Chapter III

) come into play here, and the influence of exposure, fatigue, starvation, etc., is not to be ignored in furnishing an explanation for the so-called idiopathic cases.

In the majority of instances, however, pyemia follows surgical operations and injuries, among which are compound fractures, deep injuries with small superficial evidence thereof, compound injuries of the skull, and injuries by which veins are exposed. Inasmuch as the typical pyemic manifestations require a certain length of time for their development, the onset of this disease is more delayed than in the case of septicemia. While the case may be manifestly one of septic infection of unrecognizable type, the characteristic indications of pyemia seldom appear in less than ten days, and frequently not for several days longer.

=Symptoms.=--The symptoms of pyemia do not essentially differ from those of other septic infections. The principal difference is in the _frequency of chill_ and _range of temperature_. _Chills_ are more _common_ at the _inception_ of the condition, and more _frequent_ throughout its continuance than in other septic conditions. The chill may be slight or assume the proportions of a rigor, and each chill is followed by colliquative sweat and exhaustion. In other words, chills which are infrequent in septicemia are common in pyemia. There is reason to believe that with each fresh distribution of emboli we have one or more chills as the objective evidence thereof. Distinctive also of pyemia is the _temperature curve_, which much resembles that of intermittent fever, without the regularity of change characteristic of malarial fevers. It is without regular remissions, and has been referred to as irregularly intermittent. The first rise is abrupt and usually excessive, while with each fresh chill or series of chills similar abrupt alterations will be noted. These occur so frequently and fluctuate so irregularly that in order to note them accurately the temperature should be taken at least every two hours. The temperature seldom drops to normal.

As the lungs fill with the first crop of infected emboli, and the first series of metastatic abscesses form there, there is more or less _dyspnea_ and sense of oppression; there may be also _pulmonary complications_--pleurisy, bronchitis, etc., even pulmonary edema. Frequently there is expectoration of frothy and discolored sputum; occasionally there is blood in the sputum. A peculiar _sweetish odor of the breath_ has been noted by many observers in this disease, and is supposed to be idiopathic and characteristic. (See _acetonemia_ in previous chapter.) With the dispersion of the second crop of emboli from the lungs there is apt to be _icterus_, with evidence of _metastatic abscess in the liver_, and collection of pus as the result of coalescence of small abscesses. The sensorium is not so affected in pyemia as in septicemia, and in the former disease patients are more likely to be alert and active in mind. General _hyperesthesia_ and _restlessness_ are common. Colliquative sweats are also a feature of pyemia. There is the same liability to _eruptions_, etc., which may mislead or complicate the diagnosis. A dermatitis is seen sometimes in pyemia, the lesions assuming a papular or pustular form, due to local infections of the skin. Purpuric spots are also seen, and vesication is not infrequent. Within the mouth _sordes_ collect upon the _teeth or gums_; the _tongue_ becomes dry and brown and heavily coated. Diarrhea is less common in pyemia. The urine is usually scanty and high colored, containing solids in excess; albumin is sometimes found therein, as well as peptone. The presence of _peptone in the urine_ is probably an indication of the breaking down of pus corpuscles in various parts of the tissues.

A significant objective evidence of pyemia is met with in the _metastatic collections of pus within the joints_, which occur relatively early, and which, if multiple, may lead to a correct diagnosis. One of the earliest joints to be involved is the sternoclavicular, although none of the joints are free from the possibility of invasion. The articular serous membranes seem to have the property of carrying and holding the infective thrombi better than any other tissue in the body. The _pyarthrosis of pyemia_ is for the most part painless, yet implies loss of function of the affected joints. The distention of these is usually evident to the eye, the fluctuation pronounced, tenderness not extreme, but the swollen part merges into tissues which are edematous and reddened. When pain in the limb is extreme, it is usually because of metastatic abscess within the bone-marrow cavity. In other words, we now have a _metastatic osteomyelitis_.

In all cases of pyemia prostration is marked, yet the pulse is seldom weak, at least until toward the close of life. As cases progress from bad to worse _subsultus tendinum_ is often noted.

The _appearance of the wound_ or site of operation does not differ essentially from that already described under Septicemia. There is usually, however, _less discharge_, granulations are _smoother and dryer_, and if tissues are gangrenous they are not as wet and nauseous as in the other case. _Evidences of thrombophlebitis and lymphangitis_ will proceed from the wound toward the body, as in other instances of septic infection.

