Chapter II: Part 2

I think the profession will have to keep their eyes on the legislators, perhaps on the new governor, and see that this institution is not thrown into the waste-basket, so to speak, or converted into some other sort of institution, because we need a place of this kind. Even if Minnesota can go prohibition pretty soon--and I rather think it will--we shall not get rid of our drunkards for that reason. We shall still have to have a hospital for the treatment of the morphine, cocaine, and alcoholic habits. The doctors who send patients to Willmar, I think, ought to be careful, and not try to help some municipality out of taking care of old battered hulks, who cannot hope to recover, who cannot be made well simply because they have been drinking for so many years, and their other habits of life have resulted in such a deterioration of the brain that there is no possibility of bringing them back and making really good citizens of them. Those patients should be kept in a work-house or in a special department at Willmar or some other place. We should try to reclaim all of our young men and young women habitues.

Owing to the absence of proper writeups about this hospital it is not generally known throughout the state that pay-patients can be received and treated just as in any sanitarium and at very moderate rates.

Dr. Freeman (closing): I really have nothing to add in closing except to say a word with regard to prohibition. I have a second-hand statement from the police of one of the Twin Cities that he is positive in his city there are five thousand drug-users from his experience in the police court.

With regard to the maintenance of discipline at the institution: We have sufficient law or authority for discipline, but we have not the facilities. The thing in my opinion that we mostly require is a building where we can take care of a man who is incorrigible, or a man who runs away. For two reasons: In the first place, I have known a number of men who came there unwillingly, who later were greatly benefited by their compulsory stay; second, the effect of disciplinary measures upon the population in general. If a man knows that, when he goes there, he must stay, he naturally gets over his constant thought that he is going to sneak away, and put it over. The custodial cottage to take care of forty people would allow, in all, four classes of patients. We should have a reception-ward in which to examine all new patients; one ward for the incorrigible; and we should have two other places to care for two classes of men received. This would prevent the influence of the older men who have gone further in their habits upon the young boy who has just started.

DIAGNOSIS OF INTRACRANIAL COMPLICATIONS IN DISEASES OF THE MIDDLE EAR AND ACCESSORY SINUSES OF THE NOSE[3]

By Joseph C. Beck, M. D. CHICAGO.

[3] Read before the Sioux Valley Medical Association, July 22, 1914, and published in these columns at the request of the Association.

The most important causes of intracranial complication from the middle ear and nasal accessory sinuses, are suppurations, consequently I shall confine my remarks to that subject, and not take up the neoplasms, trauma, etc.

In the diagnosis it is most important to recognize suppurative disease of the ear and sinuses, but this subject is not within the province of this paper, therefore I shall satisfy myself by mentioning only that the presence of the pus from the middle ear and nose, and Röntgenographic examination, are the most important signs of affections of these structures. The one symptom more than any other on the part of the patient of a threatening extension into the cranial cavity, is localized pain or headache, which is very persistent, instead of periodic. Especially important is this in connection with the cessation or diminution of the discharge. The knowledge of the pathological change present in the sinuses and middle ear and mastoid, is of additional value as, for instance, tuberculosis, syphilis, and cholesteatoma.

The frequency of intracranial complication in suppuration of the middle ear is much greater than that following sinus disease, about twenty-five to one in my experience.

The intracranial complications which I shall consider are--

1. Meningitis.
2. Sinus thrombosis.
3. Brain abscess.

The meningitis may be serous or suppurative, and later localized or diffuse.

The sinus thrombosis may be partial or parietal, and complete with or without involvement of the jugular bulb and vein. The brain abscess may be extradural or genuine within the brain substance proper. The complications may be further divided as to bacteriologic or etiologic factors as, for instance--

Streptococcic
Staphylococcic
Pneumococcic
Tuberculous
Syphilitic

These complications may arise following acute, or chronic and acute, exacerbation of chronic suppuration of the ear and sinuses. Meningitis and sinus thrombosis (this latter condition is very frequently associated with a localized meningitis) are usually complications following acute, or acute exacerbation of chronic, suppuration of the ear and sinuses. Brain abscess, however, is most frequently associated with the chronic form of the ear and sinus disease; but these become more manifest following an acute attack of ear or sinus trouble. Tubercular or syphilitic meningitis is chronic inflammation _per se_; but these conditions are also lit up by the acute processes within the ear and sinuses.

The cardinal symptoms of any intracranial complications are--

1. _Pain or headache._--This may be localized or diffuse; it is, however, very persistent and quite intense. It is in the recognition of this symptom that has helped me more than any other in suspecting intracranial trouble.

2. _Nausea and vomiting._--This symptom is quite constant, especially early in the disease; and projectile vomiting is quite characteristic of intracranial pressure or irritation.

3. _General septic appearance._--This of course will vary in the different conditions under consideration, but in all is it quite manifest.

4. _The vision_ is very frequently affected due to the choked disk that is present.

5. _Temperature, pulse, and respiration_ are very frequently disturbed.

6. _Definite focal symptoms_ of brain localization are of the utmost importance in the diagnosis.

7. _Blood and spinal fluid examinations_ give very valuable information.

8. _Röntgenographic findings_ are at times valuable.

9. _Exploratory operation and treatment_, as in lues, is at times necessary to make a diagnosis.

MENINGITIS

(a) _Serous meningitis._--One of the first signs is the increasing headache, at first localized, usually near the seat of the perforation or path of infection, and soon becoming diffuse over the head. The patient loses his appetite, his tongue becomes coated, the emunctaries become sluggish in their action, and nausea is a very common symptom. The temperature rises, and, if the septic form is going to follow, this rise is often quite rapid, so that there may occur small chills from the infection of the cerebrospinal fluid. The pulse and respiration rate is now considerably increased. The patient is very irritable and restless, and does not sleep. As soon as the fluid increases within the cavity there is observed the characteristic syndrome of rolling the eyes, especially upward, the neck is drawn backwards, and finally the leg upon the thigh and thigh upon the abdomen. Attempts to straighten them out is resisted and appears to be painful,--Kernig’s sign.

Stroking the bottom of the feet with some semisharp instrument or the finger-nail will cause the big toe to turn up instead of down,--Babinski’s sign.

Taking the head and tilting it forward against the chest will cause the limbs to be drawn up,--Brudzinski’s sign.

All the other symptoms, as pressing over the peroneal nerve and muscle (Gordon’s sign), which will cause the extension of the toes, the stroking of the anterior tibial surface (Oppenheim’s sign), or the stroking of the region of the external malleolus (Chaddock’s sign), will produce retraction of the toes. All these signs, I say, prove that the upper neuron (within the cranium) is involved. The patient now will lapse into unconsciousness, and be roused with more or less difficulty to again relapse in the same condition. The pupils become sluggish in their action, at first becoming small, then irregular, and finally dilated.

Ophthalmoscopic examination may reveal a choked disk. Spinal puncture shows increased pressure by fluid very frequently coming through the hollow needle with a spurt, and clear or slightly cloudy. Following such a puncture the patient is very often much improved for from a half an hour to a whole day, but the symptoms soon return. A complete examination of the cerebrospinal fluid thus removed, will aid a great deal in diagnosis. This includes the following:

1. Remove about 25 c. c. at spinal puncture.

2. Make several slides and stains for organisms, as septic and tubercular.

3. Examine and count the endothelial cells, leucocytes, and pus cells.

4. Make cultures.

5. Make a Noguchi (butyric-acid) test for excess of albumin.

6. Make a Lange colloidial test.

7. Wassermann, Nonne, and Noguchi tests for syphilis.

8. Test for sugar.

9. Test for total acidity and relative acidity.

10. Cholin may be tested for.

In the serous form one will find the cells increased somewhat, especially the leucocytes, but the micro-organisms are conspicuous by their absence.

The Lange (colloidal-goldchloride) test will show the characteristic color reaction of a septic process.

The Noguchi (butyric-acid) test will be positive. Excess of albumin.

The Wassermann, Nonne and Noguchi tests for syphilis are negative. (Unless such a case should be a complicated one.)

