Definition.—An infectious disease due to the absorption of animal poisons, principally pyogenic organisms, and characterized clinically by the formation, in the various tissues and organs, of multiple metastatic abscesses.
Etiology.—One of the forms or a combination of pyogenic micrococci are held to be responsible, by experimental investigators, for this condition. The streptococcus and the staphylococcus are the forms most constant, though it is not uncommon to find the mirococcus lanciolatus, the gonococcus, the bacillus coli communis, bacillus typhosis, bacillus pyocyaneus, and many other specific micro-organisms.
These pyogenic organisms, either by their specific action or by the toxins they produce, cause coagulation-necrosis of the neighboring tissue cells, and as this process extends, inflammation of the veins and other vessels takes place; as a result of this inflammatory action, the endothelium becomes detached, and, with its contained micrococci, is floated off by the blood-stream. In its course they reach some part of the circulatory system, where, owing to its diminished size, they can not pass through; as a result, the embolus thus obstructs the vessel, stasis occurs, and, when the soil is suitable, these micro-organisms set up new suppurating centers.
Pathology.—The cadaver, strange to say, does not undergo putrefaction as rapidly as in septicemia. The first effects of the morbid changes are found in the veins, which result in thrombi. These float off and are found in the lungs, liver, spleen, kidneys, brain, and, in fact, the various organs and tissues of the body. These thrombi, rich in micro-organisms, suppurate, and thus the so-called metastatic abscesses are formed.
The location of these abscesses depends, to some extent, upon the site of the primary focus. Thus, if it be in the region drained by the portal circulation, the liver would be the seat of these necrotic spots. If an ulcerative endocarditis be the seat of the primary lesion, the secondary abscesses will be found in the lung, spleen, kidneys, brain, intestines, and skin. These abscesses are usually small, though a coalescence of several of them may form quite a large cavity.
A favorable seat for the primary foci, when not traumatic, is the subcutaneous cellular tissue; the pelvic cellular tissues and organs; the marrow of the long bones; the neighboring tissues of the middle ear cavity; the joints, and, as already stated, an ulcerative endocarditis.
Symptoms.—The symptoms of pyemia vary greatly in different cases, depending, to a great extent, upon the local lesions, though the general symptoms will be similar in all cases.
Incubation.—Since the disease is secondary to suppuration in some part of the body, morbid changes have been going on for several days before the pyemic state is reached. From five to ten days after the reception of the wound may be considered the forming stage. The symptoms during this time are not characteristic, but may be the same as those of other lesions; viz., general malaise, headache, loss of appetite, a furred tongue, slight constipation, and a sensation of continued weariness.
The disease is ushered in with chilly sensations or a pronounced rigor. These may recur at irregular intervals, or be so regular in their cycle as to be mistaken for malaria. Following the chill, there is a rapid rise in the temperature, reaching 103° or 104° in a few hours, to be soon followed by a drop of several degrees, and attended by profuse sweating and great prostration. The fever is of an intermittent or remittent type, and interspersed by frequent chills.
There is usually but slight gastric disturbance, though the appetite is gone, the tongue is furred, and a peculiar sweet, nauseating odor tells of the involvement of the internal organs.
Where the lungs are the seat of the abscess, there is more or less dyspnea, cough, and sometimes a purulent expectoration follows. If the abscess be located superficially, there may be pain and symptoms of pleurisy present, while a rusty sputum tells of pneumonic complications.
When the liver is the seat of the local trouble, the conjunctiva and skin assume a decided jaundiced appearance. There is tenderness over the liver, and percussion reveals quite an enlargement. Diarrhea is a frequent accompaniment.
Pain, marked tenderness, and enlargement in the left hypochondrium would suggest splenic infarction.
Involvement of the kidneys will be recognized by albumen and casts in the urine, and sometimes pus and blood.
The rapid but feeble pulse, the sense of oppression in the cardiac region, would suggest endocarditis.
Delirium, followed by coma, would suggest the brain as the seat of the embolic abscess, while hemiplegia, strabismus, ptosis, deafness, etc., would determine the meningeal character without doubt.
The location of pain, the swelling and tenderness, would determine arthritic complications.
The course of the disease is marked by rapid loss of flesh, great prostration, excessive sweating, and frequent bed-sores; the patient usually dying from exhaustion or the involvement of some vital part by the suppurative process.
In chronic cases the patient may linger for months, the fever assuming a remittent type, chills occasionally intervening. The emaciation is progressive, the skin is dry, yellow, and shriveled, and ugly bed-sores may render life almost unbearable. After weeks or months of suffering, the patient succumbs to the superior septic process that waged a successful warfare.
Diagnosis.—The diagnosis is usually comparatively easy, though in some instances it may be overlooked or mistaken for typhoid fever. The irregular intermittent fever may at first be mistaken for malaria, but the administration of quinia will determine its true character, quinia having no influence in arresting the periodicity of pyemia.
The diarrhea and enlarged spleen might be mistaken for typhoid fever, but the absence of rigors, the profuse sweats of the former, and the typical eruption of the latter, will enable one to differentiate between the two.
Prognosis.—Pyemia is a very grave disease, and is usually fatal, some cases lasting only a few days. Where the surgeon can come to our aid, evacuating pus cavities and securing good drainage, and where the vitality is strong, an occasional recovery takes place.
Treatment.—Wherever possible, abscesses should be thoroughly emptied, flushed with antiseptics, or packed with antiseptic gauze, frequent dressings being necessary to keep the cavities sweet and clean. Unfortunately the region of suppuration is, many times, inaccessible, and we must resort to medicine to combat the suppurative process. Echinacea in full doses will be used with the usual symptoms calling for this agent,—the mineral acids, where the tongue is dry and red; the sulphites, where the tongue is coated with a nasty, dirty, moist coating; and the chlorates, with the unpleasant odors.
Calcium sulphide is generally indicated wherever there is pus, and may be administered on trial.
For the profuse sweating, aromatic sulphuric acid or atropin will be given.
A nutritious diet to support the patient's strength is an important feature.