BACTERIA 
AND THEIR 
INFLUENCE UPON THE ORIGIN AND DEVELOPMENT 
OF 
SEPTIC COMPLICATIONS OF WOUNDS. 
A1 BY 
L. A. STIMSON, M. I)., 
NEW YORK. 
WOOD PRIZE ESSAY OF THE ALUMNI ASSOCIATION OF 
BELLEVUE HOSPITAL MEDICAL COLLEGE, 1875. 
|REPRINTED FROM THE NEW YORK MEDICAL JOURNAL. AUGUST.\ 1S75.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
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549 & 551 Broadway, New York. Fig. 1. Coccos: a, gliacoccos ; b, free micrococcos ; c. streptococcos (of Billroth), “ vibrio 
d, spirillum, from putrefying organic solution. 
Fig. 2. a. Germinative spores opening; b. the contained coccos lengthening into bacteria : 
c, scission of bacteria and escape of one joint as act ually observed (Billroth). 
Fig. 3. Ascococeos: a, with thin wall, one is broken ; b. husks (Billroth). 
Fig. 4. a, Ordinary bacteria as seen with a power of about 200 diameters ; b. the same after 
addition of tincture of fuchsine. 
Fig. 5. Development of Ascoooccos parvu* (green mould), under a leakin'; faucet (Billroth). BACTERIA 
AND THEIK 
INFLUENCE UPON THE ORIGIN AND DEVELOPMENT 
OF 
SEPTIC COMPLICATIONS OF WOUNDS. 
BY 
L. A. STIMSON, M. D., 
NEW YORK. 
WOOD PRIZE ESSAY OF THE ALUMNI ASSOCIATION OF 
BELLEVUE HOSPITAL MEDICAL COLLEGE, 1875. 
|REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, AUGUST, 1875.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1875. BACTERIA AND THEIR INFLUENCE UPON 
THE ORIGIN AND DEVELOPMENT OF 
SEPTIC COMPLICATIONS OF WOUNDS. 
“ II s’agit ici de la penetration de substances coagulables d’origine ani- 
male ou v6g6tale en voie de putrefaction, de principes resultant de leur 
decomposition isomerique qui sont entrain6s par la vapeur d’eau en sus- 
pension dans l’atmospbere. . . . ”—Ohaki.es Robin, p. 239. 
Living organisms, microscopical in size, of the simplest, 
most elementary nature, and moving freely in different liquids, 
have been known to observers for nearly two hundred years. 
Scientific classification and description were long impossible 
on account of the meagre facilities furnished by the microscopes 
of the last century, but during the last fifty years the means 
of observation have been so much improved, and the number 
of observers has been so great, that the advance in our knowl- 
edge of microscopical organisms compares favorably with that 
in other branches in science. This advance has been greatly 
stimulated by a tendency to see in low vegetable organisms 
the exciting cause of many diseases, and the supporters of 
the theory of “Animate Pathology” have increased, by their 
attempts to classify these organisms according to their sup- 
posed pathological qualities, a confusion in the nomenclature 
which has existed almost from the beginning, and is none the 
less to be regretted, although it is easily explained by the 
great difficulties in the way of accurate observation, study, 
and description. 
To-day we are all familiar with the names bacteria and 
vibrio, and associate with them small microscopical bodies, 
round, oval, or rod-like and jointed, varying in length from 
0.0005 mm. to 0.01 mm., and found especially in putrefying 
vegetable and animal infusions. The term bacteria is in gen- 
eral use in France and Germany to indicate all organisms of 4 
this kind ; the term vibrio has performed the same service in 
England, bnt is now giving way to the former. When the words 
are used in a narrower sense, bacteria denotes stiff, rod-like 
bodies, single or jointed, montionless or endowed with an os- 
cillating movement in place ; while vibrio is applied to those 
which have an undulating, sinuous motion, and move rapidly 
across the field of the microscope. All these forms are now 
almost universally considered to be vegetables, and placed 
among the algae, in the family Oscillatoria.1 
The earliest recorded observations of any of the varieties 
were made in 1684, by Leeuwenhoek (“ Anat. et Contemp.,” 
p. 38, quoted by Dujardin). He found in his dejections dur- 
ing a slight illness microscopical bodies, which from his de- 
scription were supposed by Ehrenberg and Dujardin to be 
identical with their “vibrio rugula” and “ vibrio bacillus,” 
two of the largest varieties. In Leeuwenhoek’s “ Select 
Works,” translated by Samuel Hoole, London, 1800, a descrip- 
tion and drawings are given of similar bodies found in the mat- 
ter picked from between his teeth, and in vinegar. In the eigh- 
teenth century Muller classified the forms then known, and 
in 1838 Ehrenberg (Infusionsthierchen) made the first com- 
plete list. This was slightly modified three years later by Du- 
jardin (“ Ilistoire des Zoophytes,” 1841), and has since been 
constantly used as a standard of comparison, verification, and 
reference. As may be inferred from the titles of their wrorks, 
both these authors supposed these organisms to be animals, 
and, therefore, did not include in their lists some well-known 
vegetable forms which we now place there, and which were 
described by Kiitzing (“ Phycologia Generalis,” 1843) among 
the algae in the family Palmellcey and have been recently placed 
by Bastian (“ Beginnings of Life,” 1872) among the amoebae. 
I refer to the ascococcos of Billroth and some of the zoogloea 
forms of Cohn. The third classification was made by Cohn 
in 1873 (“ Beitrage zur Biologie der Pflanzen,” vol. ii.), and 
1 During the last few months, Robin says, the opinion has turned in 
favor of placing them among the mushrooms, of which they have to be con- 
sidered a new, hitherto unclassified species. The arguments in favor of this 
view are the general lack of color in the spores and their growth in wa- 
ter. The cocci then would be the spores, and the bacteria the mycelium 
or the “ filaments.” 5 
the fourth by Billroth in 1874 (“ Ueber Coceobacteria Sep- 
tica,” 
Elirenberg’s classification is as follows: He places all the 
forms in one family, Vibrionida, the fourth family of the class 
Polygastrica. He divides this family into five groups or 
species, and ten varieties: 
Species I., Bacterium: Variety 1. Bf triloculare; 2. B. en- 
chelys; 3. B. punctum. 
Species II., Vibrio: Variety 4, V. lineola ; 5. V. tremu- 
lans; 6. V. subtilis; 7. V. rugula; 8. V. prolifer; 9. V. 
bacillus. 
Species III., Spirochceta: Variety 10, S. plicatilis. 
Species IV., Spirillum: Variety 11. S, tenue; 12. S. un- 
dula; 13, S. volutans. 
Species V,, Spirodiscus : Variety 14. S. fulvus. 
He described the first species as a stiff-jointed rod, in cate- 
nam filiformen rigidulam aliens, the second as a flexible ser- 
pent-like chain, anguis instar fiexuosam, the third as a flexi- 
ble, the fourth as a stiff filiform spiral or tortuous chain, the 
fifth coiled on itself in the form of a disk. Those small round 
or oval forms now described as micrococcus he placed in the 
family of monads, Monas. 
Dujardin cut out Species V. because it had been seen only 
once by Ehrenberg, during a journey into Siberia, and incom- 
pletely observed, added Species IV. to Species III., and re- 
duced the number of varieties to ten, throwing out B. trilo- 
culare and B. enchelys, consolidating some and dividing up 
others. 
Cohn groups all under one name, and divides as follows: 
Bacteria.—Tribus I.,Sphoerobacteria (Ball bacteria): Va- 
riety 1, Micrococcus. 
Tribus II., Microbacteria (Rod bacteria): Variety 2, 
Bacterium, subdivided into B. termo and B. lineola. 
Tribus III., Desmobacteria (Thread bacteria): Variety 
3, Bacillus ; Variety 4, Vibrio. 
Tribus IV., Spirobacteria (Spiral bacteria): Variety 5, 
Spirillum (of Ehrenberg); Variety 6, Spirochsete (of Ehren- 
berg), 
Billroth makes no claim to a complete botanical classifiea- 6 
tion. He deals principally with the forms which are found 
in animal infusions, and in the body during disease or after 
death. But, while he does not attempt to describe all the va- 
rieties, he gives a complete history of those which he has ob- 
served, tracing the whole cycle of their development, and 
showing so close a genetic relationship between them that it 
seems probable future investigation will show the others to be 
included in it. He considers all the forms combinations of 
spherical and cylindrical bodies, representing only different 
periods of development. His nomenclature and classificaticn 
being based upon this opinion, he groups all under the name 
coccobacteria (/co/ckos, a berry, and ftaKTypia, a little rod), and 
gives to the different forms names which are compounds of 
these two with words denoting the number, size, and arrange- 
ment of the component parts; micro-, meso-, and mega-, signi- 
fying small, medium, and large; mono- and diplo-, single and 
double; strepto-, in chains; glia- (yXla, glue), in groups ; asco-, 
in bags ; and petalo-, in plates. This classification is simple 
and clear, for each name has the great advantage of describ- 
ing accurately the form to which it is applied. 
