CHAPTER VI
.
AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS.
One of the greatest advances made in pathology has been the establishment of the fact that a great many of the morbid conditions from which the human race suffer are those due to causes arising entirely from within their own systems and in consequence of deficiencies of elimination or of perverted physiological processes which, in large degree, are themselves the result of errors and indiscretions in diet, in manner of life, in habits, etc. That these general facts have been recognized for centuries is perhaps a credit to the powers of observation of practitioners of past generations. Exact knowledge, however, has come only with exact laboratory methods of research and most painstaking study of the secretions and excretions, both under normal and morbid conditions. The subject of _auto-intoxication_ has been too commonly relegated to the domain of internal medicine, and has been supposed to be one in which the surgeon need take only passing interest.
The _alkaloids_ are by no means the only poisonous products which the human body may produce and retain. That most important excrementitious material of all--_i. e._, _carbon dioxide_--could not be retained in the organism for more than a few moments without death as the inevitable consequence. The various _soluble ferments_ elaborated by certain glands may exert deleterious influence, both local and general; and in the saliva are also found products which are not ferments. The _biliary acids_ also, if they do not find free escape, may produce fatal poisoning. So also _leucin_, _tyrosin_, and all the excrementitious products which arise from insufficient liver activity, are capable of producing forms of intoxication--such, for example, as _eclampsia_, etc. The character of the solvent has much to do with toxicity. Thus aqueous extract of putrid matter is more poisonous than that of fecal matter, while alcoholic extract of fecal material is more toxic than that of putrid. All the alkaloids produced within the body are not poisonous. Some are found in the normal tissues, and they are, perhaps, only one of the results of the disassimilation of animal cells. Nor are all these poisons of bacterial origin, although many are formed only in the presence of microbes.
From these constantly menacing sources of intoxication man escapes by virtue of his intestinal, cutaneous, pulmonary, and renal emunctories. For instance, the usefulness of the perspiration is shown by the odor which it assumes under the influence of certain disorders. Among hypochondriacs and the inactive fatty acids are eliminated by the skin. Hence the odors of hospital wards, asylums, prisons, etc. So, too, in the case of many who suffer from deep-seated, indolent ulcers, the odor of the skin is suggestive of the presence of pus. During twenty-four hours there is eliminated from the lungs 1100 grams of carbon dioxide, water, etc., which sometimes contain ammonia and various volatile fatty acids; all of which will explain fetor of breath when it is the result of incomplete nutrition and destruction of food. Of the _organs of elimination_, the most important is the _kidney_, which does not reabsorb a part of its own products, as does the intestine. The kidneys eliminate fluids and solids, not gases. The most important of the toxic principles contained in the urine are:
1. _Urea_, which plays an important and useful role in the economy, since it possesses the property of forcing the renal barrier and removing along with itself the water in which it is dissolved and other toxic matters. Urea is toxic, but only in the sense that any other substance, even water, may be--_i. e._, it is toxic only in large doses, less than sugar, and no more than the most inoffensive salts. This is contrary to generally received views, but is established by the researches of Bouchard.
2. A _narcotic_ substance, and
3. A _sialagogue_ substance, whose composition is unknown;
4, 5. Two substances having the property of causing _convulsions_, one having the power of _contracting the pupils_. The composition of both is unknown.
6. A substance which _produces heat_ by diminishing heat production--possibly a coloring matter. That coloring matters are absorbed by charcoal and that urine thus decolorized is rendered less toxic are no proof that the coloring matters themselves are responsible for this toxic action. There is no doubt that numerous alkaloidal bodies possessing a high molecular weight are precipitated by means of carbon or charcoal, and to these bodies may be attributed a portion of that toxic action previously considered as due to coloring matters.
7. _Potassium salts_, which are really convulsing agencies, are the most toxic perhaps of any of the poisons contained in the urine. Chloride of potassium, for instance, is toxic at 18 Gm. for every kilo of animal.
