She now suffers from constipation, has an acid stomach, much back ache, palpitation of the heart, fainting spells and has a great deal of drowsiness, especially in the mornings. She complains of a fullness in the head, which together with weakness and lassitude trouble her so much that she cannot get out of bed mornings. No nausea, vomiting, pain or headache. She weighs at this time 98 lbs. Menstruation is regular and normal. Her general appearance is that of a girl in delicate health showing marked anemia. Her face shows nasal obstruction, adenoid type, the upper jaw being constricted with deformity of the mouth. The arch is very narrow and there is malocclusion of the teeth. There is a foul odor to the breath. There is an area of congestion over the tonsillar portion of both anterior pillars. The tonsils appear very small, are submerged, and the visible crypts are clean. There are palpable submaxillary and cervical glands. Nose, nasal accessory sinuses and teeth are negative. Temperature normal. First sound of the heart is roughened. Blood pressure is 110-70. Examination of the blood shows hemoglobin 55, whites 8,000, reds 4,246,000. Urine, Wassermann and Von Pirquet are negative. Lead and alcohol intoxication can be ruled out in this case. Recapitulation then, is that of a girl with a secondary anemia, an organic disease of the right eye and a focal infection in the tonsils. I advised tonsillectomy, which was done on July 25, 1918, under ether anesthesia. The tonsils, which were of medium size, showed debris in the crypts. Immediate relief in her eye and general symptoms began and also within a week there could be noted positive recession in the swelling of the nerve head. In three months the fundus examination showed an almost normal optic disc with the lamina in plain view. Nine months from the time of the tonsillectomy the fundus shows a normal disc and to the nasal side there are two areas of retino-choroidal atrophy, one small, the other spot oval in form about one and one-half disc diameters in size. The fields, however, for form and colors have not improved, remaining the same as at the first examination. Central vision remains normal. She has gained seven pounds in weight. In this case the rapid recovery after removal of the source of the infection gives proof that the metastatic eye lesion was due to the infection in the pharyngeal tonsils. Relief of both the ophthalmic and general symptoms followed with return to a normal healthy state. Suker22 reports a case of optic neuritis, which was unilateral and of rather sudden onset. Vision was 20/60 in each eye, not improved by lenses. Field of vision in affected eye for form and colors showed marked constriction. Fundus examination showed edges of left disc blurred and cup filled in. Veins distended, macula blurred. Blood, Wassermann and spinal puncture negative. No cause could be found but the tonsils. Examination of the tonsils after removal showed hypertrophy with crypts containing much debris. Within 72 hours after, vision rose to normal. Fields for form and color returned to normal. Sobotky's case was a patient with iritis and. binocular optic neuritis following tonsillitis, where a cure resulted after removal of the tonsils. Woman, age 21, with a history of annual attacks of tonsillitis, and following a week after one of these there was pain, blurring and inflammation of both eyes. Examination showed her to be convalescing from an acute follicular tonsillitis, with extreme injection of the right eye, which was painful and sensitive to light. Upper lid slightly swollen. Diagnosis made of iritis of right eye, optic neuritis of both with some engorgement of veins. Ten days later nasal examination showed head cold and diseased tonsils. Teeth and sinuses negative. (Blood examination was not made.) Wassermann negative. Spinal fluid shows pressure of 200. Tonsils removed 2 weeks from time first seen, show cheesy deposits with low grade inflammation. Vision is given 312 weeks after tonsillectomy R. 20/40 L. 20/30. fore removal of tonsils not given. charted.) Eleven weeks later swelling of nerve heads subsiding, vision normal and patient doing her work. ness. (Vision beFields not Hansell reports a case of bilateral optic neuritis from diseased tonsils. Patient had acute double optic neuritis with complete transient blindUrine, radiographs, Wassermann and spinal puncture were negative. Tonsils were