A detailed description of all the varieties is not needed here. 
The terms bacteria and vibrio have been already explained ; 
there remain two others, bacteridia (French, bacteridies; 
German, bacteridien) and 7nicrococcu8 1 or microzyma, which 
are constantly met with in recent pathological works. The for- 
mer was applied by Davaine to long immovable forms of bac- 
teria found by him in the blood of animals affected with an- 
thrax; they belong in Variety 3, bacillus, of Cohn, while the 
latter is applied to the innumerable round or oval forms found 
in the tissues, secretions, or blood, of persons suffering from 
septic diseases, and in putrefying liquids. 
Natural History of Bacteria.—Bacteria are cells lacking 
chlorophyl, of spherical, oblong, or cylindrical form, which 
multiply by scission and vegetate either singly or in groups 
(Cohn, loc. cit., page 136). They possess a cell-wall and col- 
orless nitrogenized Contents, protoplasm, which refracts the 
1 Micrococcus, first employed by Ilallier and adopted by Cohn, but with 
a different signification, makes the plural micrococci. Micrococcos, as 
used by Billroth, has no plural. i 
light more strongly than water, is contractile, and by its con- 
tractility occasions the movements of the plants. The exist- 
ence of the cell-wall can be sometimes made out with the aid 
of high powers, and may be easily demonstrated by its resist- 
ance to caustic potash and ammonia (Cohn). 
Both Billroth and Cohn testify that there is no genetic rela- 
tionship between bacteria and any of the yeast-plants, including 
saccharomyces, the alcoholic ferment, or indeed any of the fungi 
and moulds. Billroth says (loo. cit., page 49) that wherever 
any luxuriant yeast vegetation except oidiurn lactis is growing 
rapidly, the elements of coccobacteria septica do not flourish. 
Cohn claims that the resemblance between the alcoholic fer- 
ment and the torula form of sphaerobacteria (mesococcos of 
Billroth) is merely an external one, and that all reliable ob- 
servations controvert the opinion held by Hallier, Kars ten, 
Huxley, and others, that these two belong in one and the 
same circle of development. As to the absence of genetic 
relationship between bacteria and fungi, his views are sup- 
ported also by Burdon-Sanderson (Appendix to Thirteenth 
Report of Medical Officer of the Privy Council), and are 
founded partly on these two facts, that Pasteur’s liquid ex- 
posed to the air developed mould (penicillium, etc.) and no bac- 
teria, and when impregnated with a drop of water containing 
bacteria and placed in a tube corked with cotton it developed 
bacteria and no mould. They are also distinguished from the 
typical fungus by the absence of mycelium, and for this rea- 
son were classified by Xaegeli as schizomycetes. 
Development.—It is not necessary to discuss the possible 
origin of these organisms by spontaneous generation. Al- 
though that view is held by some, it is so manifestly incom- 
patible with the observations of the authors above mentioned 
and the complete developmental history as described by Bill- 
roth, that it needs only to be mentioned here. 
Billroth was the first to discover the nature of the germi- 
native spores (Dauersporen), although they were described and 
figured by Cohn. These germinative spores, which are glis- 
tening, dark-bordered globules, develop in their interior masses 
of coccos which are set free by the bursting of the envelope, 
but are maintained in contact with it for some time by the 8 
presence of gliai a mucous or gelatinous substance which is 
supposed by Billroth to be secreted from the wall of the coc- 
cos, and by Cohn to be the result of the softening of that walL 
This description can be easily verified ; I have found, in pu- 
trid animal infusions exposed to the air during three weeks in 
summery these spores in all conditions, from those forming 
within bacteria, as will be described hereafter* to the empty 
shell. The coccos may multiply by lengthening and scission, or 
they may lengthen into bacteria and gradually free themselves 
from the enveloping glia by their own active motions, so that 
the external portion of the masses enveloping the germina- 
tive spores is seen to be formed almost entirely of bacteria in 
active motion. This scission ordinarily occurs in one direc- 
tion only, the two pieces are held together by the glia, and 
each divides again and again, forming longer or shorter rosary- 
like chains, streptococcos (<ttpe7TT09, chain). When the scis- 
sion takes place in both directions we have the square sarcina 
forms. The bacteria also lengthen and divide transversely, 
forming the well-known jointed bacteria, diplobacteria, with 
which all are familiar. 
The scission may take place so rapidly that each bacterium 
forms a streptococcos, and when the glia is very abundant the 
scission of the coccos goes on within it indefinitely* producing 
the large masses known as zooglcea. If the glia is very tena- 
cious, it may form a thin or thick perfectly clear and trans- 
parent membrane about the mass, ascococcos (da/cos, a bag), 
which sometimes shows amoeboid movements. After a time 
this membrane bursts, the coccos escape, and the empty husk 
is found at the bottom of the vessel. It may be mentioned 
here that Billroth was fortunate enough on two occasions to see 
with Hartnack’s No. 15 immersion objective a micrococeos 
lengthen and divide, and the two parts separate from one an- 
other in the course of half an hour. 
The final fate of all bacteria presents three varieties: 1. 
The plasma may leave the husk in the form of a finelv-granu- 
lar sterile mucus. 2. It may break up rapidly into micrococ- 
cos within the husk, expanding it considerably and forming a 
variety of ascococcos. 3. It may contract into one or more 
glistening, dark-outlined bodies which are the germinative 9 
spores with which the description began, and which, after a 
certain period of repose, may again germinate. The vitality 
of the latter is not destroyed by freezing, or by 
drying, and these spores carried about in the air are undoubt- 
edly the principal agents in the production of coccobaeteria. 
Billroth had some which germinated after having been kept 
eight years. This is the only form which withstands drying ; 
the cocgos and bacteria do not, and this fact explains the fail- 
ure of many impregnations with dried bacteria. The germina- 
tive spores, having fallen to the bottom of the liquid, were not 
included in the portions taken for the experiments. 
Motions.—The isolated coccos possess only a motion which 
cannot be distinguished from the common molecular move- 
ment of very small, inert portions of matter, the so-called 
Brownian movement. Tiegel says ( Virchow's Archiv, July, 
1874) that, if the liquid in which they are contained is evapo- 
rated by a moderate heat and then fresh liquid added, they 
do not regain their motion, and one or two fine granules ap- 
pear in their interior. When, however, they remain united in 
chains (streptococcos), they appear to have a sinuous, serpent- 
like motion which carries them, sometimes with great rapidity, 
across the field of the microscope. This undulatory motion 
is denied by Cohn',yvho considers its appearance due to a real 
rotary motion about the long axis. This opinion is certainly 
correct in the case of the larger spiral forms, but I have been 
unable to verify it in the smaller, straighter forms, say 0.003 
mm. in length, whose extreme tenuity makes their examina- 
tion very difficult and uncertain. Progression is made in either 
direction, and the large spiral ones often move forward and 
backward across the field almost with the regularity of a pen- 
dulum ; sometimes one end attaches itself to the covering- 
glass or to some large object in the water, and the other 
swings slowly backward and forward, or the whole revolves 
rapidly about its long axis without change of place. The 
same motions are observed in the microbacteria chains, but 
the larger ones are generally motionless, and the isolated bac- 
teria show only an oscillatory motion without change of place. 
No locomotory or motion-producing organ has been discovered 
except upon one of the spiral forms, Spirillum volutans, on 10 
each end of which Cohn found a fine, whip-like thread. The 
motions seem to he dependent upon the fluidity of the medi- 
um and the presence of oxygen, and are much hindered by the 
glia; they persist at a temperature as low as 35°, grow slow 
at 130°, and cease at 140° Fahr. (Billroth). 
