Multiplicity of Septicæmias. Pyæmia and Septicæmia, distinction
between. Multiple secondary abscesses in pyæmia; no secondary
abscesses in uncomplicated septicæmia. Septico-pyæmia. _Pyæmia._
Causes: bacteria, deep wound infection, susceptibility, debility,
shock, illness, narcotic ptomaines, partial immunization, complexity
of infection, mutual decomposition of toxins, dose, lesions of intima
of blood vessels, thrombosis, embolism, action of microbes on
hæmatoblasts and blood globules, viscidity of cells, adhesion to
endothelium, coagula, solution of clot, escape of microbes. Lesions:
wound, abscess, thrombus, emboli, infarction, abscesses, ulceration,
endocarditis. Spleen. Blood coagulates. Symptoms: rigor, hyperthermia
with remissions, pulse weak, soft, rapid, perspiration, diarrhœa,
sweet breath, fæces, urine acid, dulness, prostration, mucosæ dusky or
yellow, blood shows leucocytosis, hæmolysis, cardiac murmur,
arthritis, stupor, coma, palsy, dry, puffy sore, source of infection.
Prognosis grave. Prevention: largely surgical, antisepsis, asepsis,
excision of infected vein. Treatment: antiseptics, locally and
internally, stimulants, tonics, nourishment. _Septicæmia_: microbes,
toxins, septic intoxication, septic infection, fermentation fever,
sapræmic fever. Lesions: blood dark, incoagulable, spleen
enlarged—gorged, petechiæ, cloudy swellings, coagulation necrosis,
organs as if parboiled, congested glands, kidneys. Symptoms: chill
slight, hyperthermia without marked remissions, weak, rapid pulse,
hurried breathing, anorexia, emesis, yellow mucosæ, nervous
disorder—dulness, apathy, stupor, paraplegia. Value of precursory
conditions. Prognosis grave. Prevention, Treatment: remove source of
poison, antiseptics, drainage, internal antisepsis, strychnia,
quinine, iron chloride, stimulants, supporting, easily digestible
food, sponging.
At first introduced to indicate the supposed results of pus and septic
material respectively in the blood, these terms have come to represent
the clinical phenomena which come from the introduction into a
susceptible system of pyogenic and necrogenic microbes and their toxic
products. Gradually different affections, which would have been included
under the same general terms, came to be identified under specific
names, and a number of these will be described as individual
diseases—strangles, mouse and rabbit septicæmias, metritis, phlebitis,
omphalitis, rouget, barbone, chicken cholera, septicæmia hæmorrhagica,
etc.—yet a certain number have been left to be referred to under the
generic terms, though respectively due to different microbes.
_Distinctions between Pyæmia and Septicæmia._ _Pyæmia_ is a morbid
condition characterized by the formation in different organs of multiple
metastatic abscesses, dependent on the transference, in the blood
stream, of infected clots, or particles containing pus microbes, and
their arrest at distant points, so as to cause foci of suppuration
commencing with the intima of the vessels.
_Septicæmia_ indicates a general infection often by the same microbes,
but showing its results in enlargement and blood engorgement of the
spleen and lymph glands and necrotic foci of the liver, kidneys and
other organs, but without the formation of multiple abscesses. The
presence of the microbes in the different organs affected, shows that it
is not due to the diffusion of the toxic chemical products alone, as at
one time supposed, and the lack of abscesses appears to be due to the
absence of clots or of modified and adhesive leucocytes or hæmatoblasts,
which adhering to the epithelium of the vessels predispose to
suppuration.
The two conditions are, however, often combined, constituting what is
known as _septico-pyæmia_.
As in the occurrence of other infecting diseases, the condition of
varying susceptibility must be taken into account, one individual, or
one species resisting an inoculation which would be deadly to another.
=Pyæmia.= _Causes._ The causation microbes are most commonly
staphylococcus pyogenes aureus, or albus, the streptococcus pyogenes,
and less frequently bacillus pyocyaneus, bacterium coli commune, and
probably any pus producing microbe. Many conditions must however be
accepted as contributing to the general infection.
Inoculation on a mere abrasion or surface sore is not to be dreaded so
much as if the virus is lodged _subcutaneously or in a deep wound_. The
ready escape of the toxic products, the active leucocytosis which takes
place in the granulations, and the action of the oxygen of the air are
more or less protective in the exposed sores.