_Salivation_ and _myosis_, as well as diarrhea, are often noticed in so-called _uremia_. In that form known as hepatic uremia, when the liver no longer forms urea, the kidneys scarcely act. In other words, if urea is no longer present in the body, the kidneys are deprived of their principal stimulation to physiological activity. Consequently urea, for so long a time the bugbear of physicians, is shown to be most dangerous when absent. When urea is deficient, blood serum or water in which the other toxic substances are dissolved should be withdrawn. This is best done by _venesection_, whose value in so-called uremia experience amply corroborates. When kidney activity ceases, intoxication is likely to be produced by potassium salts. Ptomains, amido bases, etc., are proved to be present in normal urine and are known to produce toxic effect. These ptomains increase enormously in pathological urines, and to this increase, rather than to that of potassium and coloring matters (which remain fairly constant), may be attributed the higher toxicity of pathological urine. In certain cases, however, as in that of jaundice, the toxicity of the urine is partly due to decomposition of tissue cells, whereby potassium salts and organic decomposition products are liberated and excreted in the urine. The toxicity of the urine also increases with the increase of indican, which is indirectly a product of intestinal fermentation.
The _osmotic pressure_ of the blood has much to do with the general subject of auto-intoxication, since it surrounds and permeates all the organs of the body, which are necessarily in equilibrium with it. Their individual cells functionate, then, in accordance with it, and variations in such pressure must affect their activities. It is a special function of the kidneys to eliminate enough of the accumulated metabolic products in the blood to keep this osmotic pressure at its normal. Should investigation or symptoms of disease show a wide divergence from this standard, the inference is plain, _i. e._, that there is renal insufficiency from impairment.
This test may be made with a small amount of blood by _cryoscopy_ (determination of freezing point). So, too, a determination of _electrical conductivity_ may, in a similar way and for a similar purpose, be made of clinical value. Unfortunately, these investigations are not exactly simple in character, and are not available outside of well-equipped hospitals.
Correct performance of _hepatic function_ is also necessary that surgical cases may progress without disturbance. Bile escapes direct absorption by the blood, but not all contact with it, since in the intestine it is in contact with mesenteric capillaries, but must pass again through the liver, which takes it up again and pours it once more into the intestine.
Bile in the blood is always dangerous, although its toxicity is much smaller than has been supposed. Of all the bile thrown out into the duodenum, we are only able to account for about one-half. Its coloring matter and biliary salts are metamorphosed. Yet in certain morbid conditions bile, as such, may be reabsorbed in the liver along the margin of the hepatic cells. In these cases, if the kidneys remain permeable, auto-intoxication is simply threatened; if they have ceased to be permeable, actual auto-intoxication is the result.
_Putrefaction of intestinal contents_ affords another source of auto-intoxication. This comes both from imperfect metamorphosis of food and from bacterial infection. Here the conditions are most favorable. Nitrogenous substances become peptonized, and peptones form the best culture media for microbes. Water is present in sufficient quantities, and a constant temperature of 37° C. is maintained. The digestive tube is always open, and invaded at frequent intervals. By such mechanism are formed those products whose effects are revealed in the so-called _putrid fever of Gaspard_. Brieger has shown that alkaloids are developed during the act of peptonization. Fecal matter contains also _excretin_, whose toxicity has been amply proved, and several other alkaloidal substances, soluble in various media, varying in toxicity. The potassium and ammonium salts contribute largely to the toxicity of feces; bile also, but in lesser degree. It has been shown that the aqueous extract of putrid matter is very toxic, while that of fecal matter is otherwise.
