other morbid changes in pyæmia multiplex than any other organs of the
body. There may be found emboli in the branches of the pulmonary
veins, and in the lung-tissue metastatic abscesses surrounded with
capillary congestion and other evidences of inflammation; "The smaller
vessels, trying to overcome this afflux of blood, may produce
ecchymosis or extravasation beneath the lining membrane of the
air-vesicles, but the minute capillary congestions are generally
observed as red points studded over the pulmonary surface, which by
and by exhibit yellowish-white or bluish-white centres. While one
part, generally the lower half of the {969} lung, is thus hepatized,
solid, and of a dark greenish color, the remainder of the lung is
emphysematous and more or less oedematous. A section of the former
presents the same appearance as is observed in the lungs of pneumonic
patients. Whether these incipient abscesses are developed from the
minute points of congestion before mentioned, by the breaking down of
the thrombic clots 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."[37] 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
abscesses are similar to those found in other parts of the body in
this disease. The bronchial mucous membrane is commonly of a bright
pink color, while its secretion is increased in quantity, and may be
clear and frothy. These changes are the result of acute bronchial
catarrh. Lobular pneumonia has been frequently observed as a
complication of pyæmia, and is supposed by some authors to be caused
by the vitiated condition of the blood; but probably it is more
frequently occasioned by infarctions and embolic abscesses, which have
been previously mentioned in this connection.
[Footnote 37: Braidwood, _op. cit._, p. 173 _et seq._]
Billroth and Sedillot observed pathological lesions involving a
solution of continuity in the spleen, liver, and kidneys, in the order
in which they are mentioned; 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
pyæmia multiplex. The metastatic abscesses found in the spleen and
kidneys are much smaller than those found in the lungs and liver, but
in other respects are of a similar character. The capillary congestion
and the accompanying infarctions 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
degree; 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 other pathological
changes found in this organ in pyæmia multiplex. The abscesses found
in the kidneys vary from the size of a hemp-seed to that of a bean,
and are surrounded 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 portion of the mucous membrane lining the
alimentary canal. Post-mortem examinations in pyæmia multiplex have
established the fact that there is no organ in the body that may not
become the seat of pathological lesions in this disease; but there is
unquestionably a vast difference in the relative frequency of these
changes in the various organs. In some instances of this disease
peritonitis is developed, with its concomitant changes in this
membrane and the abdominal fluid, which is generally increased in
quantity and sometimes slightly tinged with blood, but more frequently
remains clear. {970} This inflammation is commonly dependent on an
extension of the inflammatory process from a metastatic abscess, which
may be situated near the periphery of some organ covered with
peritoneum, although it is claimed that pleuritis occasionally occurs
in connection with pyæmia independent of metastatic abscesses in the
lungs.
The careful study of the pathology of pyæmia multiplex renders it
exceedingly probable that the immediate agency in the production of
all these lesions is the presence in the blood of a particular species
of living organism, and that all the morbid changes which occur in the
visceral organs are secondary to those which take place in the blood,
but that the former are only dependent on the latter in a minor
degree. The pathological changes effected by these organisms seem to
be as follows, and to occur in the following order: viz.
disorganization of the blood, especially a destruction of the red and
white blood-corpuscles; the formation of granular bodies around the
organisms out of this débris; the production of an increased
coagulability of the blood; the lodgment in the blood-vessels of these
granular bodies, which are increased in size by a deposit of fibrin;
these obstructions occur most frequently in minute ramifications of
the pulmonary arteries; nutrition is effected locally by these
infarctions, and generally by the vitiated condition of the blood,
which enables the organisms under these favorable circumstances to
penetrate the adjacent tissues and produce the metastatic abscesses
and other accompanying lesions.
The pathological changes in pyæmia simplex are of the same kind as
those which have just been described as characterizing pyæmia
multiplex, with the exception of the metastatic abscesses, which are
always absent. Furthermore, the disease in both instances is believed
to have its origin from the same causes, and the dissimilarities in
the pathological lesions are equally susceptible of a rational
explanation, as are those of scarlatina simplex and scarlatina
maligna.
There were reported by the committee of the London Pathological
Society some interesting details pertaining to this form of pyæmia.
Their report shows that among the one hundred and fifty-five cases
classed as pyæmia there were twenty-four cases without visceral
abscesses; and furthermore it shows that in twenty-three of these
cases there was no suppuration, although local inflammations affected
many of the different tissues, since these patients suffered with
arthritis, cellulitis, pleuritis, meningitis, pericarditis, and
carditis. It is also added that "the post-mortem appearances, in
addition to the local secondary inflammation before noted, were in
many cases those changes common to all forms of blood poisoning. Out
of the twenty-four cases, the following are noted: Swollen spleen,
nine times; congestion of the lungs, ten times; swollen liver, six
times; cloudy swelling of the kidney, fourteen times."[38]
[Footnote 38: _Trans. London Pathological Soc._, vol. xxx. p. 26.]
In this form of pyæmia it has been supposed by some authors that the
materies morbi occasionally produces death before the metastatic
abscesses have had time to develop, but this is not always the case.
The same committee report on the above-mentioned twenty-four cases, on
this point, as follows: "The duration of the cases before the fatal
termination was very various. It is tolerably accurately recorded in
eighteen cases: of these five died in the first week, five in the
second, {971} four in the third, and the remaining four survived to
the thirtieth, forty-ninth, fifty-second, and sixty-second days."[39]
[Footnote 39: _Trans. London Pathological Soc._, p. 25 _et seq._]
The pathology of pyæmia multiplex having been already fully described,
and since the only essential difference in these morbid conditions
consists in the complete absence of the metastatic abscesses in cases
of pyæmia simplex, it is therefore thought unnecessary to dwell here
longer on this subject.
The morbid anatomy of septicæmia has been carefully studied of late,
and it is now known that the most characteristic lesions are found in
the blood and the alimentary canal.
As a manifestation of the general poisoning of the blood, it might be
expected that putrefaction would follow rapidly after the death of the
patient. In fact, Davine defines septicæmia as "putrefaction of a
living body." Observation has now thoroughly confirmed that which was
formerly an anticipation. Panum, Hemmer, and Bergmann have each called
attention to the fact that rapid decomposition follows the death of
all animals in which septicæmia has been produced for experimental
purposes. It has also been observed that putrefaction in the human
cadaver begins much sooner, and progresses much more rapidly, under
similar circumstances, when the death has been produced by this
disease than when it has occurred from any other cause. Furthermore,
this rapid decomposition is not limited to the internal organs, but
may be frequently strongly marked on the surface of the body after the
lapse of twelve hours, although it has been kept in a comparatively
dry and cool atmosphere. In those cases where the septicæmia has
originated in an external wound it has been uniformly observed that
putrefaction goes on most rapidly in the vicinity of the wound after
the death of the patient.
In every case of fatal septicæmia the post-mortem examination will
show that the coagulability of the blood has been diminished or
destroyed. In fact, it has been abundantly shown that in all cases of
true septicæmia the coagulability of the blood is more or less
diminished. The few imperfect clots of blood found after death are of
a deep-black color. The putrefaction of the soft tissues is greatly
hastened by the presence of this blood; and, consequently, this
process goes on most rapidly in the most dependent portions of the
body, especially along the course of the large veins. The septicæmic
blood possesses a peculiar putrefactive odor, and it is occasionally
found to be acid in its reaction, according to Vogel and Scherer,
making it highly probable that it will end in the formation of the
carbonate of ammonium. The chemical examinations of septicæmic blood
which have heretofore been made have completely failed to give
satisfactory results in regard either to the existence or nature of
the materies morbi in this disease, although, without doubt, there has
occasionally been found, principally in the blood of those who have
died of acute septic intoxication, a poisonous substance, which
Bergmann designated sepsin. Microscopic examinations have shown that
in the blood and also in various organs of those who have died of
septicæmia there are always present, under these circumstances, a
large number of the rod bacteria; in fact, they are more numerous than
after death from any other infectious disease. Furthermore, they are
found in the blood, lymph-glands, and cellular tissues during the
whole course of the disease.
