ferentiate, except in the cases in which we are able to aspirate and demonstrate the gonococcus in usual smears or cultures. It has been my experience that in every case in which I have been able to find the

germ, the serum injections had absolutely no effect upon the involved joint or joints, but I have repeatedly seen cases which, from a clinical standpoint, I thought to be the type just mentioned, and to my surprise found that they responded to the serum treatment. From this, I think we must conclude that the toxemic form of gonorrheal joints is more common than those which are due to infection of the joint.

A number of questions have come up, both in my own work and from that of others who have used the serum, which I think might well be explained here. First, why do some cases in which the serum has been used with good results recur after a few weeks or months? Most of these cases recur because the source of the toxic material has not been eliminated before the use of the serum. By this, I mean the local infection should be cleaned up at the same time or, better, before the serum is used. If we do not do this, we are very likely to have a temporary relief of the joint condition, but sooner or later toxins will again be produced from the local infection, with a recurrence of the painful joints. I cannot too strongly urge the treatment of the local infection before or at the same time the serum is administered.

Another reason for the recurrence which we see in these cases is the insufficient quantity of serum given. We have found that unless the patient receives at least twenty-four to thirty c.c., (and in some instances we have found it necessary to give as high as eighty c.c.,) we are very likely

to have a recurrence. I will give the history of a case which serves to illustrate this point.

C. W. Contracted gonorrhea two and a half years ago. Three months later the right knee joint and the left ankle joint became very painful and swollen. He entered the clinic at Rush College the middle of October, 1907. On examination, we found that he was suffering from postgonorrheal prostatitis and a bilateral seminal vesiculitis; that both joints mentioned were swollen and painful, and that he was able to walk only with the aid of two canes. He was treated for the prostatitis, and, after four weeks, was given an injection of two c.c. of serum. This was followed by two injections of six c.c. each, at fortyeight hour intervals. He was greatly improved after the second injection, and did not return to the clinic after the third, thinking that he was cured. About six

weeks later he returned to the clinic in the same condition that he was when he first entered.

He was then given five injections of six c.c. each, during a period of three weeks. He improved rapidly and after the fifth injection was entirely free from pain, although there still existed a slight disability from stiffness. Nevertheless, he had good use of his limbs and, as stated before, he was free from pain. I saw him as late as last August, and found him in good condition.

Another question which has come up is the partial relief that some users of the serum have experienced. Most of these cases are due to an insufficient dosage. Unfortunately, the serum has been placed on the market in packages containing three small vials, each vial having the capacity of two C.C. On this account, many have thought that this is a sufficient amount for a cure, and have injected two c.c. at short intervals until the patient had been given the contents of the three vials. This is just one good-sized dose, and most cases require much larger quantities.

I have made some observations as to the stability of this product and have found

that serum over one year old is not active. The serum is obtained from the uncastrated male sheep (ram). Immunization requires ten weeks. The animal is given weekly injections into the peritoneal cavity; the first three injections are from dead cultures; the last seven from live cultures. The quantity of these injections is gradually increased. The cultures. are grown for twenty-four hours on ascitic agar. The serum is polyvalent, each culture being taken from six to eight strains. Recently, I have used a monovalent serum, but found the results about the same as with the polyvalent serum.

At the present time we are using a serum produced from the horse, and although our experience as yet is rather limited, nevertheless, it seems as though the reaction from this product is just as mild, if not more so, as the ram serum and the results just about as good.

100 State St.

OPTIC NERVE AFFECTIONS DUE TO ETHMOIDITIS.

BY

OTTO SCHIMER, M. D.,

Assistant Surgeon at the N. Y. Ophthalmic and Aural Institute and the German Hospital Dispensary; Instructor at the PostGraduate School.

The optic nerve is more liable to become affected by intoxication than the motor or sensible nerves; and especially poisons introduced from outside into the body are able to produce either primary atrophy of the nerve-fibers or inflammation of the interstitial tissue with consecutive atrophy. I refer here to the intoxication with ethyl and methyl alcohol, with the organic arsenical preparations, especially the atoxy

lon, with the nicotin and so on. On the contrary, poisonous substances produced in the body itself affect the retina and induce here changes partly inflammatory, partly degenerative as for instance the retinitis due to nephritis or diabetes or leukemia, the starting point being in all of them the production of some noxious substances and their presence in the body while in the beginning their action is restricted to the retina.

I wish to call your attention today to two cases of optic nerve affection due to poisonous substances produced in the body itself, which toxins in my opinion originate in purulent inflammation by the action of microbes. Both of my cases have an ethmoiditis as starting point but differ widely in their clinical course. Both patients are from my service at the N. Y. Ophthalmic and Aural Institute.

