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Infection has always been a prominent feature of human life, and sepsis in modern surgery continues to be a significant health problem throughout the world. For this reason, the Surgical Infection Society has been formed and is holding its first meeting here today.It is appropriate that we review the history of sepsis in surgery throughout the ages. Surgery's progress resembles a long river, which is fed by tributary streams that join it at irregular intervals to swell its body, increase its depth, quicken its current, and extend its influence. Before 1800, tributaries were relatively uncommon, but since then a steady inflow of developments of historic significance have swollen the stream of surgical progress. Among these should be considered the following:Hippocrates, "The Father of Medicine," in 400 BC wrote clear descriptions of many conditions, including obvious infections such as gas gangrene and staphylococcal lesions.1 Curiously enough, however, Hippocrates

The Fluoretec fluorescent antibody test kit (Pfizer Inc., New York, N.Y.), developed for the rapid detection of members of the Bacteroides fragilis and B. melaninogenicus groups, was evaluated by testing 58 stock cultures and 76 clinical specimens. The test reagents detected 100% of 40 B. fragilis and B. thetaiotaomicron stock culture strains, although only 22% of 18 B. vulgatus, B. distasonis, and B. ovatus strains showed positive fluorescence. The 76 clinical specimens were evaluated by examining fluorescent antibody-stained smears of 49 specimens of purulent material and smears of 27 blood cultures which were positive for gram-negative bacilli by Gram stain or subculture. The fluoretec reagent detected members of the B. fragilis group in 28 (97%) of the 29 specimens of purulent material and all (100%) of the 16 blood cultures in which these anaerobes were demonstrated by culture. Overall, the Fluoretec reagent detected members of B. fragilis group in 44 (98%) of the 45 clinical specimens which were shown by culture to contain these anaerobes. Two of the 76 clinical specimens gave positive fluorescence for members of the B. fragilis group but failed to yield these organisms by culture. Members of the B. melaninogenicus group were detected by culture in 15 specimens and in each case their presence was demonstrated by the Fluoretec reagent. No members of the B. melaninogenicus group were isolated from five clinical specimens that gave positive fluorescence with the B. melaninogenicus reagent.

Between 1960 and 1974, 826 specimens, excluding stool, urine, sputum, and blood, yielded 689 (83%) positive cultures, of which 403 (58.5%) contained anaerobic bacteria. This represents 48.8% of the total specimens cultured. Isolates from 153 specimens obtained and stocked from 1965 to 1974 were reidentified by current criteria. Gram-negative bacilli, primarily bacteroides, were the most frequently isolated anaerobes, being found in 70% of 153 anaerobe-positive specimens and accounting for 42% of the total anaerobes isolated. Gram-positive cocci were second in occurrence, being found in 66% of 153 specimens and accounting for 40% of the total isolates. Bacteroides fragilis was by far the most frequently isolated species. Compairson of 14 years of cumulative data with data from current studies covering 1- to 2-year periods indicated that the anaerobes isolated from clinical material have not changed significantly in type or relative numbers.

An indirect fluorescent antibody (IFA) technique was evaluated as a procedure for rapid detection and identification of members of the Bacteroidaceae. Antisera were prepared against 31 members of this family, including species of Bacteroides and Fusobacterium commonly isolated from human infections. The antisera had demonstrated species and/or subspecies specificity. Thirty clinical specimens were studied. Of 13 specimens yielding Bacteroidaceae, for which antisera were available, 23 were presumptively diagnosed by IFA to contain subspecies of B. fragilis and/or Fusobacterium species. Of 17 specimens yielding negative culture results, two were positive by IFA on direct smear. Frequently the in vivo morphology of cells detected in direct smears by this procedure closely mimicked that of cellular debris, tissue cells, and leukocytes. Polyvalent antisera pools facilitated use of the IFA procedure as a practical tool for rapid diagnosis of infections involving the Bacteroidaceae.

The successful treatment of traumatic wounds is probably the most challenging problem in surgery today. Modern life has resulted in an increasing exposure to the hazards of motorized land, air and sea transportation, to those of mechanized industry and to those of modern war. This has produced an enormous increase in the number of extensive and severe wounds.The treatment of both civil and war wounds is based on the same fundamental surgical principles. In war surgery, however, the execution of the principles is frequently compromised by such factors as stress, time lag, severe shock or lack of materials.The primary purpose of the treatment of wounded persons is "to save life" by preventing or arresting hemorrhage, by allaying shock and by preventing or controlling infection. The secondary purpose is to save the injured part and restore it as rapidly and as effectively as possible to normal function and appearance.

