Chapter LX: Part II: , Showing Predominance of Malarial Element . . . . 617 (59)

Billroth and Sedillot observed pathological lesions involving a solution of continuity in the spleen, liver, and kidneys, in the order in which they are mentioned; other authors, however, assert that the liver, next to the lungs, is the most frequent seat of purulent deposits. Enlargement of the spleen is frequently met with in cases of pyæmia multiplex. The metastatic abscesses found in the spleen and kidneys are much smaller than those found in the lungs and liver, but in other respects are of a similar character. The capillary congestion and the accompanying infarctions require no special attention here. The liver, like the spleen, is sometimes enlarged, and at other times is found to have undergone fatty degeneration to a greater or less degree; in which condition its tissues are generally soft and friable. Abscesses in the liver are so much like those in the lungs as to need no separate description. The same may be said of other pathological changes found in this organ in pyæmia multiplex. The abscesses found in the kidneys vary from the size of a hemp-seed to that of a bean, and are surrounded by the usual zone, marking more or less definitely the extent of the inflammation. The capsule is generally healthy. There are also, in very rare cases of this disease, abscesses found in the stomach and intestines, involving the thickness of the mucous membrane; and it is further supposed that these abscesses may be found occasionally on any portion of the mucous membrane lining the alimentary canal. Post-mortem examinations in pyæmia multiplex have established the fact that there is no organ in the body that may not become the seat of pathological lesions in this disease; but there is unquestionably a vast difference in the relative frequency of these changes in the various organs. In some instances of this disease peritonitis is developed, with its concomitant changes in this membrane and the abdominal fluid, which is generally increased in quantity and sometimes slightly tinged with blood, but more frequently remains clear. {970} This inflammation is commonly dependent on an extension of the inflammatory process from a metastatic abscess, which may be situated near the periphery of some organ covered with peritoneum, although it is claimed that pleuritis occasionally occurs in connection with pyæmia independent of metastatic abscesses in the lungs.

The careful study of the pathology of pyæmia multiplex renders it exceedingly probable that the immediate agency in the production of all these lesions is the presence in the blood of a particular species of living organism, and that all the morbid changes which occur in the visceral organs are secondary to those which take place in the blood, but that the former are only dependent on the latter in a minor degree. The pathological changes effected by these organisms seem to be as follows, and to occur in the following order: viz. disorganization of the blood, especially a destruction of the red and white blood-corpuscles; the formation of granular bodies around the organisms out of this débris; the production of an increased coagulability of the blood; the lodgment in the blood-vessels of these granular bodies, which are increased in size by a deposit of fibrin; these obstructions occur most frequently in minute ramifications of the pulmonary arteries; nutrition is effected locally by these infarctions, and generally by the vitiated condition of the blood, which enables the organisms under these favorable circumstances to penetrate the adjacent tissues and produce the metastatic abscesses and other accompanying lesions.

The pathological changes in pyæmia simplex are of the same kind as those which have just been described as characterizing pyæmia multiplex, with the exception of the metastatic abscesses, which are always absent. Furthermore, the disease in both instances is believed to have its origin from the same causes, and the dissimilarities in the pathological lesions are equally susceptible of a rational explanation, as are those of scarlatina simplex and scarlatina maligna.

There were reported by the committee of the London Pathological Society some interesting details pertaining to this form of pyæmia. Their report shows that among the one hundred and fifty-five cases classed as pyæmia there were twenty-four cases without visceral abscesses; and furthermore it shows that in twenty-three of these cases there was no suppuration, although local inflammations affected many of the different tissues, since these patients suffered with arthritis, cellulitis, pleuritis, meningitis, pericarditis, and carditis. It is also added that "the post-mortem appearances, in addition to the local secondary inflammation before noted, were in many cases those changes common to all forms of blood poisoning. Out of the twenty-four cases, the following are noted: Swollen spleen, nine times; congestion of the lungs, ten times; swollen liver, six times; cloudy swelling of the kidney, fourteen times."[38]

[Footnote 38: _Trans. London Pathological Soc._, vol. xxx. p. 26.]

In this form of pyæmia it has been supposed by some authors that the materies morbi occasionally produces death before the metastatic abscesses have had time to develop, but this is not always the case. The same committee report on the above-mentioned twenty-four cases, on this point, as follows: "The duration of the cases before the fatal termination was very various. It is tolerably accurately recorded in eighteen cases: of these five died in the first week, five in the second, {971} four in the third, and the remaining four survived to the thirtieth, forty-ninth, fifty-second, and sixty-second days."[39]

[Footnote 39: _Trans. London Pathological Soc._, p. 25 _et seq._]

The pathology of pyæmia multiplex having been already fully described, and since the only essential difference in these morbid conditions consists in the complete absence of the metastatic abscesses in cases of pyæmia simplex, it is therefore thought unnecessary to dwell here longer on this subject.

The morbid anatomy of septicæmia has been carefully studied of late, and it is now known that the most characteristic lesions are found in the blood and the alimentary canal.

As a manifestation of the general poisoning of the blood, it might be expected that putrefaction would follow rapidly after the death of the patient. In fact, Davine defines septicæmia as "putrefaction of a living body." Observation has now thoroughly confirmed that which was formerly an anticipation. Panum, Hemmer, and Bergmann have each called attention to the fact that rapid decomposition follows the death of all animals in which septicæmia has been produced for experimental purposes. It has also been observed that putrefaction in the human cadaver begins much sooner, and progresses much more rapidly, under similar circumstances, when the death has been produced by this disease than when it has occurred from any other cause. Furthermore, this rapid decomposition is not limited to the internal organs, but may be frequently strongly marked on the surface of the body after the lapse of twelve hours, although it has been kept in a comparatively dry and cool atmosphere. In those cases where the septicæmia has originated in an external wound it has been uniformly observed that putrefaction goes on most rapidly in the vicinity of the wound after the death of the patient.

In every case of fatal septicæmia the post-mortem examination will show that the coagulability of the blood has been diminished or destroyed. In fact, it has been abundantly shown that in all cases of true septicæmia the coagulability of the blood is more or less diminished. The few imperfect clots of blood found after death are of a deep-black color. The putrefaction of the soft tissues is greatly hastened by the presence of this blood; and, consequently, this process goes on most rapidly in the most dependent portions of the body, especially along the course of the large veins. The septicæmic blood possesses a peculiar putrefactive odor, and it is occasionally found to be acid in its reaction, according to Vogel and Scherer, making it highly probable that it will end in the formation of the carbonate of ammonium. The chemical examinations of septicæmic blood which have heretofore been made have completely failed to give satisfactory results in regard either to the existence or nature of the materies morbi in this disease, although, without doubt, there has occasionally been found, principally in the blood of those who have died of acute septic intoxication, a poisonous substance, which Bergmann designated sepsin. Microscopic examinations have shown that in the blood and also in various organs of those who have died of septicæmia there are always present, under these circumstances, a large number of the rod bacteria; in fact, they are more numerous than after death from any other infectious disease. Furthermore, they are found in the blood, lymph-glands, and cellular tissues during the whole course of the disease.

{972} There are no pathological changes in the central nervous system which arise directly from septicæmia, although in some cases, when there has been some cardiac complication or very severe dyspnoea from any cause immediately prior to the death of the patient, there may be found hyperæmia of the membranes of the cerebro-spinal axis. The brain and spinal cord remain unchanged.

The endo- and pericardium occasionally present a somewhat mottled appearance resembling ecchymosis, which is evidently a deposit from the blood, and may be washed off with water. The inner surface of the ventricles presents a similar appearance from the same cause. In addition to those changes which have been mentioned there are occasionally found some slight traces of an inflammatory process in these parts; but it never extends to the formation of pus or ulceration, which frequently happens in cases of pyæmia. The quantity of pericardial fluid is sometimes increased in septicæmia, and is generally somewhat thickened, cloudy, and slightly tinged with blood. The changes in the pleural surfaces are the same as those which have been noted in the pericardium, but any increase of the fluid within the pleural sacs is an exception to the general law, and is very rarely seen. The lungs are generally found slightly congested, but there may be some ecchymosis in exceptional cases. Pus is never found in the lungs or within the pleural cavities in pure unmixed septicæmia. The pathological changes in the liver resemble those in the lungs. This organ is commonly found in a state of passive congestion, while the color of its tissues is slightly darkened. The congestion of the kidneys and spleen in this disease is much more marked than that of the lungs and liver. The parenchymatous tissue of the kidneys is commonly found in an oedematous condition, and the tubuli uriniferi are more or less affected by a catarrhal inflammation, which is manifested by the exfoliation of granular epithelium. The same catarrhal condition, but in a milder form, is found to affect the mucous membrane of the bladder. In females the ovaries, uterus, and vagina are in a state of hyperæmia, with more or less catarrhal inflammation of the latter organ. Septicæmia invariably causes pregnant females to abort. There is commonly softening of the spleen. The alimentary canal is almost constantly affected by acute intestinal catarrh, with enlargement of the intestinal follicles and mesenteric glands, while there are frequently hemorrhages from the serous and mucous membranes. The various muscles of the body and the extremities are found to be of a dark brownish-red after the death of the patient, instead of possessing their natural pale-red color. It may now be stated, finally, that the pathological changes in septicæmia are less marked than those of pyæmia multiplex.

The semiology, etiology, and pathology of septo-pyæmia consist in a blending, in different degrees, of the essential parts of pyæmia and septicæmia; and since the pathology of both these diseases has been presented separately, it is deemed unnecessary to enter into a consideration of this combination.

SYMPTOMS OF PYÆMIA.--Pyæmia very rarely, if ever, develops except in connection with an open suppurating wound, and consequently it must generally be regarded as a wound complication or as a secondary diseased condition. Those open wounds are unquestionably the most favorably situated for the development of this disease which involve the medullary {973} cavities of the long bones, owing to the liability of unhealthy suppuration, the difficulty of complete drainage, and the favorable anatomical conditions for absorption.

Every form of pyæmia is frequently preceded by a distinctly marked prodromal stage, which varies in duration from four days to two weeks. In fact, the ordinary precursor of this disease, in all those cases in which the bones are involved, is an attack of osteo-myelitis; but in other cases the patient often complains of malaise, giddiness, headache, pain in the limbs, weakness, and loss of appetite, while the experienced surgeon will be deeply impressed with the patient's rapid emaciation and cadaverous face. These symptoms are soon followed by jaundiced skin, etc. The commencement of an attack of pyæmia is commonly manifested by a chill. The importance which will naturally be attached to this phenomenon in connection with an open wound must depend to a certain degree on the circumstances attending its occurrence; and therefore the following question will present itself: Is the chill associated with suppuration? A negative answer to this question, based on the fact that insufficient time has elapsed since the occurrence of the injury to render suppuration possible, can never fail to be a source of satisfaction to the surgeon, whose experience has taught him to dread pyæmia.

Billroth has observed in 83 cases of true pyæmia multiplex that 62 commenced with a chill, and 21 without; in 81 cases of septicæmia and simple pyæmia 24 commenced with a chill and 57 without. The number of chills in each individual patient occurred according to the following table:

Number of patients 19 21 14 15 9 5 2 3 4 1 1 1
Number of chills 1 2 3 4 5 6 7 8 9 10 13 14

In one patient during three weeks sixteen chills were observed, and probably the longer the duration of the disease the greater is the number of chills. Still, there are chronic cases with a single chill, and acute cases with many. It rarely occurs that a patient has more than one chill in twenty-four hours. Billroth noticed among his patients only sixteen who had two chills, and only six who each had three chills, in one day. The experience that fewer chills occur during the evening and night than in the morning and afternoon has been confirmed by statistics. Among 287 chills, 220 occurred from 8 A.M. to 8 P.M., while during the night, from 8 P.M. to 8 A.M., only 67 were observed. By this arbitrary division of the twenty-four hours Billroth desired to take into consideration the daily exacerbation in connection with the usual daily irritation of the wound, the bandaging, and other manipulations. He saw, for example, a chill occur three times from the introduction of a sound, and twenty times after the opening of an abscess. The time which elapsed from the first injury to the first chill is shown in the following table:

First chill began, times 14 19 15 9 4 3 2 4
Length of time after injury, in weeks 1 2 3 4 5 6 7 8

Patients who had fever before the operation were more inclined to early chills than recently-injured healthy individuals. Billroth's experience was to have only the first chill before the end of the first week. It may be further stated that nervous, irritable patients suffer much more {974} frequently from chills than those of a phlegmatic temperament. This fact has given rise to the opinion that the absorption of pus acts especially on the central nervous system.

The chills in pyæmia are supposed by Billroth to be associated with inflammation, and he says: "It must be mentioned, as a matter of observation, that chills occur almost exclusively in the commencement of an acute inflammation, and are intermittent only in intermittent fever and reabsorption of pus, while they do not occur in acute septicæmia."[40] But the fever in pyæmia rarely intermits entirely; it is generally lower, however, in the morning than in the afternoon. This symptom is even more important than the rigors in enabling the surgeon to make a correct diagnosis. Let it, however, be remembered that the temperature frequently becomes very high within a few hours after the receipt of an injury or the performance of a surgical operation; that this high temperature may be due to septic absorption, and that this diseased condition is what we designate as septicæmia. Another condition, less marked, with an elevated but somewhat lower temperature, is usually spoken of as traumatic fever. In this condition the fever may gradually increase for a few days, and then disappear.

[Footnote 40: _Surgical Pathology_, p. 344.]

One important peculiarity of the temperature in pyæmia are the sudden and great changes; thus, at one hour the temperature may be slightly raised above the normal, and at the next the thermometer may mark 105° F. These sudden changes of temperature are of frequent occurrence, are not observed to the same extent in any other disease, and therefore supply a very important diagnostic indication. It is impossible to know, or even to anticipate with any degree of certainty, when the highest temperature will exist; consequently, Billroth and other writers have suggested the desirability of having a thermometer constantly kept in a position to indicate every change in the heat of the body, and a careful attendant to note the same; but, thus far, I am not aware that this has been attempted, probably on account of the inconvenience to the patient and the additional labor in nursing it would entail. It has been further observed that during the existence of a chill the temperature continues to steadily increase, and the maximum seen during the whole course of the disease is attained during the hot stage which immediately follows the rigors. "This condition is followed by profuse cold perspirations. The perspirations which accompany this disease are most profuse, like those of advanced phthisis. They never precede the rigors, but may occur independently of them. They are either continuous in their duration, or exhibit more or less distinct exacerbations. They are occasionally accompanied by sudamina, and they do not abate with the use of any known remedy.... Occasionally perspiration is scanty; but before death a cold clammy sweat and a tawny discoloration of the skin occur."[41]

[Footnote 41: Braidwood, _op. cit._, p. 112.]

Besides the sudamina there are frequently observed on the skin vesicles, pustules, and boils, purpuric patches, and various discolorations. There is frequently observed to arise in the neighborhood of the wound a reddish erythematous blush, which soon extends to the whole limb, and commonly begins to disappear in the early part of the second week. This recently occurred to a patient under my care, and was speedily followed by an abscess of the knee-joint. The wound was situated at the hip-joint, {975} and the first change in the color of the integument took place around its lips. The redness extended rapidly downward until it covered the foot, and even the toes; but the extension upward was slight, not much above the nates, on which there was situated at the time a bed-sore. It observed the same order in passing off as in coming on--_i.e._ where it first made its appearance it first disappeared. The superficial veins leading from the wound were inflamed and cord-like. This condition of the integument and the abscess of the knee-joint were followed by diarrhoea, on which medicines had no beneficial effect. It continued, with occasional vomiting, until the death of the patient.

The pulse in pyæmia may be nearly normal as regards frequency, while at other times very rapid. It has been remarked in some cases that the pulse seldom rose above 90 per minute until near death. The pulse, although only moderately accelerated at the commencement of the disease, always becomes more rapid, quick, feeble, and irregular toward the termination of the unfavorable cases, while in cases of recovery it returns gradually to the normal standard.

In all cases in which the blood has been examined during the progress of pyæmia the examiners have agreed in regard to its extreme coagulability, the diminution of the number of red corpuscles, and the increase of the granular spherical bodies. The red corpuscles, even in the earlier stages of the disease, show evident indications of disintegrating; and these become more and more marked as the disease progresses, while there is a steady increase in the number of pus- or possibly of white blood-corpuscles. Epistaxis occasionally occurs, and also venous oozing from the wound.

