A system of practical medicine. By American authors. Vol. 1

by Unknown

PYÆMIA AND SEPTICÆMIA.

BY B. A. WATSON, M.D.

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HISTORY.—There is little to be learned from existing literature of the views which were maintained by the ancients, prior to the birth of Christ, in regard to the morbid conditions now designated pyæmia and septicæmia; although it is certain they were recognized by the "Father of Medicine," who reports a well-marked case of puerperal fever terminating fatally on the twentieth day of the disease, and also a case in which death was unquestionably caused by septic poisoning, as is clearly shown in the following:¹ "Criton, in Thasno, while still on foot and going about, was seized with a violent pain in the great toe; he took to his bed the same day, had rigors and nausea, recovered his heat slightly; at night was delirious. On the second, swelling of the whole foot, and about the ankle, erythema with distension and small bullæ (phlyctænæ); acute fever; he became furiously deranged; alvine discharges, bilious, unmixed, and rather frequent. He died on the second day from commencement." Additional confirmation of the fact that Hippocrates was familiar with the phenomena of these diseases may be found in his dissertation on empyema and fevers. Prof. C. Heuter says, under the head of septic fever,² "Hippocrates and Celsus observed the fever in cases of injuries which proved so dangerous that this danger could not have originated from the inflammation or from the wound alone." Jacotius, a commentator of Hippocrates, has even mentioned putrid fevers, the same as Adrianus Spigelius, who spoke of fevers which arise from putrefaction; but both authors, as well as their followers, did not discriminate between septicæmia arising from the putrescence of wounds and pyæmia. In the mean time both varieties were regarded as intermittent fever.

¹ Works of Hippocrates, trans. by Adams, vol. i. p. 377.

² Pitha und Billroth, Handbuch der Chirurgie, 1 Band, 2 Abth., 1 Heft, 1 Liefg., S. 6.

"Aretæus lived during the middle of the second century of the Christian era. In his remarks on pneumonia he observes that the subjects of this disease die mostly on the seventh day. 'In certain cases,' he says, 'much pus is formed in the lungs, or there is a metastasis from the side if a greater symptom of convalescence be at hand. But if, indeed, the matter be translated from the side to the intestine or bladder, the patients immediately recover from the peripneumony.' He speaks of a metastasis to the kidneys and bladder being peculiarly favorable in empyema. He ascribes suppuration of the liver to intemperance and protracted disease, especially dysentery and colliquative wasting. The symptoms described by him resemble those of chronic pyæmia."³

³ Braidwood on Pyæmia, p. 2.

Galen and some of the other ancient physicians recognized the existence of septic poisoning, as is shown by the opinions expressed on the subject of putrid fevers. According to Galen, putrid fevers may either arise from the conversion of ephemerals, or originally from putrefaction of the fluids within the vessels.

Aetius states that they arise from constriction of the skin or viscidity of the humors, whereby the perspiration is stopped, and the quantity of vital heat so altered as to give rise to putrefaction, first of the fluids, and afterward of the fat and solid parts. When these corrupted fluids are contained within the vessels they occasion synochous fevers, but when distributed over the body they give rise to intermittents. Synesius and Constantinus Africanus give a similar account. Alexander gives an interesting and ingenious disquisition on the origin and nature of putrid fevers, one of the most common causes of which he holds to be the conversion of ephemeral fevers, and the inseparable symptoms being want of concoction in the urine and quickness of the pulse with systoles. This is the account of them given by most of the other authorities, both Greek and Arabian, so that we need not enter into any circumstantial exposition of their views. We shall merely give the brief account of those furnished by Palladius. There are, he says, two kinds of synochous fevers, the one being occasioned by effervescence, and the other by putrefaction of the blood; of these the latter are the more protracted and dangerous. In them the pulse is contracted, the heat pungent, and the urine white and putrid.⁴

⁴ Paulus Ægineta, trans. by Adams, vol. i. p. 236 (Sydenham Soc., 1844).

A new era in the literature of this subject dawned during the sixteenth century. Ambrose Paré and Bartholomew Maggi each published a work in which they pointed out the old errors and announced new truths. Paré's Treatise on Gunshot Wounds was published in Paris in 1551, while Maggi's treatise appeared a year later at Bologna. Paré gained his first experience in the treatment of gunshot wounds in 1536, which is described as follows: "The storming of the small mountain-fortress Villane, near Susa, probably gave him for the first time full occupation, and he followed in all things the example of older colleagues. Like them, although hesitatingly, he poured into the gunshot wounds boiling oil of elder to destroy the poison, but the oil fell short, and then he was compelled to dress the other wounded men with an ointment of oil of roses and turpentine. Fearing that the latter would soon become victims of the wound-poison, he passed a sleepless night, got up early to see the ill consequences, but was greatly surprised to find those that he had half given up free from pain and without inflammation or swelling, while those who had been treated with boiling oil lay in a state of fever, with great pain and much swelling. He therefore determined, as he tells us, never again to burn the poor subjects of gunshot wounds so cruelly."⁵ It will be seen that Paré's treatise on gunshot wounds was published fifteen years after this impressive experience at the fortress of Villane. In this work he sought to correct the prevailing idea that gunshot wounds were poisonous, and was ably supported in his effort by Bartholomew Maggi; but it required all the respect which Paré enjoyed in riper years to gradually obtain consideration for the new view. The idea that gunshot wounds were poisonous is supposed to have originated in the fact that in every war there are cases of acute sepsis, developed after the infliction of these injuries, which agree in all their essential points with the results of the bites of poisonous snakes. We are even informed that during the late Franco-Prussian War there were cases which even excited suspicion among the laymen that the enemy had used poisoned missiles.

⁵ German Clinical Lectures, 2d series (New Sydenham Soc., 1877), p. 65 et seq.

The nature of the error which Paré and Maggi endeavored to correct is shown by the declaration made by Johannes de Vigo at the commencement of the sixteenth century, who expressed in dogmatic form the views then firmly held by physicians. "A gunshot wound is a contused wound, he says, for the bullet is round; it is burnt, for the bullet is heated; it is poisoned, for the powder is poisonous. The poisoning is the essential condition; therefore the treatment must be directed above all to counteract this."

The next step was that a poisonous substance may develop itself or settle in the wound, and especially in gunshot wounds—a substance which has nothing to do with powder or lead. Paré himself adopted this view. When he took part in the siege of Rouen many wounds sloughed and had a cadaverous smell, and on opening the bodies of those who died numerous collections of pus were found in different parts full of greenish ill-smelling ichor. Besiegers and besieged believed themselves to be wounded with poisoned bullets. Paré looked for the cause in a deterioration of the air by the large quantity of decomposing substances, and he appears to have assumed, as is done at this day, a direct action of the so-called deteriorated air upon the wound itself.

The evil influence of air vitiated by the products of decomposition, not upon wounds only, but upon the organism generally, has never been lost sight of by physicians since that time. That rotten straw, decomposing bodies of men and animals, surfaces saturated with excrement, and overcrowding of badly-ventilated hospitals give rise to infectious fevers and unhealthy state of wounds is not a result of modern observation only. That it was a question of the processes of fermentation which became communicated to the body by means of the exciters of fermentation contained in the air was a view frequently adopted. "To quote one only out of many; John Pringle, in his Observations on the Diseases of the Army, published in 1775, devotes a chapter especially to 'Diseases resulting from Bad Air,' and his forty-eight experiments on septic and antiseptic substances contain numerous hints at attempts resembling those made at the present day to determine the antiseptic power of certain things. No advance was made, however, beyond vague surmises concerning the nature of the exciters of putrefaction, and they were for the most part looked for amongst the volatile, ill-smelling products of decomposition, and were believed to be extremely subtle gaseous matters."⁶

⁶ German Clinical Lectures, Second Series (New Sydenham Soc., 1877), p. 67 et seq.

Ambrose Paré (1582) first taught that secondary abscesses in surgical cases, "which he had observed in the spleen, lungs, liver, and other viscera, were due to a changed condition of the fluids produced by some unknown alteration in the atmosphere and determining a purulent diathesis."⁷ The following quotations force the conclusion that in the early history of medicine there was supposed to be some important relation between wounds of the head and multiple abscesses. "Nicholas Massa (1553) mentions a case of abscess of the left lung, following an injury of the head."⁸ "Valsalva (1707) was induced by his own observation to say that the viscera of the thorax were sometimes affected in wounds of the head." "Desault (1794) considered abscesses of the liver to be a very frequent sequence of head injuries."⁹ The fact that wounds of the head were frequently followed by abscesses of the lungs, liver, and other organs probably led to the opinion expressed by Desault, Barthez, Brodie, W. Phillips, Copeland, and others, that the disease had its origin in a nervous agency.¹⁰ "Bertrandi and Audouille (1819) sought for a mechanical explanation of the occurrence of hepatic abscesses after head injuries and in cases of apoplexy." Morgagni (1740) somewhat obscurely hinted at the doctrine of the reabsorption of pus—a doctrine which was afterward elaborated by Quesnay in 1819. Morgagni, after quoting a great number of instances of wounds of the head followed by visceral abscesses, opposes the idea of a mechanical transportation of pus thither, and states that abscesses are not confined to the liver and that they may follow wounds and ulcers of other parts besides the head. He ascribes their formation to particles of pus (not always deposited in the form of pus) resulting from the softening and suppuration of small tubercles, which, having been mixed with the blood and disseminated, are arrested in some of the narrow passages, perhaps of the lymphatic glands, and by obstructing and irritating these, as happens in the production of venereal buboes, and by retaining the humors therein, distend them and give origin to the generation of a much more copious pus than what is carried thither; and by this means, he says, we may also conceive how it is that much more pus is frequently formed in the viscera and cavities of the bodies than a small wound could have produced.¹¹

⁷ Braidwood on Pyæmia, p. 2 et seq.

⁸ Ibid., p. 2.

⁹ Ibid., p. 3.

¹⁰ Ibid., p. 10.

¹¹ Ibid., p. 3 et seq.

Cheston (1766) believed that the translation of matter from one point to another was a frequent occurrence after amputations of the larger limbs. John Hunter (1793), and after him Velpeau, demonstrated the existence of pus in the blood. Hunter believed that the pus was derived from the interior of the inflamed veins. He described three forms of inflammation of these vessels—viz. adhesive, suppurative, and ulcerative. Pyæmia he considered to be an aggravated form of phlebitis. Arnott (1829) concluded from his observations—1, That death does not result from the extension of the inflammation of the veins to the heart; 2, that the dangerous consequences of phlebitis have no direct relation to the extent of the vein which is inflamed; and, 3, that the presence of pus in the veins, though the principal, is not the sole, cause of the secondary affection. He accordingly opposes the idea of Abernethy, Carmichael, and others that the constitutional affection is owing to the extension of the inflammation to the heart. The publication of Arnott's and Dance's treatises led to the general opinion being held in England and in France that phlebitis and purulent infection were identical affections, or, at least, that the latter was invariably caused by the former.¹²

¹² Ibid., p. 14.

Cruveilhier (1829), admitting the doctrine of the formation of secondary abscesses being due to capillary phlebitis, further laid down an axiom, since proved untenable, that the foreign body introduced into the veins, whose elimination by the emunctories is impossible, will produce visceral abscesses similar to those which occur after wounds and operations, and that these abscesses are the result of capillary phlebitis of those viscera.¹³

¹³ Braidwood on Pyæmia, p. 14 et seq.

During the early part of the present century it was generally admitted by the best authorities that the symptoms and lesions in pyæmia were entirely due to the presence of pus in the blood, but whether absorbed from the wound or developed by an inflammation of the veins was at that time a disputed question.

Haller made the first experiments on animals with putrefying substances in the latter part of the eighteenth century, and was convinced that nothing destroys the animal fluids more powerfully than putrefaction. Gaspard (1822) published a complete work based upon his experimental research in regard to the action of putrefying substances on living organisms. He, having produced septic infection in animals by injecting into their blood pus or other putrefying substances, thus prepared the way for other experimenters, by whom he was quickly followed. Ernst R. Virchow repeated the experiments of Gaspard, and discriminated with greater precision between the surgical diseases—septicæmia with its sharply-defined group of symptoms, the opposite of pyæmia. Furthermore, "he showed that the changes in the veins which had been regarded as due to phlebitis were caused by the coagulation of the blood and by subsequent degenerative changes in the thrombi thus formed; that the infarctions and abscesses seen in the viscera were due to emboli which had become detached from softened thrombi; that, as the white blood-globules and pus-globules were identical in appearance, they could not be distinguished; and that it was improbable that pus-globules made their way into the blood."¹⁴

¹⁴ The International Encyclopædia of Surgery, ed. by Ashhurst, vol. i. p. 204.

Panum (1855) conducted a series of important experiments, and endeavored to separate the infectious substance and determine its real nature. He concludes that the real poison is not identical with any of the chemical combinations or any of the single substances which have until now been isolated by chemical analysis from the products of nitrogenous decomposition, but adds that it is probably a concealed ferment belonging to the so-called extractive matters—carbonate of ammonium, leucin, tyrosin, fatty acids, acetic acid, etc. Furthermore, that the putrid poison is stable, fixed, and non-volatile; that it is neither decomposed by boiling nor by evaporation to dryness; that it is insoluble in absolute alcohol, but soluble in water; that the albuminous substances found in putrefying liquids become venomous only because they are impregnated with the septic poison; and that washing these substances in a large quantity of water renders them innocuous; and that the energy of these putrid poisons can only be compared to the venom of serpents, curare, and other vegetable alkaloids.

The prize offered by the Faculty of Medicine at Munich for the best essay on the action of putrefying substances in the animal organism was awarded to Hemmer in 1866. His essay was distinguished for its accurate delineation of the pertaining literature and for the number of experiments reported, while his conclusions bear a striking resemblance to those of Panum.

Bergmann in 1868 sought to determine the poisonous element contained in decomposing animal substances, and for this purpose chemically treated putrid fluids, hoping to find the agent that would excite all symptoms of septic poisoning. He obtained a body of this nature from decomposing yeast, which he called sepsin, although we have no proof that either he or any one else has ever found the same in pus or any decomposing animal matters; and even if it had been found in these, it would then become necessary to demonstrate the fact that no other substance contained in the putrefying liquids could produce septic poisoning. Many other experiments, similar to those which have just been mentioned, were made in the mean while by Magendie, Stich, Billroth and Hufschmidt, O. Weber, Duprey, Learet, Urfrey, Saltzman, Fischer, Frese, Muller, and others. Bergmann had extracted the sepsin from yeast, but Schmidt and Petersen (1869) were able to obtain it from putrefied blood. In 1869, Zuelzer and Sonnenschein claimed, on the contrary, to have separated a new, unnamed septic alkaloid, which was not the sepsin, and the action of which resembled that of atropine and hyoscyamine. Nevertheless, the separation of the sepsin or of the alkaloid of Zuelzer seemed to demand a talent in the manipulator which is not possessed by everybody, and rare are the chemists who possess it—so rare that these substances are not yet either officinally recognized or classified. The attention of the medical profession had now become thoroughly fixed on the chemical character and the physiological action of these newly-discovered substances. It is therefore only natural that we should find during the next few months that the medical societies were much occupied with discussions on these subjects, although no important progress seems to have been made.

Political events now gave a new direction to thought, and the Franco-Prussian War filled the hospitals of both nations with wounded in which there was opened a grand field for the practical study of purulent infection in all its various forms. Humanity now demanded the best efforts of the medical profession. Neither the mechanical nor chemical theories had ever yielded practically any beneficial results; consequently, something better was demanded in this emergency. It was during this important epoch that the germ theory began to assume form and to attract some general attention in the medical profession, although Schroeder and Dusch had shown in 1854 that the filtration of the air through cotton was sufficient to prevent the putrefaction of albuminous substances which had been previously boiled. Pasteur also demonstrated the existence of germs in the air in 1863, and likewise showed their agency in the process of fermentation.

Lister began the antiseptic treatment of compound fractures in 1865, although he did not publish his report until 1867. The cotton-wadding treatment of wounds, which is based on the fact that the air passed through cotton is freed by it from all germs, was first employed by Alphonse Guérin, who refers to it in the following language: "In the latter part of 1870 I had the idea that the cause of purulent infection existed in the germs or ferments which Pasteur had discovered in the air. It was at the end of the war; all the cases of amputation had succumbed to the purulent infection, and not a single large wound escaped the scourge. The studies which I had made from the month of September to the end of December in 1870 had confirmed me in the opinion that purulent infection is neither due to phlebitis nor to the absorption of pus. I believed more firmly than ever that the miasms emanating from the pus of the wounds were the real cause of this frightful malady to which I had been compelled to see the wounded succumb, whether they were treated with charpie or cerate, whether with the lotions of alcohol or of carbolic acid applied several times a day, and which was soaked up by the linen which remained in contact with the wounds. But this miasmatic theory remained, nevertheless, useless, since from 1847, when I professed it, the cases of amputation in my service succumbed to purulent infection in about the same proportion as those who were cared for by my partisan colleagues did from the absorption of pus or the inflammation of the veins. In my despair, seeking constantly a means to prevent this terrible complication of wounds, I had thought of the miasm of which I had admitted the existence, because I was not otherwise able to explain the production of the purulent infection, and which was not only known to me by its deleterious influence, but which appeared to consist of living corpuscles of the nature of those that Pasteur had seen in the air; and then the history of the miasmatic poison possessed for me a new clearness. So, said I then, the miasms are the ferments. I am able to protect the wounded against their fatal influence by filtering the air, as Pasteur had done, while maintaining, in opposition to Pouchet of Rouen, that there is no spontaneous generation. I thought then of the cotton-wadding treatment, and had the satisfaction of seeing my anticipation realized. It was from this time that dates in reality the theory of germs or of ferments as a cause of purulent infection."¹⁵

¹⁵ Nouveau Dictionnaire de Médicine et de Chirurgie pratiques, t. xxx. p. 265.

A series of important experiments were made in 1872 by Coze and Feltz, which consisted in injecting into the jugular vein and the subcutaneous cellular tissue putrid liquids; and they record, among other interesting results observed by them, that the blood of the animal thus destroyed always contained infusoria. These experiments have been repeated and their results confirmed by several observers, and in particular by Davine in 1872.

Another series of experiments were made by Behier and Lionville, which absolutely confirmed those of Coze and Feltz; they likewise found in the blood rounded and rod-shaped corpuscles possessed of movements more or less energetic. Vulpian also confirmed the results obtained by Davine and Behier. He says: "It will not do to deny to the immovable or movable vibriones and corpuscles found by Coze, Behier, and Davine a very important rôle, because they are not the essential contagion of the poisonous blood; it is at least necessary that they should be there in order to produce the alterations which have occurred in this fluid." Chauveau has experimented extensively, and likewise admits the action of the septic vibriones of Pasteur.

Pasteur has made known the result of his investigation in communications to the Academy of Medicine in 1877, 1878, and 1879. There exist, according to him, two principal vibriones—the pyogenic, or the producer of pus, and the septic, the producer of the properly so-called septicæmia. But the latter is not a unique disease, and, as we have seen from the outset, there are confounded under this name different states, light or grave, corresponding with as many forms of vibriones.

The questions of greatest practical importance in regard to this whole group of diseases seem to us to be, as expressed by Dr. Budd, where and how the specific poisons which cause them breed and multiply; and all who have closely followed the scientific investigations bearing on these points which Prof. Tyndall has conducted during the past few years, and who have repeated even a portion of his experiments, cannot fail to be powerfully impressed with the value of the views which he embodied in his work entitled Floating Matter of the Air.

NOMENCLATURE.—The want of a systematic classification of the various morbid conditions arising from septic infection has long embarrassed alike authors and students, and even at the present time the vague manner in which the terms pyæmia and septicæmia are used leads to much confusion. The Pathological Society of London appointed, in 1869, a committee to investigate the nature and causes of those infectious diseases known as pyæmia, septicæmia, and purulent infection. This committee, having spent ten years in the study of these affections in connection with nearly all the large hospitals of London, report the following: "Summary.—It would seem, from a careful study of all the cases here collected, that it is probable that the diseases commonly known clinically as pyæmia and septicæmia may be grouped as follows: 1. Septic intoxication.—The effects of poisoning by the chemical products of putrefaction. A non-infective disease. 2. Septic infection.—A general infective process arising from the introduction of some peculiar constituent of putrid matter into the blood-stream. It is supposed by some to be due to the multiplication of living organisms in the blood, and by others to the effect of a non-organized ferment. It terminates fatally without secondary inflammations. 3. Pyæmia (for want of a better name).—An infective process probably, similar in nature to septic infection, but differing from it by giving rise to local inflammation and suppurations, often complicated by thrombosis and embolism, probably due to the blood condition. 4. Thrombosis with softening and decomposition of the thrombus and embolism, causing local abscesses in the viscera wherever the septic emboli lodge, but without the development of any general infective process. 5. Various combinations of one or more of the foregoing conditions in the same subject. 6. Infective periostitis or acute necrosis. 7. Infective endocarditis or ulcerative endocarditis. 8. Infective myositis. 9. A group of obscure cases in which it is impossible to form any idea as to the exact nature, often called spontaneous septicæmia or pyæmia."¹⁶

¹⁶ Trans. Pathological Soc. of London, vol. xxx. p. 38.

It will be observed that the earlier writers on medicine, although aware of the existence of septic diseases, wholly failed to discriminate between pyæmia and septicæmia until 1848, and even since that date these terms have been only partially adopted by authors, by whom frequently the meaning of the same word has been so modified as to refer to essentially different conditions. Custom having fully sanctioned the use of these terms, it is now thought that a separate consideration of their nomenclature may be advantageous, and consequently we shall pursue this course.

NOMENCLATURE OF PYÆMIA.—In Dunglison's Medical Dictionary the definition given to pyæmia is, "Pyohæmia," and the latter word is defined as follows: "Pyohæmia, Pyæmia, Pyohémie (F.), from pyo, and [Greek: haema], 'blood;' alteration of the blood by pus, giving occasion to the diathesis seu infectio purulentia."

The committee appointed by the Pathological Society of London in 1869 report on this subject as follows: "The most common definition of pyæmia is, no doubt, that adopted by the College of Physicians in the nomenclature of diseases. It is as follows: 'A febrile affection resulting in the formation of abscesses in the viscera and other parts.'"

Birch-Hirschfeld includes under the name pyæmia "all cases in which any general infective process is set up as a secondary consequence of a wound."¹⁷ Virchow has proposed the name ichorrhæmia. O. Weber uses the name embolhæmia for the condition in which emboli are found in the blood. Hueter in pure cases of purulent infection without metastasis calls the disease pyohæmia simplex; in cases with metastasis, pyohæmia multiplex; and when complicated with septicæmia he designates it as septo-pyohæmia. The term hospitalism has been applied to this disease by Erichsen and Sir James Y. Simpson, and the former remarks that "the term pyæmia is used in a very wide and elastic manner, and by many is made to include various forms of blood-poisoning."¹⁸ Billroth says: "Pyæmia is a disease which we believe to arise from the taking up of pus, or of the constituent parts of pus, into the blood." Koch employs the term pyæmia merely to denote a general affection accompanied by metastatic inflammation and suppuration.

¹⁷ Trans. Pathological Soc. of London, vol. xxx. p. 22.

¹⁸ On Hospitalism, p. 73.

The French definition and nomenclature of pyæmia, according to Guérin, is as follows: "Purulent infection, or pyohæmia, purulent fever, surgical typhus." The purulent infection is a poisoning of the blood, which terminates by the formation of multiple abscesses, which have been improperly known under the name of metastatic abscesses.

From 1820 to 1870 surgeons admitted that these abscesses were the result of a phlebitis having its origin in a wound exposed to the air. Therefore, this disease was variously designated under the name of phlebitis, pyohæmia, or purulent infection. Tessier called it purulent diathesis; "in 1847, I compared it to the typhus, and, as the poison is absorbed from the surface of the wound in the purulent infection, I gave it the name of surgical typhus or purulent fever."¹⁹

¹⁹ Nouveau Dict. de Méd. et de Chir. pratiques, t. xxx. p. 222.

Having given enough on this subject to answer our purpose, we will consider the nomenclature of another septic complication.

NOMENCLATURE OF SEPTICÆMIA. The term septicæmia was first employed by Piorry, and was applied for a considerable time to all those diseases in which the blood was submitted to a septic influence. Therefore, the term was made applicable to the morbid conditions existing in anthrax, glanders, typhus and typhoid fevers, variola, and also all forms of purulent and putrid infections. Guérin now adds: "Fortunately, for several years the most competent authors seem to have wished to reserve the name of septicæmia for what surgeons call putrid infection, and for the morbid state that the experimenters produce by the injection of putrid material into healthy animal tissues; it is consequently the experimental septicæmia which we aim at first and foremost."²⁰

²⁰ Nouveau Dict. de Méd. et de Chir. pratiques, t. xxx.

Dunglison defines septicæmia with a single word, septæmia. The same authority gives the following derivation and definition to septæmia: "From [Greek: sêptos], 'rotten,' and [Greek: haema], 'blood.' A morbid condition of the blood produced by septic or putrid matters."

Sanderson says: "What I mean by septicæmia is a constitutional disorder of limited duration, produced by the entrance into the blood-stream of a certain quantity of septic material. It must, therefore, be regarded less as a disease than as a complication, differing from pyæmia not only in the fact that it has no necessary connection with any local process, either primary or secondary, but also in the important particular that it has no development."²¹

²¹ British Medical Journal, Dec. 22, 1877.

Both Davine and Koch designate as septicæmic all cases of general infection from wounds in which no metastatic changes occur. "Birch-Hirschfeld limits the term septicæmia much in the same way as Sanderson. He describes as septicæmia those cases in which the disease results merely from the absorption of the products of putrefaction, and regards it merely as a process of poisoning, such as might arise from the injection of any other noxious chemical substance into the blood. Pyæmia, on the other hand, he considers a truly infective process, probably due to the entrance of specific organisms into the body. He would therefore include many of the cases described by Koch as septicæmia under pyæmia."²²

²² Trans. Pathological Soc. of London, vol. xxx. p. 9.

