—In septicemia there is a period of incubation, usually two or three days, often longer. If this follows an operation, the mild fever which would indicate the slumbering fire is usually regarded as surgical fever. But when this rises and is followed by prostration, with alimentary disturbance, loss of appetite, headache, etc., followed by typhoidal symptoms, the alarm is sounded and should be quickly heeded. Usually, but not always, there is a preliminary or premonitory chill, after which prostration will be more marked than before. The severity of the symptoms cannot be foretold from the size, location, or character of the wound. The character of the fever is essentially continued, usually with morning remissions. Gussenbauer has called attention to a class of cases in which subnormal temperature is caused by the absorption of ammonia compounds. To these he has given the name ammoniemia. This condition may be seen in connection with gangrenous hernia, and has even been mistaken for shock (Warren). (See also [acetonemia], in previous chapter.)
In septicemia from infection of a visible portion of the body there are usually seen evidences of lymphangitis and perilymphangitis of septic character. These will be evidenced by tender and purplish lines, extending subcutaneously along the course of the known lymphatics or in connection with the more prominent subcutaneous veins. The lymph nodes, into which these visible vessels as well as the deeper ones empty, become enlarged and tender; the whole lymphatic system participates; the spleen in aggravated cases becomes notably enlarged, and even the bone-marrow more or less involved. Diarrhea is commonly an early but controllable symptom. A hematogenous icterus of mild degree is another frequent accompaniment. The conjunctiva becomes discolored and the skin slightly so. Should the blood be examined marked leukocytosis will be noted, and should cultures be made from it, in many instances at least, the organisms at fault can be detected and recovered from it. The vigor of the heart muscle is seriously impaired; the pulse becomes rapid and weak. In scarcely any form of septic infection is this more prominent than in diphtheria; and microscopic examination shows the rapid disintegration of the cells of the heart muscle, as well as those of other parts of the body, even to the almost complete molecular disintegration of the nuclei. Erythematoid, pustular, and even hemorrhagic eruptions are met with upon the skin, some of which are probably to be explained by thrombosis of the dermal capillaries. Certain complications are not infrequent, among which inflammations of the pericardium and endocardium—e. g., ulcerative endocarditis—are frequent. As the case becomes aggravated the temperature rises irregularly; the hot, dry skin becomes cold and clammy; prostration and indifference more marked; diarrhea more colliquative; icterus more pronounced; urine more reduced in quantity or suppressed; and these symptoms are succeeded by indifference, mental apathy, stupor or delirium, and finally death, the patients being comatose and collapsed.
While these are the general indications of septicemia, the wound or site of injury has undergone changes which are also characteristic. They comprise the edema and redness of wound margins, which may be seen even in sapremia, followed by increasing tumefaction, escape of foul-smelling discharge, and finally by sloughing and gangrene of the parts involved. On microscopic examination the capillaries are filled with infective thrombi and vessel walls infiltrated with microörganisms, which abound also in the lymph spaces. Bacterial infection can be traced in microscopic sections from the infected area, from the point in the neighborhood of the wound where microbes infest the tissues to points remote from it, where they are sparsely found, if at all. The same evidences of infection may be traced along the lymphatic vessels, and often the veins.
Postmortem Evidences.
—The postmortem evidences of septicemia are indicative on first sight: the blood is of the consistency of tar and does not coagulate; evidences of putrefaction are plain to sight and smell; the serous membranes, particularly the pia mater, are often extravasated; the muscles are discolored and of a darker hue than natural, edema of the lung is frequent; the intestines reveal a gastro-intestinal catarrh, the duodenum and rectum showing punctate hemorrhages; the spleen is darkened, enlarged, and softened; the liver shows similar signs, less marked, and at times an emphysematous condition due to putrefactive gases. Cultures can be made from the fluids and tissues of organs thus affected. It is also of importance to emphasize that such material is powerfully and often fatally infectious; some of the worst forms of dissecting wounds and instances of fatal infection have come from carelessness in making these postmortem examinations.
So far as concerns the character of the wound, which is most likely to be followed by septicemia, there is but little to be said. Wounds made by infected tools, the butcher’s knife, the anatomist’s scalpel, etc., are the most dangerous. All forms of phlegmonous erysipelas, many cases of gangrene following frostbite, nearly all instances of traumatic gangrene, most cases of carbuncle, and, in fact, all similar lesions, are likely to be followed by septicemia. The so-called spontaneous cases have an equally infectious origin, though one which is concealed. In unrecognized instances of appendicitis, for instance, and in many other conditions, although the path of infection may not be easily traced, it is, nevertheless, always present, and can be found if diligent search is made. The nasal cavity, the tonsils, the teeth, the middle ear, the deep urethra, and the rectum are often overlooked as offering possibilities for septic infection which may follow this general type.
Treatment.
—This should be both local and general. Local treatment should consist in complete and absolute removal of the active cause. This comprises the reopening of wounds, evacuation of clot, cutting or scraping away of sloughs and gangrenous tissue, with cauterization of the exposed living tissue, in order that absorption may be prevented, and will often include amputation or extirpation of a part. For tissues which are not too completely riddled by disease, and lost beyond possibility of redemption, continuous immersion in hot water offers the best possible prospect. By it putrefaction seems checked, the separation of dead from living tissues is accelerated, relief of pain or discomfort is afforded, and disinfection of material which is foul and infectious is guaranteed. An excellent local application is the mixture of resorcin 5 parts, ichthyol 10 parts, ung. hydrarg. 40 parts, and lanolin 45 parts, already mentioned in Chapter IV, or the application of brewers’ yeast. (See chapter on [Ulcers].) Of great value also will be found the silver ointment of Credé (Unguentum Credé). This permits of absorption of silver through the unbroken skin (as in the case of ung. hydrarg.), and the dissemination throughout the system of the antiseptic virtues of the silver itself. To ensure its greatest efficiency this ointment should be thoroughly rubbed in, especially over parts which are not too tender. Many cases of septic infection promptly yield under the influence of the argentine preparations which Credé has lately introduced.
In suitable cases also the subcutaneous injections of antistreptococcic serum will be followed by beneficial effects. The earlier the injection is given the better the prospect of benefit. Evidence is strongly in favor of this serum as a prophylactic measure, especially before operations, when septic pneumonia or other septic accidents are feared.
Another measure of great utility in selected cases is the intravenous infusion of a solution of Credé’s soluble silver, made with 1 gram of silver in 1000 Cc. of sterilized water at a temperature of 105° to 110°. In cases of profound toxemia a small amount of blood may be withdrawn (50 to 400 Cc.), for reasons stated in Chapter VI. No hesitation need be felt in introducing 500 Cc. or even 1000 Cc. of this solution. It is the ideal way of bringing a powerful non-toxic antiseptic into immediate contact with pathogenic microbes.