Title: The Journal of Ophthalmology, Otology and Laryngology. - Vol. XII. July, 1900. Part 3.
Author: Various
Language: English
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               VOL. XII.       JULY, 1900.       PART 3.
         THE JOURNAL OF OPHTHALMOLOGY, OTOLOGY AND LARYNGOLOGY.


                                EDITOR,
                          CHARLES DEADY, M. D.

                           ASSOCIATE EDITOR,
                          A. W. PALMER, M. D.



          NASAL OBSTRUCTION AS A CAUSE OF HAY FEVER OR ASTHMA.

                BY WM. WOODBURN, M. D., DES MOINES, IA.


I do not propose to treat this subject technically or theoretically,
further than to simply say, I consider the first a mild form of the
second, and both a reflex neurosis. I shall relate my experience and
treatment of some half dozen cases illustrating my subject.


  CASE I.—Mrs. H., a farmer’s wife, æt. thirty-five, had been troubled
  for a number of years with hay fever from harvest time until frost
  came in the fall. Inspection of the nose in June, 1899, showed the
  lower right and both middle turbinated bodies greatly hypertrophied.
  Removal of the anterior and lower half of the middle and
  cauterization of the lower, gave complete immunity for the entire
  season. This patient could not, at any time, sweep the floor or ride
  behind horses against the wind, without violent paroxysms of
  sneezing, but since the operation has had no further trouble on this
  score.

  CASE II.—Mr. D., æt. about thirty-five, a traveling man, the patient
  of our secretary, consulted me on August 28 last, in the midst of
  his annual attack of hay fever. Examination showed the entire nasal
  mucous membrane greatly engorged, as it always is during an attack.
  On the right side of the septum, near the floor, was a sharp septal
  spur, projecting at right angles about three-eighths of an inch,
  prodding the tumefied lower turbinated body. The removal of this
  spur under cocaine anæsthesia greatly modified the symptoms
  immediately, but a grateful frost, following in a few days,
  prevented an exact estimate of the benefit to be ascribed to the
  removal of this offending appendage.

  This year, however, will furnish opportunity to determine how
  permanent the effect will be.

  CASE III.—Wm. S., æt. four years, a great sufferer from asthma, at
  times when having a slight cold, to which he was very prone, to such
  an extent that he could not lie down for several days and nights.
  Relief had been sought in the higher altitudes of the Rockies and a
  residence of one year at Denver, but none came. I was consulted on
  November 25, 1899. An examination showed the post-nasal space almost
  occluded with adenoid vegetations. Of course I advised their
  removal, which advice was accepted, and their thorough removal,
  under the local application of cocaine, accomplished the purpose.
  This was the child of a brother practitioner, and in April this year
  I had a letter from the doctor, in which was the very gratifying
  sentence, “William has not had the asthma since you removed his
  adenoids, and is much better in every way.” This was especially
  pleasing since his suffering had always been more severe and
  constant during his previous winters.

  CASE IV.—Male, æt. forty-five, Swede; occupation, bridge-builder.
  Had suffered annually for fifteen years with, first, hay fever, and,
  later in the season, asthma. In the summer of 1899 he anticipated
  his attack by a trip to the mountains of Colorado, where he found
  exemption and remained until the first frosts had appeared here, and
  then ventured to return. Immediately on arriving at Omaha on his
  return, his old antagonist met him and the battle again raged with
  even renewed vigor. He consulted me a few days after his arrival
  home, in a frame of mind ready to accept any suggestion which
  promised him relief. I examined the nasal passages. The right lower
  turbinated was greatly hypertrophied, and on the application of
  cocaine, 3 per cent. solution, the tumefaction largely disappeared
  and great immediate, but of course, temporary, relief was
  experienced. On the left side an immense septal spur on the osseous
  portion was found and removed. After the temporary swelling incident
  to the operation had subsided, his relief was, and remains,
  complete. I subsequently cauterized the enlarged right turbinated,
  since which time, he informs me, he has breathed more freely than he
  has done for fifteen years.

  CASE V.—Lady, æt. about twenty-eight, married, had consulted all the
  physicians in her home town, except the one she should have at first
  consulted. Finally, in desperation she went to a young up-to-date
  homeopathic physician, who looked into her nose and assured her he
  knew what caused her trouble. He made an application of a solution
  of cocaine, and in a few minutes her respiration became nasal and
  normal. “Oh, what a relief! That is the first good breath I have had
  for weeks,” was her exclamation. Both lower turbinated bodies were
  immensely hypertrophied, and the doctor wisely advised their removal
  and referred her to me to do the work. When I first saw the patient
  she was a frail, pale, wan little woman, thoroughly exhausted. I saw
  her about six weeks subsequently, in a remarkably improved
  condition. Had gained about twenty pounds in weight and was plump,
  rosy-cheeked, and had entirely lost her distressed appearance.


The last two cases both occurred in the practice of my good friend, Dr.
C. M. Harrington of Knoxville, Ia., and are all the more valuable
because he is here to corroborate the fair statement of the cases I have
made, and emphasize the beneficial results in a discussion of my paper.


  CASE VI.—An old-school physician, æt. about thirty-five, had for a
  number of years been troubled during the late summer months and
  early fall with hay fever. Had sought relief from a number of
  specialists in his own school of medicine as well as prominent
  general practitioners. By chance he was directed to me, not knowing
  my school of practice, in the midst of attack in 1899. No
  satisfactory examination could be made until a 4 per cent. solution
  of cocaine had been applied and caused a lessening of the
  engorgement. There was plainly visible a large well-organized simple
  polypus hanging by a distinct pedicle from the right middle
  turbinated body. Its removal with the cold wire snare gave prompt
  and permanent relief and made a lasting and loyal friend of my
  old-school confrère.


In none of these cases do I mention any medication. None was used except
to cleanse the mucous membrane of the viscid secretion always present in
such conditions, and following such operations. All of the cases
reported were mechanical obstructions, and demanded mechanical
treatment, and no line of medicinal treatment would have done more than
temporary good.



                    DETACHMENT OF THE RETINA—A CASE.

                 BY JAS. A. CAMPBELL, M. D., ST. LOUIS.


  In May, 1885, Geo. H., age thirty-seven, came to me from Indiana,
  with the following history: He had been very nearsighted all his
  life, but had never worn glasses. His eyes had never troubled him in
  any other way, until a few days before he came. He then noticed a
  few floating white spots before his left eye. This gradually
  increased, and the vision of this eye, by degrees, grew less and
  less until after four days the sight of the left eye was gone. There
  was no pain in either eye.

  Examination showed vision of the right eye was 4/200; with a — 13
  Ds. glass, 15/200. With the left eye he could just distinguish light
  in the outer upper field of vision. With the ophthalmoscope only the
  lower fundus of the left eye could be made out, where the retinal
  vessels were seen up to the lower edge of the optic disk. The disk
  itself could not be made out, but above it a bulging, detached
  retina was prominent, with a hemorrhagic spot at its inner margin.
  In the upper outer fundus another separate bulging detachment of the
  retina could be plainly seen.

  The right eye was highly myopic, with a myopic arching around the
  disk, and the entire fundus was mottled with small choroidal
  pigmentation spots, clearly of long standing.

  The nature of his trouble was explained to him. He was kept quiet,
  and all forms of tobacco and stimulants were forbidden. He was
  placed on kali hyd. 3d, three times daily. In one week’s time a
  remarkable change for the better had taken place. The detachment was
  much reduced. The wavy retinal vessels were seen climbing over its
  edges. The optic disk was visible. In two days more he could count
  fingers with the left eye at two feet. The improvement continued. On
  June 24 vision of the left eye was 15/200; right eye, 15/100. He
  then went home for a few days; the kali hyd. being kept up. July 13
  he returned, saying that the improvement had gone on by slow
  degrees, until, suddenly, the vision of the left eye was again lost,
  on July 12. He was then placed on 5‒grain doses of kali iod. 3d,
  three times daily, which was followed by very slow improvement, so
  that in three weeks he could again count fingers with the left eye
  at two feet, and the detachment, which had resumed its former
  dimensions, was somewhat reduced. I then went back to kali hyd. 3d,
  three times daily, which was again followed by improvement for some
  months after his return home. This, with some intercurrent
  medication, was kept up from time to time for a year, gradual
  improvement being reported until the sight of both eyes seemed about
  as it was in former years.