Billroth defines septicæmia as an "acute general affection which arises from the taking up of various kinds of putrid substances into the blood, and it is believed that these putrid substances so change the quality of the blood that it can no longer fulfil its physiological functions."²³

²³ Lectures on Surgical Pathology and Therapeutics (trans. from 8th ed.), vol. ii. p. 41.

Heuter defines septicæmia as a fever caused by the entrance into the circulation of the products of putrefaction from local centres of decomposition. He draws no clear distinction between an infective and a non-infective form, but the affection he describes as pyæmia simplex or pyæmia without metastasis seems to include many cases which Davine, Koch, and others would include under septicæmia.²⁴

²⁴ Trans. Path. Soc. of London, vol. xxx. p. 9, 1879.

Having before us the views of some of the prominent authors who have written upon the nomenclature of pyæmia and septicæmia, we observe that the use of these terms is based either on known or imaginary morbid conditions of the body, more especially of the blood. It therefore seems that the first step toward determining the proper limit within which these terms can be employed consists in learning their accurate meaning, which is fortunately clearly shown by their derivation. The next step consists in the application of these terms to the morbid conditions which are described more or less completely by these words. It may be here added that there will be frequently required for a full and definite expression certain modifying words, and consequently we may properly employ such phrases as puerperal septicæmia, spontaneous pyæmia, etc.

Having carefully examined the terms employed by various authors in connection with the morbid changes which are known to occur in certain cases of septic contamination, we give our preference to the following nomenclature: Septicæmia, septo-pyæmia, pyæmia simplex, and pyæmia multiplex.

The term septo-pyæmia is applied to a morbid condition possessing certain peculiarities of both septicæmia and pyæmia, and it is supposed to arise from the absorption of both poisons; the term pyæmia simplex is applied to a pyæmic condition in which there is no metastasis; while the name pyæmia multiplex is given to that form of disease which is characterized by the existence of metastatic abscesses. It may be well to add here that this nomenclature is not intended to cover all cases of septic poisoning, but to be applied to those cases only in which the morbid changes give to the terms a certain degree of appropriateness.

Septic poisoning may be justly regarded as a single chain composed of many links. Take, for example, a case of amputation of the thigh, followed within a few hours by traumatic fever, later by septicæmia; afterward there may be developed secondary fever; formation of ichorous pus, with absorption and its concomitants; pyæmia, accompanied by embolism, thrombosis, abscess in the lungs, liver, etc. To these may also occasionally be added phlebitis and inflammation of the joints, terminating speedily in suppuration. This chain may in this case be further lengthened or varied with traumatic erysipelas or with hospital gangrene. In fact, the variations in these cases are very numerous, and all these conditions, together with many others, are due to septic blood-poisoning.

ETIOLOGY OF PYÆMIA.—Four theories have been advanced at different times to explain the etiology of pyæmia, and they have been designated as follows: the mechanical, the nervous, the chemical, and the germ theories respectively; and their action is based on the following hypotheses: 1, that pus enters the blood, circulates in it, and acts as a poison; 2, that an irritation is excited in certain visceral organs in sympathy with inflammation of the fibrous membranes of the cranium or the bones of the upper or lower extremity, and there is thus produced a metastasis to these organs of an ichorous miasm or of a fluid which is more or less acrid; 3, that a chemical poison is generated from the pus in the wound, and when it is absorbed produces pyæmic manifestations; 4, that the putrefaction of pus in wounds is caused by a microscopic organism which enters the circulation and produces pyæmia.

The first hypothesis was somewhat modified, as we have already mentioned, by John Hunter and others, who advanced the idea that pyæmia consisted essentially of a phlebitis, and that the pus found in the circulation had its origin within the veins. However, it has since been shown conclusively that pyæmia cannot be produced by the injection of healthy pus into the cellular tissue or veins. This fact having been generally admitted by the profession, it is thought unnecessary to adduce here either the experiments or the arguments which have been accepted as conclusive on this important point. It is not even necessary to bring forward the disputed question of the possibility of the entrance of pus into the blood, since laudable pus does not produce pyæmia. In fact, we have reached a point in the progress of medicine when the discussion of either the first or second hypothesis ceases to be interesting to medical men. Consequently, our chief interest in the study of the etiology of pyæmia centres in the third and fourth hypotheses; and we believe that it may be safely asserted that the origin of this disease has been fully demonstrated by an almost unlimited number of experiments.

The injection of pus into living animals produces local, remote, and constitutional symptoms. The character of these symptoms depends principally on the kind of pus, laudable or ichorous, the quantity injected, and the site of the injection. It will be readily perceived that in cases where the pus is thrown directly into a vein the local symptoms would be unimportant, while the danger of remote trouble—metastatic abscesses in the lungs, liver, etc.—would be very great; but should the injection be made into the connective tissue, then the relations would be reversed. Constitutional symptoms may exist in both cases, but will differ in character and degree.

In regard to the character of the pus, and its agency in the production of this disease, Billroth says: "The old view, that pyæmia is only induced when decomposed pus (ichor) is reabsorbed, is entirely erroneous. There are cases where decomposed, putrid pus enters the blood, and which present a combination of the symptoms of septicæmia and pyæmia (septo-pyæmia of Hueter)."²⁵ Dupuytren failed to produce metastasis by injections of pus into the veins of dogs; these results were confirmed by Boyer, who only obtained metastasis when he used ichorous pus in his experiments. The same results are recorded in the works of Günther and Sedillot, based on numerous experiments. Beck made fourteen experiments very carefully, but did not succeed in producing metastasis in a single case. The same results are recorded by a commission of the Physiological Society of Edinburgh. O. Weber has recently shown by extended experiments that carefully filtered pus will not produce metastatic abscesses in the lungs. Therefore, it may be considered as proved that fluid pus injected into the veins of an animal produces no metastatic points of inflammation.

²⁵ Surgical Pathology, p. 344.

It should not be supposed, however, that because injection of fresh (non-ichorous) pus failed to produce metastatic abscesses, it was therefore without results, as the earlier experimenters thought. Billroth and O. Weber have shown by their recent experiments that these injections are uniformly followed by fever, and, if subcutaneous, by abscess; and further, that injections of fresh pus produce even a higher temperature than do those of ichorous pus; but the pus taken from cold abscesses has apparently very slight effect. The fresh non-ichorous dried pus was found to possess in a similar degree the power to excite inflammation and suppuration; even the removal of the albumen did not change its character or power. It will be observed that these injections caused not only local inflammations, but severe constitutional symptoms, as high temperature, etc. Experiments have thus far completely failed to show the agent that excites the inflammation, although it is generally admitted that it at least exists in the molecular bodies.

Virchow and Panum have shown conclusively by their experiments on living animals that the introduction of foreign bodies into the veins—as powdered coal, wax balls, and quicksilver—fail in all cases to produce metastatic abscesses in the visceral organs or symptoms of pyæmia. These foreign bodies were frequently found blocking up the terminal branches of the pulmonary artery, in some cases encapsulated, frequently resembling miliary tubercles, and occasionally surrounded by evidences of slight local inflammation, but in every instance without suppuration. The same experimenters, however, observed that the introduction of ichorous pus and decomposing animal tissue into the veins was attended with the formation of metastatic abscesses and other symptoms of pyæmia. They therefore conclude that the introduction of putrid animal substances into the veins, and the further transport of the same to the branches of the pulmonary artery, produce metastatic abscesses, and that the origin of these deposits is independent of the mere stopping up of the branches of this artery.

The occlusion of the blood-vessels in this diseased condition is a subject which has given rise to much discussion. Some of the earlier writers supposed this phenomenon constituted the disease pyæmia, while others believed it to be the essential cause. Roser says: "But the thrombus is, as can be easily proved, not the cause, but only a symptom, of pyæmia. If a surgical patient—e.g. one suffering with an injury of the head—is attacked by inflammation, and occlusion of a large vein, as of the common iliac vein, for instance, then there are three different theories for the inflammation of the occluded vessel—viz. Hunter's, Rokitansky's, and Virchow's. According to the old Hunterian phlebitic theory, the coagulation of the blood should be the result of the inflammation of the vein. On account of the circumstances under which the coagulation of the blood in the vein has occurred, one might suppose that the cause must be the oozing of coagulable exudation from the inflamed wall of the vein, but pathological dissections, especially Rokitansky's, would not accord with it. Large veins were found plugged up without the existence of corresponding indications of inflammation, and perfectly clear indications were often present that occlusion had preceded the inflammation. Consequently, the occlusion of the vein was the primary condition, and this must be explained in some other way than by its inflammation. Rokitansky in his theory recognized an independent disease of the blood. Yet it does not appear, on examination of the morbid conditions, that this theory can account for them. If it is recognized as correct that a primary disease of the blood is to be admitted, yet the coagulation of the blood in a large vein has not been traced back to it. It remained wholly unexplained why a single vein, especially one so large and strong as the common iliac, should become the seat of the local coagulation. The necessity of finding a local basis for the local coagulation could not be denied. For that reason it was greeted as a highly desirable advance when Virchow pointed out that the occlusion of such large veins could be dependent on the coagulation of the blood in the concave spaces behind the valves of the veins, or through the coagulation in the small branches—e.g. the hypogastric veins, which is gradually carried forward until it reaches the common iliac, and by continual increase this vein may also be filled up. At the same time, it was demonstrated that not infrequently, much oftener than was formerly supposed, the coagulated masses of blood are broken up and carried farther on in the circulation, in this manner producing occlusion of the pulmonary artery or its branches."²⁶

²⁶ Archiv der Heilkunde, Erst. Jahrg., Erst. Heft, S. 4.

The examination of this subject finally brings Roser to this conclusion: "Contamination of the blood is essentially the primary cause of pyæmia; thrombosis is only a result of this morbid contamination, and cannot, therefore, be regarded as the cause of pyæmia, but only as an apparent part, as one of the symptoms of the same."²⁷ The opinion here expressed by Roser I believe to be the one generally entertained by the profession at this time.

²⁷ Ibid., S. 43.

In cases of pyæmia there are recognized two principal sources of contamination of the blood—viz. the wound itself, and the vitiated condition of the atmosphere surrounding the patient—contamination, in the first place, directly from the wound through the blood-vessels; and in the second, by the passage of disease-germs or of the poisonous elements into the blood along the respiratory tract. E. Wagner says: "The latest examinations in regard to the vegetable parasites have made it very probable not only that these are the active agents, but also—what has been clinically quite generally accepted—that septicæmia and pyæmia owe their origin to different plants (the first to rod bacteria, the latter to globular bacteria); and, finally, that both may combine."²⁸ These germs may be generated in the wound or be received into it from the surrounding atmosphere. The character of the wound and the conditions surrounding the patient thus become important subjects for the consideration of the surgeon.

²⁸ Manual of General Pathology, p. 593.

It has been observed, and is now generally admitted, that wounds complicated with a fracture of the long bones of the extremities, opening large medullary cavities and accompanied by extensive laceration of the soft parts, always increase the danger of blood-poisoning. This fact may be more thoroughly understood by a brief consideration of the condition of the parts. Frequently in open fractures large quantities of pus constantly remain in contact with the surface of the wound, while detached fragments of bone, which become speedily necrosed, move about with every motion of the injured limb, lacerating more or less the surrounding tissues, and thus exciting inflammation and suppuration. The periosteum becomes inflamed; a widespread suppurative periostitis is the result; necrosis of the bone from insufficient nutrition follows, while mechanical pressure on the pus aids in its absorption. The medulla frequently takes on suppurative inflammation, and here the surgeon fails to receive prompt warning of danger; slowly the suppuration progresses, without pain or other symptoms unless the disease has extended to the other tissues; the medullary cavity at the fractured end of the bone may be completely or partially occluded by a new osseous formation; and in such cases the absorption of pus by the comparatively large venous vessels of this cavity is greatly facilitated.

The soft parts may also be the seat of dangerous trouble. The same force that produced the wound and fracture may have also contused the soft parts, destroying in a greater or less degree their nutrition, thus giving rise to gangrenous sloughs, or in other cases to the formation of abscesses, etc. I will also call attention to the fact that the laudable pus in these cases is most favorably situated for a rapid change into that commonly called ichorous. The heat of the parts and the contact of the pus with the atmosphere will not fail to effect its rapid decomposition.

ETIOLOGY OF SPONTANEOUS PYÆMIA.—It is unquestionable that cases of true pyæmia have been observed in which the etiology was not traceable to a wound; and it is equally certain that this failure to discover such a source of contamination in the majority of cases is no proof that it did not exist. When it is remembered that a large portion of the alimentary canal, the respiratory and the genito-urinary tracts, are so situated that the existence of a contaminating wound might be absolutely undiscoverable, we are compelled to admit the possibility of a local centre of contamination in all these cases. But the question may be asked here with propriety, "Is fatal pyæmia, independent of a wound, ever produced by breathing vitiated air?" The answers to this question must generally be a negative, although it is certainly true that poisoning of the blood does take place to a certain degree, as is abundantly shown by the different symptoms arising in patients thus exposed who are not suffering with wounds. It is said that dogs exposed in this way are found to rapidly emaciate and suffer from severe and constant diarrhoea. The various symptoms arising in patients confined in overcrowded and pus-infected wards, among which may be mentioned loss of appetite, with diarrhoea and emaciation, are too well known to require an enumeration here. Therefore it appears highly probable that living in and breathing a vitiated atmosphere may act as a strongly predisposing cause, only requiring a slight scratch or abrasion of the skin, in which the infection may be said to act as an exciting cause of pyæmia.

In reference to such complications the following questions are asked by Roser: "Is it a specific deleterious material, a miasmatic or contagious disease-poison, or, as it is generally expressed, a zymotic agent? Must we regard each particular typhus-like fever, with its remarkable changes of blood, with its various localizations in all the organs and membranes, with its chills, furred tongue, petechiæ, delirium, etc., as we regard typhus, scarlatina, variola, etc.? or, as Virchow teaches us, is this pyæmia, so greatly feared by all surgeons, only an ontological idea? Is the word pyæmia only a general name for three different conditions—viz. leucocythæmia, thrombosis, and embolism, or ichorrhæmia and septicæmia? or are there, as many have supposed, two ways in which pyæmia may originate? Is there one primary miasmatic pyæmia analogous to the other epidemic, so-called zymotic diseases? and again, a secondary pyæmia arising from suppurative inflammation, wherein the poison is formed in the patient's own body, which is infected by a single organ?"²⁹

²⁹ Loc. cit., S. 39.

That this disease is caused by a specific deleterious material in the large majority of cases is no longer a question for discussion. The only question to consider is, whether it always arises from the same cause. Is it possible for pyæmia to originate spontaneously? Are there any cases of sporadic origin, or are they always due to endemic or contagious influences? No definite answer can be given to these questions, although, undeniably, the weight of the argument is strongly opposed to a sporadic origin. The term miasmatic, as used by Roser, probably refers to the vitiated condition of the atmosphere, as seen in the overcrowded surgical and obstetrical wards of hospitals. In no other sense can the word be appropriately used in connection with the subject of pyæmia. It is true, pyæmic diseases are found to prevail at certain seasons and in certain localities much more extensively than under other circumstances. The same, however, is true of cholera, typhus fever, scarlatina, variola, and other contagious diseases. That pyæmia is contagious has been frequently demonstrated. I therefore conclude that the prevalence and spread of this disease must be explained by the same rules as are applied to the existence and propagation of these allied affections.

This inquiry into the etiology of pyæmia brings before us again the four hypotheses which have been given in explanation of the same number of theories. The first and second have been already abandoned by the medical profession, after it was satisfactorily demonstrated that they were based on false theories, and consequently there remain for our consideration only the third and fourth.

The third hypothesis assumes that a chemical poison is developed in the wound-secretions, which when absorbed produces pyæmia. An examination of the subject does not justify us in asserting that this proposition has been proved, although it is certain that the results of experimental inquiry demand for it a more extended investigation. In all the analyses which have thus far been made the investigators have entirely failed to give us an adequate knowledge of this poison, and not a word has ever been said in regard to the agency by which it is produced, although it is universally admitted to have been only obtained from decomposing animal substances. It is therefore pertinent to the continuation of this inquiry to ask, By what agency is the putrefaction of animal substances produced? It has now been fully shown that there can be but one answer given to this question—viz. the putrefaction of albuminoid substances can only be effected by living organisms. We therefore conclude that the fourth hypothesis brings us at least one step nearer the correct explanation of the etiology of pyæmia than the third, since we justly assume that if there is a chemical poison in decomposing albuminoid substances, it is produced through the agency of living organisms.

ETIOLOGY OF SEPTICÆMIA.—The first question which arises in the discussion of the etiology of this morbid condition is entirely dependent on the scope which we give to the word septicæmia. Sternberg says: "The view which is entertained by high authorities, upon clinical and experimental evidence, is that there are two forms of septicæmia—the one a septic toxæmia due to the effects of a chemical poison or poisons evolved during the putrefactive decomposition of certain organic substances, especially of nitrogenous animal products; the other an infective disease produced by the rapid multiplication in the body of the infected animal of a parasitic organism. The best-studied and most widely known form of septicæmia, due to the presence of a parasitic organism, is the disease known as anthrax—charbon of the French, milzbrand of the Germans—but several other varieties are now well established, in which similar symptoms and pathological results are produced by organisms morphologically different from the bacillus anthracis. Among these may be mentioned the form of septicæmia in the mouse, so well studied by Koch, which is due to a minute bacillus, and the form of septicæmia in the rabbit, produced by the subcutaneous injections of human saliva, due to micrococci, which has been studied by Pasteur, Vulpian, and myself independently."³⁰

³⁰ Amer. Jour. Med. Sci., July, 1882, p. 70.

The terms septic toxæmia and septic intoxication are applied indiscriminately to the same disease, and the committee appointed by the London Pathological Society to investigate the nature and cause of those infectious diseases known as septicæmia, etc. further report that "ordinary wound-fever is merely septic intoxication in a very mild form, and it is only necessary for the dose absorbed to be sufficient in quantity for fatal consequences to ensue. Septic intoxication is, therefore, of the commonest possible occurrence as a complication of severe surgical injuries, but it is in so mild a form as to bear but little resemblance to that experimentally produced on animals."³¹ The question which now arises is, Shall septic intoxication be classified with septicæmia?

³¹ Trans. Pathological Soc. of London, vol. xxx. p. 14.

We have been long accustomed to speak of this complication as a surgical or traumatic fever; and consequently any change in this classification must necessarily lead to confusion. Furthermore, it is now generally supposed there is much difference in the etiology of these morbid conditions. It is claimed that septic intoxication arises from the absorption of a chemical poison evolved through the agency of living organisms during the process of putrefaction in a wound, and that the conditions are unfavorable for their development within the blood or tissues of a living animal; but in true septicæmia the organisms are developed in the wound during putrefaction, and then find their way into the blood and tissues of the body, where they rapidly multiply. Consequently, the former condition tends to a rapid recovery—unless the quantity of poison primarily admitted to the system has been excessive—while the latter tends to a fatal termination.

Septic intoxication is regarded as a non-infective disease, and true septicæmia as an infective malady. The only etiological similarity between these morbid conditions is found in the fact that they take their origin in putrefaction, which is effected by the action of different organisms possessing marked morphological differences and requiring essentially different surroundings for the maintenance of life and reproduction. Thus, it is supposed that in cases of septic intoxication the organism by which putrefaction is caused in the wound-secretions can only live in the open air, and that its life is commonly only of a few hours' duration. The brevity of bacterial action in this instance may be due to a failure of the absorptive power or to a changed condition in the wound-fluids, rendering them unfit to support the organism.

It is now a well-recognized fact that all septic absorption ends so soon as the wound-surfaces are covered with healthy granulations, but that septic absorption, which produces septic intoxication, is most commonly of a much shorter duration, and, consequently, that the wound complication, which I prefer to designate traumatic fever, is essentially an acute disease, and can only be lengthened out by unusually favorable circumstances for the continuance of the absorption of the poison by which it is produced. The severity and danger of the disease will necessarily depend on the amount of poison absorbed and the resisting power of the patient; but since there is no multiplication of the materies morbi within the body, a rapid elimination by the natural emunctories may be reasonably expected under favorable circumstances.

It should be observed here that the etiology of septicæmia differs from that of traumatic fever, since the organisms in the former condition are first formed in the wound-secretions, but quickly enter the body, where they rapidly multiply; consequently, Chauvel has defined surgical septicæmia as follows: "The particular intoxication which results from the penetration and multiplication in the body of a specific microbe designated by Pasteur under the name of septic vibrio." The bacterial origin of this disease is now generally accepted, and the only question in the professional mind seems to be whether the organisms are the direct or indirect cause of the malady.

There are also some other interesting questions which have arisen in connection with the study of this subject, and are thought to be of sufficient importance to merit mention here. It has long been known that dissecting wounds are most dangerous when made while examining the body very soon after the death of the subject. Recent observations seem to justify the conclusion that the greatest activity of the septic agent is often, if not always, attained before the odor of putrefaction has become fairly perceptible; and even before this odor has reached its maximum degree of offensiveness the danger from septic poisoning has generally disappeared. In some cases septic intoxication is promptly followed by a slight inflammation in and about the wound, which may entirely disappear within a few hours, but only to reappear after a lapse of eight to fifteen days, with the first vigorous physical exercise of the patient. Two cases of this kind have recently come under my observation. In both instances the wounds were located in the hands, and the exercise which developed the septicæmia consisted in rowing a boat, and while thus engaged the local symptoms reappeared with such severity as to cause the patients to quickly discontinue the labor. The reappearance of the local inflammation in both these instances was quickly followed by a rigor and the rapid development of other constitutional symptoms, although prior to the recurrence there was no pus, nor even marked inflammatory action, in any part of the hands.

Professional attention was first called to the above-stated facts by Panum in 1855, who discovered that the maximum toxic action of putrid substances is generally developed during the first hours of bodily activity. In this stage of incubation in cases of surgical septicæmia, if we admit the bodily action as an etiological factor, we observe a striking resemblance to one of the leading characteristics of all the infectious diseases, which unquestionably depend on some sort of septic poison. Furthermore, this analogy becomes most striking if we contrast the effects arising from dissecting wounds with those of the bites of poisonous serpents and rabid animals.

Further investigation is required to settle the perplexing questions of etiological and pathological differences in these allied morbid conditions, for although much has been accomplished during the last two decades, still much more remains to be done. It has only recently been discovered that the septic material in septicæmia is absorbed by the lymphatics, while in pyæmia the poison enters the body through the veins.

ETIOLOGY OF SEPTO-PYÆMIA.—It is now generally admitted that remittent fever and typhoid may be associated, and this morbid condition is commonly designated by the term typho-malarial fever. The etiology is unquestionably dependent upon the action of the two distinct and entirely dissimilar poisons. Scarlatina is likewise frequently complicated by diphtheria, and here we have the combined action of two poisons, each commonly designated as septic and supposed by many physicians to be similar.

In a like manner, it is believed that septicæmia and pyæmia may be associated, and take their origin in dual poisons; but since the etiology of both these morbid conditions has been already described, it is not deemed necessary to dwell longer on septo-pyæmia under this division of our subject.

PATHOLOGY OF PYÆMIA.—The study of the pathology of pyæmia is advanced by adopting the following classification, which is based on recognized post-mortem lesions. The pathological appearances in these forms of the disease differ widely, although the clinical symptoms are often similar. In pyæmia simplex the pathological conditions are essentially more negative. This variety of the disease can only destroy life by the height and duration of the fever which is maintained in connection with the continued existence of ichorous pus. There is found, as an essential basis of this form of disease, extensive suppuration in the subcutaneous tissues.

The arguments in favor of the admission of pus-corpuscles into the blood are as follows: 1. The blood in pyæmia is known to contain more white granular spherical bodies than are normal. The question has been raised, Are they pus-cells or white blood-corpuscles? The answer is difficult, and has not yet been attained. Virchow, in the mean time, has proved that we cannot differentiate, morphologically, between the blood- and pus-corpuscles. 2. Cohnheim has demonstrated the existence of the wandering corpuscles in cases of inflammation. Therefore it appears probable that in cases of pyæmia the blood may contain the pus-corpuscles, but further investigation is needed to establish this fact. However, the establishment of this point would still leave the more important undetermined.

There are often important changes observed in the blood of patients dead of pyæmia, to which I now desire to direct attention. The red corpuscles of the blood, even in the early stage of the disease, in many cases show signs of disintegrating into molecules, and are observed to be accumulated in masses without showing the slightest tendency to form rouleaux. There is a steady increase in the number of pus- or white corpuscles in the blood of pyæmic patients during the whole course of the disease in fatal cases. The condition of the red corpuscles, already mentioned, becomes more and more marked toward the fatal termination.

In all cases of pyæmia multiplex the increased coagulability of the blood may be observed in the early stages of the disease, and steadily increases as the disease progresses.

In pyæmia simplex this condition is less marked, although generally present, "while we know septicæmia diminishes or destroys the coagulability of the blood. Hereby the possibility is given, at least on the cadaver, to differentiate between pyæmia simplex and septicæmia, although cases occur of the more fatal septic infection in which the post-mortem condition is a complete or almost complete negative. Therefore, in these cases the differential diagnosis on the cadaver must be limited to this, that we are able to demonstrate the existence of a purulent or ichorous deposit." It will be readily observed that the difference in diagnosis mentioned above relates to pyæmia and septicæmia, and not to the different varieties of the former disease.

The following facts should be constantly kept in mind by the surgeon to enable him to differentiate between the two forms of pyæmia: In pure cases of purulent infection, without metastasis, the disease is called pyæmia simplex, and in cases with metastasis, pyæmia multiplex. The various conditions on which the metastasis may depend are shown by Hueter, who says: "The metastatic abscesses of pyæmia multiplex met with in the lungs, liver, spleen, and other internal organs are regarded, with the greatest probability, as a result of the embolic process. The metastatic inflammation of the serous membranes, of the cellular tissues, and of the parotid glands, and probably also a few metastatic inflammations of the internal organs, are at present supposed to arise from a general inflammatory diathesis."³² It has already been shown by numerous experiments on animals that metastatic abscesses in the lungs, liver, and other visceral organs only arise after the introduction of ichorous pus, while healthy pus has uniformly failed to produce these results.

