open wound. Therefore it appears certain that each method of treatment
may possess special advantages in particular cases, and probably the
same may be said of the antiseptic itself. The importance of this
subject may be more fully appreciated when it is remembered that it is
generally admitted by the best surgical authorities {981} that more
lives are lost from septic infection than from all other causes
combined during a war. The further consideration of this subject may
be arranged for convenience under the heads of local and general
treatment.
The local treatment of the wound should, if possible, be of such a
character as to prevent the absorption of either putrid substances or
pus. It therefore becomes highly important, in cases of amputation and
other operations, that all tissues injured to such a degree as to be
likely to excite either putrefaction, irritation, or inflammation
should be removed. The same care is necessary in removing all foreign
bodies from the wound in cases where no operation is to be performed.
The amputation of the injured limb may be necessary to prevent the
development of these diseases, or it may be resorted to in certain
rare cases after the origin of pyæmic symptoms; however, in the latter
instance great care should be taken to remove all the tissues already
infiltrated with serum, otherwise nothing will be gained. The use of
the surgeon's knife at the proper time may be the best prophylactic
against both pyæmia and septicæmia, but it should be directed by an
intelligent mind and the instrument guided by a practiced hand. Again,
it is found that opening a large medullary cavity may be attended with
danger to the patient. This fact teaches us an obvious lesson.
The wound existing or the operation having been performed, the surgeon
now turns his attention to the prevention of putrefaction and
inflammation. The first source of danger requiring attention from the
surgeon is the fluid escaping from the wounded surface. Do not allow
it to undergo putrefaction in contact with the wound. It should not be
forgotten that pyæmia is an infectious disease, having its origin in a
local nidus, an open wound, in which putrefaction of pus or other
wound-fluid is taking place. The question of amputation, or of the
extirpation of the parts for the relief of this disease, should only
be entertained when the surgeon is confident that he can remove the
whole of the infiltrated tissues. In other words, the performance of
these operations after the disease has become constitutional can never
be advantageous to the patient. Even in those cases where infiltration
is limited to the lymphatics, unless all these glands so affected are
removed the operation will be unsuccessful. It has been further
recommended in the treatment of this disease, in order to prevent the
formation of metastatic abscesses, to ligate the veins in which
thrombi have formed or may be reasonably expected to form, at some
convenient point between the heart and these obstructed points. The
value of this proceeding has never been fully determined, and may be
reasonably questioned. The formation of metastatic abscesses in
various parts of the body within the reach of the surgeon's scalpel
demands his attention; and we have been taught by experience that they
should be speedily opened, which generally lowers the temperature and
diminishes the danger from septic absorption. In the performance of
this operation Lister's antiseptic system of wound-treatment should be
strictly adhered to, since it unquestionably gives the best results
which can be obtained under the circumstances. When the metastatic
inflammation which occasionally appears in the thyroid and parotid
glands during the course of this disease terminates in the formation
of pus, this should be speedily evacuated. This prompt action is often
required, particularly for the relief of the grave symptoms which are
apt {982} to arise in connection with respiration and deglutition. The
accumulation of pus within the joints in pyæmic cases should, it is
now thought, be treated in the same manner as abscesses in the
cellular tissues--_i.e._ the articulations should be opened and
thoroughly disinfected, and afterward kept in a perfectly aseptic
condition, and also rendered absolutely immovable during the
treatment.
Having directed attention to the more important local measures, we may
now briefly enter on the consideration of some of the constitutional
remedies. In the general treatment of pyæmia there have been
recommended at various times a great variety of drugs, but the general
want of success attending their use leaves comparatively few to be
mentioned here. The mineral acids are still employed, and are found to
be at least agreeable drinks, and as such can be still recommended.
The sulphites of magnesium, sodium, potassium, and lime were
recommended by Giovanni Polli for the treatment of typhus fever,
scarlet fever, small-pox, septicæmia, and pyæmia. He further suggested
that the medicine should be given until the whole quantity taken bore
to the weight of the patient's body the proportion of 1 to 1000. The
experiments made on animals with these salts seem to confirm their
value in the treatment of septic diseases. It is certainly true that
animals treated with these salts are not so easily affected by septic
poison as those which have not received this treatment. Further, it
has been shown that putrid substances when mixed with either
permanganate of potassium or the sulphite of sodium, and then
injected, are harmless, although the same quantity of putrid matter
injected without either of these salts destroys life.
Brandy and other alcoholic stimulants have been strongly recommended
on account of their well-known antiseptic properties. The sulphate of
quinia is certainly, in most cases of pyæmia, a valuable agent. In
large doses it enables the surgeon to reduce the temperature of the
patient, and in smaller doses it frequently serves a valuable purpose
as a tonic. It has also considerable value as an antiseptic.