  May 3, 1899, fourteen years after his first visit, he again came to
  me, reporting that his eyes had gotten along very well, with no
  particular trouble until in 1897, when he took a severe cold, which
  settled in his left eye, which became badly inflamed. He went to St.
  Louis, but did not find me, as it was during my summer vacation.
  Returning home, he consulted Dr. Knapp of Vincennes, Ind., who
  advised the removal of the left eye, as it seemed hopelessly
  involved by that time. This was done, and he progressed nicely, the
  vision of the right eye remaining about the same, though
  occasionally its vision seemed not quite so clear.

  This was the situation until two weeks before his visit, when the
  sight of the eye began to grow dimmer. There was no pain present at
  any time, but vision gradually grew worse and worse.

  Examination: V. R. = 8/200; where it had before been 15/100.
  Ophthalmoscope revealed some increase of the old choroidal atrophic
  mottling, with a red blurry optic disk.

  He was placed on gels. θ, three times daily, for a few days, with
  evident improvement of the optic nerve congestion. He was then given
  kali hyd. 3d, four times daily. He returned home in a week, keeping
  up the same remedy. In three weeks he returned to me again, when
  examination showed decided improvement; with — 13 Ds., V. = 15/100
  once more; still keeping up the kali hyd. 3d.; thus having been
  brought back to the condition which followed the treatment in 1885,
  and which had remained in _statu quo_ for fourteen years.


Detachment of the retina is always a serious condition. It is not an
unfrequent complication in high degrees of myopia. In three hundred
cases collected in Horner’s clinic, 48 per cent. were in myopic eyes.
Its progress is generally unfavorable. It is usually treated by perfect
quiet, rest of patients, after confining them to bed for some weeks,
giving infusions of jaborandi and hypodermics of pilocarpin mur.
Puncture through the sclera at the points of detachment, allowing escape
of the fluid, has been advocated and performed by various well-known
authorities, but has not been successful enough to ensure its general
adoption. In rare cases spontaneous recovery has been observed, but I
cannot think that the case here presented belongs to this class, for the
original attack was in 1885, and was of such a degree that the vision of
the left eye was reduced to mere perception of light in the outer upper
field of vision. Under kali hyd. 3d, remarkable changes and rapid
improvement took place. A relapse followed on his return home, after a
couple of weeks. This again yielded to the same treatment, the vision of
the left eye regained what it had lost, and remained in this condition
for twelve years, when a severe general inflammation of the left eye
necessitated its removal. Then, in a couple of years, the vision of the
right eye became suddenly involved. Rapid improvement again followed the
same remedy, and it was restored to its original condition. Hence, I
cannot regard the improvement as either spontaneous or a coincidence,
but think I am justified in attributing it to the direct result of the
remedy given.

In the old school iodide of potash, in large and repeated doses, is a
very common remedy in all intraocular diseases, and the more obscure the
case, the more frequently and persistently it is used. Some cases are
benefited by it, others not. The points I wish to make are, first to
demonstrate the homeopathic possibilities of treatment in this serious
disease; that when you have a homeopathic kali hydriodicum case, kali
hyd. will probably help it, whether you give it in the third trituration
or in more appreciable doses. In the case here reported kali hyd. 3d was
certainly more potent than the 5‒grain doses used for one week and then
changed to the 3d trituration again.



                            CLINICAL CASES.

                 BY C. GURNEE FELLOWS, M. D., CHICAGO.


  CASE I.—Early in 1899, Mrs. H. B., age forty-nine, presented herself
  for an opinion as to her condition. She had been hoarse for three or
  four weeks, and had a little inconvenience in swallowing, with no
  cough, but she complained of ordinary sore throat such as would
  follow an everyday cold. The main symptom was an excessive amount of
  mucus from the nose, nasopharynx, and pharynx.

  Examination revealed a large pharyngeal ulcer on the left side, with
  enlarged cervical glands on the same side, and my suspicions were
  aroused as to its malignancy. Upon expressing such a fear the
  patient admitted that she had been examined by a surgeon who
  likewise had suspected carcinoma and advised its removal. She
  absolutely refused to think of operation at anybody’s hands, and
  insisted upon my giving it the best treatment possible.

  I cleansed it with the usual antiseptic solutions, and applied
  orthoform and other well-known and everyday methods for a week or
  two with a fair amount of relief, but the ulcer continuing, I
  applied specific treatment in the hope of clearing up the diagnosis,
  and, much to my delight as well as to the patient’s comfort, the
  ulcer healed, the induration disappeared and the patient was, to all
  intents and purposes, well. After a number of weeks the external
  glands even diminished in size, so that I rather felt that the
  diagnosis of cancer was wrong and that it must be specific in
  character.

  The patient ceased her visits, but returned in a few more weeks with
  a condition as at first, but upon the opposite side of the pharynx.
  Same treatment and everything else I could suggest did absolutely
  nothing for her relief, and I felt that the diagnosis this time must
  be carcinoma, but she refused even to have a small section taken for
  the purpose of diagnosis. Consultation agreed with me as to the
  malignancy of the growth, but operation was refused. She died in
  another month, practically from starvation.


I report this case after having read the article by A. Worrall Palmer
upon cancer of the larynx, in the January number of this journal,
because in the prelude, this method of diagnosis, and the application of
this specific mixed treatment is advised, and because in this case it
was followed by apparently successful results with what seemed to be an
entire cure of the case, and therefore a clearing up of the diagnosis,
but which, on the other hand, was followed by a return of the same
condition, but upon the other side of the throat. The second point in
the case is the great relief of all symptoms following the iodide of
potash and merc. administered internally, and the administration of kali
bi. and arsen., which most certainly had in the early part of the
disease a very satisfactory effect. I believe that this case was cancer
from the first, but that, contrary to expectations, it yielded
beautifully to internal treatment.


  CASE II.—Mrs. M. E. C, age fifty-six, presented herself with a
  sensation of swelling in the throat accompanied by stinging pain,
  and with a history of from one to a dozen attacks of suffocation
  each twenty-four hours, much worse at night; otherwise no soreness
  of the throat or special sickness preceding these attacks, but they
  have been fairly constant for a year. She had become suspicious of
  the trouble being cancer, and, after having had some months of
  treatment from her family physician, she was more impressed with the
  fact than ever.

  Examination revealed nothing in the way of foreign growth, but very
  much enlarged varicose veins at the base of the tongue, with a
  granular pharynx. Prognosis was favorable and the treatment as
  follows:

  Glycerole of iodine to the pharynx and base of tongue, following
  cleansing and antiseptic solutions; galvano-cautery destroying the
  largest of the blood vessels, and moschus 3x internally. A complete
  cure resulted in less than thirty days; complete cessation of all
  attacks, which, of course, proved the diagnosis to be other than any
  malignant trouble, and, although the local treatment was probably
  efficacious, I believe that much of the trouble was of a neurotic
  type, incident to the climacteric, and that moschus deserves a good
  deal of credit for the result.



                      THREE KALI CARBONICUM CASES.

             BY THOMAS M. STEWART, M. D., CINCINNATI, OHIO.


  CASE I.—Patient, a tall thin woman; dark hair and eyes. Badly
  nourished as a result of mal-assimilation of food. Troubled with
  frequent attacks of styes on the upper right eyelid. Patient anæmic.
  Complained of frequent chilliness; chilly on least exposure.
  Physically and mentally patient was exhausted.

  Some improvement was secured by correcting an eye trouble with
  glasses. Nux vomica, psorinum, and hepar of course acted
  indifferently. On a later visit the case was cleared up by the
  mention of the chilly sensation and the exhaustion. Kali carbonicum
  began an improvement and carried the case on to a point where diet
  did the rest.