removed and within 24 hours light perception returned. Slow improvement until at end of one year vision was 4/5. Both discs showed partial atrophy. Carpenter25 reports a case of a woman with unilateral optic neuritis in which cure resulted from removal of the tonsil on the side affected. Woman, aged 20, suffering from blindness, with vision reduced to finger counting. Moderate neuro-retinitis with a few scattered hemorhages and swelling of the disc. All treatment failed. Removal of the tonsil on the side that vision was affected resulted in cure. Fundus changes promptly disappeared. Vision returned to normal and has remained so. Wyler2 mentions cure of optic neuritis in a patient with diseased tonsils, which resisted all treatment until tonsillectomy had been performed. In peri-neuritis of the optic nerve, of which these cases are examples, central vision is preserved and there is concentric contraction of the field for white and colors. Suker says that this form, peri-neuritis, is more common as a result of focal infections. According to Schirmer,27 where damage to the nerve has taken place, the fibers paralyzed first are those with the poorest fibers paralyzed first are those with the poorest function-the peripheral fibers. The color sense is the higher function of the fiber and requires more normal conditions than the form sense. Thus a concentrical contraction of color fields takes place while white remains nearly normal. The nerve fiber has been found to be very enduring against pressure alone for variable lengths of time. If during this time the damaging agent is removed the nerve fiber will recover. This fact is important in the prognosis as to what vision is going to be retained. Useful vision may return after a week or two of amblyopia. We may assume that in this type of optic neuritis the action is inflammatory in origin. Intracranial pressure is not the factor in these cases and it is not likely that the toxins of bacteria produce optic neuritis of this type, for examples of ocular disturbances which are toxic in origin are paralysis of eye muscles, endogenous gonorrheal conjunctivitis, uveal tract disease, episcleritis, etc. In ocular disease of metastatic origin from infection in the tonsils, treatment of the tonsils other than excision is useless, as is shown by the work of Nichols and Bryan.28 In their experiments of injecting lamp black in paraffine into all visible openings in dissected tonsils, they were able to show the futility of any treatment directed to the tonsil itself, as it was found impossible to reach all the crypts. Furthermore, after local treatment with strong solutions of silver nitrate where surface cultures for hemolytic streptococci became negative, yet cultures from the crypts were still positive. In patients suffering with acute follicular tonsillitis, arthritis, neuritis, nephritis and general malaise, I have found hemolytic streptococci in a majority of cases by cultures from the crypts. These were patients in whom other points of infection had been eliminated. In a search of the literature, these five cases of optic neuritis and that of my own, from diseased tonsils are all that have been reported. That optic neuritis from the tonsils or other foci in the body does occur more frequently than the literature shows, is probable, but unless special attention is directed to these various foci and the source of the infection sought out and found the discovery of the causes of the nerve involvement is not made. Assurance can be given that ocular complications from distant infections in the body have been and are frequent, but the connection between the infected point and the eye disease, until recently, has been overlooked. As will be seen, the neuritis can be unilateral or bilateral and in some cases the disease is of sudden onset and destruction of vision can result very quickly. It is, therefore, necessary to find, if possible, and eliminate any or all distant diseased areas which may be the source of the inflammatory process in the optic nerves. In these cases and in other ocular or general diseases of obscure origin, where a careful study has shown the tonsils as the possible and probable point of infection, tonsillectomy is justifiable as a therapeutic measure. REFERENCES 1. Knapp, Arnold: Medical Ophthalmology, 1918, p. 285. 2. Brown, E. L. V.: Embolus of Macular Artery, Ill. Med. Jour., July, 1918, p. 52. 3. Lewis, F. Park: A Bacterial Toxin as the Cause of Retinal Hemorrhage. Jour. A. M. A., LXX, 1813. 4. Veasey, C. A.: Chronic Infection of the Faucial Tonsils as Causative Factor in Paralysis of Accommocation; two cases. Ophthalmic Record, Aug. 16, 1916. 5. Brown, E. L. V.: Sympathetic Irido-clycitis and Choroditis with Preservation of Useful Vision in the Sympa thetic Eye. Ophthalmic Record, June, 1917. 6. Zentmayer, Wm.: and Pharyngeal Disease. Ocular Lesions the Result of Oral Amer. Jour. Ophthal., April, 1918. 7. Hansell, H. F.: Ocular Affections Dependent Upon Disease of the Tonsils; Two Cases. Arch. of Ophthal., XLVII, No. 6, 1918. 8. DeSchweinitz: Etiology of Uveitis. 9. Lang, W.: The Influence of Chronic Sepsis Upon Eye Diseases. Lancet, May, 1913. 10. Lang, W.: Etiology and Treatment of Iritis. Lancet, June 23, 1917. 11. Dabney, V.: Some Unusual Disease Conditions Appar ently Cured by Tonsillectomy; Remarks on Post-Operative Treatment; Preliminary Report. Laryngoscope, 1918. 12. Levy, J. M.; Stinebugler, F. C. and Pease, M. C.: Investigations as to Frequency of Metastatic, Eye Infections from Primary Dental Foci. Jour. A. M. A., 1917, LVIX, 194. 13. Davis, D. J.: Jour. Infect. Dis., 1912. Brown, E. V. L., and Irons, E. E.: Trans. Amer. Ophthal. Soc., 1918. Etiology of 14. Iritis. 15. Adami: Text-Book Pathology, p. 507. 16. Billings & Rosenau: Jour. A. M. A., 1915, LXVI. 17. Finch, G.: A Case of Optic Neuritis Following on Gassing. Lancet, London, 1915, 11-11, 1027. 18. Von Hippel, E.: Gonorrheal Irido-cyclitis and Optic Neuritis. Graef's Árch. of Ophth., XCIV, 467. 19. Reber, Wendell: Some Phases of Modern Ocular Therapeutics. Brit. Jour. Ophth., London, 1917, p. 294. 20. Rovinsky, A.: Focal Infection of the Eye From the Intestinal Tract. Jour. A. M. A., 1919, p. 138. 21. Dwyer, I. G.: Focal Infection of Eye from Intestinal Tract. Jour. A. M. A., Dec. 21, 1918, p. 2046. 1917. 24. ritis. Hansell, H. F.: Two Cases of Monocular Optic Neu- 25. Carpenter: Amer. Jour. Ophth., Nov., 1918, p. 787. 26. Wyler, J. S.: Difficulties in the Diagnosis of Monocular Neuritis. Amer. Jour. Surg., N. Y., 1917, XXXI, 87. 27. Schirmer, O.: Optic Nerve Affections and the Ductless Glands. Jour. Nerv. & Ment. Dis., N. Y., 1916, XLIV, 358. 28. Nichols & Bryan: The Tonsils as Foci of Infection in Streptococcus Hemolyticus Carriers. Jour. A. M. A., LXXI, 1813. DISCUSSION (Abstract.) Dr. Charles H. Long believes that specialists all understand that the tonsil is only one of many and may not be the chief focal infection point and he would emphasize more than anything else to not take the tonsil out until we find out and get rid of the other sources first. Dr. J. C. Beck (Chicago) believes that the tonsil, the appendix and the gall-bladder, structures that have open tracts for getting rid of the infection, are in small part responsible for the troubles that we speak of as distant infections. He noted the danger of the closed embolic abscess, a small particle of pus causing such terrific destruction as a vegetative endocarditis, and warned that we ought to look for the places that are subject to infection and closed off. There are nine different points that have been brought out, particularly by Rosenow and his work on the closed off places, the teeth holding first place. He attributes many of the good results obtained from the removal of tonsils not to those tonsils from which pus can be squeezed, but rather to opening up peritonsillar blind abscesses, with so-called innocuous pus which is a streptococcus viridans infection. Dr. Tydings (Chicago) reported a case of cyclitis cured by a specialist, Dr. Pennington, of Chicago, due to focal infection, coming from diseased Houston's valves. In a case of choroiditis from Dr. Way, of Chicago, a surgeon, after various tests it turned out that he also had a chronic appendicitis. "Doctor, this man is suffering from appendicitis in chronic form, and I am waiting for his eye to get better to operate." I said "Operate," and in two weeks he was in my office with his eye perfectly well. Dr. Welton: I would like to say a word about the point of pillar congestion which has been mentioned in this discussion. It has been my experience that pillar congestion didn't amount to very much. I find that in nearly all cases. The main thing I have depended upon is that if the pus can be squeezed out of a tonsil, especially at the upper point of the tonsil, I