focus may be situated in any part of the body but the most potent foci that the ophthalmologist has to contend with are the teeth, tonsils, the nose with its accessory sinuses, and the toxaemias from the intestinal tract.

The secondary eye condition may be due to the action of bacteria transmitted by any of the routes mentioned or by toxins liberated at, the original focus. These toxins in many instances are more than likely a solvent protein which have a solvent action on the intra cellular cement substance of the vessel walls. The vessels in the eye having extremely thin delicate walls and no support other than is afforded by their own resistance and being end arteries very minute in size in which the circulation of the blood is at its slowest, a condition exists that is not duplicated in any other part of the body where the bacterial or toxins in the blood stream may produce deleterious results. This is evident in many cases of low grade uveitis or retinitis with exudates and small multiple hemorrhages that clear up only after the focus of infection is found and removed. It has been shown that some of the toxins and bacteria transmitted have a special affinity for the uveal tissue by injecting rabbits subcutaneously with pus from an apical abscess and producing lesions in the choroid of the animal. The epoch making work of Rosenow on the transmutation and selective localization of the pyogenic organisms in the various tissues of the body revolutionized some of our ideas of etiology and pathology. Likewise the clinical investigation of Irons and Brown have proved very helpful in classifying the infections producing intra ocular inflammations. Until recently iritis and iridocyclitis were regarded as practically always due to syphilis, gonorrhea, tuberculosis or rheumatism.

To enumerate all of the affections of the eye that may be caused by some focus outside of the orbit would include all of the inflammatory conditions acute or chronic, a large number of noninflammatory as well as the reflex neuroses presenting as sensory, vasomotor, or muscular disorders. Any of the orbital tissues may be involved but the tissues within the eyeball itself are far more prone to be affected as is readily understood from what has previously been said in regard to the histology and anatomical associations. Next to the uveal tracts the cornea is a chosen site. This is due to the fact that it has no blood supply, the corneal cells being bathed with lymph which is the only means of nourishment as well as defensive media.

William Lang of London has tabulated the etiology of three hundred and eighty-three cases

of inflammatory eye diseases and demonstrated that in two hundred and fifteen of these, some pyogenic infections existing in other regions of the body were the underlying causes. He names appendicitis, kidney, skin, nasal, chronic, pyorrhea, throat, and other chronic infections, and says that every tissue of the eye is subject to infection to either and all of these. Formerly such cases were all grouped in the so-called "rheumatic" type.

It is not necessary to cite cases to prove the existence of secondary eye infections for it is a daily experience for every ophthalmologist to be confronted with these cases. It is sufficient to remind us that they are very common and when we are confronted with an eye infection the patient should be subjected to a rigid examination, not only for a systemic malady but also for any possible focus of infection. For even though it be proven that the patient has syphilis, gonorrhea, or tuberculosis, it does not mean that the eye condition is due to the constitutional disease for it is quite possible that his eye trouble is due to a pyogenic infection situated in some part of the body outside of the orbit. If such should be the case it is not sufficient to treat the constitutional disease alone but the focus of infection should be removed as well. A patient suffering from some systemic disease is rendered that much more likely to secondary infection because his resistance is lowered to a marked degree.

The argument is raised that the connection between the focus of infection and eye affections is too hypothetical and problematical and that they are not related in cause and effect but are coincidental. This view is based upon the great prevalence of these conditions and the relative infrequency of associated eye disease. But the same is true of syphilis, gonorrhea, and tuberculosis. How common are these and how relatively infrequent are ocular diseases the result of them. Yet no one disputes the syphilitic, or tubercular iritis or keratitis. The same can be said of any other focus of infection. Also it must not be forgotten that individuals are not possessed of an equal degree of natural immunity or of defensive processes. On the other hand a patient may unknowingly be harboring a focus of infection for a variable time, his defensive properties being able to cope with the toxins or bacteria liberated until a link in his defensive chain breaks due to an increase in years and consequently a decrease in his resistance, a lowered resistance from a cold, some general disease, or an injury. The eye being constructed as it is and so intimately connected with frequent foci of infections it is very

frequently the site of infection. These conditions. should always be considerded when contemplating an intra ocular operation, for an operation can be considered as an injury. Many a poor result following an operation is due to toxins or bacteria transmitted from some focus of infection which if it had been located and removed previously would have resulted favorably to all parties concerned.

On the other hand we should not allow the idea of local infections to become a hobby with us to be ridden to death. A great deal of harm has been done by some who have become too enthusiastic, thinking that in focal infections we have the cause for all ills. The teeth have borne the brunt of such radicalism and as a result many good teeth have been sacrificed. This only emphasizes the fact that it is essential for the ophthalmologist and dentist to cooperate more closely for the interest of themselves as well as the patient. In fact it is only by a close cooperation with all branches of medicine as well as the dentists that the ophthalmologist will be able to treat such cases properly.

In presenting this paper to you it was not with the idea of adding anything to what we already know but rather to bring to your attention a subject that confronts us in our daily work with the hope that through the general remarks made in the paper, with the discussions brought forth, we all may gain some useful information that will serve to keep the subject of focal infections uppermost in our minds for by so doing we will best serve the interests of our patients and at the same time gather new facts.

Discussion

Dr. Leroy R. Tripp, Sioux City-The paper just presented by Dr. Maiden in which he makes plain the simplicity with which bacteria or their toxins gain access to the orbital structures by one or more of four different routes certainly should be made of practical application in the daily routine of every ophthalmologist. There are none I'm sure who question the fact that the different tunics of the eye suffer from systemic and focal infection yet many times if the cause is not apparent we are content with local treatment and fail to find and eradicate the true cause. The majority of intraocular inflammatory conditions the doctor is called upon to treat could be presented as illustrating the significance of this paper. The unusual instances serve to keep us patient and thorough in our search for the true source of the infection. I have in mind a little patient whom I treated for corneal ulcer. The Wassermann and tuberculin reactions were both negative and the tonsils and adenoids which were hypertrophic were later removed without any improvement of the ulcer. On

further examination it was found she had a chron

ically inflamed appendix. The appendix was removed by the general surgeon and the ulcer rapidly cleared up. The teeth and maxillary antra are perhaps together more often responsible for eye disease than any of the other foci and as 20 per cent of the antral infections are in turn occasioned by diseases of teeth it behooves us to obtain most competent assistance from the dentist being careful as Dr. Maiden says not to become over zealous permitting the removal of healthy structures. Much work has been done on the teeth which from the standpoint of mechanics is perfect yet which encourages the production and retention of infectious material making potent foci of infection easily carried to more vulnerable areas. I wish to mention but one additional point in relation to focal infection. Intestinal auto intoxication is frequently accorded credit for being the disturbing element in uveal disease, etc., but possibly it is more often due to the absorption of toxins of the bacteria themselves which cause the faulty metabolism rather than absorption of toxic food products.

ROENTGENOLOGY IN PULMONARY DISEASES*

HERBERT M. DECKER, M.D., Davenport

Early diagnosis of pulmonary disease is a very broad subject which should include every conceivable disease condition possible to occur within the chest cavity.

Practically it is not possible to consider more than one disease in an ordinary volume, and in a paper such as this, even one cannot be considered as it deserves.

The subject will be limited to the work on tuberculous children by the Visiting Nurses' Association and the Medical Supervisor of Schools in Davenport.

The aim is to find these children and start treatment before the condition has developed to the point where even the parents suspect that they are not doing well. Necessarily the whole organization must exercise the keenest cooperation and intelligent observation. Every child is inspected soon after entry into school and at intervals during their entire grade school course. Unfortunately, the law does not permit the removal of any clothing, so this examination is limited to eye, ear and throat work and a general inspection. Every defect is recorded and the parents are urged to have them corrected. The school nurses interview the parents and explain the trouble and the remedy. In all cases they are specially urged

*Presented at the Sixty-Ninth Annual Session, Iowa State Medical Society, May 12, 13, 14, 1920, Des Moines, Iowa.

to consult their family physician or to take the child to the Visiting Nurses' Free Clinic where a careful diagnosis can be made. All children who do not progress with the average either in work or in play are to be reported for more careful observation.