The test for sugar is very important in that in serous meningitis sugar is present.

The relative acidity is not markedly affected, and cholin is not present, or, if so, in only small quantity.

(b) _Septic meningitis._--If this is _localized_, and there is a collateral serous meningitis associated with it, then the symptoms may be the same, as just described; however, the cerebrospinal fluid will show a greater degree of irritation, and the fluid may contain some micro-organisms. The majority of localized septic meningitis cases, however, are not as severe in their course as the serous or diffuse septic forms. The one important symptom is the localized headache, which is quite persistent, and the greater rise in the temperature. There are, undoubtedly, many cases of localized meningitis that show a perfectly normal cerebrospinal fluid, and most of the cardinal symptoms absent; and these are the cases that usually get well or lead to extradural abscesses subsequently.

The _diffuse septic meningitis_ is the most discouraging intracranial complication that we have to deal with, and the diagnosis as a rule is not difficult. It usually is preceded by the serous form, but within a very short time develops the graver symptoms of sepsis. The most positive symptom is the spinal puncture. The fluid comes out under pressure, but not so great as in the serous form, and is turbid. The turbidity varies in degree with the amount of infection. It has the appearance at times of pure pus; in fact, that is what it is. Bacteriologically one will find many micro-organisms of the character of the infection; and leucocytes or pus cells are very numerous.

The sugar reaction is always absent, and the acidity is much increased as is the quantity of cholin.

The pressure or irritative symptoms as the Kernig and Babinski tests, as well as the pupillary reactions, are practically the same as in the serous meningitis, only that they soon give away to the paralytic form, namely: pupils dilate, patient is in a constant stupor or coma, and the involuntary urination and bowel movements become very manifest. The patient is, as a rule, unable to take or be given nourishment. The outcome is, in my experience, with one exception, always fatal, due to diffuse cerebritis. I have had a case of diffuse septic meningitis in the early stages of a pneumococcic type which I operated on by the Haynes’ method of drainage of the cyscterna magna, and which recovered; and I believe that the success in that case was due to the very early intervention, because I have operated by the same method on eight other cases more advanced and of streptococcic and staphylococcic type of infection, which ended fatally.

_Sinus thrombosis._--This complication is the one that is recognized as giving the best prognosis because it can be very readily recognized, and even exploration is warranted to make such diagnosis. It most frequently follows, or is associated with, acute infections of the middle ear and mastoid process. The most important symptoms are the chills and fever of a distinct septic type, and, as a rule, increasing in frequency. There is invariably a blood-picture of sepsis, namely, a very high leucocyte count and the polymorphonuclear type in marked excess. Blood cultures are, as a rule, positive of a bacteriemia. If the process has extended to the bulb and internal jugular vein, then one may feel a thickening or cord-like mass along the anterior border of the sterno-cleido-mastoid muscle. The fundus examination often reveals a choked disk, especially on the side where the thrombosis is located. A symptom recently described by Beck, of Vienna, and Crowe, of Baltimore, and proven by me to be of positive value in several cases, is the production or increase of a choked disk by compression of the healthy internal jugular vein. Urbanschitch has shown in quite a number of cases of sinus thrombosis that the blood-clotting time is very much enhanced. This of course is true of any case of bacteriemia or septic phlebitis anywhere in the body. I have proven this test to be of value to me in several cases of sinus thrombosis. The exploratory exposure of the lateral sinus is of distinct value, and the only fact to remember is to expose a sufficient area so that one is able to deal with the sinus in case it be opened accidentally, because such an accident when this precaution was not taken has led to serious consequences.

The diagnosis of a thrombotic sinus when exposed is made first by its discoloration, usually of a grayish pink; secondly, it feels harder than normal and is not resilient when compressed, that is, it does not spring back. It, however, may be soft in case the thrombus has broken down; and in cases of parietal thrombosis it may spring back because there is blood circulating through it. One will at times find a small collection of pus about the sinus, a condition known as perisinus abscess, and in many instances of this condition the sinus itself is not thrombosed. The puncture of the sinus by a hypodermic needle and attempt to withdraw some blood, is not at present considered good practice owing to the danger of infecting a non-infected sinus. An incision is considered a wiser plan, and subsequently packing both sides (torcular and bulb) so they are shut off from the general circulation. There are many instances of secondary infection by embolism, either in or about the joints, and infection into the lungs, spleen, pancreas, etc., with the entire train of symptoms from such complications.