³³ Billroth's Handbuch der Chirurgie, S. 88.

It now remains to be shown how the introduction of ichorous pus acts in the production of pyæmia multiplex. The ichorous pus, having found its way into the venous circulation, gives rise to the formation of thrombi in the veins; these clots become more or less broken up, and are carried forward by the blood to the right auricle; from this auricle to the right ventricle; from this ventricle to the pulmonary artery, and through its ramifications to every part of the lungs. In the minute ramifications of this vessel are found wedge-shaped clots of various sizes in different conditions, some softened and others still firm. The possibility of these clots ever passing through the lungs, and afterward being arrested in other visceral organs, has been demonstrated on animals. It has been shown that fine particles of foreign matter injected into the veins have passed through the lungs and subsequently lodged in the liver. This theory enables us to account, upon a mechanical basis, for the existence of the metastatic abscesses in the liver which have apparently originated as the result of primary infection.

In other cases these abscesses are supposed to arise from secondary infection. Thus, ichorous pus, having found its way into the venous circulation, produces primarily venous thrombi, which, as in other instances, break up, the clots being carried in the same manner into the terminal branches of the pulmonary artery, where they are designated as emboli. The first action of the emboli is the mechanical closure of these vessels, thus depriving the surrounding parts of nutrition to a greater or less extent. It will be proper now to recall the fact that the composition of these emboli is such as to favor rapid suppuration; this commonly commences in the clot and surrounding tissues, having been preceded by a brief stage of congestion and inflammation. There is also occasionally found around these points more or less extravasation. The metastatic abscess thus formed in the lungs is favorably situated for the production of secondary infection. From this abscess thrombi arise in the pulmonary veins, which become disintegrated, and are carried to the auricle, thence to the left ventricle, and finally through the aorta, and find lodgment in the terminal branches of the arteries of the various organs, where they produce the characteristic lesions.

The organs which most frequently become the seat of this secondary infection are the liver, spleen, kidneys, brain, and eyes.

Let us now briefly examine this mechanical theory. Do metastatic abscesses arise from a single cause or from a combination of causes? I am inclined to the opinion that the proximal cause of metastatic abscesses in the visceral organs is the existence of emboli in the terminal branches. The vitiated atmosphere surrounding the patient, the existence of a wound, and the formation of ichorous pus are conditions which should not be lost sight of. These are the elements acting on the blood, producing in it morbid changes, and may therefore be regarded as predisposing causes. The morbid conditions of the blood, the increased number of white blood-corpuscles (possibly pus), the disintegration and other changes in the red corpuscles, may be regarded as the exciting causes of metastatic abscesses. It is thus readily observed that emboli may form in the lungs and liver at the same time, or the origin of those in the lungs may precede the formation in other organs.

Is the formation of emboli in the terminal branches of arteries always dependent on the disintegration of thrombi? The answer to this question must, I think, be a negative, although in surgical practice it rarely happens that the emboli take their origin from any other cause. In the large majority of cases, unquestionably, the thrombi primarily exist in the vicinity of the wound in which ichorous pus is generated; but it not infrequently happens during the process of disintegration that broken-up clots are carried forward by the current of blood, receiving accretions on the way, until finally they fill a large venous trunk. In confirmation of these facts relating to the primary origin of thrombi, it is said to have been observed in epidemics of puerperal fever, which were complicated with metastatic abscesses of the visceral organs, that the thrombi occurred in the pelvic veins. In case of wounds of the lower extremity the clot is frequently found in the common iliac vein, although probably it should always be regarded as a secondary formation. In rare cases the only thrombi discovered at the autopsy are found situated far away from the injury.

Observation fully establishes the fact that, after death from pyæmia, pathological changes are much more frequently met with in the lungs than in any of the other organs. This certainly strengthens the embolic theory. Billroth mentions eighty-three cases of true pyæmia multiplex, in which the metastatic abscesses occurred as follows: seventy-five times in the lungs, seventeen times in the spleen, eight times in the liver, and four times in the kidneys. Sedillot remarks that in one hundred cases of pyæmia we find the lungs affected in ninety-nine, the liver and spleen in eight, the muscles in seven, and the heart and peripheric cellular tissue in five cases. The brain and kidneys are comparatively seldom involved.

The theory previously mentioned as the embolic relates to the aggregation of fibrin into clots; but another theory has been recently advanced by E. Wagner, who found in many cases the capillaries in the lungs filled with fat, and was inclined, from the direction it extended in these vessels, to explain a certain number of the pyæmic cases by the fat emboli; but it has been shown that the existence of the fat emboli in pyæmia is purely accidental and possesses no significance. Pyæmia multiplex very frequently occurs without fat emboli, and vice versâ; either process may complicate the other, and so the fat emboli may acquire special importance by obstructing the respiration, and probably also in their way the embolic fat may serve as a carrier of putrid material.

MORBID ANATOMY.—The external appearance of the body varies greatly. The skin, in those cases in which the patient was jaundiced before death, will be found in every part of the body to be of a dark orange or dirty icteric tinge, but in other cases it may present a pale or anæmic appearance. There are also sometimes found circumscribed ecchymoses or purpuric patches, while the edges of ulcers or open wounds are generally of a blackish or dirty yellow color. The lips and finger-nails present a livid appearance; epithelial defects are observed in the cornea, but these had their origin there before the death of the patient.

The eyes in some cases are sunken deeply in their sockets, and where the disease has been protracted there is often very great emaciation. Rigor mortis is commonly well marked after a few hours. When death occurs from puerperal pyæmia there are generally found some indications of the recent parturition, although the principal lacerations or injuries may be confined to the womb. All fluids disappear from external wounds before the death of the patient, and they remain dry afterward.

In some cases the cellular tissue is the seat of diffuse suppuration. The pus formed is thin, fetid, and unhealthy. This suppuration is limited to certain parts of the body, as an injured extremity, or, as frequently happens, it may be found on the trunk and limbs at the same time. The pus in this form of suppuration is exceedingly apt to burrow, on account of the peculiarities of the tissue in which it occurs, and also the condition of the surrounding structures, especially the relaxed and flabby condition of the skin. These abscesses in some instances are superficial, in others deep-seated.

There are few changes which occur in the muscles, and these are not uniform or constant. They are occasionally the seat of abscesses, which have been observed in the heart, tongue, and other organs. The muscles may be of a light-brown or greenish color when they have been covered a considerable time with pus, and are sometimes softened and pultaceous. Suppuration may also take place beneath the fascia of the tendons.

The brain and its membranes are frequently found in a perfectly healthy state after death from pyæmia, although when the diseased process has extended during the life of the patient to the lungs and pleura, giving rise to great dyspnoea, there will generally be observed some congestion of the membranes, an increased quantity of fluid in the brain-substance and ventricles, and also an increased fulness of the meningeal veins and sinuses. Occasionally there have been observed suppurative meningitis, blood extravasations on the surface of the brain, lymph-deposits on the membranes, softening of the cerebral tissues, and circumscribed abscesses in the substance of the brain, which in some cases have been traceable to embolism of its vessels. The changes in the spinal cord and its membranes are probably similar to those found in the brain, but these parts appear to have been rarely examined.

Virchow found emboli of the retinal and choroidal vessels. Heiberg found these vessels occluded with colonies of micrococci. There have also been observed opacity of the cornea, sloughing of the conjunctival epithelium, suppurative infiltration into the periphery of the vitreous body, and deposits of pus in Petit's canal and in the anterior and posterior chambers. Pyæmic ophthalmia has been observed somewhat frequently in puerperal cases, especially when preceded by endocarditis, with deposits on the semilunar or mitral valves. In surgical cases it is rarely seen.

Toynbee "relates several cases of purulent infection following suppuration of the ear. Cases of disease in the mastoid cells terminate fatally, he says, from two different causes: first, from purulent infection, arising from the introduction of pus into the circulation through the lateral sinus; second, from disease of the cerebellum or its membranes. Cases of purulent infection, he further remarks, have not been met with where the disease occurs in the tympanic cavity."³⁴

³⁴ Braidwood on Pyæmia, pp. 168, 169.

Numerous lesions of the osseous system have been noted in pyæmia, probably from the fact that this disease results very frequently in cases of bone-lesions, but these changes have very little diagnostic importance. The following have been observed: thickening or infiltration of the periosteum, which may be found to separate readily from the bone after the death of the patient, or there may be pus found between the periosteum and the bone. In the bone-structure there were found caries and necrosis, "while in other cases the whole thickness of the compact tissue is perforated in a honeycomb-like manner by minute cavities filled with thickish pus or caseous matter of a pinkish-white color."³⁵ "To sum up, the chief morbid alterations met with in the bones are congestion, dilatation of the Haversian canals and cancellated tissue, tending to abscess formation, and the excavation of the cavities by the unhealthy pus."³⁶

³⁵ Ibid., p. 192.

³⁶ Ibid., p. 194.

The pathological lesions of the joints commence with marked congestion of the synovial membranes and increase in the synovial fluids, and afterward the fluid is mixed with pus; these conditions are followed by erosion of the cartilage and ligaments, the former thus becoming separated from the bone. Both the small and large joints are occasionally the seat of morbid changes.

The parotid gland is occasionally the seat of a secondary inflammation during the progress of pyæmia, and this may endanger life by interfering with respiration and deglutition. The lymphatic glands are only secondarily affected, and even this takes place very rarely. The changes in the glandular system, when observed, are similar to those which happen in other tissues of the body—viz. congestion, inflammation, and suppuration.

The arteries are usually found empty after death from this disease, and the coats are sometimes apparently thickened. The veins, on the contrary, are commonly found filled, or even distended, with firm fibrinous clots. They are sometimes also found inflamed or altered, although more commonly healthy. The distended condition of the veins gives rise to the cord-like feeling often mentioned by different observers. In some cases of phlebitis there may be pus deposited between the coats of these veins. The most important pathological changes are found in the blood. These changes occur early in the disease, become more marked toward its fatal termination, and may be always studied after death. It is generally admitted that pus is frequently found in the blood of these patients; but it has been shown by numerous experiments that healthy pus never produces the pathological changes which characterize this disease. Pyæmia is only produced by the presence in the blood of ichorous pus or some other decomposing animal substance, or some material having its origin in the decomposition of the same, and no decomposition in these substances is ever effected except through the agency of living organisms. It therefore follows that the discovery of living organisms in the blood of those sick and dead of this disease has given a renewed interest to the study of its pathology. The recent investigations made by Pasteur, Koch, Birch-Hirschfeld, and the London Pathological Society show conclusively that in all cases of pyæmia and septicæmia organisms are present in the blood during the entire course of the disease, and that in the former there is found the globular, and in the latter the rod bacteria. It has further been observed in each morbid condition that the severity of the disease is always increased in proportion to the increase of the organisms in the blood, and that the bacteria found within the body are of the same species as those in the wound from which they have gained admission. The micrococci found in the blood of pyæmic patients are surrounded by the decomposed products of the red and white corpuscles, which appear in the blood-plasma in the form of pale granular bodies. There is likewise in this disease an increased coagulability of the blood, and it steadily increases as the disease progresses. In this condition there may be found in the blood-vessels both thrombi and emboli. The thrombi are occasionally observed as firm fibrinous clots, but they may be likewise found in the rapidly fatal cases to have undergone suppurative changes. These changes begin in the centre of the clots, which often contain true pus or a greenish or puriform fluid.

The pericardium may contain a small amount of serum tinged with blood, but it is seldom covered with recent lymph. Both the lung-tissue and pleuræ are commonly inflamed in this disease. The costal and visceral layers may be agglutinated by old adhesions, but are more commonly united together by recently formed lymph. The pleural cavities often contain some opaque, muddy, sero-purulent fluid, mixed with blood and having masses of lymph floating in it.

The lungs are more frequently the seat of metastatic abscesses and other morbid changes in pyæmia multiplex than any other organs of the body. There may be found emboli in the branches of the pulmonary veins, and in the lung-tissue metastatic abscesses surrounded with capillary congestion and other evidences of inflammation; "The smaller vessels, trying to overcome this afflux of blood, may produce ecchymosis or extravasation beneath the lining membrane of the air-vesicles, but the minute capillary congestions are generally observed as red points studded over the pulmonary surface, which by and by exhibit yellowish-white or bluish-white centres. While one part, generally the lower half of the lung, is thus hepatized, solid, and of a dark greenish color, the remainder of the lung is emphysematous and more or less oedematous. A section of the former presents the same appearance as is observed in the lungs of pneumonic patients. Whether these incipient abscesses are developed from the minute points of congestion before mentioned, by the breaking down of the thrombic clots in their centres, or whether the pus is developed out of the serum exuded by the walls of the engorged capillaries, cannot be easily determined, and has as yet not been decided. These secondary abscesses vary in size from that of a hemp-seed to that of a hen's egg."³⁷ These are generally situated on the periphery of the lungs and in the lower lobe, although in some cases they are found imbedded deeply in the pulmonary tissue. The contents of these abscesses are similar to those found in other parts of the body in this disease. The bronchial mucous membrane is commonly of a bright pink color, while its secretion is increased in quantity, and may be clear and frothy. These changes are the result of acute bronchial catarrh. Lobular pneumonia has been frequently observed as a complication of pyæmia, and is supposed by some authors to be caused by the vitiated condition of the blood; but probably it is more frequently occasioned by infarctions and embolic abscesses, which have been previously mentioned in this connection.

