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minute sloughs, which, if observed under the microscope, are found
to be undergoing a granular disintegration preparatory to absorp-
tion.

In a section taken from a wound in the abdominal wall the
wound was found to have united, but beneath the surface of one
of the lips was seen a granular mass of material which represented
a dead portion of the skin about to be absorbed. Such changes
are seen on a larger scale in very extensive wounds, such as ampu-
tation at the hip-joint, or in crushed wounds which have been
thoroughly disinfected and are healing well. In both these cases
the amount of disintegration with injury in the cellular tissue, the
integuments, and even the muscles, must be considerable. Let us
see what the effect of the introduction of such substances into the
circulation has been shown to be by experiment.

The chemistry of coagulation has already been alluded to, and
the reader is aware of the process by which fibrin is formed.
Occasionally small quantities of fibrin-ferment are liberated in the
circulating blood by the breaking down of cells, but the vessels
appear able to dispose of it and to prevent any coagulating action.
When, however, this ferment is introduced into the circulation in
any considerable quantity, remarkable results are found from its
action. The fluid part of coagulated blood, if introduced into the
circulation of an animal, will bring about a very pronounced and
extensive coagulation.
21



322 SURGICAL PATHOLOGY AND THERAPEUTICS.

From 10 to 12 cc. of blood are taken from a rabbit and allowed to coagu-
late into a solid cake : the fluid being pressed out and filtered, 5 to 6 cc. are
then carefully injected into the jugular vein of the same animal. Immediately
there occur opisthotonos, dilatation of the pupils, dyspnoea, etc., the symp-
toms of fatal pulmonary embolism. On examination the right heart is found
full of tough clot, although still beating, and the ramifications of the pul-
monary artery are distended with a red thrombus. The left heart has small-
sized clots, but the blood in the remaining vessels is strikingly hard and
slow to coagulate. Solutions of blood-corpuscles in ether and solution of
haemoglobin have also produced similar results. Other observers have also
recorded a rise of temperature from the injection of defibrinated blood.

The same group of symptoms was also produced by watery
extracts of pulverized blood freed from its ferment, which was
accounted for by assuming that ferment was developed in the
blood. The rise of temperature produced by the injection of water
was explained in the same way. Solutions of carbolic acid were
found at times to weaken, and at times to increase, the action of
the ferment, particularly when strong.

Indeed, quite a variety of substances of ferment-like nature,
such as pepsin and pancreatin, are pyrogenic in their action quite
independently of any bacterial infection. The breaking down and
absorption of the blood-clot or coagulated serum caught between
the apposed surfaces of a wound or surrounding the ends of a frac-
tured bone, or in a large haematoma, must therefore necessarily
liberate pyrogenous substances which are readily absorbed. The
same may be said of other cell-structures, as connective tissue or
muscle. With the disintegration of bruised masses of tissue like
these, either as the result of direct injury or from the cutting off
of the circulation, there is liberated not only fibrin-ferment, but
doubtless also other substances slightly altered from their original
composition during life, which substances, when absorbed, produce
a rise of temperature. Their close relationship to living substances
renders them less intolerant to the system than the more virulent
substances manufactured by bacterial action; consequently we fail
to observe many of the more disagreeable symptoms of fever.
These homologous substances appear to have the power to act upon
the thermic centres, but to cause little other disturbance in the
economy.

When a large wound heals with a minimum amount of fever, as
in the amputation of the breast above alluded to, the adjustment
of the wound has been so perfect that no blood-clot forms between
its lips: the incisions have been cleanly cut with the knife, and
no fragments remain behind to be absorbed. The effusion of



SURGICAL FEVERS. 323

serum that always occurs in greater or lesser quantity is either
checked by the firm pressure of the dressings or is conducted off
immediately through the drainage-tubes. Many compound frac-
tures which have been thoroughly cleaned of clot and properly
drained heal without rise of temperature, while a simple fracture
may show a fever-curve of several days' duration.

