PYEMIA 
AND 
SEPTICEMIA. 
7 
' I s 
B. A. WATSON, M.D., 
SURGEON TO JERSEY CITY CHARITY AND ST. FRANCIS HOSPITALS, 
JERSEY CITY. N. J. 
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SEPTICEMIA. 
B. A. WATSON, M.D., 
SUBGEON TO JEBSEY CITY CHABITY AND ST. FBANCIS HOSPITALS, 
JEBSEY CITY, N. J. 
[REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, OCTOBER AND 
NOVEMBER, 1877.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1877. ERRATA. 
Page 7, twenty-seven th line from top, should read "substances 
which excite." 
Page 15, twentieth line from top, should read "would still leave." 
Page 23, thirty-fifth line from top, should read "the theories." 
Page 33, eleventh line from top, should read "The term mias- 
matic." 
Page 44, ninth line from top, should read "the acute sepsis men- 
tioned." 
Page 45, twenty-ninth line from top, should read " sine quibus 
non" 
Page 51, sixth line from top, should read " The first effort." PY2EMIA AND SEPTICAEMIA.' 
I. History.-The morbid conditions now designated pyae- 
mia and septicaemia were recognized by the " Father of Medi- 
cine," who reports' a well-defined case of puerperal fever ter- 
minating fatally on the twentieth day of the disease ; and also 
the following fatal case of erysipelas : " Criton, in Thasus, 
while still on foot, and going about, was seized witli a violent 
pain in the great-toe; he took to bed the same day, had rig- 
ors and nausea, recovered his heat slightly, at night was de- 
lirious. On the second, swelling of the whole foot, and about 
the ankle erythema, with distention, and small bullae *(phlyc- 
taenae); acute fever; he became furiously deranged; alvine 
discharges bilions, unmixed, and rather frequent. He died 
on the second day from the commencement." 3 
Further confirmation of the fact that Hippocrates was fa- 
miliar with the phenomena of these diseases may be found in 
his dissertation on " Empyaema and Fevers." 
Prof. C. Hueter, under the head of " Septic Fever," says : 
" Hippocrates and Celsus observed the fever in cases of inju- 
ries which proved so dangerous, and that this danger must 
have originated neither from the inflammation nor from the 
wound alone, but from some unknown cause. 
1 President's Address before the New Jersey Academy of Medicine at 
its Annual Meeting, June 20, 1877. 
2 Works of Hippocrates, translated by Adams, vol. i., p. 373. 
3 Ibid., p. 377. 4 
" Jacotius, a commentator of Hippocrates, has even men- 
tioned putrid fevers, the same as Adrianus Spigelius, who 
spoke of fevers which arise from putrefaction ; but both au- 
thors, as well as their followers, did not discriminate between 
septicaemia arising from the putrescence of wounds, and pyae- 
mia. In the mean time, both varieties were regarded as in- 
termittent fever.1 
" Aretaeus lived during the middle of the second century of 
the Christian era. In his remarks on pneumonia, Aretaeus 
observes that the subjects of this disease die mostly on the 
seventh day. ' In certain eases,' he says, ' much pus is formed 
in the lungs, or there is a metastasis from the side if a greater 
symptom of convalescence be at hand. But if, indeed, the 
matter be translated from the side to the intestine or bladder, 
the patients immediately recover from the peripneumony.' He 
speaks of metastasis to the kidneys and bladder being pecul- 
iarly favorable in empyema. He ascribes suppuration of the 
liver to intemperance and protracted disease, especially from 
dysentery and colliquative wasting. The symptoms described 
by him resemble those of chronic pyaemia." 2 
A new era in the literature of this subject dawned during 
the sixteenth century. 
Ambroise Pare and Bartholomew Maggi each published a 
work in which they pointed out the old errors and announced 
new truths. Carl Thiersch, in his lecture on " Kliniscke 
Ergebnisse der Lister* schen Wundbehandlung und Uber den 
Ersatz der Carbolsdure durch Salicylsaure" says : " When, 
in the year 1536, a strong army of the ' famous King Francis ' 
marched over Mt. Cenis into Piedmont, it was accompanied 
by an inexperienced surgeon only nineteen years of age-the 
subsequently so highly honored Ambroise Pare. The storming 
of the mountain citadel of Vallane, near Susa, gave him indeed, 
for the first time, plenty to do, and he put in practice everything 
in accordance with the example of his older colleagues. Like 
them, if also with fear, he poured the boiling oil of elder into 
the gun-shot wounds, in order to destroy the poison; but as 
1 Pitha u. Billroth, " Handbuch der Chirurgie," 1. Band, 2. Abth., 1. 
Heft, 1. Liefg., 6. S. 
9 Braidwood on " Pyaemia," p. 2. 5 
there was not sufficient oil, he was compelled to dress the re- 
mainder of the wounded with a salve prepared from oil of rose 
and turpentine. Pained by the fear that the latter, in a short 
time, would become a sacrifice to the poison, he passed a 
sleepless night, arose early from his bed in order to examine 
the unfortunates, but was greatly surprised to find the half- 
given-up almost free from pain, without inflammation or swell- 
ing. ' Then I determined,' said he, ' never again to burn the 
poor wounded soldiers so cruelly.' " 
Pare's "Treatise on Gun-shot Wounds" first appeared in 
Paris in 1551, fifteen years after the occurrence of the previ- 
ously-narrated event, in which he declared in favor of the non- 
poisonous character of these wounds. He had spent a part of 
the intervening time in Italy, and it is supposed that he there 
became acquainted with the investigations of the learned Bo- 
logna physician, Bartholomew Maggi, and had appropriated to 
himself the demonstrations on the non-poisonous nature of gun- 
shot wounds. Maggi's treatise appeared a year later (1552), 
at Bologna. In whatever manner Pare may have obtained 
the priority, certain it is that it required all the influence 
which he in more mature years enjoyed, especially in things 
pertaining to military surgery, in order to provide a gradual 
introduction for the new theory. Still one meets with the 
old error among the more modern physicians. How this er- 
ror could have attained such a widespread influence is, indeed, 
scarcely susceptible of demonstration. It is certain that, origi- 
nally, gun-shot wounds passed for contused wounds, and were 
usually treated with warm, moist poultices. But as gun-shot 
wounds are naturally inclined to a bad course, especially if 
complicated with a fracture, and as this bad termination has 
become more frequent since the introduction of firearms, de- 
pending on an increase in the number of that kind of inju- 
ries, while the care of the wounded at that time was always 
insufficient: in this way was encouraged the formation of a 
false opinion, based on the experience at the bedside, of the 
special danger of gun-shot wounds. 
Cases of acute sepsis which developed after the infliction 
of gun-shot wounds, and which agreed in essential points with 
the results of the bite of poisonous snakes, had given a turn 6 
to events. There were such cases during the late Franco- 
Prussian war, which here and there among the laymen even 
excited suspicion that the enemy used poisoned missiles. 
Thus it was only necessary for Johannes de Vigo, in the 
commencement of the sixteenth century, to express in dog- 
matic form the already firmly-held views of physicians. " The 
gun-shot wound," said he, " is a contused wound, for the ball 
is round ; it is a burned wound, for the ball is heated ; it is a 
poisoned wound, for the powder is poisonous. The poison is 
the chief characteristic ; therefore the treatment should be di- 
rected against that, before anything else." And it was on this 
theory that J. de Vigo stood to decide the fate of gun-shot 
wounds for many years. Among the different forms of treat- 
ment, that most frequently used against the poison was the 
repeated application of escharotics-e. g., pouring boiling oil 
into the fresh wounds. Should the topic of discussion at the 
present time be the treatment of wounds, then it might be 
said that this historical information was rather far-fetched; 
nevertheless, the lapse of three and a half centuries is only ap- 
parently a long time. The theoretical error is merely removed, 
but there remains the undetermined question which Pare sought 
to explain. We no longer seek the poison in the powder and 
lead ; but, as at that time, we speak of a poisonous effect of the 
wound on the body; now, as then, this poisonous condition 
forms the central point of our therapeutical efforts. Indeed, J. 
Lister's first method of cauterizing fresh wounds with concen- 
trated carbolic acid has certainly much to remind one of the 
burning-out of gun-shot wounds in the citadel of Vallane. 
That a poisonous substance develops in wounds, or may in- 
sinuate itself into them, more especially in gun-shot wounds- 
a substance which has nothing to do with powder and lead- 
was the next step advanced. Pare himself came to this con- 
clusion. 
When he was present with the besieging army before 
Rouen, many of the wounds became putrid, and the stench 
arising from them highly offensive. In the bodies of the 
dead on whom autopsies were made, there were found nu- 
merous pus infarctions in varidus organs. The pus was 
greenish and the odor very disgusting. Besieger and be- 7 
sieged believed themselves wounded with poisoned missiles. 
Pare sought the cause in the contamination of the atmosphere 
through the accumulation of decaying material, and advised for 
such cases the scabbing treatment: cauterization with Egyptian 
ointment, prepared from equal parts of alum, verdigris, and 
sulphate of copper. Thus he seems to have accepted the doc- 
trine, as it is received to-day, that there is an immediate effect 
produced on the wound by the vitiated air. The contaminat- 
ing influence of the air, combined with the products of putre- 
faction, not merely on the wound but on the organism gen- 
erally, has never disappeared from the intellectual horizon 
of physicians. That the mouldering couch of straw, the 
putrefying bodies of men and animals, the floor and earth 
saturated with excrement, the overcrowding of badly-ventila- 
ted hospitals, give rise to infectious fevers and a bad course to 
wounds, is not the result of recent observation ; also, that it 
depends on a kind of fermentation, which, by means of the 
germs contained in the air, is transferred to the body, has be- 
come a familiar notion ; citing one only of the many authors 
on this subject, viz., John Pringle, in his " Observations on 
the Diseases of the Army," published in 1775, in which he 
devotes a special chapter to the diseases in consequence of the 
more putrid air, and his forty-eight experiments on septic and 
antiseptic substances. This chapter contains experiments simi- 
lar to those made at the present day, in order to prove the 
anti-putrefactive power of this or that material. Still there 
remains a vague idea of the nature of the substance which 
excites putrefaction, and they are mostly sought among the 
gaseous, bad-smelling products of decomposition.1 " Ambroise 
Pare (1582) first taught that secondary abscesses in surgical 
cases," which he had observed in the spleen, lungs, liver, and 
other viscera, " were due to a changed condition of the fluids, 
produced by some unknown alteration in the atmosphere, and 
determining a purulent diathesis." 2 
" He also recognized the fever which is dependent on the 
production of pus, and classified here especially that fever 
which arises between the tenth and fourteenth days after the 
1 Volkmann's " Sammlung klinischer Vortrage," No. 84 u. 85, S. 639. 
3 Braidwood on " Pyaemia," p. 2. 8 
receipt of an injury, and is ushered in by a chill." 1 The fol- 
lowing quotations force the conclusion that in the early his- 
tory of medicine there was supposed to be some important 
relation between wounds of the head and multiple abscesses: 
"Nicolaus Massa (1553) mentions a case of abscess of the 
left lung, following an injury of the head." 2 
"Valsalva (1707) was induced by his own observations to 
say that the viscera of the thorax were sometimes affected in 
wounds of the head." 3 
" Desault (1794) considered abscess of the liver to be a 
very frequent sequence of head-injuries."4 The fact that 
wounds of the head were frequently followed by abscesses of 
the lungs, liver, and other organs, probably led to the opinion 
expressed by Desault, Barthez, Brodie, W. Phillips, Copland, 
and others, that the disease had its origin from a nervous 
agency. 
" Bertrandi and Audouille (1819) sought for a mechanical 
explanation of the occurrence of hepatic abscesses after head- 
injuries, and in cases of apoplexy." 6 
"Morgagni (1740) somewhat obscurely hinted at the doc- 
trine of the reabsorption of pus-a doctrine which was after- 
ward elaborated by Quesnay in 1819. Morgagni, after quoting 
a great number of instances of w'ounds of the head followed by 
visceral abscesses, opposes the idea of a mechanical transport 
of pus thither-states that such abscesses are not confined to 
the liver-and that they may follow wounds and ulcers of other 
parts besides the head. He ascribes their formation to particles 
of pus (' not always deposited in the form of pus '), resulting 
from the softening and suppuration of small tubercles, which, 
having been mixed with the blood and disseminated, are ar- 
rested in some of the narrow passages, perhaps of the lymphat- 
ic glands, and by obstructing and irritating these, as happens 
in the production of venereal buboes, and by retaining the 
humors therein, distend them, and give origin to the genera- 
tion of a much more copious pus than what is carried thither. 
