Sepsis
SEPSIS (Gr. (riji/as, putrefaction), or SEPTIC INFECTION, a term applied in medicine and surgery to indicate the resultant infection of a wound or sore by micro-organisms or by their products. Under this general heading come three great constitutional diseases, differing radically from each other in their aetiology and pathology: sapraemia, septicaemia and pyaemia.
Sapraemia (Gr. <rairp6s, rotten, afyio, blood), or septic intoxication, is the result of the absorption of a dose of the toxins produced by micro-organisms from some area of infection without the entrance of the micro-organisms themselves into the blood. This condition was for a long time confounded with septicaemia, but is distinguished from it in being a chemical intoxication. The blood in sapraemia if injected into an animal is incapable of reproducing the disease as in septicaemia. Any condition in which there is a mass of decomposing tissue in the neighbourhood of an unhealed wound may give rise to sapraemia. In surgical practice it may be met with in.large, deep and badlydrained wounds where a quantity of putrifying material is pent up. When it arises in connexion with wounds accidentally received, it may be unavoidably due to the dirty state of the skin or to foreign bodies entering the wound. Absorption of toxins is notably frequent in portions of decomposing placental tissue which may accidentally have remained behind in the uterus after childbirth, and may give rise to puerperal sapraemia. Sapraemia is acute or subacute directly according to the amount of toxin absorbed. By some writers it is divided as follows: (i) Hectic fever is a chronic blood poisoning with continual absorption of small doses of the toxins. This variety usually arises in long-continued suppuration of bones and joints, and in decomposition occurring in a pulmonary cavity. The marked symptom is a sharp rise of temperature in the evenings; the face becomes flushed and the pulse rapid. After profuse sweating the temperature drops. Diarrhoea and wasting are a usual accompaniment. (2) Septic traumatic fever is a slight form which may follow burns or compound fractures and which tends to subside in a few days. (3) In acute septic intoxication large amounts of the poison are absorbed. It generally starts with a severe rigor followed by a continuous high temperature, dry tongue, rapid pulse and severe headache, together with nausea and vomiting, and in the later stages diarrhoea. If the case be a severe one rapid prostration speedily conies on with low muttering delirium, the temperature may fall to subnormal, and a gradually deepening coma may end in death; other cases pass into a typically " typhoid state," death occurring from exhaustion at the end of about a week. (4) Amyloid (Gr. a.nv\ov, starch, tl&os, form), or lardaceous disease, usually of the liver, spleen, kidneys or other organs, is one of the results of long-continued septic intoxication. A substance derived from the breaking down of pus and tissue cells is carried in the blood and deposited in the connective tissue of the coats of the smaller arteries, and the viscera become infiltrated with a material looking like lard. The liver and spleen, being the organs most usually affected, become immensely enlarged.
No form of septic infection yields so easily to treatment as sapraemia. The prompt removal of the cause of septic absorption, the flushing out of the wound with weak antiseptic solutions, in order to mechanically remove any decomposing masses, and the establishment of proper drainage in deep wounds, is usually followed by a fall in temperature and an improvement in the general condition. A strong, preferably mercurial, purgative should be given to aid in the elimination of toxic material. For the same purpose the injection into the veins or into the cellular tissue of large quantities of normal saline solution is useful. Heart depression should be overcome by diffusible stimulants and hypodermic injections of strychnine. 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 septicaemia. The most frequently found is the Streptococcus pyogenes, which is present in 50% of the cases and is common in puerperal septicaemia and in ulcerative endocarditis. The Stapttylococcus Pyogenes aureus et albus is also a frequent cause, but sometimes septicaemia may be due to other pathogenic microbes such as the Pneumococcus, the Bacillus coli communis, Bacillus pyocyaneus. Bacillus oedematis maligni and the Gonococcus. 