Part 4

_Intracranial pressure_, being increased in brain abscess, will cause the cerebrospinal fluid to be increased and found to be so by spinal puncture, although no pus cells or micro-organisms will be found, unless there is also a concomitant diffuse septic meningitis or ventricular infection present. The ocular symptoms of intracranial pressure, such as pupillary (often one large and one small) and choked disk, are usually present. The _pulse rate_ and _respiration_ will be affected, as in brain tumor, according to the size of the abscess. The larger the abscess the slower the pulse and respiration. The temperature, as well as the pulse and respiration, will vary as to whether the abscess be intradural or extradural. Intradural abscesses will frequently cause considerable rise of temperature, and acceleration of the pulse and respiration, and a remission when the abscess has become partially walled off. As soon as a fresh invasion of brain tissue takes place another rise of temperature, etc., occurs.

_Projectile vomiting_ is, as in brain tumor, quite frequently encountered.

_The Röntgenogram_, especially a stereoscopic one, will be of some value in cases where through its chronicity a change of bone by pressure has taken place, or if one may follow the path of necrosis from the nasal accessory sinuses or the middle ear and mastoid process towards the brain. I will state, however, as I have stated on several occasions before, that not too much emphasis should be laid on the diagnostic value of the _x_-ray in intracranial lesions, especially abscess. I have been disappointed in this great method of diagnosis (_x_-ray) and much annoyed at the positiveness of some observers without sufficient evidence.

As in sinus thrombosis, so in brain abscess one should not hesitate in the exploratory operation, because waiting too long will often reduce the patient’s ability to stand an operation later on. Should one not find the abscess, then the decompression has done a great deal to prevent destruction of brain tissue by pressure, besides the patient will be very much relieved of the severe head-pains. This may be said also of spinal punctures. In this way one may wait for development of localization for another operation.

In conclusion, I would like to repeat the words of Prof. Neumann as to the differential diagnosis between meningitis, sinus thrombosis, and brain abscess: “A patient that has meningitis is one that wishes to be left alone and allowed to sleep, although when roused is not particularly irritable. If he has brain abscess then he is constantly very irritable and difficult to manage, while a patient that has sinus thrombosis when he is free from the chill and fever is very pleasant, apparently well.”

THE TREATMENT OF GONORRHEAL OPHTHALMIA

Arthur Edward Smith, M. D. MINNEAPOLIS

In ophthalmology, as in other branches of medical science, the advance in therapeutics has hardly kept pace, in recent years, with that in pathology and diagnosis. Comparatively few of the therapeutic innovations of the past decade have stood the test of time; and, in the main, the ophthalmological materia medica of today bears a striking resemblance to that of fifteen or twenty years ago. Our poverty of therapeutic resource has been notably exemplified in the generally accepted method of treatment of gonorrheal ophthalmia; and the results obtained with the conventional treatment as outlined in the current text-books are far from satisfactory.

