I DO not doubt that you will all be prepared to admit that the most elevating conception of the highest and noblest of all profession is that which views it as a means of preventing disease. Because this is so, it is difficult to overestimate the importance of establishing aetiology on a sound and scientific basis. So swift have been recent strides towards this excellent consummation of our desires that it is quite impossible for a single intelligence to keep pace with them.
Though it is undoubtedly true that we can, with some measure of success, encounter certain manifestations of disease, knowing nothing of their real causation, it is equally true, that without aetiology we cannot do our best by our client to protect him for future visitations of the same malady.
We say most truly felix qui potuit cognoscere causas, for not only is some knowledge of aetiology needed for the prevention of disease, but some special knowledge of predisponents and excitants must deeply tinge our general selection of measures designed to afford relief to those entrusted to our care.
It is plain that there could be no State medicine without scientific aetiology.
Equally there can be no fixed basis of nomenclature; for example, have we not seen that the selection of names based on physical characters alone may lead, as in the absurd artificial classification of skin diseases, to the most ridiculous results? Arranging small-pox with ecthyma antimoniale and erythema mercuriale with scarlet fever.
The only hope a definite taxonomy is to have the generic terms founded on physical or physiologic characters and the specific distinctions based on causation. Examples are “chondritis arsenicalis,” “synovitis traumatica,” and “pharyngitis septica”.
It will be then from the aetiologic side that I shall, with your permission, approach this important subject.
ACUTE SEPSIS.-Concerning acute sepsis I shall have very little to say. In women its most typical, and certainly its most appalling form, is child-bed fever; a disease which has grown to be more rare since Listerism has come into vogue. A disease destined, let as hope, ere long to disappear altogether from civilized communities.
I was assured by Professor Victor Horsley, when he acted as Register of the Maternity Department of the University College Hospital, London, England, that the substitution of Vaseline for lard on the hands of students, who went from dressing surgical injuries to the lying-in beside, effected a perceptible diminution in the number of cases of puerperal septicaemia. Inasmuch as this disease is easily prevented and is nearly incurable, all our energies should be devoted to rendering the parturient woman and all her surroundings as aseptic as possible.
A few words as to the chief indications for managing a case: .
1. See that the uterine cavity is absolutely clear. it is better to remove a part of the wall of the womb than to leave behind the very smallest portion of chorion after an abortion, or of placental membrane after miscarriage or labor at term.
2. Keep the cavity constantly irrigated with some warm solution of harmless antiseptic, such as boric acid, taking care that the egresstube of the double canula employed be far larger in internal sectional area than the ingress-tube.
3. Keep the cervix patulous, and if possible arrange that the patient be in an appropriate posture for easy drainage.
4. Protect or remove needless absorbent surfaces.
SUBACUTE AND CHRONIC SEPSIS.-We see example of rather less acute septic intoxication in surgical erysipelas, established gonorrhoea, coprostatic urticaria resembling the form which arises from decomposing food, extensive cutaneous burn, diphtheria, pyometra, pyocolpos, otitis suppurans, and disseminated abscess, infective osteomyelitis, and in the so- called “zymotic” fevers.
The infinite varieties of toxin produced during these invasions of anabolic and catabolic tissue changes, and by the decomposition of pus, of mucus, and of other liquid products of the body, exhibit, when we consider their elaborate differentiation, a curious unanimity both in method of attack and in the selection of sites for action.
Thus, they all prefer to act on the endothelium and the epithelium of children. They is, of course, only another way of saying that the skin and mucosa of the young, the cerebro-spinal system of women and the joints in men, are either their weakest points, respectively, or else they are the most active in their efforts to rid themselves of poisonous material.
To avoid repetition I will consider the distinctive characters of subacute septic invasion with those of the chronic form, for, into the latter the former insensibly merge.
Skin-Just as in acute sepsis, the skin affection is usually erythematous, so, in the more chronic forms, the cutaneous manifestation is nearly always some variety of nettle-rash. In the ill-fed and the aged, it may be replaced by petechial or purpuric affections.
