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ferentiate, except in the cases in which we to have a recurrence. I will give the hisare able to aspirate and demonstrate the tory of a case which serves to illustrate gonococcus in usual smears or cultures.
this point. It has been my experience that in every
C. W. Contracted gonorrhea two and a half years ago.
Three months later the case in which I have been able to find the
right knee joint and the left ankle joint germ, the serum injections had absolutely
became very painful and swollen. He enno effect upon the involved joint or joints, tered the clinic at Rush College the middle
of October, 1907.
On examination, we but I have repeatedly seen cases which,
found that he was suffering from postfrom a clinical standpoint, I thought to be gonorrheal prostatitis and a bilateral semthe type just mentioned, and to my sur- inal vesiculitis; that both joints mentioned prise found that they responded to the were swollen and painful, and that he was
able to walk only with the aid of two canes. serum treatment. From this, I think we
He was treated for the prostatitis, and, afmust conclude that the toxemic form of ter four weeks, was given an injection of gonorrheal joints is more common than two c.c. of serum. This was followed by
two injections of six c.c. each, at fortythose which are due to infection of the
eight hour intervals. He was greatly imjoint.
proved after the second injection, and did A number of questions have come up, not return to the clinic after the third,
thinking that he was cured. About six both in my own work and from that of
weeks later he returned to the clinic in the others who have used the serum, which I
same condition that he was when he first think might well be explained here. First, entered. . He was then given five injec
tions of six c.c. each, during a period of why do some cases in which the serum has
three weeks. He improved rapidly and been used with good results recur after a
after the fifth injection was entirely free few weeks or months? Most of these cases from pain, although there still existed a recur because the source of the toxic ma- slight disability from stiffness. Nevertheterial has not been eliminated before the
less, he had good use of his limbs and, as
stated before, he was free from pain. I use of the serum. By this, I mean the
saw him as late as last August, and found local infection should be cleaned up at the him in good condition. same time or, better, before the serum is Another question which has come up is used. If we do not do this, we are very the partial relief that some users of the likely to have a temporary relief of the serum have experienced. Most of these cases joint condition, but sooner or later toxins are due to an insufficient dosage. Unforwill again be produced from the local in- tunately, the serum has been placed on the fection, with a recurrence of the painful market in packages containing three small joints. I cannot too strongly urge the vials, each vial having the capacity of two treatment of the local infection before or On this account, many have thought at the same time the serum is administered. that this is a sufficient amount for a cure, Another reason for the recurrence which and have injected two c.c. at short inter
see in these cases is the insufficient vals until the patient had been given the quantity of serum given. We have found contents of the three vials. This is just that unless the patient receives at least one good-sized dose, and most cases retwenty-four to thirty c.c., (and in some in- quire much larger quantities.
. stances we have found it necessary to give I have made some observations as to the as high as eighty c.c.,) we are very likely stability of this product and have found
that serum over one year old is not active. lon, with the nicotin and so on. On the The serum is obtained from the uncas- contrary, poisonous substances produced in trated male sheep (ram). Immunization the body itself affect the retina and induce requires ten weeks. The animal is given here changes partly inflammatory, partly weekly injections into the peritoneal cav- degenerative as for instance the retinitis ity; the first three injections are from due to nephritis or diabetes or leukemia, dead cultures; the last seven from live cul- the starting point being in all of them tures. The quantity of these injections is the production of some noxious subgradually increased. The cultures stances and their presence in the body grown for twenty-four hours on ascitic while in the beginning their action is reagar. The serum is polyvalent, each cul- stricted to the retina. ture being taken from six to eight strains. I wish to call your attention today to Recently, I have used a monovalent serum, two cases of optic nerve affection due to but found the results about the same as poisonous substances produced in the body with the polyvalent serum.
itself, which toxins in my opinion originate At the present time we are using a in purulent inflammation by the action of serum produced from the horse, and al- microbes. Both of my cases have an though our experience as yet is rather ethmoiditis as starting point but differ limited, nevertheless, it seems as though widely in their clinical course. Both the reaction from this product is just as patients are from my service at the mild, if not more so, as the ram serum and N. Y. Ophthalmic and Aural Institute. the results just about as good.
The first concerns a woman of 25 years. 100 State St.
When I saw her first in the early part of
April there was a severe phlegmonous inOPTIC NERVE AFFECTIONS DUE TO flammation around the lacrymal sac, exETHMOIDITIS.
ophthalmus, chemosis, edema of the lids: i. e. phlegmon of the orbit. The re
fractive media of the eyeball were clear, OTTO SCHIMER, M. D.,
but the disc showed some venous hyperAssistant Surgeon at the N. Y. Ophthalmic and Aural Institute and the German Hospital
emia. The vision was reduced to recogDispensary; Instructor at the Post- nizing movements of the hand. There Graduate School.
was very severe pain, temperature of 101° The optic nerve is more liable to become and extensive suppuration of the ethmoidal affected by intoxication than the motor or cells. sensible nerves; and especially poisons in- Until two days ago the patient had felt troduced from outside into the body are well but for some discharge from the able to produce either primary atrophy of nose and slight sensibility of the lacrymal the nerve-fibers or inflammation of the region. There was no doubt that we had interstitial tissue with consecutive atrophy. to deal with a perforation of an ethmoidal I refer here to the intoxication with ethyl empyema into the orbit and it was to be and methyl alcohol, with the organic ar- feared that there was already a thrombosis senical preparations, especially the atoxy- of the central vein of the optic nerve be
ing the usual cause as far as we know of proved how severe the attack had been. the blindness in phlegmon of the orbit. Of In the second case, we had to deal with course, the prognosis is bad under direct influence of the inflamed such conditions. But I considered that ethmoidal cells on the optic nerves, sitwe possibly might have to deal only with uated in close proximity of the posterior an intoxication of the nerve and if that
ethmoidal cells. The patient 45 years of was the case still an operation rapidly per- age, came to see me at the 12th of April, formed was able to secure a good vision. because his sight has been diminishing for
Therefore before an hour had elapsed five months. I found on the right eye a the patient was on the operating table. I vision of counting fingers immediately bemade a large incision from the eyebrow fore the eye, the left eye, with four around the inner angle of the eye until to diopters minus, counted fingers in 5 m. the lower orbital margin, carrying it down Pupils were wider than normal, especially to the bone and removed the periosteum the right one and reacted very slowly to backwards until I had found the perfora- light. Media normal; temporal halves tion in the orbital ethmoidal plate and a of both discs quite white. Visual field of the pus cavity extending from there into the left eye somewhat contracted from the temorbital tissue. I allowed to escape as much poral side. No colors recognized. The pus as possible but refrained from a radi- right eye sees movements of the hand only cal operation of the ethmoidal cells as it in the upper nasal quadrant. is not without danger in this acute stage No symptoms of locomotor ataxia, or of according to my experience. I introduced tumor of the hypophysis, to which the conwet gauze into the depth of the wound and dition of the field and the temporal pallor applied wet dressings.
of the disc appeared to point. Intraocular The fever and pain ceased im- tension normal. I sent the patient to Dr. mediately and two days later the pa- Tieck, who found suppuration of both tient was able to count fingers at one meter
ethmoidal bones, and on my request redistance, “at the 6th of April the vision moved the middle turbinates and treated was 5/200, exophthalmus had almost dis- the ethmoiditis. appeared; at the 21st, the vision being Since that time three weeks have elapsed 20/50, the wound granulating well I and there is a slight improvement of the evacuated from the old wound all the an- left eye, the right remaining unchanged. terior ethmoidal cells, made a large .open
The vision of the left eye has increased to ing into the nose, introduced a strip of 1/10 and red and blue are recognized in gauze from there into the nose and an- the periphery, a large central colorscotoma other one through the lower part of the being present. wound while I closed the upper part with It seems to be uncertain if the further sutures. There is still a tampon in the improvement will be a considerable one as wound but it is closing and I have a great quantity of the nerve-fibers have no doubt that an after-treatment from already undergone degeneration. We have the nose will give us a complete cure. The to suppose that toxic substances from the vision is nearly normal and the hyper- suppurating ethmoidal cells entered the aemia of the disc has nearly disappeared. optic nerve five months ago and probut it has become rather pale, which duced there a chronic inflammation and
New Series, Vol. V., No.
Series, Vol. XVI. partial degeneration of the nerve-fibers. pneumonia symposium in your April issue. An operation on the ethmoidal bone at that It seems, should this escape the maw
of your waste basket, a good chance to time would have stopped the inflammation
use the treatment of pneumonia to press and probably have saved the vision as it is upon the attention of your readers, views reported in many
of internal medication I have been presentBut the nerve-fibers can stand the noxious ing to the profession at medical societies
and in different journals for fourteen or influence of the toxins only for a certain fifteen years. I embrace this opportunity time: this is of shorter duration when the in the hope that I may shake, the con
servatism of 15 or 20 out of your 15,000 or pus is in the very neighborhood of the
20,000 readers; enough to induce them to optic nerves as in my first case and ex
quit the game of "follow my leader"tends over weeks and months if the pus is they have been playing and think for enclosed in the ethmoidal cells and pene
I must, however, premise that I am untrates through the thin bone only in small
able to follow Rokitansky if he did, as quantities. After that time the nerve- you claim differentiate lobar and lobular fibers degenerate and then they cannot re- pneumonia ; for it seems to me that lobar
and broncho-pneumonia is a satisfactory cover.
division of the acute type. It is therefore of the utmost importance
I hold as a working hypothesis that the to think of ethmoiditis in cases of optic first departure from health in the majority atrophy of unknown origin. The charac- of diseases is derangement (stimulation, teristic symptoms are considered to be in alteration, depression) of the sympathetic the onset diminution of central vision, in diminished functional efficiency.
or trophic nervous system, which results
This pallor of the temporal halves of the disc permits the various pathogenic germs to and central colorscotoma.
get in their work and establish organic or pathological changes, provided they are not interfered with by our art or the de
fensive forces of the diseased body. CORRESPONDENCE.
The acknowledged leaders in medical science have been earnestly studying
germs and these pathological changes exTHE TREATMENT OF PNEUMONIA. clusively, to gain light upon their treat
ment; leaving to the rank and file upon
the firing line the duty of meeting disease GEO. M. AYLSWORTH,
while functional, which means,
means, before Collingwood, Canada.
changes have occurred. In this, the latter Editor AMERICAN MEDICINE:
have met with some success—the treatDr. Kahrs' paper in your June issue ment of pneumonia being notably one of starts off by saying that “Treatment of these successes. pneumonia has been so thoroughly dis- Among my earliest recollections is havcussed here and elsewhere, that to add to ing my face and pinafore well sprinkled what is known seems superfluous and out with blood from a robust man suffering of place” (!!!) and concludes, “There from pneumonia upon whom my father is no specific to date.” “Superfluous and was performing venesection in due and out of place”—to try and learn something ancient form. Sixteen or seventeen years that will lessen the unnecessary enormous later I saw my preceptor-a professor in and increasing death rate of pneumonia one of Toronto's medical colleges, treat forsooth!
with varying success, all types of pneuSurely such statements will produce an monia with the ant. et potass. tart.
Since aftermath to your able and instructive I began to practice I have seen aconite
, 1910. Complete Series, Vol
, Vol. V., No. S. and veratrum viride placed upon the cluding myself in the first instance, did pedestal of The Treatment for Pneumonia expect, if we are to judge from their clin-only to be discarded. Some criticism ical use. Who has used aconite and verais in the air but strychnine occupies the trum separately and has not been astonpedestal now, and in the way it is general- ished at their marvelous effects for good ly used is as successful in curing pneu- and evil, but only semi-occasionally does monia as the use of a spur is in curing an an obscure physician differentiate between exhausted horse.
sthenic and asthenic cases of pneumonia Do such experiences justify us who are and point out to supercilious confreres that on the firing line, in accepting Kahrs' view aconite should never be used in sthenic that there is nothing new to be learned cases and veratrum should never be used about the treatment of pneumonia, or in in asthenic cases. Such a charge of stupidblindly following "the greatest Roman of ity against the mass of the profession could them all" who having passed his both not be sustained did not Dr. Kahrs advise birthday has been translated to a higher aconite without differentiating between sphere from whence he exhibits his con- sthenic and asthenic pneumonia, and Dr. clusion exuded from his purely hospital Butler in your symposium either follows or experience—that the non-surgical treat- accompanies the alkaloidalists in their use ment of disease consists in a "little nux of aconitine, digitalin and veratrine in one vomica and hope" or from our view point, tablet. are these changes warning wrecks upon Believe me, brethren, that any intelligent the shoals of superficial thought?
physician having grasped the ideas herein In reply it may be said that, for at least advanced as to sthenic and asthenic pneu15 years, I have regarded aconite and ver. monia and the administration of aconite vir. in lobar and tart. ant. in broncho- and veratrum in its treatment will promptpneumonia as specifics; where accom- ly learn from experiment at the bedside panied with treatment based upon the gen- that these drugs are not only as much eral principles so well set forth in your specifics in lobar pneumonia as quinine is symposium, though actively engaged in in malaria, but the same principles apply general practice for these fifteen years I in many other diseased conditions. I am have not seen a death from acute pneu- well aware that these views because they monia under my treatment. But I have ignore to some extent the bacterial origin seen one of my patients die under the sug- and vaccinal treatment of pneumonia, will gestions of consultants who insisted upon
not be received with extreme cordiality by increasing doses of strychnine and oxygen. the ultra scientific. My adoption of aconite and veratrum is
But when contributors to your symbased upon the aforementioned working posium like Drs. Wm. P. Northrup and hypothesis and because I do not believe a
H. A. Heiman claim that the pneumococcus drug can act as a stimulant one minute causes pneumonia in the ear, in the preand as a depressant the next; but having cordium and the heel, and F. E. Stewart advanced and defended these points to the
concludes his paper on vaccines by expressbest of my ability elsewhere without be- ing the hope "that a verdict may be ing driven from my position, it would reached supported by sufficient evidence be inappropriate to discuss them here and to make it conclusive" as to their efnow, even were space available. But
ficiency; ordinary physicians like myself granting the hypothesis, it is a mere
may be excused if in the meantime they corollary that depressed nervous energy
look elsewhere for aid in their ever prescould be raised, and excited nervous
ent fight against disease or continue to energy could be depressed to the normal,
use their old and tried remedies. provided we had the agents; as we have in aconite and veratrum respectively. Is it worthy the intelligence of the profession
SURGICAL HINTS. to have its members expect to produce Deforming cicatrices of the face folthese two results with a single agent? And lowing burns are best completely removed yet that is exactly what the profession, in- and the space filled in by skin grafting.