times of forcible restraint in a building especially constructed
for detention cases. There is a small class of people who are,
perhaps, suffering from a disease state, who are irresponsible. Most
of them are common drunkards, who create all sorts of disturbances
and who really need discipline--who need to be detained forcibly
for a sufficient length of time to enable them to recover their
normal physical tone, and until they recover something of their
natural mental tone. If this could be incorporated in the rules and
regulations of the governing body of the inebriate farm it would make
a great increase in the total number of improvements and recoveries.
Dr. Freeman has emphasized the necessity of getting the physical
condition up to a high point. He has said all that is really needed
on the subject. I believe drugs and drink should be reduced rapidly
in almost every case. If you look over some of the literature of some
institutions that take these people, you will find they reduce the
morphine down from fifty grains to forty, and then to thirty-nine,
until, finally, after a period of so many weeks or months, they cut it
down to the two-hundredth of a grain, and give it hypodermically. You
can readily see the absurdity of that treatment. The average man can
have the total reduction made within thirty-six or forty-eight hours.
I hope you will take more interest in the inebriate farm, and see that
your legislator is interested as well.
Dr. Haldor Sneve (St. Paul): I have listened with a great deal of
pleasure to Dr. Freeman’s paper, and especially because there are some
statistics as to what can be accomplished in such an institution even
in a comparatively short time. Personally, I think that six months as
an average time to stay in this institution would be too short. It
will be found, however, in time, whether this is true, but just now
the institution is in the experimental trial stage.
A great many legislators are, as Dr. Jones said, trying to convert
this institution either into an insane asylum or a tuberculosis
sanatorium; and it is up to the profession of the state to back up the
establishment of this institution for the treatment of a class which
is growing.
Personally, I think drink is a vice and not a disease, and until we
can eradicate from the minds of the laity and from the minds of some
physicians the idea that a man who drinks is some sort of a nervous
invalid, the sooner we shall get better results in the handling of
this question. Even the dipsomaniac has periodic brain-storms, which
Dr. Ball has likened to attacks of migraine; that is a good simile,
they do not always take to drink, but go off in other ways.
I have treated from twenty to fifty cases of delirium tremens at the
City Hospital every year for twenty years, and I have had considerable
experience in institutions; and yet I cannot find anything to
criticize about the principles of treatment that Dr. Freeman has put
forth here today. The idea in the minds of the laity is that inebriety
is a disease, and they want drugs for it to make them well, and
that is one reason why so many patients go to Keeley cures and get
well. They go there because they find a drug that cures _disease_.
I find that the Towne-Lambert treatment is an excellent _mental_
treatment for the inebriate in private practice. It can be used in the
institution at Willmar, as well as in private practice, and putting a
patient upon the Towne-Lambert treatment satisfies his desire to cure
the disease he is suffering from.
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