There are, however, many slight disturbances which, occurring
during the healing process of a wound dressed with aseptic precau-
tions, cause a rise of temperature, and which should not be over-
looked. Great tension of the lips of the wound may cause ulcera-
tion about the stitch-holes. Minute quantities of micrococci may
be found in the secretions accumulating at such spots. The micro-
cocci are insufficient in numbers, or they are so enfeebled by the
antiseptics with which they come in contact as to have the power
to cause putrefactive action, but they may be able to liberate a fer-
ment capable of producing a rise of temperature. Collections of
fluid may be caused by imperfect drainage, which collections,
although aseptic, are still pyrogenous.

Finally, it must not be forgotten that the powerful antiseptic
agents employed are potent for evil as well as for good. The
poisonous action of carbolic acid and of iodoform is now well rec-
ognized, but undoubtedly many a fatal case of poisoning by these
agents has been mistaken for septic infection. The rise of tem-
perature and the digestive disturbance, with the presence of pro-
nounced nervous symptoms, produced by carbolic-acid absorption
caused the writer to be summoned in haste to a supposed case of
blood-poisoning. The dark color of the urine gave at once a clue
to the diagnosis. Delirium accompanying an unusual amount of
inflammation after an operation for rectocele induced the writer on
one occasion to take out the stitches so early as to lose much of the
benefit which might have been derived from a successful operation.
The cause of the trouble was subsequently found to be due to the
excessive use of iodoform powder by an over-zealous nurse.

Surgical Scarlet Fever. Many drugs are apt to cause eruptions
which, in some cases, resemble those of scarlet fever. This disease
has, in fact, been associated closely with surgical operations, and
this supposed connection has given rise to the expression "surgical
scarlet fever." Observations of this kind are exceedingly numer-
ous, and few surgeons have failed to meet with them ; whereas the
association of other exanthemata as, for instance, measles with
surgical operations does not appear to occur in sufficient numbers
to be worthy of special notice.



324 SURGICAL PATHOLOGY AND THERAPEUTICS.

Horsley refers to the fact that scarlet fever is particularly liable
to attack children recently operated upon, especially in cases where
an operation has been performed for stone in the bladder or for
cleft palate. Sir James Paget, who is one of the chief authorities
on this subject, is confident that there is something in the conse-
quences of surgical operations that makes patients peculiarly sus-
ceptible to the influence of the scarlatina poison. He mentions
the following case:

A boy operated upon for stone had an eruption with fever exactly like
that of scarlet fever the day following the operation. Two days later it
began to fade, and quickly disappeared. A month later, when the wound had
nearly healed, he had haematuria and increased mucus, with pain on micturi-
tion. Two days after this he had sore throat, accompanied with a scarlatina
eruption, followed by desquamation.

Although the symptoms, in this case, of two attacks were not
typical, Paget regards it as true scarlet fever. Thomas Smith had
10 cases of scarlet fever in 43 cases of lithotomy in children.
This is certainly more than a coincidence. In all cases the erup-
tion appeared on the second or third day.

The appearance of scarlet fever in puerperal women is a well-
recognized occurrence, and all the symptoms are usually so well
marked that little doubt is expressed about the diagnosis. The
somewhat "disorderly" appearance of the symptoms in surgical
cases, as Sir James Paget expresses it, has led to the belief that
these cases are not genuine scarlatina, but of septic infection of the
wound; and the fact that eruptions of this character are often seen
in the course of pyaemia appears to be confirmatory of this view.
In a monograph on this subject Albert Hoffa states that he analyzed
the different forms of eruptions which occur during the healing of
a wound, and recognized four types. A certain number he regards
as purely vaso-motor disturbances, arising from an irritation of the
sensitive nerves and occurring after operations upon parts abun-
dantly supplied with nerves, such as the genitalia. The eruption
appears a few hours after an operation for circumcision, for
instance, and resembles an erythema or an urticaria, and disap-
pears as quickly. The cases of puerperal scarlet fever are also
placed in this category- by Hoffa.

The next class he calls "toxic erythema." These eruptions are
analogous to the medicinal eruptions (as the rash which sometimes
follows the use of copaiba or antipyrine). They occur without pro-
dromal symptoms, and usually appear from twenty-four to forty-
eight hours after all kinds of operations, and even in simple frac-



SURGICAL FEVERS. 325

tures. The febrile disturbance is usually intense, and in children
delirium or coma may accompany the eruptions. Gastric disturb-
ance is also a prominent symptom. Toxic erythema appears as a
diffused redness or as isolated large patches with comparatively
clear intervals between them. It is seen only on the body and
extremities, and disappears in twenty-four hours without any sub-
sequent desquamation.