The condition of the tongue in pyæmia may be regarded as an important symptom, indicating the state of the alimentary canal--not, however, during the prodromal stage, but after the disease has progressed a few days. It is then observed that the tongue has become peculiarly smooth, dry, and often excessively red. This smoothness is caused by the collapse of the papillæ, and the dryness by a diminished secretion. The organ now frequently appears as if covered with a thin layer of collodion which had been caused to dry on the surface, so as to present a glazed look. Again, the tongue may be covered with brown crusts and the teeth with sordes. These brown crusts and sordes are usually seen in advanced cases, following the first condition described. Much importance is attached to these brown crusts by many experienced surgeons, and although there may be very marked improvement in all other symptoms, still they insist on a very guarded prognosis until the tongue has assumed a healthy appearance. Aphthæ on various parts of the mouth and pharynx are frequently present in the more chronic cases, but are usually absent in acute cases. Herpes of the lips sometimes occurs in the commencement of the disease.

Vomiting is comparatively rare, but there is, even in the early stages, a complete failure of the appetite, with great thirst. Singultus is rarely present in genuine pyæmia, but frequently so in septicæmia, and occasionally in septo-pyæmia. Diarrhoea is not so frequent or the stools so copious in pyæmia as in septicæmia. Billroth observed in one hundred and eighty cases of pyæmia thirty-two cases of diarrhoea. It is impossible to determine whether those cases in which the diarrhoea {976} occurred were pure or mixed pyæmia. The stools are often of a pappy consistence, and passed involuntarily in bed. There are, however, severe cases of pyæmia with high fever, and accompanied by obstinate constipation.

Examination of the heart may, in rare cases, show the existence of pericarditis, although usually the only indications of disease are the too feeble sounds. Auscultation and percussion of the lungs may yield unsatisfactory results when the metastatic abscesses are small and scattered, for the same reason as in miliary tuberculosis. The large deposits in the lungs are by these means readily determined. There may be a sensation of suffocation, the pneumonic sputa, the friction sound of pleurisy, or the signs of pleuritic effusion; and the existence of these symptoms or signs would naturally aid in the diagnosis of metastatic abscesses.

Enlargement of the liver and spleen may be determined before death, and in connection with other symptoms would aid in diagnosing deposits in these organs.

The urine in the first stage of this disease is scanty, high-colored, contains a large amount of salts, and is of a high specific gravity. Epithelial, fibrinous, and blood casts, and also albumen, are occasionally found in it during the course of the disease. Billroth mentions a case in which there was complete suppression, with uræmia.

In many cases of pyæmia suppuration of the joints, one after another, takes place with great rapidity and with comparatively little pain, but occasionally some swelling, redness, etc. are present. In most cases these suppurations are easily diagnosed. Instead of suppuration taking place in the joints, there are cases in which it occurs in the cellular tissue; and I have recently seen a case where abscess after abscess formed with such rapidity that within a single week the patient was literally covered with abscesses from the crown of his head to the soles of his feet.

Delirium generally exists during some stage of the disease, more frequently the last, and is then mild in its character, although active delirium has been observed in the first stage. Patients are low-spirited and very apprehensive of death. The face at the beginning of the attack may be flushed or pallid, but toward the end it always becomes careworn and haggard. The breath occasionally has a sweetish or purulent odor.

The changes in the wound are in some cases very marked, even in the first stage of the disease. The suppuration, which has been previously free and healthy, may be suddenly checked, the wound becoming dry. The discharge, if it continues, becomes scanty, thin, ichorous, or greenish. The granulations, if previously healthy, may soon slough. These changes may not always appear in the first stage, but should they not then take place they may be expected later in the disease.