  The woman’s means were limited, but she was able to carry out the
  diet direction, because her principal articles of diet had been meat
  and eggs. She was getting too much nitrogen. A generous supply of
  the carbo-hydrates; a direction to drink plenty of water, but not at
  meal times; and more exercise in the open air changed the conditions
  to healthful ones.

  CASE II.—A young woman, well nourished, but not muscularly strong.
  Catches cold easily and is readily exhausted by muscular exertion.
  Sensation of a lump in the throat, with stitching sensation at each
  cold. With each cold has some cough, due largely to an elongated
  uvula. With each cold must “hawk” a great deal in the mornings to
  “clear the throat.” The patient was a vocalist and suffered
  frequently from these acute colds and hoarseness.

  The case had been prescribed for by several physicians. A study of
  the case brought out the kali carbonicum picture of “coryza with
  hoarseness; catches cold at least exposure to fresh air, and with
  each cold there is a stitching pain in the pharynx,” and kali
  carbonicum 6x trituration cured the case, including the relaxed
  uvula. The patient has frequently presented this picture and each
  time kali carb. did the work.

  Some additional benefit, in lessening the liability to these
  attacks, has been secured by the cold sponge bath each morning. Deep
  inhalation of fresh air three times a day, to aid in the oxidation
  of the food stuffs; and by inculcating the habit of daily attending
  to Nature’s demands, whether there is any desire or urging in that
  direction or not.

  CASE III.—Patient a nervous woman. Suffering from mixed astigmatism
  and pronounced insufficiency of the internal recti muscles, which we
  oculists denominate an exophoria. Patient suffered terribly from
  headaches, almost daily in their occurrence, frequently with nausea.
  The muscular trouble was cured by the use of prisms, the mixed
  astigmatism corrected by a glass, and there remained a severe
  backache. It was located in the small of the back as if there were a
  heavy weight pressing there; worse during menses, with bearing-down
  pain; patient was obliged to sit down frequently, on account of the
  ache. Her physician had prescribed sepia, cimicifuga, and natrum
  muriaticum—and in response to a question, “Could the eye treatment
  have had anything to do with apparently aggravating the backache?” I
  replied, “No; I think the relief of the headache has simply allowed
  the attention to be drawn to the backache.” I asked for other
  symptoms and one day received a little line stating that the
  “backache was worse after eating, and the patient could not walk
  much on account of the backache, was obliged to sit down
  frequently,” and kali carbonicum was advised. It cured the case.



                           ATROPHIC RHINITIS.

               BY C. R. ARMSTRONG, M. D., THORNTOWN, IND.


Atrophic rhinitis is that chronic disease in which there is a wasting
away of more or less of the mucous membrane, glands, and turbinated
bones, and is generally accompanied by some abnormal conditions of
pharynx and all the sinuses connected with the nasal cavities.

This is no new disease, but one physicians have had to deal with these
many years; one we meet in practice every little while, and one which we
cannot study too carefully, because the treatment for the disease in
many cases ends in failure to cure.

I do not know that I will be able to say anything new of this morbid
condition of nose, but will state a few things as I see them in practice
day by day. There is always a favorable point about having a patient
with this disease, along with the unfavorable ones. That is—the
physician always has plenty of time to study his case and see every
minute change in the recovery ere the patient is pronounced cured. This
is more commonly known as ozena, or fetid catarrh, from the odor which
accompanies the trouble. However, there is a form of the disease in
which the atrophy is present, but has no fetor accompanying it. The
latter is a much drier form with no secretions at all.

The ætiology of this disease has been discussed pretty thoroughly. It
has been a question as to just what the initial symptoms and changes
really are. In a majority of cases it is a secondary disease. That is,
it follows other forms of rhinitis. Some authors claim that atrophic
rhinitis follows the hypertrophic rhinitis. Others claim that there may
be some shrinking in hypertrophic rhinitis, but that it does not end in
atrophy, but comes from the purulent rhinitis: I believe they both are
right. Either form I feel confident may precede atrophy. Again, I do not
think that hypertrophic or purulent rhinitis is always followed by the
atrophic form. If they were we would have many more cases of atrophic
rhinitis to treat than we do at present. In my opinion this disease is
brought on directly at times from various causes. Many a case of ozena
has been brought on by the indiscriminate use of caustics on the mucous
membrane of nose. Also injudicious cutting away of inferior and middle
turbinated bones. Then again there is a predisposition to disease,
especially in those people with a syphilitic and scrofulous diathesis.
Excessive drinking of alcohol, excessive smoking of tobacco, working in
poorly ventilated rooms or where there is a great deal of dust, and
where there is an impoverished condition of blood from malaria or
malnutrition, all have a tendency to set up this disease.

The name of this ailment tells much of the pathology of the disease. As
atrophy implies, there is a wasting away of all tissues attacked. Upon
examination the first thing observed is a dry, shriveled state of the
mucous membrane of the nose and pharynx. The glands and follicles are
all obliterated, which accounts for the dryness of the mucous membrane.
The turbinated bones are dwindling away. Frequently the whole anterior
portion of the turbinated bones is absorbed. This causes the nasal
cavities to be so enlarged that we may see the pharyngeal walls from the
anterior opening of nose. The glazed or dry appearance extends to the
pharynx and in this manner affects the eustachian tubes. All over the
nasal cavities and pharynx numerous granulations can be noticed.
Tortuous and enlarged vessels run over the walls. As a rule there is not
that bright red congested appearance of membrane as in other forms of
catarrh.

Patients with this form of catarrh are frequently mistaken in diagnosing
their own cases. I have had them to come in my office asking me to make
a prescription for biliousness. They get that idea because they have a
dry and coated tongue and a very bitter taste in mouth. After an
examination is made you fail to find symptoms to corroborate the
patient’s diagnosis, but will soon find the real cause. With the
reflected light and nasal speculum it takes but a short time to satisfy
your mind from conditions of nose that have all the symptoms of ozena.
There is a discharge made up of mucus which is very thick, therefore not
very easily expelled, and as a result finds its way into all the fossæ
and crevices in the nose. It is not long until this is dried into crusts
which obstruct the passages of air, and being retained, decompose,
throwing off a peculiar, penetrating stench. These crusts adhere very
firmly to the membranes. The patients will remove them by artificial
means, owing to the uncomfortable feeling produced by them. When the
scabs are torn away there may be an oozing of blood. A stuffed up and
oppressed fullness in the superior and posterior portion of the nasal
passages is present. In the first stages of the disease the mucus will
fall down from the palate in small slugs or masses, which as the disease
goes on become more and more tenacious and more of a muco-purulent
nature. In the beginning this discharge can be “hawked up,” but soon it
becomes too thick and dry. While the membranes may be so irritated that
there will be a free discharge of blood, still there is no real
ulcerative process. The septum in some cases is perforated, but this is
caused more by tearing away the dried-up discharge than anything else.

The sufferers from ozena are never the strong and vigorous people. They
are generally anæmic and having family histories which would make a
physician think that the diseases were hereditary. These discharges
being retained so long the poison may be absorbed into the blood, and
soon the whole system will show the effects of the poison. In children
the nostrils are so filled up that they can scarcely breathe at night,
and it will not be far in the future when the child will be weak,
nervous, irritable, and unable to sleep well. The stomach raises a
disturbance as the disease gets older, which is accompanied by an
occipital headache. The food which is eaten goes for naught, because the
system does not seem to get the desired nourishment. Taste is destroyed,
appetite gone, loss of energy for everything is apparent.

The patients scarcely ever can detect the bad odor unless their
attention is called to it. After being told a few times about the odor
of the breath they will shun public gatherings. If the patient is a
woman, who because of offensive breath is barred from society, she will
become morbid and hypochondriacal in time. There is so much of the thick
mucus hanging on the walls of the pharynx that the openings into the
eustachian tubes are filled up and in a short time a certain degree of
deafness appears—roaring in the head and other manifestations of ear
trouble. As soon as the hearing is noticed to be abnormal the patient
will be ready to consult some physician.

