The urine in the first stage of this disease is scanty, high-colored, contains a large amount of salts, and is of a high specific gravity. Epithelial, fibrinous, and blood casts, and also albumen, are occasionally found in it during the course of the disease. Billroth mentions a case in which there was complete suppression, with uræmia.
In many cases of pyæmia 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 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 rapidity 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, and 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, but toward the end it always becomes careworn and haggard. The breath occasionally has a sweetish or purulent odor.
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 be suddenly checked, the wound becoming dry. The discharge, if it continues, becomes scanty, thin, ichorous, or greenish. The granulations, if previously healthy, may 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.
SYMPTOMS OF SEPTICÆMIA.—These are commonly developed within twenty-four hours after the receipt of an injury or the performance of a surgical operation, and they may be sketched as follows: Frequent pulse; 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 receipt of the injury or the performance of the operation. If the dressings are now removed from the wound, the foul odor of putrefaction greets the attendants. In cases of amputation-wounds considerable discoloration of the flaps may be observed, the edges being blackened. Above these blackened edges the integument is reddened and slightly oedematous. The wound having been closed with sutures, which are now removed, there escapes a few drachms—possibly ounces—of highly offensive fluid, the decomposed remains of blood, etc. A further examination of the flaps on their inner surfaces show that their capillary circulation has ceased. The tissues, instead of presenting a life-like appearance, are now of a very dark color and occasionally mottled with dull grayish spots, although the movements of the ligature at the point where it embraces the femoral artery, for example, 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 dryness 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, and has taken very little nourishment, and that only at the earnest solicitations of the attendants. The temperature is higher than at the former examination, and has been steadily increasing; in the morning it is lower, however, than in the evening of the same day. The patient is lethargic, and is suffering with a profuse diarrhoea. The odor of the stools is highly offensive; they are properly described as rice-water evacuations. The abdomen is tympanitic; the body bathed in perspiration; the respirations rapid; the urine scanty, high-colored, and contains albumen. The examination of the stump shows that gangrene has extended rapidly, involving not only the flap, but a portion of the adjacent tissues. The stench arising from the wound is almost stifling. The decomposing fluids are continually forming. That portion of the thigh not already gangrenous is now very oedematous, and the integument covering 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 is more moist; the body still bathed in perspiration; the eyes dull; the conjunctivæ icteric, and the same hue extends to the body, though in a less marked degree; the pulse has become very frequent, feeble, and not easily counted; the temperature is below normal. Singultus is now present, and has been so during the last twenty-four hours. Bronchial symptoms, combined with marked oedema of the right lung, have appeared; the diarrhoea continues the same; the gangrene is still extending.
It must be admitted that the report here offered shows only the symptoms that are found in a single class of cases. The symptoms vary greatly in different cases, but they are especially marked in the acute sepsis mentioned by Massanneuve under the head of gangrène foudroyante. 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 administration of an anæsthetic, and his patient recovered.
The symptoms of septicæmia must necessarily depend greatly on the condition of the patient and the amount of septic material introduced, but it is not deemed necessary to dwell longer on this subject.
DIAGNOSIS.—It is thought that a brief presentation of the etiological, pathological, and semiological differences may be advantageous to busy physicians who desire to obtain, with the least expenditure of time, an accurate knowledge of the chief points of distinction between these morbid conditions. This effort at differentiation is merely intended to place the most important characteristics in marked contrast; and consequently it should be remembered that it is not our intention to give here the complete etiology, pathology, or semiology of either of these morbid states, but only their essential differences. Furthermore, it is thought that the following arrangement will facilitate the object which we desire to accomplish: