A system of practical medicine. By American authors. Vol. 1

by Unknown

It is now a well-recognized fact that all septic absorption ends so soon as the wound-surfaces are covered with healthy granulations, but that septic absorption, which produces septic intoxication, is most commonly of a much shorter duration, and, consequently, that the wound complication, which I prefer to designate traumatic fever, is essentially an acute disease, and can only be lengthened out by unusually favorable circumstances for the continuance of the absorption of the poison by which it is produced. The severity and danger of the disease will necessarily depend on the amount of poison absorbed and the resisting power of the patient; but since there is no multiplication of the materies morbi within the body, a rapid elimination by the natural emunctories may be reasonably expected under favorable circumstances.

It should be observed here that the etiology of septicæmia differs from that of traumatic fever, since the organisms in the former condition are first formed in the wound-secretions, but quickly enter the body, where they rapidly multiply; consequently, Chauvel has defined surgical septicæmia as follows: "The particular intoxication which results from the penetration and multiplication in the body of a specific microbe designated by Pasteur under the name of septic vibrio." The bacterial origin of this disease is now generally accepted, and the only question in the professional mind seems to be whether the organisms are the direct or indirect cause of the malady.

There are also some other interesting questions which have arisen in connection with the study of this subject, and are thought to be of sufficient importance to merit mention here. It has long been known that dissecting wounds are most dangerous when made while examining the body very soon after the death of the subject. Recent observations seem to justify the conclusion that the greatest activity of the septic agent is often, if not always, attained before the odor of putrefaction has become fairly perceptible; and even before this odor has reached its maximum degree of offensiveness the danger from septic poisoning has generally disappeared. In some cases septic intoxication is promptly followed by a slight inflammation in and about the wound, which may entirely disappear within a few hours, but only to reappear after a lapse of eight to fifteen days, with the first vigorous physical exercise of the patient. Two cases of this kind have recently come under my observation. In both instances the wounds were located in the hands, and the exercise which developed the septicæmia consisted in rowing a boat, and while thus engaged the local symptoms reappeared with such severity as to cause the patients to quickly discontinue the labor. The reappearance of the local inflammation in both these instances was quickly followed by a rigor and the rapid development of other constitutional symptoms, although prior to the recurrence there was no pus, nor even marked inflammatory action, in any part of the hands.

Professional attention was first called to the above-stated facts by Panum in 1855, who discovered that the maximum toxic action of putrid substances is generally developed during the first hours of bodily activity. In this stage of incubation in cases of surgical septicæmia, if we admit the bodily action as an etiological factor, we observe a striking resemblance to one of the leading characteristics of all the infectious diseases, which unquestionably depend on some sort of septic poison. Furthermore, this analogy becomes most striking if we contrast the effects arising from dissecting wounds with those of the bites of poisonous serpents and rabid animals.

Further investigation is required to settle the perplexing questions of etiological and pathological differences in these allied morbid conditions, for although much has been accomplished during the last two decades, still much more remains to be done. It has only recently been discovered that the septic material in septicæmia is absorbed by the lymphatics, while in pyæmia the poison enters the body through the veins.

ETIOLOGY OF SEPTO-PYÆMIA.—It is now generally admitted that remittent fever and typhoid may be associated, and this morbid condition is commonly designated by the term typho-malarial fever. The etiology is unquestionably dependent upon the action of the two distinct and entirely dissimilar poisons. Scarlatina is likewise frequently complicated by diphtheria, and here we have the combined action of two poisons, each commonly designated as septic and supposed by many physicians to be similar.

In a like manner, it is believed that septicæmia and pyæmia may be associated, and take their origin in dual poisons; but since the etiology of both these morbid conditions has been already described, it is not deemed necessary to dwell longer on septo-pyæmia under this division of our subject.

PATHOLOGY OF PYÆMIA.—The study of the pathology of pyæmia is advanced by adopting the following classification, which is based on recognized post-mortem lesions. The pathological appearances in these forms of the disease differ widely, although the clinical symptoms are often similar. In pyæmia simplex the pathological conditions are essentially more negative. This variety of the disease can only destroy life by the height and duration of the fever which is maintained in connection with the continued existence of ichorous pus. There is found, as an essential basis of this form of disease, extensive suppuration in the subcutaneous tissues.

The arguments in favor of the admission of pus-corpuscles into the blood are as follows: 1. The blood in pyæmia is known to contain more white granular spherical bodies than are normal. The question has been raised, Are they pus-cells or white blood-corpuscles? The answer is difficult, and has not yet been attained. Virchow, in the mean time, has proved that we cannot differentiate, morphologically, between the blood- and pus-corpuscles. 2. Cohnheim has demonstrated the existence of the wandering corpuscles in cases of inflammation. Therefore it appears probable that in cases of pyæmia the blood may contain the pus-corpuscles, but further investigation is needed to establish this fact. However, the establishment of this point would still leave the more important undetermined.

There are often important changes observed in the blood of patients dead of pyæmia, to which I now desire to direct attention. The red corpuscles of the blood, even in the early stage of the disease, in many cases show signs of disintegrating into molecules, and are observed to be accumulated in masses without showing the slightest tendency to form rouleaux. There is a steady increase in the number of pus- or white corpuscles in the blood of pyæmic patients during the whole course of the disease in fatal cases. The condition of the red corpuscles, already mentioned, becomes more and more marked toward the fatal termination.