Gonorrheal ophthalmia, in both infants and adults, continues to cause an appalling amount of blindness; and only a part of this can, with justice, be ascribed to ignorance and neglect. The number of cases which, in spite of the most careful treatment, go on to corneal ulcer, perforation, panophthalmitis, and irreparable blindness, continues to be considerable. Further, a decided difference of opinion still exists among well-trained oculists of wide experience as to the best method of handling these cases. For over a hundred years silver nitrate has enjoyed an unquestioned pre-eminence in the treatment of the purulent ophthalmias, particularly those cases in which the gonococcus was the etiological factor; and even now to question its right to a place in the treatment of gonorrheal conjunctivitis seems to many to be as heretical as to abandon mercury in the treatment of syphilis. For many years the only difference of opinion in regard to silver nitrate seemed to be as to whether it should be employed in the first stage of the disease, or whether one should wait until the discharge became purulent. Of late years, however, a number of experienced oculists have gone on record as being of the opinion that the majority of these cases do distinctly better without the nitrate than with it. As is well known, the nitrate destroys only those gonococci lying upon the surface or in the most superficial layers of the conjunctiva; and, far from reaching those in the deeper layers, rather forms a film over the surface which protects them from the irrigating solution used later. It also appears to be certain that the use of the nitrate, for a time at least, increases the ratio of extra-to intracellular gonococci in the discharge, which furnishes another valid argument against its use. That a subsequent chronic conjunctivitis with hypertrophy is often a disagreeable sequel in cases in which an energetic course of silver nitrate has been used is a matter of common observation. The vogue of certain of the organic silver salts, such as argyrol, protargol, etc., is no doubt, not so much due to any intrinsic therapeutic merit which they possess as to the fact that the average case gets along better without the local application of strong chemical antiseptics. However one may feel about the abandoning of such a time-honored drug as the nitrate of silver in the treatment of this disease, it must be conceded that it is entirely inadequate to control the process in the severer cases, and as a therapeutic sheet-anchor leaves a great deal to be desired.

The use of cold compresses in gonorrheal ophthalmia continues to be advocated in text-books and practiced in many clinics, especially in America, in spite of the fact that the progressive men in general medicine and surgery seem pretty generally to have abandoned the use of cold applications in the treatment of acute inflammations of bacterial origin. Any merit the cold compresses may have in the reducing of the edema and relieving pain are more than counterbalanced by the fact that the vitality of the tissues is at the same time lowered. In cases in which there is a sufficient swelling of the lids to cause a dangerous pressure on the eyeball, cold should not for a moment be depended upon to control the inflammatory edema but instant recourse had to canthotomy: in cases where this swelling is not marked cold compresses are unnecessary and apart from a certain analgesic effect, of no value. The skepticism, which is becoming more general, in regard to the value of silver nitrate and cold applications has not extended to the third member of the classic trinity,--irrigations,--the efficacy of which seems to be generally conceded. Various substances have been advocated for this purpose,--boric acid, potassium permanganate, bichloride of mercury, normal salt solution, etc., and the consensus of opinion seems to be that it is practically indifferent which one of these is used, the action being mechanical rather than chemical. The ordinary method of half-hourly irrigations has been abandoned by Hosford, Ulbrich, and others in favor of the constant irrigation with the Hosford apparatus or some modification of it.

The English adherents of the constant irrigation treatment, who, for the most part, dispense with the use of silver nitrate altogether, report excellent results; but the method is not without its drawbacks. The apparatus is awkward to use, requires as much or more attention than the intermittent irrigations, and undoubtedly disturbs the rest of the patient at night more. Further, since the lids are, of course, not held apart for the constant irrigation, but the flow of the solution across the palpebral fissure is depended on to cleanse the eye of secretion, one is inclined to question whether the mechanical cleansing is as thorough as when the lids are gently held apart while the eye is being irrigated.

The more one sees of these cases, the more one is impressed with two things: first, that a certain percentage of them would make a complete and uncomplicated recovery, even if they were entirely untreated (undoubtedly this number is larger than we think, especially in children); second, that the usual treatment is entirely inadequate in those cases in which there is an especially virulent infection or a lowered resistance of the tissues. When antigonococcic serum was first developed and its action observed in cases of acute gonorrheal ophthalmia, the results were, as in acute urethritis, disappointing. Many oculists are of the opinion that the serum is entirely without value in acute blenorrhea, even though its use be indicated in metastatic eye disease of gonorrheal origin. Of late, however, at least two men in America have written enthusiastically of serum-therapy in acute gonorrheal conjunctivitis, advocating its employment in the usual manner and also its use locally, i.e., dropped into the conjunctival sac in place of the usual antiseptics. It would seem that the data now available hardly warrant a positive statement in regard to the serum-therapy.