Nourishment.—For their nourishment bacteria need carbon, 
which they can assimilate from any carbon compound (except 
carbonic acid), nitrogen, which they can take from ammonia, 
urea, and probably also from nitric acid, and certain of the 
elements of the ashes of ordinary yeast, of which the most 
desirable are phosphate of potash, sulphate of magnesia, and 
nitrate of lime or chloride of calcium (Cohn). All the ex- 
perimental liquids in ordinary use are composed in accordance 
with this. Pasteur’s liquid has been found to be better fitted 
for the nourishment of bacteria when it contains no simar.1 
Bacteria resemble green plants in this, that they assimilate the 
nitrogen contained in their cells in the form of ammonia com- 
pounds, which animals cannot do ; on the other hand, they 
differ from green plants and resemble animals in this, that 
they cannot take carbon from carbonic acid, but only from 
organic compounds of carbon, especially the hydro-carbons and 
their derivatives (Cohn). 
Functions.—Bacteria are not parasitesj they do not live 
upon the materials intended for the nourishment of the tissues 
in which they are found, and cause the death of these tissues 
by starvation, but they are saprophytes,3 and probably live 
upon some of the elements of the substance itself by the with- 
drawal of which new chemical combinations of the others are 
caused. Putrefaction is a correlative phenomenon of life, be- 
cause it occurs only when a microscopical vegetable organism 
nourishes itself and multiplies at the expense of a part of the 
‘Cohn used the following modification of Pasteur’s: Distilled water, 
100 parts; nitrate of ammonia, 1 part; ash-elements, about 1 part. He 
recommends also Mayer’s normal solution of nutritive mineral salts: 
Phosphate of potash .... 0.1 gramme. 
Crystallized sulphate of magnesia . . 0.1 “ 
Tribasic phosphate of chalk . . . 0.01 “ 
Distilled water . . . . . .20 cub. ctms. 
2 Saprophyte, canpog, putrid, and <pvrbv, plant. 11 
putrescible substance. This organism is the bacterium, or at 
least some of its forms or varieties, for many authors agree 
with Colin that putridity is excited only by Bacterium termo, 
a form which Cohn describes as having a length of 0.002-0.003 
mm., found often in pairs and possessing a tremulous motion ; 
it is the microbacterium of Billroth. Cohn (loc. cit., pages 
169, 170) says they multiply as long as the putrid process lasts, 
and disappear as soon as it ceases; that he is convinced B. 
termo is the ferment of putrefaction, as yeast is the ferment 
of alcoholic fermentation, and that no putrefaction can begin 
without it, or progress without its multiplication. Other 
bacteria may aid in the process, but their role is secondary, 
and B. termo is the primary exciter of putrefaction, the only 
saprogenic ferment. Organic nitrogenized substances never 
putrefy bv themselves, but only when they are decomposed 
by the vitality and multiplication of bacteria. “This is not 
only supported by microscopical researches, which show that 
B. termo is constant in putrefaction, but comes with con- 
vincing certainty from an unprejudiced consideration of the 
innumerable researches into generatio cequivoca, especially 
those of the last few years. These show that putrefaction of 
an organic nitrogenized substance cannot occur if bacteria are 
kept away from it, after those that were already present have 
been killed; that it begins as soon as even the smallest num- 
ber of bacteria are added, and advances at the same rate as 
that in which they increase, and stops when exposed to any 
one of the influences which prevent the multiplication of, or 
kill, bacteria. On the other hand, bacteria multiply only as 
long as they tind material capable of putrefaction.”1 Cohn 
carries this physiological distinction still further, and divides 
his ‘ ball-bacteria,” micrococcus, in which no morphological 
differences can be seen, into three groups, according to their 
supposed power to produce pigment, fermentation, or disease, 
1 It may be proper to mention that, while this (Pasteur’s) theory of fer- 
mentation or putrefaction is generally accepted to-day, the followers of 
Liebig deny its entire correctness, and maintain that “certain non-living 
albuminoid substances are also capable of acting as ferments ” (Bastian, 
“ Beginnings of Life,” vol. i., p. 405). Billroth attaches much importance 
to a saying of Hoppe-Scyler: “Fermentation is possible without organisms, 
but not definite fermentations without definite organisms.” 12 
and again subdivides the third group according to the differ- 
ent diseases in which the micrococcus is found (M. vaccinae, 
M. diphtheriticus, M. septicus). That these plants do not 
possess in themselves the power of causing disease, but that, at 
the most, they act only as carriers of contagion, and therefore 
that the above classification is unjustifiable, will be shown in 
the second part of this article. The coccobacteria then have 
but three Well-marked functions: 1. Some of them produce 
certain pigments (Cohn); 2. Some cause special fermentation 
(Pasteur) ; 3. Some excite putrefaction. They may also aid 
mechanically in the transport of Various contagions, and, bv 
their presence and rapid multiplication in the body during 
the existence of an abnormal condition of the blood, juices, or 
tissues, may mechanically impede normal physiological pro- 
cesses, and perhaps render the increase of an already existing 
poison more rapid and fatal. 
Distribution.—Bacteria exist in one form or another in all 
■water (Cohn), most animal tissues (Billroth), and in the air. 
In the latter they are found only in the form of germinative 
spores, the other forms not being able to support the absence 
of moisture. Their presence in the healthy living body lias 
been often affirmed and denied, but has recently been de- 
monstrated beyond cavil by Billroth, and still more recently 
by Tiegel (Virchow's Archiv, vol. lx., July, 1874). Burdon- 
Sanderson’s denial of their presence (quoted by Cohn) was 
based upon the fact that the addition of small portions of 
fresh meat and blood from animals in full health did not 
cause cloudiness of Pasteur’s liquid ; Rindfleisch ( Virchow's 
Archiv, vol. liv.) got the same result and drewT the same 
conclusion, having used rain-water in place of Pasteur’s liquid. 
Billroth denies the correctness of the inference, because it is 
nowr well known that the strongly acid, sugary Pasteur’s liquid 
is not favorable for the development of bacteria, particularly 
of those found in the alkaline blood, and that as all liquids 
are not favorable for the growth of all bacteria, and as the lat- 
ter are not universally present in forms capable of further 
development, Ilindfleisch’s single experiment cannot weigh 
against the very numerous and carefully-conducted ones 
which have demonstrated the presence of these organisms. 13 
Iii the air spores are present, but apparently so few In 
number, and so light* that they do not alter the artificial nu- 
tritive liquids* and only very slowly infusions of animal and 
vegetable tissues (Cohn). All observers agree that they are 
found at times in all kinds of water. Rindfleisch thinks they 
are sometimes absent from rain-water; but Cohn found them 
in the moisture condensed upon the interior of a bell-glass 
placed over an open dish of water. Of course, they may have 
been deposited from the air, but the question of their origin 
does not affect the fact of their universal presence. Recent 
investigations have shown them to exist in large quantities on 
the walls of old hospitals (Nepveu, in Gazette Medicate, 
June 27, 1874). The spores, which float in the air, or are de- 
posited upon exposed surfaces, remain inert and innocuous 
until the conditions necessary to their development are sup- 
plied, among which moisture is the chief. Cohn maintains 
that 140° Fahr. is sufficient to kill bacteria and bacteria-spores, 
and that when any are found to have survived that tempera- 
ture, or even 212°, it is probably because the liquid contain- 
ing them has been unevenly heated. Billroth, on the other 
hand, says that the germinative spore can withstand more 
than 212° Fahr. Both agree that all the forms withstand very 
low degrees of temperature (even zero Fahr., Cohn), but that 
at the freezing-point, and probably even at a somewhat higher 
temperature, they lose their power of motion and multiplica- 
tion, and consequently their power of causing fermentation 
and decomposition, but regain it as soon as the temperature is 
raised. 
To recapitulate: Bacteria are microscopical vegetable or- 
ganisms of two main varieties: 1. Round or oval cells 0.0005 
-0.0010 mm. in diameter, single or arranged in lines or groups 
(sphserobacteria, micrococcus, Cohn: micrococcos, streptococ- 
cos, Billroth). 2. Cylindrical cells 0.002-0.003 mm. long, 
single, or arranged in lines (bacteria of both authors). There 
is no genetic relationship between them and ordinary mould 
and fungus. They are found in the air, water, and most ani- 
mal and vegetable tissues. They are saprophytes, not para- 
sites, and are unable in themselves to cause any of the infec- 
tious diseases. 14 
What influence have bacteria upon the origin and develop- 
ment of septic complications of wounds f 
The frequency and gravity of these complications have 
made their etiology, pathology, and treatment, one of the 
most important and interesting of all surgical problems, and 
the scanty success that has hitherto attended all prophylactic 
and remedial measures shows that the problem, in part at 
least, is still unsolved. Their cause was first supposed to lie 
in the absorption of the pus of the wound through the open 
mouths of the severed vessels; then in poisoning of the blood 
by pus formed in the interior of the vessels by phlebitis 
(Hunter), or by thrombosis (Darcet, 1842, popularized ten or 
fifteen years later by Virchow); then in the absorption of 
putrid matter from the surface of the wound (Gosselin);1 in 
the formation of a virus in the secretions of the wound and its 
penetration into the circulation; and, finally, in the introduc- 
tion of bacteria. 
