Part 149

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."

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.

Lattin has recommended the use of large doses of ergotine in infectious fevers, but this substance, when employed in the treatment of pyæmia, should be given in the formative stage of the disease. The use of drastic cathartics should be avoided, as should that of sudorifics, on account of their prostrating effects. In some cases hypnotics may be required to secure sleep.

Tonics are always more or less useful. The free use of stimulants and nutritious food is also indicated. Brandy, wine, and whiskey may be advantageously used as stimulants. Musk, ammonia, and camphor are occasionally required. However, it should not be forgotten that in cases where the disease has become fully developed the usual termination is death, few recoveries being recorded. In the early stages of this affection, by the removal of the patient from an overcrowded hospital ward to some place where pure air and proper hygienic arrangements can be obtained, recovery may take place, but under other circumstances the prognosis is exceedingly grave.

The treatment of septicæmia in most particulars is the same as that of pyæmia. The first effort should be to prevent the development of the disease, and the second to care for the patient in cases where the affection has already developed. It is not, of course, in our power to limit or in any way {983} regulate the primary injury, for we are obliged to take the patient as he is. The amount of injury to living tissue may be great or small. The question of an operation, the character of the same, and the subsequent management must be determined in accordance with the circumstances of each particular case.

The primary death of the parts is generally due chiefly to the injury itself; the secondary, frequently to bad surgical management. Let us now take a case in which the primary injury has been severe, greatly diminishing, but not destroying, the circulation in the injured parts. Here the immediate application of ice would be injurious, but a warm application might assist nature. It is humiliating to the profession that we are obliged even at this date to admit that the treatment of septicæmia is largely symptomatic. The profuse choleraic diarrhoea which generally accompanies this disease may be regarded as an effort of nature to eliminate the septic poison; but, nevertheless, it is so prostrating in its effects that it requires to be controlled with properly selected astringents, and these remedies may be still further aided by the use of stimulants and tonics.

The treatment of septicæmia may be summarized as follows: (1) A strict adherence to the five rules given under the head of the prophylactic treatment of pyæmia. (2) The avoidance of all putrefaction in contact with the wound, especially prior to the development of sufficient granulations to completely cover its surface. This object is to be accomplished by the removal of all necrotic tissues, the avoidance of putrescent fluids by cleanliness, and the proper use of antiseptic agents. (3) Free use of the alkaline sulphites and hyposulphites. These drugs should be used in all cases where there is reason to anticipate the development of septic diseases, as soon after the receipt of the injury as practicable, but should not be neglected even after the disease has become fully developed. (4) Sulphate of quinia should be used in all cases where the temperature is above 100° F., and its persistent use in large doses may be necessary to prevent the fever from rising still higher. It will be remembered in this connection that experience has taught us that "a temperature of 108.5° F. is the limit beyond which life can no longer exist," and even a much lower temperature is not without dangers. "The essential danger of fever in acute diseases consists, then, in the deleterious influence of a high temperature on the tissues."

The treatment of puerperal septicæmia, although requiring the application of the same principles as any other form of this disease, may be briefly described as follows: The womb should be maintained in a firmly-contracted state by the proper use of ergot, even as a prophylactic measure, and also during the whole course of the disease; the uterus and vagina should be kept in an aseptic condition by the efficient use of antiseptics; sulphate of quinia should be given in large doses, and repeated as often as may be necessary in order to lower the temperature; and morphia or some form of opium should be employed for the relief of the pain.

{984}

PUERPERAL FEVER.

BY WILLIAM T. LUSK, M.D.

DEFINITION.--Puerperal fever is an infectious disease, due, as a rule, to the septic inoculation of the wounds which result from the separation of the decidua and the passage of the child through the genital canal in the act of parturition.

To maintain this definition it is, however, necessary to group by themselves cases of childbed fever dependent upon causes which are operative in the non-puerperal condition, though the latter imparts to these causes oftentimes an exceptional activity and virulence. In this category are to be placed especially scarlatina, typhus, typhoid, and malarial fevers. It is to be borne in mind that the zymotic fevers may provoke in the puerperal woman the same inflammatory lesions commonly associated with puerperal fever. This is in accordance with the well-known surgical experience that a febrile paroxysm from any cause exerts an unfavorable influence upon a wounded surface.