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. {962} 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 {963} 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 {964}
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.
[Footnote 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 {965} 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 {966} 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 {967} 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]
[Footnote 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]
[Footnote 35: _Ibid._, p. 192.]
[Footnote 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 {968} 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.