CHAPTER VII
.
THE SURGICAL FEVERS AND SEPTIC INFECTIONS.
SURGICAL FEVER, KNOWN ALSO AS TRAUMATIC FEVER, OR ASEPTIC WOUND FEVER.
Formerly the surgical fevers were all grouped together, and a certain amount of febrile disturbance was looked for after any injury. But with the introduction of antiseptic methods and the healing of wounds by primary union, with absence of all septic phenomena, and the use of the clinical thermometer, it is noted that there is a certain rise of temperature more or less quickly after an operation or reception of a wound, with fever of mild grade, persisting for several hours or two or three days, and with other accompaniments. This phenomenon has been carefully studied, and so separated from the septic fevers as to deserve a distinct recognition under the names above given, of which the most common in this country is _surgical fever_.
As long as this fever is free from indications of septic character it is without significance and needs only symptomatic treatment. It begins usually within the first twenty-four or thirty-six hours, after which the temperature may rise, progressively or with a morning remission, to a height of 102° or possibly 103°. In children we are more likely to get extremes in this regard than in healthy adults. It will be followed by some disturbance of alimentary function, glazing or drying of the tongue, deficiency in urinary secretion, and subside generally spontaneously--invariably so if cathartics, diuretics, cool sponge baths, etc., are used. It is usually due to the retention of blood clot, ligatures, etc., or tissues which have been ligated and whose stumps remain; in all instances there is some foreign material to be removed. This means unusual phagocytic activity, perhaps temporary leukocytosis, with active metamorphosis of clot and other material, of all of which the elevated temperature is an accompaniment and expression. It is not unlikely that the antiseptic materials used may sometimes occasion this pyrexia.
Iodoform and carbolic acid are among the drugs in common use which are known to be irritating and capable of producing toxic symptoms. Often after the use of the latter the urine will be discolored and will furnish the clue to the fever. In young children particularly, and not infrequently in adults, mental disturbance, even active delirium, may characterize the case. This is not always to be explained by cerebral anemia due to loss of blood during the operation or accident, but is probably due to drug toxemia or to intoxication from materials furnished by the altered tissues.
_Surgical fever of strict type may merge into a more or less continuous fever as the result of intestinal toxemia_ permitted by failure to evacuate the bowels, and this _intestinal toxemia may be a predisposing cause of genuine septic infection_. Consequently a surgical fever which does not disappear within two days is to be viewed with suspicion, especially if it does not subside after the administration of cathartics.
Some surgical fevers are accompanied by eruptions, a number of which may be due to drugs and some to intrinsic poisons. Thus carbolic acid and iodoform give rise occasionally to erythematous eruptions, and the concomitant administration of drugs like potassium iodide, quinine, antipyrine, and copaiba may produce urticarial or other manifestations. Again, it is known that certain toxins--produced, _e. g._, by the bacillus pyocyaneus--are capable of causing dilatation of the superficial vessels and various flushes or eruptions. To one of these, which dilates the capillaries, Bouchard has given the name of _ectasine_. Consequently it by no means follows that every eruption or rash following operations or injuries is of a specific character. On the other hand it seems to be established by numerous observers--among whom Paget is perhaps the most prominent--that surgical patients,
## particularly the young, are particularly liable to infection by
scarlatina; and in the experience of Thomas Smith, of forty-three children whom he cut for stone, ten had scarlet fever. Therefore, in spite of the fact that a certain number of cases of eruption may have been mistaken for scarlet fever, it is undoubtedly true that in surgical and puerperal cases patients are more than usually liable to this invasion. The use of antitoxins or serums is also occasionally followed by intense urticaria.
The subject of surgical fever may then be epitomized as consisting of elevation of temperature with certain accompanying disturbances, which appear to be essentially due to the results of tissue metabolism, including also metabolism of blood clot, ligatures, etc. It is not a necessary nor conspicuous accompaniment of all surgical cases, and in some individuals, even after grave operations, it will scarcely be noted. It is more likely to be extreme in children than in adults. As a result of excessive loss of blood it may be postponed. It may be complicated and prolonged by any one of the auto-infections,
## particularly that already mentioned in the preceding chapter as
intestinal toxemia, as a result of which septic infection may ensue, and that which was at first a legitimate surgical fever may thus become merged into a septic condition. In the absence of auto-infection, and with appropriate treatment, surgical fever should quickly subside until it becomes indistinguishable about the second or third day.