With these symptoms it may not require much time to make a correct
diagnosis, but it may be some time ere the patient is entirely free from
the trouble even if he does use good homeopathic treatment. Then it is
the treatment which interests us most. The patient at the beginning will
ask if you can cure him and how long it will require to do it. The
physician necessarily must guard his prognosis, especially if it is a
case of long standing. If there is much atrophy, which has extended over
several years, a permanent cure is very doubtful. But even with these
cases much can be done to make patients more comfortable. Correct the
odor, the dryness, and the formation of scabs. If the case is not of too
long standing, very likely you will be able to produce a healthy
condition of the mucous membrane. If you are so fortunate as to produce
a cure, the patient will always remember you for it, and you will or
should feel proud of it yourself. Much will depend on occupation, age,
and persistence with which the patient carries out treatment.

The treatment, to be beneficial, implies the discovery and removal of
all predisposing and exciting causes. To do this will require both local
and systemic treatment. No cure can result unless good constitutional
treatment is persisted in. When taking the case it is wise to inform the
patient that he must expect treatment through several months, and even
then the case must be examined once in a while or there may be a
recurrence of the disease.

Too much time cannot be spent in a careful examination of the patient.
Be certain the cause of trouble is ferreted out. The course of treatment
will depend upon the cause of the disease. After thorough examination a
course of treatment is planned. As I have said before, each case must be
studied. There are no specifics for the disease.

In the local treatment the important object is cleanliness. The mucous
membrane must be kept in a perfectly clean condition all the time. This
is the main object of all local treatment. In some cases I assist nature
to heal parts by getting a slight stimulating effect of medicine.

It is not always an easy task to remove all the dry crusts, but where
the scabs are very dry I use an application of peroxide of hydrogen on
cotton, or with the atomizer, to soften them. When the atomizer or
douches are used post-nasal injections must be given as well as through
the anterior chambers of nose. Any application can be used which will
soften up scabs. Can use “Dobell’s Solution,” solution of sea salt,
listerine, or glycerine. After all the crusts have been removed, others
must be prevented from forming. This I do by keeping on an application
of glycerine. A very good formula to keep the nostrils free is calendula
and glycerine, at 2 drams to ounce water, and used in nebulizer or
directly applied on cotton. When the odor is present after removal of
scabs, I use permanganate of potash, 10 grs. to ounce in spray, or
aristol in lavolene used in nebulizer.

After the cleaning process has been gone through with and all the mucous
membrane is perfectly clean, naturally it is ready for some healing
application. A good one to use is calendula and hamamelis in lavolene.
If there should be any ulceration of septum, apply an ointment of yellow
oxide of mercury, 10 grs. to the ounce. This will heal ulcer in short
time.

Where membranes need some stimulation a glycerite of tar, hydrastis, or
eucalyptol in nebulizer will be found to be of service.

Many times patient will complain more of the deafness than anything
else. When you have this complication it will be necessary to give
attention to some special treatment for the pharynx and eustachian
tubes. The latter must be kept open by Valsalva’s method or the Politzer
air bag.

In selecting the internal remedy keep in mind the constitutional and
local lesions. Often I use the internal remedy locally; say 5 to 20
drops of tincture to ounce water. Make yourself confident that you have
the indicated remedy. There are many remedies which are of service. Some
of the more common ones, which have syphilitic taint are, aurum, kali
iod., mercury, nitric acid, argentum nitricum, and calc. iod. In
scrofulous diathesis and ill-nourished patients such remedies as aurum
mur., silicea, calc. phos., sulph., phosphorus, ars., hepar sulph.,
alumin., kali bich., cal. carb., and graphites are useful.

All through the treatment the physician should have perfect control of
patient. Should be able to direct his diet and hygiene. Use all means
that will recuperate the general health. If patient is laboring day by
day in dust and dirt, he may be compelled to change his occupation.

It is only by looking after the general health that the physician may
expect to be rewarded with any success.



                               SPRAYS.[1]

                BY FRED D. LEWIS, M. D., BUFFALO, N. Y.


In considering the subject of sprays, it is not my intention to present
to you a number of formulas that I have found useful in my practice, but
to consider the matter on a broader and more general basis. That sprays
have been, and are still used, in various conditions with the most
gratifying results, we all know. But that they should be prescribed to a
much larger extent than they now are is a fact that the physician, as a
rule, is not aware of.

We have learned to know that the skin is one of the great vital organs
of the human system. That if its action is impeded, the kidneys and
intestines are thereby given a greater amount of work to perform. That
with the morning sponge, followed by a brisk friction and an occasional
Russian or Turkish bath, in chronic cases, such as rheumatism, we can
expect quicker and better results from our remedies.

The public generally have been educated to that point where they
recognize the importance of proper care of the teeth. They not only
regularly cleanse them, but at stated intervals, usually every six
months, go to the dentist and have a thorough examination to anticipate
rather than wait for trouble.

Many persons have learned that a lavage of the stomach, in the shape of
a cup of hot water, before meals, has converted a sluggish digestion
into a normal one.

We are all familiar with the structure and object of the nasal cavities.
The tortuous turbinateds provide a large surface for the air to secure
heat and moisture, before reaching the lungs; and also remove from the
air such impurities as are of a solid nature. Now we all know that the
atmosphere of cities, especially where there are large manufacturing
interests, is loaded with impurities, such as soot, dust, particles of
pavement ground to impalpable powder, etc., etc. This fact can easily be
demonstrated when the city is on a plain or in the neighborhood of a
large body of water. When in the city the air seems pure, the sky
unobstructed, and no evidence of floating particles of matter, if an
observation is taken from a few miles’ distance, the city appears to be
encompassed by a cloud.

That the disposition of foreign matter on the sensitive lining membranes
of the nose should produce disturbances, there can be no doubt.

The only point I wish to bring out, and I hope it may stimulate some
discussion, is this: Should not the care of the nasal mucous membranes
be considered as important as the care of the skin and teeth?

In recent years I have asserted to my patients that the spray, in my
opinion, is as essential on the toilet table as the toothbrush. As to
the nature of the spray to be used, I think one must be guided by
conditions. If there has already been a catarrhal condition established,
then some remedial agent had better be employed; but if used simply as a
prophylactic, then a neutral cleansing solution would be preferable.

I think this subject is deserving of profound consideration, when we
know that there are establishments in most of our leading cities that
advertise the cure of catarrh for so much a month. Their methods are
simply to insist on the patient coming to their offices daily, and
having their noses thoroughly cleansed. And they are curing many cases.
Would it not be wise to educate our patients, not only to keep their own
noses clean, and thus cure themselves, but, by attending to themselves
early enough, avoid the development of that, perhaps, most prevalent of
all diseases, catarrh?



                   GALVANISM IN NASAL HYPERTROPHY.[2]

                 BY JOHN B. GARRISON, M. D., NEW YORK.


Hypertrophic rhinitis is one of the most frequent of the diseased
conditions pertaining to the nasal cavities that we are called upon to
treat, and the question of the most suitable method of treatment is to
be decided with care.

We have all used, for the removal of the excess of tissue, perhaps, with
more or less success, the acids, the actual cautery, or some form of
cutting instrument, but the patient, at least, will welcome a method
that promises a good result with the least amount of pain at the time of
treatment, and the least soreness afterward.

I have found that the application of the galvanic current does, in many
cases, furnish just the method desired, and I shall beg your attention
for a few minutes while I speak of the method as I practice it.

I shall not burden you with my ideas of what cause most enters into the
production of these nasal hypertrophies, leaving to you the perusal of
the text-books that will give all the knowledge extant upon the subject.
We do find an increase of the nutritive forces, and our treatment must
be directed to a lessening of the blood supply in some way. Of course
where there is a local source of irritation, that must be removed at
once. If it is a deflected septum that is causing an irritation by
contact with the opposite side, suitable means must be adopted for its
repair before attempting to treat the hypertrophies opposing the
irregularities of the septum.