The most serious features of the conditions grouped under the heading of _Bright’s disease_ are their _so-called uremic_ features. These happen at the period when retention of toxic products is peculiarly harmful. As long as the urine is ample in amount and density--_i. e._, containing enough toxic materials in solution--there is no danger of intoxication. But when it no longer eliminates in twenty-four hours what it should, then we see the chronic and paroxysmal nervous accidents, the edemas, fluctuations of temperature, etc. Oliguria with urine of increasing density and general edema of the tissues may be noticed, although the other secretions continue natural and the tongue moist. As long as the normal amount of solids is eliminated, this form of “uremia” may be due to mere accumulation of water and may not be serious. _Ordinarily, uremic patients are those whose urine has lost its toxicity._ Usually on the day in which so-called uremic accidents happen the urine quite ceases to be toxic and is scarcely more so than distilled water. Urea alone is not to be held guilty for this condition. In order to kill a man with urea it would require the quantity which he makes in sixteen days. Nevertheless, it may become harmful after undergoing transformation into ammonium carbonate or other substances.
Among the most poisonous substances in the urine are the _extractive_ and _coloring materials_. Normal urine loses one-half of its toxicity by decoloration; bile acts in the same way. _Urea_ alone represents about one-eighth of the total toxicity of urine. _Ammonia_ is toxic, but present in small amounts. The _coloring matters of the urine cause two-thirds of its toxicity_, the remainder of which is to be ascribed to its mineral salts, which it contains in the following proportion: A liter of urine ordinarily contains 44 Gm. of solid matter, of which 32 are organic, 12 mineral. Of the latter, potassium salts constitute 3 Gm., sodium salts 7.5 Gm., and other earthy salts constitute the remainder.
In these conditions physicians have relied largely upon purgatives, hoping thereby to remove urea from the blood. But intestinal elimination has no elective affinity for it, and removes it only in its normal proportion with the balance of the blood. Purgatives, however, help, first, by dehydrating the tissues--_i. e._, removing water with toxic material in solution. But they should be followed by restoring to the tissues pure water. By bleeding more extractives are removed than by any other channel, except by the kidneys. A bleeding of 32 Gm. removes from the body as much toxic matter as would 280 Gm. of a liquid diarrhea or 100 liters of perspiration. This much may be removed by two leeches. It is especially in the _subacute nephritis of scarlatina_, etc., _that bleeding finds its greatest indication_. If the kidneys are chronically diseased, the utility of bleeding is doubtful. Between the arterial capillaries of the bowels, however, and the liver is found a mass of blood accumulated in the _portal_ vessels. This may be regarded as a reserve which can be thrown into the general circulation when needed, in order that thereby arterial tension may be augmented and the function of the kidney increased. _Cold injections_ into the bowels will often accomplish this, and serious _anuria frequently disappears after their use_. It is advisable, also, to make use of urea by subcutaneous administration, as the most powerful diuretic known, surface friction, caffeine, digitalis, etc., being far behind it in efficiency. In the form of intoxication noted in the eclampsia of puerperal patients _inhalations of chloroform_ are valuable. Potassium salts should, under these circumstances, _never_ be employed. An exposure of urine in compressed air will diminish its toxicity, on account of contact with the oxygen; the most toxic bacteria are those which grow without oxygen. Consequently patients inhaling this gas may overcome this kind of auto-intoxication.
The value of an active liver is not appreciated by most surgeons to the full extent. The blood of the _portal vein_ is so much more toxic than that of the _hepatic vein_ that it is evident that the function of the liver is to purify and remove the toxic material from the blood that comes from the intestines. This has been called by Flint and others the _depurative action_ of the liver. The activity of the liver also may be proved by grinding up a freshly removed liver with alkaloids, whereby the latter are chemically changed.
That the facts above stated, or others related thereto, have not been lost sight of by surgeons is shown by such expressions as _septic enteritis_, _enterosepsis_, etc., which are used by various writers. In previous publications the writer has made a separate topic of so-called _intestinal toxemia_, which he has preferred to introduce here as one of the many possible auto-intoxications. It is a condition not always permitting of exact definition, nor, still less, can the exact toxic agency be indicated in a given case. Nevertheless, it has been made plain that there is perhaps no condition which so _predisposes to sapremia_, _septicemia_, or even _pyemia_ as this vague condition of intestinal toxemia, which, notwithstanding, is so often present. Many surgical patients present forms of blood poisoning in which the poison has _not_ proceeded from the wound, for which the surgeon is not responsible, except that he may have neglected to avail himself of certain precautions.