Recent wars have crystallized interest in the bacteriology of traumatic wounds. The literature which accumulated from the first world war alone was enormous. Because of the limited methods of cultivation and identification of bacteria in use then, many of these studies were not entirely satisfactory. However, they showed the frequency with which the anaerobic bacteria of gas gangrene could be cultivated from war wounds. As a result of the intensive study of Fleming, Wright, Henry, Weinberg and Sequin, and others, several fundamental concepts were developed. Wounds received in combat usually were grossly contaminated and all became infected if untreated. The organisms found in wounds were roughly divided into three groups: (1) sporulating microbes of fecal origin, (2) nonsporulating microbes of fecal origin and (3) pyogenic cocci. The first group consisted chiefly of gas producing bacteria, such as Clostridium welchi (perfringens), Clostridium oedematis maligni, Clostridium histolyticus, Clostridium sporogenes, Clostridium fallax, Clostridium

During the phenomenal development of chemotherapy in the past thirteen years, considerable confusion has arisen regarding the value of the various agents in the management of acute septic peritonitis. Although most surgeons agree that chemotherapy has been of great value, there is no agreement as to which is the best agent to use or what is the best manner of its application. A summary of the present knowledge and experience is presented to establish the relative place of chemotherapy, the most effective agents and any changes in surgical practice made possible in the management of acute septic peritonitis.There is still no specific treatment for acute septic peritonitis, and successful management is dependent primarily on good surgical intervention, aided by early and correct diagnosis, chemotherapy and adequate preoperative and postoperative care.Early Correct Diagnosis.—When peritonitis exists, the earlier the diagnosis is made, the more effective is prompt treatment. A

Tetanus, or lockjaw, is one of the most dreaded infectious complications of wounds. Although its specific etiology has been known for sixty years and its diagnosis has been relatively easy, the treatment of tetanus, once established, is still unsatisfactory and the results are uncertain. It has been disappointing to see the failure of large doses of antitetanic serum to alter the course or lower the mortality of this disease once it has developed, particularly since a small dose of the antitetanic serum has been so effective in preventing the development of the disease when given prophylactically at the time of injury. This has been particularly true in the cases with incubation periods of less than six days. The studies of Abel and Firor1 have revolutionized the concept of the pathogenesis of tetanus and crystallized the facts known regarding the value and limitations of active therapy of established tetanus. Firor

THE REPAIR of complete rectal prolapse in aged or debilitated patients requires the use of a surgical procedure which is followed by a high percentage of cure, a low mortality, and minimal morbidity. The large number of operations which have been suggested, tried, and often abandoned is indicative of the difficulties attending the management of rectal prolapse and of the frequency of unsatisfactory results. In general, the principles involved in the various operative procedures which have been advocated include the following: (1) resection of the protruding bowel; (2) reduction of the size of the anus and lower rectum; (3) plastic reconstruction or reinforcement of the perineal floor; (4) abdominal suspension, fixation, or both, of the prolapsed bowel, and (5) obliteration of the cul-de-sac.The studies of Moschcowitz,1 Todd,2 Graham,3 and Orr4 have shown that a large rectal prolapse is essentially a sliding hernia of the anterior

A VARIETY of natural and synthetic colloidal solutions have been used for the reestablishment of the circulation, but experience has emphasized that the ideal fluid for use in hemorrhagic or traumatic shock is blood of an identical grouping. Since methods have not been developed for the stockpiling of blood, it has become readily apparent that a sufficient supply of blood would not be available for emergency use for mass casualties resulting from an atomic attack. The search for a plasma substitute suitable for stockpiling has therefore been intensified in recent years. Polyvinylpyrrolidone, or PVP, is one of the three agents under intensive investigation for this purpose. It is an entirely synthetic product which is water-soluble, hydrophilic, and of high molecular weight. Originally introduced in 1943 by Hecht and Weese,1 it was administered to approximately one-third million German casualties at the Russian front, and a summary of the results of

THUS FAR, it has been assumed that successful penicillin therapy of susceptible surgical infections depended primarily on the maintenance of a therapeutic concentration of this agent in the blood and tissues. A concentration of 0.03 unit per cubic centimeter has usually been recognized as a therapeutic level. The origin of this concept was probably the result of a transfer of experimental and clinical experience with the sulfonamide drugs.At the time of its introduction to clinical surgery, penicillin was given by continuous infusion, either intravenously or intramuscularly, in the majority of instances. Because of the patient's discomfort and the amount of time and effort needed to insure its efficiency, this method was soon abandoned in favor of single injections made at intervals of two to four hours. Although this plan did not maintain a constant level, it insured a concentration of penicillin in excess of the therapeutic dose in most

