| ETIOLOGY. | |
| PYÆMIA.. | SEPTICÆMIA. |
| 1. Pyæmia generally commences with the putrefaction in an open wound of the secondary wound-fluids—pus, etc.—in which there are developed globular bacteria, which enter the blood and certain tissues of the body, where they multiply and produce constitutional disturbances. | 1. Septicæmia generally commences with the putrefaction in an open wound of the primary wound-fluids—blood, serum, etc.—in which there are developed rod bacteria, which enter the blood and certain tissues of the body, where they multiply and produce constitutional disturbances. |
| 2. Pyæmia is commonly preceded by some local inflammatory wound-complication, such as suppurative periostitis, osteo-myelitis, etc., and is rarely developed before the end of the second week after the receipt of the injury. | 2. Septicæmia is commonly a primary wound-complication, which is generally developed within forty-eight hours after the receipt of the injury. |
| PATHOLOGY. | |
| 1. Increased coagulability of the blood. | 1. Diminished coagulability of the blood. |
| 2. There are metastatic abscesses in various parts of the body, especially in the lungs, liver, and kidneys: serous cavities frequently contain sero-purulent deposits; similar deposits are often found in the joints; abscesses in the cellular tissue; and also abundant evidence of the existence during the life of the patient of pyæmic endo- and pericarditis. | 2. Complete absence of purulent or ichorous deposits in all cases of unmixed septicæmia. Post-mortem appearances may be completely negative, with the exception of the condition of the blood, although there is often some oedema of the lungs. |
| SEMIOLOGY. | |
| 1. Pyæmia commonly commences with a chill. | 1. Septicæmia commonly commences without a chill. |
| 2. Fever variable, but rarely entirely intermits. | 2. Fever steadily increases, but is lower in the morning. |
| 3. Sudden and great changes in temperature, followed by profuse perspiration. | 3. The temperature is high at the beginning of the disease, increases until near the fatal termination, when it falls below the normal. The skin is moist, but without profuse sweatings. |
| 4. Pulse variable; toward the fatal end rapid, feeble, and irregular. | 4. Pulse rapid, and gradually increases in frequency toward the fatal end. |
| 5. Facies at the beginning flushed or pallid, toward the end careworn. | 5. Facies expressive of a dull, listless condition throughout the whole course of the disease. |
| 6. Tongue smooth, dry, and excessively red, later brown-coated, and even the teeth coated with sordes. | 6. Tongue, lips, and throat dry at the commencement, toward the end moist. Thirst is marked. |
| 7. Diarrhoea with stools of a pappy consistence. | 7. Rice-water evacuations, very offensive; obstinate vomiting. |
| 8. Epistaxis. | 8. Epistaxis rarely occurs. |
| 9. Mild delirium toward the fatal end. | 9. A lethargic condition from the beginning, increasing toward the fatal end. |
| 10. Aphthæ in the mouth and throat, sudamina, vesicles, pustules, and purpuric patches. | 10. Icteric hue of conjunctivæ; singultus often present. |
The differences in the local manifestations occurring in and around the wound, during the progress of these diseases, may be summed up as follows:
| At the commencement of this disease the suppuration is commonly checked, the wound becoming dry, and if a discharge continues, it becomes scanty, thin, ichorous, greenish, etc. The granulations, when previously healthy, soon slough, and venous oozing sometimes takes place. There occasionally appears in the later stages of this disease around the wound a reddish erythematous blush, which soon extends over the whole limb. | The odor of putrefaction is commonly very marked within twenty-four hours after the receipt of the injury, the integument slightly reddened about the wound, and the surrounding parts somewhat oedematous. The wound-tissues soon assume a dark-brown color, and are occasionally mottled with dull grayish spots, while the edges of the wound are at the same time blackened, although the movements of the ligature, when arteries have been tied, show us that the blood still rushes against its artificial boundary. |
TREATMENT.—It must be admitted that the management of either pyæmia or septicæmia, when fully developed, is always unsatisfactory, and generally unsuccessful; consequently, the success which has attended the use of the prophylactic measures employed in connection with the treatment of wounds during the last ten years has given much satisfaction to the medical profession. The committee of the London Pathological Society reports as follows on this subject: "The accumulation of septic matter in the uterus after labor, in contact with the raw surface left by the separation of the placenta, would also present the conditions favorable to acute septic intoxication. In the present day, when the necessity of thorough drainage of wounds is so thoroughly understood, and the means at the surgeon's command for carrying it out are so efficient, it can only be under peculiar circumstances that a sufficient quantity of putrid serum or pus to yield the fatal dose of the septic poison is allowed to accumulate in the wound. Moreover, the antiseptic treatment of wounds, now so largely adopted, by preventing decomposition of course renders septic intoxication impossible. Ovariotomy would seem to furnish conditions most favorable to septic intoxication, and a large proportion of the deaths occurring in the first forty-eight hours have always been attributed to it. The proportion of fatal cases from this cause has, however, of late been greatly diminished by drainage, and more especially by the employment of the antiseptic treatment."42
