Septicaemia, Pyaemia, and Septicopyaemia.
A thorough understanding of the conditions represented in the above title necessitates a more comprehensive and exhaustive consideration of certain etiological factors and pathological conditions than is possible in this work. It will suffice to say the terms septicaemia and pyaemia were originally used in connection with certain conditions of blood infection, the first when actual "putrid" matter (of unknown character) was supposed to be present in the blood, and the latter—pyaemia—when pus cells were floating in that fluid. Bacteraemia the better expresses the conditions as now known to exist, of bacteria in the blood. The conditions named in the title include all infections—those caused by bacteria, and those resulting from the influence of those toxines which are the products of the growth, nutrition and development of specific micro-organisms in distinct localities of the body, as the Klebs-Loeffter bacillus of diphtheria or the bacillus typhosus. Also those infections from auto intoxication caused by deficient and imperfect excretion, as uraemia, and the infections caused by the bites of poisonous insects and vermin and rabid and infected animals. Septicaemia comprehends systemic infection from various causes; the original infection is not always to be determined, and it is so often of a mixed character that its real nature is difficult of determination. The micro-organisms multiply, reproduce themselves in their progeny, and the processes of their growth and nutrition develop toxines, all of which, with other substances—products of chemical change in the normal body waste—retained, combine to produce the phenomena classed under this head.
Pyaemia in its present acceptance comprehends a focus of necrotic tissue, caused by the peculiar organisms of pus development with pus cells present in greater or less quantities. The location of the primary infection is usually the seat of the first abscess, but the pyogenic organisms are readily absorbed and metastatic abscess is the result. This condition is induced by impeded capillary circulation from the presence of a septic embolus, which acts as a focus of infection and tissue necrosis. These abscesses occur in the various organs, as the liver, spleen, kidneys, lungs, bronchial glands, lympathic glands, mammary glands, ovaries or testes, or even in the cortical substance of the brain. Abscess is common also in bones and deep muscles, in sub-cutaneous and sub-mucous tissues, and in the salivary glands.
The primary cause of pus production in pyaemia, is invasion by the staphylococcus and streptococcus directly, into cut, wound or abraded surface, but there are other microorganisms which cause the formation of pus. Among these are the pneumococcus, the gonococcus, the bacillus coli communis, and others of a distinctly specific character. General pus infection is apt to occur in cold weather, more often in males than in females, and in middle adult life.
Symptomatology:—The symptoms vary in septicaemia with the cause of the infection. The period of incubation may be very short if the infection is virulent, or it may last ten to fourteen days when the intoxication is from the products of germ development. There is malaise and headache, disordered digestion and perhaps nausea, vomiting and diarrhea, with perhaps dullness and tendency to sleep. The temperature usually increases rapidly, and with most cases symptoms closely resembling those of typhoid fever appear—suppressed secretions, dry, narrow, pointed, red tongue covered with a dark fur, dark mucous membranes, sordes and delirium, or the persistent, moderately high temperature of miliary tuberculosis, with irregular remissions. The fever in any case is continuous, the pulse is small and frequent, and evidences of blood changes are conspicuous. The spleen is tender and enlarged, and the skin discoloration, as well as that of the conjunctivae, suggests a mild form of jaundice. Septic nephritis, with scanty urine containing albumin and tube casts, or more or less complete suppression, is a common result of septic infection.
In pyaemia, from four to fourteen days after a wound becomes infected, there is a slight chill, unless the infection was virulent when it may be very severe. There may be only a primary chilliness which is accompanied by an irregular fever varying greatly in the character of its remissions.
It may be irregularly intermittent in character, with much variation in the periods of intermission, or it may be irregularly remittent, or it may be both intermittent and remittent, but usually there is no return to normal during the period of infection. During a marked remission the patient may sweat profusely and become quite weak; exhaustion, however, is not marked, except in protracted cases. It is difficult from the symptoms alone to distinguish between septic infection and malarial manifestations. There is anorexia with disordered stomach; malaise, increasing emaciation, some jaundice perhaps, and usually marked anaemia. In marked and protracted cases the face assumes a characteristic expression, sometimes called the septic facies.
After a few days evidences may appear of localization of the infection in some special organ. The lungs, spleen, liver or kidneys show signs of local inflammation. The lung symptoms are not so readily distinguished as are the signs of ordinary inflammation, but the liver and spleen may become enlarged, painful and tender, and the function of the kidneys may be materially interfered with, and albuminuria appears with epithelium tube casts and blood corpuscles, or direct evidences of pyelitis or pyelo-nephritis may be present.
The impression made by septic invasion upon the kidneys is sometimes most pronounced, resulting in retarded and deficient secretion, and occasionally, as after scarlet fever, diphtheria, typhoid fever, erysipelas, sapremia, and from septic infection after confinement, or after a miscarriage, there may be abrupt and immediate suppression of urine, more or less complete. In these cases, uremic symptoms arc apparent in addition to the other phenomena, and convulsions are not uncommon.
Marked gastric symptoms or gastro-enteritis frequently occurs with nausea, vomiting and persistent diarrhea, with large serous discharges. Persistent looseness of the bowels accompanies even mild cases.
>The form of toxemia known as ptomaine or tyrotoxicon poisoning (sepsis intestinalis), which occurs from eating canned meats, or sausage, or cold pressed meats which were pressed hot and cooled some hours previously, or from ice cream or cheese, develops usually without fever, but with prostration and a reduction of the temperature, cold skin, with often a marked chill, extreme gastric or gastrointestinal irritation and pain, persistent nausea, vomiting and diarrhea, which may increase, with mental dulness, weak, rapid pulse and failing heart, until death occurs. In some cases, after the initial chill, while the surface of the body and extremities continue cold, the internal temperature of the body rises rapidly to perhaps 103° or 104° F., and in fatal cases the final temperature may be extreme, 107° or 108° F.
