Part 145

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."

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."

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." 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." 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.

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."

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."

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."

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."

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."

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.

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.

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 {956} 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.