The poisonous effects of putrid matter have long been 
known; in 1815 Orfila (quoted by Piorry) killed dogs by in- 
oculation of putrid blood, bile, and fragments of tissue; and 
in 1827 Hamont (quoted by Coze and Feltz) killed a horse by 
means of injections of putrid pus taken from a gangrenous ab- 
scess, and a second horse with blood taken from the first—the 
first dying on the fourth, the second on the fifth, day. Piorry, 
in an article on typhohemie, written probably in 1835, gives 
a full and accurate account of those symptoms to which he af- 
terward gave the name septicaemia, by which they are now 
known. He ascribed the disease solely to the effects of the 
absorption of putrid matter through the lungs, skin, intestine, 
or the surface of a wound, but did not attempt to discover the 
cause of its virulence. Panum {Virchow'1 s Archiv, vol. xxv., 
1862, quoting from an article of his own published April, 
1 The question of priority in discovery is always a difficult one to settle. 
The works which have popularized our knowledge of septicaemia have been 
largely German, but it seems to me clear that the possibility of absorption 
by granulating wounds and the marrow of bones was first demonstrated by 
Gosselin in 1855 (“Memoires de la Societe de Chirurgie,” tome v., p. 147), 
and that he was the first to publish the theory that the ensemble of symp- 
toms now known as septiefemia was due to the penetration into the body 
by such absorption of putrid matter. 15 
1856) speaks of a non-volatile septic poison, which is insoluble 
in absolute alcohol, soluble in water, and not destroyed by pro- 
longed boiling.—Robin (“ Dictionnaire de Medecine”) consid- 
ered the virulence due to a catalytic effect produced upon the 
humors and tissues of the body by contact with a substance in 
which putrefaction had brought about an isomeric change in 
the fundamentalu immediate principle,” and he said (“ Comptes 
Rendus de la Societe de Biologie,” 1863), “ Putridity is not 
virulence; on the contrary, when it has advanced to a certain 
degree, it destroys virulence,” a statement which is universally 
accepted to-day.—Bergmann (“ Das pntride Gift,” 1868) said ; 
“ The toxic action of putrid organic substances is not due to 
inferior organisms, but to a diffusible nitrogenized toxic sub- 
stance which resists alcohol, ether, and boiling heat, and is 
formed during putrefaction.” 
But the believers in the importance of bacteria were not 
idle. Mayrhofer (“ Jahrbiicher der Gesellschaft der Aertze in 
Wien,” 1863), claimed that puerperal fever was due to low 
organisms which he called vibriones. He had observed that 
they appeared first in the lochia of healthy lying-in women on 
the fifth day after delivery, and in small quantities; but in 
those sick with puerperal fever they appeared immediately 
after delivery, and in much larger quantities. He then in- 
jected a putrid infusion of meat into the uterus of a rabbit 
soon after delivery, causing its death from endometritis with 
septicaemic symptoms. Leplat and Jaillard (“ Comptes Ren- 
dus de l’Academie des Sciences,” vol. lix., p. 250, 1864) made 
nine inoculations with putrefying animal and vegetable infu- 
sions; eight of these caused no serious symptoms. They con- 
cluded that “ vibriones coming from any substance whatever 
cause no accidents in the animals into the blood of which they 
have been introduced, unless they should be accompanied by 
virulent agents, which latter are alone responsible for any un- 
fortunate results which may ensue.” In 1865 Coze and Peltz 
published a series of observations (Gazette Medicate de Stras- 
bourg), which they claimed proved that the blood of animals 
inoculated with putrefying liquids is itself infectious; that its 
red corpuscles are profoundly altered, and that it contains 
bacteria; also, that successive inoculations of different indi- 16 
viduals of the same kind—that is, from Ho. 1 to Ho. 2, from 
Ho. 2 to Ho. 3, etc.—become rapidly fatal ; that the infectious 
ferment gains in force by its passage through the organism. 
In 1872 they published a book in which the results of these 
and later experiments were set forth. They claimed that the 
figured elements which they found in the blood were the ac- 
tive efficient agents in the poisoning. They called these ele- 
ments infusoria, and said they appeared to belong rather to 
the genus Bacterium than Vibrio, and to be the B. punctilio 
and B. eatenula of Dujardin ; they were probably the micro- 
coccos and micro-bacteria of Billroth. The authors agreed 
with Pasteur that there were two phases of putrefaction, of 
which only the first would cause poisonous symptoms. This 
is another way of stating the fact which has been already 
mentioned, that putrefaction destroys virulence. They were 
also the first to find micrococcus during life in the blood of 
typhoid patients. 
In the mean time Davaine had been studying anthrax in 
animals (malignant pustule in man), and had discovered bac- 
teridia, which lie claimed to be the toxic principle of that dis- 
ease. In 1869 he had repeated and confirmed the earlier ex- 
periments of Coze and. Feltz (his studies were interrupted by 
the war in 1870—’71), but on September 17. 1872, he read be- 
fore the Academie de Medecine in Paris a report of three 
series of inoculations with putrid blood. The first series 
showed that inoculation with several drops was fatal in less 
than half of the cases; those with one drop of blood putrefied 
in the open air rarely killed, and that sometimes ten or fifteen 
drops were necessary. The second series comprised successive 
inoculations of blood from one animal to the next; it showed 
that TTir to TV of a drop was sufficient to kill the fifth, 
to Yoyg-oY W0llld kill the tenth, while for the twenty-fifth tire 
one-ten trillionth part of a drop was sufficient. The third series 
showed that the septicaemia virus is destroyed by putrefaction. 
We must pass rapidly over the discussion that followed. These 
experiments, received with much distrust at first, were sub- 
stantially verified by many observers, and the conclusions 
finally accepted by most were: 1. That the susceptibility to 
the virus varies much in different animals, rabbits being the 17 
most susceptible, 2. Putrid blood loses its virulence as it gets 
older, 3. That septicaemia is a putrefaction taking place in 
the blood of an animal, and induced by bacteria and vibriones 
(.Bulletin de VAcademie de Medecine, October 8, 1872). 4. 
That blood putrefied outside of the body is much less poison- 
ous than that of an individual whose death has been caused 
by, or who is still suffering from, septicaemia, typhoid fever, 
or gangrene of the lung. 5. That the one-millionth part of a 
drop of such blood injected into the cellular tissue of a rabbit 
will cause the death of the animal in less than twenty-four 
hours. 6. That the poisonous quality of the blood is entirely 
due to the presence of bacteria. Most of the inoculations 
wTere made with blood taken from the cadaver several hours 
after death, and. containing multitudes of bacteria. Vulpian 
denied that inoculations with blood taken from patients affect- 
ed with typhoid fever would cause death by septicaemia, and 
claimed that inoculations with blood taken from the cadaver 
must be considered only as inoculations with putrid blood. 
He failed to find in blood taken during life more than a few 
scattered granulations (micrococcus) and bacteria. lie also 
claimed that septicaemia produced experimentally differed from 
that observed in man ; that the former appeared to be “ a sort 
of internal parasitic affection, which certainly was not the case 
with typhoid septicaemia in man, in which the presence of in- 
ferior organisms in the blood was a variable circumstance, and 
unquestionably only accessory.” In order to mark this dis- 
tinction, he suggested for the former the name hacteremie 
(.Bulletin de VAcademie de Medecine, second series, vol. ii., p. 
420). 
On April 15, 1873, Onimus reported a series of experi- 
ments, conducted under the direction of Prof. Pobin, by which 
he claimed to have demonstrated: 1. “ That virulent blood can 
preserve its virulence in spite of the disappearance of vibrios 
and bacteria. 2. That blood may contain these inferior or- 
ganisms, and still not be virulent; consequently, that the 
virus of putrid infection is not an organized ferment, but an 
albuminoid substance. These conclusions were denied by 
Davaine and Pasteur on the ground that the absence of bac- 
teria from the material used for the inoculations was only ap- 18 
parent; that, although none were visible at the time, they 
existed nevertheless in an invisible stage of development. 
All the original opponents of Davaiue had now given their 
adhesion to his views, and this report of Onimus made little 
or no impression, opposed as it was by the great authority of 
Pasteur. The question, which had been discussed at every 
meeting of the Academy since September, 1872, now received 
much less attention; an occasional report upon it was made 
by those who had been specially identified with it, and by the 
majority it was considered to be definitively settled. In the 
mean time the discussions had excited a great deal of interest 
in all countries, and the experiments were repeated in many 
of the laboratories of England and Germany; an occasional 
article showed that the importance claimed for the bacteria 
was not universally admitted; and, since the publication of 
Billroth’s work in 1874, the weight of testimony has been 
against them. The results of experimental pathology were 
subjected to the light of clinical observation, and extensive in- 
vestigations were made to determine the presence or absence 
of bacteria in the liquids and tissues of the body during the 
different stages of septic diseases and after death. Of these 
none were more thorough than those conducted by Billroth. 
He found, in two hundred autopsies of all diseases, cocco-bac- 
teria present in eighty-seven in the pericardial liquid. The 
longer the interval between the time of death and the exam- 
ination, and the higher the temperature of the air, the more 
certainly were these organisms found. Although they are 
found in abundance during life on many of the mucous mem- 
branes, it is probable that they make their way into the tissues 
and circulation only through the lungs, and that they remain, 
especially in the blood, in the form of germs capable of devel- 
opment. This view is opposed by Burdon-Sanderson, and 
Ilindfleisch, and supported by IXeusen (Afchiv fur micro- 
scopische Anatomic, vol. iii.), and more recently by Klebs. It 
is probable that the organisms also make their way rapidly 
after death from the stomach and intestines, and from open 
wounds into the tissues. 
Lewis and Cunningham (Calcutta, 1874) made seventy- 
three examinations of the blood, and forty-three examinations 19 
of tlie mesenteric glands of dogs killed by various means, and 
state that the only feature common to the cases in which bac- 
teria were found was, that a certain period of time had elapsed 
after death before the examination was made. The shortest 
was five and one-lialf hours. In an examination of blood 
taken from a dog in a state of great depression, and just before 
his death from the effects of intense inflammation excited by 
the injection, not of a putrefying organic liquid, but of am- 
monia into the peritoneal cavity, large quantities of bacteria 
were found. 
Offensive rancid pus from wounds contains micrococcos 
chiefly, and yet the quantity is not proportionate to the in- 
tensity of the odor; and, further, as great quantities of micro- 
coccos can be present without the coexistence of any fever, 
their appearance in the pus of a wound has no immediate con- 
nection with the unfavorable course of a traumatic inflamma- 
tion, or with pyaemia; the pus from cavities communicating 
with the external air almost always contains micrococcos, and 
yet the patients may remain perfectly free from fever, and 
make good recoveries. 
Billroth relates three cases of acute closed abscesses, which 
may have communicated at some earlier period with the air. 
The first was an abscess of the epitrochlear gland following a 
wound of the fingers; the pus was sweet, and contained masses 
of micrococcos. The second was an abscess of the scrotum fol- 
lowing lithotomy, which contained a bloody, brown, badly- 
smelling pus, and no micrococcos; but he thinks the latter 
may.have existed previously, and perished from lack of oxy- 
gen. The third was a case of osteomyelitis of the upper end 
of the tibia; the pus contained no eoccos; but pus which 
formed subsequently in the knee-joint, and was removed by 
aspiration, was full of streptococcos, and was odorless; the 
fever ran high, and death followed amputation. Examination 
showed no organisms in the blood or inguinal glands, but the 
stump was infiltrated with pus containing many free micro- 
coccos. 
Inodorous, thick pus from several cases of completely closed 
acute abscesses contained no organisms, and in one case of 
marked septic poisoning, with oedematous phlegmon of the 20 
thigh, following a bruise of the skin, the inodorous liquid re- 
moved by incision contained no trace of cocoobacteria. This 
case shows that the most dangerous and extensive phlegmon 
wTith septic poisoning caft occur without the aid of this vege- 
tation. An inodorous, lialf-purulent extravasation of blood 
opened fourteen days after the accident, on account of inflam- 
mation of the parts, a metastatic abscess of the thyroid gland, 
and very fetid pus from a subcutaneous abscess caused by 
passive motion of a stiff elbow, all contained micro- and strepto- 
coccos. 
Pus, freshly taken from cold abscesses caused by injury to 
bone or joint, was never found to contain cocoobacteria. In 
a case of dissection wound followed by lymphangitis, the pus 
contained no coccos.1 
In some cases of erysipelas he found cocoobacteria in the 
bullae, in others he found none. 
In ulcerative diphtheria of wounds and hospital gangrene, 
he found large quantities of micro- and streptococcos. 
Vogt (Centralblatt, Vo. 44, 1812) found crowds of micro- 
coccos in blood taken from the skin of a pyaemic patient near 
the point at which amputation had been performed, and also 
in pus from a metastatic abscess in the wrist, while very few 
were found in blood taken from other parts of the same patient. 
Injections of the first blood into the back of a rabbit caused a 
large abscess, which was found to contain large quantities of 
micrococcos, as did also the neighboring muscles. 
Wolff (Virchow's Archiv, December, 1873) claims that 
there are cases of acute pyaemia and septicaemia in which the 
presence of bacteria in the blood cannot be proved microscop- 
ically or experimentally, and vet the pus of' the wound con- 
tains them, and inoculation with it is fatal. 
In the body of a healthy animal, the development of cocco- 
1 Dr. Bergeron presented a paper to the Acaddsmie des Sciences, the 
15th of February, 1875, which contained the result of the examination of 
the pus of eighteen closed abscesses. He found bacteria in all the hot 
abscesses of adults, and none in cold abscesses, or in hot ones of patients 
below the age of twenty-two years. Their presence was not accompanied 
by any serious symptoms. In a second series of examinations, not yet pub- 
lished, bacteria were found in the pus of a hot abscess of a boy about 
sixteen years old, and were absent in one or two abscesses pf adults. 21 
bacteria is very difficult if not impossible. The active move- 
ment of the blood hinders it greatly, and the vital energy of 
the tissues is a very serious obstacle, because the normal ex- 
change of nutritive material is so energetic that these plants 
cannot check it and absorb the nourishment needed for their 
own growth. This is an important fact, for, according to all 
analogy, only by active vegetation of this plant could an 
alteration of the blood occur which would lead to its death. 
Fresh blood and pus are not favorable to the development of 
coccobacteria even under the most favorable conditions, and 
when masses of microeoccos are found in the tissues, and in 
pus, it is certain that some change has taken place to render 
the medium suitable for their nourishment; the moribund dog 
of Lewis and Cunningham, already mentioned, is a case in 
point. This change is thought by many to be due to the sup- 
ply to the pus of certain materials, products of unhealthy in- 
flammation, from the neighboring inflamed tissues. If this 
neighboring inflammation ceases, if the pus beeomes surround- 
ed by healthy granulations, and can flow freely away, then 
its alteration ceases, and so too does the vegetation of micro- 
coccos; but if this barrier is not formed, if the inflammation 
continues, the alteration of the pus and the rapid vegetation 
of the plant react upon and increase the original inflamma- 
tion, thus forming a vicious circle, which may rapidly produce 
the most fatal results. Experiment shows that decomposition 
of fresh pus rapidly follows the addition of a drop that has 
been already affected. The same effect is produced by the 
addition of a drop of a putrefying infusion of meat, or of the 
serum of a wound, or of urine, and this showrs that the poison 
is produced as well outside of the body as in inflamed tissues. 
If the pus of an open wound has been infected from the out- 
side, its prompt removal and extreme cleanliness of the wound 
for a few days may restore it to its healthy condition, and the 
principal danger does not lie in the ordinary spores which 
may fall upon the wound from the air, for they require a cer- 
tain time for their development, and do not act at once as 
ferments, but it does lie in those which have taken up some 
of this virus, and which, aided probably by it, act at once as a 
ferment upon any pus with which they come into contact. 22 
To this material Billroth gives the name phlogistic zymoid 
(£v/jlv, ferment material), because it is produced by inflamma- 
tion, and is capable of reproducing it in turn, and while it is 
not a ferment in the sense in which yeast is one, it is ferment 
like, zymoid. 
