Some of the clinical aspects of septic invasion
Some of the clinical aspects of septic invasion (Edward Blake)
By Edward Blake, M.D. , London, England
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 and 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.
Sleep.-It must not be taken that the absorption o septic matter is always an evil. we se certain persons who are always absorbing septic matter from dirty teeth or from neglected genito urinary catarrh, and who yet enjoy vigorous health. This apparent contradiction is explained in the following way:.
1. Degraded tissue-material, in minute doses, forms one of the normal stimuli of the heart; witness, for example, the exhilaration which follows exercise.
2. Larger doses over-stimulate the heart-athletic sleeplessness.
3. Over-doses cause profound sopor-toxic coma of extreme fatigue, of uraemia, and of puerperal septicaemia.
Sleep is also secondarily disturbed by the distressing itching of the dermatitis septica, which we call "nettle-rash." Apis and Sulphur relieve this. I have sometimes stopped it completely by giving a very hot bath, followed by painting over the affected part; after patting, not rubbing, the patient dry, the following solution:.
Cocaine mur.,; gr. 2.
Chloral hydrat., j.
Glycerine,; j.
Camphor, instead of Cocaine, and sometimes Sal ammoniac, will give relief.
The smarting may be stopped by.
Ichthyol,; gr. 20.
Collodion flexile, j.
Applied pure three times a day.
The Skin.-Disregarding the rarer and more recondite results of sapraemia, we will glance quickly at the ordinary superficial phenomena of passive poisoning by purulent products in a female patient.
As the subject of chronic septic absorption enters the room, we are struck by her death-like pallor. There are exceptions. Some women become sallow, some bronzed, so as to resemble a case of Addison's disease, [Addison's, Drummond's and Nothnagel's diseases are all probably septic], or one of the other disorders connected usually with xanthelasma. Others present discrete spots of melanosis, the favorite sites being, as we have seen, the forearm and the face.
I have already noted multiple symmetrical petechiae on the cheeks of the aged, which have disappeared on removing rotten teeth. Purpura has been caused experimentally by injecting toxins into the circulations. Scorbutic petechiae are possibly of this nature. There are grounds, too, for looking upon general haemorrhagic purpura as septic in origin. Acne rosacea will follow pyorrhoea alveolaris and vaginal xanthorrhoea is often associated with pustule so the chin (acne menti). The rose spots on the abdomen of an enteric patent are probably of the same nature. It will be remembered that they do not appear during the first week of the disease; in other words, till there is time for the establishment of necrosis in the neighborhood of Peyer's patches.
Raimondi found the same atrophy and degeneration of the bone marrow in saturnine case as appears to occur from septic causes in the course of male urethritis.
A profound and inexplicable hydraemia + [Compare with recent observations by Dr. Archibald Garrod on the blood changes of rheumatism] should always arouse our suspicious of septic intoxication or of lead poisoning.
In old cases of septic invasion the corner of the mouth is prone to show a fissure. This cracking o the lip commissure appears preferentially on the side of habitual decubitus. It is not quite so insignificant a matter as might at first blush be thought, for the act of opening the mouth becomes so painful that the patient would cease to eat unless the corner were protected. A strip of adhesive plaster servers sufficiently well for this purpose. I have found it acid even when escaping from the salivary duct, antecedent to its admixture with the mucus the mouth. It is possible that the mere subalkalinity of the blood which passes through the cortex [Compare observations of Hughlings Jackson.] may induce various neuro-psychotic phenomena, as ill-temper, headache, despondency, chorea, or epilepsy. We know that the last of these is influenced by the various salts of Sodium and Potassium. This property, possessed by the alkalies, of modifying some nerve storms, may depend on mere chemical action rather than on any specific relation to the pathological condition. The advent of the epileptiform convulsion is aided, doubtless, by the contracted state of the cerebral arterioles.
We have been accustomed to view puerperal convulsions as in part sapraemic, but chronic idiopathic epilepsy, not unusual as a result of lead poisoning, is not ordinarily recognized as a septic symptom. Professor Wood, of Michigan University, has narrated the particulars of a case, and I have myself placed two on record. [+ Septic Intoxication, pp. 52, 53. F.A. Davis and Co., Philadelphia, 1892.] One showed petit mal, associated with depravity, the other genuine epilepsy.
Recurrent nettle-rash, as well as lichen urticatus, especially the post-partum form, should lead us to search for septic intoxication, and to take immediate steps for its remedy.
Hyperhydrosis of the hands, the feet and the axillae is by no means uncommon in sepsis. Compare this with the localized sweats observed by Dr. Kent Spender in the course of osteo-arthritis.
Drs. Ord and Spender have also pointed out various sensory perversions as occurring in the course of rheumatic gout, itself often septic in origin. Such are lightning pains of the lower extremity, a sense of tearing up of the skin, spots of anaesthesia and of hyperaesthesia. These are common in septic cases. They serve to show that rheumatic gout is not merely a disease of the joints. [++ Compare with Charcot's disease and with tabes.] Rheumatic tremors point in the same direction.
The temperature of the extremities rises during the chondritic stage of rheumatic gout. This increase in surface warmth is often diffused in the neighborhood of an articulation; it is not confined to the point of incidence of the arthropathy. Afterwards the limbs are prone to be purple and chilled. The arterial tension [On September 6th the right radial of gentlemen, aged 72, recorded 9 ounces whilst sitting down. Late in September be contracted a sharp attack of urethritis and the tension rose to 10 ounces. A man of 36, with acute urethritis, showed 10 and 8 ounces in right and left radials. Out of 36 patients suffering from various slight disorders, 32 had differing radials. In 26 the right was the more vigorous; a greater disproportion was observed in women, whose tension rules much higher than that of men. Six persons, including both sexes, had the left higher. Four only were symmetrical. 16 ounces right, 12 left, was recorded in septic goitre, with chondritis, eczema and severe varicosis, associated with suppurating endometritis in a woman of 51, wife of a seafaring man. The observations were taken by means of Dr. Rayner Batten's manometer] is heightened at first by septine and is followed by increased vigor of ventricular contraction. But there is a later stage in septic invasion, where the systole is defective even to the extent of developing anginous symptoms, as I have more than once witnessed.
Mental solicitude and gloom are nearly always present in septic patients. The memory is sometimes seriously impaired during or after sepsis-as, for example, from enteric fever and diphtheria.
The Digestive Tract. -The septic tongue is peculiar, the type of acute sepsis being the enteric tongue; in chronic cases it may be coated, sometimes preternaturally clean, with raised, irritable papillae. Sometimes very thin at the edge, often oedematous-showing the marks of the teeth.
In acute sepsis, as after diphtheria, we may have pharyngeal paralysis; in acute saturnism, we get spasm of the pharyngeal constrictors. Both are prone to be followed, at a later stage, by incoordination of the muscles concerned in the swallowing.
Loss of appetite, resulting in emaciation, is common in both these poisonings.
I have seen three cases of recurrent gastralgia-of six weeks' three years', and ten years' duration respectively- disappear on removing pus deposits. We have seen that Sepia appears to possess the property of causing pain, called "gastralgia," in the terminal twigs of the anterior or ventral branches of the fourth, fifth and sixth dorsal nerves.
Drs. Pearson Irvine and Wm. Pasteur have shown that death from diphtheria, especially in boys, may come from paralyzed phrenic. This is confirmed by Suckling, of Birmingham. It is interesting as showing another point of contact between septic toxis and lead poisoning; for phrenic palsy occasionally closes the scene in acute head poisoning.
One of the last results of old-established septic intoxication is hepatic disease of lardaceous type. In these cases the liver ceases to seize upon and change the various degenerative gastro-intestinal products, which now enter the general circulation and prove most pernicious, especially to the nerve centres.
The Eye.-The eye-symptoms of sepsin present a superficial resemblance to those of lead, but there is a deep-seated difference.
The septic affections of the oculo-motor apparatus generally are familiar to us after diphtheria. There are good grounds for suspecting the existence of a septic glaucoma, which, though the eye-symptoms came on in the course of plumbism, may be viewed as saturnine; for it occurred in a woman fourteen days after her confinement, so it probably had septic elements in it. Mr. Lennox Browne, in his work on diseases of the upper respiratory tract, gives details of a very remarkable case of septic glaucoma. Mr. Browne quotes also some American observations on the same subject.
Sepsin is very prone to produce supraorbital pain, sometimes symmetrical, more frequently sinistral, rarely on the right side. The lead headache, when lateral, is on the right side. The actual recorded relation is 7 to 3. Asthenopia is common to both lead and sepsin. The defective vision of sepsin is usually an accommodation error of temporary character, but persistent blindness from optic atrophy has more than once followed poisoning by lead. It is curious that sepsin appears to pick out the nervous and muscular structures and choroidal coat. Lead first attacks the vessels (hypertrophic peri-arteritis) of the retina. This has been verified by John Couper. The observations of Dr. Rayner D. Batten [Ophthalmic Review, January, 1892.] make it likely that septic saturation may intensify myopia. I once saw capsular cataract with descematitis supervene in a man of forty, on ulceration of the gums, probably of specific character. Mr. Juler, of St. Mary's. tells me that be, too, has seen cataract co-existing with intra-oral suppuration.
The Ear.-Ten persons poisoned by lead had tinnitus aurium, which is a common symptom of sapraemia.
An aching myalgia is very typical of septic poisoning combined with the "fidgets" (anaemia of anterior cornua), reminding us of saturnine muscle-ache and of the actions of certain vegetable poisons, such as Actaea racemosa, of Arnica, Eupatoria, Baptisia, and Rhus toxicodendron.
We have seen that gastralgia of persistent type may arise from passive septic invasion. There is little doubt that many of these cases are associated with unsuspected gastric ulcer.
I shall seek in another place, and at another time, to show that there is a form of gastric ulcer related to Charcot's perforating ulcer and to chronic scrofulous sinus. It is a kind of circumscribed caries of the stomach analogous to dystrophic dental decay. It is a local necrosis of neurotic origin.
The Thyroid Gland.-I have, in my work on Septic Intoxication placed on record some curious examples of paludal and septic goitre. I say, in deference to ordinary modes of speech, "paludal" and "septic," though in reality these are identical. It may be supposed that marsh miasmata consist of the products of decaying vegetable matter only. But a little thought will remind us that there is no swamp which does not teem with myriads of minute, short-lived animal organisms. These perpetually perish and become putrescent. Their toxins mingle with the products of decomposing vegetable life. Miasmatic invasion and septic invasion are then one and the same thing. The clinical history of the symptoms closely coincide, and the same germicidal remedies benefit both. We have in ague a paralysis of the sympathetic with the natural circulation changed and the same arrest of haematopoiesis as in passive septicaemia. The stress of ague may fall in women with its greatest impulse on the nervous system; in men, on the articulo-muscular apparatus.
The influence of the miasmatic poisons may forsake the general nervous system and confine its effects to the floor of the fourth ventricle, and thus lead to goitre. In the same way, some persons exposed persistently to ordinary toxins will, instead of rheumatism or neuralgia, show a bronchocele with or without proptosis.
By Edward Blake, M.D. , London, England
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 and 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.
Sleep.-It must not be taken that the absorption o septic matter is always an evil. we se certain persons who are always absorbing septic matter from dirty teeth or from neglected genito urinary catarrh, and who yet enjoy vigorous health. This apparent contradiction is explained in the following way:.
1. Degraded tissue-material, in minute doses, forms one of the normal stimuli of the heart; witness, for example, the exhilaration which follows exercise.
2. Larger doses over-stimulate the heart-athletic sleeplessness.
3. Over-doses cause profound sopor-toxic coma of extreme fatigue, of uraemia, and of puerperal septicaemia.
Sleep is also secondarily disturbed by the distressing itching of the dermatitis septica, which we call "nettle-rash." Apis and Sulphur relieve this. I have sometimes stopped it completely by giving a very hot bath, followed by painting over the affected part; after patting, not rubbing, the patient dry, the following solution:.
Cocaine mur.,; gr. 2.
Chloral hydrat., j.
Glycerine,; j.
Camphor, instead of Cocaine, and sometimes Sal ammoniac, will give relief.
The smarting may be stopped by.
Ichthyol,; gr. 20.
Collodion flexile, j.
Applied pure three times a day.
The Skin.-Disregarding the rarer and more recondite results of sapraemia, we will glance quickly at the ordinary superficial phenomena of passive poisoning by purulent products in a female patient.
As the subject of chronic septic absorption enters the room, we are struck by her death-like pallor. There are exceptions. Some women become sallow, some bronzed, so as to resemble a case of Addison's disease, [Addison's, Drummond's and Nothnagel's diseases are all probably septic], or one of the other disorders connected usually with xanthelasma. Others present discrete spots of melanosis, the favorite sites being, as we have seen, the forearm and the face.
I have already noted multiple symmetrical petechiae on the cheeks of the aged, which have disappeared on removing rotten teeth. Purpura has been caused experimentally by injecting toxins into the circulations. Scorbutic petechiae are possibly of this nature. There are grounds, too, for looking upon general haemorrhagic purpura as septic in origin. Acne rosacea will follow pyorrhoea alveolaris and vaginal xanthorrhoea is often associated with pustule so the chin (acne menti). The rose spots on the abdomen of an enteric patent are probably of the same nature. It will be remembered that they do not appear during the first week of the disease; in other words, till there is time for the establishment of necrosis in the neighborhood of Peyer's patches.
