when present in sufficient amount, or when sufficiently virulent, manifest their action by the production of fever and other disturbances of the general condition. They may be living micro-organisms which are capable of multiplying in the blood, or they may be chemical substances which are produced by the bacteria or by the local inflammatory or degenerative process. Ordinarily the term is not used in such general sense, but only to denote the constitutional disturbances which result from the absorption of injurious substances from wounds, and as before mentioned, the condition so produced was, or perhaps is, divided into two groups, septicemia and pyemia. The onset in some cases is insidious, and in some it seems to completely overwhelm the patient at once and to render him septically intoxicated from the start. Before the advent of aseptic surgery it was the thing expected, and should a major operation be made, such as the amputation of a leg or arm, the temperature, the slough, the delirium more or less marked, were always conditions expected; but happily for us to-day, with our great advance in surgical procedures, septic complications following surgical measures are rarely or never seen. So it is not this class of cases that furnishes us our work in blood-poisoning. The cases seen to-day are generally the result of neglect following some trivial injury, and it is to this class that I especially desire to call your attention to-day. What do we first learn in these cases? A number of days previous to seeing the patient, this person sustained a slight injury as crushing of the end of the finger, an incision into the hand or foot made by some foul-cutting tool, neglect of a whitlow, etc., etc., and up to the time first seen (sometimes ten days or two weeks), no care whatever has been given the injured member, and, consequently, we are at first confronted with an enormously swollen hand or foot, with deep pus formation and more or less general disturbance. This is frequently the condition in which we find our patients, and instead of having a trivial injury to deal with (as) it probably was at first), we are confronted with a great battle, and one not only for the saving of the afflicted leg or arm, but one for the life of the patient. This, I believe, is a true picture of the majority of cases as presented to the surgeon. Now what is to be done in the care of these cases? The parts are first thoroughly cleaned by the use of antiseptic washes, and then an attempt is made to completely open all pus-forming cavities and to keep these wounds in as pure a condition as possible. We will always find in these cases of from ten days to two weeks' duration without proper care, that the pus cavities are deep, away down in the bellied portion of the limb, and the drainage of these places is unavoidably made difficult. There is but one thing to do and that is to make free incision from the start. No incision can be made too long, and the trouble that does arise comes from the limited way in which we are apt to use the knife. If the seat of trouble is in the finger, hand or arms, the incisions should reach from far in front to far behind the affected region, and should be as deep as is needed. With this beginning there will be but little trouble further in the case, except its care. But there are cases that seem to baffle everything that is attempted, and with these there seems to be no limit except amputation and as a rule that generally comes too late. These are some of the many things that try the souls and better judgment of surgeons, for, as before stated, it may not be the loss of a limb only, but in fact the loss of a life. In the care of these patients there is one thing that I have especially observed, and that is that this dread disease seems to spend all its force on the tendons of the muscles, and the course of these tendons forms the channels along which the disease travels. If in the early care of the case the incision made is free enough to permit the removal of the already diseased tendon, the course of the disease is at once cut short; but should conservative treatment be continued until the tendons of the afflicted region are well complicated, nothing short of their entire removal will be of any value, and this may be too late. It may be said by some that all of this work need not be done, as cases of recovery are known where in fact very little if anything was ever attempted. But it is known also that the post-mortem room reveals case after case of arrested tubercular invasion, and it could with as much correctness be said that these tubercular patients did not need and demand climatic changes, simply because some cases failed to pursue their almost never deviating course, as to say that blood-poisoning needs no surgical interference because some had recovered without the use of the scalpel. I have seen a number of advanced cases that threatened the destruction of the entire hand and arm, where after free incision and complete removal of all complicated tendons, the progress of the disease would be at once arrested and the patient make a safe and speedy recovery. I have every reason to believe from my own experience in these cases, that where the patient is seen early, the prognosis ought to be good, provided there are no complicating conditions such as alcoholism, organic heart lesion or any other advanced organic affection. It is not uncommon for the course of the disease to be long and varied, and the patient in every case of long duration, is greatly reduced. In these cases of neglect, delirium of from two or three days to two or three weeks is not at all uncommon, but this is due to nothing but a condition of profound septic intoxication. This period of marked delirium is often one of great trial to the surgeon, for unless