³⁷ Braidwood, op. cit., p. 173 et seq.

Billroth and Sedillot observed pathological lesions involving a solution of continuity in the spleen, liver, and kidneys, in the order in which they are mentioned; other authors, however, assert that the liver, next to the lungs, is the most frequent seat of purulent deposits. Enlargement of the spleen is frequently met with in cases of pyæmia multiplex. The metastatic abscesses found in the spleen and kidneys are much smaller than those found in the lungs and liver, but in other respects are of a similar character. The capillary congestion and the accompanying infarctions require no special attention here. The liver, like the spleen, is sometimes enlarged, and at other times is found to have undergone fatty degeneration to a greater or less degree; in which condition its tissues are generally soft and friable. Abscesses in the liver are so much like those in the lungs as to need no separate description. The same may be said of other pathological changes found in this organ in pyæmia multiplex. The abscesses found in the kidneys vary from the size of a hemp-seed to that of a bean, and are surrounded by the usual zone, marking more or less definitely the extent of the inflammation. The capsule is generally healthy. There are also, in very rare cases of this disease, abscesses found in the stomach and intestines, involving the thickness of the mucous membrane; and it is further supposed that these abscesses may be found occasionally on any portion of the mucous membrane lining the alimentary canal. Post-mortem examinations in pyæmia multiplex have established the fact that there is no organ in the body that may not become the seat of pathological lesions in this disease; but there is unquestionably a vast difference in the relative frequency of these changes in the various organs. In some instances of this disease peritonitis is developed, with its concomitant changes in this membrane and the abdominal fluid, which is generally increased in quantity and sometimes slightly tinged with blood, but more frequently remains clear. This inflammation is commonly dependent on an extension of the inflammatory process from a metastatic abscess, which may be situated near the periphery of some organ covered with peritoneum, although it is claimed that pleuritis occasionally occurs in connection with pyæmia independent of metastatic abscesses in the lungs.

The careful study of the pathology of pyæmia multiplex renders it exceedingly probable that the immediate agency in the production of all these lesions is the presence in the blood of a particular species of living organism, and that all the morbid changes which occur in the visceral organs are secondary to those which take place in the blood, but that the former are only dependent on the latter in a minor degree. The pathological changes effected by these organisms seem to be as follows, and to occur in the following order: viz. disorganization of the blood, especially a destruction of the red and white blood-corpuscles; the formation of granular bodies around the organisms out of this débris; the production of an increased coagulability of the blood; the lodgment in the blood-vessels of these granular bodies, which are increased in size by a deposit of fibrin; these obstructions occur most frequently in minute ramifications of the pulmonary arteries; nutrition is effected locally by these infarctions, and generally by the vitiated condition of the blood, which enables the organisms under these favorable circumstances to penetrate the adjacent tissues and produce the metastatic abscesses and other accompanying lesions.

The pathological changes in pyæmia simplex are of the same kind as those which have just been described as characterizing pyæmia multiplex, with the exception of the metastatic abscesses, which are always absent. Furthermore, the disease in both instances is believed to have its origin from the same causes, and the dissimilarities in the pathological lesions are equally susceptible of a rational explanation, as are those of scarlatina simplex and scarlatina maligna.

There were reported by the committee of the London Pathological Society some interesting details pertaining to this form of pyæmia. Their report shows that among the one hundred and fifty-five cases classed as pyæmia there were twenty-four cases without visceral abscesses; and furthermore it shows that in twenty-three of these cases there was no suppuration, although local inflammations affected many of the different tissues, since these patients suffered with arthritis, cellulitis, pleuritis, meningitis, pericarditis, and carditis. It is also added that "the post-mortem appearances, in addition to the local secondary inflammation before noted, were in many cases those changes common to all forms of blood poisoning. Out of the twenty-four cases, the following are noted: Swollen spleen, nine times; congestion of the lungs, ten times; swollen liver, six times; cloudy swelling of the kidney, fourteen times."³⁸

³⁸ Trans. London Pathological Soc., vol. xxx. p. 26.

In this form of pyæmia it has been supposed by some authors that the materies morbi occasionally produces death before the metastatic abscesses have had time to develop, but this is not always the case. The same committee report on the above-mentioned twenty-four cases, on this point, as follows: "The duration of the cases before the fatal termination was very various. It is tolerably accurately recorded in eighteen cases: of these five died in the first week, five in the second, four in the third, and the remaining four survived to the thirtieth, forty-ninth, fifty-second, and sixty-second days."³⁹

³⁹ Trans. London Pathological Soc., p. 25 et seq.

The pathology of pyæmia multiplex having been already fully described, and since the only essential difference in these morbid conditions consists in the complete absence of the metastatic abscesses in cases of pyæmia simplex, it is therefore thought unnecessary to dwell here longer on this subject.

The morbid anatomy of septicæmia has been carefully studied of late, and it is now known that the most characteristic lesions are found in the blood and the alimentary canal.

As a manifestation of the general poisoning of the blood, it might be expected that putrefaction would follow rapidly after the death of the patient. In fact, Davine defines septicæmia as "putrefaction of a living body." Observation has now thoroughly confirmed that which was formerly an anticipation. Panum, Hemmer, and Bergmann have each called attention to the fact that rapid decomposition follows the death of all animals in which septicæmia has been produced for experimental purposes. It has also been observed that putrefaction in the human cadaver begins much sooner, and progresses much more rapidly, under similar circumstances, when the death has been produced by this disease than when it has occurred from any other cause. Furthermore, this rapid decomposition is not limited to the internal organs, but may be frequently strongly marked on the surface of the body after the lapse of twelve hours, although it has been kept in a comparatively dry and cool atmosphere. In those cases where the septicæmia has originated in an external wound it has been uniformly observed that putrefaction goes on most rapidly in the vicinity of the wound after the death of the patient.

In every case of fatal septicæmia the post-mortem examination will show that the coagulability of the blood has been diminished or destroyed. In fact, it has been abundantly shown that in all cases of true septicæmia the coagulability of the blood is more or less diminished. The few imperfect clots of blood found after death are of a deep-black color. The putrefaction of the soft tissues is greatly hastened by the presence of this blood; and, consequently, this process goes on most rapidly in the most dependent portions of the body, especially along the course of the large veins. The septicæmic blood possesses a peculiar putrefactive odor, and it is occasionally found to be acid in its reaction, according to Vogel and Scherer, making it highly probable that it will end in the formation of the carbonate of ammonium. The chemical examinations of septicæmic blood which have heretofore been made have completely failed to give satisfactory results in regard either to the existence or nature of the materies morbi in this disease, although, without doubt, there has occasionally been found, principally in the blood of those who have died of acute septic intoxication, a poisonous substance, which Bergmann designated sepsin. Microscopic examinations have shown that in the blood and also in various organs of those who have died of septicæmia there are always present, under these circumstances, a large number of the rod bacteria; in fact, they are more numerous than after death from any other infectious disease. Furthermore, they are found in the blood, lymph-glands, and cellular tissues during the whole course of the disease.

There are no pathological changes in the central nervous system which arise directly from septicæmia, although in some cases, when there has been some cardiac complication or very severe dyspnoea from any cause immediately prior to the death of the patient, there may be found hyperæmia of the membranes of the cerebro-spinal axis. The brain and spinal cord remain unchanged.

The endo- and pericardium occasionally present a somewhat mottled appearance resembling ecchymosis, which is evidently a deposit from the blood, and may be washed off with water. The inner surface of the ventricles presents a similar appearance from the same cause. In addition to those changes which have been mentioned there are occasionally found some slight traces of an inflammatory process in these parts; but it never extends to the formation of pus or ulceration, which frequently happens in cases of pyæmia. The quantity of pericardial fluid is sometimes increased in septicæmia, and is generally somewhat thickened, cloudy, and slightly tinged with blood. The changes in the pleural surfaces are the same as those which have been noted in the pericardium, but any increase of the fluid within the pleural sacs is an exception to the general law, and is very rarely seen. The lungs are generally found slightly congested, but there may be some ecchymosis in exceptional cases. Pus is never found in the lungs or within the pleural cavities in pure unmixed septicæmia. The pathological changes in the liver resemble those in the lungs. This organ is commonly found in a state of passive congestion, while the color of its tissues is slightly darkened. The congestion of the kidneys and spleen in this disease is much more marked than that of the lungs and liver. The parenchymatous tissue of the kidneys is commonly found in an oedematous condition, and the tubuli uriniferi are more or less affected by a catarrhal inflammation, which is manifested by the exfoliation of granular epithelium. The same catarrhal condition, but in a milder form, is found to affect the mucous membrane of the bladder. In females the ovaries, uterus, and vagina are in a state of hyperæmia, with more or less catarrhal inflammation of the latter organ. Septicæmia invariably causes pregnant females to abort. There is commonly softening of the spleen. The alimentary canal is almost constantly affected by acute intestinal catarrh, with enlargement of the intestinal follicles and mesenteric glands, while there are frequently hemorrhages from the serous and mucous membranes. The various muscles of the body and the extremities are found to be of a dark brownish-red after the death of the patient, instead of possessing their natural pale-red color. It may now be stated, finally, that the pathological changes in septicæmia are less marked than those of pyæmia multiplex.

The semiology, etiology, and pathology of septo-pyæmia consist in a blending, in different degrees, of the essential parts of pyæmia and septicæmia; and since the pathology of both these diseases has been presented separately, it is deemed unnecessary to enter into a consideration of this combination.

SYMPTOMS OF PYÆMIA.—Pyæmia very rarely, if ever, develops except in connection with an open suppurating wound, and consequently it must generally be regarded as a wound complication or as a secondary diseased condition. Those open wounds are unquestionably the most favorably situated for the development of this disease which involve the medullary cavities of the long bones, owing to the liability of unhealthy suppuration, the difficulty of complete drainage, and the favorable anatomical conditions for absorption.

Every form of pyæmia is frequently preceded by a distinctly marked prodromal stage, which varies in duration from four days to two weeks. In fact, the ordinary precursor of this disease, in all those cases in which the bones are involved, is an attack of osteo-myelitis; but in other cases the patient often complains of malaise, giddiness, headache, pain in the limbs, weakness, and loss of appetite, while the experienced surgeon will be deeply impressed with the patient's rapid emaciation and cadaverous face. These symptoms are soon followed by jaundiced skin, etc. The commencement of an attack of pyæmia is commonly manifested by a chill. The importance which will naturally be attached to this phenomenon in connection with an open wound must depend to a certain degree on the circumstances attending its occurrence; and therefore the following question will present itself: Is the chill associated with suppuration? A negative answer to this question, based on the fact that insufficient time has elapsed since the occurrence of the injury to render suppuration possible, can never fail to be a source of satisfaction to the surgeon, whose experience has taught him to dread pyæmia.

Billroth has observed in 83 cases of true pyæmia multiplex that 62 commenced with a chill, and 21 without; in 81 cases of septicæmia and simple pyæmia 24 commenced with a chill and 57 without. The number of chills in each individual patient occurred according to the following table:

Number of patients	19	21	14	15	9	5	2	3	4	1	1	1
Number of chills	1	2	3	4	5	6	7	8	9	10	13	14

In one patient during three weeks sixteen chills were observed, and probably the longer the duration of the disease the greater is the number of chills. Still, there are chronic cases with a single chill, and acute cases with many. It rarely occurs that a patient has more than one chill in twenty-four hours. Billroth noticed among his patients only sixteen who had two chills, and only six who each had three chills, in one day. The experience that fewer chills occur during the evening and night than in the morning and afternoon has been confirmed by statistics. Among 287 chills, 220 occurred from 8 A.M. to 8 P.M., while during the night, from 8 P.M. to 8 A.M., only 67 were observed. By this arbitrary division of the twenty-four hours Billroth desired to take into consideration the daily exacerbation in connection with the usual daily irritation of the wound, the bandaging, and other manipulations. He saw, for example, a chill occur three times from the introduction of a sound, and twenty times after the opening of an abscess. The time which elapsed from the first injury to the first chill is shown in the following table:

First chill began, times	14	19	15	9	4	3	2	4
Length of time after injury, in weeks	1	2	3	4	5	6	7	8

Patients who had fever before the operation were more inclined to early chills than recently-injured healthy individuals. Billroth's experience was to have only the first chill before the end of the first week. It may be further stated that nervous, irritable patients suffer much more frequently from chills than those of a phlegmatic temperament. This fact has given rise to the opinion that the absorption of pus acts especially on the central nervous system.

