is customary to speak of infec- tions in which the two conditions are combined as cases of septico-pyemia. Under the head of local infections we at the present day group together all those so-called “ accidents” which befall wounds: suppuration, traumatic fever, hospital gangrene, wound-diphtheria, and erysipelas. All of these, though met with much less often than 16 ASEPTIC SURGICAL TECHNIQUE. of old, are still occasionally seen. The rarity of their occurrence is to be attributed to the improvement in operative technique and the less frequent infection of wounds. The phenomena appearing after the absorp- tion into the general circulation of the products re- sulting from the local growth of micro-organisms, especially putrefactive forms, have been included under the term sapremia or toxemia, but it is not possible to make any sharp distinction between sapremia and septicemia. The importance of recog- nizing clearly the distinction between a purely local infection and a general infection of the blood and organs with bacteria will be easily understood. In the former case the symptoms produced are in direct proportion to the amount of poison absorbed, and if this absorption has not been too great, they will all disappear with the subsidence of the local infection. In a general infection, on the other hand, fresh poi- son is being constantly produced by the bacteria dis- tributed everywhere through the body, so that local therapeutic measures can then be of no avail. General septicemia, or pyemia, may be set up by almost any of the micro-organisms which have pyo- genic properties,—i.e., which are capable of giving rise to local suppuration. The organisms most frequently met with in surgical experience are: the staphylococcus pyogenes aureus, the streptococcus pyogenes, and the bac- terium coli commune. Less frequently we have to deal with the staphylococcus epidermidis albus, the staphylococ- cus pyogenes albus, the staphylococcus pyogenes citreus, the PATHOGENIC ORGANISMS. 17 gonococcus of Neisser, the bacillus of green pus (bacillus pyocyaneus), the bacillus aérogenes capsulatus, and the micrococcus lanceolatus (diplococcus pneumonie). It will be well, perhaps, to describe briefly the prin- cipal micro-organisms which concern us in our work, and especially the pyogenic bacteria. The forms chiefly concerned in suppurative processes are cocci. Of these the staphylococcus, of which several varieties have been isolated, distinguished by differences both in their chromogenic properties and in their pathogenic power, has been found more frequently than any other associated with acute phlegmons. The staphylococcus pyogenes aureus (Ogston, Rosen- bach, et al.), or golden staphylococcus, is the most im- portant form for the surgeon, and is more common than any other. It is widely distributed in nature, its presence having been repeatedly demonstrated upon the skin of healthy persons, in the secretions of the mouth, beneath the finger-nails, in the air, especially in that of hospital wards, in the water, and elsewhere. It can thus be easily understood how readily it can come in contact with the field of operation. The cocci grow in grape-like bunches, but in the tissues are also seen in pairs or in groups of four. Plate L, Fig. 1. They stain well in the ordinary aniline dyes, and also by the method of Gram. The staphylococcus aureus grows well on all the culture media of the laboratory, and forms, especially when allowed to grow slowly with free access of air, large golden-yellow masses. 2 18 ASEPTIC SURGICAL TECHNIQUE. Its pathogenic power is variable, some varieties being much more virulent than others. Its pyogenic properties for human beings have been clearly proved by the experiments’ of Garré, who rubbed into the uninjured skin of his left forearm a pure culture of thisorganism. Four days afterwards a large carbuncle, which was surrounded by isolated furuncles, appeared at the site of the inoculation. The inflammation thus established ran the usual course, and it was only after several weeks that the skin healed over completely. Seventeen scars remained as a lasting proof of the success of the experiment. When cultures of this coccus are injected into the vein of a rabbit’s ear, the animal dies after a certain period of time (which varies according to the viru- lence of the particular culture used), with symptoms of acute septicemia, and at the autopsy necroses or small abscesses are found in the various organs. In human beings this organism has been isolated from suppurating foci of all kinds and in all situations. It is the most frequent cause of superficial and deep abscesses as well as of acute osteomyelitis, and has often been recognized as the infectious agent in acute ulcerative endocarditis and general septicemia follow- ing operations or childbirth. The staphylococcus pyogenes albus, while resembling the aureus in form, can be distinguished from it in that it grows as a white coating on the culture media, and moreover is possessed of less virulence. It has in some instances been found as the only micro-organism PATHOGENIC ORGANISMS. 