42 Trans. Path. Soc. of London, vol. xxx. p. 15.
We cannot repeat too frequently or too emphatically the fact that the treatment of pyæmia and septicæmia, when fully developed, is almost invariably unsuccessful, and that consequently he who desires to save the greatest number of lives must make every exertion and use all available means to prevent their development—a task which fortunately has now been brought within the scope of possibility in the large majority of cases. Every surgeon will readily admit that, were it possible to secure union by first intention in all cases of wounds, then it would be impossible for either septicæmia or pyæmia to occur in surgical practice. Therefore, it follows that the character of the wound, the method of operation, the surroundings of the patient, the character of the treatment, become proper points to consider in this division of the subject. The character of the wound and its relations to pyæmia and septicæmia have already been briefly referred to under the etiology of these diseases. The various methods of operating, with their respective advantages and disadvantages, are of course not suitable topics for discussion in this work.
The surroundings of the patient form a subject of vast importance in a prophylactic view, and should never be lost sight of in the construction of hospitals. I desire here to express my firm conviction that surgical pyæmia is essentially and almost wholly a hospital disease. The question of surroundings for the patient presents to my mind the following demands as a sine quâ non for obtaining the best possible results in surgery: (1) Absolute cleanliness. This demand should be strictly enforced in regard to the wound, the patient's body, the bedding, and everything else, including nurses and instruments. (2) Absolute purity of the atmosphere. (3) Moderate and equable temperature, containing a proper amount of moisture. (4) Proper quantity of nutritious and easily digestible food, with suitable drinks, etc. (5) Cheerful and pleasant surroundings, especially in companions, nurses, and other attendants. It may be objected to these conditions that they can never be obtained. I must confess that perfection in every detail cannot always be attained, but I am thoroughly convinced that he who makes a determined effort in this direction will succeed far better than that person who is constantly looking about for some excuse for negligence.
The question of treatment brings up the entire subject of antiseptics. The favorite remedies of this class are carbolic and salicylic acids, permanganate of potassium, chloride of zinc, bichloride of mercury, and liquor sodæ chlorinatæ. There is no doubt that good results may be obtained with any of these remedies. The surgeon should never forget that he uses medicines merely as agents to enable him to accomplish certain objects; and, keeping this in mind, he need very seldom fail with his antiseptic when the object is to prevent putrefaction in an open wound. Therefore it appears certain that each method of treatment may possess special advantages in particular cases, and probably the same may be said of the antiseptic itself. The importance of this subject may be more fully appreciated when it is remembered that it is generally admitted by the best surgical authorities that more lives are lost from septic infection than from all other causes combined during a war. The further consideration of this subject may be arranged for convenience under the heads of local and general treatment.
The local treatment of the wound should, if possible, be of such a character as to prevent the absorption of either putrid substances or pus. It therefore becomes highly important, in cases of amputation and other operations, that all tissues injured to such a degree as to be likely to excite either putrefaction, irritation, or inflammation should be removed. The same care is necessary in removing all foreign bodies from the wound in cases where no operation is to be performed. The amputation of the injured limb may be necessary to prevent the development of these diseases, or it may be resorted to in certain rare cases after the origin of pyæmic symptoms; however, in the latter instance great care should be taken to remove all the tissues already infiltrated with serum, otherwise nothing will be gained. The use of the surgeon's knife at the proper time may be the best prophylactic against both pyæmia and septicæmia, but it should be directed by an intelligent mind and the instrument guided by a practiced hand. Again, it is found that opening a large medullary cavity may be attended with danger to the patient. This fact teaches us an obvious lesson.