The native _susceptibility of the subject_,—horse, ox,—conduces to the
disease, while the insusceptibility,—bird—tends to obviate it.
The _debility of the system or of individual tissues attacked_, lowers
the resistant power, and especially that of leucocytosis, and thus
favors survival and encrease of the microbes and their chemical
products. Thus the _shock_ succeeding a serious operation, the general
depression attendant upon severe illness, or the poisoning by
narcotizing ptomaines and toxins, may easily become the extra weight
which causes the system to succumb. On the contrary, pre-existing or
long standing disease, with consequent general debility appears at times
to prove to some extent a protective factor, the previous exposure to
the invading germ having educated the leucocytes to resist the toxins
and to produce the defensive sera which neutralize the latter or keep
the invading microbes in check. A measure of immunization has been
secured.
The resulting immunization cannot be looked on as very perfect, nor
permanent, as a specially strong inoculation by a virulent microbe, or
large dose, or different conditions of life, will entirely overcome it,
and the pyæmic fever appears. Yet in chronic cases of secondary
abscesses from a deep source of infection, the resistance is often such
as to ward off febrile pyæmia. In a horse with primary abscess situated
deeply under the humerus, free evacuation and healing of the wound,
have, in my experience, been followed by the formation of abscesses in
distant points for a period of seven years, but without any marked
febrile reaction.
The _complex nature of the infection_ appears at times to overcome the
vital resistance more effectively than will the presence of even a
potent microbe alone. Some of the worst cases follow on a wound, the
seat of complex infection, and even saprophytes are to be dreaded in
this connection. This may operate in various ways, either by mutual
combinations or decompositions of the toxic products of associated germs
producing more deleterious products, or by the individual action of one
ptomain or toxin on leucocytes, hæmatoblasts, sera, or tissue, laying it
more open to the attacks of those of another microbe which by itself
would have been comparatively harmless.
Koch’s experiments showed that the _attack is violent in ratio with the
size of the dose_: one-thousandth part of a drop of pyæmic blood was
harmless to the rabbit, while one tenth of a drop killed in one hundred
and twenty-five hours, and a syringe full in forty hours.
In ordinary cases of pyæmia the occurrence of internal _phlebitis_ or
_arteritis_ with the inevitable thrombosis is an important step in
causation. Any inflammation of the inner coat of the vessel leads
promptly to the formation of a coagulation of the contained blood, and
blocking of the lumen. Beginning on the diseased or abraded surface, the
clot forms backward along the line from which the blood normally comes
(proximal in the arteries; distal, in the veins), until it reaches the
next considerable colateral branch. The clot is firmly adherent to the
intima except at the free end, which is conical and projects into the
blood current.
If small portions are detached from the thrombus and washed on in the
blood stream they become arrested when they reach a vessel too small to
admit them, it may be a smaller artery, or it may be a capillary, and
always in the line of the circulation,—from the systemic circulation to
the lungs, or from the lungs to the system at large. This is =embolism=.
Wherever arrested, the contact of the leucocytes and hæmatoblasts with
the inner coat of the vessel, leads to metabolic changes and firm
adhesion, and the pus microbes in the clot determine suppuration and
abscess.
Eberth and Schimmelbusch have shown that the hæmatoblasts, even more
than the other blood elements, when acted on by the pus microbes become
viscous and stick not only to each other, but to any floating body, and
to the inner serous coat of the vessel, particularly when the latter has
been abraded or injured. This clumping together of the hæmatoblasts
forms white clots which block the smaller vessels, but in the viscous
condition they further the coagulation of the fibrine, and again when
they come in contact with the intima, instead of passing through, or
moving on, they remain adherent and start the formation of thrombi. This
is above all common in given tissues, and the medulla of bone has in
this respect a bad preëminence, so that acute suppurative osteomyelitis,
is a familiar lesion and is liable to become chronic, and determine
distant abscesses and general infection long after.
The thrombus thus formed is an infective coagulum, tending to constant
encrease, as the clot is a favorable culture-field for the microbes, and
the tendency is to coagulate more and more of the adjacent blood. It
tends further to disintegration, as the action of the microbes and their
toxins on the leucocytes, transforms these into pus cells, inducing
softening of the mass, and the washing on of individual infective pus
cells and minute portions of the clot to form infective centres and
abscesses at distant parts.