=Prognosis.=--Prognosis is usually _bad_. While recovery may follow where metastatic infiltration has not been too general, the ordinary case of pyemia will die within twelve to fourteen days after diagnosis. Sometimes the entire process is much slower, and isolated cases occur which can be designated as _so-called chronic pyemia_, which differs but little from the acute form. A case of pyemia should not fail of recognition because there is no evidence of infection from without. A fatal case of pyemia has been known to occur from a suppurating soft corn which was not discovered during life; also from _peridental abscess_, etc., which had been overlooked. Death is the result of tissue destruction and septic intoxication.

=Postmortem Appearances.=--In the vessels these consist essentially of _thrombosis_, examples of which may be seen, for instance, in the cranial sinuses and in the large veins. Aside from these, with the _enlargement and softening of the spleen_, the _liver_, and _lymphatic structures_, already described under Septicemia, the principal objective evidences consist in the discovery of metastatic abscesses in many or all parts of the body. As stated above, there is no tissue or organ in which they may not be found. The mechanism of their production has been already described. _Infarcts_ may also be met with, in the kidneys especially, the liver and spleen as well, and indicate areas already cut off from blood supply by thrombo-arteritis, in which abscess formation would have occurred had time been given. In the liver large abscesses may be found; joint cavities may be filled with pus; the lungs are usually the site of innumerable small abscesses. The other postmortem changes commonly noted are not difficult of explanation, but are not so characteristic or pathognomonic as to call for further mention. In a joint which has become filled with pus there usually has been loosening of the cartilage and more or less disorganization of all the joint structures, which appear to have undergone rapid ulcerative destruction and putrefaction.

=Treatment.=--Treatment of pyemia is in large degree unsatisfactory. That which used to be the terror of surgeons in the pre-antiseptic era is now, thanks to Lister and others, almost abolished. Pyemia is a rare disease in modern surgical practice. Its possibility should be borne constantly in mind, however, and the necessity for careful antiseptic or for a rigid aseptic technique is in large degree based upon fear of pyemic consequences.

When once established, the disease is to be treated on lines nearly similar to those laid down for septicemia, including resort to the ichthyol or silver ointments, and to intravenous infusion of silver solution. (See p. 89.) Amputation or extirpation of the part from which infection has first proceeded may be of avail. Among the most successful measures for surgical treatment of this disease is to expose the infected area, open the involved veins, and either excise them or scrape them out and disinfect them. This treatment has been successful in cases of cranial infection following middle-ear disease, etc. (See chapter on Cranial Surgery.)

Disinfection of the infected area and immersion in hot water should be practised. Metastatic abscesses should be opened and drained, and every accessible collection of pus evacuated, either by the knife or aspirator needle--_e. g._, in the liver.

The medicinal treatment is practically the same as in septicemia, while the surgeon’s mainstays are alcohol and strychnine. These, with cathartics and intestinal antiseptics, will practically sum up the drug treatment, the surgeon meantime not neglecting the matter of nutrition, crowding it in every assimilable form.

ERYSIPELAS.

Erysipelas is an _acute infectious disease characterized by its tendency to involve the skin and cellular structures, to extend along the lymphatic vessels, to involve wounds and injuries under certain conditions, accompanied by more or less fever of septic type, leading frequently to septic disturbances of profoundest character, yet tending in the majority of instances to spontaneous recovery_. It has been observed probably from prehistoric times, but has not found a proper description nor appreciation until perhaps within the past century. It occurs in so-called _traumatic_ and _idiopathic_ form--which latter means that the site of infection is not discovered--and also in a _virulent_ and _contagious_ type, which leads to the appearance of a number of cases over a large territory; it often appears in the _epidemic_ form. On account of the reddening of the skin it goes by the name of _the rose_ among the German laity. It may assume the type of an infectious dermatitis, subsiding without suppuration, or a similar lesion of exposed mucous membrane may be noted, or, occasionally, its virulence seeming greater, its lesions are met with in more deeply seated parts, accompanied by suppuration or even gangrene, and it is then called _phlegmonous_. In a small proportion of cases the infectious organism appears to be transported from one part of the body to another, and thus we have _metastatic_ expressions of this disease. The most common examples of this are seen in erysipelatous meningitis after erysipelas of the face or scalp, and erysipelatous peritonitis after the disease has manifested itself on the truncal surface. It is of a type which makes itself almost interchangeable with puerperal fever; and when epidemics of erysipelas have involved certain states or areas, it has been noted also that nearly every obstetrical case developed puerperal septicemia.