1 Pitha u. Billroth, " Handbuch der Chirurgie," 1. B., 2. A., 1. IL, 1. L., 
57. S. 
2 Braidwood on " Pyaemia," p. 2. 8 Ibid., p. 3. 
4 Ibid., p. 5. 5 Ibid., p. 10. 9 
4 And by this means,' he says, 4 we may also conceive how it is 
that much more pus is frequently found in the viscera and cavi- 
ties of the bodies than a small wound could have generated.' "1 
44 Cheston (1766) remarks that 4 translations of matter 
from one part to another are by no means uncommon, 
but are frequently to be met with after amputations of the 
larger limbs, when the vis vitce is impaired, and cannot sup- 
port that discharge of matter, so necessary to complete the 
design of Nature in healing a large wound ; but, under such 
circumstances, there is very little, if any, appearance of an in- 
flammation, and the matter is rather disseminated through 
the viscus on which it falls, than is collected in one or more 
large vomicae.' "2 
44 John Hunter (1793), in this country, and after him Vel- 
peau, in France, demonstrated the existence of pus in blood. 
Hunter further pointed out the influence and mode of action 
of phlebitis. He described three forms of inflammation of the 
veins-viz., adhesive, suppurative, and ulcerative. Pyaemia 
he considered to be an aggravated form of phlebitis. He re- 
marks that in all cases where inflammation of the veins runs 
high, or extends itself considerably, it is to be expected that 
the whole system will be affected." 3 Hodgson (1815) be- 
lieves in the doctrine of phlebitis, 44 and affirms that the in- 
flammation extends in some instances even to the membrane 
which lines the cavity of the heart." 4 
"Arnott (1829) concluded from his observations-1. That 
death does not result from the extension of the inflammation 
of the veins to the heart; 2. That the dangerous consequences 
of phlebitis have no direct relation to the extent of the vein 
which is inflamed; and, 3. That the presence of pus in the 
veins, though the principal, is not the sole cause of the second- 
ary affection. He, accordingly, opposes the idea of Abernethy, 
Carmichael, etc., that the constitutional affection is owing to 
the extension of the inflammation to the heart. The publica- 
tion of Arnott's and Dance's treatises led to the general opinion 
being held in England and France that phlebitis and puru- 
1 Braidwood on Pyaamia, p. 3. 2 Ibid., p. 4. 
3 Ibid., p. 4. 4 Ibid., p. 7. 10 
lent infection were identical affections; or, at least, that the 
latter was invariably caused by the former." 1 
" Cruveilhier (1829), admitting the doctrine of the formation 
of secondary abscesses being due to capillary phlebitis, further 
laid down an axiom, since proved untenable, 'that any foreign 
body introduced into the veins, whose elimination by the 
emunctories is impossible, will produce visceral abscesses simi- 
lar to those which occur after wounds and operations, and that 
these abscesses are the result of capillary phlebitis of those vis- 
cera." 2 Liston (1837) and Berard (1842) held the phlebitic doc- 
trine. The following authors believed pyaemia to be produced 
by the admission of pus into the blood, viz.: Boerhaave and Van 
Swieten (1737), Morgagni (1740), Cheston (1766), Berthelot 
(1780), John Hunter (1793), Larrey (1812), Montezzia (1813), 
R. Carmichael (1818), Quesnay (1819), Velpeau (1823 and 
1826), Sir Astley Cooper (1827), Marechai (1828), Dance 
(1828), Arnott (1829), Piorry (1831), Liston (1837), Dupuy- 
tren (1839), Castelnau and Ducrest (1848), Sedillot (1849), 
Solly (1851), Wilks (1861), and Baker (1866). " Haller made 
the first experiments as to the action of putrefying substances 
on animals, and said, ' Nothing destroys our fluids more 
powerfully than putrefaction.' B. Gaspard, Doctor of Medi- 
cine in St.-Etienne, published the first complete work, found- 
ed on abundant experimental materia], on the action of putre- 
fying substances on the organism ; and since that time (1822) 
one may look upon the doctrine of septicaemia as established. 
Leuret and Dupuy followed him; so that in France the 
doctrine of septic blood-poisoning soon won the ground. 
Soon, however, the investigators who followed them re- 
jected both the septicaemic and pyaemic conditions, and the 
effect of the former investigators could have been only unim- 
portant. Ernst R. Virchow, who repeated the experiments 
of Gaspard, discriminated with greater precision between the 
surgical diseases-septicaemia as a sharply-defined group, the 
opposite of pyaemia. From this date (1848) tlie difference be- 
tween septicaemia and pyaemia has been fully established in 
the literature. . . . The most important series of experiments 
1 Braidwood on "Pyaemia," p. 14. 2 Ibid., p. 14. 11 
conducted according to Gaspard belong to Stich (1853) and 
Panum (1856); the latter endeavoring to separate the putrefy- 
ing poison. In this, however, neither he nor his followers have 
succeeded very satisfactorily. These experimenters were fol- 
lowed by Urfrey, Saltzmann, and others. ... In 1865-'66 
the Faculty of Medicine in Munich offered a prize-question 
on the action of putrefying substances on the animal organ- 
ism, and awarded the prize to Hemmer for his work, which 
was distinguished for its accurate delineation of the pertain- 
ing literature and the number of prepared experiments. In 
the mean time Pasteur was making a noise in France by his 
researches. . . . Billroth, Roser, and O. Weber published new 
and valuable works, which considered the observations at the 
bedside, as well as the experiments."1 
" Lister, fully appreciating the necessity of protecting 
wounded surfaces, as far as possible, from the contaminating in- 
fluences arising from contact with the vitiated air of hospitals, 
has, by the antiseptic treatment, already accomplished much 
good. He still adheres to the use of carbolic acid. Binz 
has proved that a solution of one part of quinine to four bun 
dred parts of water still sufficed with certainty to destroy the 
life of bacteria. R. Geissler, a few years previously, had men- 
tioned the anti-putrefying property of the salts of quinine, 
and has used the same as a surgical dressing in carbuncle, 
cancer, bed-sores, etc." 2 
Bergmann, and others, have sought to determine the poi- 
sonous element contained in decomposing animal substances, 
and for this purpose have chemically treated putrid fluids, 
hoping to find the agent that would excite all the symptoms 
of septic poisoning. Bergmann obtained a body of this na- 
ture from decomposing yeast, which he calls sepsin, although 
we have no proof that either he or any one else has ever found, 
the same in pus or any decomposing animal substance; and 
even if it had been found in these substances, it would then 
become necessary to demonstrate the fact that no other sub- 
stance contained in putrefying fluids could produce septic 
1 Pitha u. Billroth, " Ilandbuch der Chirurgie," 1. B., 2. A., 1. H., 
1. L., 6. u. 7. S. 
2 Langenbeck, " Archiv f. klin. Chirurgie," Band 4, S. 550, 564. 12 
poisoning. It has, however, been satisfactorily shown that 
several elements found in decomposing animal bodies, when 
injected into the blood, excite septic action. 
II. Nomenclature.-The want of an established nomen- 
clature of pyaemia, and the loose manner in which the terms 
pyaemia and septicaemia are used by the profession, have 
doubtless led to much embarrassment. 
It will be observed that the early writers on medicine 
were ignorant of the causes of these diseases, as well as of 
their pathology. Prior to the publications of Ambroise Pare 
and Bartholomew Maggi, we find that the diseased conditions 
now described as pyaemia and septicaemia were supposed to 
be due to a direct poisonous influence of the powder in cases 
of gun-shot wounds. It appears that the first pathological 
condition that attracted the attention of the early observers 
was the formation of metastatic abscesses in the lungs, liver, 
and kidneys. At that time the deposits were usually sup- 
posed to arise from the mechanical transport of pus from 
wounds on the surface to the visceral organs. At a later 
period, John Hunter, and others, supposed pyaemia and phle- 
bitis to be identical diseases; but the more modern writers 
have used the term " suppurative fever." " Virchow has 
proposed the name ichor rhcemia. O. Weber uses the name 
ernbolhwmia for the condition in which emboli are found in 
the blood. The classification given by in his excel- 
lent work on this subject, appears to me very practical. In 
pure cases of purulent infection without metastasis he calls 
the disease £ pyohaemia simplex; ' in cases with metastasis, 
' pyohaemia multiplex.' " 1 The term hospitalism is used by 
John Eric Erichsen and Sir James Y. Simpson. The former 
says: " The overcrowding of wounded people-whether the 
wound be accidental or surgical matters not-will develop 
septic disease in one of four forms, viz., hospital gangrene, 
septicaemia, pyaemia, or erysipelas." 2 And the latter: " The 
general and acknowledged cause of death after operations in 
1 Billroth, "Surgical Pathology," p. 345. 
2 " On Hospitalism " (1874), p. 59. 13 
hospitals is some of the forms of surgical fever-as pyaemia, 
erysipelas, phagedena, etc.'' 1 
Erichsen further says, " The term pyaemia is used in a 
very wide and elastic manner, and by many is made to in- 
elude various forms of blood-poisoning." 2 This remark is 
especially true of the English writers. Thus G. W. Callender, 
under the head of " Pyaemia," says : " It signifies little whence 
these matters are derived-whether from decomposing pus, un- 
healthy secretions, decomposing hides, dead bodies, vegetable 
putrefactions, or from animals suffering from acrid discharges, 
as in glanders ; since the influence of all such, regulated by 
the intensity of the poison, for they vary in this respect, and 
by predisposing causes presently to be mentioned, may be 
conveniently described under two modifications."3 The modi- 
fications here referred to are designated as acute and chronic. 
American authors, much more than the English, are in- 
clined to use the term pyaemia in the restricted sense. In 
fact, the German nomenclature has already been adopted in a 
great measure ; and the present indications are, that at no 
distant day this perplexing question will be finally settled. 
A correct idea of the sense in which the Germans use this 
word may be derived from the following extract from Prof. 
C. Hiieter, who says, " If we give to pyaemia, at the start, a 
-definite scope, then we must regard suppuration as the first 
and most necessary condition for its existence." 4 The above 
remark is the foundation, and at the same time supplies the 
boundary, for the use of the term pyaemia by a large majority 
of German practitioners, although Prof. Poser divides the 
cases of septic blood-poisoning into four classes : " (1.) Trau- 
matic sepsis (pure traumatic, primary traumatic sepsis). (2.) 
The poisoning with ichorous pus (secondary infection, self-in- 
fection). (3.) Infection from dissecting wounds and similar 
material (infected wounds). (4.) The specific zymotic septic 
process (hospital gangrene, carbuncle, cancer, etc.). 
1 " Anaesthesia, Hospitalism," etc., p. 350. 
2 Loe. cit., p. 73. 
3 Holmes's "System of Surgery," vol. i., p. 253. 
4 Pitha u. Billroth, "Handbuch der Chirurgie," 1. B., 2. A., 1. H., 1. 
L., 89. S. 14 
" Stromeyer furnishes the following classification, viz.: (1.) 
A very rapid decomposition of the blood prior to the com- 
mencement of suppuration. (2.) Acute pyaemia with the 
commencement of suppuration. (3.) Subacute pyaemia. (4.) 
Chronic pyaemia."1 
It will be observed that Stromeyer's classification does not. 
differ materially from the one ordinarily used. The first 
order refers to septicaemia, while the second, third, and fourth 
indicate the varieties of pyaemia. 
Roser's classification is intended to cover all cases of septic 
blood-poisoning, which may truly be viewed as a single chain 
composed of many links. Take, for example, a case of am- 
putation of the thigh, followed within a few hours by trauma- 
tic fever, later by septicaemia ; afterward there may develop- 
secondary fever, formation of ichorous pus with absorption, 
and its concomitants, pyaemia, accompanied by embolism, 
thrombosis, abscesses in the lungs, liver, etc. To these may 
also occasionally be added phlebitis, inflammation of the 
joints, terminating speedily in suppuration. The chain may 
in this case be further lengthened or varied with traumatic 
erysipelas, hospital gangrene, etc. In fact, the variations in 
these cases are very numerous, and all these conditions, to- 
gether with many others, are due to septic blood-poisoning. 
The nomenclature of septicaemia requires little attention here, 
although now and then we find the terms " septic fever " or 
" putrid fever " used in its place. 
III. Pathology.-The study of the pathology of pyaemia 
may be advanced by adopting Ilueter's classification, which 
is based on recognized post-mortem lesions, and designated 
pyaemia simplex and pyaemia multiplex. The pathological 
appearances in these forms of the disease differ widely, al- 
though the clinical symptoms are often similar. In pyaemia, 
simplex the pathological conditions are essentially more nega- 
tive. This variety of the disease can only destroy life by the 
height and duration of the fever, which is maintained by the 
absorption of the fluid or molecular elements of pus. There 
1 Pitha u. Billroth, " Handbook der Chirurgie," 1. B., 2. A., 1. H., 1- 
L., 40. S. 15 
is found, as an essential basis of this form of the disease, ex- 
tensive suppuration in the subcutaneous or subfascial tissues. 