The management of acute infections of the skeletal system has been greatly modified during the past decade by the use of antibacterial agents. These agents, which include those of nonbiologic origin, such as the sulfonamides, and those of biologic origin, such as the antibiotics, not only have radically changed our ideas concerning the most satisfactory methods of treatment in many instances but have also emphasized the extraordinary recuperative and regenerative powers of bone unimpeded by continuing infection. The intention of this discussion is to summarize the current knowledge of the use of various antibiotic and chemotherapeutic agents in the management of certain infections of the skeletal system, including acute osteomyelitis, acute purulent arthritis, chronic osteomyelitis, tuberculosis, syphilis, actinomycosis, and blastomycosis. Because of the increasing percentage in our environment of bacteria that are progressively developing resistance to the antibiotics, it is important to reappraise at frequent intervals the results obtained with

Rat bite fever is a peculiar and relatively rare disease of man which occasionally develops after the bite of a rat. There is some evidence that this condition has been known in India for two thousand three hundred years and that India may have been its source. Modern medical literature on this subject began with the report of Wilcox in 1840, who recorded a group of symptoms that followed the bite of a rat. Since then case reports have been published in nearly all of the countries of the world, including Asia, Japan, Europe, England, North and South America, Hawaii and Australia. In the United States the disease has now been reported in twenty-eight states and the District of Columbia, but the incidence has been greatest in Ohio, Pennsylvania, New York and Illinois. In spite of its worldwide distribution, an epidemic spread of rat bite fever has never been recorded.

ACUTE or subacute pyogenic thyroiditis is a rare disease which is characterized by a sudden onset, fever, chills, leukocytosis and variable symptoms and signs of inflammation in the thyroid gland and the lower cervical region. It is far less common than other clinical types of thyroiditis such as subacute pseudotuberculous thyroiditis, Hashimoto's thyroiditis and Riedel's struma, which occur in less than 1 per cent of all patients with thyroid disease.1 Young2 reported 26 cases of various types of inflammatory disease of the thyroid in 2,900 patients undergoing operation on this gland, and only 4 were cases of acute suppurative thyroiditis. Other isolated case reports of acute thyroiditis with abscess formation have been made by Henderson,3 Cochrane and Nowak,4 Stock,5 Derbyshire and Gray,6 and Crile.7The infection is usually caused by the staphylococcus, streptococcus or pneumococcus, but there is some question of whether these

Clinical experience during the past 12 years with the one-stage perineal operation for type III prolapse of the rectum has shown this surgical procedure to be definitive and curative in patients of all age groups. Since its original description in 1952,1 a total of 53 patients have been operated upon by this method on the Surgical Services of the Cincinnati General Hospital and the University of Cincinnati. The results obtained and the observations made in this series indicate that it has certain advantages making it worthy of serious consideration.2In the past, many operations have been suggested, tried, but often abandoned. This has been indicative of the difficulties attending the management of rectal prolapse and the frequency of unsatisfactory results obtained after operation.2,3 More than 50 different operative procedures have been devised to cure rectal prolapse since the report of Moschcowitz in 1912.4,5 While it is

Abscesses developing within the retroperitoneal spaces are serious surgical infections which are associated with prolonged morbidity and high mortality unless diagnosed early and treated adequately. These lesions are usually secondary, being complications of infections, injuries, or malignancy of adjacent retroperitoneal or intraperitoneal organs1-5; osteomyelitis of the vertebral column or 12th rib; suppurative lymphadenitis; or bacteremia.The frequency with which these abscesses have been seen in recent years, even though antibiotic therapy has been in widespread use, and the associated diagnostic and therapeutic problems presented by them have stimulated us to review our cases seen in the Department of Surgery of the Cincinnati General Hospital and University of Cincinnati.Relatively little attention has been given to the problem of retroperitoneal infections, and most published reports have been concerned with case presentations and short reviews.5-11 The review by Neuhof and Arnheim in 19447 is more comprehensive. MATERIAL The records

ALTHOUGH modern antibiotic therapy has been in widespread use for 22 years, invasive infection with septicemia continues to be a serious problem in surgical practice.1, 6,7 After the introduction of penicillin, followed in succession by a multiplicity of broad spectrum antimicrobial agents, there were high hopes that the incidence, severity, and mortality from septicemia would be drastically reduced. Such appears not to have been the case, however, and clinical experience has suggested that the incidence of septicemia is probably increasing.2,3,5,9 Moreover, many cases of severe and often rapidly fatal septicemia caused by gramnegative bacteria have occurred in recent years.2,6,8,10-16 During a 21-day period in November and December 1964, the senior author saw 24 surgical patients with septicemia in consultation. Only three of these were caused by the Staphylococcus aureus, the remainder were caused by various types of gram-negative bacilli which in 13 instances were strains of Pseudomonas