If the pathogenesis of the invading microbe is weak and the resistance
of the leucocytes potent, such clots may remain circumscribed or may
even be absorbed, but in the opposite conditions with potent and
numerous microbes and abundant and effective toxins, the disposition is
not only to a continuance of infection, but to an acute febrile pyæmia.
Pyæmia does not supervene at once upon a trauma as may septicæmia, but
only after a variable number of days, (3 to 8), a peculiarity which is
explained by the temporary protection of the clot. By the constant
accretions on its exterior, of the new layers of hæmatoblasts and
fibrin, the microbes are at first imprisoned, and it is only when
softening has taken place, or when the coagulum has extended into the
free flowing current passing into a colateral trunk, that the infection
is liable to be washed on in dangerous amount.
The mere presence of pus microbes or their toxins in the blood, does not
determine pyæmia: a modification of the intima of the vessels leading to
local infections with thrombosis or embolism and abscess is an essential
condition. This lesion of the vessels may be a trauma, as from bruise,
puncture, operation, ligature, or it may be the extension of a disease
process as in arteritis, phlebitis, atheroma, the growth of a tumor from
adjacent tissues, or parasitism. The seat of the secondary abscess
depends primarily on the location of the original suppurating centre. As
such centres are most commonly in the systemic circulation
(osteomyelitis, omphalitis, wounds, traumas) the lungs are most commonly
attacked, the pulmonary capillaries acting as a sieve and arresting the
floating infective coagula. When the primary infection comes from the
chylo-poietic viscera, the liver is likely to show the first crop of
secondary abscesses. When, on the other hand, the primary abscess is in
the lungs, the great flow of blood through the kidney renders it
especially subject to secondary suppurating foci, though these may form
in any part of the body.
_Lesions._ Pyæmia may result from a wound or abscess in connection with
which will usually be found a vein containing a thrombus more or less
softened or liquefied. If from a deep seated injury or from
osteomyelitis, the same condition is met with. The thrombus and
circulating blood furnish abundance of the infective microbes, and at
distant points, in the complimentary circulation, most commonly in the
lungs the arteries are found to be the seats of _embolism_ from arrested
clots. The arrest always takes place where the vessels are diminished by
bifurcation, or the giving off of a considerable colateral trunk, and
the appearances will depend on the duration of the embolism. If quite
recent, a wedge-shaped mass of tissue supplied by the vessel is ischæmic
and pale, its blood passing on into the veins without further arterial
supply; if later, this tissue forms an _infarct_ being gorged with deep
red or black blood which has filtered in from adjacent anostomosing
capillaries and distended those of the exsanguine area. This area
becomes of a deep red or black color, consolidated by an exudate of
lymph, and rapidly invaded by suppuration. The microbes determine
suppuration and softening, first in the clot and intima, and next in the
outer coats of the vessel and the surrounding exudate, so that an
abscess of variable size may result. Abscesses are usually smaller and
more numerous in the acute forms of the disease, and larger and less
numerous in the more chronic.
Ulcerative endocarditis with coagula on the valves is not uncommon. The
spleen is often the seat of small abscesses in the centre of solid
exudates, with in many cases softening and enlargement of the organ. The
blood tends to retain its normal bright red color, and clots firmly,
contrary to the usual condition in septicæmia.
_Symptoms._ The formation of emboli and secondary abscess is usually
marked by a violent rigor, lasting from a few minutes to an hour and
which may be repeated at irregular intervals, serving, in some measure,
to distinguish pyæmia from septicæmia. The temperature rises with the
rigor, (102° to 105°) but shows marked remissions especially in the
morning, when it may not exceed the normal, and rising again with the
recurrence of chill or staring coat. The pulse is usually encreased in
frequency even during the remissions and is soft and compressible.
Remissions may be attended by profuse perspirations or even, in the
advanced stages, by fœtid diarrhœa. The breath has a peculiar sweetish
or mawkish odor. Blood passed with the fæces may indicate intestinal
abscess, and albumen or pus in the acid urine, bespeaks suppurating foci
in the kidney. The cloudy mucus from the pelvis of the kidney in the
horse must not be mistaken for this. Cough or dyspnœa will indicate
abscess of the lungs, and intercostal tenderness, pleurisy.
The buccal mucosa may be dry and cracked, and the tongue coated. From
the first the animal is dull, and prostrate, and the visible mucosæ
become dusky brown or even yellowish from the liberated hæmatin. Blood
abstracted, will show the microörganism, an excess of leucocytes and
diminution of the red globules. The poison determines hæmolysis. A
cardiac murmur, usually with the first sound, betrays endocarditis. This
is especially characteristic of chronic pyæmia. Again multiple
suppurating arthritis may appear. Stupor, coma or paralysis will
indicate cerebral or meningeal lesions.
In pyæmia following trauma there is drying up of the pus which becomes
serous or bloody, a puffy condition of the granulations, and the
evidence of a thrombus in one or more veins leading out from the wound.
In other cases the occurrence of pyæmic symptoms, consequent on
parturition, metritis, omphalitis, bone-abscess or osteomyelitis, on
suppurating internal inflammations, ulcerative endocarditis, or
infective fevers like strangles, influenza, contagious pneumonia, cattle
plague, distemper, rouget, hog cholera, etc., serves to identify the
disease.
The _prognosis_ of pyæmia is always grave, and death may be expected in
six to fourteen days in acute cases. Chronic forms last much longer.
_Prevention_ is the great object in regard to surgical cases, and this
means the prevention of suppuration in the wound. As far as possible,
however, this is to be sought by asepsis, or the use of weak non-caustic
antiseptics only, as cauterized tissues form favorable culture media,
when the action of the antiseptic is spent, there being no longer any
living and resistant leucocytes present. The early excision of veins,
the seat of thrombosis, has proven successful.
In purely medical cases, the seat of the primary suppuration is not
always obvious and one is thrown back on medical treatment which is
rarely satisfactory in severe cases.
_Treatment._ When accessible even the secondary abscesses may be opened,
washed out with a weak antiseptic (3 per cent. carbolic acid solution),
and covered with antiseptic dressing. Antipyretics are worse than
useless, because of the resulting depression of the vital powers, and
the reduction of the natural powers of resistance. Calomel in small and
repeated doses tends to assist in elimination, and to counteract
complications through sepsis of the contents of the bowels. Quinine and
chloride of iron continued in large doses have been especially relied on
as antiseptic tonics. Liberal feeding, if the appetite will admit, is
all important, to tide the patient over the period of depression. In the
chronic cases tepid bathing is of great value (Senn). Senn has great
confidence in the stimulating and supporting action of alcoholic
liquors—beer, ale, porter and even whisky, and in human beings
accustomed to the daily use of these beverages they are more imperative
than in the lower animals.
=Septicæmia.= The micro-organisms causing septicæmia are the same as
those of pyæmia, but they differ somewhat in activity, and act upon a
system with a modified susceptibility, and above all one void of lesions
in the internal membrane of the vascular system. The symptoms can be
developed by the introduction of the ptomaines and toxins alone, which
hypothetical condition has been named _septic-intoxication_. In case of
excessive doses of septic material, death occurs so early as to indicate
simple narcosis. If, as is usually the case, the microbes also gain
access to the blood and multiply there, the condition has been known as
_septic infection_. In any prolonged case of septicæmia, the tendency is
to the formation of suppurating foci (_septico-pyæmia_), so that the two
affections may be looked upon as probably the same, with modifications
of the earlier phenomena.
In connection with septicæmia must be mentioned the _fermentation fever_
of Bergmann, (_aseptic_ or _resorption fever_) which follows on
extensive wounds, even if aseptic, on the intravenous injection of the
blood of healthy animals or even of fine foreign particles (charcoal,
flour), of a normal salt solution, or of well water, or of pancreatin,
pepsin or trypsin. It has been attributed to the introduction and
metabolism of fibrine and other elements, but manifestly arises also
from the solution of blood globules, (hæmolysis). It comes on within a
few hours after a severe operation or other cause and lasts from one to
three days, terminating in recovery, unless complicated by some
intercurrent infection.
The _sapræmic fever_, of Mathews Duncan (sapros—putrid, haima—blood) may
also be named in this connection. It is associated with one or more of
the common saprophytes (Bacillus saprogenes 1–2 and 3 of Rosenbach,
Proteus Vulgaris, Proteus Zenkeri, Proteus mirable, etc.) These are
propagated with difficulty in the blood, but grow readily in pus or
necrotic tissue from which their toxic products can pass into the blood.
Again the observations of Brieger and Maas, Ruine, Vaughan, Bourget and
others show that the isolated toxins from putrefactive fermentation of
animal matters, apart from the living bacteria are capable of producing
the characteristic symptoms of septicæmia.
