—The symptoms of pyemia do not essentially differ from those of other septic infections. The principal difference is in the frequency of chill and range of temperature. Chills are more common at the inception of the condition, and more frequent throughout its continuance than in other septic conditions. The chill may be slight or assume the proportions of a rigor, and each chill is followed by colliquative sweat and exhaustion. In other words, chills which are infrequent in septicemia are common in pyemia. There is reason to believe that with each fresh distribution of emboli we have one or more chills as the objective evidence thereof. Distinctive also of pyemia is the temperature curve, which much resembles that of intermittent fever, without the regularity of change characteristic of malarial fevers. It is without regular remissions, and has been referred to as irregularly intermittent. The first rise is abrupt and usually excessive, while with each fresh chill or series of chills similar abrupt alterations will be noted. These occur so frequently and fluctuate so irregularly that in order to note them accurately the temperature should be taken at least every two hours. The temperature seldom drops to normal.
As the lungs fill with the first crop of infected emboli, and the first series of metastatic abscesses form there, there is more or less dyspnea and sense of oppression; there may be also pulmonary complications—pleurisy, bronchitis, etc., even pulmonary edema. Frequently there is expectoration of frothy and discolored sputum; occasionally there is blood in the sputum. A peculiar sweetish odor of the breath has been noted by many observers in this disease, and is supposed to be idiopathic and characteristic. (See [acetonemia] in previous chapter.) With the dispersion of the second crop of emboli from the lungs there is apt to be icterus, with evidence of metastatic abscess in the liver, and collection of pus as the result of coalescence of small abscesses. The sensorium is not so affected in pyemia as in septicemia, and in the former disease patients are more likely to be alert and active in mind. General hyperesthesia and restlessness are common. Colliquative sweats are also a feature of pyemia. There is the same liability to eruptions, etc., which may mislead or complicate the diagnosis. A dermatitis is seen sometimes in pyemia, the lesions assuming a papular or pustular form, due to local infections of the skin. Purpuric spots are also seen, and vesication is not infrequent. Within the mouth sordes collect upon the teeth or gums; the tongue becomes dry and brown and heavily coated. Diarrhea is less common in pyemia. The urine is usually scanty and high colored, containing solids in excess; albumin is sometimes found therein, as well as peptone. The presence of peptone in the urine is probably an indication of the breaking down of pus corpuscles in various parts of the tissues.
A significant objective evidence of pyemia is met with in the metastatic collections of pus within the joints, which occur relatively early, and which, if multiple, may lead to a correct diagnosis. One of the earliest joints to be involved is the sternoclavicular, although none of the joints are free from the possibility of invasion. The articular serous membranes seem to have the property of carrying and holding the infective thrombi better than any other tissue in the body. The pyarthrosis of pyemia is for the most part painless, yet implies loss of function of the affected joints. The distention of these is usually evident to the eye, the fluctuation pronounced, tenderness not extreme, but the swollen part merges into tissues which are edematous and reddened. When pain in the limb is extreme, it is usually because of metastatic abscess within the bone-marrow cavity. In other words, we now have a metastatic osteomyelitis.
In all cases of pyemia prostration is marked, yet the pulse is seldom weak, at least until toward the close of life. As cases progress from bad to worse subsultus tendinum is often noted.
The appearance of the wound or site of operation does not differ essentially from that already described under Septicemia. There is usually, however, less discharge, granulations are smoother and dryer, and if tissues are gangrenous they are not as wet and nauseous as in the other case. Evidences of thrombophlebitis and lymphangitis will proceed from the wound toward the body, as in other instances of septic infection.
Prognosis.
—Prognosis is usually bad. While recovery may follow where metastatic infiltration has not been too general, the ordinary case of pyemia will die within twelve to fourteen days after diagnosis. Sometimes the entire process is much slower, and isolated cases occur which can be designated as so-called chronic pyemia, which differs but little from the acute form. A case of pyemia should not fail of recognition because there is no evidence of infection from without. A fatal case of pyemia has been known to occur from a suppurating soft corn which was not discovered during life; also from peridental abscess, etc., which had been overlooked. Death is the result of tissue destruction and septic intoxication.
Postmortem Appearances.
—In the vessels these consist essentially of thrombosis, examples of which may be seen, for instance, in the cranial sinuses and in the large veins. Aside from these, with the enlargement and softening of the spleen, the liver, and lymphatic structures, already described under Septicemia, the principal objective evidences consist in the discovery of metastatic abscesses in many or all parts of the body. As stated above, there is no tissue or organ in which they may not be found. The mechanism of their production has been already described. Infarcts may also be met with, in the kidneys especially, the liver and spleen as well, and indicate areas already cut off from blood supply by thrombo-arteritis, in which abscess formation would have occurred had time been given. In the liver large abscesses may be found; joint cavities may be filled with pus; the lungs are usually the site of innumerable small abscesses. The other postmortem changes commonly noted are not difficult of explanation, but are not so characteristic or pathognomonic as to call for further mention. In a joint which has become filled with pus there usually has been loosening of the cartilage and more or less disorganization of all the joint structures, which appear to have undergone rapid ulcerative destruction and putrefaction.