Proceeding then in the order of pathological complexities, the first of the surgical infectious fevers to be considered is sapremia.
SAPREMIA.
The term _sapremia_ will be used here as indicating a condition which is often likened to an _intoxication produced by a supposititious septic suppository_. The term was first used by Duncan, and was largely confined to puerperal cases. Some of the most ideal cases of sapremia are those of puerperal origin.
In each of the three conditions comprised under the general term of _septic infection_ it is not now a question of particular organisms, but of intoxication by products which are more or less common to at least several of them. In a general way, they are mainly _due to the
## activity of the organisms already grouped as pyogenic_. Those which
produce pus are capable of causing septic infection. In addition to these, it is probable that certain of the saprophytes or ordinary putrefactive organisms may produce the same effect.
=Symptoms.=--In sapremia the symptoms begin promptly, depend for their intensity upon the dosage of poison, and recede quickly as soon as the source of poisoning is removed or its activity subdued. An instance of the possible causes of sapremia will perhaps best illustrate its pathology. Take, for example, the act of delivery of the full-term fetus. At the completion of this operation there is left a fresh, bleeding wound of large area which is more or less exposed to putrefactive agencies. This is reduced with the contraction of the uterine walls to a comparatively small cavity containing more or less freshly coagulated blood. As long as this clot does not putrefy it is disintegrated inoffensively, to be discharged in large part with the lochia. If germs of putrefaction enter, either during the act of labor or afterward, and linger, putrefactive processes are set up in the clot with the prompt production of certain toxins and ptomains. There is here then a _septic suppository_ with conditions favorable for absorption by the containing tissues. How quickly the poisoning may show itself, and how soon it may subside after removal of the putrefying clot, daily experience may tell.
_Sapremia then is intoxication produced by absorption of the results of putrefaction of a contained material within a more or less closed cavity_, whose walls are capable of absorption of noxious products as they form. _As long as putrefaction is essentially limited to the contained mass_, and does not spread to and involve the containing or surrounding tissues the case is one of sapremia. _As soon as the process spreads from the containing tissues the case merges from one of sapremia into one of septicemia._ That this may occur in any case without prompt intervention will be readily understood. Sometimes patients may die of sapremia, though rarely, and in such case ordinarily as the result of gross neglect. Once the septicemic process is begun, however, its spread cannot always be checked, and the case which one day is sapremic and redeemable may later become septicemic and practically lost.
The symptoms of sapremia are not essentially different from those common to septic infection, save that ordinarily they are, at least at first, milder. There are flushing of the face, dry tongue, mental disturbance, pyrexia, while usually all the symptoms are ushered in by a chill, which may have been preceded only by slight malaise. These are followed by nausea and vomiting, with headache, and often, later, by diarrhea or active purging. Later delirium may occur, possibly even fatal coma. On postmortem examination there are few changes revealed; alterations in the blood, a failure to coagulate, and some softening of the spleen and liver would probably be the only ones.
=Treatment.=--The treatment should be prompt and the cause removed. In puerperal sapremia the uterus should be emptied, antiseptic douches given, irrigating as often as necessary to prevent offensive odor to the discharge, and combating general signs of poisoning by plainly indicated measures. Heart depression should be overcome by diffusible stimulants and hypodermic injections of strychnine in doses of ¹⁄₂₅ grain or more. The _bowels should be unloaded_ by a mercurial followed by a saline cathartic; suppression of urine treated by venesection and hot-air baths or sweats; diuretics should also be prescribed, and fluids administered copiously. If the patient is restless, an opiate should be given; if delirious, necessary restraint should be resorted to.
Essentially the same measures should be pursued in a surgical wound or in a case of compound fracture, or any injury where retained material may be undergoing changes already alluded to. General measures should be the same. _Purgatives_ are advisable in these cases.