{972} There are no pathological changes in the central nervous system
which arise directly from septicæmia, although in some cases, when
there has been some cardiac complication or very severe dyspnoea from
any cause immediately prior to the death of the patient, there may be
found hyperæmia of the membranes of the cerebro-spinal axis. The brain
and spinal cord remain unchanged.
The endo- and pericardium occasionally present a somewhat mottled
appearance resembling ecchymosis, which is evidently a deposit from
the blood, and may be washed off with water. The inner surface of the
ventricles presents a similar appearance from the same cause. In
addition to those changes which have been mentioned there are
occasionally found some slight traces of an inflammatory process in
these parts; but it never extends to the formation of pus or
ulceration, which frequently happens in cases of pyæmia. The quantity
of pericardial fluid is sometimes increased in septicæmia, and is
generally somewhat thickened, cloudy, and slightly tinged with blood.
The changes in the pleural surfaces are the same as those which have
been noted in the pericardium, but any increase of the fluid within
the pleural sacs is an exception to the general law, and is very
rarely seen. The lungs are generally found slightly congested, but
there may be some ecchymosis in exceptional cases. Pus is never found
in the lungs or within the pleural cavities in pure unmixed
septicæmia. The pathological changes in the liver resemble those in
the lungs. This organ is commonly found in a state of passive
congestion, while the color of its tissues is slightly darkened. The
congestion of the kidneys and spleen in this disease is much more
marked than that of the lungs and liver. The parenchymatous tissue of
the kidneys is commonly found in an oedematous condition, and the
tubuli uriniferi are more or less affected by a catarrhal
inflammation, which is manifested by the exfoliation of granular
epithelium. The same catarrhal condition, but in a milder form, is
found to affect the mucous membrane of the bladder. In females the
ovaries, uterus, and vagina are in a state of hyperæmia, with more or
less catarrhal inflammation of the latter organ. Septicæmia invariably
causes pregnant females to abort. There is commonly softening of the
spleen. The alimentary canal is almost constantly affected by acute
intestinal catarrh, with enlargement of the intestinal follicles and
mesenteric glands, while there are frequently hemorrhages from the
serous and mucous membranes. The various muscles of the body and the
extremities are found to be of a dark brownish-red after the death of
the patient, instead of possessing their natural pale-red color. It
may now be stated, finally, that the pathological changes in
septicæmia are less marked than those of pyæmia multiplex.
The semiology, etiology, and pathology of septo-pyæmia consist in a
blending, in different degrees, of the essential parts of pyæmia and
septicæmia; and since the pathology of both these diseases has been
presented separately, it is deemed unnecessary to enter into a
consideration of this combination.
SYMPTOMS OF PYÆMIA.--Pyæmia very rarely, if ever, develops except in
connection with an open suppurating wound, and consequently it must
generally be regarded as a wound complication or as a secondary
diseased condition. Those open wounds are unquestionably the most
favorably situated for the development of this disease which involve
the medullary {973} cavities of the long bones, owing to the liability
of unhealthy suppuration, the difficulty of complete drainage, and the
favorable anatomical conditions for absorption.
Every form of pyæmia is frequently preceded by a distinctly marked
prodromal stage, which varies in duration from four days to two weeks.
In fact, the ordinary precursor of this disease, in all those cases in
which the bones are involved, is an attack of osteo-myelitis; but in
other cases the patient often complains of malaise, giddiness,
headache, pain in the limbs, weakness, and loss of appetite, while the
experienced surgeon will be deeply impressed with the patient's rapid
emaciation and cadaverous face. These symptoms are soon followed by
jaundiced skin, etc. The commencement of an attack of pyæmia is
commonly manifested by a chill. The importance which will naturally be
attached to this phenomenon in connection with an open wound must
depend to a certain degree on the circumstances attending its
occurrence; and therefore the following question will present itself:
Is the chill associated 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 pyæmia.
