There have been recent suggestions as to the intravenous injection of very dilute formalin solution, in order to take advantage of its remarkable germicidal activity; it has been employed in a few cases, especially of puerperal sepsis, with success, 1 Cc. of standard formalin solution is mixed with 800 Cc. of sterilized salt solution. It has been shown that if 50 Cc. of this is thrown into the veins of an average adult it will form with the 5000 Cc. of blood a mixture of 1 to 200,000, in which strength it may be expected to prove an efficient bactericidal agent. Indeed, a smaller amount or a weaker preparation would probably suffice. Barrows has reported success following two infusions, two days apart, of first 500 Cc., then 750 Cc. of a 1 to 5000 formalin solution. Still, these injections may be followed by cramps in the arms, cardiac discomfort or distress, and blood (or blood cells) in the urine. It would probably be well to limit this use of formalin to those cases at least in which the presence of cocci in the blood can be demonstrated by culture or other method.
An excellent method in the local treatment of parts which admit of it (hands and feet) is their exposure to dry hot air in the Kelly heater or some similar apparatus. Hot air will be borne at a temperature of 210° to 220°, which may be destructive to germs while still tolerable for a short time by the tissues. Clinton, of Buffalo, with whom this method is original, reports that the temperature within the tissues thus treated is raised to about 107°, which is above the thermal death point of the ordinary pyogenic organisms, and that this method gives better results than any other of treatment of septic infection of those parts which can be subjected to it.
The general treatment of septicemia is, in the main, stimulant and tonic. Fever is not to be treated with arterial sedatives nor often with antipyretics. It is a symptom of poisoning, and its too prompt suppression prevents both the recognition of the intoxication and the measure of its degree. Pyrexia then is best combated with cool sponge baths and stimulant measures of a general character. The principal reliance must be upon nutrition and stimulants. Assimilation may be impaired when gastro-intestinal catarrh is as prominent a feature as it is in many of these cases. Consequently the simplest and most assimilable food, often that which is predigested, should be administered. Milk, eggs, beef peptonoids, and fruits are among the most appropriate. The best stimulants and tonics are alcohol and strychnine. Strychnine is preferably administered hypodermically in doses of ¹⁄₂₅ grain from two to four times a day. Heart depression is best combated by this measure, or by quinine in large doses, while digitalis and atropine may be added. For internal use alcohol is, par excellence, the remedy. This is administered in doses only to be measured by their effect. In fact, the administration of alcohol in these cases is a matter of effect, and not of dosage. Aside from these measures the intestinal antiseptics should be administered, among these being corrosive sublimate, ¹⁄₁₀₀ grain, every three or four hours, salol in large doses, bismuth salicylate, or naphthalin—any or all of these in connection with powdered charcoal. Intestinal pain and frequency of stool can be more or less controlled by opium, while disinfection of the alimentary canal is only to be accomplished by the above remedies, in connection with flushing of the colon with saturated boric acid solution or something of that kind. Pain is to be controlled by morphine administered subcutaneously.
No special attention need be given to the so-called septicopyemia. It represents a mixed condition of septic intoxication, local infection, and destruction, with metastatic abscess, and is a term appropriately applied to cases which combine the significant features of each type.
PYEMIA.
The derivation of the term pyemia, which came into general use in 1828, is misleading. Although septic fever always accompanies suppuration, it is not certain that pus as such circulates in the blood, as the term pyemia implies, the error having arisen originally from mistaking the contents of breaking-down thrombi for pus from ordinary sources. While a recognition of the etiology of the disease is new, the disease itself has been recognized for many centuries.
Pyemia is only met with in connection with suppuration, as far as known, never without it. In those cases which appear to be free from suppuration pus will be found. Pyemia may be described as septicemia plus thrombotic and embolic accidents, which lead to distribution of infectious material to all parts of the body. This distribution is made by the bloodvessels, although to some extent the lymphatics undoubtedly participate. When pyogenic organisms reach bloodvessel walls they tend to set up a mycotic phlebitis, which, by virtue of the coagulating blood, becomes soon what is known as thrombophlebitis. Infection proceeding through the vessel walls, the endothelial lining is loosened, while to these rotting spots leukocytes adhere and coalesce into a more or less homogeneous mass. This so-called white thrombus becomes also infected with bacteria; portions of it, loosened and dislodged, are carried by the returning blood stream to the right side of the heart, whence they are distributed through the lungs. Dislodgement may be made by mere force of the blood stream, or may be assisted by movements of the part or handling of the same. These particles of thrombi are loaded with the infectious organisms which began the disease, and wherever one settles a reproduction of the original thrombophlebitis is rapidly produced. In this way numerous infected thrombi are formed within the vessels of the lungs, which, again, loosen, and are now swept into the left side of the heart, whence they are distributed with arterial blood in all directions. While it is true that they are equably distributed, it is also positive that certain tissues seem more capable of lodging and being attacked by the contained organisms than are others. When it is once appreciated that each particle of infected clot is capable of setting up, either in the lungs or in the other tissues, upon the second distribution, other abscess formations analogous in etiology to that from which came the first disturbance, then the fundamental idea of metastatic abscess is fully impressed. The term metastasis may be regarded as synonymous with transportation, and metastatic abscesses are those produced by transportation of infected particles from one part of the body to another. Wherever they lodge similar trouble will result. Contiguous minute metastatic abscesses quickly coalesce, and in this way large collections of pus are formed. The blood also contains organisms not attached to thrombi, and from the blood of the pyemic patient cultures can at almost any time be made. Until this is done it will be virtually impossible to incriminate any particular organism as the one at fault. Thrombo-arteritis is the equivalent in the arteries of thrombophlebitis in the veins, and is accompanied by the same detachment of endothelium, adhesion of leukocytes, etc. Whenever such a lesion occurs in artery or vein, coagulation necrosis takes place and suppuration occurs around it. The metastatic abscess is thus the result of breaking down of this affected tissue, and is often called miliary abscess. Particles of infective thrombi cling also to the valves of the heart and a septic endocarditis may result.
The possibility of so-called spontaneous or idiopathic pyemia is occasionally discussed. This means a pyemia whose cause is concealed. The explanation will be found sometimes in an acute infectious osteomyelitis, sometimes in ulcerative endocarditis, or inflamed appendix or other portion of the peritoneal cavity. Again, it may proceed from middle-ear disease, in which there is so little discharge as scarcely to attract attention. Thus causes which predispose to suppuration (see [Chapter III]) come into play here, and the influence of exposure, fatigue, starvation, etc., is not to be ignored in furnishing an explanation for the so-called idiopathic cases.
In the majority of instances, however, pyemia follows surgical operations and injuries, among which are compound fractures, deep injuries with small superficial evidence thereof, compound injuries of the skull, and injuries by which veins are exposed. Inasmuch as the typical pyemic manifestations require a certain length of time for their development, the onset of this disease is more delayed than in the case of septicemia. While the case may be manifestly one of septic infection of unrecognizable type, the characteristic indications of pyemia seldom appear in less than ten days, and frequently not for several days longer.