Of the numerous surgical procedures which have been developed for the treatment of cirrhotic patients with portal hypertension complicated by esophageal varices and gastrointestinal hemorrhage, ligation of the hepatic and splenic arteries with or without ligation of the left gastric artery has received considerable attention during the past four years.Opinions among surgeons have differed greatly as to whether or not the procedure of arterial ligation offers any lasting benefit to cirrhotic patients. The original reports of Rienhoff1 and Berman2 indicated that favorable results followed the procedure. In Rienhoff's series, 50% of the cases surviving hepatic and splenic arterial ligation for hemorrhage were benefited, and 11 of 13 who underwent ligation for intractable ascites were improved.On the other hand, Madden3 and McFadzean and Cook4 have concluded that the operation was useless. Only one of Madden's eight cases survived hepatic artery ligation, and he therefore felt

Recently lymphangiography has provided a useful and dynamic method of studying in vivo the lymphatic spread of malignant tumors and their involvement of regional and distant lymph nodes. Although the spread of malignant tumors by means of the lymphatic system has been recognized since the mid nineteenth century,1 this recognition has been based primarily on the pathologic study of surgical and autopsy material. Only recently have attempts been made to study the lymphatic system in vivo. In 1955 Kinmonth devised a method for the vital visualization of the lymphatic vessels and nodes.2 The modifications of this by Wallace et al3 and others have made practical the radiographic demonstration of the lymphatic system in clinical patients by the intralymphatic injection of contrast media. Lymph nodes involved with metastatic tumor can be shown to have a characteristic radiographic appearance, and thus lymphangiography offers a means of demonstrating lymph node

Abscesses developing as sequelae of acute pancreatic inflammation are infrequent and serious surgical complications11,12 which usually present a confusing clinical picture. In addition, their successful management is beset by many problems in diagnosis, localization of the abscess, selection of the correct type of surgical operation, and recognition and treatment of a variety of complications.The sparse number of published reports of patients with pancreatic abscess and the absence of any comprehensive review of this subject in the literature were both surprising. The first successful treatment of this condition was apparently reported by Davis in 1917.5 Beller and Nach reported a case in 1942 and reviewed five previously reported cases.3 Eleven years later Welborn reported three more cases,13 but the remainder of reports have dealt with only one or two patients. A thorough clinical review and study of the subject have been made after several patients with

Diverticulosis of the jejunum, generally considered to be an asymptomatic condition, may produce a variety of interesting clinical and pathophysiologic syndromes which are correctable by surgical intervention. In a group of 62 patients with jejunal diverticulosis seen at the Cincinnati General Hospital and associated hospitals of the University of Cincinnati, the natural history and complications of this poorly understood condition have been delineated. In this series significant symptomatic complications have occurred in 16 patients, and these form the basis of this report.As seen at operation or the autopsy table, acquired jejunal diverticula appear as thinwalled, round, elliptical or multilobulated sacs continuous with the wall of the intestine and extending between the leaves of the mesentery, in contrast to the congenital Meckelian diverticulum which arises from the antimesenteric border of the intestine. A branch of the mesenteric vessel can often be seen coursing across the fundus of a sac. When

Tetanus, one of the most dreaded complications of wounds, continues to be a serious clinical problem. Neither its incidence nor its mortality appear to have been significantly decreased in civilian practice during the past 20 years by programs or active immunity.1Large doses of antitetanic serum have been ineffective in preventing death during this violent disease, particularly in those patients with incubation periods of less than six days. The military experience of World War I and of the Korean War has demonstrated conclusively the superior prophylactic effectiveness of tetanus toxoid in producing immunity, but this valuable lesson has not been transferred to civilian life on a broad scale as yet.Equally disappointing has been the apparent failure of prophylactic antibiotic therapy in wounded persons to reduce the number of cases of tetanus or to alter the course of the disease per se, once it has become established.2The

The studies of Fine and his co-workers suggested that a bacterial factor was a cause of irreversibility of prolonged hemorrhagic shock in experimental animals and that the defense mechanism against this factor could be enhanced by the preliminary administration of certain antibiotics, principally chlortetracycline (Aureomycin).Fine et al.1 had reported dramatic and interesting data which they interpreted as indicative of a bacterial factor being important in the production of "irreversible" hemorrhagic shock in dogs. Their conclusion was based in part upon the finding that the survival rate in their experiments with a standardized challenge by hemorrhagic shock was significantly increased by the preliminary administration of certain antibiotic agents. Other workers, notably DeBakey,2 were unable to demonstrate this protection or to demonstrate any significant difference in mortality between the control group and the group treated with antibiotics. The detection of the nature and method of action of bacterial factors