Billroth has observed in 83 cases of true pyæmia multiplex that 62
commenced with a chill, and 21 without; in 81 cases of septicæmia and
simple pyæmia 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 4 5 6 7 8 9 10 13 14
In one patient during three weeks sixteen chills were observed, and
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. Billroth noticed among his
patients only sixteen who had two chills, and only six who each had
three chills, in one day. The experience 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
were observed. By this arbitrary division of the twenty-four hours
Billroth desired to take into consideration the daily exacerbation in
connection with 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
the opening of an abscess. The time which elapsed from the first
injury to the first chill is shown in the following table:
First chill began, times 14 19 15 9 4 3 2 4
Length of time after injury, in weeks 1 2 3 4 5 6 7 8
Patients who had fever before the operation were more inclined to
early chills than recently-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 {974} 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 pyæmia are supposed by Billroth to be associated with
inflammation, and he says: "It must be mentioned, as a matter of
observation, that chills occur almost exclusively in the commencement
of an acute inflammation, and are intermittent only in intermittent
fever and reabsorption of pus, while they do not occur in acute
septicæmia."[40] But the fever in pyæmia rarely intermits entirely; it
is generally lower, however, in the morning than in the afternoon.
This symptom is even more important than the rigors in enabling the
surgeon to make a correct diagnosis. Let it, however, be remembered
that the temperature 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 may be due to septic absorption,
and that this diseased condition is what we designate as septicæmia.
Another condition, less marked, with an elevated but somewhat lower
temperature, is usually spoken of as traumatic fever. In this
condition the fever may gradually increase for a few days, and then
disappear.
[Footnote 40: _Surgical Pathology_, p. 344.]
One important peculiarity of the temperature in pyæmia are the sudden
and great changes; thus, at one hour the temperature may be slightly
raised above the normal, and at the next the thermometer may mark 105°
F. These sudden changes of temperature are of frequent occurrence, are
not observed to the same extent in any other disease, and therefore
supply a very important diagnostic indication. It is impossible to
know, or even to anticipate with any degree of certainty, when the
highest temperature will exist; consequently, Billroth and other
writers have suggested the desirability 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 this has been attempted, probably on account of the
inconvenience to the patient and the additional labor in nursing it
would entail. It has been further observed that during the existence
of a chill the temperature continues to steadily increase, and the
maximum 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 are either continuous in their duration, or exhibit more
or less distinct exacerbations. They are occasionally accompanied 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 discoloration of the skin occur."[41]
[Footnote 41: Braidwood, _op. cit._, p. 112.]
Besides the sudamina there are frequently observed on the skin
vesicles, pustules, and boils, purpuric patches, and various
discolorations. There is frequently observed to arise in the
neighborhood of the wound 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 to a patient
under my care, and was speedily followed by an abscess of the
knee-joint. The wound was situated at the hip-joint, {975} and the
first change in the color of the integument took place around its
lips. The redness 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--_i.e._ 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. It
continued, with occasional vomiting, until the death of the patient.
The pulse in pyæmia may be nearly normal as regards frequency, while
at other times very rapid. It has been remarked in some cases that the
pulse seldom rose above 90 per minute until near death. The pulse,
although only moderately accelerated at the commencement of the
disease, always becomes more rapid, quick, feeble, and irregular
toward the termination of the unfavorable cases, while in cases of
recovery it returns gradually to the normal standard.
In all cases in which the blood has been examined during the progress
of pyæmia the examiners have agreed in regard to its extreme
coagulability, the diminution of the number of red corpuscles, and the
increase of the granular spherical bodies. The red corpuscles, even in
the earlier stages of the disease, show evident indications of
disintegrating; and these become more and more marked as the disease
progresses, while there is a steady increase in the number of pus- or
possibly of white blood-corpuscles. Epistaxis occasionally occurs, and
also venous oozing from the wound.