_Brain Abscess._--This is most frequently associated with chronic suppuration of the middle ear and mastoid, and labyrinthine disease. As stated before, we must consider two principal types, namely, those outside the dura and those within. They may exist at the same time, or the intradural abscess may frequently follow, especially in acute exacerbations, the extradural abscess. The paramount symptom is the great pain in the head, most frequently localized at or in close proximity to the abscess. I have, however, found several instances where the patient located the pain in the anterior portion of the head, and operation or post-mortem examination disclosed it in the posterior cerebral fossa. This pain is not at all unlike that in brain tumor, and there are exacerbations in the headaches sometimes at night, other times in the mornings, and in one of my cases the patient would have about ten attacks of severe head-pains within twenty-four hours, and in the intervals be fairly comfortable.

The next group of symptoms of importance are the focal lesions, which will correspond to the anatomicophysiologic locations and actions. These focal symptoms will vary in degree in that they be either irritative or destructive. So, for instance, a small abscess pressing over the motor area will cause clonic contraction and a still larger abscess, especially if it be intradural, will produce paralysis of that portion of the body governed by that particular area. Again, if it be located in the cerebellar region it will cause a train of symptoms of imbalance and loss of interpretation of direction, which must be carefully differentiated from the irritation of the labyrinth. In this department there has been much work done by Barany, Ruttin, Neumann, and other Viennese, and many others to make it possible to make a differential diagnosis; and there is a great deal more to be done. One of the most important recent contributions in this regard is the “pointing test” of Barany in connection with cerebellar lesions; and careful study and experimenting at every opportunity is very much recommended, in order to familiarize one’s self with this test. This in connection with the various labyrinth tests makes the differential diagnosis much more easy. One must remember that both labyrinthian irritation in connection with suppuration of the ear and cerebellar irritation from brain abscess may exist at the same time.

_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

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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.

“Leaves of Healing” leaves out of its vaporings the fact that Zion City had a smallpox epidemic not long ago, and was quarantined by the health authorities, and that the people submitted to vaccination with gratifying results. Nor does the above-mentioned magazine record the fact that the president and secretary of a local branch of antivaccinationists in Minneapolis, who were fighting a compulsory vaccination law before the Minnesota Legislature a few years ago, died of virulent smallpox during that meeting of the Legislature.

The antivaccinationist usually has at his command a set form of speech that contains more vituperant adjectives, and less reason and judgment, than the average self-constituted reformer. Smallpox and other preventable diseases will continue to exist while the uneducated and ill-balanced minds are permitted their volley of wind-laden speech. Some day the people will wake up, cast the “reformer” aside, and climb on to the band-wagon of health and happiness.

It will take our educators and sanitarians some time to harness the team to the wagon, but when it starts it will go on merrily to its destination.

OWNERSHIP OF THE JOURNAL-LANCET

In answer to a number of inquiries the following statement is made:

The stock of the JOURNAL-LANCET is held by a number of Twin City physicians, and the publisher, Mr. W. L. Klein.

The JOURNAL-LANCET is the official organ of the State Medical Associations of Minnesota, North Dakota, and South Dakota. The responsibility for its reading matter and editorials rests with the publication committees of the state associations.