19 present in acute abscesses, but, as a rule, it is asso- ciated with other pyogenic cocci, most frequently with the staphylococcus pyogenes aureus. The staphylococcus epidermidis albus is so called be- cause it is almost always present, even under nor- mal conditions, in the human skin. According to Welch, it is often found in parts of the epidermis deeper than can be reached by any known method of cutaneous disinfection without injuring the patient, and he therefore regards it as a nearly constant in- habitant of the epidermis. This coccus resembles very closely the staphylococcus pyogenes albus, and is distinguished from it only by minor cultural differ- ences and by its lower virulence. It has frequently been found in wounds, the healing of which did not appear to be at all delayed; but experiments have proved that it sometimes causes suppuration along the line of the stitches and in the track of a drainage- tube. In a series of forty-five laparotomy wounds examined by Dr. Ghriskey and myself, where every aseptic precaution had been observed, bacteria were found in thirty-one, or sixty-nine per cent. of the whole; in only fourteen were the results of the cul- tures negative. In nineteen cases we found the staphylococcus epidermidis albus, in five the staphylo- coccus pyogenes aureus, in six the bacterium coli commune, and in three only the streptococcus pyo- genes, Cuitures made also in a large number of cases from the hands and from the surface of the abdomen showed. 20 ASEPTIC SURGICAL TECHNIQUE. that, even after the application of the different methods recommended for surface disinfection, the staphylo- coccus epidermidis albus still remained, and that, too, in such a condition as to be capable of developing on the ordinary media. The staphylococcus pyogenes citreus (Passet) is char- acterized by its lemon-yellow growth on agar-agar. It has been found alone in abscesses, and must be looked upon as a pyogenic micro-organism, although it occurs much more rarely than any of the other forms. The streptococcus pyogenes grows in chains consisting of from four to ten or more cocci, each individual coccus being somewhat larger than those seen in cul- tures of the staphylococcus. Plate I, Fig. 2. This organism stains well by all the ordinary methods. In culture media it grows very differently from the staphylococcus, forming, as a rule, minute pin-point colonies. The streptococcus is one of the most im- portant micro-organisms with which the surgeon has to deal. It has long been known that erysipelatous inflammations are due to the so-called streptococcus erysipelatosus ; it is doubtful, however, whether this coccus can be distinguished from the ordinary strepto- coccus pyogenes. In fact, the differentiation of strep- tococci into distinct species or varieties has thus far met with little success. The streptococcus is found sometimes in acute abscesses, but not so frequently as the staphylococcus pyogenes aureus, with which it is often associated in acute suppurative processes. PATHOGENIC ORGANISMS. o1 External inflammations due to the streptococcus are characterized especially by their spreading character and erysipelatous redness. The streptococcus pyo- genes is one of the most frequent causes of post-opera- tive peritonitis. It has further been proved to be the etiological factor in many cases of ulcerative endo- carditis as well as of acute septicemia in human beings, and it is a well-known fact that the pseudo- membranous anginas complicating scarlet fever and measles are, as a rule, due to this organism. It has been found in some forms of acute broncho-pneu- monia, sometimes in acute pleurisy and empyema, and occasionally in acute osteomyelitis. Compara- tively recent researches have shown an interesting relation to exist between the streptococcus pyogenes and the different forms of puerperal infection. Déder- lein has shown that in the pathological secretions from the vagina, immense numbers of organisms, and gen- erally streptococci, are present. His work was based upon the study of the vaginal secretions from nearly two hundred women, about one-half of which were found to be abnormal; in ten per cent. of the patho- logical secretions he was able to demonstrate the presence of the streptococcus pyogenes; inoculation experiments proved that in at least fifty per cent. of these the organism was pathogenic for animals. It is not difficult, then, to understand how after labor, when the parts are wounded, organisms can enter the circulation and give rise to a general in- fection, the infectious agent being not infrequently 22 ASEPTIC SURGICAL TECHNIQUE. the streptococcus pyogenes. Clivio and Monti have demonstrated the presence of streptococci in five cases of puerperal inflammation of the peritoneum. Ozer- niewski found the same organism in the lochia of thirty-three out of eighty-one women suffering from puerperal fever, while in those of fifty-seven healthy women he was able to find it only once. In ten fatal cases he demonstrated its presence in the organs of the body after death. Such observations as these, and many more might be cited, are sufficient to impress upon us the importance of preventing the access of the streptococcus to open wounds. The organism is of very wide distribution, and it is only strange that more patients in surgical and obstetrical practice do not become infected by it. It may be that in many cases, having led a saprophytic existence, it has lost some of its virulence, and is not capable of setting up pathological processes unless it happens to enter a soil particularly suited for its development. Any one who has examined a drop of the fluid exudate from the abdominal cavity in a case of streptococcus peritonitis, and has seen the myriads of cocci present in a single microscopic field, will appreciate somewhat the developmental power of this organism. From what has been said, the danger of going from a case of erysipelas or of streptococcus phlegmon to a surgical operation or an obstetrical case will be sufficiently evident. Even with every antiseptic pre- caution more or less danger will be incurred, and one should never take the risk unless it is absolutely PATHOGENIC ORGANISMS. 23 unavoidable. To go to such a case without thorough disinfection would be criminal. The micrococcus gonorrhae, or gonococcus, was dis- covered by Neisser in 1879. It is found in the gonor- rheeal discharge and in the secretions from the eyes in cases of gonorrheal ophthalmia. According to some it is always present in the joints in gonorrheal rheu- matism, and it has been isolated from the muscular structures of the heart in cases of myocarditis following gonorrhea. It is usually to be seen lying within the pus-cells or attached to the surface of the epithelial cells. (Plate I., Fig. 3.) Its specific character has been proved by inoculation into man. It is extremely diffi- cult to grow outside of the body and will not develop at all on the ordinary culture media. A mixture of human blood-serum and agar-agar, or hydrocele-agar, gives excellent results. Very considerable pathogenic importance has been attributed to this organism, and many gynecologists are ready to assert that nearly all inflammations of the tubes and ovaries in women are due to its agency. That it does play an important part in the etiology of these affections there can be but little doubt, but whether such an extreme opinion is justifiable remains still uncertain. The clinical history of the patient is occasionally of some assistance, but in the vast ma- jority of cases it is difficult to determine positively whether a pelvic abscess has or has not been preceded by an attack of gonorrhea. The micrococcus lanceolatus is also known as the 24 ASEPTIC SURGICAL TECHNIQUE. diplococcus pneumonie and as the pneumococeus. It was discovered by Sternberg, and also independently by Pasteur. It has been studied thoroughly by Fraenkel, Weichselbaum, Welch, and others. It is an oval or lancet-shaped encapsulated diplo- coccus which often grows out into short chains, and on that account it was called by Gamaléia the strep- tococeus lanceolatus. Plate I, Fig. 4. It is present normally, either with or without virulence, in the saliva of nearly all human beings, and is the cause of the acute septicemia (sputum septicaemia) which fre- quently results in rabbits from the inoculation into them of small quantities of human sputum. It is the causative factor in acute lobar pneumonia and also in many cases of acute broncho-pneumonia, and has been recognized as having given rise to many of the acute inflammations of the serous membranes of the body, —pleuritis, pericarditis, peritonitis, endocarditis, and meningitis. It is now known to be a definite pus- producer, and has been found more than once in acute abscesses, in empyema, in suppurative otitis media, in quinsy, and in suppurative polyarthritis, It is a rapidly-growing micro-organism, but is rather difficult to cultivate outside the body; it easily succumbs under adverse circumstances, and is extremely vari- able in its virulence. The bacillus coli communis, or bacterium coli commune, is constantly present in the freces of man and of the higher animals. It is a bacillus about one and four-tenths micro-millimetres in thickness and two or three PATHOGENIC ORGANISMS. 25 micro-millimetres in length. Plate I, Fig. 5. It is pathogenic for mice, rabbits, and guinea-pigs, and re- cently has been proved to be of some importance as an etiological factor in many of the inflammatory processes which occur in human beings. It appears to be the cause more often than any other organism of acute suppurative peritonitis, especially where there has been any communication between the lumen of the gastro-intestinal canal and the peritoneal cavity.* It has also been found in localized abscesses, in suppu- rative infections of the liver and gall-bladder, in acute hemorrhagic pancreatitis, in cystitis, in pyelitis, and in other conditions. It is interesting to note that in the infections due to this organism and to the micrococcus lanceolatus we have to deal with pathological lesions resulting from the action of bacteria which we nor- mally carry about with us in the exposed cavities of our bodies. The bacillus pyocyaneus was first isolated in pure cul- tures by Gessard, in 1882, from pus having a green or * In an article dealing with micro-organisms concerned in perfora- tion-peritonitis, Barbacci has endeavored to show that the bacillus coli communis, while always present in the exudate, is not the exciter of the inflammation. He believes that other bacteria, which do not grow from cultures made at the autopsies, but which can be observed in cover-slip preparations, are responsible for the setting up of the in- flammation. Moreover, Welch pointed out the frequency with which the streptococcus is present in such eases associated with the bacillus coli communis. He adds that the colon bacillus grows so rapidly and abundantly that the minute colonies of the more important strepto- cocci are often overshadowed, and thus may escape observation.
Key Takeaways
- The staphylococcus pyogenes aureus is the most common pathogen in surgical infections, causing abscesses and osteomyelitis.
- Streptococcus pyogenes can cause post-operative peritonitis and septicemia following childbirth.
- Micrococcus lanceolatus, while normally present in saliva, can cause acute septicemia.
Practical Tips
- Always perform thorough hand and surface disinfection before any surgical procedure to minimize the risk of infection.
- Be cautious when moving between patients with different infections; cross-contamination is a significant risk.
- Understand that bacteria like Staphylococcus epidermidis can persist despite surface disinfection, highlighting the need for strict aseptic techniques.
Warnings & Risks
- Cross-contamination between cases of erysipelas and surgical operations can lead to severe systemic infections.
- The presence of microorganisms in normal bodily fluids (like saliva) underscores the importance of thorough sterilization practices.
- Infections from bacteria like Streptococcus pyogenes are common post-surgery, necessitating vigilant monitoring.
Modern Application
While many of the techniques described in this chapter have been refined and improved upon, understanding pathogenic organisms remains crucial for modern survival preparedness. Knowledge of these microorganisms helps in recognizing signs of infection early and implementing effective preventive measures to avoid complications.
Frequently Asked Questions
Q: What is the most common cause of acute osteomyelitis according to this chapter?
The staphylococcus pyogenes aureus is identified as the most frequent cause of acute osteomyelitis in this chapter.
Q: How can Streptococcus pyogenes enter the body during childbirth, leading to post-operative infections?
Streptococcus pyogenes can be present in the vaginal secretions from women who have had an attack of gonorrhea. Infection can occur when the birth canal is damaged during delivery, allowing these bacteria into the bloodstream and causing septicemia or other post-operative complications.
Q: What are some common symptoms of a general infection caused by microorganisms like Staphylococcus aureus?
General infections caused by such organisms typically present with symptoms proportional to the amount of poison absorbed. These can include fever, inflammation at the site of infection, and in severe cases, systemic symptoms like septicemia.