can say that that tonsil is infected, but as far as the congestion is concerned, I have found that in some cases where neither pus nor debris of any kind could be found or exuded there still would be found congestion of the anterior pillar and I do not place much reliance on this symptom. NEW PROBLEMS IN EMPYEMA* EMIL G. BECK, M.D., F.A.C.S., Surgeon to The North Chicago Hospital. CHICAGO Now that the epidemic of influenza has subsided, there remains an accumulation of chronic suppurations. We have learned and are still learning new things about empyema and its treatment as a result of this last epidemic. I believe, therefore, it is timely to bring this subject before the Association again this year for discussion. The following questions are most pertinent: 1. We should try to explain the great mortality in operations of empyema during the recent epidemics. 2. We should define the term "Empyema." When is a fluid in the chest cavity called and pronounced an empyema? 3. Multiple encapsulation of pleuritic exudates, what are the causes? 4. What is the proper procedure in bi-lateral empyema? 5. We should define the indications for rib resection, aspiration, or the catheter drainage. 6. Let us study the advantages over pre-epidemic methods. Flush or not to flush is the question. 7. Let us discuss the treatment of the cases which persisted in drainage of pus after operation and flushing. Since there are only a few minutes allotted to the presentation of each paper, I shall not be too liberal with another man's time, and instead of reading a paper I will throw on the screen a few slides which will suggest the points just mentioned for discussion. I shall not try to answer all of these questions myself, but initiate the discussion by raising the questions. In regard to my comments on Question 1. The high mortality in operations was mainly due to the inability of the surgeons to choose the right time for the operation. As a rule I believe they operated too early, probably in the stage of acute pneumonia with effusion. The effusion is thrown out by nature to immobilize the lung during the acute stage, and in the removal of the fluid the immobilized lung again follows the respiratory movement and thus the condition *Read before the yearly session of the Association for Thoracic Surgery at Atlantic City, June 8, 1919. is aggravated. We might say the surgeons operate on acute pneumonia instead of an empyema and nobody would think it wise to operate in an acute stage of pneumonitis. The proof of my inference might be gained by reading the report of Major Max Ballin of Detroit of his surgical service at Camp Grant, in the Journal A. M. A., page 335, vol. 72, No. 5. I quote his words: "The results of such early operations in streptococcic empyema were so lamentable that the Surgeon General sent an empyema commission to Camp Lee to study the question. The report of this commission brought out several points: "First, not to operate as long as the pneumococcic process was in existence. "Second, to aspirate if the quantity of serous exu forations from the lung lead to the infection of the pleural sac, just as general peritonitis is due to perforation of some intra-abdominal organ. He also regards the operative treatment in this stage as a mistake and now that time has given us a chance for reflection, it may be put down as law: Never operate in the formative stage of empyema. Question 2: The word "empyema" is derived from the Greek, em-inside, peon-pus, meaning pus inside. We should therefore only regard these cases as empyema in which the exudate is true pus. Fig. 1. Shows multiple abscesses in Right and Left Lung date in the chest was such as to interfere mechanically with respiration. "Third, to operate only after the pneumococcic process has subsided, when real pus has formed. "These rules were observed on twenty-three consecutive cases at Camp Lee and there was only one death, whereas previously the mortality had been as high as 50 per cent." Col. A. Moschkovitz divides empyema into three stages: First, the formative; second, the acute; third, the chronic. He has made one interesting observation, namely, that small per Fig. 2. Bi-lateral Empyema. Lung abscess. AResected Rib, drainage. B-Counter-drainage opening. What constitutes pus? We will have to arrive at some definite rule as to when the fluid may be called pus, semi-purulent, or serous fluid. The term pus has been used in a somewhat indefinite sense, in such descriptions as "a purulent substance," "a sero-purulent discharge" or "a pusy discharge." The fact is that a serous exudate, such as we find in these acute cases of empyema, will gradually become purulent and finally become a creamy thick substance, which is designated as true pus. At what particular stage of purulization should we regard this fluid as pus? In my paper on the "Empyema Problem," I have put down an arbitrary rule for myself and it might be here considered whether such a rule would stand. I herewith repeat the rule: If we withdraw about 10 cubic centimeters of this fluid every 24 hours. and pour it into a test-tube we will note that the sediment of these samples will vary. The amount of the grayish purulent material settling at the bottom of the tube will be greater each day, so that the fluid drawn on the tenth day might contain as much as 30 to 40 per cent of sediment and 60 to 70 per cent of clear serous fluid. If the fluid withdrawn contains more than 20 per cent of sediment after standing for 24 hours, it may be considered true pus. Question 3: I should regard the multiple encapsulation of pleuritic exudates due to the character of the infection, namely, the streptococcus, which causes adhesions of the lung to the costal pleura. The more acute the condition the more likely that multiple encapsulation will occur. The reason that formerly we did not meet this condition so often is the fact that we rarely had to deal with very acute pleurisies as we did in these recent epidemics. In some instances the surgeons have found blebs on the surface of the lung containing pus. It is likely that these peripulmonal little abscesses did not break and empty their contents into the pleural cavity but that they became adherent to the costal pleura and gradually enlarged and formed real abscesses. Another reason for multiple encapsulation is advanced by Major Moschkovitz. namely, that when patients are not operated upon, the pleural surfaces will adhere around the accumulations of pus. Question 4: Bi-lateral empyema has occurred. more frequently for two reasons: In the first place the pneumonia was very frequently bilateral, which was not quite as often the case in ordinary times. Secondly, among a large number of cases it is likely that more than one case will fall into the hands of one man, which in former times was very unusual. I cite one very interesting and unusual case: BY-LATERAL EMPYEMA IN PREGNANT WOMAN, CHILD BIRTH NORMAL DURING ACUTE STAGE (RECOVERY). Mrs. S., aged 35 years, developed a severe case of influenza in September, 1918, followed by bi-lateral pneumonia and consequent pleural pus effusion on both sides. The house physician punctured the right chest repeatedly, withdrawing small quantities of pus. She was then in the eighth month of pregnancy and gave birth to a normal child while both pleurae were filled with pus. On December 21, under local anesthesia a catheter was introduced in the interspace of the 8th rib on the right side in the axillary line. This relieved her somewhat, as she was moribund at the time this was performed. She rallied and on January 11, one inch of the right 8th rib posteriorly was resected and a large tube introduced. Stereo-radiograms at this time showed that there were multiple abscesses in the left as well as the right side. Fig. I. Temperature kept up from 99 to 101, daily respirations 40, pulse 130 to 150. On January 14 another operation was performed on the left side, the counter-drainage operation, which is here illustrated in Fig. II, described recently in Surgery, Gynecology, & Obstetrics, April, 1919. After this operation the lung began to re Fig. 3. Skin sliding operation for very chronic empyema. Left lung exposed for regeneration of skin into cavity. expand and both cavities were injected with bismuth paste. The fever gradually disappeared and patient gained in strength and weight. At the present time both sides are closed and she is gradually regaining her health. Whether there will be any recurrence we cannot say at present. Question 5. I do not think it is necessary to resect a rib in every case. I believe that the treatment with introduction of a catheter through a cannula and gradual withdrawal of the pus by gentle suction should be given a trial on a large scale before we decide that a resection of a rib must be done in every case. |