MISCELLANY

To the Physicians of the State of Minnesota:

The Committee on Public Policy and Legislation most earnestly asks the co-operation of every physician in the State of Minnesota in procuring the passage of the several bills that have been decided upon, and either have been or will be introduced into the legislature during this session. It is believed that there is not a man upon the roster of the State Medical Society, or indeed any physician in Minnesota, who does not see the necessity of certain legislation for the protection of the physicians in the State, and also that the common weal will be advanced by the passage of the telephone bill introduced by Senator Andrews, of Blue Earth, and by the passage of the bill relative to trachoma, which is a constant menace to the public health, and several other bills that are in course of preparation, but which await certain developments before their presentation. The committee earnestly begs of all the physicians in the State that they will write to their representatives and senators from time to time urging with great earnestness their support for the several measures advanced by the Committee on Public Policy and Legislation. It is believed that every physician can influence at least from 10 to 100 votes at a general election, and this fact, of itself, makes the physician a factor in the election of any candidate. It is believed by this committee that the medical men of the State, if they will but unite and act in concert, can measurably influence legislation. The time has come for the physician to take his place in the political system of the State, both as an active agent and, indirectly, through his influence of others.

The telephone bill provides for physical connection between all telephone companies in the State without extra charge, except a small toll. It provides that telephone companies shall be placed under the direction of the Railroad and Warehouse Commission. It provides that no greater net income than 5 per cent shall be allowed upon the capital actually used in the operation of the telephone companies. It provides for intercity telephone service in the cities whose city limits adjoin without extra charge.

The trachoma bill provides for the segregation of trachomats, and, under certain circumstances, for the maintenance by the State of special schools for their education in school districts having as many as 20 trachomats.

There is also drafted and ready for introduction a bill requiring all persons who seek to practice medicine in any form whatever to pass the regular examination before the State Board of Medical Examiners.

There is in contemplation a bill for the purpose of procuring certain lands for the building of cottages thereupon and establishing farms to be worked by lepers who may be or shall have been committed to the leprosarium farm, the intention being that those lepers in the State that are able to work shall have an opportunity to do so, and that the said lepers should care for lepers who are unable to work or earn a living. It is also proposed to purchase a small tract of land not far from the State University for the purpose of allowing an exhaustive study of certain forms of leprosy with the aid of the State University Medical Staff. The leprosarium farm would be under the direction of the State Agricultural School.

The Chairman of this Committee will be very glad to receive advice and suggestions from the physicians in the State.

Cornelius Williams, M. D.,
Chairman of the
Committee on Public Policy and Legislation.
St. Paul, Minn., February 3, 1915.

REPORTS OF SOCIETIES

MINNESOTA ACADEMY OF MEDICINE

The Academy met at the St. Paul University Club, Feb. 3. Dr. C. M. Carlaw presided.

Four doctors were proposed for membership: Drs. W. H. Condit and Stephen Baxter, of Minneapolis, and Drs. Wilhelm Lerche and F. C. Schuldt, of St. Paul. All four names were referred to the executive committee.

Dr. Arnold Schwyzer showed some x-ray pictures of a penetrating gastric ulcer. He also made a report of a case where gall-stones gave a feeling of emphysematous crackling, due to small marble-sized stones with no more fluid than enough to fill the spaces between the stones (perhaps a teaspoonful in all).

The paper of the evening was presented by Dr. A. E. Benjamin, the subject being “Goiter Operations with Simplified Technic.” The paper was thoroughly discussed, the whole evening being given over to its consideration.

The reading of Dr. White’s thesis was deferred until another meeting.

Twenty-seven were present.

Fred E. Leavitt, M. D., Secretary.

CORRESPONDENCE

To the Editor:

In the February 15th issue of THE JOURNAL-LANCET is a discussion by Dr. Klaveness, of Sioux Falls, S. D., on a paper on “Syphilis and Its Relation to Society” by Dr. McLaughlin, of Sioux City, Iowa. In this discussion Dr. Klaveness states: “We are unfortunate here in South Dakota in this respect, that we do not have the population and the laboratory facilities for resorting to the Wassermann reaction at all times, and any man within the State who would systematically carry out a Wassermann reaction now and then would invalidate his findings very materially, inasmuch as it is very well established that, in order to obtain reliable readings, you must have a serologist or bacteriologist to follow this work exclusively in order to get accurate findings. It is immensely important, and it would be a boon to the suffering people, if we could have a state serologist.”

This statement by Dr. Klaveness is contrary to the facts as they now exist and did exist at the time he discussed the paper at Watertown, S. D., in May, 1914.