Raimondi found the same atrophy and degeneration of the bone marrow in saturnine case as appears to occur from septic causes in the course of male urethritis.
A profound and inexplicable hydraemia + [Compare with recent observations by Dr. Archibald Garrod on the blood changes of rheumatism] should always arouse our suspicious of septic intoxication or of lead poisoning.
In old cases of septic invasion the corner of the mouth is prone to show a fissure. This cracking o the lip commissure appears preferentially on the side of habitual decubitus. It is not quite so insignificant a matter as might at first blush be thought, for the act of opening the mouth becomes so painful that the patient would cease to eat unless the corner were protected. A strip of adhesive plaster servers sufficiently well for this purpose. I have found it acid even when escaping from the salivary duct, antecedent to its admixture with the mucus the mouth. It is possible that the mere subalkalinity of the blood which passes through the cortex [Compare observations of Hughlings Jackson.] may induce various neuro-psychotic phenomena, as ill-temper, headache, despondency, chorea, or epilepsy. We know that the last of these is influenced by the various salts of Sodium and Potassium. This property, possessed by the alkalies, of modifying some nerve storms, may depend on mere chemical action rather than on any specific relation to the pathological condition. The advent of the epileptiform convulsion is aided, doubtless, by the contracted state of the cerebral arterioles.
We have been accustomed to view puerperal convulsions as in part sapraemic, but chronic idiopathic epilepsy, not unusual as a result of lead poisoning, is not ordinarily recognized as a septic symptom. Professor Wood, of Michigan University, has narrated the particulars of a case, and I have myself placed two on record. [+ Septic Intoxication, pp. 52, 53. F.A. Davis and Co., Philadelphia, 1892.] One showed petit mal, associated with depravity, the other genuine epilepsy.
Recurrent nettle-rash, as well as lichen urticatus, especially the post-partum form, should lead us to search for septic intoxication, and to take immediate steps for its remedy.
Hyperhydrosis of the hands, the feet and the axillae is by no means uncommon in sepsis. Compare this with the localized sweats observed by Dr. Kent Spender in the course of osteo-arthritis.
Drs. Ord and Spender have also pointed out various sensory perversions as occurring in the course of rheumatic gout, itself often septic in origin. Such are lightning pains of the lower extremity, a sense of tearing up of the skin, spots of anaesthesia and of hyperaesthesia. These are common in septic cases. They serve to show that rheumatic gout is not merely a disease of the joints. [++ Compare with Charcot's disease and with tabes.] Rheumatic tremors point in the same direction.
The temperature of the extremities rises during the chondritic stage of rheumatic gout. This increase in surface warmth is often diffused in the neighborhood of an articulation; it is not confined to the point of incidence of the arthropathy. Afterwards the limbs are prone to be purple and chilled. The arterial tension [On September 6th the right radial of gentlemen, aged 72, recorded 9 ounces whilst sitting down. Late in September be contracted a sharp attack of urethritis and the tension rose to 10 ounces. A man of 36, with acute urethritis, showed 10 and 8 ounces in right and left radials. Out of 36 patients suffering from various slight disorders, 32 had differing radials. In 26 the right was the more vigorous; a greater disproportion was observed in women, whose tension rules much higher than that of men. Six persons, including both sexes, had the left higher. Four only were symmetrical. 16 ounces right, 12 left, was recorded in septic goitre, with chondritis, eczema and severe varicosis, associated with suppurating endometritis in a woman of 51, wife of a seafaring man. The observations were taken by means of Dr. Rayner Batten's manometer] is heightened at first by septine and is followed by increased vigor of ventricular contraction. But there is a later stage in septic invasion, where the systole is defective even to the extent of developing anginous symptoms, as I have more than once witnessed.
Mental solicitude and gloom are nearly always present in septic patients. The memory is sometimes seriously impaired during or after sepsis-as, for example, from enteric fever and diphtheria.
The Digestive Tract. -The septic tongue is peculiar, the type of acute sepsis being the enteric tongue; in chronic cases it may be coated, sometimes preternaturally clean, with raised, irritable papillae. Sometimes very thin at the edge, often oedematous-showing the marks of the teeth.
In acute sepsis, as after diphtheria, we may have pharyngeal paralysis; in acute saturnism, we get spasm of the pharyngeal constrictors. Both are prone to be followed, at a later stage, by incoordination of the muscles concerned in the swallowing.