This form is the result of an absorption of the secretions of the
wound particles of tissue or fibrin-ferment such as occurs in
aseptic fever. In some of the experiments of transfusion in ani-
mals patches of eruption are noticed. It is a not uncommon occur-
rence to find transitory erythema during etherization. The erup-
tions of carbolic-acid and sublimate poisonings would belong in
this category. Hoffa reports the case of a boy whose resected
knee-joint wound was syringed out with a i : 1000 solution of subli-
mate. Half an hour later the patient had a chill accompanied with
fever and typical scarlet rash on the whole body that lasted for
twenty-four hours. The presence of mercury was afterward dem-
onstrated in the urine and faeces.

These two varieties are strictly to be distinguished from the third
form, which is infectious, and in which the eruptions are indications
of a general infection of the body, occurring as they do in septicaemia
and pyaemia. The eruptions are generally more marked in charac-
ter and exhibit a greater variety in appearance. They may appear
in the form of erythema or as urticaria. They may be diffused or
be in isolated patches. The eruption may become pustular or hem-
orrhagic. Even purpura spots may be seen. The eruption, how-
ever, occasionally resembles the scarlet rash very closely. Some-
times curiously enough it affects only one-half of the body.
After disappearance of the eruption desquamation may follow, and
there may even be suppuration beneath the skin, with the forma-
tion of abscesses. The eruption is said to be caused by a capillary
embolism of micrococci. An example of this type is reported by
Ffolliott:

A soldier in India received an extensive burn from the explosion of pow-
der. On the third day a scarlet rash appeared. The temperature had been
high from the beginning. In five days the eruption disappeared, and it was
followed by desquamation. The patient had been three years in India, and
in that country scarlet fever is never seen.

Konetschke reports a case belonging to this variety:

A boy with compound comminuted fracture of the leg had septic infection
of the wound. In forty-eight hours after the injury an eruption appeared,



326 SURGICAL PATHOLOGY AND THERAPEUTICS.

with a rise of temperature, and remained six days, being followed by desqua-
mation. Two weeks later a second eruption occurred, followed by desquama-
tion, lasting only two days. One week later another eruption, with desqua-
mation, lasting this time four days. There was some swelling of the legs
each time, but no angina or swelling of the submaxillary gland, and no
source of infection from scarlet fever was discernible.

Finally, in another set of cases it is evident that we have to do
with genuine scarlet fever; that is, there are, in addition to the
skin eruption, angina, swelling of the submaxillary glands, desqua-
mation, and nephritis. This regularity of symptoms is not consid-
ered by Sir James Paget as necessary for diagnosis, for he expressly
states that deviations from the typical course of scarlet fever are
common, one or more symptoms being absent.

Another point upon which a difference of opinion appears to
exist is the origin of the attack. Hoffa is inclined to think that
the disease enters the organism through the wound, and cites cases
to show that the eruption often begins at the edges of the wound
and gradually spreads over the body. Paget is inclined to the
view that the patient may have imbibed the poison before the
reception of the wound, and that the disease might not have
shown itself at all unless the vitality of the system had been
impaired.

A case strongly suggestive of this view occurred in the writer's
own practice:

A little girl twelve years of age fell and cut her forehead against a sharp
piece of furniture. The wound was cleansed and united by three sutures.
That evening there was swelling of the edges of the wound and a rise of
temperature. These symptoms were more marked the next morning, and
on the following day a scarlet rash occurred, and the patient went through
a typical case of scarlet fever. The wound healed by first intention.