The auto-intoxications, then, which have peculiar interest for the surgeon may be conveniently classified as follows:
1. Those caused by failure in the function of particular organs; _e. g._, myxedema, cretinism, and cachexia strumipriva from thyroidal failure; pancreatic diabetes, where the islands of Langerhans are invaded (interstitial pancreatitis, _q. v._); Addison’s disease from adrenal failure (this being at present the prevailing belief).
2. Those caused by general disturbance of metabolism, where its incomplete or abnormal products reach the general circulation, _e. g._, oxaluria, gout, diabetes. (See Diabetic Gangrene.)
3. Those caused by retention in particular organs or tissues of disturbed metabolic products, _e. g._, the toxemias following serious burns and many septic conditions.
4. Those due to excessive formation of more or less normal products, _e. g._:
(_a_) _Hydrothionemia_, _i. e._, the presence of hydrogen sulphide in the blood. This results from one form of gastro-intestinal putrefaction and causes violent symptoms with evidences of hydrogen sulphide poisoning. It is seen in some cases of gastric dilatation, especially those caused by pyloric obstruction (_q. v._).
(_b_) _Acetonuria and Acetonemia._--The former sometimes follows chloroform anesthesia, and occurs especially in diabetes (particularly after removal of the pancreas in experimental animals). Acetone _per se_ is nearly or quite harmless, but its congeners, diacetic and beta-oxybutyric acids, are very toxic. The danger in so-called acetonuria is from acid intoxication by these acids, which has been described as “excessive acidosis,” and its co-existence with glycosuria makes diabetes certain, while prognosis is grave in proportion to its presence. Prominent among the symptoms produced by it are delirium and coma.
When either or all of these three substances are present in the blood its alkalinity is reduced and its ability to absorb carbon dioxide impaired; hence, acetonemia is evidenced by carbon dioxide poisoning. To the brain symptoms above noted is added a peculiar odor in the breath--sweetish or ethereal. This has been noted in pyemia. This condition may set in after various operations, but whether due to disease, the traumatism itself, or to chloroform may not always be determined.[3]
[3] See paper by Brewer, Annals of Surgery, 1902, vol. xxxvi, No. 4, p. 481.
(_c_) _Cystinuria._
(_d_) _Coma of cancerous cachexia_ (coma carcinomatosum).
(_e_) _Exophthalmic goitre_, from excess of thyroidal activity (thyroidism).
Besides the above there is auto-intoxication proceeding especially from the gastro-intestinal and hepatic systems. Of the former, the best surgical examples are seen in the tetany which occasionally takes its rise from a dilated stomach, and which may be cured by a pyloroplasty or a gastro-enterostomy; in the nephritis which follows stercoremia of intestinal obstruction; and in oxaluria, with its painful, serious, and often deforming or crippling joint affections. Of the latter we have examples in the cholemia of acute atrophy or of biliary obstruction, and in the uremia of hepatic origin which occasionally terminates a surgical case.
In addition to the above there should also be mentioned the auto-intoxications of pregnancy, with the consequent salivation, peripheral neuritis, pigmentations of the skin, icterus, and pruritus, which are mainly attributed to perverted action of the liver or kidneys.
