A system of practical medicine. By American authors. Vol. 1

by Unknown

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

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, 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.

The condition of the tongue in pyæmia may be 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 often excessively red. This smoothness is caused by the collapse of the papillæ, and the dryness by a diminished secretion. The organ now frequently appears as if covered with a thin layer of collodion which had been caused to dry on the surface, so as to present 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. Aphthæ on various parts of the mouth and pharynx are frequently present in the more chronic cases, but are usually absent in acute cases. Herpes of the lips sometimes occurs in the commencement 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 in genuine pyæmia, but frequently so in septicæmia, and occasionally in septo-pyæmia. Diarrhoea is not so frequent or the stools so copious in pyæmia as in septicæmia. Billroth observed in one hundred and eighty cases of pyæmia thirty-two cases of diarrhoea. It is impossible to determine whether those cases in which the diarrhoea occurred were pure or mixed pyæmia. The stools are often of a pappy consistence, and passed involuntarily in bed. There are, however, severe cases of pyæmia with high fever, and accompanied by obstinate constipation.

Examination of the heart may, in rare cases, show the existence of pericarditis, although usually the only indications of disease are the too feeble sounds. Auscultation and percussion of the lungs may yield unsatisfactory results when the metastatic abscesses are small and scattered, for the same reason as in miliary tuberculosis. The large deposits in the lungs are by these means readily determined. There may be a sensation of suffocation, the pneumonic sputa, the friction sound of pleurisy, or the signs of pleuritic effusion; and the existence of these symptoms or signs would naturally aid in the diagnosis of metastatic abscesses.

Enlargement of the liver and spleen may be determined before death, and in connection with other symptoms would aid in diagnosing deposits in these organs.