The first concerns a woman of 25 years. When I saw her first in the early part of April there was a severe phlegmonous inflammation around the lacrymal sac, exophthalmus, chemosis, edema of the lids: i. e. phlegmon of the orbit. The refractive media of the eyeball were clear, but the disc showed some venous hyperemia. The vision was reduced to recognizing movements of the hand. There was very severe pain, temperature of 101° and extensive suppuration of the ethmoidal cells.

Until two days ago the patient had felt well but for some discharge from the nose and slight sensibility of the lacrymal region. There was no doubt that we had. to deal with a perforation of an ethmoidal empyema into the orbit and it was to be feared that there was already a thrombosis of the central vein of the optic nerve be

I

ing the usual cause as far as we know of the blindness in phlegmon of the orbit. Of course, the prognosis is bad under such conditions. But I considered that we possibly might have to deal only with an intoxication of the nerve and if that was the case still an operation rapidly performed was able to secure a good vision. Therefore before an hour had elapsed the patient was on the operating table. I made a large incision from the eyebrow around the inner angle of the eye until to the lower orbital margin, carrying it down to the bone and removed the periosteum backwards until I had found the perforation in the orbital ethmoidal plate and a pus cavity extending from there into the orbital tissue. I allowed to escape as much pus as possible but refrained from a radical operation of the ethmoidal cells as it is not without danger in this acute stage according to my experience. I introduced 'wet gauze into the depth of the wound and applied wet dressings.

The fever and pain ceased immediately and two days later the patient was able to count fingers at one meter distance, "at the 6th of April the vision was 5/200, exophthalmus had almost disappeared; at the 21st, the vision being 20/50, the wound granulating well I evacuated from the old wound all the anterior ethmoidal cells, made a large .opening into the nose, introduced a strip of gauze from there into the nose and another one through the lower part of the wound while I closed the upper part with There is still a tampon in the wound but it is closing and I have no doubt that an after-treatment from the nose will give us a complete cure. The vision is nearly normal and the hyperaemia of the disc has nearly disappeared. but it has become rather pale, which

proved how severe the attack had been.

a

In the second case, we had to deal with direct influence of the inflamed ethmoidal cells on the optic nerves, situated in close proximity of the posterior ethmoidal cells. The patient 45 years of age, came to see me at the 12th of April, because his sight has been diminishing for five months. I found on the right eye a vision of counting fingers immediately before the eye, the left eye, with four diopters minus, counted fingers in 5 m. Pupils were wider than normal, especially the right one and reacted very slowly to light. Media normal; temporal halves of both discs quite white. Visual field of the left eye somewhat contracted from the temporal side. No colors recognized. The right eye sees movements of the hand only in the upper nasal quadrant.

No symptoms of locomotor ataxia, or of tumor of the hypophysis, to which the condition of the field and the temporal pallor of the disc appeared to point. Intraocular tension normal. I sent the patient to Dr. Tieck, who found suppuration of both ethmoidal bones, and on my request removed the middle turbinates and treated the ethmoiditis.

Since that time three weeks have elapsed and there is a slight improvement of the left eye, the right remaining unchanged. The vision of the left eye has increased to 1/10 and red and blue are recognized in the periphery, a large central colorscotoma being present.

It seems to be uncertain if the further improvement will be a considerable one as a great quantity of the nerve-fibers have already undergone degeneration. We have to suppose that toxic substances from the suppurating ethmoidal cells entered the optic nerve five months ago and produced there a chronic inflammation and

, 1910

, Vol. V.,

partial degeneration of the nerve-fibers. An operation on the ethmoidal bone at that time would have stopped the inflammation. and probably have saved the vision as it is reported in many cases in literature. But the nerve-fibers can stand the noxious influence of the toxins only for a certain time; this is of shorter duration when the pus is in the very neighborhood of the optic nerves as in my first case and extends over weeks and months if the pus is enclosed in the ethmoidal cells and penetrates through the thin bone only in small quantities. After that time the nervefibers degenerate and then they cannot re

cover.

It is therefore of the utmost importance to think of ethmoiditis in cases of optic atrophy of unknown origin. The characteristic symptoms are considered to be in the onset diminution of central vision, pallor of the temporal halves of the disc and central colorscotoma.

CORRESPONDENCE.

pneumonia symposium in your April issue.

It seems, should this escape the maw of your waste basket, a good chance to use the treatment of pneumonia to press upon the attention of your readers, views of internal medication I have been presenting to the profession at medical societies and in different journals for fourteen or fifteen years. I embrace this opportunity in the hope that I may shake, the conservatism of 15 or 20 out of your 15,000 or 20,000 readers; enough to induce them to quit the game of "follow my leader❞— they have been playing and think for themselves.

I must, however, premise that I am unable to follow Rokitansky if he did, as you claim differentiate lobar and lobular pneumonia; for it seems to me that lobar and broncho-pneumonia is a satisfactory division of the acute type.

