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 {948} 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]
[Footnote 7: Braidwood on _Pyæmia_, p. 2 _et seq._]
[Footnote 8: _Ibid._, p. 2.]
[Footnote 9: _Ibid._, p. 3.]
[Footnote 10: _Ibid._, p. 10.]
[Footnote 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]
[Footnote 12: _Ibid._, p. 14.]
{949} 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]
[Footnote 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]
[Footnote 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
{950} 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
{951} 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]
[Footnote 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 {952} 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]
[Footnote 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 {953} 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.
[Footnote 17: _Trans. Pathological Soc. of London_, vol. xxx. p. 22.]
[Footnote 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]
[Footnote 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 {954}
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]
[Footnote 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]
[Footnote 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]
[Footnote 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]
[Footnote 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]
[Footnote 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 {955} 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.