SYMPTOMS OF SEPTICÆMIA.--These are commonly developed within twenty-four hours after the receipt of an injury or the performance of a surgical operation, and they may be sketched as follows: Frequent pulse; tongue, lips, and throat dry; skin hot and the temperature of the body high. The patient replies accurately to questions, but with some hesitation. He is much inclined to sleep, has entirely failed to take nourishment, drinks frequently when aroused from his lethargic condition, and has vomited everything taken into his stomach since the receipt of the injury or the performance of the operation. If {977} the dressings are now removed from the wound, the foul odor of putrefaction greets the attendants. In cases of amputation-wounds considerable discoloration of the flaps may be observed, the edges being blackened. Above these blackened edges the integument is reddened and slightly oedematous. The wound having been closed with sutures, which are now removed, there escapes a few drachms--possibly ounces--of highly offensive fluid, the decomposed remains of blood, etc. A further examination of the flaps on their inner surfaces show that their capillary circulation has ceased. The tissues, instead of presenting a life-like appearance, are now of a very dark color and occasionally mottled with dull grayish spots, although the movements of the ligature at the point where it embraces the femoral artery, for example, show that the blood still rushes against the artificial boundary.

Let us now leave our patient, without further comment, for the next forty-eight hours, when we will resume the examination. We now find the same dryness of the mouth that was previously noticed; the pulse is more frequent, and has become very feeble; he complains of much thirst, has vomited frequently, and has taken very little nourishment, and that only at the earnest solicitations of the attendants. The temperature is higher than at the former examination, and has been steadily increasing; in the morning it is lower, however, than in the evening of the same day. The patient is lethargic, and is suffering with a profuse diarrhoea. The odor of the stools is highly offensive; they are properly described as rice-water evacuations. The abdomen is tympanitic; the body bathed in perspiration; the respirations rapid; the urine scanty, high-colored, and contains albumen. The examination of the stump shows that gangrene has extended rapidly, involving not only the flap, but a portion of the adjacent tissues. The stench arising from the wound is almost stifling. The decomposing fluids are continually forming. That portion of the thigh not already gangrenous is now very oedematous, and the integument covering it is much discolored, being of a dark, icteric, or reddened hue.

We now allow twenty-four hours to elapse, and then make our final examination. The patient's tongue is more moist; the body still bathed in perspiration; the eyes dull; the conjunctivæ icteric, and the same hue extends to the body, though in a less marked degree; the pulse has become very frequent, feeble, and not easily counted; the temperature is below normal. Singultus is now present, and has been so during the last twenty-four hours. Bronchial symptoms, combined with marked oedema of the right lung, have appeared; the diarrhoea continues the same; the gangrene is still extending.

It must be admitted that the report here offered shows only the symptoms that are found in a single class of cases. The symptoms vary greatly in different cases, but they are especially marked in the acute sepsis mentioned by Massanneuve under the head of _gangrène foudroyante_. In these cases there appears, immediately after the receipt of an injury, enormous oedema about the wound, which extends rapidly in every possible direction, followed by the death of the patient within a few hours unless prompt measures are adopted. The puncture of the cellular tissue or of the blood-vessels involved in the oedema prior to the death of the patient gives rise to the escape of a highly offensive gas. Roser mentions a case of this disease in which he promptly amputated {978} the limb of the patient through the healthy parts, without even waiting for the administration of an anæsthetic, and his patient recovered.

The symptoms of septicæmia must necessarily depend greatly on the condition of the patient and the amount of septic material introduced, but it is not deemed necessary to dwell longer on this subject.

DIAGNOSIS.--It is thought that a brief presentation of the etiological, pathological, and semiological differences may be advantageous to busy physicians who desire to obtain, with the least expenditure of time, an accurate knowledge of the chief points of distinction between these morbid conditions. This effort at differentiation is merely intended to place the most important characteristics in marked contrast; and consequently it should be remembered that it is not our intention to give here the complete etiology, pathology, or semiology of either of these morbid states, but only their essential differences. Furthermore, it is thought that the following arrangement will facilitate the object which we desire to accomplish:

ETIOLOGY.
PYÆMIA. | SEPTICÆMIA.
1. Pyæmia generally commences | 1. Septicæmia generally commences
with the putrefaction in an | with the putrefaction in an
open wound of the secondary | open wound of the primary
wound-fluids--pus, etc.--in | wound-fluids--blood, serum,
which there are developed | etc.--in which there are
globular bacteria, which enter| developed rod bacteria, which
the blood and certain tissues | enter the blood and certain
of the body, where they | tissues of the body, where
multiply and produce | they multiply and produce
constitutional disturbances. | constitutional disturbances.
2. Pyæmia is commonly preceded by| 2. Septicæmia is commonly a
some local inflammatory | primary wound-complication,
wound-complication, such as | which is generally developed
suppurative periostitis, | within forty-eight hours after
osteo-myelitis, etc., and is | the receipt of the injury.
rarely developed before the |
end of the second week after |
the receipt of the injury. |

PATHOLOGY.
1. Increased coagulability of the| 1. Diminished coagulability of
blood. | the blood.
2. There are metastatic abscesses| 2. Complete absence of purulent
in various parts of the body, | or ichorous deposits in all
especially in the lungs, | cases of unmixed septicæmia.
liver, and kidneys: serous | Post-mortem appearances may be
cavities frequently contain | completely negative, with the
sero-purulent deposits; | exception of the condition of
similar deposits are often | the blood, although there is
found in the joints; abscesses| often some oedema of the
in the cellular tissue; and | lungs.
also abundant evidence of the |
existence during the life of |
the patient of pyæmic endo- |
and pericarditis. |

SEMIOLOGY.
1. Pyæmia commonly commences with| 1. Septicæmia commonly commences
a chill. | without a chill.
2. Fever variable, but rarely | 2. Fever steadily increases, but
entirely intermits. | is lower in the morning.
3. Sudden and great changes in | 3. The temperature is high at the
temperature, followed by | beginning of the disease,
profuse perspiration. | increases until near the fatal
| termination, when it falls
| below the normal. The skin is
| moist, but without profuse
| sweatings. {979}
4. Pulse variable; toward the | 4. Pulse rapid, and gradually
fatal end rapid, feeble, and | increases in frequency toward
irregular. | the fatal end.
5. Facies at the beginning | 5. Facies expressive of a dull,
flushed or pallid, toward the | listless condition throughout
end careworn. | the whole course of the
| disease.
6. Tongue smooth, dry, and | 6. Tongue, lips, and throat dry
excessively red, later | at the commencement, toward
brown-coated, and even the | the end moist. Thirst is
teeth coated with sordes. | marked.
7. Diarrhoea with stools of a | 7. Rice-water evacuations, very
pappy consistence. | offensive; obstinate vomiting.
8. Epistaxis. | 8. Epistaxis rarely occurs.
9. Mild delirium toward the fatal| 9. A lethargic condition from the
end. | beginning, increasing toward
| the fatal end.
10. Aphthæ in the mouth and |10. Icteric hue of conjunctivæ;
throat, sudamina, vesicles, | singultus often present.
pustules, and purpuric |
patches. |

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 | The odor of putrefaction is
disease the suppuration is | commonly very marked within
commonly checked, the wound | twenty-four hours after the
becoming dry, and if a discharge | receipt of the injury, the
continues, it becomes scanty, | integument slightly reddened
thin, ichorous, greenish, etc. | about the wound, and the
The granulations, when previously| surrounding parts somewhat
healthy, soon slough, and venous | oedematous. The wound-tissues
oozing sometimes takes place. | soon assume a dark-brown color,
There occasionally appears in the| and are occasionally mottled
later stages of this disease | with dull grayish spots, while
around the wound a reddish | the edges of the wound are at
erythematous blush, which soon | the same time blackened,
extends over the whole limb. | 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 {980} 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]

[Footnote 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 {981} 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.

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 {982} 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 {983} 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]

[Footnote 43: Liebermeister, _New Sydenham Soc. Trans._, vol. lxvi. p. 278.]

[Footnote 44: _Ibid._, p. 280.]

The treatment of puerperal septicæmia, although requiring the application of the same principles as any other form of this disease, may be briefly described as follows: The womb should be maintained in a firmly-contracted state by the proper use of ergot, even as a prophylactic measure, and also during the whole course of the disease; the uterus and vagina should be kept in an aseptic condition by the efficient use of antiseptics; sulphate of quinia should be given in large doses, and repeated as often as may be necessary in order to lower the temperature; and morphia or some form of opium should be employed for the relief of the pain.

{984}

PUERPERAL FEVER.

BY WILLIAM T. LUSK, M.D.

DEFINITION.--Puerperal fever is an infectious disease, due, as a rule, to the septic inoculation of the wounds which result from the separation of the decidua and the passage of the child through the genital canal in the act of parturition.