The hypertrophies that I shall speak of as being most amenable to
treatment by means of the aid suggested in my title are mainly those of
the turbinated bodies: and, of these, the inferior is the one most often
enlarged. It may be confined to either extremity, or the whole body may
be the subject of hypertrophy. When, as is sometimes the case, the bony
portion of the turbinate has become enlarged, the saw, and not
electricity, will be the best means of cure.

But when the occlusion of the nares is caused by true increase of tissue
we have, in galvanic electricity, a potent agent to safely and rapidly
remove the obstruction.

To prepare a case for treatment, I always first thoroughly irrigate the
nasal cavities with some antiseptic fluid, using the post-nasal syringe.
The solution that I most frequently use is Electrozone one part, and
tepid water four parts. Then an application of a four per cent. solution
of cocaine is made to the location about to be treated, simply to
prevent the little pain which accompanies the introduction of the
electrode.

The electrode I use is a slender needle about the size of an ordinary
darning needle, of suitable length for easy use on the part selected,
and I insulate it by dipping it in shellac and laying it away until it
is perfectly dry, then scraping away the insulation as far from the
point as it is calculated it will be impaled into the tissues. It is
fastened into an ordinary needle-holder and connected with the negative
pole of the battery, when it is introduced into the tissue at the point
selected. The patient is then given the sponge electrode connected with
the positive pole of the battery and is told to grasp it firmly, and the
current is slowly turned on until the meter registers from three to five
ma., which current is allowed to remain stationary for about five
minutes, unless the patient is very nervous, when three minutes should
be the limit.

The current is now turned off as gradually as it was turned on and the
needle carefully removed. I do not attempt a second treatment at the
same point until a week has expired, and in some cases two weeks can be
permitted to go by before the shrinkage due to the electrolysis has
subsided. The stronger currents have been tried, but the strength I have
used and given here acts much more pleasantly and gives equally good
results.

During the summer just past I had the opportunity of noticing the
reduction of an enormously hypertrophied inferior turbinate in a most
unexpected manner, which I am glad to relate at this time.

A lady of about fifty years of age, who was stopping at the hotel at
which my family and myself were located, came to me one day to ask my
opinion as to her eye and nose. She had had a stricture of the nasal
duct for a number of years, which had been duly dilated several times,
and for a considerable time had had a dacryocystitis which annoyed her
greatly, and from which she was able to press a large amount of mucus
and pus from the canaliculus.

The inferior turbinate on the affected side was hypertrophied for nearly
its whole length and was in contact with the septum for some distance at
the anterior extremity, being of a deep red color and very sensitive to
touch. I told her that I believed it would be necessary to remove the
turbinate with the saw and advised its removal as soon as possible,
giving it as my opinion that it would be necessary to do the operation
before the condition of the eye could be relieved. The patient admitted
the force of my argument, but was inclined to wait a while until she
could get her courage up a little higher. Meanwhile she wanted the canal
dilated and begged me to do it. Visiting New York, I supplied myself
with a canaliculus syringe and a set of Bowman’s probes, and on my
return announced myself ready to commence treatment. I proceeded to
insulate the probes in the manner alluded to for needles in nasal work,
scraping the points bright for about a quarter of an inch.

Before introducing the probe I washed the sac out thoroughly with a
fifty per cent. solution of enzymol, and then, connecting the probe
electrode with the negative cord of a galvanic battery by means of an
artery forceps, introduced it (No. 2,—a No. 1 would not pass in the
ordinary manner with considerable pressure) into the canal, and turned
on the current until the meter registered two milliamperes. Using just
enough pressure to guide the electrode, it gradually found its way along
the canal, and in less than five minutes it had entered the nasal cavity
without causing the loss of a drop of blood. In three days I passed a
No. 4 in the same manner, and four days later a No. 6 passed easily.
Three days after this a No. 7 was passed, and that size was passed three
or four times afterwards at intervals three or four days. After the
first passage of the No. 7, all of the solution used for the purpose of
cleansing the sac passed through into the nasal cavity directly from the
syringe, and there was no further collection of pus in the sac during a
week in which the syringe was not used.

The point I wanted to bring out, however, is that after the second
treatment by electricity, the color of the mucous membrane covering the
turbinate began to grow paler, and at the end of the treatments the
entire body had contracted sufficiently to permit free and easy drainage
and natural respiration.

I am led, by this, to the thought that it may be good treatment in many
cases of hypertrophy of the inferior turbinate, and possibly the others
as well, to use the insulated probe electrodes in the lachrymal canal
with the weak current, not exceeding one or two milliamperes. The
careful use of this method may prove it to be a valuable addition to the
present means of treating a class of cases that are troublesome to the
patient and the doctor.



    THE PATHOGENIC AND THERAPEUTIC ACTION OF RHUS TOX. UPON THE EYE.

                        BY CHARLES DEADY, M. D.


In the collection of provings of rhus toxicodendron made by Samuel
Hahnemann, and published in Vol. II. of the Materia Medica Pura, the
number of symptoms relating to the eye and its neighborhood is so large
as to lead to the supposition that, if the theory of homeopathy be a
correct one, this drug should prove of special value in the treatment of
diseases of the visual organs. Never did an hypothesis receive better
support when reduced to practice; and if the efficacy of the law of
_similia similibus curentur_ were compelled to rest upon a single test
to demonstrate its truth, few better selections could be made than that
of rhus tox. in the department of ophthalmology.

Many of the symptoms contained in the Materia Medica Pura are
indefinite, and the great majority of them point to apparently
superficial diseases, but when we consider the fact that at the time
these provings were made the science of ophthalmology, as understood at
the present day, actually had no existence, that the principle of the
ophthalmoscope had not yet been discovered, and that the methods of
precision in the examination and diagnosis of diseases of the eye now
available were at that time unknown, this is little to be wondered at.
And we are compelled to admire the industry and energy of the men, some
of them of our own day and generation, whose tireless labor has sifted
and arranged the numerous symptoms of this and other drugs and indicated
the method of their proper application to the various pathological
processes.

When the New York Ophthalmic Hospital was placed in charge of the
adherents of the homeopathic school, they were confronted by the fact
that no definite materia medica of diseases of the eye and ear, as such,
was in existence, and in order to ascertain the remedy for a given case
of disease they were obliged to take the conditions throughout the body,
and by comparing these with the general materia medica find a suitable
drug for the totality of the symptoms. Had they been content with simply
curing their cases in this routine way little would have been gained,
but they made it a rule to take down the special eye or ear symptoms in
each case with great care, and when a drug had cured a certain case of
disease the eye or ear symptoms which had disappeared under its use were
carefully noted. With a multiplicity of cases, and a systematic
verification of symptoms, a valuable special materia medica of these
diseases was compiled, and the curative properties of drugs in the
various pathological entities of the eye and ear were definitely
demonstrated and their characteristic symptoms for each disease mapped
out.

Under this methodical procedure the relative value of drugs apparently
indicated in these diseases gradually became better known; some,
although presenting many and varied symptoms, were found by experience
to be superficial and evanescent in their action, while others proved of
the greatest efficacy in the most serious lesions, and became
indispensable in the armamentarium of the physicians of the hospital
staff.

In the latter group, rhus tox. speedily assumed prominence as a drug of
special value in ocular disease, and this was enhanced by such a large
measure of success in its application over a wide range of affections
that it came to be regarded (at least in this hospital) as a veritable
sheet-anchor in ophthalmological work, and as time passed it was used
more or less in almost all the acute diseases to which the eye and its
adnexa are subject.