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. The period of incubation may be from a few hours to several days. The condition of the wound or site of injury shows marked changes. In severe cases following a prick received in conducting a post-mortem the finger in a few hours becomes greatly swollen and painful, the pain spreading up the lymphatic vessels to the nearest lymphatic glands, which may become enlarged, and sloughing or gangrene of the parts involved may take place. In milder cases the wound remains with reddened and oedematous margins in a more or less unhealthy state. In mild cases of septicaemia the local condition of the wound, high temperature and feeling of illness are the distinguishing features. The treatment of septicaemia may be preventive or active. The preventive side consists in the performance of operations with all due aseptic precautions. Since the days when I. P. Semmelweiss (q.v.) of Vienna insisted on cleanliness in his maternity wards, the death-rate of puerperal septicaemia has been enormously reduced. In the British registrar-general's returns for 1868 it was stated that in twenty-two years no less than 23,689 women in England and Wales had died of puerperal septic diseases. In the reports of the Rotunda Hospital, Dublin, the largest maternity hospital in the United Kingdom, we ascertain that of 30,023 women delivered during the ten years 1894- 1903 there was only a mortality of 21 due to sepsis, a ratio of 0-066%, while the registrar-general's returns for England and Ireland for the period have a ratio for sepsis' of 0-216%. When dealing with a wound that is already septic, free incision and swabbing the surface with pure carbolic acid may have to be resorted to, and constitutional treatment must be undertaken at once. Should the infection be due to a Streptococcus, an antistreptococcic serum may be injected. There are, however, many strains of Streptococci, and a polyvalent serum may give good results. Menzer's antistreptococcic serum has been successful in puerperal septicaemia not of gonococcic origin. Many cases have also now been recorded in which the systemic infection is combated by means of an autogenous vaccine. The first case was described by Sir James Barr before the Liverpool Medical Institute in May 1906. In urgent cases, where time will not allow of the manufacture of a vaccine, quinine in large doses, stimulants and liquid nourishment must be given, and the temperature controlled by tepid sponging.
Pyaemia (Gr. irvov, pus, at/m, blood), which got its name from an erroneous idea that the pus passed into the blood, is now understood to mean an acute disease with the formation of metastatic abscesses. The first definite account of the disease was published by Boerhaave in 1720. Virchow in 1846 pointed out that it was not pus in the veins, but altered blood-clot. Jean D'Arcet showed the separate processes of poisoning by products of decomposition and the blocking of the veins with emboli. Any pyogenic organism may give rise to pyaemia, or it may follow any acute abscess. The cause of pyaemia may be said to be any condition favouring the formation of emboli. An occasional cause of pyaemia is infective endocarditis, while puerperal pyaemia may arise from infection of the genital tract. When the emboli lodge in the lung there is a breaking down of the tissue in front of the embolus, a haemorrhagic infarct being formed. The clinical symptoms of acute pyaemia generally start with a rigor repeated at periodic intervals; the skin 'becomes hot and the patient soon develops an earthy colour, the pulse becomes frequent and weak and the tongue dry. In about a week secondary abscesses appear, most frequently in the region of joints. There may be little or no pain to herald the formation of an abscess, but usually there is intense pain followed by suppuration. Unless early treatment is undertaken the joint may be rapidly destroyed. In acute cases multiple abscesses in the kidney may give rise to pain and albuminuria, abscesses in the lungs to dyspnoea, while acute peritonitis may arise from rupture of a splenic abscess into the peritoneal cavity, and sudden blindness be the result of the plugging of the arteria centralis retinae. The duration of a case of pyaemia depends on the severity of the infection. Death may occur from the formation of abscesses in vital organs such as the brain and heart, or from exhaustion from continued suppuration, or chronic forms may after months pass on to complete recovery. Unfortunately pyaemia cannot be recognized apart from other blood infections until abscesses begin to form. The local treatment is to endeavour to prevent the detachment of infected emboli and the infection of the general blood-stream thereby. An infected limb may be dealt with by amputation above the seat of the lesion, or it may be feasible to dissect out the infected veins. When abscesses have formed they must be dealt with by opening and washing out the cavities. Antistreptococcic serum may be tried, as in septicaemia; and if there be time to prepare a vaccine it offers the best prospects, more particularly in the subacute and chronic forms of pyaemia. The usual administration of nourishing diet and stimulants when required should be undertaken, and every effort made to keep up the patient's strength.
REFERENCES. Watson Cheyne in Clifford Albutt's System of Medicine (1906) ; Horder in the Practitioner (May 1908) ; Spencer and Cask's System of Surgery (1910); Barr, Bell and Douglas, Lancet (Feb. 1907); H. Jellett, Manual of Midwifery (1905); Whyte in Edinburgh Medical Journal (Dec. 1907); Sir A. Wright in the Lancet (Nov. 1907) ; Whitridge Williams in American Journal of Obstetrics (May 1909) ; R. Park, The Principles of Surgery (1908) ; George Taylor in the Practitioner (March 1910). (H. L. H.)
Note - this article incorporates content from Encyclopaedia Britannica, Eleventh Edition, (1910-1911)