To maintain this definition it is, however, necessary to group by themselves cases of childbed fever dependent upon causes which are operative in the non-puerperal condition, though the latter imparts to these causes oftentimes an exceptional activity and virulence. In this category are to be placed especially scarlatina, typhus, typhoid, and malarial fevers. It is to be borne in mind that the zymotic fevers may provoke in the puerperal woman the same inflammatory lesions commonly associated with puerperal fever.[1] This is in accordance with the well-known surgical experience that a febrile paroxysm from any cause exerts an unfavorable influence upon a wounded surface.

[Footnote 1: Hervieux, _Traité clinique et pratique des maladies puerperales_, pp. 1073 _et seq._]

Like all brief statements, the writer is well aware that the foregoing definition is necessarily imperfect, and stands in need of further limitations to meet the requirements of exactness. Exceptions, however, either apparent or real, will be noted hereafter in their proper connections.

FREQUENCY.--In a careful search through the records preserved by the Health Department of New York City, I found that from 1868 to 1875 inclusive the total number of deaths for nine years was 248,533. Of these, 3342 were from diseases complicating pregnancy, from the accidents of child-bearing, or from diseases of the puerperal state; or, in other words, 1:75 of all the deaths occurring during that period was the result of the performance of what we are in the habit of regarding as a physiological function.

The deaths from miscarriage, from shock, from prolonged labor, from instrumental delivery, from convulsions, from hemorrhage, from rupture of the uterus, and from extra-uterine pregnancy, and deaths from eruptive fevers, from phthisis, and from inflammatory non-puerperal affections complicating childbirth, made a total of 1395, or about 42 per cent. of the entire number. The remaining 1947 cases, variously reported as puerperal fever, puerperal peritonitis, metro-peritonitis, phlebitis, phlegmasia dolens, pyæmia, and septicæmia, represent the very serious sacrifice of life resulting from inflammatory processes which have their starting-point in the generative apparatus. If we apply the general term, puerperal fever, to this class of cases, it will be seen that the malady is the cause of nearly one {985} one-hundred-and-twenty-seventh of all the deaths occurring in the city. The actual number of births for the nine years in question was roughly estimated at 284,000[2]--an estimate erring upon the side of liberality. The total number of deaths to the entire number of confinements was, then, at least in the proportion of 1:85, or, from puerperal fever alone, in the proportion of 1:146. Garrigues[3] examined the records of the various city institutions during the period in question, and from them estimated the number of births which took place in hospitals at 10,572. The recorded deaths were 420. Deducting these from the totals given above, the general death-rate in civil practice from puerperal causes in New York City was in the proportion of 1:94. Max Boehr[4] in his now-famous statistics reckons that one-thirtieth of all married women in Prussia die in childbed. The Puerperal Fever Commission[5] appointed by the Berlin Society of Obstetrics and Gynæcology arrived at the conclusion that from 10-15 per cent. of the deaths occurring in women during the period of sexual activity were due to childbed fever, and that this disease destroyed nearly as many lives as small-pox or cholera. But puerperal fever differs from either small-pox or cholera in that the latter presses largely upon the aged and the very young, while the former gathers its victims exclusively from a selected class--viz. from women in adult life, the mothers of families, whose loss, as a rule, is a public as well as a private calamity.

[Footnote 2: This estimate was based upon the assumption that the natural birth-rate is 33 to the 1000--a proportion believed by the statisticians of the Board of Health to be approximatively correct, though probably somewhat in excess of the reality. P. Osterloh has recently stated that my statistics were computed in so arbitrary a manner as to render deductions from them valueless. In this, however, he is mistaken. The most conscientious care was taken in their preparation; wherever the possibility of error existed the fact was distinctly indicated, and all calculations were made in such a way that whatever corrections might be required would strengthen the conclusions.]

[Footnote 3: "On Lying-in Institutions," _Trans. Am. Gyn. Soc._, vol. ii., 1878.]

[Footnote 4: "Untersuchungen über die Haüfigkeit des Todes im Wochenbett in Preussen," _Zeitschr. f. Geburtsk. und Gynaek._, vol. iii. p. 82.]

[Footnote 5: _Zeitschr. f. Geburtsk. und Gynaek._, vol. iii. p. 1.]