A prominent symptom of rhus is great swelling of the eyelids. This it
has in common with a number of other remedies, but differentiation
becomes less difficult when we remember that rhus is specially indicated
when swelling and œdema of the lids are the result of the deeper and
more serious lesions. After the operation for cataract, one of the first
symptoms indicating danger is œdematous swelling of the lids, and no
drug in the materia medica compares with rhus for insuring the safety of
the eye. When the pathological process becomes advanced, even to the
appearance of pus within the eyeball, still we may confidently rely on
this remedy, which has cured many such cases when they were apparently
hopeless. In all postoperative complications it is of the greatest
value, and too much emphasis cannot be placed upon this statement.

When a sound eye takes on sympathetic irritation from its diseased
fellow, the fact is first manifested by a certain amount of swelling of
the lids and more or less profuse lachrymation, the latter another
valuable indication for rhus tox. In this condition I have personally
used it many times with complete success, and it is the first drug to be
thought of in this extremely dangerous complication.

It is a well-known fact at the present time that rhus is particularly
applicable in rheumatic conditions, especially where these are resultant
upon a wetting or exposure to dampness. This, together with its nightly
aggravation, points to another sphere of usefulness in rheumatic iritis,
where it will prove all-sufficient when the characteristic symptoms
exist. In suppurative iritis and cyclitis it is very serviceable, no
matter what the cause.

The symptom “while he turns the eye or it is pressed, the eyeball is
painful, can hardly move it,” indicates its use in acute retrobulbar
neuritis, which causes this symptom exactly and is well known to be
frequently due to a rheumatic diathesis. The same symptom may call for
its use in tenonitis, in which the stiffness, difficulty of and pain on
moving the eye are specially prominent and which also has swelling and
œdema of the upper lid, chemosis of the conjunctiva, and protrusion of
the eyeball; all symptoms of rhus tox. The idiopathic form of this
disease is almost always rheumatic or gouty in origin, furnishing still
another indication for the remedy. In orbital cellulitis we have
swelling of the lids, chemosis, protrusion of the eyeball, almost
complete abolition of motion with pain on the attempt and also on
pressure, aching in and around the eye, with the probable formation of
pus in the deeper structures, all conditions curable by rhus tox., which
is one of the best remedies for this disease whatever may be its origin,
traumatic or otherwise, and has cured many of the most desperate cases.

In panophthalmitis, or suppurative inflammation of the eyeball, we find
the swollen lids, difficulty of, and pain on motion, chemosis of the
conjunctiva, severe pain in the eyeball, lachrymation, etc., again
indicating the remedy. Rhus tox. is one of the few drugs that have cured
this most fatal of lesions, and its success in restoring the integrity
of the eye, in some cases where this result has seemed almost
impossible, is a matter of record.

The symptom “heaviness and stiffness of the eyelids, like paralysis, as
if difficult to move the eyelids,” would seem to indicate its use in
ptosis, and this condition as well as paralysis of certain of the ocular
muscles, is curable by rhus tox., especially if due to wetting or
dampness. Such cures have been made frequently in the clinics of the
Ophthalmic Hospital. Erysipelas of the eyelids often presents the
characteristic symptoms of rhus. Of course the swelling of the lids is
always present, but many of these cases have in addition the chemosis,
hot lachrymation, the characteristic pains and aggravation,
restlessness, vesicular eruptions, etc., and it is a valuable and
efficient remedy when these exist.

Although rhus tox. is specially useful in the most serious inflammations
of the deeper and more important structures of the eyeball and
surrounding tissues, its sphere is not confined to these conditions
alone, but seems to cover almost all the acute diseases to which the
visual organs are subject. Given a rheumatic origin, especially if it be
from exposure to damp or wet weather, with profuse lachrymation (pain in
and about the eye) a tendency to chemosis of the conjunctiva, œdema of
the lids, photophobia, and the characteristic aggravation and
restlessness at night, and this valuable drug will rarely be found
wanting in any of the inflammations of the conjunctiva, cornea, or lids.

I have many times cured with it acute catarrhal conjunctivitis,
phlyctenular conjunctivitis and keratitis and ulcers of the cornea, and
have subdued the acute aggravations of conjunctivitis trachomatosa,
where the above symptoms, or some of them, were present. It is also
frequently successful in the treatment of abscess of the lid, which,
while not a serious, is an extremely painful disease.

Dr. W. A. Phillips, in an article published in the _Jour. of Oph., Otol.
and Lar._, July, 1899, page 224, recommends the use of rhus tox., “when
the ciliary muscle itself seems to be the special seat of trouble; when
its muscular tone is disturbed from previous straining, and when
inability is present after using the eyes for reading any considerable
time, notwithstanding optical correction.”

He has had much success with the drug in these cases and considers that
its action here is on a plane with that on lameness or soreness due to
rheumatism. In my opinion another factor may be spoken of. One of the
differential points between arsenic and rhus is that the arsenic patient
is _actually_ so weak that he cannot do what he would wish, while the
rhus patient _feels_ so weak that he cannot do it, but by making the
effort he can overcome his weakness and accomplish what he desires. This
seems to indicate in the rhus case an indisposition to exertion due to
want of _tone_ of the muscular system, and this explanation applied to
the ciliary muscle would account for the successful action of this drug
in the class of cases indicated.

I would not have it understood that I consider rhus tox. an universal
panacea for all the inflammatory diseases of the eye; all of these
affections are many times extremely variable in their presenting
symptoms and other remedies are frequently called for, but the drug
under consideration is one of the first importance and is most reliable
and efficient when accurately prescribed.



 TREATMENT OF SARCOMA WITH THE MIXED TOXINS OF ERYSIPELAS AND BACILLUS
                              PRODIGIOSUS.

                 BY A. WORRALL PALMER, M. D., NEW YORK.


The numerous modes of treating sarcoma or any other variety of cancer,
and the constant experimentation on the part of the profession with new
methods, only go to show how inadequate is our ability to meet this
intractable disease.

These neoplasms are not so rare, as there are ninety-nine authentically
recorded cases, situated within the restricted domain of the
naso-pharynx and pharynx.

For these reasons, and because I have been able to find only one case of
sarcoma treated with Coley’s fluid reported in our homeopathic
literature, do I take the liberty of occupying your time with the
_résumé_ of my investigations into the subject and my meager practical
experience.

Although surgery is, at present, the best method to meet this condition,
personally I believe that more investigation into or trials of the
remedial treatment should be made, because cancer is a constitutional
disease, and it so very frequently recurs after removal with the knife.

Apropos to this, C. Mansell Moullin says in the Boston _Medical
Journal_: “There is at least as much hope after an internal remedy that
causes disappearance by atrophy or fatty degeneration as from the most
extensive removal by operation. On _a priori_ grounds there may be even
more.”

Among the numerous drugs or substances which have been experimented with
are the interstitial injection of alcohol 40 per cent., by Haase; the
injection of Pure Yeast Ferment, by De Bracher; subcutaneous use of 50
per cent. solution of the fluid extract of chelidonium majus re-enforced
by same drug per orem; the cataphoric diffusion of mercury from gold
electrodes used by Massey; and lastly the mixed toxins of the
streptococcus erysipelas and bacillus prodigiosus.

From my research the last is the only one that has attained any success
or wide reputation and not been relegated to the usual oblivion of other
medical fads. The reason for this I consider to be because Dr. Coley has
not only been persevering, but scientific, unbiased, and very cautious
in its advocacy. At first he hoped and believed that in some form it
would be beneficial in all forms of cancer; but he now only recommends
it in sarcoma, and claims marked results only in the spindle-celled
variety of this.

As in many other cases, the discovery of the influence of erysipelas on
sarcomatous growths was by investigation founded upon accidental
occurrences, to wit: Busch reported a case of multiple sarcoma of the
face cured by an attack of facial erysipelas; Durante, a sarcoma of the
neck; Biedert, an enormous round-celled sarcoma, including the mouth,
nose, and pharynx; Bruns, a melanotic sarcoma of the breast; Gerster and
Bull, each a recurrent sarcoma of the neck; all cured or disappeared
with no return, after an erysipelatous attack. This happy result does
not always follow erysipelas, as cases of sarcoma relieved by
erysipelas, and later recurring or progressing after the attack is over,
are reported by Busch, Nelaton, Deleus, Richochon, Winslow, Powes, and
Dowd.

On account of these accidental cures a few observers produced erysipelas
artificially by infusion with the living culture, with success in many
cases.

Then almost simultaneously Lassar of Berlin, Spronck of Utrecht, and
Coley of New York, believing that the curative action of erysipelas lay
in the toxin of the living culture, experimented and found that they
could produce equally good results with toxin, thereby avoiding both the
danger and discomfort of the patient passing through an attack of
erysipelas.

It has been shown by different observers that the combination of certain
bacilli with disease toxins makes such toxins more potent, and Rogers of
Paris demonstrated that the combination of the bacillus prodigiosus with
the streptococcus of erysipelas greatly augmented the virulence of the
streptococcus on rabbits. Thereupon Dr. Coley used the combination on
the human subject in sarcoma with far better results than before.

Regarding this, Dr. Coley says he cannot say exactly what part the
bacillus prodigiosus plays in the cure of sarcoma, but remarks that the
only cases cured were treated by the combination.

This preparation, the combined toxins, had been given the name of
Coley’s fluid, and that used during the last seven years has been made
by Dr. B. H. Buxton of Loomis Laboratory.

Until about five years ago the toxins were made from cultures from a
fatal case of erysipelas, but since that, sufficient strength has been
obtained by passing the cultures through about fifty rabbits. The method
of the preparation is virtually this: the mixed unfiltered toxins of the
streptococcus of erysipelas and the bacillus prodigiosus are made from
cultures grown together in the same bouillon and sterilized by heating
to 58 degrees C. and then diluted in a sterilized menstruum.

In a recent conversation with Dr. Buxton he said that at present he made
a double sterilization and then added some drugs such as thymol to
preserve the preparation.

Dr. Coley, in his exhaustive article in the _Jour. Am. Med. Assoc._,
August 20 and 27, 1898, affixed a table of fifty-seven cases of
cancerous tumors treated with either his fluid or other preparation of
erysipelatous poison with cure, or at least disappearance of the then
present manifestation of the disease and lengthening of the usual period
of a recurrence of the condition.

The following is a list of cases of sarcoma of the nose and throat
treated by cultures of erysipelas, or Coley’s fluid, the physicians in
charge, and the time the patient is living after treatment at the time
of the report in Dr. Coley’s paper, in 1898:

(a) A spindle-celled sarcoma of the neck and tonsils, inoculated
culture—patient living six years after.

(b) A spindle-celled sarcoma of the parotid; it had been extirpated
twice previous to treatment—patient living one year after.

(c) A sarcoma (mixed celled) of the parotid—patient living three years
after. The foregoing under Dr. Coley’s care.

(d) A spindle-celled sarcoma of the palate and pharynx extending to the
vocal cords—Dr. W. B. Johnson—living four and three-quarter years.

(e) A round-celled sarcoma of antrum, pharynx, and neck—Dr. L. L.
McArthur—child aged five years, weight gained from 37 to 69
pounds—later, fatal recurrence.

(f) A round-celled sarcoma of parotid, size of the fist—Czerny of
Heidelberg—living over a year.

(g) A spindle-celled sarcoma of the parotid—Horace Packard—living two
and three-quarter years.

(h) A round-celled sarcoma of the neck—H. Montague—slight return in six
months.

(i) A recurrent sarcoma of the neck and tonsil—J. O. Roe—six months
after treatment died of erysipelas.

The mode of administration is cumulative. The injection is of course to
be made under the most thorough antiseptic principles attainable. It is
by far preferable to make the injection into the growth itself,
although, if this is impossible, it may be introduced into the nearest
accessible point, but in the latter case the dosage needs to be doubled.

As a rule one-half drop is the initial dose, and this is increased
one-half drop each succeeding day until toleration is reached. This is
evidenced by the natural reactionary fever rising to 102° or 103° F. In
such case the following dose should be the same as the preceding, and if
it should again go so high reduce the next dose one-half drop. The dose
is increased in this manner until the maximum is attained. When applied
to the neoplasm itself 8 drops is the full dose, or if elsewhere, double
that amount, 16 drops.

This last amount is to be continued daily until the tumor has
disappeared.

The toxin may commence to reduce the tumor in a week, but its
administration should not be abandoned in less than three weeks’ trial.
The time necessary to effect a cure is very variable; occasionally the
neoplasm will almost disappear in two weeks, while on the other hand it
may take several months.

The reactionary symptoms are a chill, followed by fever, generally
lasting about three hours, although occasionally it may continue twelve
hours; acute transitory swelling of tissues in the immediate vicinity of
injection; usually myalgic pains commencing at point of injection and
radiating frequently over the whole body; in the more severe reactions
there is nausea or even vomiting—in my own case it produced a weakening
menorrhagia.


  CASE.—Mrs. E. C., æt. thirty-four years. A tall, thin woman of
  neurotic temperament.

  _Family History._—Father had chronic bronchitis, but died of kidney
  disease. Mother was an invalid for seven years with rheumatism of
  hip and knee until death, which was caused by apoplexy; a sister
  died of gastric disease. The patient married eleven years; has two
  children living; boy at nine months died of entero-colitis; boy
  three and one-half years died of fall from window; two miscarriages.
  At ten years æt. the patient had diphtheria; at twenty-six,
  pleurisy; at thirty-one years, rheumatism of left shoulder and
  post-cervical region. It is impossible to obtain any indication of
  hereditary predisposition.

  _Subjective Symptoms._—Complains of post-nasal dropping of mucus,
  constant short hacking cough, malodorous breath, pain in region of
  spleen; aggravated when lying down and throbbing in character when
  walking rapidly. After discovering the swelling in the throat and
  speaking of it she admitted there had been a sensation of a lump in
  the throat for about a year, but so slight she considered it of
  little consequence.

  _Objective Symptoms._—Nares: Rhinitis sicca, covered with dry
  crusts, but turbinated bodies hypertrophied.

  Naso-pharynx and pharynx: Mucosa slightly hyperæmic, follicles
  inflamed and enlarged. On the left side of these cavities is a
  sessile swelling, the general surface of which is much inflamed, and
  half of the surface is covered with varicose veins about one-eighth
  of an inch in diameter; it extends more than half the width of the
  pharynx and vertically from the vault above to the lateral sinuses
  below; is neither painful nor hyperæsthetic; it has a boggy feel,
  but not as soft as an abscess. The tumor springs from the posterior
  wall of the pharynx, not connected with the tonsil, as the left
  posterior pillar lies in front of the neoplasm and can be lifted
  free from it. Neither of the tonsils is inflamed nor hypertrophied;
  a few cervical lymphatics on the left side are slightly indurated,
  but slightly sensitive—if at all.

  The swelling had probably existed longer than an abscess would be in
  forming, and there was neither pain nor fluctuation. Still an
  exploratory incision was made, but with the expected negative
  results.

  Although the tumor was situated over the principal chain in
  lymphatics of the pharynx, it was not nodular, but smooth. Therefore
  the neoplasm was probably not of lymphatic origin, but an
  implication of the muscular tissue behind the pharynx.

  A specimen was submitted by Dr. Klotz, the pathologist of the
  hospital, and the provisional diagnosis of angio-sarcoma
  made—sarcoma because it seemed to spring from the muscular tissue
  and apparent predominance of blood-vessels, and of the angiomatous
  variety because of the enlarged blood vessels on the surface.

  The removal of the specimen for microscopical examination caused
  quite a severe hemorrhage, lasting about two hours, notwithstanding
  the employment of the usual hemostatics.

  The microscopist pronounced it a small round-celled sarcoma.

  I showed the case to the Academy of Pathological Science, where two
  general surgeons who examined the case advised against extirpation
  of the tumor, because of its close proximity to the important blood
  vessels and nerves of the neck, an opinion I entirely coincided
  with, because of seeing two similar cases before. This agreement
  decided me in determining to try the mixed toxins as the treatment
  promising the best results for the patient.