It seems quite evident, as Paget says, that "a peculiar liability
to contagion is induced by an operation, and that the poison pro-
duces its specific effects in much less than the usual period of incu-
bation." It is also highly probable that direct infection through
the wound occurs. Thus, Paget reports a case of a child who was
seized with scarlet fever the day after an operation had been per-
formed on her mouth. Her mother knew nothing of any source
of poisonous infection, but the surgeon who performed the opera-
tion was at the time nursing his own children with the disease.
Billroth reports a similar case of scarlet fever following an opera-
tion upon the tongue, and it seems probable at least that Smith's
ten cases of scarlet fever following lithotomy may be examples of
infection of a wounded mucous membrane by that disease. Hoffa



SURGICAL FEVERS. 327

thinks that the reason a wound seems to give a certain predisposi-
tion for the disease is because a larger dose of the micro-organisms
may enter through the wound, and that patients thus become
affected who are not so affected by smaller numbers of bacteria
through ordinary channels. The short incubation-period of surgi-
cal scarlet fever favors this view.

One of the most striking cases of infection of the wound by
scarlet fever that the writer has been able to find is the following:

A physician, apparently without predisposition to scarlatina, received a
scratch with a knife at an autopsy of a case of scarlet fever. On the ninth
day a rash started from the wound and followed a typical course.

A case illustrating Hoffa's theory of wound-infection is the
following:

A patient with stricture and urinary infiltration and gangrene of the
scrotum had, on the ninth day of entrance to the hospital, a scarlet rash
starting from the wound and covering the abdomen, the breast, and the
neck, to the lower third of the thighs, and remaining six days. Angina
was present, also high fever. Two days after the disappearance of the rash
desquamation took place. Death occurred on the eleventh day after the
appearance of the rash. At the autopsy a parenchymatous nephritis was
found. Four days after the appearance of the eruption on this patient, a boy
in the same ward with a fractured thigh and lacerations in the perineum
broke out with a rash on the limbs and face. It was followed by desquama-
tion, but there was no angina, or albumin in the urine.

It is probably not advisable to attempt to make a differential
diagnosis from all kinds of skin eruptions or erythemata that may
occur in surgical practice and scarlatina. Enough, however, has
been said to show that a great many cases closely resemble that
disease; that a certain number, and probably the majority, of cases
of so-called "surgical scarlet fever" are cases of genuine scarla-
tina; that some of the scarlet rashes that might easily be mistaken
for the disease are cases of septic infection of the skin; that in
many of these cases it is extremely difficult to decide between the
two affections in making a diagnosis, and that it would be well to
be on the safe side and exercise all the precautions necessary to iso-
late the patient.

Suppurative Fever. The fevers thus far considered have not
necessarily been directly connected with suppuration. In fact, it
has been shown that surgical fever subsides with the appearance of
pus. The fevers already mentioned are developed during the early
stages of the healing process in wounds. They may, therefore, with
propriety be called " primary fevers," although this name is not
usually applied to them. The term secondary fever is, however,



328 SURGICAL PATHOLOGY AND THERAPEUTICS.

sometimes given to that form which occurs during the period of sup-
puration, although suppurative fever is the more common expres-
sion. Hectic fever (from i/zvxoc, a habit) is a name usually applied to
the chronic forms of suppuration, such as accompany tuberculosis.

The high temperature usually accompanying aseptic or surgical
fever rarely lasts beyond the first week. If, however, the temper-
ature does not fall, or about the beginning of the second week there
should be a sharp rise of temperature, or even a chill, then there is
reason to suspect the presence of pus in the wound. If the wound
be examined, undoubtedly there will be found an amount of inflam-
mation which would account for the high temperature. The lips
of the wound are red and swollen, and on removing an obstructed
drainage-tube or on slightly separating the edges of the wound an
escape of pus follows. If proper drainage and antiseptics are now
employed, the temperature will soon fall- and the febrile disturb-
ances will disappear. If, however, parts are involved whose ana-
tomical structure makes it difficult to effect a thorough disinfection
of the wound (as, for instance, a joint), or pus begins to burrow
among deep layers of muscles, as often happens in a compound
fracture, the fever will continue to keep pace more or less accu-
rately with the local condition. If the infective inflammation,
which has now established itself, is of an acute type, there will
be a continued form of fever with frequent marked exacerbations.
Usually, however, the local inflammation yields more or less to
proper remedies, and becomes less acute in character: numerous
sinuses are formed running in various directions ; the integuments
are swollen and cedematous, but are pale and flabby, and pus dis-
charges freely from numerous openings. Chronic suppuration is
established. The fever now assumes the characteristic remittent
type of suppurative fever. In the morning the temperature is nor-
mal or even subnormal, but in the afternoon there is a sharp rise,
varying from two to six degrees. There are then the hectic flush
and the other symptoms of fever. Unless the progress of the sup-
puration is soon checked, the constitutional disturbance produces a
marked change in the appearance of the patient. Great loss of
flesh and prostration result, which are aggravated by " colliqua-
tive" diarrhoea and by profuse perspiration or "night-sweats."