The chills in pyæmia are supposed by Billroth to be associated with inflammation, and he says: "It must be mentioned, as a matter of observation, that chills occur almost exclusively in the commencement of an acute inflammation, and are intermittent only in intermittent fever and reabsorption of pus, while they do not occur in acute septicæmia."⁴⁰ But the fever in pyæmia rarely intermits entirely; it is generally lower, however, in the morning than in the afternoon. This symptom is even more important than the rigors in enabling the surgeon to make a correct diagnosis. Let it, however, be remembered that the temperature frequently becomes very high within a few hours after the receipt of an injury or the performance of a surgical operation; that this high temperature may be due to septic absorption, and that this diseased condition is what we designate as septicæmia. Another condition, less marked, with an elevated but somewhat lower temperature, is usually spoken of as traumatic fever. In this condition the fever may gradually increase for a few days, and then disappear.

⁴⁰ Surgical Pathology, p. 344.

One important peculiarity of the temperature in pyæmia are the sudden and great changes; thus, at one hour the temperature may be slightly raised above the normal, and at the next the thermometer may mark 105° F. These sudden changes of temperature are of frequent occurrence, are not observed to the same extent in any other disease, and therefore supply a very important diagnostic indication. It is impossible to know, or even to anticipate with any degree of certainty, when the highest temperature will exist; consequently, Billroth and other writers have suggested the desirability of having a thermometer constantly kept in a position to indicate every change in the heat of the body, and a careful attendant to note the same; but, thus far, I am not aware that this has been attempted, probably on account of the inconvenience to the patient and the additional labor in nursing it would entail. It has been further observed that during the existence of a chill the temperature continues to steadily increase, and the maximum seen during the whole course of the disease is attained during the hot stage which immediately follows the rigors. "This condition is followed by profuse cold perspirations. The perspirations which accompany this disease are most profuse, like those of advanced phthisis. They never precede the rigors, but may occur independently of them. They are either continuous in their duration, or exhibit more or less distinct exacerbations. They are occasionally accompanied by sudamina, and they do not abate with the use of any known remedy.... Occasionally perspiration is scanty; but before death a cold clammy sweat and a tawny discoloration of the skin occur."⁴¹

⁴¹ Braidwood, op. cit., p. 112.

Besides the sudamina there are frequently observed on the skin vesicles, pustules, and boils, purpuric patches, and various discolorations. There is frequently observed to arise in the neighborhood of the wound a reddish erythematous blush, which soon extends to the whole limb, and commonly begins to disappear in the early part of the second week. This recently occurred to a patient under my care, and was speedily followed by an abscess of the knee-joint. The wound was situated at the hip-joint, and the first change in the color of the integument took place around its lips. The redness extended rapidly downward until it covered the foot, and even the toes; but the extension upward was slight, not much above the nates, on which there was situated at the time a bed-sore. It observed the same order in passing off as in coming on—i.e. where it first made its appearance it first disappeared. The superficial veins leading from the wound were inflamed and cord-like. This condition of the integument and the abscess of the knee-joint were followed by diarrhoea, on which medicines had no beneficial effect. It continued, with occasional vomiting, until the death of the patient.

The pulse in pyæmia may be nearly normal as regards frequency, while at other times very rapid. It has been remarked in some cases that the pulse seldom rose above 90 per minute until near death. The pulse, although only moderately accelerated at the commencement of the disease, always becomes more rapid, quick, feeble, and irregular toward the termination of the unfavorable cases, while in cases of recovery it returns gradually to the normal standard.

In all cases in which the blood has been examined during the progress of pyæmia the examiners have agreed in regard to its extreme coagulability, the diminution of the number of red corpuscles, and the increase of the granular spherical bodies. The red corpuscles, even in the earlier stages of the disease, show evident indications of disintegrating; and these become more and more marked as the disease progresses, while there is a steady increase in the number of pus- or possibly of white blood-corpuscles. Epistaxis occasionally occurs, and also venous oozing from the wound.

The condition of the tongue in pyæmia may be regarded as an important symptom, indicating the state of the alimentary canal—not, however, during the prodromal stage, but after the disease has progressed a few days. It is then observed that the tongue has become peculiarly smooth, dry, and often excessively red. This smoothness is caused by the collapse of the papillæ, and the dryness by a diminished secretion. The organ now frequently appears as if covered with a thin layer of collodion which had been caused to dry on the surface, so as to present a glazed look. Again, the tongue may be covered with brown crusts and the teeth with sordes. These brown crusts and sordes are usually seen in advanced cases, following the first condition described. Much importance is attached to these brown crusts by many experienced surgeons, and although there may be very marked improvement in all other symptoms, still they insist on a very guarded prognosis until the tongue has assumed a healthy appearance. Aphthæ on various parts of the mouth and pharynx are frequently present in the more chronic cases, but are usually absent in acute cases. Herpes of the lips sometimes occurs in the commencement of the disease.

Vomiting is comparatively rare, but there is, even in the early stages, a complete failure of the appetite, with great thirst. Singultus is rarely present in genuine pyæmia, but frequently so in septicæmia, and occasionally in septo-pyæmia. Diarrhoea is not so frequent or the stools so copious in pyæmia as in septicæmia. Billroth observed in one hundred and eighty cases of pyæmia thirty-two cases of diarrhoea. It is impossible to determine whether those cases in which the diarrhoea occurred were pure or mixed pyæmia. The stools are often of a pappy consistence, and passed involuntarily in bed. There are, however, severe cases of pyæmia with high fever, and accompanied by obstinate constipation.

Examination of the heart may, in rare cases, show the existence of pericarditis, although usually the only indications of disease are the too feeble sounds. Auscultation and percussion of the lungs may yield unsatisfactory results when the metastatic abscesses are small and scattered, for the same reason as in miliary tuberculosis. The large deposits in the lungs are by these means readily determined. There may be a sensation of suffocation, the pneumonic sputa, the friction sound of pleurisy, or the signs of pleuritic effusion; and the existence of these symptoms or signs would naturally aid in the diagnosis of metastatic abscesses.

Enlargement of the liver and spleen may be determined before death, and in connection with other symptoms would aid in diagnosing deposits in these organs.

The urine in the first stage of this disease is scanty, high-colored, contains a large amount of salts, and is of a high specific gravity. Epithelial, fibrinous, and blood casts, and also albumen, are occasionally found in it during the course of the disease. Billroth mentions a case in which there was complete suppression, with uræmia.

In many cases of pyæmia suppuration of the joints, one after another, takes place with great rapidity and with comparatively little pain, but occasionally some swelling, redness, etc. are present. In most cases these suppurations are easily diagnosed. Instead of suppuration taking place in the joints, there are cases in which it occurs in the cellular tissue; and I have recently seen a case where abscess after abscess formed with such rapidity that within a single week the patient was literally covered with abscesses from the crown of his head to the soles of his feet.

Delirium generally exists during some stage of the disease, more frequently the last, and is then mild in its character, although active delirium has been observed in the first stage. Patients are low-spirited and very apprehensive of death. The face at the beginning of the attack may be flushed or pallid, but toward the end it always becomes careworn and haggard. The breath occasionally has a sweetish or purulent odor.

The changes in the wound are in some cases very marked, even in the first stage of the disease. The suppuration, which has been previously free and healthy, may be suddenly checked, the wound becoming dry. The discharge, if it continues, becomes scanty, thin, ichorous, or greenish. The granulations, if previously healthy, may soon slough. These changes may not always appear in the first stage, but should they not then take place they may be expected later in the disease.

SYMPTOMS OF SEPTICÆMIA.—These are commonly developed within twenty-four hours after the receipt of an injury or the performance of a surgical operation, and they may be sketched as follows: Frequent pulse; tongue, lips, and throat dry; skin hot and the temperature of the body high. The patient replies accurately to questions, but with some hesitation. He is much inclined to sleep, has entirely failed to take nourishment, drinks frequently when aroused from his lethargic condition, and has vomited everything taken into his stomach since the receipt of the injury or the performance of the operation. If the dressings are now removed from the wound, the foul odor of putrefaction greets the attendants. In cases of amputation-wounds considerable discoloration of the flaps may be observed, the edges being blackened. Above these blackened edges the integument is reddened and slightly oedematous. The wound having been closed with sutures, which are now removed, there escapes a few drachms—possibly ounces—of highly offensive fluid, the decomposed remains of blood, etc. A further examination of the flaps on their inner surfaces show that their capillary circulation has ceased. The tissues, instead of presenting a life-like appearance, are now of a very dark color and occasionally mottled with dull grayish spots, although the movements of the ligature at the point where it embraces the femoral artery, for example, show that the blood still rushes against the artificial boundary.

Let us now leave our patient, without further comment, for the next forty-eight hours, when we will resume the examination. We now find the same dryness of the mouth that was previously noticed; the pulse is more frequent, and has become very feeble; he complains of much thirst, has vomited frequently, and has taken very little nourishment, and that only at the earnest solicitations of the attendants. The temperature is higher than at the former examination, and has been steadily increasing; in the morning it is lower, however, than in the evening of the same day. The patient is lethargic, and is suffering with a profuse diarrhoea. The odor of the stools is highly offensive; they are properly described as rice-water evacuations. The abdomen is tympanitic; the body bathed in perspiration; the respirations rapid; the urine scanty, high-colored, and contains albumen. The examination of the stump shows that gangrene has extended rapidly, involving not only the flap, but a portion of the adjacent tissues. The stench arising from the wound is almost stifling. The decomposing fluids are continually forming. That portion of the thigh not already gangrenous is now very oedematous, and the integument covering it is much discolored, being of a dark, icteric, or reddened hue.

We now allow twenty-four hours to elapse, and then make our final examination. The patient's tongue is more moist; the body still bathed in perspiration; the eyes dull; the conjunctivæ icteric, and the same hue extends to the body, though in a less marked degree; the pulse has become very frequent, feeble, and not easily counted; the temperature is below normal. Singultus is now present, and has been so during the last twenty-four hours. Bronchial symptoms, combined with marked oedema of the right lung, have appeared; the diarrhoea continues the same; the gangrene is still extending.

It must be admitted that the report here offered shows only the symptoms that are found in a single class of cases. The symptoms vary greatly in different cases, but they are especially marked in the acute sepsis mentioned by Massanneuve under the head of gangrène foudroyante. In these cases there appears, immediately after the receipt of an injury, enormous oedema about the wound, which extends rapidly in every possible direction, followed by the death of the patient within a few hours unless prompt measures are adopted. The puncture of the cellular tissue or of the blood-vessels involved in the oedema prior to the death of the patient gives rise to the escape of a highly offensive gas. Roser mentions a case of this disease in which he promptly amputated the limb of the patient through the healthy parts, without even waiting for the administration of an anæsthetic, and his patient recovered.

The symptoms of septicæmia must necessarily depend greatly on the condition of the patient and the amount of septic material introduced, but it is not deemed necessary to dwell longer on this subject.

DIAGNOSIS.—It is thought that a brief presentation of the etiological, pathological, and semiological differences may be advantageous to busy physicians who desire to obtain, with the least expenditure of time, an accurate knowledge of the chief points of distinction between these morbid conditions. This effort at differentiation is merely intended to place the most important characteristics in marked contrast; and consequently it should be remembered that it is not our intention to give here the complete etiology, pathology, or semiology of either of these morbid states, but only their essential differences. Furthermore, it is thought that the following arrangement will facilitate the object which we desire to accomplish:

ETIOLOGY.
PYÆMIA..	SEPTICÆMIA.
1. Pyæmia generally commences with the putrefaction in an open wound of the secondary wound-fluids—pus, etc.—in which there are developed globular bacteria, which enter the blood and certain tissues of the body, where they multiply and produce constitutional disturbances.	1. Septicæmia generally commences with the putrefaction in an open wound of the primary wound-fluids—blood, serum, etc.—in which there are developed rod bacteria, which enter the blood and certain tissues of the body, where they multiply and produce constitutional disturbances.
2. Pyæmia is commonly preceded by some local inflammatory wound-complication, such as suppurative periostitis, osteo-myelitis, etc., and is rarely developed before the end of the second week after the receipt of the injury.	2. Septicæmia is commonly a primary wound-complication, which is generally developed within forty-eight hours after the receipt of the injury.
PATHOLOGY.
1. Increased coagulability of the blood.	1. Diminished coagulability of the blood.
2. There are metastatic abscesses in various parts of the body, especially in the lungs, liver, and kidneys: serous cavities frequently contain sero-purulent deposits; similar deposits are often found in the joints; abscesses in the cellular tissue; and also abundant evidence of the existence during the life of the patient of pyæmic endo- and pericarditis.	2. Complete absence of purulent or ichorous deposits in all cases of unmixed septicæmia. Post-mortem appearances may be completely negative, with the exception of the condition of the blood, although there is often some oedema of the lungs.
SEMIOLOGY.
1. Pyæmia commonly commences with a chill.	1. Septicæmia commonly commences without a chill.
2. Fever variable, but rarely entirely intermits.	2. Fever steadily increases, but is lower in the morning.
3. Sudden and great changes in temperature, followed by profuse perspiration.	3. The temperature is high at the beginning of the disease, increases until near the fatal termination, when it falls below the normal. The skin is moist, but without profuse sweatings.
4. Pulse variable; toward the fatal end rapid, feeble, and irregular.	4. Pulse rapid, and gradually increases in frequency toward the fatal end.
5. Facies at the beginning flushed or pallid, toward the end careworn.	5. Facies expressive of a dull, listless condition throughout the whole course of the disease.
6. Tongue smooth, dry, and excessively red, later brown-coated, and even the teeth coated with sordes.	6. Tongue, lips, and throat dry at the commencement, toward the end moist. Thirst is marked.
7. Diarrhoea with stools of a pappy consistence.	7. Rice-water evacuations, very offensive; obstinate vomiting.
8. Epistaxis.	8. Epistaxis rarely occurs.
9. Mild delirium toward the fatal end.	9. A lethargic condition from the beginning, increasing toward the fatal end.
10. Aphthæ in the mouth and throat, sudamina, vesicles, pustules, and purpuric patches.	10. Icteric hue of conjunctivæ; singultus often present.