I hold as a working hypothesis that the first departure from health in the majority of diseases is derangement (stimulation, alteration, depression) of the sympathetic or trophic nervous system, which results in diminished functional efficiency. This permits the various pathogenic germs to get in their work and establish organic or pathological changes, provided they are not interfered with by our art or the defensive forces of the diseased body.

The acknowledged leaders in medical science have been earnestly studying germs and these pathological changes ex

BY

GEO. M. AYLSWORTH,

Collingwood, Canada.

Editor AMERICAN MEDICINE:

Dr. Kahrs' paper in your June issue starts off by saying that "Treatment of pneumonia has been so thoroughly discussed here and elsewhere, that to add to what is known seems superfluous and out of place" (!!!) and concludes, "There is no specific to date." "Superfluous and out of place"-to try and learn something that will lessen the unnecessary enormous and increasing death rate of pneumonia forsooth!

Surely such statements will produce an aftermath to your able and instructive

ment; leaving to the rank and file upon the firing line the duty of meeting disease while functional, which means, before demonstrable permanent pathological changes have occurred. In this, the latter have met with some success-the treatment of pneumonia being notably one of these successes.

Among my earliest recollections is having my face and pinafore well sprinkled with blood from a robust man suffering from pneumonia upon whom my father was performing venesection in due and ancient form. Sixteen or seventeen years later I saw my preceptor-a professor in one of Toronto's medical colleges, treat with varying success, all types of pneumonia with the ant. et potass. tart. Since I began to practice I have seen aconite

and veratrum viride placed upon the pedestal of The Treatment for Pneumonia -only to be discarded. Some criticism is in the air but strychnine occupies the pedestal now, and in the way it is generally used is as successful in curing pneumonia as the use of a spur is in curing an exhausted horse.

Do such experiences justify us who are on the firing line, in accepting Kahrs' view that there is nothing new to be learned about the treatment of pneumonia, or in blindly following "the greatest Roman of them all" who having passed his 60th birthday has been translated to a higher sphere from whence he exhibits his conclusion exuded from his purely hospital experience that the non-surgical treatment of disease consists in a "little nux vomica and hope" or from our view point, are these changes warning wrecks upon the shoals of superficial thought?

In reply it may be said that, for at least 15 years, I have regarded aconite and ver. vir. in lobar and tart. ant. in bronchopneumonia as specifics; where accompanied with treatment based upon the general principles so well set forth in your symposium, though actively engaged in general practice for these fifteen years I have not seen a death from acute pneumonia under my treatment. But I have seen one of my patients die under the suggestions of consultants who insisted upon increasing doses of strychnine and oxygen. My adoption of aconite and veratrum is based upon the aforementioned working hypothesis and because I do not believe a drug can act as a stimulant one minute and as a depressant the next; but having advanced and defended these points to the best of my ability elsewhere without being driven from my position, it would be inappropriate to discuss them here and now, even were space available. But granting the hypothesis, it is a corollary that depressed nervous energy could be raised, and excited nervous energy could be depressed to the normal, provided we had the agents; as we have in aconite and veratrum respectively. Is it worthy the intelligence of the profession to have its members expect to produce these two results with a single agent? And yet that is exactly what the profession, in

mere

cluding myself in the first instance, did expect, if we are to judge from their clinical use. Who has used aconite and veratrum separately and has not been astonished at their marvelous effects for good and evil, but only semi-occasionally does an obscure physician differentiate between sthenic and asthenic cases of pneumonia and point out to supercilious confreres that aconite should never be used in sthenic cases and veratrum should never be used in asthenic cases. Such a charge of stupidity against the mass of the profession could not be sustained did not Dr. Kahrs advise aconite without differentiating between sthenic and asthenic pneumonia, and Dr. Butler in your symposium either follows or accompanies the alkaloidalists in their use of aconitine, digitalin and veratrine in one tablet.

Believe me, brethren, that any intelligent physician having grasped the ideas herein advanced as to sthenic and asthenic pneumonia and the administration of aconite and veratrum in its treatment will promptly learn from experiment at the bedside that these drugs are not only as much specifics in lobar pneumonia as quinine is in malaria, but the same principles apply in many other diseased conditions. I am well aware that these views because they ignore to some extent the bacterial origin and vaccinal treatment of pneumonia, will not be received with extreme cordiality by the ultra scientific.

But when contributors to your symposium like Drs. Wm. P. Northrup and H. A. Heiman claim that the pneumococcus causes pneumonia in the ear, in the precordium and the heel, and F. E. Stewart concludes his paper on vaccines by expressing the hope "that a verdict may be reached supported by sufficient evidence to make it conclusive" as to their efficiency; ordinary physicians like myself may be excused if in the meantime they look elsewhere for aid in their ever present fight against disease or continue to use their old and tried remedies.

SURGICAL HINTS.

Deforming cicatrices of the face following burns are best completely removed and the space filled in by skin grafting.