=Etiology.=--There is more than passing interest connected with this last statement. It is now definitely established that the infectious organism is a _streptococcus_ which is allied to, if not identical with, the streptococcus pyogenes, the ordinary pyogenic organism of this form. This specific organism has been separated, studied, and its role assigned by Fehleisen, and the organism is frequently called _Fehleisen’s coccus_. Preserving always its morphological characteristics, it acts, as do many other pathogenic organisms, within wide limits in virulence. Cultivated from some cases, it scarcely seems infectious, while from others it is fatal.

=Pathology.=--The disease manifests a tendency to travel _via lymphatic routes_. As long as it is confined to the skin and superficial tissues it has the appearance of an acute dermatitis. When it migrates deeper it generally leads to suppuration, another reason for believing that the streptococci of erysipelas and of pus production are the same. In the affected and infected area the minute lymphatics will be found crowded with the cocci, which are seen much less often in the small bloodvessels; also in the tissues beyond the apparently infected area they may be found dispersed less freely. The bacterial activity seems most active along the advancing border of the superficial lesion. Here the phenomena of hyperemia and phagocytosis are most active. Even in the vesicles that are characteristic of the disease the organisms may be found.

The _discharges_ from this region are _infectious_, and caution should be observed in dressing such cases. A finger pricked by a pin from a dressing may subject the individual to loss of life. The _dressings_ containing the discharges should be _burned_ immediately.

The path of infection is usually through a wound, and as soon as discovered a case of erysipelas should be separated from all surgical cases, or if the erysipelatous patient cannot be isolated, he should be removed from proximity of other wounded individuals.

Erysipelas which follows injury, however slight, is termed _traumatic_. The terms “idiopathic” or “spontaneous” should be restricted to those cases in which the path of infection is not discovered.

=Symptoms.=--With the exception of the local appearances, they are essentially the same in both of the above-mentioned forms. The characteristic feature of the disease is a _dermatitis_ with its peculiar _roseate_ hue, which it is impossible to describe in words. In tint it differs slightly from that noted in certain cases of erythema. It is, however, accompanied by an infiltration of the structures of the skin, so that the area which is reddened is at the same time elevated above the surrounding surface. Its edges are often irregular. As exudate takes the place of blood in the tissues, the red tint merges into a yellow. At this time there is more induration of the skin and tendency to pit on pressure. Vesication of this involved area is now frequent, the vesicles often coalescing and forming large blebs and bullæ, which fill with serum that may become discolored or purulent. When exposed to the air, unless the tissues become gangrenous, this serum usually evaporates and forms scabs. This disturbance of the skin is always followed after a number of days by desquamation. This infectious dermatitis shows a constant tendency to spread in all directions. Its most characteristic appearances are limited to the margin of the enlarging zone, while in its centre there may be evidences of recession of the disease. If it commences in the vicinity of a wound it will probably spread in all directions from it. Beginning in the face, it usually spreads upward; in the trunk, in all directions; if on the extremities it tends to migrate toward the trunk. _Wandering erysipelas_ is a term often applied to these phenomena. The _metastatic_ expressions of the disease have been described.

When this affection attacks a recent wound the local appearances are not essentially distinct from those mentioned under Septicemia. The wound margins separate to a greater or less extent, the surfaces slough, and a characteristic seropurulent discharge occurs. Granulating surfaces usually become glazed--often covered with a membrane resembling that of diphtheria; deep sloughs may occur, undermining of wound edges, even hemorrhages from destruction of vessel walls. In rare instances, however, under the influence of the microbic stimulation granulations proceed faster than normal.

Whether the disease proceeds from an injury or not, the _constitutional_ symptoms vary but little. There is usually a period of _malaise_ with _nausea_, followed by alimentary disturbance, coating of the tongue, elevation of _temperature_, sometimes with occurrence of _chill_. Complaint of pain or unpleasant sensation will lead to examination of the area involved, when the above symptoms will be noted, with evidences of _lymphangitis_ and enlargement of lymph nodes. When chill occurs it is followed by pyrexia. Temperature fluctuates, with a tendency to assume the remittent type. When the disease subsides spontaneously it is by a gradual process of betterment and subsidence of temperature. In other instances the constitutional symptoms assume more or less of the _septicemic_ or _typhoid_ type, and it is seen that the patient’s condition is practically one of mild septicemia, which often proves fatal.