Urticaria septica is sometimes seen in the course of chronic gonorrhoea, when it may be complicated with certain drug rashes- such as the Copaiva dermatitis, which occasionally presents features resembling nettle-rash.
In a pamphlet entitled “Sepsis and Saturnism,” in which I have shown the curious resemblance which exists between the modus operative of septic matter, and of the soluble salts of lead, I have described a form of acne rosacea of the face arising from carious teeth. This may be compared with the septic rash (roseola enterica) seen on the abdomen of the typhoid patient.
Also, at page 15 of my work on Septic Intoxication, I have given an example of multiple symmetrical petechiae occurring on the cheeks of an old lady, evidently arising from suppurating fangs, for it disappeared after the removal of the carious roots.
Purpurea has been produced by direct experimentation of poisoning by ptomaines, and there is little doubt that the diseases roughly grouped together as haemorrhagic purpurea are, some of them, septic in origin.
I have elsewhere shown that nearly all the toxic eruptions may attack any portion of the epithelium. But there are favored sites.
Internally, the throat is, for many reasons, a preferred locality, as we see in diphtheria, scarlet fever, and some of the other zymotics.
Outside the body, the forearm is the most common site of septic rash. The musculo-spiral distribution is the area most frequently affected.
The musculo-spiral has a few peculiarities which we shall be repaid for noting. Developmentally it is a very old nerve, being found in the earliest types of anterior limbed organisms. In its personal habits it is a punctiliously polite nerve, and it never encroaches on its neighbors. Unlike the ulnar, which often reaches as far into the musculospiral area as the root of the index finger, the musculo-spinal shows no retaliatory spirit. It is a nerve of vicissitudes.
besides being perpetually and abruptly stretched during pronation, it receives most of the blows which reach the forearm. Being a silhouette or outline nerve, it is much exposed to the changes of external temperature. Many toxic eruptions appear first, either on its superficial area or on that of the fifth cranial pair. An example is iododerma, which is usually best seen on the forearm and the face. It follows occasionally the dressing of the endometrium with iodized Phenol.
The distribution of the musculo-spiral is the point to examine for the earliest manifestations of the peculiar eruption characteristic of uraemia. These are the so-called maculae uraemicae, first described, with anything approaching accuracy, by Le Cronier Lancaster, of Swansea, England. Here are also often first seen the xanthoma of osteo-arthritis, so often septic in origin.
These pigment spots on the forearm, yellows under the clothes and Sepia-like where they are exposed, were first alluded to by me in the British Journal of Homoeopathy in 1881. The various forms of dyschromia associated with rheumatism were afterwards, in 1885, most carefully and elaborately described by Dr. Kent Spender, of Bath, under the name of multiple xanthoma.
Next in order of frequency is the trigeminus or nerve of sensation of the face. Then come the cervical spinal nerves.
It is full of interest to note that the area of distribution of toxic skin-staining corresponds with the area of the distribution of osteoarthritis. But I have already explained elsewhere why this should be so. [See pp. 19 et seq. of Septic Intoxication, published by F.A. Davis & Co., 1231 Filbert Street, Philadelphia.]. The toxins which induce abnormal pigmentation also have the property of causing rheumatic gout.
The xanthoma of septic goitre, of glycosuria septica, and of purulent infection of the adrenals (Addison’s bronzing), are familiar examples of the chromatic changes induced by chronic sapraemia.
A form of ptomaine pigmentation has been recorded by Dr. John Macpherson, [Journal of Mental Science, January, 1893, London, England.] of Sterling Asylum, at Larbert, N.B., in an article entitled “intestinal Disinfection,” where he found that by destroying the toxins of the prime viae in lunatics by means of Naphthalin he could relieve insomnia and remove the morbid pigmentation of the skin which occurs in cases of melancholia. The relief given by Macpherson to his sleepless maniacs, by rendering their intestinal canal aseptic, brings us naturally to the consideration of the influence of sepsis on.