Emaciation becomes extreme, so that the joints have an unusu-
ally prominent appearance; bed-sores appear, and it soon becomes
merely a question of the power of endurance on the part of the
patient. In the most chronic forms of suppuration, such as accom-
pany tubercular disease, this type of fever may continue for many



SURGICAL FEVERS. 329

months ; the emaciation will be more gradual, but when death
finally occurs from exhaustion there will be found extensive
amyloid disease of the internal organs.

If in the early stages of the suppuration the surgeon gains con-
trol by free incisions and drainage and removal of the suppurating
walls of the wound by the curette, by resection of a joint, or by
amputation, the febrile disturbance immediately subsides. This
fact shows clearly that the high temperature is due to the contin-
ued absorption of pyrogenous material from the wound into the
blood, and that the material when once absorbed is no longer
capable of further action, for when the supply is cut off pyrexia
ceases.

The precise nature of this poisonous substance is not fully
understood. It is certain, however, that bacteria are only indi-
rectly concerned in its production. The pus-coccus is indeed
sometimes found in the blood, but it is also seen in cases where
no febrile disturbance exists, and its presence is quite uncertain
and irregular. The amount of degeneration of tissue and destruc-
tion which such a process involves must necessarily liberate a
number of pyrogenous materials which find their way into the
circulation and produce fever. The extensive breaking down of
white blood-corpuscles in the granulation tissue forming the wall
of the abscess would alone liberate sufficient fibrin-ferment to pro-
duce considerable constitutional disturbance. The virus, therefore,
must be regarded as principally a chemical one, and not essentially
different from that which produces surgical fever.

The principal changes found at the post-mortem examination
of such cases is the so-called "amyloid degeneration of the internal
organs." It is a retrograde metamorphosis of the albuminoid con-
stituents of the protoplasm of the cells. It usually attacks the small
arteries, but extensive changes of this character are frequently seen
in the spleen, the liver, the intestines, the kidneys, and the heart,
and, as Billroth has shown, even in the lymphatic glands. It is
supposed to be caused by the constant drain upon the body of the
alkaline salts, notably the compounds of potassium, produced by
the suppurative discharge.

It is important to be able to recognize the presence of such
changes during life, for the existence of such a degeneration of the
internal organs would clearly be a contraindication for operative
interference; for the disease, when once established, is generally
regarded as incurable. It would obviously be useless to attempt
the radical cure of hip- or knee-joint disease by resection if such



33 SURGICAL PATHOLOGY AND THERAPEUTICS.

a complication existed. The condition of the liver or the spleen
should carefully be looked into, and any enlargement of those
organs be sought for. An examination of the urine would throw
valuable light upon the presence of organic diseases of the kidney.
Amyloid or albuminoid degeneration of the mucous membrane of
the intestinal canal would possibly betray itself by diarrhoea, by
paleness of the discharges, or by the absence of bile, and by other
symptoms of disordered function.

Severe operations in the later stages of cases of long-standing
suppuration are rarely attempted by surgeons of experience. It is
in the early stages of suppuration that prompt interference should
take place. A counter-opening in one of the lips of a wound, with
insertion of a drainage-tube in acute cases, will usually suffice to
prevent further trouble. When the pus begins to burrow the
micrococci appear to be endowed with unusual activity, and ex-
tensive sinuses form in various directions unless further progress
is checked by free openings with the knife extending to the extrem-
ity of the cavity and freely exposing its walls. The walls should
then be curetted carefully to remove all bacterial growth, and



Online LibraryJohn Collins WarrenSurgical pathology and therapeutics → online text (page 32 of 84)