In true sapremia the removal of the cause results in an immediate abatement of the symptoms. And those which have been induced by the condition yield rapidly to treatment.
In direct septic infection of the skin of the extremities, the point of infection becomes tender, painful, swollen, red and hot, and soon redness develops upward over the course of the lymphatics, with swelling and pain toward the body. Unless at once controlled and the advance of the infection retarded, constitutional symptoms of a violent character, with general lymphatic involvement, may occur.
There are cases of pus infection, in which the cause is not plainly apparent, and where foci of secondary infection do not quickly appear. In these a bacteriological examination of the blood discloses a general diffusion of the characteristic micro-organisms, and a post-mortem examination shows evidences of diffused infection in nearly every organ of the body, with but few if any purulent foci. With these there is persistent temperature, variable but not usually high, occasional chilliness, nausea, anorexia, progressive debility and emaciation, the characteristic hue, leucocytosis, extreme anemia and often jaundice.
Treatment:—In the treatment of septic poisoning the cause must be at once removed. Thorough cleansing and the use of antiseptics are all important. Existing abscesses should be opened and evacuated, and thoroughly irrigated and rendered aseptic. Local points of infection should be dressed with a saturated solution of boric acid or a strong carbolic acid solution on gauze and evaporation prevented by rubber protective or oiled silk. The skin over the lymphatics, reddened and inflamed, may be painted with tincture of iron.
In uterine or vaginal infection curetting and thorough antiseptic irrigation are practiced. In ptomaine poisoning there is usually complete evacuation of the stomach and bowels as a result of action of the poison.
Where marked depression is present in acute cases this must be combated by stimulants and heart tonics. Where chill and fever are the primary symptoms these must be positively met with the specific sedatives.
In sthenic cases elimination must be thorough and as persistent as is consistent with the vitality and strength of the patient. Pilocarpine at the onset of the fever is essential, but this agent cannot be continued. Where any cause of infection induces the slightest decrease of elimination by the kidneys I am heartily in favor of applying extreme heat to the limit of endurance over these organs, and persisting in that application unremittingly until the kidneys are increased in activity even beyond the normal point. I consider no measure more important than this. This sustains the blood pressure in the kidneys, prevents local septic development there, overcomes albuminuria, prevents and relieves uremic symptoms and stimulates the most essential elimination. When local pus infection is determined and general constitutional invasion is anticipated active alterative treatment should be given in conjunction with elimination. Remedies that directly inhibit pus formation are echinacea, calcium sulphide and the tincture of the chlorid of iron. The first is a truly excellent remedy in septic invasion of any organic character. It has produced really startling results in pyemia, restoring alone to health cases that were apparently beyond all aid. It destroys the pus micro-organisms within the blood, vitalizes that fluid and thence all the tissues of the body, stimulates the nervous system and thus encourages an improved action of the gastro-intestinal tract, encouraging an immediately improved nutrition. Its benefits are more widely diffused than any other single remedy we have at our command. It acts promptly and in a manner difficult to explain. There is at first an abatement of the progressive symptoms. Then improvement slowly appears and continues. The remedy should be given in septic cases in doses of from ten to forty minims every two hours, according to the severity of the symptoms. In cases of direct local infection the remedy in full strength should be applied to the part and even injected directly into the surrounding tissues. A proof of its virtue is in the fact that all who use it immediately become enthusiastic in its praise. This remedy should be given in uremic poisoning in all cases and as a constitutional remedy in puerperal convulsions. The calcium sulphide in doses of from one-twelfth to the one-fourth of a grain four or five times daily has been used freely for some years with satisfaction in certain cases of general infection. The tincture of iron is of value where the lymphatics are involved and also in cases of pus formation. Ten-drop doses every three or four hours are required. I have found it available in all cases where pus is found in the urine. Veratrum is a most active alterative. It may be given in the initial fever until there is some impression made upon the temperature, and then it may be continued in five-minim doses three or four times daily for its alterative effect, unless debility is marked. Phytolacca is indicated specifically wherever the glands or glandular organs are involved. It is an active alterative and restorative in addition to its influence upon the functional action of all glandular structure. It is given conjointly with other indicated remedies. Podophyllin may be given in very small doses with phytolacca and also whenever the liver and spleen are involved. It should not be permitted to irritate the gastro-intestinal tract. Berberis aquifolium is a remedy of value as auxiliary to other measures when the skin is involved and when pimples, pustules, bullae, vesicles or skin abscesses appear as, a result of the infection. This remedy is given to good advantage when so indicated with small doses of the carbonate of iron. Quinin should be given in toxaemia, when the temperature is not too high. It is a stimulant and tonic of much value. Strychnin or strychnin arsenate are valuable for regular administration. During a period of extreme weakness, exhaustion or threatened collapse hypodermoclysis with the normal salt solution should be resorted to. It is profoundly stimulating in its influence, but of no less importance is its influence in antagonizing the micro-organisms and their toxines in the blood, and in effecting their elimination. From one-half to two or more pints can be used, much care being exercised in its administration every day in extreme cases. When extreme distention of parts or extreme stretching of the integument has occurred over a mass of fluid injected and not rapidly diffused, there has followed strangulation, gangrene and sloughing. This must be avoided, as conditions in toxemic cases are more than usually favorable to such a result.
The feeding of these patients should be judiciously conducted, especially where the stomach and intestinal canal have been involved. Liquid foods, eggs, milk, gruels, bovinine and concentrated, easily absorbable preparations are indicated.