A suppurating wound, then, may be poisoned by the in- 
troduction of foreign matter from without, decomposition of 
the pus is caused, and if the latter is not promptly removed, 
and the wound cleansed so as to prevent further decomposition, 
the granulations are destroyed and a special inflammatory pro- 
cess is set up in the neighboring tissue. Or this special in- 
flammatory process may be the result of mechanical violence 
due to improperly-arranged bandages, or irritation and crush- 
ing of the granulations; the phlogistic material is formed and 
mixed with the pus, insuring its decomposition, the growth 
of coccobacteria and septic poisoning. In either case the 
presence and development of coccobacteria are not necessary 
to the process, and the most dangerous phlegmons may occur 
without the slightest trace of these organisms. Billroth gives 
a case in point which has been already referred to: 
“ A man, fifty-four years old, irritated the skin over his shin hy friction 
against the hard edge of his boot; lie continued to work for ten days, and 
was then compelled to take to his bed with high fever and chills; four days 
afterward he was brought to the hospital, apparently in collapse, with all 
the symptoms of intense septicaemia. A superficial scab was found on the 
shin of the right leg, around it the skin normal, but on the knee and entire 
outer half of the thigh it was very red and swollen, doughy to the touch, 
and without distinct fluctuation. After the patient had taken some brandy, 
he rallied sufficiently to allow an. incision to be made along the outer part 
of the thigh and front of the knee. The serum mixed with pus which 
escaped was entirely odorless, and showed no trace of micrococcus. The 
patient did well until the twelfth day, when he was attacked by pneumo- 
nia and died.” 
Acute grave inflammation can be excited by many causes, 
of which crushing is the type, and this effect is produced not 
by putrefaction of the parts which are entirely killed, but by 
the chemical changes in those which are half killed, in which 
the circulation still goes on. A break in the skin increases 
the danger. Similarly, the most dangerous freezing is that 
which does not go on to absolute death of the tissues; and 23 
partial obstruction of the circulation, as effected by the stitches 
in a wound, is far more dangerous than ligature of an artery. 
So far as we know, the products of all acute inflammations 
are infectious in certain stages; this virulence is also shared 
by certain substances formed by putrefaction, but no one has 
yet been able to separate the poison or to describe it fully. 
Most writers agree that it is not destroyed by boiling heat, a 
fact which seems to be an additional proof that it cannot be 
due to the presence of vegetable organisms. Pannm (Vir- 
chow’s Archiv, July, 1874, page 348) says, “Putrid poison is 
formed in putrefying tissues and liquids, is a peculiar chemi- 
cal substance, not composed of albuminous matter, not de- 
stroyed by heat, is soluble in water, and can be thence pre- 
cipitated by means of alcohol.” He thinks it is perhaps 
produced by the growth of bacteria, especially B. termo. He 
also testifies to a fact which has been already stated, that 
putrefactive bacteria which may make their way into the cir- 
culation of healthy men cannot continue to exist there, and 
can multiply only after a certain grade of decomposition after 
death has been reached, the appearance of which is greatly 
hastened by the presence of putrid poison. “ But,” he con- 
tinues, “putrid poison with or without bacteria can make its 
way, especially from wounds, into the blood during life, and 
cause the ordinary symptoms of putrid infection, septicaemia; 
and there is a certain specifically pathogenic fungus, Micro- 
sjporon septicum of Klebs, which differs from B. termo, and, 
when carried by the air or intentionally inoculated, is devel- 
oped especially in the blood and pus, probably under the 
predisposing influence of the putrid poison, and seems to be 
able to multiply very rapidly in the blood and tissues of living 
bodies, and cause fever, suppuration, and inflammation, in part 
by the production of a special poison, and in part mechani- 
cally.” 
There is but little difference between this description and 
Billroth’s, for “ putrid poison,” “ phlogistic zymoid ” must be 
substituted, and for “ microsporon septicum,” “ micrococcus.” 
Both consider the development of the plant made possible 
only by the presence of a predisposing poison, and both think 
it may be carried by the air, but, where Pan urn’s theory re- 24 
quires the cooperation of two processes,' Billroth’s requires only 
one; for, according to the latter, the spore may take up and 
“ fix ” the poison, so that when floating in the air it carries in 
itself, though not of itself, the means to render the soil upon 
which it falls suitable for its future growth. One of Panum’s 
experiments deserves mention. lie made a watery extract 
of the residue left after alcoholic extraction of the dried resi- 
due of a putrid liquid. Inoculation of a dog with this wa- 
tery extract caused its death in three hours with acutest 
symptoms of septicaemia. Injections of the alcoholic ex- 
tract had no effect (loc. cit., p. 335). These experiments sup- 
plement Hiller’s* and together they confirm those of Onimus 
which have been already, mentioned. Hiller (Centralblatt, 
February, 1874) made thirty-two injections with putrid matter 
subjected to various processes designed to remove from it 
every thing except the bacteria, and got no results beyond 
finding masses of dead bacteria in the skin at the place of in- 
jection. Other portions of the injected liquid caused active 
vegetation in Pasteur’s liquid. He concluded consequently 
that bacteria have no phlogogenic or pyrogenic influence, and 
that their development is possible only in material that is dead 
or incapable of regular exchange, and finally that septicaemia 
is due not to bacteria but to the absorption of the products of 
inflammation and decay. 
The demonstration of the existence of a virus, far from solv- 
ing the question of the etiology of septicaemia, only removes 
it a step backwardi We have yet to learn the conditions of 
the formation of this virus both in putrefying matter and in 
the living, although injured, body. This is a question which, 
strictly speaking, is not included in the subject of this article, 
and can, therefore, receive only a passing mention. Pasteur’s 
brilliant studies of fermentation, of which putrefaction is a 
variety, have shown that the process cannot go on without the 
aid of living organisms, among which the cells of vegetables 
and even of animals are to be classed. For instance, during 
the ripening of fruits alcohol is formed within them and car- 
bonic acid is given off in considerable quantities as a result of 
the transformation of the sugar. In this case the ordinary 
alcoholic ferment is not present, and its part is performed by 25 
the cells of the fruit. There is reason to believe that a simi- 
lar function belongs to the cells of animal tissues, that all life 
is a fermentation/ and that for the Vague term “ vitality ” or 
“ vital action,” we have to substitute another which conveys 
the idea of a definite chemical process. 
It is easy to comprehend that among the products of pu- 
trefaction there may be one which is very deleterious to the 
living body when the latter has been inoculated with it, and, 
on the other hand, that the portions of an organism which 
have been injured and are living under altered conditions, 
such as constant pressure, mechanical or chemical irritation, or 
insufficient supply of blood, may cease to functionate normally 
and may give rise to abnormal products which are as deadly 
to the parent organism as is the sting of a scorpion when 
plunged into its own body. 
This is a question for the physiologists and pathologists of 
the future. At present it is but an hypothesis, a “ working 
hypothesis,” a convenient form for expressing the relations 
between certain well-established processes, and is not yet a 
fact definitively acquired by science ; but, as it is now under 
investigation by its author, perhaps the most successful experi- 
menter of the age, we have a right to expect its speedy verifi- 
cation or abandonment. 
The question at once arises, Why does not this acute spe- 
cific inflammation spread rapidly in all cases over the whole 
body ? Its course in the tissues is often limited by fasciae ; 
this is due probably to the slight diffiisibility of the poison, 
and to the fact that it is diluted by the serous exudations 
and carried by them to the surface, or if absorbed it is ab- 
sorbed by the lymphatics, so that the inflammation follows the 
course of these vessels. When this specific decomposition of 
pus has taken place on a wound covered with healthy granu- 
lations, the latter form a very strong barrier against infec- 
1 M. Poggiale : “... si la definition de M. Pasteur devait compre- 
hendre les cellules v6ggtales et, ainsi qu’il nous l’a annoucS, les cellules 
animales, la vie dans les vegfitaux, coniine dans les animaux, ne serait qu’une 
fermentation universelle.” 
M. Pasteur: “ Ce serait bien possible.” 
Bulletin de VAcademie de Medecine, 1875, p. 283. 26 
tion of tlie Underlying tissues, and time is thus afforded for 
proper cleansing of the wound and arrest of the process. It 
cannot be admitted that the leucocytes have any share in in- 
oculation or spread of the contagion except so far as they may 
be able to take up and “fix” the poison, as do the vegetable 
organisms; upon this point nothing is known beyond the fact 
that occasionally leucocytes are found which seem to inclose 
bacteria or coccos, although the testimony of the microscope 
is not conclusive when its highest powers have to be employed. 