the patient is kept under constant observation, you may be called to dress the affected limb from two to four or more times a day. Nearly every case will annoy you more or less in this respect, and I recall one case that especially annoyed me. With this patient the initial lesion was on the dorsum of the hand, the disease rapidly spreading until the whole forearm was involved. The dressing of this case was no small task at any time, but the second or third day after the appearance of the delirium the patient was determined to tear off the dressings. To stop this, the other hand was placed in splint and bandage, and with this precaution the dressings of the injured arm would be entirely removed if the patient were left alone but a few moments. It was found that he did this with his knees and teeth, and so to block it all, he was placed in a straight jacket suit. This is cited only to show some of the difficulties attending these cases. While the mortality of this disease, statistically given, is very high, yet in all the cases with which I have been associated (some forty), there has been but one death, and as this case was a typical one of blood-poisoning, showing the complications that sometimes confront us, I desire to conclude my paper by giving a brief history of the case. Victor P., Co. A, 15th Ohio Vol. Infantry; age 58; admitted to hospital, May 16, 1896. April 27, 1896, patient became intoxicated, for which he was sent to guard-house. His cell-mate for the night was a negro of not a very loving disposition and in the night sometime they got into a fight and in some way the negro got the patient's thumb in his mouth and chewed it badly. The wound received no care of the proper kind until ten days after, when the patient applied for treatment. At this time he claimed that his thumb was mashed by machinery and it was weeks before the true nature was known. May 6, 1896. Entire thumb very much swollen and painful with bad smelling discharge; wound gave evidence of extensive contusion. Complained of rigors. Slight elevation of temperature. The wound was thoroughly cleansed and given an iodoform dressing for a few times. May 10. A free incision was made along the palmar surface from the phalangeal articulation to within three-fourths of an inch of the carpo-metacarpal articulation. Pieces of sloughing tendons were removed and hot applications applied with directions to change as often as necessary. Following this treatment the swelling was greatly reduced, although the tendons continued to slough. At each dressing these sloughing tendons were removed. May 15. A free incision was made along the dorsum of thumb extending to the carpal joint. Suppuration continued and broken-down tendons found and removed at each dressing. May 25. Inflammation apparently broke out afresh, passing up into wrist. Incision made and drainage well established by tubes. Carbolized solution 1 to 25 used at each dressing. Wound dressed with bichlorid gauze. June 10. Inflammation has now extended to middle of forearm. Incision was now made to point beyond and all pieces of sloughing tendon and broken-down tissue removed. Wound dressed twice each day with bichlorid dressings throughout. Patient as yet shows no signs of septic intoxication, but is gradually losing flesh and strength. Supportive and stimulating treatment as required. June 25. The entire anterior region of forearm is involved with great swelling above elbow. Incision extended to elbow. All tissues that can be found in broken-down condition removed and wound dressed as before. July 5. Swelling of upper arm entirely disappeared with but very slight swelling of fore arm. Very free drainage of purulent matter, and deep pockets in bellied portion of fore arm found and thoroughly opened. Patient has complained of but little pain since the fore arm was first invaded. July 20. Patient gradually losing flesh and strength. Temperature normal except when new areas are invaded. Dressing has become difficult on account of pus burrowing in back of the muscles, making it difficult to wash out. No general septic condition. Appetite poor. Large quan tities of milk and egg-nog taken at regular intervals. Sleeps well. July 28. Some swelling on posterior portion of arm. No chill' or elevation of temperature. August 2. More swelling with slight fever. Incision on back of forearm, extending from wrist to uper third. Pus excavated and long pieces of sloughing tendon removed. Severe chill and wild delirium followed dressing. August 3. Patient in a semi-comatose condition. Pulse 115 and temperature 102° F. Incision extended upward nearly to elbow. Thorough irrigation of arm both anterior and posterior.. Wound dressed as before. Case continues from bad to worse. Patient prepared for amputation as a last resort, although evidently too late, but could not have been done previously on account of opposition on the part of the patient. At 2 p. m. patient placed on table. Respiration 26, pulse 115, temperature 101° F. Semicomatose condition. Anesthesia quickly produced; in fact I doubt whether it was needed. Amputation at lower third arm, using the modified circular method. Vessels ligated and wound closed with drainage. Forty minutes occupied in operating room. Condition very bad, artificial heat, strychnine and all effort accomplished but little. Died at 9:40 p. m. Hospital and Clinical Reports. SYNOPSIS OF FIFTY-SIX CASES OF EMPYEMA BY B. SCHARLAU, M. D., NEW YORK. Read before the American Pediatric Society, Washington, May 4, 1897.. The proper treatment of empyema is still open to discussion, and the views differ widely; therefore I thought it timely to bring before you a comparatively large number of cases, all treated within one year in the same hospital after a uniform plan: namely, pri-mary exsection of a rib in every case. |