=Chronic Sapremia.=--Chronic sapremia is a better name for what used to be known as _hectic fever_. It is characterized by rapid, feeble pulse, a temperature but little elevated in the morning and rising to 102° or 103° in the latter part of the day, with profuse perspiration, or sometimes colliquative sweats that leave patients exhausted. There is usually a distinctive flushing of the cheeks. Emaciation is a marked feature in most instances. Hectic means simply _habitual_ fever. It is met with particularly in tuberculous cases, whether of lungs or bones or joints, in empyema, psoas abscess, and most all chronic pyogenic infections. It is frequently followed by or associated with amyloid or waxy degeneration of the liver, kidneys, and spleen. This process commences in the walls of the bloodvessels and by its spread to the surrounding connective tissue leads to notable enlargement of these organs, with albuminuria, edema, ascites, and the usual associated phenomena.
=Treatment.=--Treatment, in addition to that already indicated above, should be addressed to removal of the cause. In all instances it should comprise attention to elimination, digestion, nutrition, and fresh air. By such measures even distinct amyloid changes may be arrested, or possibly improved.
=Cryptogenetic or Spontaneous Septicemia.=--Cryptogenetic or spontaneous septicemia is a term applied to those cases in which the port of entry of the germs is no longer visible--_e. g._, a hypodermic puncture--or cannot be positively determined. On careful study this may be found to consist of a small focus where pus is forming within narrow confines and under great pressure. Under these circumstances, as Kocher has shown, toxic virulence is rapidly augmented. This is doubtless one reason why the septic features of many cases of osteomyelitis and appendicitis are so pronounced.
SEPTICEMIA.
According to the views thus enunciated, the difference between sapremia and septicemia is not one of character as much as of location. _In septicemia the putrefactive action is no longer confined to material enclosed by_ (_yet not of_) _the tissues themselves, but has spread from this to the surrounding living cells_, which are being attacked by bacterial enemies; in other words, we deal with _infection of living tissues rather than with mere intoxication_. This is a _progressive invasion_ of tissues by continuity, _with_ a constantly proceeding systemic _intoxication_ by poisons produced in larger quantities. So rapid may this action be--as may be seen in malignant diphtheria--that the individual speedily succumbs before evidences of abscess or local gangrene appear. On the other hand, providing that the toxic action is less pronounced or the patient’s vitality more enduring,--_i. e._, his tissues more resistant--abscess, phlegmon, or local gangrene may result in the destruction of tissue being limited to the environs of the parts first involved. Bacteria are also found in the blood.
While septicemia then may be a direct continuance of an original sapremia, it is not intended to intimate that it may not originate _de novo_; that is, _many cases may begin as a pronounced septicemia from a local infection_. This is the case, for instance, with the majority of dissecting wounds, etc.
=Symptoms.=--In septicemia there is a period of incubation, usually two or three days, often longer. If this follows an operation, the mild fever which would indicate the slumbering fire is usually regarded as surgical fever. But when this rises and is followed by prostration, with alimentary disturbance, loss of appetite, headache, etc., followed by typhoidal symptoms, the alarm is sounded and should be quickly heeded. Usually, but not always, there is a preliminary or _premonitory chill_, after which prostration will be more marked than before. The severity of the symptoms cannot be foretold from the size, location, or character of the wound. The character of the fever is essentially continued, usually with morning remissions. Gussenbauer has called attention to a class of cases in which subnormal temperature is caused by the absorption of ammonia compounds. To these he has given the name _ammoniemia_. This condition may be seen in connection with gangrenous hernia, and has even been mistaken for shock (Warren). (See also _acetonemia_, in previous chapter.)