The pathological findings in gonorrheal ophthalmia are simple but significant, in that the gonococcus of Neisser is found, not only on the surface and in the superficial cells of the conjunctiva, but also, often within forty-eight hours, has invaded the deeper layers of the epithelium and the subepithelial connective tissue. This at once makes clear the reason for the inefficacy of the local antiseptics, particularly those like silver nitrate, the action of which is very superficial. Organic silver preparations and irrigations of various kinds are equally powerless to reach any but the most superficially situated of the bacteria.

Since the destruction of the bacteria lying on the surface is not sufficient to control the disease, it may be stated that the problem of the destruction or inhibition of the deep-lying bacteria is the essential problem in curing gonorrheal ophthalmia.

The gonococcus numbers among its biological peculiarities an unusual intolerance of extremes of temperature, its growth in culture being inhibited by temperature above 38° C. or below 18° C. Text-books on bacteriology state that exposure to a temperature of 60° C. for a period of ten minutes destroys the gonococcus. Experimentation in the laboratory of the Dimmer Clinic in Vienna in April and May, 1913, with cultures from forty-two cases of acute gonorrheal urethritis, seemed to indicate that this point may be placed from one and one-half to two degrees lower than this, i.e.,--from 58° C. to 58.5° C.

Thus, theoretically, at least, it would appear that, if the conjunctiva could be subjected to a temperature as near as possible to this without injury to the tissues, a marked effect should be observed in the course of the disease, particularly if the heat can be applied in such a way as to penetrate as deeply into the tissues as does the gonococcus. This theoretical requirement has, in my opinion, been perfectly met practically by the local use of steam as practiced in the Dimmer Clinic since February, 1913, with the apparatus devised by Lauber and modified by the writer. Goldzieher of Vienna was probably the first to employ steam in the treatment of the purulent ophthalmias; and in his first series of cases reported fifteen patients treated with the application of steam passing through a nozzle held at a distance of about four centimeters from the eye, the temperature of the steam striking the tissues being about 45° C. (113° F.). Although the results indicated that the method was a distinct step in advance there were still a number of important details to be worked out, in order to get the best possible results. First of all, experiment showed that the temperature of the steam at a given distance from the nozzle was not constant, so that an arbitrary distance could not be set. This suggested the advisability of providing the apparatus with a sliding-guard, which could be set at the exact distance from the nozzle where the steam was shown by the thermometer to be at the desired temperature. Secondly, it was determined that the tissues would sustain without injury a considerably higher temperature than that set by Goldzieher, and that the effect upon the diseased process was markedly better when the temperature was raised. Steam at from 50° C. to 53° C. gave the best results; and in one case in which a temperature of 55° C. was inadvertently reached no injury was done the tissues. Further experience naturally suggested other changes in the original technic. In the first place, the lids were held apart by an assistant in the usual manner; but, even with gloves on, the exposure of the fingers to the steam was more or less painful, and gauze wound on little sticks was substituted. The time of exposure was finally set at six minutes; and since the application of the steam could not be borne for longer than from forty-five to sixty seconds without severe pain it usually took twenty minutes or so to complete the six-minute exposure. This was done once every twenty-four hours, and was combined with half-hourly irrigations with potassium-permanganate solution. No other treatment was used. The results attained with this method in 34 cases (7 adults, 2 children and 25 infants) has left nothing to be desired. In no case has there been any corneal complication; swelling and pain subsided with unusual promptness; and the course of the disease was notably shortened, whereas, after the first application of silver nitrate a considerable increase in the number of gonococci in the discharge is often observed. A striking diminution in the number is noted after the initial application of the steam. In 8 of the cases in the series mentioned (all infants), the disease affected both eyes; and in 5 of these cases the experiment was made of treating one eye with steam in the manner described and the other with applications of silver nitrate in the usual manner, using the permanganate irrigations in both. The difference in the results attained was very striking. In every instance the eye in which the steam was used was brought much more quickly under control than the one under nitrate. In cases brought under treatment early the edema of the lids did not become severe; and the course of the disease seemed, in general, to be shortened by about one-third. There were no corneal complications, except in one case in which there was a corneal ulcer present when the man presented himself at the clinic. In no case was canthotomy necessary; and no case was followed by a chronic hypertrophic conjunctivitis. The application of the steam is undeniably painful, but not unbearably so.