The differences in the local manifestations occurring in and around the wound, during the progress of these diseases, may be summed up as follows:

At the commencement of this disease the suppuration is commonly checked, the wound becoming dry, and if a discharge continues, it becomes scanty, thin, ichorous, greenish, etc. The granulations, when previously healthy, soon slough, and venous oozing sometimes takes place. There occasionally appears in the later stages of this disease around the wound a reddish erythematous blush, which soon extends over the whole limb.

The odor of putrefaction is commonly very marked within twenty-four hours after the receipt of the injury, the integument slightly reddened about the wound, and the surrounding parts somewhat oedematous. The wound-tissues soon assume a dark-brown color, and are occasionally mottled with dull grayish spots, while the edges of the wound are at the same time blackened, although the movements of the ligature, when arteries have been tied, show us that the blood still rushes against its artificial boundary.

TREATMENT.—It must be admitted that the management of either pyæmia or septicæmia, when fully developed, is always unsatisfactory, and generally unsuccessful; consequently, the success which has attended the use of the prophylactic measures employed in connection with the treatment of wounds during the last ten years has given much satisfaction to the medical profession. The committee of the London Pathological Society reports as follows on this subject: "The accumulation of septic matter in the uterus after labor, in contact with the raw surface left by the separation of the placenta, would also present the conditions favorable to acute septic intoxication. In the present day, when the necessity of thorough drainage of wounds is so thoroughly understood, and the means at the surgeon's command for carrying it out are so efficient, it can only be under peculiar circumstances that a sufficient quantity of putrid serum or pus to yield the fatal dose of the septic poison is allowed to accumulate in the wound. Moreover, the antiseptic treatment of wounds, now so largely adopted, by preventing decomposition of course renders septic intoxication impossible. Ovariotomy would seem to furnish conditions most favorable to septic intoxication, and a large proportion of the deaths occurring in the first forty-eight hours have always been attributed to it. The proportion of fatal cases from this cause has, however, of late been greatly diminished by drainage, and more especially by the employment of the antiseptic treatment."⁴²

⁴² Trans. Path. Soc. of London, vol. xxx. p. 15.

We cannot repeat too frequently or too emphatically the fact that the treatment of pyæmia and septicæmia, when fully developed, is almost invariably unsuccessful, and that consequently he who desires to save the greatest number of lives must make every exertion and use all available means to prevent their development—a task which fortunately has now been brought within the scope of possibility in the large majority of cases. Every surgeon will readily admit that, were it possible to secure union by first intention in all cases of wounds, then it would be impossible for either septicæmia or pyæmia to occur in surgical practice. Therefore, it follows that the character of the wound, the method of operation, the surroundings of the patient, the character of the treatment, become proper points to consider in this division of the subject. The character of the wound and its relations to pyæmia and septicæmia have already been briefly referred to under the etiology of these diseases. The various methods of operating, with their respective advantages and disadvantages, are of course not suitable topics for discussion in this work.

The surroundings of the patient form a subject of vast importance in a prophylactic view, and should never be lost sight of in the construction of hospitals. I desire here to express my firm conviction that surgical pyæmia is essentially and almost wholly a hospital disease. The question of surroundings for the patient presents to my mind the following demands as a sine quâ non for obtaining the best possible results in surgery: (1) Absolute cleanliness. This demand should be strictly enforced in regard to the wound, the patient's body, the bedding, and everything else, including nurses and instruments. (2) Absolute purity of the atmosphere. (3) Moderate and equable temperature, containing a proper amount of moisture. (4) Proper quantity of nutritious and easily digestible food, with suitable drinks, etc. (5) Cheerful and pleasant surroundings, especially in companions, nurses, and other attendants. It may be objected to these conditions that they can never be obtained. I must confess that perfection in every detail cannot always be attained, but I am thoroughly convinced that he who makes a determined effort in this direction will succeed far better than that person who is constantly looking about for some excuse for negligence.

The question of treatment brings up the entire subject of antiseptics. The favorite remedies of this class are carbolic and salicylic acids, permanganate of potassium, chloride of zinc, bichloride of mercury, and liquor sodæ chlorinatæ. There is no doubt that good results may be obtained with any of these remedies. The surgeon should never forget that he uses medicines merely as agents to enable him to accomplish certain objects; and, keeping this in mind, he need very seldom fail with his antiseptic when the object is to prevent putrefaction in an open wound. Therefore it appears certain that each method of treatment may possess special advantages in particular cases, and probably the same may be said of the antiseptic itself. The importance of this subject may be more fully appreciated when it is remembered that it is generally admitted by the best surgical authorities that more lives are lost from septic infection than from all other causes combined during a war. The further consideration of this subject may be arranged for convenience under the heads of local and general treatment.

The local treatment of the wound should, if possible, be of such a character as to prevent the absorption of either putrid substances or pus. It therefore becomes highly important, in cases of amputation and other operations, that all tissues injured to such a degree as to be likely to excite either putrefaction, irritation, or inflammation should be removed. The same care is necessary in removing all foreign bodies from the wound in cases where no operation is to be performed. The amputation of the injured limb may be necessary to prevent the development of these diseases, or it may be resorted to in certain rare cases after the origin of pyæmic symptoms; however, in the latter instance great care should be taken to remove all the tissues already infiltrated with serum, otherwise nothing will be gained. The use of the surgeon's knife at the proper time may be the best prophylactic against both pyæmia and septicæmia, but it should be directed by an intelligent mind and the instrument guided by a practiced hand. Again, it is found that opening a large medullary cavity may be attended with danger to the patient. This fact teaches us an obvious lesson.

The wound existing or the operation having been performed, the surgeon now turns his attention to the prevention of putrefaction and inflammation. The first source of danger requiring attention from the surgeon is the fluid escaping from the wounded surface. Do not allow it to undergo putrefaction in contact with the wound. It should not be forgotten that pyæmia is an infectious disease, having its origin in a local nidus, an open wound, in which putrefaction of pus or other wound-fluid is taking place. The question of amputation, or of the extirpation of the parts for the relief of this disease, should only be entertained when the surgeon is confident that he can remove the whole of the infiltrated tissues. In other words, the performance of these operations after the disease has become constitutional can never be advantageous to the patient. Even in those cases where infiltration is limited to the lymphatics, unless all these glands so affected are removed the operation will be unsuccessful. It has been further recommended in the treatment of this disease, in order to prevent the formation of metastatic abscesses, to ligate the veins in which thrombi have formed or may be reasonably expected to form, at some convenient point between the heart and these obstructed points. The value of this proceeding has never been fully determined, and may be reasonably questioned. The formation of metastatic abscesses in various parts of the body within the reach of the surgeon's scalpel demands his attention; and we have been taught by experience that they should be speedily opened, which generally lowers the temperature and diminishes the danger from septic absorption. In the performance of this operation Lister's antiseptic system of wound-treatment should be strictly adhered to, since it unquestionably gives the best results which can be obtained under the circumstances. When the metastatic inflammation which occasionally appears in the thyroid and parotid glands during the course of this disease terminates in the formation of pus, this should be speedily evacuated. This prompt action is often required, particularly for the relief of the grave symptoms which are apt to arise in connection with respiration and deglutition. The accumulation of pus within the joints in pyæmic cases should, it is now thought, be treated in the same manner as abscesses in the cellular tissues—i.e. the articulations should be opened and thoroughly disinfected, and afterward kept in a perfectly aseptic condition, and also rendered absolutely immovable during the treatment.

Having directed attention to the more important local measures, we may now briefly enter on the consideration of some of the constitutional remedies. In the general treatment of pyæmia there have been recommended at various times a great variety of drugs, but the general want of success attending their use leaves comparatively few to be mentioned here. The mineral acids are still employed, and are found to be at least agreeable drinks, and as such can be still recommended. The sulphites of magnesium, sodium, potassium, and lime were recommended by Giovanni Polli for the treatment of typhus fever, scarlet fever, small-pox, septicæmia, and pyæmia. He further suggested that the medicine should be given until the whole quantity taken bore to the weight of the patient's body the proportion of 1 to 1000. The experiments made on animals with these salts seem to confirm their value in the treatment of septic diseases. It is certainly true that animals treated with these salts are not so easily affected by septic poison as those which have not received this treatment. Further, it has been shown that putrid substances when mixed with either permanganate of potassium or the sulphite of sodium, and then injected, are harmless, although the same quantity of putrid matter injected without either of these salts destroys life.

Brandy and other alcoholic stimulants have been strongly recommended on account of their well-known antiseptic properties. The sulphate of quinia is certainly, in most cases of pyæmia, a valuable agent. In large doses it enables the surgeon to reduce the temperature of the patient, and in smaller doses it frequently serves a valuable purpose as a tonic. It has also considerable value as an antiseptic.

Lattin has recommended the use of large doses of ergotine in infectious fevers, but this substance, when employed in the treatment of pyæmia, should be given in the formative stage of the disease. The use of drastic cathartics should be avoided, as should that of sudorifics, on account of their prostrating effects. In some cases hypnotics may be required to secure sleep.

Tonics are always more or less useful. The free use of stimulants and nutritious food is also indicated. Brandy, wine, and whiskey may be advantageously used as stimulants. Musk, ammonia, and camphor are occasionally required. However, it should not be forgotten that in cases where the disease has become fully developed the usual termination is death, few recoveries being recorded. In the early stages of this affection, by the removal of the patient from an overcrowded hospital ward to some place where pure air and proper hygienic arrangements can be obtained, recovery may take place, but under other circumstances the prognosis is exceedingly grave.

The treatment of septicæmia in most particulars is the same as that of pyæmia. The first effort should be to prevent the development of the disease, and the second to care for the patient in cases where the affection has already developed. It is not, of course, in our power to limit or in any way regulate the primary injury, for we are obliged to take the patient as he is. The amount of injury to living tissue may be great or small. The question of an operation, the character of the same, and the subsequent management must be determined in accordance with the circumstances of each particular case.

The primary death of the parts is generally due chiefly to the injury itself; the secondary, frequently to bad surgical management. Let us now take a case in which the primary injury has been severe, greatly diminishing, but not destroying, the circulation in the injured parts. Here the immediate application of ice would be injurious, but a warm application might assist nature. It is humiliating to the profession that we are obliged even at this date to admit that the treatment of septicæmia is largely symptomatic. The profuse choleraic diarrhoea which generally accompanies this disease may be regarded as an effort of nature to eliminate the septic poison; but, nevertheless, it is so prostrating in its effects that it requires to be controlled with properly selected astringents, and these remedies may be still further aided by the use of stimulants and tonics.

The treatment of septicæmia may be summarized as follows: (1) A strict adherence to the five rules given under the head of the prophylactic treatment of pyæmia. (2) The avoidance of all putrefaction in contact with the wound, especially prior to the development of sufficient granulations to completely cover its surface. This object is to be accomplished by the removal of all necrotic tissues, the avoidance of putrescent fluids by cleanliness, and the proper use of antiseptic agents. (3) Free use of the alkaline sulphites and hyposulphites. These drugs should be used in all cases where there is reason to anticipate the development of septic diseases, as soon after the receipt of the injury as practicable, but should not be neglected even after the disease has become fully developed. (4) Sulphate of quinia should be used in all cases where the temperature is above 100° F., and its persistent use in large doses may be necessary to prevent the fever from rising still higher. It will be remembered in this connection that experience has taught us that "a temperature of 108.5° F. is the limit beyond which life can no longer exist,"⁴³ and even a much lower temperature is not without dangers. "The essential danger of fever in acute diseases consists, then, in the deleterious influence of a high temperature on the tissues."⁴⁴

⁴³ Liebermeister, New Sydenham Soc. Trans., vol. lxvi. p. 278.

⁴⁴ Ibid., p. 280.

The treatment of puerperal septicæmia, although requiring the application of the same principles as any other form of this disease, may be briefly described as follows: The womb should be maintained in a firmly-contracted state by the proper use of ergot, even as a prophylactic measure, and also during the whole course of the disease; the uterus and vagina should be kept in an aseptic condition by the efficient use of antiseptics; sulphate of quinia should be given in large doses, and repeated as often as may be necessary in order to lower the temperature; and morphia or some form of opium should be employed for the relief of the pain.