When the disease assumes the _phlegmonous_ type the constitutional symptoms become more and more typhoidal and the septicemia becomes most pronounced. Locally exudation goes on to the point of threatening, even of actual, gangrene, unless tension is relieved by incisions. Pain is usually intense, partly because of confined exudates beneath resisting structures. More or less rapidly the local and constitutional signs of pus formation are noted, and unless these are observed and acted upon early there will not only be suppuration, but more or less actual gangrene, so that not only pus, but sloughs of tissue will be discharged through the incision, or will, when this is delayed, make their escape by death of overlying textures.

In all _phlegmonous_ cases there is practically coincidence of septicemia, already described, and of the local appearances above noted. In proportion to the extent of the lesion in these phlegmonous cases, and failure to afford relief, will be the opportunity for septic intoxication.

The mucous membrane does not always escape, and even in the nose, the pharynx, the vagina, and the rectum a distinctive erysipelatous lesion may be found. The disease may travel from the pharynx through the nose and involve the face, or through the Eustachian tube to the ear and thence to the scalp, or _vice versa_. _Erysipelatous laryngitis_ is to be feared on account of edema of the glottis, which would soon be fatal unless overcome by intubation or tracheotomy. An infectious exudation into the lungs is also known to follow erysipelas, and has been considered an _erysipelatous pneumonia_. The cellular tissue of the orbits may also be involved, when abscesses will occur, which should be opened early; the parotid and other salivary glands may become involved, usually in suppuration.

Many cases are accompanied by much _gastric irritation_, which it is difficult to explain. Ulcers are sometimes found in the intestines, as after burns. These usually give rise to bloody diarrhea. The cerebral symptoms may be simply those of delirium from irritation or of meningitis from infection. Strange phenomena have followed the disease in certain instances--cessation of neuralgic and of vague, unexplainable pain, improvement in deranged mental condition, spontaneous disappearance of tumors, etc. Advantage has been taken of this last in the treatment of these cases. (See Cancer.)

It is quite likely that some of the worst forms of phlegmonous erysipelas are due to _mixed infection_. To inject the bacillus prodigiosus together with the streptococcus of erysipelas will greatly enhance the virulence of the latter, so that reaction may proceed even to gangrene.

=Postmortem Appearances.=--These are not distinctive, but are a combination of local evidences of suppuration and gangrene, with the deterioration of the blood, the softening of the spleen, etc., which are characteristic of septic poisoning. Only in the skin, and then under microscopic examination, can any pathognomonic appearance be discovered. This will consist in the crowding of the lymphatic vessels and connective-tissue spaces with cocci, in the evidences of rapid cell proliferation, in the quantity of exudate, in vesication, sloughs, etc.

=Diagnosis.=--Diagnosis of erysipelas should be made mainly from various forms of erythema, from certain drug eruptions, and from other forms of septic infection which do not assume the clinical type of erysipelas. The gastric symptoms of this disease are sometimes produced by certain poisonous foods or the distress which is produced by medicines, such as quinine, antipyrine, etc.

=Prognosis.=--The majority of instances of idiopathic erysipelas run a certain limited course, although the eruption may spread to almost any distance upon the body. When the disease attacks surgical cases, and especially when it involves wound areas, the prognosis is not so good. When the disease assumes an _epidemic_ type and involves cases of all kinds, it will be found to have a _virulence_ that may make it a most serious affair. In proportion to the extent to which it assumes the phlegmonous type it will be found locally, if not generally, destructive. The ordinary case of facial erysipelas will recover with almost any treatment. Nevertheless meningitis may develop, and even a mild case is to be treated with care and caution.

=Treatment.=--Danger comes from two sources--_septic intoxication_ and _local phlegmons_ or gangrenous destruction. Each is therefore to be combated. Treatment should consist of isolation. There is _no specific internal treatment_ for this disease. Tincture of iron, which was long vaunted as such, has proved unsatisfactory, and is of benefit only as a supporting measure in a limited class of cases. _Constitutional_ measures should be employed: First, for the purpose of maintaining _free excretion_ by bowels and kidneys; second, for the purpose of _supporting_ and maintaining strength; third, for tonic and _stimulant_ measures in prostrated and debilitated patients; and, fourth, for the purpose of _combating intestinal sepsis or intoxication_ from any other source. The robust patients with this disease need no particular tonic. The aged, the enfeebled, the dissipated, the prostrated individuals, and the confirmed alcoholics are those who need vigorous stimulation,

## partly by alcohol and quinine, and partly by strychnine, preferably

given hypodermically, and by the other diffusible stimulants by which they may be kept alive. Pilocarpine, given subcutaneously and pushed to the physiological limit, has been praised by some. If along with prostration there occur restlessness and delirium, then anodynes and hypnotics are serviceable, and should be administered to meet the indication--morphine hypodermically and any of the agents which produce sleep are now most beneficial. Finally, if there is any drug which can be administered in doses sufficient to saturate the system with an antiseptic which shall at the same time not prove fatal because of toxicity, this is the ideal medicament for constitutional use only. Such a drug is not known, but it will be well to give some near approach to it internally, as by administering corrosive sublimate, salol, naphthalin, or something else of this character in doses as large as can be tolerated.

Should patients become violent it may be necessary to resort to _mechanical restraint_--a strait-jacket, a restraining sheet, a camisole, etc.

_Nourishment_ must be kept up by the administration of the easily assimilable and predigested foods.

_Locally_ the number of remedies that have been resorted to is legion. In a mild case of spontaneous erysipelas--_i. e._, where no infection can be traced--it will sometimes be sufficient to put on a soothing application, like a lead-and-opium wash. It often gives relief to have the part protected from air contact, which may be done by a soothing ointment or by dusting the part with a powder, such as bismuth oleate or subnitrate, zinc oxide, etc., these being rubbed up with powdered starch; or by a film of rubber tissue or of oiled silk. Brewers’ yeast applied on compresses and covered with oiled silk is efficacious.

Even before the bacterial origin of the disease was accepted it had been suggested to use _antiseptic applications_, either in watery solution or combined with oil or some unguent; this is now the ideal method of local treatment, the difficulty being only to find that which shall be efficacious as an antiseptic, yet not injurious in other ways. Compresses wrung in solutions of various antiseptics are often serviceable. The following preparation has given satisfaction: Resorcin (or naphthalin) 5, ichthyol 5, mercurial ointment 40, lanolin 50. The proportions of these ingredients may be varied, and the amount of ichthyol sometimes increased, especially when the skin is not too tender. The affected parts are anointed with this, and then covered with oiled silk or other impermeable material, simply to prevent its absorption by the dressings; the parts are then enveloped in a light dressing and bandaged. Credé’s silver ointment has also proved useful. As the disease becomes mitigated the ointment may be reduced with simple lard, and discontinued when local signs have disappeared. Absorption of any of these preparations may be hastened by scratches over the affected area with the sharp point of a knife.

Treatment of _threatening phlegmon_, or phlegmonous erysipelas, must be more radical, and consists of free incision down to the depth of the deepest tissues involved. In treating dissecting and other septic wounds of the fingers incision should be made to the tendon sheaths, even to the bone. It is only by such radical measures that worse disaster may be avoided. Some aggravated local cases are treated by a series of deep incisions with the use of the curette, the surface after careful clearing being kept buried under an antiseptic solution (silver lactate 1 to 500) or ointment.

RELATION OF LYMPH NODES AND GRANULATION TISSUE TO INFECTION.

In connection with erysipelas and the _role_ of the lymphatics, it is advisable to consider the relation and behavior of the lymph nodes and granulation tissue to infecting agents. Depending on the virulence of the infectious material, the site of infection, and the variety of the microbe will be its arrival in these protective filters. Then follows a series of cycles of maximum and minimum activity in the nodes, during the former the bacteria almost disappearing. The more pathogenic the microörganism the more certain the destruction of the lymph node, or perhaps of the individual. The well-known enlargement of the nodes is due almost solely to an increase in their lymphoid elements. Halban, who demonstrated these cyclic variations in the contents of the lymph nodes, is inclined to insist on an intimate relation between them and the temperature variations noted in cases of septic infection.

When _granulations_ are present the lymph sacs are closed, as by a sanitary cordon. Unless this tissue is broken they are proof against ordinary infection. It is well known that erysipelas will appear about an old wound or sinus that has been rudely probed. Even virulent organisms spread upon healthy granulating surfaces fail to infect. Strong carbolic and other toxic agents can be used in and about such granulating cavities with an exemption from poisoning that otherwise would produce dangerous effects.

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