We are not able to demonstrate the pyrogenous substance jn 
the blood, since its chemical composition is unknown. It is 
supposed that possibly the pyrogenous material finds its ad- 
mission into the blood with the pus-corpuscles, but still it 
remains to be proved that pus-corpuscles are thus admitted. 
The arguments in favor of the admission of the pus-corpuscles 
into the blood are as follows : 1. The blood in pyaemia is 
known to contain more white granular spherical bodies than 
are normal. The question has been raised, Are they pus-cells, 
or white-blood-corpuscles? The answer is difficult, and has 
not yet been attained. Virchow, in the mean time, has proved 
that we cannot differentiate, morphologically, between blood 
and pus corpuscles. 2. Cohnheim has demonstrated the 
existence of the wandering corpuscles in cases of inflammation. 
Therefore it appears probable that in cases of pyaemia the 
blood may contain the pus-corpuscles, but further investiga- 
tion is needed to establish the fact. However, the establish- 
ment of this point would still have the more important one 
undetermined. Billroth supposes the pyrogenous substance 
exists in connection with the pus-corpuscles; but this may be 
justly questioned after the experiments of O. Weber and 
Frese. These experiments consisted in carefully filtering pus 
and then injecting the filtrate into healthy animals. It was 
found that these injections were uniformly followed by a 
marked increase in the temperature. Therefore, these inves- 
tigators supposed that the pyrogenous elements of the pus are 
contained, at least in part, in its serum. There are other im- 
portant changes observed in the blood of patients dead of 
pyaemia, to which I desire now' to direct attention. The red 
corpuscles of the blood, even in the early stages of the disease, 
in many cases show signs of disintegrating into molecules, and 
are observed to be accumulated in masses without show- 
ing the slightest tendency to form roulettes. There is a 
steady increase in the number of pus or white-blood corpuscles 
in the blood of pyaemic patients, during the whole course of 
the disease, in fatal cases. The condition of the red corpuscles, 
already mentioned, becomes more and more marked toward 16 
the fatal termination. In all cases of pyaemia multiplex the 
increased coagulability of the blood may be observed in the 
early stages of the disease, which steadily increases as the dis- 
ease progresses. In pyaemia simplex this condition is less 
marked, although generally present; " while, e. g., we know 
septic poison diminishes or destroys the coagulability of the 
blood. Hereby the possibility is given, at least on the cada- 
ver, to differentiate between pyaemia simplex and septicaemia; 
if, in the mean time, the study ;of the pathology of septicaemia 
was prosecuted even by comparison, since cases occur of the 
more fatal septic infection, in which the post-mortem condition 
is a complete, or almost complete, negative. Therefore the 
differential diagnosis on the cadaver must be limited to this, 
that we are able to demonstrate the existence of a purulent or 
ichorous deposit."1 It will be readily observed that the differ- 
ential diagnosis mentioned above relates to pyaemia and septi- 
caemia, and not to the different varieties ot the former disease. 
The following facts should be kept constantly in mind by the 
surgeon, to enable him to differentiate between the two forms 
of pyaemia. In pure cases of purulent infection without me- 
tastasis, the disease is called pyaemia simplex; and in cases 
with metastasis, pyaemia multiplex. The various conditions 
on which the metastasis may depend are shown by Hueter, 
who says: " The metastatic abscesses of pyaemia multiplex 
met with in the lungs, liver, spleen, and other internal organs, 
are regarded, with the greatest possibility, as a result of the 
embolic process. The metastatic inflammation of the serous 
membranes, of the cellular tissue, and of the parotid glands, 
and probably also a few metastatic inflammations of the inter- 
nal organs, are at present supposed to arise from a general 
inflammatory diathesis." 2 It has already been shown, by nu- 
merous experiments on animals, that metastatic abscesses in 
the lungs, liver, and other visceral organs only arise after the 
introduction of ichorous pus, while healthy pus has uniformly 
failed to produce this result. I shall take occasion to refer to 
this subject more fully under the " Etiology of Pyaemia." It 
1 Pitha u. Billroth, " Ilandbuch der Chirurgie," 1. B., 2. A., 1. IL, 1. 
L., 70. S. 
2 Ibid., 88. S. 17 
now remains to be shown how the introduction of ichorous 
pus acts in the production of pyaemia multiplex. The ichorous 
pus, having found its way into the venous circulation, gives rise 
to the formation of thrombi in the veins ; these clots become 
more or less broken up, and are carried forward by the blood 
to the right auricle: from this auricle to the right ventricle ; 
from this ventricle to the pulmonary artery, and through its 
ramifications to every part of the lungs. In the minute rami- 
fications of this vessel are found wedge-shaped clots of various 
sizes, in different conditions, some softened and others still 
firm. The possibility of these clots ever passing through the 
lungs, and afterward being arrested in other visceral organs, 
has been demonstrated on animals. It has been shown that 
fine particles of foreign matter, injected into the veins, have 
passed through the lungs, and subsequently lodged in the 
liver. This theory enables us to account for the existence of 
metastatic abscesses in the liver, which have apparently origi- 
nated as the result of primary infection, but thus far only on 
a mechanical basis. In other cases these abscesses are sup- 
posed to arise from secondary infection. Thus ichorous pus, 
having found its way into the venous circulation, produces 
primarily venous thrombi, which, as in the other instances, 
break up, the clots being carried in the same manner into the 
terminal branches of the pulmonary artery, where they are 
designated as emboli. The first action of the emboli is the 
mechanical closure of these vessels, thus depriving the sur- 
rounding parts of nutrition, to a greater or less extent. It will 
be proper now to recall the fact that the composition of these 
emboli is such as to favor rapid suppuration ; this commonly 
commences in the clot and surrounding tissues, having been 
preceded by a brief stage of congestion and inflammation. 
There is also occasionally found around these points more or 
less extravasation. The metastatic abscess thus found in the 
lungs is favorably situated for the production of secondary 
infection. From this abscess thrombi arise in the pulmonary 
veins, which become disintegrated, and are carried to the auri- 
cle, thence to the left ventricle, and finally through the aorta, 
and find lodgment in the terminal branches of the arteries of 
the various organs, where they produce the characteristic 
2 18 
trouble. The organs that most frequently become the seat of 
this secondary infection are the liver, spleen, kidneys, brain, 
and eyes. Let us now briefly examine this mechanical the- 
ory. Do metastatic abscesses arise from a single cause, or 
from a combination of causes? I am inclined to the opinion 
that the proximal cause of metastatic abscesses in the visceral 
organs is the existence of emboli in the terminal branches of 
arteries. The vitiated atmosphere surrounding the patient, 
the existence of a wound, and the formation of ichorous pns, 
are conditions which should not be lost sight of. These are 
the elements acting on the blood, producing in it morbid 
changes, and may therefore be regarded as the predisposing 
causes. The morbid condition of the blood, the increased 
number of white-blood-corpuscles (possibly pus), the disinte- 
gration and other changes in the red corpuscles, may be re- 
garded as the exciting causes of metastatic abscesses. It is 
thus readily observed that emboli may form in the lungs and 
liver at the same time, or the origin of those in the lungs may 
precede the formation in other organs. Again, the formations 
may be limited to a single or exist in several organs at the 
same time. Is the formation of emboli in the terminal 
branches of arteries always dependent on the disintegration of 
thrombi? The answer to this question must, I think, be a 
negative, although in surgical practice it rarely happens that 
an embolus takes its origin from any other cause. In the 
large majority of cases, unquestionably, the thrombi primarily 
exist in the vicinity of the wound in which the ichorous pus 
is generated; but it not unfrequently happens, during the 
process of disintegration, that broken-up clots are carried for- 
ward by the current of blood, receiving accretions on the way, 
until Anally they fill a large venous trunk. In confirmation 
of these facts relating to the primary origin of thrombi, it is 
said to have been observed, in epidemics of " puerperal fever" 
which were complicated with metastatic abscesses of the vis- 
ceral organs, that the thrombi occurred in the pelvic veins. 
In case of wounds of the lower extremity the clot is frequent- 
ly found in the common iliac vein, although probably it should 
always be regarded as a secondary formation. In rare cases 
the only thrombi discovered at the autopsy are found situated 19 
far away from the injury. Billroth records the case of a, 
young woman who died of phlegmonous erysipelas of the 
lower extremities, where thrombi were only found in the 
brain. Observation fully establishes the fact that pathologi- 
cal changes are much more frequently met with in the lungs 
than in any of the other organs of patients dead of pyaemia. 
This certainly strengthens the embolic theory. Billroth men- 
tions eighty-three cases of true pyaemia multiplex in which 
the metastatic abscesses occurred as follows: seventy-five 
times in the lungs, seventeen times in the spleen, eight times 
in the liver, and four times in the kidneys. 
"Prof. Sedillot, of Strasburg, who has studied this dis- 
ease with great care, and who has combined the results of his 
observation in a highly instructive and interesting mono- 
graph, published in 1849, remarks that, in one hundred cases 
of pyaemia, we should find the lungs affected in ninety-nine; 
the liver and spleen in one of twelve, the muscles in one of 
fifteen, and the heart and peripheric cellular tissue in one of 
twenty; the brain and kidneys are comparatively seldom in- 
volved." 1 The theory previously mentioned as the embolic 
relates to the aggregation of the fibrine into clots ; but another 
theory has been recently advanced by E. Wagner, who "found 
in many cases the capillaries in the lungs filled with fat, and 
was inclined, from the direction it extended in these vessels, 
to explain a certain number of the pysemic cases by the fat- 
emboli. Here arose the necessity for the experimental ex- 
aminations of this question, which were soon undertaken by 
different parties. As still further pathological observations 
followed these experiments, so arose over the question of fat- 
emboli an extensive literature, to the analysis of which I can- 
not now give my attention. This condition is not very rare, 
especially after severe injuries of bones; and the medullary 
substance appears to be the most frequent source of the fat- 
emboli, although the fatty connective tissue, the collection of 
fat-drops in venous thrombi, etc., are also to be taken into 
consideration. The easiest method to produce the fat-emboli 
experimentally is by crushing a medullary cavity in animals, 
1 Gross, " System of Surgery," vol. i., p. 150. 20 
or otherwise by the direct introduction of fluid fat into the 
veins. We have satisfied ourselves, by such experiments, that 
fat-emboli destroy life only when the occlusions of the capil- 
laries of the lungs are very numerous, and when the act of 
respiration is thereby greatly disturbed. Insignificant fat- 
emboli are easily borne. The existence of fat-emboli in pyae- 
mia is therefore purely accidental, and has no characteristic 
significance. Multiple pyaemia very frequently occurs with- 
out fat-emboli, and vice versa ; either process may complicate 
the other, and so the fat-emboli may acquire special impor- 
tance by obstructing the respiration, and probably also in this 
way the embolic fat may serve as a carrier of a putrid and 
phlogogenous material."1 Having already examined the 
theories pertaining to the various forms of pyaemia, and the 
general characteristics of this disease, as well as of septicaemia, 
we are now prepared to begin with the post-mortem appear- 
ances of pyaemia multiplex. 
General Appearance of the Body.-Rigor mortis, com- 
monly well marked a few hours after death ; great emaciation, 
and other important changes, rendering the appearance of the 
body repulsive, and sometimes hideous. 
Skin and Cellular Tissue.-The integument is flabby, 
pale, or occasionally of a deep icteric hue ; sometimes sudam- 
ina, circumscribed ecchymoses, pustular eruption, irregular 
spots of a dusky color, gangrenous patches, etc. The cellular 
tissue in some cases is the seat of diffuse suppuration. The 
pus formed is generally thin, fetid, and unhealthy. This sup- 
puration may be limited to certain parts of the body, as an 
injured extremity, or, as frequently happens, it may be found 
on the trunk and limbs at the same time. The pus in this 
form of suppuration is exceedingly apt to burrow, on account 
of the peculiarities of the tissues in which it occurs, and also 
the condition of the surrounding structures, especially the re- 
laxed and flabby condition of the skin. These abscesses in 
some instances are superficial, in others deep-seated. The 
edges of the wound, after death, are of a blackish-green color, 
frequently showing evidences of the separation of a recent 
1 Pitha u. Billroth, " Handbuch der Ohirurgie," 1. B., 2. A., 1. EL, 1. L., 
88. u. 89. S. ' 21 
slough. The surface is usually dry, but may be covered with 
foul pus. 