Loss of appetite, resulting in emaciation, is common in both these poisonings.
I have seen three cases of recurrent gastralgia-of six weeks' three years', and ten years' duration respectively- disappear on removing pus deposits. We have seen that Sepia appears to possess the property of causing pain, called "gastralgia," in the terminal twigs of the anterior or ventral branches of the fourth, fifth and sixth dorsal nerves.
Drs. Pearson Irvine and Wm. Pasteur have shown that death from diphtheria, especially in boys, may come from paralyzed phrenic. This is confirmed by Suckling, of Birmingham. It is interesting as showing another point of contact between septic toxis and lead poisoning; for phrenic palsy occasionally closes the scene in acute head poisoning.
One of the last results of old-established septic intoxication is hepatic disease of lardaceous type. In these cases the liver ceases to seize upon and change the various degenerative gastro-intestinal products, which now enter the general circulation and prove most pernicious, especially to the nerve centres.
The Eye.-The eye-symptoms of sepsin present a superficial resemblance to those of lead, but there is a deep-seated difference.
The septic affections of the oculo-motor apparatus generally are familiar to us after diphtheria. There are good grounds for suspecting the existence of a septic glaucoma, which, though the eye-symptoms came on in the course of plumbism, may be viewed as saturnine; for it occurred in a woman fourteen days after her confinement, so it probably had septic elements in it. Mr. Lennox Browne, in his work on diseases of the upper respiratory tract, gives details of a very remarkable case of septic glaucoma. Mr. Browne quotes also some American observations on the same subject.
Sepsin is very prone to produce supraorbital pain, sometimes symmetrical, more frequently sinistral, rarely on the right side. The lead headache, when lateral, is on the right side. The actual recorded relation is 7 to 3. Asthenopia is common to both lead and sepsin. The defective vision of sepsin is usually an accommodation error of temporary character, but persistent blindness from optic atrophy has more than once followed poisoning by lead. It is curious that sepsin appears to pick out the nervous and muscular structures and choroidal coat. Lead first attacks the vessels (hypertrophic peri-arteritis) of the retina. This has been verified by John Couper. The observations of Dr. Rayner D. Batten [Ophthalmic Review, January, 1892.] make it likely that septic saturation may intensify myopia. I once saw capsular cataract with descematitis supervene in a man of forty, on ulceration of the gums, probably of specific character. Mr. Juler, of St. Mary's. tells me that be, too, has seen cataract co-existing with intra-oral suppuration.
The Ear.-Ten persons poisoned by lead had tinnitus aurium, which is a common symptom of sapraemia.
An aching myalgia is very typical of septic poisoning combined with the "fidgets" (anaemia of anterior cornua), reminding us of saturnine muscle-ache and of the actions of certain vegetable poisons, such as Actaea racemosa, of Arnica, Eupatoria, Baptisia, and Rhus toxicodendron.
We have seen that gastralgia of persistent type may arise from passive septic invasion. There is little doubt that many of these cases are associated with unsuspected gastric ulcer.
I shall seek in another place, and at another time, to show that there is a form of gastric ulcer related to Charcot's perforating ulcer and to chronic scrofulous sinus. It is a kind of circumscribed caries of the stomach analogous to dystrophic dental decay. It is a local necrosis of neurotic origin.
The Thyroid Gland.-I have, in my work on Septic Intoxication placed on record some curious examples of paludal and septic goitre. I say, in deference to ordinary modes of speech, "paludal" and "septic," though in reality these are identical. It may be supposed that marsh miasmata consist of the products of decaying vegetable matter only. But a little thought will remind us that there is no swamp which does not teem with myriads of minute, short-lived animal organisms. These perpetually perish and become putrescent. Their toxins mingle with the products of decomposing vegetable life. Miasmatic invasion and septic invasion are then one and the same thing. The clinical history of the symptoms closely coincide, and the same germicidal remedies benefit both. We have in ague a paralysis of the sympathetic with the natural circulation changed and the same arrest of haematopoiesis as in passive septicaemia. The stress of ague may fall in women with its greatest impulse on the nervous system; in men, on the articulo-muscular apparatus.
The influence of the miasmatic poisons may forsake the general nervous system and confine its effects to the floor of the fourth ventricle, and thus lead to goitre. In the same way, some persons exposed persistently to ordinary toxins will, instead of rheumatism or neuralgia, show a bronchocele with or without proptosis.
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