The visiting nurses enter the homes of the poorer people where they advise and assist in sanitary and dietary problems. The members of the family are carefully inspected, and if there is a question as to the health of any individual they are urged to report to the clinic, where a carefuì diagnosis can be worked out and treatment begun. Every case of tuberculosis is sought out and those who have been in contact with the patient are especially urged to determine if there is a possible infection.

The frank case is naturally not difficult to diagnose or handle, but in the case of the child under twelve years of age with a very early infection difficulties arise both in diagnosing the condition and in convincing the parents that the case demands prompt and energetic treatment. The records show that practically none of the patients who have an open case of tuberculosis are cured, so it becomes necessary to locate the lesions and begin the fight before the open stage has developed and a mixed infection is present. It is an old statement that the bacillus tuberculosis never kills its host. This is probably true except in such disease as tuberculous meningitis. The bacillus tuberculosis is a very slow growing organism; so slow in fact that the protective forces of a normal, vigorous individual can easily keep well in advance of its progress. Unless there is constant reinfection or a massive single infection the average child can either eradicate the organism or surround it with a protective barrier which will prevent its spread and development, but which does not destroy it. Probably over 90 per cent of all children are infected before they are ten years old, but so long as their resistance is not broken down they do not develop a true pulmonary tuberculosis.

The favorite site of the original focus seems to be in the lower lobe, a fact that is not generally appreciated. This focus heals, but the lymph nodes about the hilus become involved and the spread to the upper lobes is from these nodes. One or more of these rupture and discharge a massive dose of active tubercle bacilli some of which are coughed up and some aspirated into the smaller bronchioles where they can locate permanently.

In many of these children with early cases there is a beading along the smaller bronchioles which

is so uniform that it is not possible to believe that they are the result of a progressive infection. These minute areas of increased density all being so uniform must have started to develop synchronously from a single massive infection.

In these cases there is always a dense mass of lymph nodes at the hilus and very frequently an area which seems to be an empty shell of a fibrosed or calcareous node which has evacuated its contents into a bronchus.

These old arrested foci may remain for many years before they break down and start a widespread infection. The tuberculosis developing in adult life after some other disease has lowered the vitality or an irritation such as gas poisoning, is not the result of a recent infection, but is practically always due to breaking down of the protective barrier around an old quiescent area.

The nature of this disease, beginning as it does in early childhood, demands that the fight against it be begun with the child. In other words, we must work along the lines laid down for the care of the wounded soldiers. Begin work on those who can in all probability be cured, and if there is time after they are atended to, those who are not liable to recover may receive attention. This does not mean that the well developed, open case should be ignored. These should be placed where they cannot spread the infection to virgin soil. They should especially be kept away from infants and growing children.

The x-ray examination is one of the greatest aids to a diagnosis of the very early lesions. A good plate can now be made in a surprisingly short time. With the double-coated film and two intensifying screens an exposure can be made as fast as the current can be broken, some operators regularly making these exposures in 1/40 of a second. Speed is a great factor when working with children under ten years of age, as it is impossible to keep them quiet. They are usually nervous with strangers and particularly so when taken to a strange place and stripped. Any gross movement of the ribs and lung tissue will fog the outlines and make the plate unreadable and utterly useless.

The position which has given best results is the prone position. The patient is placed perfectly straight and flat with the arms out at right angles to the long axis. The exposure is taken at full inspiration so that all areas of density are surrounded by as much air as can be taken in. It is obvious that better differentiation can be secured when the lung is full of air than when it is emptied and partially collapsed.

Failure of one side to expand can be noted and

the excursion of the diaphragm is easily seen. Adhesions of the pleura with obliteration of the various angles cannot be determined when the chest is contracted unless they are very extensive, in which case they can be located by physical diagnostic methods without much trouble.

Increased density of the hilus is a very early finding in this disease, and fibrosed or calcareous areas are found fairly early. However, these easily seen dense areas are usually fairly well protected by fibrous tissue or calcareous deposit and are not usually causing much disturbance.