Muscles.-There are few changes which occur in the mus- 
cles, and none are uniform or constant. They are occasion- 
ally the seat of abscesses, and these have been observed in the 
heart, tongue, and other organs. They may be of a light- 
brown or greenish color, when they have been covered for a 
•considerable time with pus, and are sometimes softened and 
pultaceous. Suppuration does occasionally take place beneath 
the fascia of the tendons. 
Brain and its Membranes.-Neither the brain nor its 
membranes are constantly the seat of pathological changes, 
although congestion of one or more of its membranes is by 
no means rare, " particularly where death has been preceded 
by great dyspnoea." 1 Occasionally there have been observed 
suppurative meningitis, engorgement of the venous sinuses, 
blood-extravasations on the surface of the brain, lymph-de- 
posits on the membranes, softening of the cerebral tissues, 
circumscribed abscesses in the substance of the brain, which 
in some cases have been traceable to embolism of its vessels. 
The fluids in the ventricles may be either diminished or in- 
creased, and very rarely are found mixed with pus. The 
-changes in the spinal cord and its membranes probably are 
similar to those found in the brain, but appear to have been 
rarely examined. 
Eyes.-" H. Meckel first called attention to the fact that 
examinations of the eye in persons who died of pyaemia, which 
is certainly rarely enough performed, might lead to the dis- 
covery of pyaemic ophthalmia. Virchow found, in a few such 
cases, emboli of the retinal and choroidal vessels. Probably 
this would be proved correct by more industrious examina- 
tions of the eye, that these conditions are somewhat less sel- 
dom than, until now, had been supposed." 2 " Arnott thus de- 
scribes this affection of the eye : ' There is redness of the con- 
junctiva, intolerance of light, and contracted pupil; rapidly 
followed by opacity of the cornea, and excessive chemosis. 
The eye ultimately sloughs, and its contents escape.' " 3 
1 Pitha u. Billroth, "Handbuch der Chirurgie," 70. S. 
3 Ibid., 71. S. 3 Braidwood on " Pyaemia," p. 168. 22 
Ears.-" The late Mr. Toynbee, in his admirable treatise 
on ' Diseases of the Ear,' relates several cases of ' purulent 
infection ' following suppuration in the ear. ' Cases of dis- 
ease in the mastoid cells terminate fatally,' he says, ' from 
two different causes: first, from purulent infection, arising 
from the introduction of pus into the circulation through 
the lateral sinus; second, from disease of the cerebellum or 
its membranes. Cases of purulent infection,' he further re- 
marks, 'have not been met with when the disease occurs in 
the tympanic cavity.' " 1 
Bones.-There are numerous changes, in pyaemic cases, 
occurring in the bones-probably from the fact that pyaemia 
results very frequently in cases of bone lesions; but these 
changes have very little diagnostic importance. The follow- 
ing have been observed : thickening, absence, or infiltration of 
the periosteum, which may be found to separate readily from 
the bone after the death of the patient ; or there may be pus 
found between the periosteum and bone. In the bone-structure 
there are found caries and necrosis, " while in other cases the 
whole thickness of the ' compact ' tissue is perforated in a 
honeycomb-like manner by minute cavities, filled with thickish 
pus, or caseous matter of a pinkish-white color. "2 "To sum 
up-the chief morbid alterations met with in the bones are, 
congestion, dilatation of the Haversian canals, and cancellated 
tissue, leading to abscess formation, and the excavation of 
cavities by the unhealthy pus." 3 
eTbinfe.-The pathological lesions of the joints commence 
with marked congestion of the synovial membranes, increase 
of the synovial fluid, and afterward the fluid is mixed with 
pus; these conditions are followed by erosion of the cartilage 
and ligaments, the former thus becoming separated from the 
bone. Both the large and small joints are occasionally the 
seat of morbid changes. 
The Glandular System.-Lymphatic glands are only sec- 
ondarily affected in pysemia, and even this takes place very 
rarely. The changes, when observed, are similar to those 
1 Braidwood on "Pyaemia," pp. 168, 169. • 
- ' 4 Ibid., p. 192. 3 Ibid., p. 194. 23 
which happen in the other tissues of the body, viz., conges- 
tion, inflammation, and suppuration. 
Blood.-The changes in the blood have been so fully de- 
tailed in other portions of this article, tbit it is now thought 
unnecessary to enter again on the subject. The arteries are 
usually found empty after death from this disease, and the 
coats are sometimes apparently thickened. The veins are 
commonly found, on the contrary, filled, or even distended, 
with firm fibrinous clots. They are also sometimes found 
inflamed or altered, although commonly healthy. The dis- 
tended condition of the veins gives rise to the cord-like feeling 
often mentioned by different observers. In some cases of 
phlebitis there may be pus deposited between the coats of 
these veins. The thrombi are occasionally observed as firm 
fibrinous clots, but they are frequently found, in the rapidly- 
fatal cases, to have undergone suppurative changes. These 
changes begin in the centre of the clots, which often contains 
true pus, or a greenish puriform fluid. 
Pericardium and Pleurae,.-The pericardium occasionally 
contains a small amount of serum tinged with blood, but is 
rarely covered with recent lymph. " The pleurae are general- 
ly inflamed in this disease, along with the pulmonary tissue 
proper. The costal and visceral layers are sometimes found 
firmly, even inseparably, agglutinated together by old adhe- 
sions. They are, however, more commonly united by recent- 
ly-formed lymph, which covers more or less of their extent, 
and is easily broken down. Occasionally both sides of the 
chest, but generally one only, is the seat of this inflammatory 
process. The pleural cavities commonly contain some opaque, 
muddy, sero-purulent fluid mixed with blood and having 
masses of lymph floating in it." 1 
Lungs.-It has already been shown that the lungs, much 
more frequently than the other organs, are the seat of metas- 
tatic abscesses and other morbid changes in pyaemia multi- 
plex. The theory of their formation and frequency are in 
complete accord. The following is a summary of the morbid 
changes in these organs : 
1 Braidwood on "Pyaemia," p. 172. 24 
Emboli in the branches of the pulmonary veins, metastatic 
abscesses surrounded with capillary congestion, and other 
evidences of inflammation. "The smaller vessels, trying to 
overcome this afflux of blood, may produce ecchymoses or 
extravasations beneath the lining membrane of the air-vesi- 
cles ; but these minute capillary congestions are generally 
observed as red points studded over the pulmonary surface, 
which by-and-by exhibit yellowish-white or bluish-white cen- 
tres. While one part, generally the lower half of the lung, 
is thus hepatized, solid, and of a dark-greenish color, the re- 
mainder of the lung is emphysematous, and more or less 
oedematous. A section of the former presents the same ap- 
pearance as is observed in the lungs of pneumonic patients. 
Whether these incipient abscesses are developed froih the 
minute points of congestion aforementioned by the breaking 
down of some thrombic clot in their centres, or whether the 
pus is developed out of the serum exuded by the walls of the 
engorged capillaries, cannot be easily determined, and has as 
yet not been decided. These secondary abscesses vary in size 
from that of a hemp-seed to that of a hen's-egg." 1 These are 
generally situated on the periphery of the lungs and in the 
lower lobe, although in some cases they are found imbedded 
deeply in the pulmonary tissue. The contents of these ab- 
scesses are similar to those found in other parts of the body 
in this disease. The bronchial mucous membrane is common- 
ly of a bright pink color, while its secretion is increased in 
quantity, and may be clear and frothy. These conditions in 
this membrane are the result of acute bronchial catarrh. The 
peritoneal cavity may contain an increased quantity of clear 
or cloudy fluid. 
Spleen, Liver, and Kidneys.-Billroth and Sedillot ob- 
served pathological lesions involving a solution of continuity 
in these organs, in the order in which they are mentioned 
above; other authors, however, assert that the liver, next to 
the lungs, is the most frequent seat of purulent deposits. 
Enlargement of the spleen is frequently met with in cases of 
pyaemia multiplex. The metastatic abscesses found in the 
1 Braidwood on "Pyaemia, p. 173. 25 
spleen and kidneys are much smaller than those found in the 
lungs and liver, but in other respects are of a similar char- 
acter. The capillary congestion and the accompanying in- 
farctions require no special attention here. The liver, like 
the spleen, is sometimes enlarged, and at other times is found 
to have undergone fatty degeneration to a greater or less de- 
gree-in which condition its tissues are generally soft and 
friable. Abscesses in the liver are so much like those in the 
lungs as to need no separate description. The same may be 
said of the other pathological changes found in this organ in 
pyaemia multiplex. The abscesses found in the kidneys vary 
from the size of a hemp-seed to that of a bean, and are sur- 
rounded by the usual zone, marking, more or less definitely, 
the extent of the inflammation. The capsule is generally 
healthy. There are, also, in very rare cases of this disease, 
abscesses found in the stomach and intestines, involving the 
thickness of the mucous membrane; and it is further supposed 
that these abscesses may be found, occasionally, on any por- 
tion of the mucous membrane lining the alimentary canal. 
Post-mortem examinations in pyaemia multiplex have estab- 
lished the fact that there is no organ in the body but what 
may become the seat of the pathological lesions in this dis- 
ease ; but there is unquestionably a vast difference in the rela- 
tive frequency of these changes in the various organs. It is 
now readily observed that the pathological lesions in pyaemia 
multiplex are so positive as to render further discussion of the 
subject unnecessary. 
Pyaemia simplex may be readily mistaken for septicaemia, 
and vice versa. In both conditions the pathological appear- 
ances are, occasionally, nearly or completely negative. "The 
materies morbi occasionally induces death ere the local lesions 
have had time to manifest themselves." 1 I shall now attempt 
to point out the pathological peculiarities pertaining to each 
of these diseases, and also mention the important difference in 
origin, for the purpose of aiding in the determination of the 
differential diagnosis on the cadaver. I must therefore call 
attention to the fact that pure septicaemia is a disease which 
1 Braidwood on ''Pyaemia," p. 164. 26 
owes its origin to the absorption of septic, not purulent, mat- 
ter. In all cases where there is absorption of both septic and 
purulent matter, the disease is properly called septopyaemia; 
and should the autopsy reveal the presence of metastatic 
abscesses, then we would immediately recognize the fact that 
there had been an absorption of ichorous pus and septic mat- 
ter ; while the non-existence of metastatic abscesses, under 
somewhat similar circumstances, would certainly imply the 
absorption of non-ichorous pus and septic matter. Pus is 
often rendered ichorous by the action of the atmosphere; 
therefore the pus exposed to this action may be regarded as 
possessing the power of producing metastatic abscesses. In 
other cases there may be extensive suppuration while the pus 
does not, at any point, come in contact with the air; and here 
the purulent absorption would fail to produce these peculiar 
lesions-metastatic abscesses-but might produce pyaemia sim- 
plex. This subject is further explained under the " Etiology 
of Pyaemia." The question now arises, How soon after the 
receipt of an injury, or the performance of an operation, may 
pus form ? Ilueter, who has given much time and attention 
to the study of pyaemia and septicaemia, and who certainly 
has written the best monograph on this subject ever published 
in any language, thinks the formation of pus must require 
four or five days. It therefore becomes probable that, in all 
cases of blood-poisoning before the lapse of that time, the case 
is one of pure, unmixed septicaemia; after the lapse of this 
period there is always a possibility that the case is one of 
septopyaemia. We have previously mentioned the fact that 
septic poison diminishes or destroys the coagulability of the 
blood. Here is the important point in our differential diag- 
nosis on the cadaver. In septicaemia there is at least dimin- 
ished coagulability of the blood. In pyaemia simplex, gen- 
erally, there is increased coagulability, with the other changes 
already noted. 
Pyaemia simplex must take its origin from the develop- 
ment of pus in the patient's body, or the pus must certainly 
be brought in contact with a wounded surface. The existence 
of suppuration in any portion of the patient's body would cer- 
tainly render doubtful the diagnosis of pure septicaemia. In 27 
pure septicaemia there are no purulent deposits to be found on 
the cadaver. In pyaemia simplex there is a purulent deposit, 
or deposits, but these are generally excluded from the atmos- 
phere. In both forms of septopyaemia there are purulent 
deposits, or at least there must be evidence of suppuration 
having taken place. 
IV. Etiology. 1. Pyaemia.-It is said by Billroth that 
"the term septicaemia essentially depends on the etiology," 1 
and the same remark would apply with equal force to the 
term pyaemia. The latter term was first used by Piorry, and 
the disease is supposed to be due to the absorption of pus, or 
its constituents, into the blood. In fact, if we use the term 
pyaemia in the restricted sense in which it is now commonly 
employed by German and American authors, then it may be 
safely asserted that the origin of the disease has been fully 
demonstrated by an almost unlimited number of experiments. 
That pus, or some of its elements, produces this condition, is 
not denied by any observer; but there are many disputed 
points bearing on this question, and I regret that, for the pres- 
ent, I shall be obliged to limit myself by merely mentioning 
the same without giving either the experiments or arguments 
relating to them. 
The injection of pus into living animals produces local, 
remote, and constitutional symptoms. The character of these 
symptoms depends largely on the kind of pus, laudable or 
ichorous, the quantity injected, and the site of injection. It 
will be readily perceived that, in cases where the pus is direct- 
ly thrown into a vein, the local symptoms would be unimpor- 
tant, 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 rela- 
tions would be reversed. Constitutional symptoms may exist 
in both cases, but will differ in character and degree. In 
regard to the character of the pus, and its agency in the pro- 
duction of this disease, Billroth says : " The old view, that 
pyaemia is only induced when decomposed pus (ichor) is reab- 
sorbed, is entirely erroneous. There are cases where decom- 
1 " Surgical Pathology," p. 336. 28 
posed, putrid pus enters the blood, and which present a com- 
bination of the symptoms of septicaemia and pyaemia (septo- 
pyaemia of Ileuter)." 1 
Dupuytren failed to produce metastasis by injections of 
pus into the veins of dogs ; these results were confirmed by 
Boyer, who only obtained metastasis when he used ichorous 
pus in his experiments. The same results are recorded in the 
works of Gimther and Sedillot, based on numerous experi- 
ments. Beck made fourteen experiments, very carefully, but 
did not succeed in producing metastasis in a single case. 
The same results are recorded by a commission of the Physio- 
logical Society of Edinburgh. O. Weber has recently shown, 
by extended experiments, that carefully-filtered pus will not 
produce metastatic abscesses in the lungs. Therefore it may 
be considered as proved that fluid pus injected into the veins 
of an animal produces no metastatic points of inflammation. 
It should not be supposed, however, that because injections 
of fresh (n on-ichorous) pus failed to produce metastatic 
abscesses, it was therefore without results, as the earlier ex- 
perimenters thought. Billroth and O. Weber have shown, 
by their recent experiments, that these injections are uni- 
formly followed by fever, and if subcutaneous, by abscess ; 
and further, that injections of fresh pus produce even a higher 
temperature than the ichorous ; but the pus taken from cold 
abscesses has apparently very slight effects. The fresh, non- 
ichorous, dried pus was found to possess in a similar degree 
the power to excite inflammation and suppuration ; even the 
removal of the albumen did not change its character or 
power. It will be observed that these injections caused not 
only local inflammation, but severe constitutional symptoms, 
as high temperature, etc. Unfortunately, thus far all the ex- 
periments made have completely failed to show the agent that 
excites the inflammation, although it is generally admitted 
that it exists, at least, in the molecular bodies. Virchow and 
Panum have shown conclusively, by their experiments on 
living animals, that the introduction of foreign bodies into 
veins-as powdered coal, wax-balls, and quicksilver-fail in all 
cases to produce metastatic abscesses in the visceral organs, 
* " Surgical Pathology," p. 344. 29 
or other symptoms of pyaemia. These foreign bodies were 
frequently found blocking up the terminal branches of the 
pulmonary artery, in some cases encapsuled ; frequently re- 
sembling miliary tubercles, and occasionally surrounded by 
evidences of slight local inflammation, but in every instance 
without suppuration. The same experimenters, however, 
observed that the introduction of ichorous pus and decom- 
posing animal tissue into the veins was attended with the 
formation of metastatic abscesses and other symptoms of 
pyeemia. They therefore conclude that the introduction of 
putrid animal substances into the veins and the further 
transport of the same to the branches of the pulmonary ar- 
tery, produce metastatic abscesses, and that the origin of these 
deposits is independent of the mere stopping up of the 
branches of this artery. The occlusion of the blood-vessels 
in this diseased condition is a subject which has given rise to 
much discussion. Some of the earlier writers supposed this 
phenomenon constituted the disease pyaemia, while others 
believed it to be the essential cause. Prof. Poser says, 
" But the thrombus is, as can be easily proved, not the cause 
but only a symptom of pyaemia. If a surgical patient, e. g., 
one suffering with an injury of the head, is attacked by in- 
flammation and occlusion of a large vein, perhaps the com- 
mon iliac, then there are three different theories for the in- 
flammation of the occluded vein, viz., Hunter's, Rokitansky's, 
and Virchow's. According to the old Hunterian phlebitic 
theory, the coagulation of the blood should be a result of the 
inflammation of the vein. On account of the circumstances 
under which the coagulation in the vein should have occurred, 
one represents that the cause must be an oozing of coagu- 
lable exudation from the inflamed walls of the vein. But 
pathological dissections, especially Rokitansky's, would not 
accord with it. Large veins were found plugged up without 
the existence of corresponding indications of inflammation, 
and frequently perfectly clear indications that occlusion pre- 
ceded the inflammation. Consequently the occlusion of the 
vein was the primary condition, and this must be explained 
in some other way than by its inflammation. Rokitansky, in 
his theory, recognized an independent disease of the blood. 30 
Certainly, had these diseased conditions of the blood been 
examined into, it would have supplied no theory for the ex- 
planation of the preceding facts. If it is recognized as cor- 
rect that a primary disease of the blood is to be admitted, 
yet the coagulation of the blood in a large vein has not 
been traced back to it. It remained wholly unexplained 
why a single vein, especially one so large and strong as the 
common iliac, should become the seat of the local coagula- 
tion. The necessity of finding a local basis for the local 
coagulation could not be denied. For that reason it was 
greeted as a highly-desirable advance when Virchow pointed 
out that the occlusion of such large veins could be dependent 
on the coagulation of the blood in the concave spaces behind 
the valves of the veins, or through the coagulation in the 
small branches, e. g., the hypogastric vein, which is gradually 
carried forward until it reaches the common iliac, and by 
the continual increase this vein also may be filled up. At 
the same time it was demonstrated that not unfrequently, 
much oftener than was formerly supposed, the coagulated 
masses of blood are broken up and carried further on in the 
circulation, in this manner producing occlusion of the pul- 
monary artery or its branches." 1 The examination of this 
subject finally brings Prof. Roser to this conclusion: " Con- 
tamination of the blood is essentially the 'primary cause of 
pyaemia ; thrombosis is only a result of this morbid contami- 
nation, and cannot therefore be regarded as the cause of 
pyaemia-but only as an apparent part, as one of the symp- 
toms of the same." 2 The opinion here expressed by Prof. 
Roser I believe to be the one generally entertained by the 
profession at this time. This fact being admitted, the most 
important question presenting itself for our examination is, 
"How is this contamination of the blood produced?" A 
complete investigation of this subject would require the pres- 
entation of the entire subject of "Disease Germs; their Na- 
ture and Origin." I shall not venture to enter on this disputed 
field, but shall confine myself strictly to that form of the dis- 
ease arising from, or associated with, traumatic injuries. In 
1 " Archiv der Heilkunde," erst. Jahrg., erst. Heft, S. 4. 
2 Ibid., S. 43. 31 
these cases surgeons recognize two principal sources of con- 
tamination of the blood, viz., the wound itself and the viti- 
ated condition of the atmosphere surrounding the patient: 
contamination in the first place directly from the wound 
through the blood-vessels ; and in the second, by the passage 
of disease-germs, or the poisonous elements, into the blood 
along the respiratory tract. These germs may be generated 
in the wound, or be received into it from the surrounding 
atmosphere. The character of the wound and the conditions 
surrounding the patient thus become important subjects for 
the consideration of the surgeon. It has been observed, and 
is now generally admitted, that those wounds complicated 
with a fracture of the long bones of the extremities, opening 
large medullary cavities and extensive lacerations of the soft 
parts, always increase the danger of blood-poisoning. This 
fact may be more thoroughly understood by a brief considera- 
tion of the condition of the parts. 
Frequently, in open fractures, large quantities of pus con- 
stantly remain in contact with the surface of the wound, 
detached fragments of bone, which become speedily necrosed, 
moving about with every motion of the injured limb, lacer- 
ating more or less the surrounding tissues, and thus exciting 
inflammation and suppuration. The periosteum becomes in- 
flamed, a wide-spread suppurative periostitis is the result; 
necrosis of the bone, from insufficient nutrition, follows, while 
mechanical pressure on the pus aids in its absorption. The 
medulla frequently takes on this suppurative inflammation, 
and here the surgeon fails to receive a prompt warning of 
danger; slowly the suppuration progresses, without pain or 
other symptoms, unless the disease has extended to the other 
tissues; the medullary cavity, at the fractured end of the 
bone, may be completely or partially occluded by a new 
osseous formation ; in such cases the absorption of pus by the 
comparatively large venous vessels of this cavity is greatly 
facilitated. The soft parts also may be the seat of dangerous 
trouble. The same force that produced the wound and fract- 
ure may have also contused the soft parts, destroying in a 
greater or less degree their nutrition, thus giving rise to 
gangrenous sloughs, or in other cases to the formation of 32 
abscesses, etc. I will also call attention to the fact that the 
laudable pus in these cases is most favorably situated for a 
rapid change into that commonly called ichorous. The heat 
of the parts and the contact of the pus with the atmosphere 
will not fail to effect its rapid decomposition. The question 
may be with propriety asked here, " Is fatal pyaemia, inde- 
pendent of a wound, produced by breathing vitiated air?" 
The answer to this question must generally be a negative, 
although it is certainly true that poisoning of the blood does 
take place to a certain degree, as is abundantly shown by the 
different symptoms arising in patients thus exposed who are 
not suffering with wounds. It is said that dogs exposed in 
this wray are found to rapidly emaciate, and suffer from severe 
and constant diarrhoea. The various symptoms arising in 
patients confined in the overcrowded and pus-infected wards, 
among which might be mentioned loss of appetite, with diar- 
rhoea and emaciation, are too well known to require an enu- 
meration here. Therefore it appears highly probable that 
living in and breathing a vitiated atmosphere may act as a 
strongly predisposing cause, only requiring a slight scratch or 
abrasion of the skin, in which the infection may be said to act 
as an exciting cause, to produce pyaemia. In reference to 
such complications the following questions are asked by Prof. 
Poser: "Is it a specific deleterious material, a miasmatic or 
contagious disease-poison, or, as it is generally expressed, a 
zymotic agent? Must we regard each particular typhus-like 
fever, with its remarkable changes of the blood, with its 
various localizations in all the organs and membranes, with 
its chill, furred tongue, petechiae, delirium, etc., as we regard 
typhus, scarlatina, variola, etc. ? or, as Virchow teaches us, is 
this pyaemia, so greatly feared by all surgeons, only an onto- 
logical idea ? Is the word pyaemia only a general name for 
three different conditions, viz., leucocythaemia, thrombosis 
and embolism, or ichorrhaemia and septicaemia ? or are there, 
as many have supposed, two ways in which pyaemia may 
originate ? Is there one primary miasmatic pyaemia analogous 
to the other epidemic, so-called zymotic diseases? and again, 
a secondary pyaemia arising from suppurative inflammation 
wherein the poison is formed in the patient's own body which 33 
is infected by a single organ ? " 1 That this disease is caused 
by a specific deleterious material, in the large majority of 
cases, is no longer a question for discussion. The only ques- 
tion to consider is, whether it always arises from this cause. 
We must necessarily admit that spontaneous cases do occur, 
especially if we include in our classification of pyaemia puer- 
peral fever and erysipelas. Are there really any cases of 
sporadic origin, or are they always due to endemic or con- 
tagious influences? No definite answer can be given to these 
questions, although undeniably the weight of argument is 
opposed to a sporadic origin. The true miasmatic, as used 
by Prof. Poser, probably refers to the vitiated condition of 
the atmosphere, as seen in the overcrowded surgical and ob- 
stetrical wards of hospitals. In no other sense can the word 
be appropriately used in connection with the subject of py- 
aemia. It is true that pyaemic diseases are found to prevail 
at certain seasons and in certain localities much more exten- 
sively than under other circumstances. The same, however, 
is true of cholera, typhus fever, scarlatina, variola, and other 
contagious diseases. That pyaemia is contagious has been 
frequently demonstrated. I therefore conclude that the prev- 
alence and spread of this disease must be explained by the 
same rules as are applied to the existence and propagation of 
these allied affections. 
2. Septicaemia.-The etiology of septicaemia primarily in- 
volves two essential facts, viz.: (a) the development of putrid 
poison, and (Z>) its reception into the blood. That the origin 
of this disease may be more easily understood, it may be ad- 
vantageous to examine the circumstances under which it too 
frequently occurs. Take, for example, a patient who has 
received a compound comminuted fracture of the leg, necessi- 
tating amputation of the thigh. The amputation is performed 
a few hours after the injury; the flaps are closed, after which 
some oozing takes place which is mechanically retained with- 
in the flap, where the warmth of the parts and the presence 
of the atmosphere are favorable conditions for a rapid decom- 
position of this effused blood. Here we have a very rapid 
1 " Archiv der Heilkunde," erst. Jahrg., erst. Heft, S. 3&. 
3 34 
formation of the putrid poison, and further examination 
shows a condition highly favorable to its speedy absorption. 
It is a fact recognized by all surgeons that opening the medul- 
lary cavities of long bones is an invitation to putrid poison 
to enter the circulation ; but here we find not only an invi- 
tation, but compulsion, in the form of pressure. The flaps 
are nicely approximated, this approximation aided by sutures 
and straps of adhesive plaster-conditions facilitating the ag- 
glutination of the lips of the wound which speedily follows. 
Other conditions which undoubtedly act as predisposing 
causes are, a fresh wound and the lowered vitality of the 
patients due to loss of blood, shock, etc. In reference to the 
former condition, C. Busch has shown by experiments on 
animals that a rapid absorption of colored oil, which as a test 
he injected into the medullary cavities, took place in the 
lymph and blood-vessels.1 Cases answering the above de- 
scription are still occasionally seen, and, should septicaemia 
fail to develop within forty-eight hours, it certainly could 
not be attributed to good surgery. Probably it is very rarely 
the case that all, or even a majority of the conditions detailed 
above, are present, but they exist in a modified form; for in- 
stance, they frequently occur in cases of compound fracture 
of the long bones, with or without contusion of the soft 
parts, with or without extravasation into the cellular tissue, 
during an effort to save the limb. This putrid poison, the ex- 
istence of which in the blood is a conditio sine qua non for the 
production of septicaemia, is supposed to act as a ferment in 
the blood, so deteriorating it that it cannot perform its 
physiological functions. The disease may be induced in ani- 
mals at any time by the injection of putrid animal or vege- 
table substances, and Hemmer declares in regard to the in- 
tensity of its action that it can only be compared with woo- 
rara and the poisonous bites of snakes. Further, other experi- 
menters have shown that the intensity of action principally 
depends on the quantity of poison introduced into the circu- 
lation ; hence injections made into the connective tissue are 
less fatal than those directly into the veins. Granulating 
1 Pitha und Billroth, "Handbuch der Ohirurgie," 1. B., 2. A., 1. H., 1. 
L., 28 8. 35 
wounds may be with impunity covered with putrid substances 
so long as the granulations are not destroyed. 
Healthy integument and mucous membranes resist the 
absorption of putrid materials, while, on the contrary, fresh 
wounds permit absorption to take place readily, and it may 
be greatly facilitated by pressure. The question has been 
frequently discussed, in relation to pyaemia and septicaemia, 
whether molecular bodies ever sufficiently enter the circula- 
tion through healthy tissues to act as ferments in the blood. 
Billroth says: " That deleterious, infectious matters may also 
enter the body otherwise than through wounds, especially 
through the lungs, cannot be doubted; we explain to our- 
selves thereby, in fact, the origin of all infectious diseases, 
that substances find their way into the organism which act as 
organic poisons upon the blood and upon the whole organism ; 
but whether these disease-elements which cause the infec- 
tious diseases occurring chiefly in the wounded enter the or- 
ganism otherwise than through the wound is a question the 
answer to which must depend very much upon the particular 
interpretation of the cases observed." 1 That septicaemia may 
arise from an ulcer, covered by necrotic tissue, in the aliment- 
ary canal, or from a similar condition in the respiratory tract, 
is undoubted. The fact that many questions pertaining equal- 
ly to the etiology of septicaemia have already been discussed 
under the etiology of pyaemia, has caused their omission here. 
V. Symptoms. 1. Pyaemia.-The symptoms which pyae- 
mia in its various forms give rise to are numerous and not 
easily described. Therefore it is necessary that the surgeon 
keep the fact constantly in mind, that this disease depends on 
suppuration, cannot exist without it, although it does not fol- 
low that in every case of suppuration there will be pyaemia; 
but it does follow that in every case of pyaemia there must be 
a vitiated condition of the blood, due to pus or its elements. 
Taking the natural order in which the symptoms occur, I shall 
begin with the chill which commonly announces the com- 
mencement of a new era in surgical cases-one of extreme 
1 Billroth's " Surgery," vol. i., p. 218. " New Sydenham Society Trans- 
lations," vol. Ixxiii. 36 
danger to the patient, and the occasion of great anxiety on the 
part of the surgeon. The importance that will naturally be 
attached to this phenomenon must, to a certain degree, depend 
on the circumstances attending its occurrence, and therefore 
the following question will present itself: " Is the chill associ- 
ated with suppuration ? " A negative answer to this question, 
based on the fact that insufficient time has elapsed since the 
occurrence of the injury to render suppuration possible, can 
never fail to be a source of satisfaction to the surgeon whose 
experience has taught him to dread pyaemia. 
Prof. Billroth has observed, in 83 cases of true multiple 
pyaemia, that 62 commenced with a chill, and 21 without; in 
81 cases of septicaemia and simple pyaemia, 24 commenced 
with a chill and 57 without. The number of chills in each 
individual patient occurred according to the following table: 
Number of patients, 19 21 14 15 9 5 2 3 4 1 1 1 
Number of chills, 1 2 3 456789 10 13 14 
In one patient, during three weeks sixteen chills were ob- 
served, and sex appeared to have no influence on the number; 
but probably the longer the duration of the disease the greater 
is the number of chills. Still there are chronic cases with a 
single chill, and acute cases with many. It rarely occurs that 
a patient has more than one chill in twenty-four hours. Bill- 
roth noticed among his patients only 16 who each had two chills, 
and only six who each had three chills, in one day. The experi- 
ence that fewer chills occur during the evening and night than 
in the morning and afternoon has been confirmed by statistics. 
Among 287 chills, 220 occurred from 8 a. m. to 8 p. m., while 
during the night, from 8 p. m. to 8 a. m., only 67 wrere observed. 
By this striking division of the twenty-four hours, Billroth 
desired to take into consideration the daily exacerbation, the 
usual daily irritation of the wound, the bandaging, and other 
manipulations. He saw, for example, a chill occur three times 
from the introduction of a sound, and twenty times after open- 
ing an abscess. The time which elapsed from first injury to 
first chill is seen by the following table: 
First chill began, times, 14 19 15 9 4 3 2 4 
In the week, __ 12345678 37 
Patients who had fever before the operation were more in- 
clined to early chills than freshly-injured healthy individuals. 
Billroth's experience was to have only the first chill before the 
end of the first week? It may be further stated that nervous, 
irritable patients suffer much more frequently from chills than 
those of a phlegmatic temperament. This fact has given rise 
to the opinion that the absorption of pus acts especially on the 
central nervous system. The chills in pyaemia are supposed by 
Billroth to be associated with inflammation, and he says: " It 
must be mentioned, as a matter of observation, that chills oc- 
cur almost exclusively in the commencement of acute inflam- 
mations, and are intermittent only in intermittent fever and 
reabsorption of pus, while they do not occur in acute septicae- 
mia.'12 But the fever in pyaemia rarely entirely intermits; it 
jg generally lower, however, in the morning than in the after- 
noon. This symptom is even more important than the rigors 
in enabling the surgeon to make a correct diagnosis. The use 
of the thermometer enables us to determine, at will, the pres- 
ence or absence of fever, and there is no disease in which it 
should be more frequently used than in the one now under 
•consideration. Let it, however, be remembered that the tem- 
perature frequently becomes very high within a few hours 
after the receipt of an injury, or the performance of a surgical 
•operation; that this high temperature is due to septic absorp- 
tion and the diseased condition we designate septicaemia. 
Another condition, less marked, with an elevated but some- 
what lower temperature, is usually spoken of as traumatic 
fever. In both the conditions already mentioned the fever 
may gradually increase for a few days, or possibly.only hours, 
and then slowly disappear. The patient, on or before the 
tenth day, in favorable cases, will be found to be free from 
fever. It will now be observed that sufficient time has elapsed 
for the formation of pus, and the patient may, with or without 
a chill, be again attacked with fever. This fever, if moderate, 
may be designated as secondary fever, and, if more marked in 
1 Pitha und Billroth, " Handbuch der Chirurgie," 1. B., 2. A., 1. H., 
1 L., 97 und 98 S. 
2 " Surgical Pathology," p. 344. 38 
its character, as pyaemia. Again, in cases of severe, acute sep- 
ticaemia, the patient may die before the lapse of sufficient time 
for the formation of pus, or, as occasionally happens, before 
the disappearance of fever. Associated with the septicaemia, 
the system becomes contaminated still further by the absorp- 
tion of pus, thus producing a condition appropriately called 
septo-pyaemia. One important peculiarity of the temperature 
in pyaemia is the sudden and great changes; thus, at one hour 
the temperature may be but slightly raised above the normal, 
and at the next the thermometer may mark 105° Fahr. These 
sudden changes of temperature, in this disease, are of frequent 
occurrence, are not observed in other diseases, and therefore 
supply a very important diagnostic indication. It is impossi- 
ble to know, or even to anticipate with any degree of certain- 
ty, when the highest temperature will exist; consequently, 
Prof. Billroth and other writers have suggested the desirabil- 
ity of having a thermometer constantly kept in a position to 
indicate every change in the heat of the body, and a careful 
attendant to note the same ; but, thus far, I am not aware that 
it has been attempted, probably on account of the inconven- 
ience it would entail on the patient, and the additional labor 
in nursing. It has been further observed that, during the 
existence of a chill, the temperature continues to steadily in- 
crease, and the highest seen during the whole course of the 
disease is attained during the hot stage which immediately 
follows the rigors. " This condition is followed by profuse, 
cold perspirations. The perspirations which accompany this 
disease are most profuse, like those of advanced phthisis. They 
never precede the rigors, but may occur independently of them. 
They either are continuous in their duration, or exhibit more 
or less distinct exacerbations. They are occasionally accom- 
panied by sudamina and they do not abate with the use of 
any known remedy. . . . Occasionally perspiration is scanty; 
but, before death, a cold, clammy sweat and a ' tawny ' dis- 
coloration of the skin occur."1 
Besides the sudamina, there are frequently observed on 
the skin vesicles, pustules, and boils, purpuric patches, and 
1 Braidwood on " Pyaemia," p. 112. 39 
various discolorations. There is frequently observed to arise 
in the neighborhood of the wounds a reddish, erythematous 
blush, which soon extends to the whole limb, and commonly 
begins to disappear in the early part of the second week. 
This recently occurred in a patient under my care, and was 
speedily followed by an abscess of the knee-joint. The wound 
was situated at the hip-joint: at this point-on the lips of the 
wound-the first change in the color of the integument took 
place. It extended rapidly downward until it covered the 
foot, and even the toes ; but the extension upward was slight, 
not much above the nates, on which there was situated at 
the time a bed-sore. It observed the same order in passing 
off as in coming on, viz., where it first made its appearance 
it first disappeared. The superficial veins leading from the 
wound were inflamed and cord-like. This condition of the 
integument and the abscess of the knee-joint were followed 
by diarrhoea, on which medicines had no beneficial effect. 
Diarrhoea continued, with occasional vomiting, until the death 
of the patient. The pulse in pyaemia is variable-often near- 
ly normal as regards frequency, and at other times very fre- 
quent. It has been remarked, in some cases, that the pulse 
seldom rose above 90 per minute, until near the fatal end. 
The pulse, although only moderately accelerated at the com- 
mencement of the disease, always becomes more rapid, fre- 
quent, feeble and irregular, toward the termination of the un- 
favorable cases; while in cases of recovery it returns gradu- 
ally to the normal standard. In all cases in which the blood 
has been examined during the progress of pyaemia, the ex- 
aminers have agreed in regard to the extreme coagulability, 
diminution of the number of red corpuscles, and the increase 
of granular spherical bodies. The red corpuscles, even in the 
earlier stages of the disease, show evident indication of dis- 
integrating ; but, as the disease progresses, the microscopical 
examination steadily confirms, with increasing proofs from 
day to day, that the first idea was correct. There is a steady 
diminution in the number of red corpuscles, a steady increase 
in the number of pus- or possibly white blood-corpuscles. 
Epistaxis occasionally occurs, and also venous oozing from 
the wound. The condition of the tongue in pyaemia may be 40 
regarded as an important symptom, indicating the state of 
the alimentary canal; not, however, during the prodromal 
stage, but after the disease has progressed a few days. It is 
then observed that the tongue has become peculiarly smooth, 
dry, and frequently excessively red. This smoothness is caused 
by the collapse of the papillae, and the dryness by a diminished 
secretion. 