In septicemia from infection of a visible portion of the body there are usually seen evidences of _lymphangitis_ and _perilymphangitis_ of septic character. These will be evidenced by tender and purplish lines, extending subcutaneously along the course of the known lymphatics or in connection with the more prominent subcutaneous veins. The _lymph nodes_, into which these visible vessels as well as the deeper ones empty, become _enlarged and tender_; the whole lymphatic system participates; the _spleen_ in aggravated cases becomes notably enlarged, and even the bone-marrow more or less involved. _Diarrhea_ is commonly an early but controllable symptom. A hematogenous icterus of mild degree is another frequent accompaniment. The conjunctiva becomes discolored and the skin slightly so. Should the blood be examined marked _leukocytosis_ will be noted, and should cultures be made from it, in many instances at least, the organisms at fault can be detected and recovered from it. The vigor of the heart muscle is seriously impaired; the _pulse_ becomes _rapid_ and _weak_. In scarcely any form of septic infection is this more prominent than in diphtheria; and microscopic examination shows the rapid disintegration of the cells of the heart muscle, as well as those of other parts of the body, even to the almost complete molecular disintegration of the nuclei. Erythematoid, pustular, and even hemorrhagic _eruptions_ are met with upon the skin, some of which are probably to be explained by thrombosis of the dermal capillaries. Certain _complications_ are not infrequent, among which inflammations of the pericardium and endocardium--_e. g._, ulcerative endocarditis--are frequent. As the case becomes aggravated the temperature rises irregularly; the hot, dry skin becomes cold and clammy; prostration and indifference more marked; diarrhea more colliquative; icterus more pronounced; urine more reduced in quantity or suppressed; and these symptoms are succeeded by indifference, mental apathy, stupor or delirium, and finally death, the patients being comatose and collapsed.
While these are the general indications of septicemia, the _wound_ or site of injury has undergone _changes_ which are also _characteristic_. They comprise the _edema and redness of wound margins_, which may be seen even in sapremia, followed by increasing _tumefaction_, escape of _foul-smelling discharge_, and finally by _sloughing and gangrene_ of the parts involved. On microscopic examination the capillaries are filled with infective thrombi and vessel walls infiltrated with microörganisms, which abound also in the lymph spaces. Bacterial infection can be traced in microscopic sections from the infected area, from the point in the neighborhood of the wound where microbes infest the tissues to points remote from it, where they are sparsely found, if at all. The same evidences of infection may be traced along the lymphatic vessels, and often the veins.
=Postmortem Evidences.=--The postmortem evidences of septicemia are indicative on first sight: the blood is of the consistency of tar and does not coagulate; evidences of putrefaction are plain to sight and smell; the serous membranes, particularly the pia mater, are often extravasated; the muscles are discolored and of a darker hue than natural, edema of the lung is frequent; the intestines reveal a gastro-intestinal catarrh, the duodenum and rectum showing punctate hemorrhages; the spleen is darkened, enlarged, and softened; the liver shows similar signs, less marked, and at times an emphysematous condition due to putrefactive gases. Cultures can be made from the fluids and tissues of organs thus affected. It is also of importance to emphasize that such material is _powerfully_ and often fatally _infectious_; some of the worst forms of dissecting wounds and instances of _fatal infection_ have come from carelessness in making these _postmortem examinations_.
So far as concerns the character of the wound, which is most likely to be followed by septicemia, there is but little to be said. Wounds made by infected tools, the butcher’s knife, the anatomist’s scalpel, etc., are the most dangerous. All forms of phlegmonous erysipelas, many cases of gangrene following frostbite, nearly all instances of traumatic gangrene, most cases of carbuncle, and, in fact, all similar lesions, are likely to be followed by septicemia. The so-called spontaneous cases have an equally infectious origin, though one which is concealed. In unrecognized instances of appendicitis, for instance, and in many other conditions, although the path of infection may not be easily traced, it is, nevertheless, always present, and can be found if diligent search is made. The nasal cavity, the tonsils, the teeth, the middle ear, the deep urethra, and the rectum are often overlooked as offering possibilities for septic infection which may follow this general type.
=Treatment.=--This should be both local and general. Local treatment should consist in complete and absolute removal of the active cause. This comprises the reopening of wounds, evacuation of clot, cutting or scraping away of sloughs and gangrenous tissue, with cauterization of the exposed living tissue, in order that absorption may be prevented, and will often include amputation or extirpation of a part. For tissues which are not too completely riddled by disease, and lost beyond possibility of redemption, _continuous immersion in hot water_ offers the best possible prospect. By it putrefaction seems checked, the separation of dead from living tissues is accelerated, relief of pain or discomfort is afforded, and disinfection of material which is foul and infectious is guaranteed. An excellent local application is the mixture of resorcin 5 parts, ichthyol 10 parts, ung. hydrarg. 40 parts, and lanolin 45 parts, already mentioned in