The practice of preparing patients for operation by a course of purgatives, emetics, etc., is based upon the recognition of certain principles. The general symptoms included under the name _enterosepsis_, _stercoremia_, _copremia_, are due to the activity of the colon bacillus, which seems to be made more virulent by certain conditions of diet or retained fecal excretions, and to such an extent that it wanders widely from its normal habitat and may be found in distant parts of the body. _Enterosepsis may be mistaken for surgical fever_, and is to be distinguished from it, perhaps, only by the study of the excretions of a case and establishing the fact that they are free, and that consequently pyrexia, etc., cannot be due to diminished elimination. Aside from the migrations of the colon bacillus, it is also possible for auto-intoxication to occur. Thus that which is stercoremia one day may later become a genuine septicemia, vital resistance being so lowered as to permit of local infection. The various conditions are so often merged that it is difficult to separate and identify them. Nevertheless, enterosepsis differs from sapremia in that in the one instance the putrefying material is contained within a normal cavity, whereas in sapremia it is contained within an abnormal cavity, in either case corresponding to a _septic suppository_, varying, however, in the place of insertion, also in the nature of the surrounding tissues, which in the latter case are more capable of absorption and of becoming infected than in the former.
A determination of indol and indican is often of the greatest value, both in determining the extent of infection and the presence of pus. Indol is set free under the following circumstances: (_a_) Suppuration in a closed cavity. (_b_) Continued suppuration in a cavity with an outlet. (_c_) Ulceration or necrosis of tissue. The degree of indicanuria will depend on the length of time pus has been present, the possibility of absorption from the tissues surrounding it, and its degree. When pus is fully formed in a serous sac the indican reaction becomes intense according to the length of time pus has been present. This is particularly true in the empyemas of childhood. In continued suppuration with a free outlet the production of indol will be great; but the amount finally eliminated will depend upon the character of the surrounding tissue. When solid tissue, like bone, becomes affected, the elimination of indol is intense. Rapid biogenic degeneration of tissue causes an increased amount of indol to be deposited in the liver, and it is possible at postmortem, by simple extraction with absolute alcohol, to take from the liver this excess deposit in the shape of its oxidation product, indigo blue. Lardaceous degeneration is characterized by marked and persistent elimination of indol, which seems to be a product of tyrosin. It occurs frequently in the liver, in which indol is notably deposited. Its primary factor is deposited by the blood, in which latter indol circulates and is oxidized. Lardaceous material gives a red or blue color with oxidizing agents, which latter yield with indol an indigo red or blue.
The practical outcome of such a chapter as this is, then, to insist as strongly as possible on the preparation of patients, whenever this is feasible, for an ordeal which comprises the combined effect of anesthesia and consequent disturbance of secretion and elimination, with loss of blood and of strength, and subsequent confinement in bed, with, moreover, all that this entails in further impairment of
## activities of important organs. It is not always possible, practically
rarely so in emergency cases, to adopt these precautions; in which cases they must be atoned for, as far as possible, by extra attention in the same directions after the emergency is passed or has been met. In the former case, however, the functions of the skin, the kidneys, and the abdominal viscera should be regulated, the first by hot-air baths; the second by this same measure in conjunction with copious draughts of pure water, the correction of hyperacidity of the urine, and the administration of whatever drugs may be of benefit as diuretics, etc.; and the third by a course, perhaps covering several days, of gentle or active purgation, by which the alimentary canal will be entirely emptied of all that may serve to act as a source of poisoning. In addition to this, in certain cases careful massage will dislodge from the muscles and other tissues material which they ought not to retain, and which will be washed away, as it were, by the extra amount of fluid which this preparation, necessitates. Again, the activity of the heart should be stimulated, perhaps by digitalis, but preferably by that best of all tonics, strychnine, which is to be administered hypodermically in average doses of a thirtieth or twenty-fifth of a grain, morning and night. When these precautions are taken, patients will successfully pass through trying ordeals without anything which may give rise to alarm. When they are not possible, the risk of operating, even in a small way, is materially enhanced. So, too, after operations when these precautions have not been taken, it is necessary to give careful attention to atoning for their lack by such
## active purgation as a now reduced patient may bear--by hot-air baths,
if feasible, and by the administration of such intestinal antiseptics as charcoal, naphthalin, corrosive sublimate, bismuth salicylate, salol, etc., for the purpose of reducing to the lowest possible minimum the opportunity for formation of poisons which will disturb the proper repair of injury.
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