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 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 patients1921141595234111
Number of chills123456789101314

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, times14191594324
Length of time after injury, in weeks12345678

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 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.