The areas of slightly increased density are of prime importance, as they show inflammation in an early stage. This density may vary from a mere smoky area to a distinct density, or may show a beading due to the development of many concrete areas of inflammatory thickening.

These early manifestations are not easily recognized unless the observer is well trained in interpretation. The normal markings must be thoroughly understood before the abnormal can be appreciated. 'It is rare that the surgeon, internist or general practitioner has the time, opportunity or desire to become expert in plate interpretation, and he should not attempt to interpret plates without considerable training.

The x-ray in the hands of one who is not qualified to correctly interpret what he sees is dangerous to a very great degree. Not a few have been wrongly sentenced to a tuberculosis cure or have been assured that there was no disease condition

present. The x-ray is only part of the investigation necessary in very early tuberculosis, but it is and should be recognized as a very important part of the routine procedure. It seems of the utmost imoprtance that the control of tuberculosis begin with the young child and that those who are concerned in this question should maintain an organization which will seek out these very early cases and give them the benefit of every recognized method of diagnosis and rational treatment. Discussion

It

Dr. J. F. Herrick, Ottumwa-I am very much interested in this paper, for I believe that the x-ray as a means of diagnosis in tuberculosis is very little understood. I know it is very little used, and I cannot get away from the impression expressed by the essayist that it would be an aid worthy of anybody's attention in the diagnosis of this class of cases. does not always differentiate tuberculosis from other lung conditions, but in many instances we are at a loss to know where to look in the individual for the cause of poor health, poor nutritition, and sometimes slight elevation of temperature. Physical examination of the lungs may not aid us in differentiating between infection in the lung or some other place.

It often happens that the area involved is deep in the lungs, and even a trained clinician cannot determine for certain that there is involvement. The x-ray will often show it. The essayist did not speak of the stereoscopic pictures. At times they make the diseased area stand out as plain and apparent as if feature stands out so plainly and so clearly that the looking your best acquaintance in the face. Every

whole question is settled right there and then as to where your trouble is. Your judgment then, will have to settle whether the condition is tuberculosis or not. But in the diagnosis of pulmonary troubles or obscure conditions in children at any time from the early months of infancy up, I think there is noth ing so useful as properly made stereoscopic plates, as the essayist says. It is very important that they be properly made, and I hope that the physicians of Iowa will take this matter up, for I know it is well worthy of their attention.

Dr. Daniel J. Glomset, Des Moines-I would like to say something about my experience in the army in the matter of reading roentgenograms of the lungs and also of my experience in doing autopsies on cases in which the roentgenologist had made diagnosis of lung involvement. I have not been able to satisfy myself that these fan-shaped shadows that Dr. Decker speaks of are indicative of tuberculosis. In my experience tuberculosis does not act that way. In tuberculous lungs you will invariably find areas of caseation, areas of proliferation. In other words, tuberculosis always produces the tubercle, and it will go on to caseation and you will have this marked spotted condition that some of these cases show. Such cases alone turn out to be tuberculosis at caused by some infection other than tuberculosis. If autopsy. The fan-shaped areas are almost invariably

we learned anything in the army it was that the fanshaped affair is not tuberculosis, but due to thickening of the bronchi from other infections. Another point I would like to emphasize is this: That unless one takes a stereoscopic picture of the chest it is exceedingly difficult to determine the nature of the shadows, and it is not then possible unless you examine the active process repeatedly and observe the changes which occur. Conditions that suggest tuberculosis one day will disappear within a week if you repeat the picture. I have seen that occur again and again in France where we examined patients suspected of having tuberculosis. It is only by repeated stereoscopic pictures of the lung that you can get an approximately correct diagnosis of pulmonary tuberculosis.

Dr. Granville N. Ryan, Des Moines-We use the x-ray in correlating the findings just as we do with the Wassermann. In our routine we take the blood for the Wassermann. In the same way we use the x-ray in correlating our findings as to chest conditions, which is extremely important.

Dr. Decker-Dr. Herrick and Dr. Glomset both mentioned the stereoscopic end of the subject. I do

not believe that anybody who is doing much x-ray work is examining these cases without stereoscopic plates, but you cannot show them in a lantern, and so it was not specifically mentioned that this was the method employed. Dr. Glomset questions the sig nificance of certain findings. It is probably true that no one of these findings will definitely tell us that the condition is tuberculosis. We have to work with

the clinician, and the results of all the examinations must subsequently be correlated in order to make your final diagnosis. The idea of this paper was merely to stimulate interest in all kinds of examinations of these little children and emphasize the fact that in some places the x-ray is being ignored. The fan is due to thickening of the bronchial tree, and that thickening may be the result of any infection that persists long enough to make a real inflammation or fibrosis, it makes no difference whether caused by a streptococcus or bacillus tuberculosis. However, I believe when you find one of these fans with beading, the numerous concrete spots localized, that is practically always of tuberculous origin. In the army, of course, they were able to bring to autopsy all of these cases that died if they so desired, the limit being dependent entirely upon the endurance of the man who did the autopsy work. They learned a great deal, and we are going to learn a lot from their findings after repeated examinations. There isn't anything in medicine that will get along nicely with a snap-shot-you do not treat any chronic condition in that way. You do not examine your You do not examine your case and then give him a certain amount of medicine and say, when that is gone you are going to be well. You see those cases repeatedly, of course. Those things are so obvious that it didn't seem necessary to mention them except in a general way in the body of the paper, where I said that these children were repeatedly examined and treated during their early childhood.

BEFORE AND AFTER THE OPERATION*

N. SCHILLING, M.D., F.A.C.S., New Hampton

The great French philosopher Mantesquieu made the observation "Happy is the nation whose Annals are tiresome."

We might well paraphrase this statement by saying: Happy is the patient whose post-operative history is monotonous.

And, during the past few decades, the surgeon has had every reason to contemplate with pride and satisfaction the striking and gradual decrease in the percentage of morbidity and mortality following surgical operations. But even now we are not justified in assuming the pose of the inimitable Dr. Quill who boasted that he had reached the

*Read at Austin Flint-Cedar Valley meeting at Algona, Iowa.

"top of his profession" and that there was nothing left for him to accomplish. Unfortunately, it is still true that every surgeon who does much surgery has "troubles of his own." And, if he has learned anything in the school of experience he will have realized "many times" that the old medical maxim "prevention is better than cure" applies with particular force to post-operative sequelæ and complications.

Accordingly, it is from this angle that I shall endeavor to direct your attention to this manysided topic.

The choice of an anesthetic may determine absolutely the clinical fate of a patient. In at least. one instance in my own experience a fatal result was decreed the moment it was decided to administer chloroform. The case was that of a young woman who was suffering from an attack of subacute appendicitis and who, in accordance with the surgical fashion of that time, had been treated by the so-called Ochsner method. When after a week of starvation the symptoms had not been entirely relieved it was decided to remove the appendix. It was difficult for the anaesthetist to keep the patient sufficiently under the influence of ether, so he substituted chloroform. After this the anesthesia was delightfully complete. But about forty-eight hours later we had to face that awful clinical picture resulting from liver necrosis. The patient became restless, jaundiced, delirious, maniacal and died in coma on the fourth day after the operation.

The circumstance that Dr. Kearn of Waverly has observed a case, similar, in practically every respect, would tend to show that such unfortunate terminations after chloroform anesthesia are, by no means, uncommon. Dr. Kearn has ventured the opinion that in these patients the long fast before operation had something to do with lessening the resistance of the liver cells to the toxic action of chloroform.

Personally, it is my firm conviction that in the hands of the average anesthetist ether is about the only safe general anesthetic. Nitrous oxide so fashionable at the present time is certainly not superior to it from the standpoint of safety. Dr. W. J. Mayo says that it is the most dangerous of all anesthetics.

He bases this conclusion on his own experience and on observations made in several prominent Eastern university clinics. On a visit to these model institutions several years ago he found that scarcely an operation was undertaken without in some way "working in" nitrous oxide. subsequent visit several years later he found that

On a