The practical outcome of such a chapter as this is, then, to insist as strongly as possible on the preparation of patients, whenever this is feasible, for an ordeal which comprises the combined effect of anesthesia and consequent disturbance of secretion and elimination, with loss of blood and of strength, and subsequent confinement in bed, with, moreover, all that this entails in further impairment of activities of important organs. It is not always possible, practically rarely so in emergency cases, to adopt these precautions; in which cases they must be atoned for, as far as possible, by extra attention in the same directions after the emergency is passed or has been met. In the former case, however, the functions of the skin, the kidneys, and the abdominal viscera should be regulated, the first by hot-air baths; the second by this same measure in conjunction with copious draughts of pure water, the correction of hyperacidity of the urine, and the administration of whatever drugs may be of benefit as diuretics, etc.; and the third by a course, perhaps covering several days, of gentle or active purgation, by which the alimentary canal will be entirely emptied of all that may serve to act as a source of poisoning. In addition to this, in certain cases careful massage will dislodge from the muscles and other tissues material which they ought not to retain, and which will be washed away, as it were, by the extra amount of fluid which this preparation, necessitates. Again, the activity of the heart should be stimulated, perhaps by digitalis, but preferably by that best of all tonics, strychnine, which is to be administered hypodermically in average doses of a thirtieth or twenty-fifth of a grain, morning and night. When these precautions are taken, patients will successfully pass through trying ordeals without anything which may give rise to alarm. When they are not possible, the risk of operating, even in a small way, is materially enhanced. So, too, after operations when these precautions have not been taken, it is necessary to give careful attention to atoning for their lack by such active purgation as a now reduced patient may bear—by hot-air baths, if feasible, and by the administration of such intestinal antiseptics as charcoal, naphthalin, corrosive sublimate, bismuth salicylate, salol, etc., for the purpose of reducing to the lowest possible minimum the opportunity for formation of poisons which will disturb the proper repair of injury.
CHAPTER VII.
THE SURGICAL FEVERS AND SEPTIC INFECTIONS.
SURGICAL FEVER, KNOWN ALSO AS TRAUMATIC FEVER, OR ASEPTIC WOUND FEVER.
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.