The organ now frequently appears as though covered 
with a thin layer of collodion, which had been caused to dry 
on the surface, presenting something of a glazed look. Again, 
the tongue may be covered with brown crusts, and the teeth 
with sordes. These brown crusts and sordes are usually seen 
in advanced cases, following the first condition described. 
Much importance is attached to these brown crusts by many 
experienced surgeons, and although there may be very marked 
improvement in all other symptoms, still they insist on a very 
guarded prognosis until the tongue has assumed a healthy 
appearance. Aphthae on various parts of the mouth and 
pharynx are frequently present in chronic cases and absent in 
acute cases. Herpes of the lips sometimes occurs in the com- 
mencement of the disease; vomiting is comparatively rare ; 
but there is, even in the early stages,.a complete failure of 
the appetite, with great thirst. Singultus is rarely present, 
possibly never in genuine pyaemia, but frequently in septicae- 
mia, and occasionally in septo-pyaemia. Diarrhoea is not so 
frequent, or the stools so copious, in pyaemia as in septicaemia. 
Billroth observed, in one hundred and eighty cases of pyaemia, 
thirty-two cases of diarrhoea. It is impossible to determine 
whether these cases in which the diarrhoea occurred w'ere pure 
or mixed pyaemia. The stools are generally of a pappy consist- 
ence, and often passed involuntarily in bed. There are, how- 
ever, severe cases of pyaemia with a high fever, accompanied 
by obstinate constipation, which requires the administration 
of cathartics. Examination of the heart may, in rare, excep- 
tional cases, show the existence of pericarditis, although usu- 
ally the only indications of disease are the too feeble sounds. 
Auscultation and percussion over the lungs, even in cases of 
diffuse metastatic abscesses, are frequently unsatisfactory, for 
the same reasons as in miliary tuberculosis. The large depos- 41 
its in the lungs are by these means readily determined. There 
may be a sensation of suffocation, the pneumonic sputa, the 
friction-sounds of pleurisy or pleuritic effusion ; and the ex- 
istence of these symptoms would materially aid in the diag- 
nosis of metastatic abscesses. Enlargement of liver and spleen 
may be determined before death, and in connection with 
other symptoms would aid in diagnosing deposits in these 
organs. The urine in the first stage of the disease is scanty, 
high-colored, contains a large amount of salts, and is of a 
high specific gravity. Epithelial, fibrinous, and blood casts, 
and albumen, are also occasionally found in it during the 
course of the disease. Billroth mentions a case in which there 
was complete suppression, with uraemia. In many cases of 
pyaemia, suppuration of the joints, one after another, takes 
place with great rapidity and with comparatively little pain; 
but occasionally some swelling, redness, etc., are present. In 
most cases these suppurations are easily diagnosed. Instead 
of the suppuration taking place in the joints, there are cases 
in which it occurs in the cellular tissue ; and I have recently 
seen a case where abscess after abscess formed with such ra- 
pidity that within a single week the patient was literally 
covered with abscesses, from the crown of his head to the 
soles of his feet. Delirium generally exists during some stage 
of the disease, more frequently the last ; is then mild in its 
character, although active delirium has been observed in the 
first stage. Patients are low-spirited, and very apprehensive 
of death. The face at the beginning of the attack may be 
flushed or pallid, and toward the end becomes careworn. The 
breath sometimes has a " sweetish " or " purulent " odor. 
The patient rapidly emaciates. The changes in the wound 
are in some cases very marked, even in the first stage of the 
disease. The suppuration, which has been previously free 
and healthy, may suddenly be checked, the wound becoming 
dry. The discharge, if it continues, becomes scanty, thin, icho- 
rous, or greenish. The granulations, if previously healthy, 
soon slough. These changes may not always appear in the 
first stage, but, should they not then take place, they may be 
expected later in the disease. 
Summary of the Symptoms.-Suppose that a patient, suf- 42 
fering with a compound fracture of the leg, has been admitted 
to a ward in a hospital in which this disease is prevailing. 
The surgeon is determined to save the limb, if possible. The 
dressings are carefully applied, the wound frequently cleansed, 
and the patient appears to be doing well, until the twelfth 
day, when he is suddenly seized with a chill, which is followed 
by a high fever and profuse sweating. The countenance shows 
anxiety ; the patient is evidently depressed ; the face flushed ; 
the conjunctivae congested ; the pulse frequent ; he complains 
of great thirst; and his breath has a sweetish odor. Several 
days have elapsed-the temperature of the body has been taken 
very frequently, and always found above the normal. There 
is now observed a dusky and icteric discoloration of the skin ; 
tongue peculiarly smooth, red, and glossy; disinclination to 
take food ; frequently bronchial, pleuritic, or pneumonic symp- 
toms now make their appearance, or the patient may complain 
of pain in some joint, which an examination will show to be 
slightly tender to the touch, oedematous, and the integument 
over it slightly reddened ; abscesses quickly form. The wound 
assumes an unhealthy appearance. The discharge from it 
either ceases, or is changed in character. Granulations, slough, 
and abscesses, now form in the cellular tissue with great rapid- 
ity. Diarrhoea may make its appearance; if so, the stools are 
passed involuntarily. The patient loses strength, and rapidly 
emaciates. At this stage of the disease he remains in an 
unconscious condition, and death soon closes the scene. 
2. Septicemia.-The symptoms of septicaemia may be 
sketched as follows : A patient is admitted to the hospital 
with a severe injury of the leg, requiring an amputation of 
the thigh. The amputation is performed, and the flaps are 
closed. The surgeon visits the patient twenty-four hours 
after the operation, and finds the pulse frequent; tongue, lips, 
and throat dry ; skin hot, and the temperature of the body 
high. The patient replies accurately to questions, but with 
some hesitation. He is much inclined, to sleep; has entirely 
failed to take nourishment; drinks frequently when aroused 
from his lethargic condition; and has vomited everything 
taken into his stomach since the operation. The dressings are 
now removed from the stump, when the foul odor of putrefac- 43 
tion greets the attendants. It is observed that there is consid- 
erable discoloration of the flaps, the edges of which are black- 
ened. Above these blackened edges the integument is red- 
dened, and oedematous. The sutures are cut, and 
there escapes a few drachms-possibly ounces-of highly-of- 
fensive, odorous fluid, the decomposed remains of blood, etc. 
Further examination of the flaps on their inner surface shows 
that their capillary circulation has ceased. The tissues, instead 
of presenting a life-like appearance, are now of a very dark 
brown color and occasionally mottled with dull grayish spots, 
although the movements of the ligature at the point where it 
embraces the femoral artery show that the blood still rushes 
against the artificial boundary. Let us now leave our patient, 
without further comment, for the next forty-eight hours, when 
we will resume the examination. We now find the same dry- 
ness of the mouth that was previously noticed; the pulse is 
more frequent, and has become very feeble; he complains of 
much thirst; has vomited frequently; taken but very little 
nourishment, and that only at the urgent solicitation of the 
attendants. The temperature of the body is higher than at 
the former examination ; has been steadily increasing; in the 
morning it is lower, however, than in the evening of the same 
day. The patient is lethargic; is suffering with a profuse 
diarrhoea. The odor of the stools is highly offensive: they 
are properly described as rice-water evacuations. Abdomen 
tympanitic, body bathed in perspiration ; respiration rapid ; 
slight bronchial symptoms; urine scanty, high-colored, and 
contains albumen. The examination of the stump shows that 
gangrene has extended rapidly, involving not only the flaps 
but a portion of the adjacent tissues. The stench arising from 
the wound is almost stifling. The decomposing fluids are con- 
tinuously dropping. That portion of the thigh not already 
gangrenous is now very oedematous; the integument cover- 
it is much discolored, being of a dark, icteric, or reddened hue. 
We now allow twenty-four hours to elapse, and then make our 
final examination. The patient's tongue more moist, body 
still bathed in perspiration; eyes dull; conjunctivae icteric, 
and the same hue extends to the body, though in a less marked 
degree; pulse very frequent, feeble, and not easily counted; 44 
temperature below normal. Singultus is now present, and 
has been, during the last twenty-four hours, very troublesome. 
Bronchial symptoms, combined with marked symptoms of 
oedema of the right lung; diarrhoea the same; gangrene still 
extending. 
It must be admitted that the report here offered shows 
only the symptoms that are found in a single class of cases. 
These symptoms vary much in different cases, and the varia- 
tions are especially marked in the acute sepsis maintained 
by Maisonneuve, under the head of " Gangrene Foudroy- 
ante." In these cases there appears, immediately after the 
receipt of an injury, enormous oedema about the wound, 
which extends rapidly in every possible direction, followed 
by the death of the patient within a few hours, unless 
prompt measures are adopted. The puncture of the cellular 
tissue, or of the blood-vessels involved in the oedema prior to 
the death of the patient, gives rise to the escape of a highly- 
offensive gas. Roser mentions a case of this disease in 
which he promptly amputated the limb of the patient through 
the healthy parts without even waiting for the administra- 
tion of an anaesthetic, and the patient recoyered. The symp- 
toms of septicaemia must, necessarily, greatly depend on the 
condition of the patient and the amount of septic material 
introduced. But it is not deemed necessarv to dwell longer 
on this subject. The intelligent surgeon has little difficulty 
in making the differential diagnosis in pyaemia, septicaemia, 
and septo-pyaemia. The chill at the commencement of pyae- 
mia may possibly be mistaken for the chill of intermittent 
fever; but the proper use of the thermometer cannot fail to 
correct this error. It will be remembered that in cases of in- 
termittent fever there is, usually, a distinct intermission ; but 
in pyaemia the fever is constant, with a tendency to exacerba- 
tions. Again, the chills of intermittent fever occur usually at 
regular intervals, while in pyaemia they are irregular. 
VI. Treatment. 1. Pywmia.-The treatment of pyaemia 
and septicaemia necessarily opens the whole question of sur- 
gery as it pertains to the management of wounds. The pre- 
vention of these diseases is of primary importance, and he 
who desires to save the greatest number of lives possible is, 45 
therefore, compelled to use all available means for the accom- 
plishment of this object. The knowledge that the profession 
now possesses in regard to variola and its management teaches 
us an important lesson. The prevention of both pyaemia and 
septicaemia is probably within the scope of possibility in the 
large majority of cases; but the cure of the affection when 
fully developed is always doubtful and frequently impossible. 
Every surgeon will readily admit that, were it possible to 
secure union by first intention in all cases of wounds, then it 
would be impossible for either septicaemia or pyaemia to oc- 
cur in surgical practice. Therefore it follows that the charac- 
ter of the wound, the method of operation, the surroundings 
of the patient, and the character of the treatment, thus be-' 
come proper points to consider in this division of the sub- 
ject. The character of the wound and its relations to pyae- 
mia and septicaemia have already been briefly referred to under 
the etiology of these diseases. The various methods of oper- 
ating, their respective advantages and disadvantages, require 
more consideration than space will admit of here. The sur- 
roundings of the patient is a subject of vast importance in a 
prophylactic view, and should never be lost sight of in the 
construction of hospitals. I desire here to express my firm 
conviction that surgical pyaemia is essentially and almost 
wholly a hospital-disease. It is true there are some eminent 
surgical authorities who deny its contagiousness, but this 
denial seems to me a mere quibble-opposed to the etiology 
and history of the disease. The question of surroundings for 
the patient presents to my mind the following demands as 
sine quoe non for obtaining the best possible results in surgery : 
(1.) Absolute cleanliness. This demand should be strictly en- 
forced in regard to the wound, the patient's body, the bed- 
ding, and everything else, including nurses and instruments. 