VAGINAL HYSTERECTOMY UNDER SPINAL ANESTHESIA: REPORT ON A CASE

By R. R. Cranmer, M. D. MINNEAPOLIS

I wish to report this case of vaginal hysterectomy under spinal anesthesia on a patient whose age and physical condition were not favorable for the use of ether or chloroform. The case belonged to that comparatively small class in which a general anesthetic cannot be used; and it was because of this fact that spinal anesthesia was resorted to. Had it not been necessary for this patient to earn a livelihood by hard labor the operation would not have been done; but, in her case, it was necessary, and the condition of prolapse, therefore, was a source of continual pain and trouble. The fact that the diet was not restricted after the operation assisted greatly in shortening her stay in bed and her rapid recovery.

Patient, aged 59, married, mother of six children. She had been suffering from prolapsus uteri of a severe degree for five years. The cervix presented at the vaginal orifice at times. Mitral insufficiency and arteriosclerosis were present. She also had chronic bronchitis and a mild nephritis. Chloroform and ether being contra-indicated, spinal anesthesia was used, two drachms of 2 per cent novocaine solution being injected through the fourth lumbar interspace. The vagina was prepared for operation, and the hysterectomy started within four minutes after the spinal injection. The patient did not complain of any pain; and there was no shock or other untoward symptoms. She was immediately put upon a general diet and was able to leave the hospital on the twelfth day.

THE JOURNAL-LANCET

The Journal of the Minnesota State Medical Association and Official Organ of the North Dakota and South Dakota State Medical Associations

PUBLISHED TWICE A MONTH ESTABLISHED 1870

W. A. JONES, M. D., Editor

ASSOCIATE EDITORS:

R. D. Alway, M. D. Aberdeen, S. D. H. J. Rowe, M. D. Casselton, N. D.

PUBLICATION COMMITTEE:

THOS. McDAVITT, M. D. St. Paul J. L. ROTHROCK, M. D. St. Paul F. A. KNIGHTS, M. D. Minneapolis

W. L. KLEIN, Publisher

Subscription $2.00 a year

PUBLICATION OFFICE

839-840 Lumber Exchange Minneapolis, Minn.

March 1, 1915

A NEW REMEDY FOR PYORRHEA ALVEOLARIS

Diseased teeth and gums have an undoubted and pernicious effect upon the general health of the individual. This condition as a cause of disease has been the subject of many papers written by physicians and dentists.

Now a new remedy has been proposed by Bass and Johns which promises relief in the majority of cases. Emetin is the drug that destroys the ameba of pyorrhea just as ipecac destroys the ameba of dysentery. The lesion should be attacked persistently until healed and the use of emetin continued to prevent reinfection.

Emetin may be used hypodermically in one-half grain doses for at least three days and as often as is necessary to destroy the ameba.

The presence of the ameba can be determined only by proper microscopic examinations. The healing process may require considerable time, according to the extent and character of the necrosis. Deep pockets require careful cleansing to clear the pus-forming cavities. After this has been accomplished and pus ceases to form Bass and Johns recommend the use of fluid extract of ipecac as a local application to prevent reinfection. Ipecac will actually destroy the ameba if used persistently and is preferable to the many commercial preparations now in use. The teeth should be brushed in the ordinary way, after which one drop of fluid extract of ipecac should be applied to the wet brush, forcing some of the solution between the teeth and spitting out the excess without further washing of the mouth.

