Sepsis

“ Antisepsis.—Cleanliness and antisepsis should be observed in the management of abortion as strictly as in that of labor or in surgical operations, as sepsis, either in the form of acute infection or an insidious undermining of the constitution, is among the more frequent of the dangerous consequences which follow in the wake of abortion. Circumstances permitting, it is desirable that carbolated vaseline or vaseline with iodoform, carbolated or some similarly prepared soap, be on hand, and also permanganate of potassium, carbolic or boracic acid, and iodoform. ”

“ But all antiseptics have a slight irritant action which is disagreeable if there be an intact mucosa, although they may be more helpful in certain cases of ulceration or intranasal sepsis. When the Schneiderian membrane is more or less damaged, when there are foreign bodies, sloughs, necrosis, &c., in the nasal chambers, these or similar antiseptics can be employed, though always with an alkaline basis.
All nose lotions should be employed tepid. ”

“ As dessication proceeds the constitutional symptoms decline, the appetite returns, and the patient gains strength.
Complications.—Sepsis is the one generally to be expected, and this may assume any form from a local affection, such as a furuncle, to a general septicæmia. Furunculosis is frequent and is often annoying, and no sooner is one boil healed than others follow. Bed-sores are also frequent if proper care is not used to prevent them. ”

“ He also introduced the carbolic spray apparatus for disinfecting the air in the field of the operation, being at that time impressed with the belief that the air was a most important factor in the causation of sepsis, owing to the presence of germs in its dust. ”

“ When operating upon the eye, a surgeon has to face the great difficulty that he is operating in an area which is not always aseptic, since it is practically impossible to render the conjunctival sac sterile. At the same time, the conjunctiva has been shown to be sterile in health in 25% of cases, pyogenic organisms (principally the staphylococcus albus) being found only in 15%; but, although these are usually not of a very virulent character, they are by far the most frequent cause of sepsis; ten cases of suppuration after operation which the author has examined were all due to this organism. ”

“ Bacteria were known to exist but had not yet been accepted as a cause of disease. Antiseptic surgery was still in the future, and asepsis was not yet even an ideal to be sought. The occurrence of pus in wounds or as a result of surgery was looked upon as part of the process of healing, a necessary suppuration. ”

“ Mortality 50 to 80 per cent. Complications: mostly septic, abscess, gangrene of other organs, lungs, joints, glands, etc. Lesions: rapid sepsis, blood deep red, coagulum loose, venous congestion, large intestines congested, tumefied, softened, desquamated, eroded, sloughing, necrotic, folds perforated, cicatrizing, contents mucopurulent, bloody, putrid, microbes, glandular lesions, implication of small intestines, stomach mouth, liver, spleen, hepatic abscess. ”

“ As a matter of fact, however, one feels that in many of these cases the intercurrent pneumonia or infection—frequently of the bladder,—bedsores, sepsis, and the like, are merely accidental incidents in a condition that is leading to death, and which has caused a lowered resistance to infection. In certain instances where nursing is exceptionally good and where no such infection occurs, the patient continues to grow weaker and weaker, paralyses of all the muscles follow and finally paralysis of deglutition or 198respiration may lead to death. ”

“ The term _sepsis_ as now used in clinical surgery no longer retains its original meaning as synonymous with "putrefaction," but is employed to denote all conditions in which bacterial infection has taken place, and more particularly those in which pyogenic bacteria are present. In the same way the term _aseptic_ conveys the idea of freedom from all forms of bacteria, putrefactive or otherwise; and the term _antiseptic_ is used to denote a power of counteracting bacteria and their products. ”

“ It is true that to the Civil Surgeon accustomed to surroundings replete with every modern appliance and convenience, and the possibility of exercising the most stringent precautions against the introduction of sepsis from without, abdominal operations presented difficulties only faintly appreciated in advance ”

“ I am fully of the opinion that chemical antiseptics would be needless if absolute freedom from germs was easily obtained. When I know that even such an enthusiast as I myself is continually liable to forget or neglect some step in this direction, I feel that the additional security of chemical antisepsis is of great value. It is difficult to convince the majority of physicians, and even ourselves, that to touch a finger to a door knob, to an assistant's clothing, or to one's own body, may vitiate the entire operation by introducing one or two microbic germs into the wound. ”

“ The diffuse septic meningitis is the most discouraging intracranial complication that we have to deal with, and the diagnosis as a rule is not difficult. It usually is preceded by the serous form, but within a very short time develops the graver symptoms of sepsis. The most positive symptom is the spinal puncture. The fluid comes out under pressure, but not so great as in the serous form, and is turbid. The turbidity varies in degree with the amount of infection. It has the appearance at times of pure pus ”

“ Much stress has been laid upon the subject of asepsis and antisepsis. The foot is peculiar in that conditions surrounding it are especially congenial to the development and multiplication of bacteria. Modern surgery has been built upon the recognition of the rôle of bacteria in the behaviour of wounds, and the greatest hazard to successful surgery lies in the ever-present possibility of bacterial invasion. Surgical safety, however, can be secured by the employment of a perfect technic for asepsis. ”

“ Asepsis aims at thorough sterilization of the parts and of all the objects brought into contact with the wounds, and the exclusion of germs by the use of occlusive bandages and dressings.
Antisepsis is that method of wound treatment which keeps germicidal agents continuously in direct contact with the wound. Its object, therefore, is to produce asepsis. It is the duty of the surgeon to guard against the contact of microorganisms in the wound and to employ whatever means science has evolved for their destruction. ”

