Manual of Surgery by Alexis Thomson (golden son ebook .TXT) 📕

Fig. 13.—Chart of Pyæmia following on Acute Osteomyelitis.

Clinical Features.—Before antiseptic surgery was practised, pyæmia was a common complication of wounds. In the present day it is not only infinitely less common, but appears also to be of a less severe type. Its rarity and its mildness may be related as cause and effect, because it was formerly found that pyæmia contracted from a pyæmic patient was more virulent than that from other sources.

In contrast with sapræmia and septicæmia, pyæmia is late of developing, and it seldom begins within a week of the primary infection. The first sign is a feeling of chilliness, or a violent rigor lasting for perhaps half an hour, during which time the temperature rises to 103°, 104°, or 105° F. In the course of an hour it begins to fall again, and the patient breaks into a profuse sweat. The temperature may fall several degrees, but seldom reaches the normal. In a few days there is a second rigor with rise of temperature, and another remission, and such attacks may be repeated at diminishing intervals during the course of the illness (Figs. 12 and 13). The pulse is soft, and tends to remain abnormally rapid even when the temperature falls nearly to normal.

The face is flushed, and wears a drawn, anxious expression, and the eyes are bright. A characteristic sweetish odour, which has been compared to that of new-mown hay, can be detected in the breath and may pervade the patient. The appetite is lost; there may be sickness and vomiting and profuse diarrhœa; and the patient emaciates rapidly. The skin is continuously hot, and has often a peculiar pungent feel. Patches of erythema sometimes appear scattered over the body. The skin may assume a dull sallow or earthy hue, or a bright yellow icteric tint may appear. The conjunctivæ also may be yellow. In the latter stages of the disease the pulse becomes small and fluttering; the tongue becomes dry and brown; sordes collect on the teeth; and a low muttering form of delirium supervenes.

Secondary infection of the parotid gland frequently occurs, and gives rise to a suppurative parotitis. This condition is associated with severe pain, gradually extending from behind the angle of the jaw on to the face. There is also swelling over the gland, and eventually suppuration and sloughing of the gland tissue and overlying skin.

Secondary abscesses in the lymph glands, subcutaneous tissue, or joints are often so insidious and painless in their development that they are only discovered accidentally. When the abscess is evacuated, healing often takes place with remarkable rapidity, and with little impairment of function.

The general symptoms may be simulated by an attack of malaria.

Prognosis.—The prognosis in acute pyæmia is much less hopeless than it once was, a considerable proportion of the patients recovering. In acute cases the disease proves fatal in ten days or a fortnight, death being due to toxæmia. Chronic cases often run a long course, lasting for weeks or even months, and prove fatal from exhaustion and waxy disease following on prolonged suppuration.

Treatment.—In such conditions as compound fractures and severe lacerated wounds, much can be done to avert the conditions which lead to pyæmia, by applying a Bier's constricting bandage as soon as there is evidence of infection having taken place, or even if there is reason to suspect that the wound is not aseptic.

If sepsis is already established, and evidence of general infection is present, the wound should be opened up sufficiently to admit of thorough disinfection and drainage, and the constricting bandage applied to aid the defensive processes going on in the tissues. If these measures fail, amputation of the limb may be the only means of preventing further dissemination of infective material from the primary source of infection.

Attempts have been made to interrupt the channel along which the infective emboli spread, by ligating or resecting the main vein of the affected part, but this is seldom feasible except in the case of the internal jugular vein for infection of the transverse sinus.

Secondary abscesses must be aspirated or opened and drained whenever possible.

The general treatment is conducted on the same lines as on other forms of pyogenic infection.

The process of ulceration may be defined as the molecular or cellular death of tissue taking place on a free surface. It is essentially of the same nature as the process of suppuration, only that the purulent discharge, instead of collecting in a closed cavity and forming an abscess, at once escapes on the surface.

An ulcer is an open wound or sore in which there are present certain conditions tending to prevent it undergoing the natural process of repair. Of these, one of the most important is the presence of pathogenic bacteria, which by their action not only prevent healing, but so irritate and destroy the tissues as to lead to an actual increase in the size of the sore. Interference with the nutrition of a part by œdema or chronic venous congestion may impede healing; as may also induration of the surrounding area, by preventing the contraction which is such an important factor in repair. Defective innervation, such as occurs in injuries and diseases of the spinal cord, also plays an important part in delaying repair. In certain constitutional conditions, too—for example, Bright's disease, diabetes, or syphilis—the vitiated state of the tissues is an impediment to repair. Mechanical causes, such as unsuitable dressings or ill-fitting appliances, may also act in the same direction.

Clinical Examination of an Ulcer.—In examining any ulcer, we observe—(1) Its base or floor, noting the presence or absence of granulations, their disposition, size, colour, vascularity, and whether they are depressed or elevated in relation to the surrounding parts. (2) The discharge as to quantity, consistence, colour, composition, and odour. (3) The edges, noting particularly whether or not the marginal epithelium is attempting to grow over the surface; also their shape, regularity, thickness, and whether undermined or overlapping, everted or depressed. (4) The surrounding tissues, as to whether they are congested, œdematous, inflamed, indurated, or otherwise. (5) Whether or not there is pain or tenderness in the raw surface or its surroundings. (6) The part of the body on which it occurs, because certain ulcers have special seats of election—for example, the varicose ulcer in the lower third of the leg, the perforating ulcer on the sole of the foot, and so on.

The Healing Sore.—If a portion of skin be excised aseptically, and no attempt made to close the wound, the raw surface left is soon covered over with a layer of coagulated blood and lymph. In the course of a few days this is replaced by the growth of granulations, which are of uniform size, of a pinkish-red colour, and moist with a slight serous exudate containing a few dead leucocytes. They grow until they reach the level of the surrounding skin, and so fill the gap with a fine velvety mass of granulation tissue. At the edges, the young epithelium may be seen spreading in over the granulations as a fine bluish-white pellicle, which gradually covers the sore, becoming paler in colour as it thickens, and eventually forming the smooth, non-vascular covering of the cicatrix. There is no pain, and the surrounding parts are healthy.

This may be used as a type with which to compare the ulcers seen at the bedside, so that we may determine how far, and in what particulars, these differ from the type; and that we may in addition recognise the conditions that have to be counteracted before the characters of the typical healing sore are assumed.

For purposes of contrast we may indicate the characters of an open sore in which bacterial infection with pathogenic bacteria has taken place. The