The investigators have found that this simple procedure will keep the mouth free from pyorrhea. It stands to reason, however, that the teeth must be thoroughly cleaned in the usual manner by the dentist, otherwise it will be impossible for the emetin or ipecac to penetrate the deep crusts which are found about old and uncared for mouths. It is remarkable how many people neglect the care of their teeth and it is equally strange that so little constitutional disorder is found in those who neglect an ordinary and simple sanitary toilet requisite. One of the first rules for hospital patients when they come under the supervision of the nurse is the provision of a tooth brush and a suitable mouth wash.

Many patients from the country, a lesser number from the cities, never employ a tooth brush. Some even resent a suggestion of clean teeth. Nature gave them teeth and nature is supposed to keep them in order, but unclean teeth are the rule rather than the exception in hospital practice.

Not infrequently animals need the services of a dentist, but their numbers are few compared to man. When a simple remedy for pyorrhea, like ipecac, promises to clear the teeth of amebas, there is no excuse for neglecting nature’s adornment.

LOWERING THE MILK GRADE

A bill has been introduced in the Minnesota State Legislature for the purpose of lowering the butterfat requirement in milk from three and one-quarter to three per cent. This means a reduction of solids in milk from thirteen to eleven per cent, and it further means that more water will be added to much of the milk sold in Minnesota. A Minneapolis ordinance prescribes the butterfat content to be as high as three and one-half per cent. Minneapolis has enough water in its milk now, and, if this bill goes through, the city may expect to use skim-milk almost exclusively.

It hardly seems credible that any one should desire the quality of milk to be reduced for any purpose whatever unless it is for commercial reasons.

Fortunately, at this writing the bill is held up for consideration, and it is to be hoped that sufficient pressure will be brought to bear to insure its defeat. Too many cows give poor milk and any effort to standardize and legalize the inferior cow is a reflection on the integrity of milk sellers. Inferentially, there are too many under-fed children and yet if milk is reduced in quality, we must expect less vigor in the growing child.

One wonders why such a bill should get into the Legislature; what are the real reasons for its passage?

“LEAVES OF HEALING!”

The late issue of “Leaves of Healing,” published by the Dowieites at Zion City, near Chicago, has been sent broadcast among physicians. This sheet is an antivaccination propaganda, and is profusely illustrated by horrible pictures of supposed diseased states caused by vaccination. The text is, as is all others of its ilk, full of misinformation, garbled extracts from known and unknown writers and speakers, and tirades against all who believe in vaccination.

If these sheets would present a fair and broad view of the evils of vaccination they might find more adherents to antivaccination doctrines among medical men; but, as it contains so many misstatements and is so overbearingly one-sided in its efforts, the effect is nil, except when it is circulated among those unbalanced in mind and judgment. Physicians in general freely acknowledge that vaccination, or the introduction of a serum, may produce, in some people, unexpected and sometimes disastrous results. Most physicians hesitate to vaccinate people with active syphilis, or even those in whom the syphilis has been seemingly inactive for years, or those who have hereditary syphilis. These persons are quite apt to have an accentuation of their old blood disorder under slight infections or injuries; but that should not militate against vaccination when an epidemic is probable. Some of the pictures in “Leaves of Healing” were undoubtedly pictures of syphilis, and should have been so labeled; but that could not have been expected in a partisan publication.

Physicians also know that people who have chronic eczema should not be vaccinated until the eczema clears up; and doubtless in hurried or extensive vaccinations that are deemed necessary to prevent the spread of smallpox in a community cases of eczema are overlooked. Children who are the victims of chronic digestive disorders, or who react to mild febrile or diarrheal conditions more than the average child, are commonly exempted from vaccination. On the whole, there are but few conditions that are made worse by careful vaccinations with proper dressings and after-care.

When one considers what wonders in the way of control of smallpox have been recorded in medical history, the few mishaps that occur among the vaccinated, the proportion of illness due to vaccination is so infinitesimal that they cannot be classed among the “fearful” results of vaccination.