Of course, it is theoretically possible that the inclosed or ad- 
herent plants may have previously been in contact with and 
have absorbed the poison, but this is an unnecessary refine- 
ment, since the spread of the process can be easily accounted 
for without the aid of the pus-corpuscles. 
As pus is not affected morphologically by the presence of the 
virus, and may have all the appearances of pus that is bonum 
et laudabile, and does not necessarily have an offensive odor, 
we can account for the difference of the results obtained by 
experimenters; and, further, as the presence of the virus in 
stagnant pus favors the free development of micrococcos, and 
is itself in turn increased thereby, we must admit the correct- 
ness to a certain extent of the observation of Klebs and others, 
that pus containing micrococcos is especially infectious. 
In the other specific acute inflammations—diphtheria, 
erysipelas, hospital gangrene—this influence of the micrococ- 
cos does not differ from that which it possesses in the acute 
phlegmon which we have described. Its appearance is always 
preceded by the characteristic lesion of the affection ; in the 
diphtheritic affection of a wound, for example, the borders be- 
come hard and infiltrated with coagulated flbrine before the 
appearance of more than a few isolated micrococcos in the 
secretions; in erysipelas, as has been already mentioned, they 
are sometimes absent and sometimes present in the serum of 
the bullse, and this affection certainly is not dependent upon 
the presence of vegetable organisms; in phagedenic or hospi- 
tal gangrene a stiff fibrinous infiltration always precedes the 
ulceration, and, while the micrococcos is very abundant on 
the surface, it penetrates only to a very slight depth; in 
phlebitis, the inflammation begins in the outer coat of the 27 
vessel, and, after the latter has become hard and cord-like 
to the touch, it still remains pervious—-coecobacteria have 
evidently nothing to do with this process; and, lastly, they 
are almost always absent in thrombi and small metastatic 
abscesses. 
To conclude, the argument may be summarized as follows : 
Septicaemia is the name given to an adynamic condition of the 
organism caused by a certain alteration of the blood. This 
alteration is not due to a parasitic influence exerted by the 
rapid growth of coecobacteria, because all observations show 
that this plant is present in the blood of the living animal only 
in exceptional and rare cases, and then its presence can be 
proved to be due to local and exceptional causes. Moreover, 
clinical observation shows that the disease always has its ori- 
gin in a lesion of the tissues, generally an open wound, either 
through inoculation from without, or through •mechanical or 
chemical irritation of the parts; but coecobacteria are often 
entirely absent from these starting-points of the disease; and, 
secondly, are often present in the pus and secretions of wounds 
and abscesses, without exciting septicsemia. 
Inoculations which will cause septicaemia may be made 
with materials coming from the acute special inflammations 
mentioned, or from putrefying animal liquids and infusions. 
Coecobacteria are almost always present in these liquids, but 
they may be removed, and yet the virulence of the liquid will 
still be preserved {see experiments of Onimus, Hiller, and 
Panum). 
Coecobacteria having thus been eliminated, what remains? 
Only the products of putrefaction in one case, and those of 
inflammation in the other. Must we not, then, conclude that 
there is produced in the secretions of these wounds, or in the 
adjoining tissues, a certain product of inflammation which re- 
sembles, if it is not identical with, the poisonous principle of 
the products of putrefaction. The latter is known as “ putrid 
poison ; ” to the former Billroth gives provisionally the name 
“ phlogistic zymoid.” 
It is highly probable that this virulent substance can be 
taken up by vegetable forms (coecobacteria), which may then 
serve as carriers of contagion, and that it is very favorable to 2S 
their rapid multiplication, by which it is itself in turn very 
much increased in amount. 
Prophylaxis and treatment. 
The practical result of all these experiments and observa- 
tions is to be sought in the treatment of wounds. They indi- 
cate that the acute inflammatory complications to which so 
many of the deaths following surgical operations are due, are 
induced by certain alterations in the secretions of the wound, 
or in the adjoining tissues, and that these alterations are due 
to abnormal chemical (“vital”) action of the cell-elements of 
the tissues, itself caused by mechanical or chemical irritation 
of the parts, or by inoculation, and that this inoculation is 
effected bv means of particles of this abnormal product, or by 
low vegetable organisms which have previously been in con- 
tact with and have absorbed it. Treatment, then, must be 
directed to avoid injurious mechanical and chemical action, to 
prevent inoculation, and to remove or destroy the poison when 
it has been formed, 
The extent to which these indications can be met will be 
best learned from a description of the measures in general use. 
Billroth (loc. cit.) discusses subcutaneous wounds, treatment 
with caustics, attempts to get union by first intention, open 
treatment, immersion and irrigation, treatment of deep irregu- 
lar wounds, disinfection, and antiseptics. In addition to these 
should be mentioned Gudrin’s permanent dressing of cotton- 
wool without attempting primary union, a mode of treatment 
which is now quite popular in France. 
The favorable course of subcutaneous wounds is too well 
known to need more than a passing mention, but the applica- 
tion of this method is limited to comparatively few surgical 
operations, most fractures* and some penetrating wounds which 
heal on the surface by first intention. Recent investigations 
have not added much to our knowledge of the causes of the 
good results of this method. They appear to be due to the 
slight extent of the injury, the favorable conditions for reunion, 
and the exclusion of the air. 
Treatment with caustics is based upon the fact that primary 
acute phlegmonous inflammations often occur during the first 
two or three days, before suppuration has fairly set in. By 29 
producing an eschar upon the whole surface is protected as 
by a shin; and, when the eschar falls, a healthy granulating 
surface is left behind* To avoid too great febrile reaction, the 
cauterization must be superficial and applied only to wounds 
of moderate size. The same result may be obtained in exten- 
sive superficial injuries, such as burns of the second or third 
degree, by creating an artificial skin by means of various ad- 
hesive preparations, such as collodion mixed with castor-oil, 
gum-tragacanth, finely-powdered flour dusted over the surface, 
or a mixture of molasses and gum-arabic. 
Union of the wound by first intention throughout its whole 
extent is theoretically the best w'ay to meet all the indications, 
but the failures of attempts to procure this result are so fre- 
quent in all large or irregular wounds, and their consequences 
so disastrous, that the method is now generally abandoned in 
large hospitals, except tor minor cuts, wounds of the face, and 
also, according to Billroth, after enucleation of tumors or 
glands which have a firm fibrous capsule. If it is attempted, 
great care must be taken that the stitches be not too tight, 
and the pressure of the bandages not too great; and, for the 
deeper wounds, Simpson recommends deep metallic sutures 
and occlusion of the arteries by acupressure, and it has also 
been advised that the ends of the ligatures should be attached 
to a long needle and carried to the surface through the neigh- 
boring tissues so as to leave the main wound unobstructed by 
them. The causes of the frequent failures will be mentioned 
under treatment of large irregular wounds. A serious com- 
plication appears during the first forty-eight hours in the form 
of acute phlegmonous inflammations, followed by septic poi- 
soning, and it is always doubtful if the bad effects of the first 
treatment can be overcome. 
The open treatment of wounds consists in free exposure 
of their whole surface to the air. Part of the secretions form 
a crust upon the surface of the wound, the rest flows away, and 
the wound remains odorless. The crust is dry and conse- 
quently unfavorable for the development of spores that may 
fall upon it; and when it comes off it discloses a healthy, 
granulating, perhaps partly cicatrized surface, which cannot 
easily be injured by contact with ferments. This is the “ heal- 30 
ing unde!* a scab ” of the English authors, of which Paget 
speaks so highly. Billroth says the method was first introduced 
in 1856 by Vezin, and that be himself adopted it in 1860, and 
has since employed it with the best results in amputations, 
resections, and after removal of many tumors. Its chief ad- 
vantage is that it protects against the dangerous primary 
phlegmonous inflammations by allowing free escape of all the 
secretions, but it does not protect against erysipelas and hospi- 
tal gangrene, and is useless when inflammation has once set 
in. If the wound is irregular and permits the accumulation 
of pus and secretions, there ife danger of inoculation by micro- 
coccus. 
