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.
“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: