The indications for treatment are those already detailed; though the general infection has already been established, it is nevertheless imperative that the primary focus should be prevented from supplying further streams of the Streptococcus pyogenes to the circulating fluid. A radical operation should be undertaken in every case in preference to a partial one for the removal of the tissue in which the disease has started.
As the infective process spreads by the breaking down of septic emboli in thrombosed veins, starting usually in the neighbourhood of the primary focus, it is obvious that the best procedure is amputation in such con ditions as compound comminuted fractures. In lateral sinus thrombosis or phlebitis in association with ear disease an attempt should be made to prevent the further sweeping onwards of septic emboli by tying the internal jugular vein, and sometimes good results have been obtained by ligaturing the main vein of a limb when amputation is impracticable.
An autogenous vaccine should he prepared without delay from the blood or from one of the metastatic abscesses and the killed organisms (the dose depending on the microbe) injected.
All metastatic or secondary abscesses should be freely incised and drained as soon as detected.
The symptomatic treatment should be conducted upon the lines laid down for the management of sapnemia and septicemia; free alcoholic stimulation is always necessary, and during the severe rigors a moderate dose of whiskey made into punch by boiling water often affords prompt relief. Quinine is always clearly indicated, and may be freely given in 5-gr. doses. If combined with 15-min. doses of Tinct. Ferri Perchlor., the best routine drug treatment will be secured.
. Tr. Ferri Perchloy. 3iv.
Quinines Sulphatis gr. Lxxx.
Potassii Chloratis 5j.
Glycerini Purif. 5j.
Aqua Chloroformi ad Misce.
Ft. mistura. Cpt. 5ss. ex 5ij. aqua pater in die.
Many authorities recommend intravenous injections of antiseptic substances, and Collargo] has been advocated by Crede. and I 0 c.c. of a r per cent. solution may be injected without danger into the main vein in the forearm. Eusol and I )akin's solution have both been used. Whilst they may be introduced into the blood-stream with safety, their curative results have not been established.
The administration of various antiseptics by the mouth has not given the results which theory had led the earlier observers to expect, since it is impossible to saturate the blood to such an extent as will destroy the cocci without killing the patient. Creosote seems to be the safest drug
to employ in this way, and so to 15 mins. daily may be administered in the form of capsules.
Normal Saline solution should always be freely resorted to, and is obviously of most use when injected directly into the veins, but pre liminary yeneseetion is contra-indicated in a disease associated with such extreme prostration and adynamic symptoms. For similar reasons assiduous feeding by strong soups and other liquid foods is of primary importance.
In the chronic stages of pyxmia, should the patient survive the acute phase, open-air treatment and removal to the pure atmosphere of a seaside resort should he insisted upon.
Obviously little need be said about preventive measures, since the impor tance of asepsis in every case where the continuity of the skin has been broken is now universally recognised. In the case of compound fractures where disinfection of the skin wound is difficult or impossible and in all deep punctured wounds the application of Klapp's or Bier's congestion method is useful in order to flush the injured tissues with a stream of healthy immunising lymph. Wright carries out the same principle by irrigating the injured tissues with a Citrated lIypertonie Salt solution (5 parts of chloride of sodium and half a part of sodium citrate dissolved in so.) of boiling water).
The writer has had extensive experience in the surgical wards before the advent of Listerism, when septic poisoning and pyxmia were almost daily results, and he was satisfied about the preventive value of large doses of Iron administered for some days before operations of all kinds.
To prevent a saprtemia passing into a septicemia or pyxmia, as some times occurs in erysipelas and puerperal septic intoxication, is an important matter. This may usually be accomplished by vaccine treatment, and in the absence of an autogenous killed culture large doses of Polyvalent Antistreptococcic Serum may be tried. The free and speedy evacuation of all purulent collections, the establishment of abundant drainage and the gentlest manipulation of compound fractures are essentials in carrying out preventive treatment of pyxmia in sapriemia and septicaemia.