Treatment by immersion and irrigation is based upon the 
same principle as the preceding. Irrigation is difficult to 
apply, but has the great advantage of washing away all the 
secretions as soon as they are formed ; but, when simple 
immersion is used, more or less pus remains adherent to the 
wound. In both modes of treatment primary phlegmonous 
inflammation rarely occurs, but if any does begin, its conse- 
quences are rendered more disastrous than ever by the tume- 
faction of the granulations which imprison the products of de- 
composition. 
Deep irregular wounds, forming pockets or cavities in 
which the secretions may stagnate and decompose, are the 
most dangerous. If the wound involves normal loose cellular 
tissue, the confined secretions trickle back into it and cause 
acute inflammation, or are absorbed by the lymphatics and 
veins, giving rise to thrombi, which break down and cause 
dangerous emboli, generally of the pulmonary arteries. If 
the tissues are firmer, or if they have been thickened bv 
chronic inflammation, the danger of infiltration is much less, 
and this is one reason why subperiosteal resection of bones 
results less frequently in pyaemia ; similar favorable condi- 
tions exist when an inflammatory process has attacked the 
interior of the sheath of a tendon, or when an encapsulated 
tumor or gland has been removed. During the first two or 
three days every care must be taken to insure the removal 
of all the secretions; after suppuration has begun, the danger 
is less, and is due chiefly to the collection of pus in cavities 31 
formed by irregular lines of union, or sometimes in the sub- 
cutaneous tissue, or between the muscles, or in the marrow 
of the bones. This happens about the end of the first week, 
and, if the complication is promptly recognized and its cause 
is accessible, all the new adhesions must be broken up, free 
incisions made into all purulent cavities and infiltrations, and 
the wound cleansed and allowed to lie open. In cases of deep 
suppuration, or those involving joints and bones, this cannot 
always be done, and it then becomes a problem, as difficult 
as it is important, to determine whether amputation shall be 
performed, and at what time. On this point Billroth says 
(ioc. tit., p. 227), in suppuration of the shoulder, elbow, and 
ankle joint, we can accomplish something by means of care- 
fully-conducted treatment with ice ; but in deep suppuration 
of the lower leg or of the forearm, extending along the bone, 
or of the thigh, or of the knee-joint, he would decide promptly 
upon amputation, after the complication had made steady prog- 
ress for a few days. The result of amputation depends upon 
the extent of the general infection. If metastatic abscesses 
have formed, it is seldom of any avail; but if this is not the 
case, then, no matter how high the fever nor how frequent 
the chills, amputation is always to be tried. 
A consideration of the source whence the infection is de- 
rived is essential to treatment by means of antiseptics or dis- 
infectants. Practically we need not consider the possibility 
of infection by means of spores entering the body through 
the lungs or the intestines, for a general destruction of all the 
spores in the air and food is impossible, but against immediate 
inoculation of the wound much may be done by the strictest 
cleanliness on the part of the surgeons and attendants, and by 
the use of various disinfectants. We know that all coccobac- 
teria-spores cannot grow in all liquids, and that many which 
fall from the air upon wounds do not vegetate because they 
do not find there the necessary nourishment and conditions ; 
and we have every reason to suppose that there is developed in 
hospitals, in the pus and secretions of wounds, a variety of 
this plant which becomes especially adapted, by this cultiva- 
tion, to live tipon such materials, and from such a variety 
most danger is to be apprehended. Such spores could be 32 
transported by the air, by the hands and instruments of the 
attendants, and by the bandages., Billroth considers this 
source of danger so important that he uses no sponges in 
operations or dressings, except in cases of ovariotomy and the 
like, where they cannot be dispensed with, and substitutes for 
them pledgets of cotton. Those which lie is compelled to use 
lie disinfects thoroughly with hydrochloric and carbolic acids. 
Thorough ventilation is the only practicable means of dis- 
infecting the air, but there is no lack of good antiseptics 
which may be used directly upon wounds. It is essential to 
their efficacy that they should be constantly in contact with 
every portion of the wound, and, since that is practically im- 
possible, the use of these agents does not release the surgeon 
from the obligation to employ every additional means to in- 
crease the cleanliness of the wound and promote the free dis- 
charge of all its secretions. 
Among the best known disinfectants the following may be 
mentioned: 
Chlorine-water—in its concentrated form (one to ten); it is 
rather painful, and Avhen diluted its application must be fre- 
quently renewed. 
Iodine—a very active antiseptic, and especially useful 
against diphtheria and hospital gangrene; the objection to it 
is that the applications must be frequently renewed, and are 
then likely to cause acute inflammation. 
Glycerine—a very useful and cleanly dressing. 
AIcoliol—theoretically excellent, but its rapid evaporation 
is a great objection. Gosselin uses it for all wounds of the 
head and face, to prevent suppuration, and favor union by 
first intention. 
Camjohor—only slightly soluble in water, and is not a 
deodorizer. 
Olive-oil—useful to prevent inoculation by falling spores, 
but is useless after infection 'has taken place. 
aSubacetate of lead—very highly recommended; even in a 
very weak solution it kills bacteria, and has a slight astringent 
effect upon the surface of the wound, but it is not a good 
deodorizer. 
Carbolic acid— has become very popular of late years, 33 
Billroth thinks it is in no way superior to many others; its 
odor is very offensive to some, and when dissolved in oil it 
ruins the dressings and bedding. Salicylic acid is beginning 
to replace it. 
We have finally to consider the cotton-wool dressing, the 
2Mnsement d Vouate of A. Guerin. After the operation has been 
completed, bleeding arrested, and the surface of the wound 
washed with water or some weak disinfecting solution, a large 
bunch of cotton-wool is placed between the lips of the wound, 
and the whole limb is then enveloped in a layer of cotton 
eight or ten inches thick, which is then bound down very 
firmly with roller-bandages, which are tightened on the follow- 
ing day, and then the dressing remains untouched for about 
three weeks. If the pus makes its way between the limb and 
the dressing, and appears after a few days at its free margin, 
additional bunches of cotton are placed over the edge and 
bound down. Clinical experience shows that patients whose 
wounds are dressed in this way generally remain free from 
fever and pain, eat and sleep well, and make good recoveries. 
In one case that came under my own notice, and two recently 
reported by M. Guerin (Academie des Sciences, March 23, 
1874), removal of the dressing at the end of the third week 
was followed on the first or second day thereafter by severe 
phlegmonous complications, due, apparently, to the temporary 
exposure. Guerin claims that this method differs from “ occlu- 
sion,’ because air can pass freely through the cotton which acts 
only as a filter, freeing it from all spores and ferments. Pas- 
teur says that ferments are undoubtedly present in the cotton 
and in the wound, but that the physical condition of the pus 
is rendered unfavorable for their multiplication by the absorp- 
tion of its liquid portions, and he advises exposure of the cot- 
ton to a temperature of about 400° Fahr. before application as 
an additional precaution.1 However that may be, the method 
has two evident advantages; equable temperature and com- 
plete immobility of the limb. 
1 I have had occasion to examine several of these dressings after re- 
moral and have always found living bacteria present in the more or less 
liquid pus which bathed the wound, even when (he dressing had been per- 
fectly successful. 84 
It must be borne in mind that these procedures have 
been instituted to meet the exigencies of, and have been 
judged by their results in, large hospitals, especially those of 
Europe. The hygienic conditions found in those establish- 
ments are very unfavorable; many of the buildings were 
erected generations ago, and in accordance with ideas which 
are now universally rejected. They are found in the centre 
of large cities, surrounded by other buildings, their ceilings 
low, their beds crowded, and ventilation dependent entirely 
upon the will and intelligence of the nurses. 
In the country and in new hospitals of improved construc- 
tion attempts to get union by first intention are generally suc- 
cessful, and the dangerous acute primary phlegmonous in- 
flammations, to which reference has been made, so frequently 
are rare. 
To the efforts of the Sanitary Commission during the war 
of 1861-’65 is due the spread of the pavilion system of hospi- 
tal construction. This consisted of groups of separate build- 
ings of only one story, removed sufficiently from one another 
to allow free circulation of air, thus supplying as nearly as pos- 
sible the conditions of open-air treatment; and the success of 
those army hospitals was so great that the principle of their 
construction is now generally accepted, and a large hospital 
has been recently built at Leipzig on this plan. 
The ideal hospital is one that shall be destroyed and re- 
placed every year or two, and, although that is practically im- 
possible, may we not hope that the statistics of the future will 
show that intelligent construction of hospital buildings has at 
last removed the evil influence which has so long baffled the 
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