“ The usual faults in technique are a lack of cleanliness, resulting in sepsis, the use of too strong an antiseptic when cleaning the skin, over-heating of the lancet, needle or scarifier when purifying it, drawing too much blood, which washes away the lymph, exposure of the recently vaccinated area to the hot sun, and charring of the lymph in the capillary tube when sealing. All that is necessary is to clean the part to be vaccinated with soap and water, using a nail-brush, then rub the skin with alcohol, and when the latter dries proceed with the little operation. ”

“ The triumphs of antisepsis and asepsis, or keeping the "bugs" out of the cuts, have been illustrated scores of times already by abler pens, and are a household word, but certain of its practical appliances in the wounds and scratches and trifling injuries of every-day life are not yet so thoroughly familiar as they should be. When once we know who our wound-enemies are, whence they came, and how they are carried, the fate of the battle is practically in our own hands. ”

“ Who can compute the relief from suffering and the saving of life which may be traced through Lister to Pasteur's laboratory experiments on fermentation?
The recognition of the principle of asepsis by the surgeons was, then, as we have seen, slow and grudging enough; among the profession at large the theory of infection as applied to acute diseases gained more slowly still. It was not until 1880 that advance in the knowledge of the bacterial etiology of infectious diseases assumed such definite shape as to attract general attention. ”

“ This was particularly true prior to the [p149] development of antisepsis. Antiseptic techniques, of course, were based on discoveries by Lister, Pasteur, and others first announced in 1867, but were not generally accepted and employed until about the turn of the century. ”

“ But now a flareup had occurred. The Lancet brought in supplies of the antibiotic, and Tiger Martin spent two days showing Singallese physicians how to control further outbreaks with modern methods of immunization and antisepsis. ”

“ The symptoms of sapremia depend upon the amount of intoxication.
In septic infection, or septicemia, only a small number of organisms may get into the blood, but they multiply rapidly. A drop of blood from a man with septic infection will reproduce the disease when injected into the blood of an animal; hence it is a true infective disease. The wound in such a case is often small, and is commonly punctured or lacerated. ”

“ It is probable that these complications are all the result of septic infection and absorption, and since the modern antiseptic treatment of burns they have become much less common. The third period is prolonged until recovery takes place. Death may result from septic absorption, or from the wound becoming infected with some organism, as tetanus, erysipelas, &c. The prognosis depends chiefly on the extent of skin involved, death almost invariably resulting when one-third of the total area of the body is affected, however superficially. ”

“ Septicemia may be defined as an acute febrile affection, characterized by marked nervous, cutaneous and visceral manifestations, and due to the introduction into the system of bacteria and their toxins from an infected wound. It applies to diseases which present poisons in the blood that are of parasitic origin, the parasite itself being either present or absent in the blood. Septicemia, in strong contrast to the definition of toxemia, would include diseases arising from the invasion of the tissues and fluids of the body by animal or vegetable parasites or their poisonous products. ”

“ In sapremia the blood contains the toxins and dead saprophytic organisms. In septicemia the blood contains both pyogenic toxins and multiplying pyogenic organisms. In sapremia the causative condition is putrid material lodged like a foreign body in the tissues. In septic infection the tissues themselves are suppurating, and both bacteria [Pg 50] and toxins are absorbed by the lymphatics. Of course, septic infection may be associated with septic intoxication or may follow it. ”

“ The micro-organisms are conveyed by the blood-stream to different parts of the body, in which as in the original wound itself they both multiply and set up factories for the production of toxins. The disease commonly follows blows or wounds which have not been treated on surgical lines. Much laceration of the tissues at the time of the injury offers increased liability to infection. Septicaemia is frequent in spreading gangrene, in diseases of the periosteum, and in fevers such as scarlatina, diphtheria or plague, and in the puerperal state. ”

“ When the wound has become “ surgically clean ” recovery is usually rapid.
Septicaemia is an acute infective disease differing from sapraemia in that the micro-organisms themselves are absorbed, entering the general circulation, and may on examination be found in greater or lesser number in the blood-stream itself. The organism or organisms grow and reproduce themselves in the blood or tissues. A number of different organisms have been isolated from the blood-stream in cases of septicemia. ”

“ Pyæmia is closely allied to septicæmia. It is due to the setting free of bacterial emboli or septic emboli from a broken-down, septic thrombus in the neighborhood of the wound, and the circulation of these emboli in the blood until they are arrested and form the characteristic metastatic abscesses, especially in the lungs, joints, abdominal viscera, and parotid gland. Almost always the source of infection is an infected wound. Granulation does not prevent the occurrence of pyæmia, which, as a rule, commences at a later stage than septicæmia. ”

“ 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. ”

“ When the slough gives way the pus escapes and, tension being relieved, pain ceases. A local necrosis or death of tissue takes place at that part of the inflammatory swelling farthest from the healthy circulation. When the attack of septic inflammation is very acute, death of the tissue occurs en masse, as in the core of a boil or carbuncle. Sometimes, however, no such mass of dead tissue is to be observed, and all that escapes when the skin is lanced or gives way is the creamy pus. ”

“ In order that the treatment may be satisfactory, the abscess must be seen before it has opened. Then, except in very rare and peculiar cases, [6] there are no septic organisms in the contents, so that it is needless to introduce carbolic acid into the interior. Indeed, such a proceeding would be objectionable, as it would stimulate the pyogenic membrane to unnecessary suppuration. All that is necessary is to guard against the introduction of living atmospheric germs from without, at the same time that free opportunity is afforded for the escape of discharge from within. ”