(2.) Absolute purity of the atmosphere. (3.) Moderate and 
equable temperature, containing a proper amount of moist- 
ure. (4.) Proper quantity of nutritious and easily-digestible 
food, with suitable drinks, etc. (5.) Cheerful and pleasant sur- 
roundings, especially in companions, nurses, and other attend- 
ants. It may be objected to these conditions that they can 
never be obtained. I must confess that perfection in every 46 
detail cannot always be attained, but I am thoroughly con- 
vinced that he who makes a determined effort in this direc- 
tion will succeed far better than that person who is constantly 
looking about for some excuse for his negligence. The over- 
crowding of surgical wards with severe surgical cases, espe- 
cially where the ventilation is defective, is only one step 
removed from homicide. I remember a small ward, crowded 
with the worst surgical cases which could be conveniently col- 
lected, in which there was less than six hundred cubic feet of 
air to each patient, and this in mid-winter, with no other 
means of ventilation than that furnished by lowering or rais- 
ing the windows ; the odor of pus constantly pervaded this 
ward in spite of fruitless attempts made every day to purify 
it; the windows were frequently lowered by the attendants, 
but very quickly closed by some of the patients. The result 
was here, as had been anticipated, an outbreak of pyaemia, 
which carried off three of the nine patients. There should be 
allowed to each surgical patient, while there is considerable 
suppuration still going on, two thousand cubic feet of air, and 
more if possible. The ventilation should be so arranged that 
neither the patient nor the nurse can change it. The venti- 
lation ought to be wholly under the control of the attending 
surgeon. There are very few surgeons who give to these im- 
portant matters the time arid consideration that they should 
receive, and few who accomplish here as much as they 
might. The question of treatment brings up the entire sub- 
ject of antiseptics. The favorite remedies of this class are 
carbolic and salicylic acids, permanganate of potash, chloride 
of zinc, and liquor sodae chlorinatae. There is no doubt that 
good results may be obtained with any of these remedies. 
Much more will depend on the manner in which they are 
used than on the remedy itself. The surgeon should never 
forget that he uses medicines merely as agents to enable 
him to accomplish certain objects, and, keeping these in 
mind, he need very seldom fail with bis antiseptic when the 
object is to prevent putrefaction in an open wound. He 
should at all times, by the proper use of the senses of sight 
and smell, be able to decide promptly whether or not the an- 
tiseptic is accomplishing the work. In certain cases, while 47 
using certain antiseptics, it will be found advantageous to 
keep up constant irrigation ; and in other cases, by certain 
methods of treatment, the antiseptic is stored up for gradual 
use, as may be required. 
Therefore, it appears certain that each method of treat- 
ment may possess special advantages in particular cases, and 
probably the same may be said of the antiseptic itself. The 
importance of this subject may be more fully appreciated 
when it is remembered that it is generally admitted by the 
best surgical authorities that more lives are lost from septic 
infection than from all other causes combined during a war. 
The further consideration of this subject may be arranged for 
convenience under the heads of local and general treatment. 
The local treatment of the wound should, if possible, be of 
such a character as to prevent the absorption of either putrid 
substances or pus. It, therefore, becomes highly important, 
in cases of amputations and other operations, that all tissues 
injured to such a degree as to be likely to excite either putre- 
faction, irritation, or inflammation, should be removed. The 
same care is necessary in removing all foreign bodies from the 
wounds in cases where no operation is performed. The am- 
putation of the injured limb may be necessary to prevent the 
development of these diseases, or may be resorted to in cer- 
tain rare cases after the origin of pysernic symptoms; how- 
ever, in the latter instance great care should be taken to re- 
move all the tissues already infiltrated with serum, otherwise 
nothing will be gained. The use of the surgeon's knife at the 
proper time may be the best prophylactic measure against 
both pyaemia and septicaemia, but this measure should be di- 
rected by an intelligent mind, and the instrument guided by 
a practised hand. Again, it is found that opening a large 
medullary cavity is attended with danger to the patient. This 
fact teaches an obvious lesson. The wound existing, or the 
operation having been performed, the surgeon now turns his 
attention to the prevention of putrefaction and inflammation. 
The first source of danger requiring attention from the sur- 
geon is the fluid escaping from the wounded surface. Do not 
allow" it to undergo putrefaction in contact with the wound. 
Whether or not there is danger to be apprehended from in- 48 
flammation, depends largely on the character of the wound : 
contuso-lacerated wounds are especially liable to become in- 
flamed, and many other varieties, only in a less degree. The 
use of sutures is a question to be decided in each particular 
case. The same may be said of the use of antiphlogistic rem- 
edies. The question having been decided in favor of their 
use, then comes the selection of the special remedy. Prof. 
Billroth has recently given this subject much thought, and 
thus records his opinion: he inclines to the belief that the 
bath may be properly used in the treatment of contuso-lacer- 
ated wounds confined strictly to the hands and feet. Here 
the patient finds comfort when the temperature of the bath is 
properly regulated and the limb allowed to float in the water. 
Tn the majority of cases he prefers the use of ice either with 
or without the ice-bags. He found that the application of ice 
to a limb lowered the general temperature of the body, dimin- 
ished the size of the capillaries in the diseased parts, and re- 
tarded putrefaction, also lessening the absorption of putrid sub- 
stances and limiting the extension of inflammation. He also 
claims that wounds heal kindly even during the continuation 
of the treatment. There are cases in which the use of leeches 
may be advantageously resorted to for the purpose of reliev- 
ing inflammation. Warm poultices may be used for the pur- 
pose of effecting a more speedy removal of the necrotic tissues 
covering the surface of the wound than would otherwise take 
place, but it should never be forgotten that the " poultice is 
a means of applying continuous heat with moisture, and of 
softening the tissues. An afflux of blood takes place to the 
parts, the vessels dilate, the tissues, softened by the combined 
influence of heat and moisture, permit the easy diffusion of 
fluids. . . . Foul-smelling wounds requiring the use of poul- 
tices are best treated with the yeast or charcoal poultice. 
. . . The application of poultices sometimes degenerates 
into abuse. If too long continued the skin becomes white, 
wrinkled, and sodden, small abscesses or boils form, and the 
vessels of the parts very slowly regain their tone. If kept too 
long in contact with wounds or ulcerated surfaces, the granu- 
lations become pale and flabby, and the healing process is 
retarded. Applied indiscreetly to inflamed joints, they may 49 
promote suppuration, and thus permanently injure these 
structures. If kept long in contact with a large extent of 
surface, they will lower the general tone and vigor of the sys- 
tem, depress the systemic circulation, exhaust the irritabil- 
ity of the vaso-motor nerves, and thus seriously embarrass the 
reparative process, if not wholly prevent repair."1 
It appears probable that more injury than good results 
from the use of poultices in cases where there is reason to 
fear pyaemia. I think, in all such cases, the use of the poul- 
tice should be limited to the cleansing of the wound by hasten- 
ing the removal of necrotic tissues, and am satisfied that the 
practice of wrapping the whole arm or leg in hot poultices, in 
cases of cellulitis arising in connection with septic absorption, 
is highly injurious, especially when continued for a longtime. 
Free scarification of the integument where there is great ten- 
sion of the parts may possibly become necessary for the pur- 
pose of relieving pain and aiding the circulation ; but the 
surgeon should not forget here that he is opening new ave- 
nues for the admission of the poison. Abscesses should be 
opened as soon as discovered, in the majority of cases, because 
of the pain and fever caused by them. Tincture of iodine is 
serviceable, in certain stages of inflammation, as a local ap- 
plication. Caustics may be used to aid Nature in throwing 
off* a slough, and occasionally as a stimulant to an indolent 
wound which fails to granulate properly. Healthy granula- 
tions should never be destroyed lest their destruction should 
open other channels for the admission of the septic poison in 
the system. Drain-tubes may be required to prevent any ac- 
cumulation of pus within the wound. It has been suggested 
as a prophylactic measure against pysemia that a ligature of 
the veins between the thrombus and the heart would be a 
rational measure. It seems to present an almost insurmount- 
able obstacle in the determination of the venous branch which 
should be ligated, and the impracticability of ligating the 
principal venous trunk of the limb. However, it is said that 
Lee has successfully ligated the cephalic vein at the elbow, in 
two cases of injury of the hand, after the appearance of the 
1 Bartholow, " Materia Medica and Therapeutics," pp. 515, 516. 
4 50 
pysemic chill. It has also been suggested that transfusion of 
healthy blood ought to be tried in suitable cases of this affec- 
tion. In the general treatment of pyaemia there has been 
recommended at various times a great variety of drugs; but 
the general want of success attending their use leaves com- 
paratively few to be mentioned here. The mineral acids are 
still employed, and are found, at least, agreeable drinks, and 
as such can still be recommended. The sulphites of magne- 
sia, soda, potassa, and lime, are recommended by Giovanni 
Polli for the treatment of typhus fever, scarlet fever, small-pox, 
septicaemia, and pyaemia. He further suggests that the medi- 
cine should be given until the whole quantity taken bears to 
the weight of the patient's body the proportion of one to a 
thousand. The experiments made on animals with these salts 
seem to confirm their value in the treatment of septic disease. 
It is certainly true that animals treated with these salts are 
not so easily affected by septic poison as those which have not 
received the treatment. Further, it has been shown that 
putrid substances when mixed with either the permanganate 
of potassa or the carbolate of soda, and then injected, are harm- 
less, although the same quantity of putrid matter without the 
salts destroys life. Quinine certainly, in most cases of pyae- 
mia, is a valuable agent. In large doses it enables the surgeon 
to reduce the temperature of the patient, and in smaller doses 
it frequently serves a valuable purpose as a tonic. It has also 
undoubtedly considerable value as an antiseptic. Labbin has 
recommended the use of large doses of ergotine in infectious 
fevers, which should begin on the day the injury is received. 
The use of drastic cathartics should be avoided, and also su- 
■dorifics, on account of their prostrating effects. In some cases 
hypnotics may be required to secure sleep. Tonics are al- 
ways more or less useful. The free use of stimulants is also 
indicated. Brandy, wine, and whiskey, may be used by the 
patient in accordance with his own taste. Musk, ammonia, 
and camphor, are occasionally required. However, it should 
not be forgotten that, in cases where the disease has become 
fully developed, the usual termination is death, few recoveries 
being recorded. In the early stages of this affection, by the 
removal of the patient from an overcrowded hospital-ward to 51 
■some place where pure air, proper hygeinic arrangements, 
and a judicious use of medicines, can be obtained, recovery 
may take place ; but under other circumstances the prognosis 
is exceedingly grave. 
2. Septicaemia.-The treatment of septicaemia in most par- 
ticulars is the same as that of pyaemia. The first effect should 
be to prevent the development of the disease, and the second 
to cure the patient in cases where the affection has already 
developed. It is not in our power to limit or in any way 
regulate the primary injury, but we are obliged to take the 
patient as he is. The amount of destruction to living tissues 
may be great or small. The question of an operation, the 
character of the same, and the subsequent management, must 
be determined in accordance with the circumstances of each 
particular case. The primary death of the parts is generally 
due chiefly to the injury itself; the secondary, frequently to 
bad surgical management. Let us take a case in which the 
primary injury has been severe, greatly diminishing but not 
destroying the circulation in the injured parts: here the im- 
mediate application of ice would be locally injurious, but an 
evaporating lotion or warm applications might assist Nature. 
We have already seen, while speaking of the treatment of 
pyaemia, that the continuance, for a long time, of hot applica- 
tions, is frequently injurious, or even pernicious. Let us now 
call to mind a -case of contusion situated in the neighborhood 
of a large joint, where the injury to the soft parts will proba- 
bly be followed by much sloughing if ice is used; but the 
great danger is inflammation of the synovial membrane, and, 
to avoid this danger, the surgeon requires perfect rest of the 
parts, the application of leeches, and finally cold, or even 
ice. It is humiliating to the profession that we are obliged, 
even at this date, to admit that the treatment of septicaemia 
is largely symptomatic. The profuse choleraic diarrhoea 
which generally accompanies this disease may be regarded as 
an effort of Nature to eliminate the septic poison ; but, never- 
theless, it is so prostrating in its effects on the patient, that it 
requires to be controlled with properly-selected astringents, 
and these remedies may be still further aided by the use of 
tonics and stimulants. The treatment of septicsemia may be 52 
summarized as follows : (1.) A strict adherence to the five rules 
given under the head of prophylactic treatment. (2.) The 
avoidance of all putrefaction in contact with the wound, espe- 
cially prior to the development of sufficient granulations to 
completely cover its surface. This object is to be accom- 
plished by the removal of all necrotic tissues, the avoidance 
of putrescent fluids by cleanliness, and the proper use of anti- 
septic agents. (3.) Free use of the alkaline sulphites and hy- 
posulphites. These drugs should be used, in all cases where 
there is reason to anticipate the development of septic disease, 
as soon after the receipt of the injury as practicable, but 
should not be neglected even after the development has 
occurred. (4.) Sulphate of quinine should be used in all cases 
where the temperature is above 100° Fahr., and its persistent 
use in large doses may be necessary to prevent its rising still 
higher. It will be remembered in this connection that experi- 
ence has taught that " a temperature of Fahr, is the limit 
beyond which life can no longer exist,"1 and a much lower 
temperature is not without danger. " The essential danger 
of fever in acute diseases consists, then, in the deleterious in- 
fluence of a high temperature on the tissues."a 
1 Liebermeister, "New Sydenham Society Translations," vol. lxvi.r 
p. 278. 
2 Ibid., p. 280. MEDICAL WORKS 
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