Читать книгу Surgery, with Special Reference to Podiatry - Maximilian Stern - Страница 20

Table of Contents

Toxemia applies to the diseases in which one or more poisons are present in the blood which are not necessarily of parasitic origin and production.

The word poisons is here used in a broad sense to cover any substance applied to the body, ingested, or developed within the body which causes disease. It of course includes ptomains, leukomains, toxins and sepsins.

Toxemia, according to this definition, would include the diseases due to poisons not arising from parasitic invasion of the tissues and fluids of the body, at times of vegetable and alkaloidal nature, such as strychnine or morphine; of animal origin, such as the toxin of snake venom, the ptomains of milk or shell fish; then again a mineral such as arsenic or lead; and lastly the leukomains arising from disturbed excretion and perverted metabolism and grouped under such terms as intestinal or uremic poisoning.

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.

Symptoms. The onset, as a rule, is slow, beginning from 4 to 7 days after an injury, with a chill, which is followed by fever, at first moderate, but soon becoming high. The fever presents morning remissions and evening exacerbations and may occasionally show an intermission. When the remission begins, there is a copious sweat. The pulse is small, weak, very frequent, and compressible; the tongue is dry and brown with a red tip; the vomiting is frequent, and diarrhea is the rule; delirium alternates with stupor, and coma is usual before death; prostration is very great, and visceral congestion occurs; the spleen is enlarged, ecchymoses and petechiae are noted, secretions dry up, urinary secretion is scanty or is suppressed, and the wound becomes dry and brown.

Blood examination detects disintegration of red globules and marked leukocytosis. When a wound becomes septic, red lines of lymphangitis are seen about it and there is enlargement of the related lymphatic glands. No thrombi or emboli exist in septicemia. The prognosis is bad, and in some malignant cases death occurs within 24 hours.

Treatment is the same as for septic intoxication (see “sapremia”). Antistreptococci serum can be used, but the value of this method is doubtful.

Sapremia may be defined as an intoxication due to the absorption of dead saprophytes and their products (ptomains and toxalbumins).

Symptoms. The disease sometimes begins with a chill, followed by a marked rise in the temperature, but in most cases the latter is the first evidence of the disease. The skin becomes cold and clammy, there is marked prostration and sometimes diarrhea. When these manifestations occur while a wound is present, they are ominous, and the dangerous complications can be avoided if the dressing of the wound is renewed and perfect antiseptic precautions are taken to thoroughly remove all septic matter from its surface. The constitutional symptoms often disappear of their own accord, when the above has been done, unless the systemic intoxication has not already advanced to thwart all endeavors. There is also a diminution or suppression of the urine, and a blood examination shows leukocytosis.

Treatment. The treatment is at once to drain and asepticize the putrid area and to give large amounts of alcohol. Strychnine and digitalis are useful. Purge the patient, and favor diaphoresis, using in some cases the hot bath. Establish the action of the kidneys; allay vomiting by champagne, cracked ice, calomel, cocain or bismuth. Give liquid food every three hours. Feed on milk, milk and lime water, liquid beef, peptonoids, and other concentrated foods. Use quinine in stimulant doses. Antipyretics are useless. Watch for visceral congestion and treat it at once.

The use of saline fluid by hypodermoclysis or by venous infusion dilutes the poison and stimulates the heart, skin, and kidneys to activity.

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 and toxins are absorbed by the lymphatics. Of course, septic infection may be associated with septic intoxication or may follow it. 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.

Pyemia may be defined as a condition in which metastatic abscesses arise as a result of the existence of pyogenic bacteria in the circulating blood, either free or contained in pus cells or thrombi.

Symptoms. The symptoms of pyemia are a febrile movement with a severe chill and a sudden marked rise in the temperature which lasts for a few hours and passes off with profuse sweating. The chills recur every other day, every day, or oftener. The general symptoms of vomiting, wasting, etc., resemble those of septicemia.

The lodgment of emboli produces symptoms whose nature depends upon the organ involved. If in the lungs, there is shortness of breath and cough, with slight physical signs.

In a suspected case of pyemia, always look for a wound, and if this does not exist, remember that the infection may arise from an osteomyelitis.

Chronic pyemia may last for months; acute pyemia may prove fatal in a few days.

Treatment. The treatment is the usual supporting one that should be employed in septic affections, and all suppurating focci must be opened and drained as soon as detected. Every branch of the irregular cavities must be opened and drained at the most dependent part, and the sinuses must be treated to prevent pocketing. Serum therapy is also indicated.