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.