We have a well equipped medical laboratory in South Dakota in connection with the medical department at the State University at Vermillion, and we have been doing the Wassermann test.

This misstatement should have been corrected at the time it was made, but was not, as I was in Watertown but part of one day during the State Meeting last May and did not hear the paper or its discussion.

Permit me to state through your columns that we do the Wassermann test at the State Health Laboratory and have been doing it on Thursday of each week since March 21, 1914. At that time a circular letter announcing the fact was sent to every physician in the State, including Dr. Klaveness. This announcement was made only after several months of experimental work in perfecting the technic and controlling all factors.

We do the original Wassermann test, using the Nogouchi antigen. All our reagents are prepared in our laboratory and every possible control is carried out each time the test is set up. We therefore believe that our results will compare favorably with the best scientific work of this character.

At the present time a fee of $5.00 for each test is charged, containers and instructions are supplied upon request.

We have done the Wassermann test for the State Hospital for the Insane at Yankton from the first.

Mortimer Herzberg, M. D., Director.
Vermillion, S. D., February 18, 1915.

* * * * *

THE LOYALTY OF NURSES

To the Editor:

My attention has just been called to an article published in THE JOURNAL-LANCET, August 1, 1914, it being an address by Dr. George D. Head to the graduating class of the Asbury Hospital. The advice Dr. Head gives to the nurses seems very good, and very elevating to our profession, but I would like to analyze it to show that it is not quite practical.

It has taken considerable effort on the part of nurses to convince the people, and to convince some doctors, that they are any more than machines. Because we ask for three hours rest out of the twenty-four, and because we asked for a fixed rate for service, Dr. Head says that our loyalty to high ideals is diminishing. Unfortunately, in the nursing profession, as in all other professions, there are some who are incapable and unconscientious; and, if Dr. Head had the experience of having a nurse leave a patient, unattended, at a critical time, she probably was one of the few incapables, or was so overtired from loss of sleep that it was necessary for her to have rest. When Dr. Head says that a nurse should waive her rest hours for days or a week at a time, if necessary, I think he is making a mistake. A nurse cannot do her duty by a patient if she does not have proper rest. It is unfair to both the patient and the nurse. Dr. Head may say that most patients are not in need of constant attention for more than a few days or a week, and that a nurse can stand it for that length of time without rest hours. This is true; but we have to consider that the next case may be just as critical, and so the nurse must reserve some strength for the cases to follow. And more often than not, the nurse is obliged to take cases with very little or no rest between them.

In the second place, Dr. Head thinks that the nurses ought to have a varying scale of charges for service. The doctors do it; why shouldn’t the nurses? Dr. Head does not seem to consider the fact that the nurse has one patient, while the doctor has many. Suppose a nurse takes care of a poor patient for five or ten dollars a week, where is the rich patient who is willing to pay forty or fifty dollars a week to make up the loss? The nurses have found that twenty-five dollars a week is the price that is necessary for them to live on in order to keep themselves clothed, pay for their laundry (no small item), and carry them over the few weeks of rest or over the dull season. The average life of a nurse, as a nurse, is, I believe, not more than ten years. In that length of time, at the wages she gets, she is not able to lay away a great amount for a rainy day, which usually comes all too soon.

We have a number of good hospitals in Minneapolis where people in moderate circumstances can be very comfortably cared for at a considerably less expense than employing a nurse in their homes. The poor in our city, I think, are fairly well taken care of in the city hospitals and by the visiting nurses, who are paid for such work.

As for nurses refusing cases because they are afraid of them: I think there is usually some just cause. If a nurse has a tendency towards tuberculosis, she should refuse such cases; or if she has a tendency towards throat troubles, she should refuse diphtheria and scarlet-fever cases. A nurse who is constantly with a patient runs considerably more risk of infection than the physician, whose visits are usually short. There are nurses who make a specialty of such cases, and usually there is no trouble finding such a nurse. Nurses who make a specialty of obstetrical cases or of children should not take contagious work. As for a nurse refusing a typhoid case because she is afraid of it: I cannot believe that any real nurse would do such a thing.