The wound existing or the operation having been performed, the surgeon now turns his attention to the prevention of putrefaction and inflammation. The first source of danger requiring attention from the surgeon is the fluid escaping from the wounded surface. Do not allow it to undergo putrefaction in contact with the wound. It should not be forgotten that pyæmia is an infectious disease, having its origin in a local nidus, an open wound, in which putrefaction of pus or other wound-fluid is taking place. The question of amputation, or of the extirpation of the parts for the relief of this disease, should only be entertained when the surgeon is confident that he can remove the whole of the infiltrated tissues. In other words, the performance of these operations after the disease has become constitutional can never be advantageous to the patient. Even in those cases where infiltration is limited to the lymphatics, unless all these glands so affected are removed the operation will be unsuccessful. It has been further recommended in the treatment of this disease, in order to prevent the formation of metastatic abscesses, to ligate the veins in which thrombi have formed or may be reasonably expected to form, at some convenient point between the heart and these obstructed points. The value of this proceeding has never been fully determined, and may be reasonably questioned. The formation of metastatic abscesses in various parts of the body within the reach of the surgeon's scalpel demands his attention; and we have been taught by experience that they should be speedily opened, which generally lowers the temperature and diminishes the danger from septic absorption. In the performance of this operation Lister's antiseptic system of wound-treatment should be strictly adhered to, since it unquestionably gives the best results which can be obtained under the circumstances. When the metastatic inflammation which occasionally appears in the thyroid and parotid glands during the course of this disease terminates in the formation of pus, this should be speedily evacuated. This prompt action is often required, particularly for the relief of the grave symptoms which are apt to arise in connection with respiration and deglutition. The accumulation of pus within the joints in pyæmic cases should, it is now thought, be treated in the same manner as abscesses in the cellular tissues—i.e. the articulations should be opened and thoroughly disinfected, and afterward kept in a perfectly aseptic condition, and also rendered absolutely immovable during the treatment.
Having directed attention to the more important local measures, we may now briefly enter on the consideration of some of the constitutional remedies. In the general treatment of pyæmia there have been recommended at various times a great variety of drugs, but the general want of success attending their use leaves comparatively few to be mentioned here. The mineral acids are still employed, and are found to be at least agreeable drinks, and as such can be still recommended. The sulphites of magnesium, sodium, potassium, and lime were recommended by Giovanni Polli for the treatment of typhus fever, scarlet fever, small-pox, septicæmia, and pyæmia. He further suggested that the medicine should be given until the whole quantity taken bore to the weight of the patient's body the proportion of 1 to 1000. The experiments made on animals with these salts seem to confirm their value in the treatment of septic diseases. It is certainly true that animals treated with these salts are not so easily affected by septic poison as those which have not received this treatment. Further, it has been shown that putrid substances when mixed with either permanganate of potassium or the sulphite of sodium, and then injected, are harmless, although the same quantity of putrid matter injected without either of these salts destroys life.
Brandy and other alcoholic stimulants have been strongly recommended on account of their well-known antiseptic properties. The sulphate of quinia is certainly, in most cases of pyæmia, a valuable agent. In large doses it enables the surgeon to reduce the temperature of the patient, and in smaller doses it frequently serves a valuable purpose as a tonic. It has also considerable value as an antiseptic.
Lattin has recommended the use of large doses of ergotine in infectious fevers, but this substance, when employed in the treatment of pyæmia, should be given in the formative stage of the disease. The use of drastic cathartics should be avoided, as should that of sudorifics, on account of their prostrating effects. In some cases hypnotics may be required to secure sleep.
Tonics are always more or less useful. The free use of stimulants and nutritious food is also indicated. Brandy, wine, and whiskey may be advantageously used as stimulants. Musk, ammonia, and camphor are occasionally required. However, it should not be forgotten that in cases where the disease has become fully developed the usual termination is death, few recoveries being recorded. In the early stages of this affection, by the removal of the patient from an overcrowded hospital ward to some place where pure air and proper hygienic arrangements can be obtained, recovery may take place, but under other circumstances the prognosis is exceedingly grave.
The treatment of septicæmia in most particulars is the same as that of pyæmia. The first effort should be to prevent the development of the disease, and the second to care for the patient in cases where the affection has already developed. It is not, of course, in our power to limit or in any way regulate the primary injury, for we are obliged to take the patient as he is. The amount of injury to living tissue may be great or small. The question of an operation, the character of the same, and the subsequent management must be determined in accordance with the circumstances of each particular case.
The primary death of the parts is generally due chiefly to the injury itself; the secondary, frequently to bad surgical management. Let us now take a case in which the primary injury has been severe, greatly diminishing, but not destroying, the circulation in the injured parts. Here the immediate application of ice would be injurious, but a warm application might assist nature. It is humiliating to the profession that we are obliged even at this date to admit that the treatment of septicæmia is largely symptomatic. The profuse choleraic diarrhoea which generally accompanies this disease may be regarded as an effort of nature to eliminate the septic poison; but, nevertheless, it is so prostrating in its effects that it requires to be controlled with properly selected astringents, and these remedies may be still further aided by the use of stimulants and tonics.
The treatment of septicæmia may be summarized as follows: (1) A strict adherence to the five rules given under the head of the prophylactic treatment of pyæmia. (2) The avoidance of all putrefaction in contact with the wound, especially prior to the development of sufficient granulations to completely cover its surface. This object is to be accomplished by the removal of all necrotic tissues, the avoidance of putrescent fluids by cleanliness, and the proper use of antiseptic agents. (3) Free use of the alkaline sulphites and hyposulphites. These drugs should be used in all cases where there is reason to anticipate the development of septic diseases, as soon after the receipt of the injury as practicable, but should not be neglected even after the disease has become fully developed. (4) Sulphate of quinia should be used in all cases where the temperature is above 100° F., and its persistent use in large doses may be necessary to prevent the fever from rising still higher. It will be remembered in this connection that experience has taught us that "a temperature of 108.5° F. is the limit beyond which life can no longer exist,"43 and even a much lower temperature is not without dangers. "The essential danger of fever in acute diseases consists, then, in the deleterious influence of a high temperature on the tissues."44
43 Liebermeister, New Sydenham Soc. Trans., vol. lxvi. p. 278.
44 Ibid., p. 280.