It is now generally concluded that the septicæmic phenomena can be
produced by the introduction of such poisons, whether they are the
product of septic fermentations outside the animal poisoned, or of
fermentation in dead matter in the economy of such animal.
_Lesions._ In _fermentation fever_ no tissue lesions are known. In
_septicæmia_ gross lesions are usually lacking unless the case has been
prolonged to allow of secondary abscesses (septico-pyæmia). The blood
however is dark and coagulates feebly if at all. The spleen is enlarged,
softened, dark in color and gorged with blood. There are petechial
hæmorrhages into the serosæ and mucosæ, and the solid organs; cloudy
swelling of internal organs from coagulation necrosis; a parboiled
appearance of heart, liver, kidneys and voluntary muscles; congestion of
the lymph glands and usually the presence of the specific microbes in
the blood and local lesions. The kidneys are always congested, and their
epithelia granular and swollen, and there may be exudation between the
glomeruli and their capsules.
_Symptoms._ Septic intoxication or septic infection may be ushered in by
a staring coat or slight chill, but it rarely shows a violent rigor,
such as inaugurates pyæmia. There is a rapid rise of temperature (102°
to 104°), which persists for three to seven days without the marked
remissions of pyæmia; weak, compressible pulse; great muscular debility;
hurried, shallow breathing, usually without cough; anorexia; emesis in
vomiting animals; dusky or yellow mucosæ from dissolved hæmoglobin;
scanty, high colored urine, rarely albuminous; dulness, sometimes
nervous twitching, delirium, apathy, stupor or paraplegia; and either
constipation or, later, diarrhœa. When such symptoms supervene on a
gangrenous sore, septic abscess or fistula, retained placenta, blood
clot in the uterus or elsewhere, suppurating tubercle, or other morbid
product, gangrenous lung or other internal organ, purulent pericarditis,
pleuritis or peritonitis, or any febrile affection which is complicated
by necrosis, septicæmia is to be suspected. “Septicæmia should always be
suspected during the course of any disorder the lesions of which afford
an opportunity for the growth and development of septic microörganisms,
when the symptoms of that disorder depart from the usual type and an
elevated temperature continues beyond the usual duration.” (Atkinson).
“The final diagnosis of septic infection must be based on the existence
of an infection atrium, through which pus microbes have entered the
tissues, and from which they have reached the general circulation.”
(Senn).
_Prognosis_ is always grave. A slight infection, overcome by the
leucocytes or a simple septic intoxication may get well in two or three
days, but an _acute progressive septic infection_ will usually prove
fatal in from one to seven days.
_Prevention_ does not differ from that recommended for pyæmia.
_Treatment_ is virtually hopeless unless it can secure the removal of
the necrotic tissue or fermenting material from which the poison is
derived. When the poisoning is due to the absorption of septic products
only, with little or no introduction of microbes (septic intoxication)
the removal of their source of supply may bring about a speedy and
permanent improvement. The removal of a putrid placenta, or liquid from
the womb, followed by irrigation with an antiseptic lotion, the
evacuation of a putrid abscess, empyema, or ascites, followed by a
similar disinfection, or indeed the extirpation of a sloughing and
putrid mass of any kind may be followed by a lowering of temperature
within a few hours, and a steady improvement in the general symptoms.
The antiseptic agents employed must be sufficiently potent, and
persistently applied to render the surface sterile and yet not so
caustic as to destroy more tissue to become a future culture medium for
the septic microbes. Mercuric chloride (1:2000), aluminium acetate
(1:100), powdered iodoform, or aristol will often serve a good purpose,
to be followed, when necessary, by efficient drainage and a covering of
antiseptic gauze. When the primary source of infection is in the
intestinal canal, calomel, naphthalin or B. napthol may be tried.
For the weak heart strychnine is the most safe and reliable agent.
Quinia in large doses acts as an antipyretic, without the attendant
dangers of the coal tar products. It may be advantageously combined with
tincture of chloride of iron.
Ammoniacal and alcoholic stimulants are largely resorted to to tide the
patient over the period of depression, and nourishing and easily
digested food should be given so far as the stomach can make use of it.
Skim milk, eggs, and beef tea may be given even to the herbivorous
patient.
The thirst should be met by plenty of pure water to favor elimination of
the toxins, and the surface frequently sponged with tepid water, not
only on the ground of cleanliness and disinfection, but also as
calculated to lower the febrile temperature.