  April 4. Commenced injections with one-quarter of a drop. I
  diminished the initial dose one-half because Dr. Coley personally
  advised it, as he thought the possible reactionary local swelling
  might seriously interfere with respiration.

  April 14. The dose was increased one-quarter drop each day to
  date—when she took only two drops, because it was deemed advisable
  to omit treatment two days during menstruation on account of great
  weakness of patient.

  April 20. Increased dose half drop per diem—on 16th and 19th
  treatment omitted on account of debility—dose 4 drops, which dose
  was continued till April 23, when on account of the temperature
  twice having risen to 103° F. and menorrhagia having supervened only
  ten days after previous regular menstruation, I thought it prudent
  to reduce dosage to 3½ drops, which was continued until April 26.
  Examination of pharynx to-day for first time showed a decided
  diminution in the congested appearance and size of the tumor.
  Formerly the tumor pushed the posterior pillar forward, so that, if
  the pillar could not have been lifted away from swelling by the ring
  probe, it would have seemed to be part of it; while to-day a small
  space could be distinguished between the tumor and the pillar.
  Dosage 4 drops.


In _résumé_, I would call attention to the apparent susceptibility of
the patient to the toxin. Because, although she never received over half
the maximum dose, the following reactionary symptoms developed: Of the
seventeen days on which full records were kept, on thirteen she had
chills after every dose; there were muscular pains throughout the left
side, occasionally extending to the right—one-third of the time the
patient was nauseated, and three times vomited—the average temperature
was 100.8° F.; twice it did not rise at all after injections of ½ or 2½
drops. ’Tis well to bear in mind that chills very seldom occur after the
third injection.

Finally, I wish to thank Dr. Clausen, resident physician, who carried
out most of the treatment while the patient was at the Ophthalmic
Hospital; also Dr. Bernard Clausen, who continued it after she returned
home.



            REPORT ON “HENPUYE” IN THE GOLD COAST COLONY.[3]

         BY ALBERT J. CHALMERS, M. D., VICT., F. R. C. S. ENG.


Henpuye, or dog nose, is a disease frequently met with in the Gold Coast
Colony and in certain portions of its Hinterland. The hideous deformity
of the face which it causes is very striking to anyone who has lived in
this part of West Africa. It is also known on the French Ivory Coast
under the name of “goundu” or “anakhre,” but “henpuye” is the native
name (Appolonian) for the disease on the Gold Coast. The peculiar nature
of the disease and the fact that, as far as I could find, very little
was known as to its nature led me to make the inquiries which are now
embodied in this report. I regret very much that I am unable to refer to
original papers on the subject or to be certain that I have the full
literature, but my excuse is that libraries do not exist in West Africa.
The only references which I have met with are those mentioned in Dr.
Patrick Manson’s work on “Tropical Diseases” (p. 594), and they are
those of (1) Professor Alexander Macalister (Royal Irish Academy, 1882),
(2) Surgeon J. J. Lamprey, A. M. S. (_Brit. Med. Jour._, vol. ii.,
1887), (3) Dr. Henry Strachan (_Brit. Med. Jour._, vol. i., 1894), and
(4) Dr. Maclaud (Archives de Médecine Navale, 1895). It is by the kind
permission of the Governor of this colony, Sir Frederick Hodgson, K. C.
M. G., that I am allowed to publish this report. I am much indebted to
Captain Armitage for his kindness in giving me information with regard
to the different places in which he has noticed this disease in his
travels, for drawing my attention to notes of the late Mr. Ferguson on
the presence of the disease in Akim and Kwahu, and for making a painting
of an advanced case of the disease; also to Dr. Henderson, the chief
medical officer of the colony for many kind suggestions: and, lastly, to
Mr. Crowther, draughtsman in the Public Works Department, for supplying
me with a map of the colony and its Hinterland. The description of the
disease will be divided into the following headings: (1) the General
Description of the Disease; (2) the Description of Cases of the Disease;
(3) the Treatment; (4) the Morbid Anatomy; (5) the Ætiology; and (6) the
Geographical Distribution.


                THE GENERAL DESCRIPTION OF THE DISEASE.

Henpuye starts in a native of West Africa during or soon after an attack
of yaws in which there is a history of the nasal mucous membrane being
attacked as a small bony swelling symmetrically placed on either side of
the nose. This swelling, which is generally oval with the long axis
directed downwards and outwards, is attached to the nasal bones, the
nasal process of the superior maxilla, and also to the superior maxilla
in the more advanced cases. It is produced by the deposition of new bone
under the periosteum on the external aspect of these bones and grows
slowly in all directions. It in no way affects the mouth or the orbital
or nasal cavities in any case which I have seen, and the nasal ducts are
quite unaffected. Rarely the growth is asymmetrical, being situated only
on one side of the nose. Pain in the nose and the presence of a sore in
that organ are the symptoms complained of at the commencement of the
disease; later headache is sometimes felt, and pain in the swelling
during wet weather. As the growth becomes larger it seriously interferes
with the sight by growing up in front of the eyes and even hiding them,
but I have never seen it cause destruction of the eyeball. In many cases
the patient has to bend his head downwards in order to be able to see
over the tops of the swellings. The skin over the tumor is normal and is
freely movable. The course of the disease is that the swellings may
cease to grow at any period of their existence or may continue to grow
for years—that is to say, they may remain quite small or may grow to be
large lumps, in the latter case giving rise to the deformity and the
interference with the sight, but I am unacquainted with any case in
which they break down or ulcerate. Finally, the disease is much more
common, in my experience, in men than in women.


                         DESCRIPTION OF CASES.

The following cases will be described: (1) slightly developed cases; (2)
moderately developed cases; (3) an advanced case; and (4) an
asymmetrical case.


  _Slightly Developed Cases._—CASE I.—The patient, a boy of about
  seventeen years of age, said that about seven years ago he noticed
  two small lumps on the nose which began after yaws in which there
  was a sore in the nose. They increased slightly in size, but soon
  ceased to grow and have been in their present condition for some
  years. He never felt any discomfort or pain in them. The two lumps
  had their long axis directed downwards and outwards, the
  measurements being half an inch by a quarter of an inch. They were
  attached to the nasal bones just above the cartilages and the nasal
  process of the superior maxilla, and were firm, smooth, bony tumors.
  The skin over them was quite normal and they did not in any way
  project into the nasal cavity or affect the line of vision, being
  too small for the latter purpose. There was very little deformity
  and no treatment was necessary. In this case the lumps soon ceased
  to grow.

  CASE II.—A small Grunshi girl from Kumassi, about seven years of
  age, who had had yaws some time previously, felt pain in the nose a
  few months ago and noticed a small swelling on each side of the
  nose, and this gradually increased in size till it reached its
  present condition. Her mother was most anxious to have it removed on
  account of the deformity. On inspection there was found to be an
  oval swelling on each side of the nose, attached to the nasal bones
  and the nasal process of the superior maxilla. The long axis of the
  swelling was directed downwards and outwards—an inch in length and
  half an inch in breadth. The nasal cartilages were not affected and
  the interior of the nose was normal. The orbital cavity, the mouth,
  and the nasal ducts were quite unaffected. The skin over the
  swelling was normal and freely movable. The patient felt no pain in
  the tumor and she had never had any headache. The growths were
  removed by operation. It was very difficult to obtain definite
  history as to the time when this patient had had yaws and as to the
  time when the growth appeared, but as far as I could make out the
  yaws were well developed when the swelling was first noticed.

  _Moderately Developed Cases._—CASE III.—A young man, a Ga native,
  who had had yaws about seven years ago, felt pain in the nose and
  got a person to look into it, who said that there were yaw spots on
  the mucosa, and later a small swelling on each side of that organ
  was noticed. These small swellings grew slowly to their present
  size, and the patient said that they were still increasing. He
  complained of frontal headache and of slight pain in the swellings
  in wet weather. On inspection two symmetrically placed swellings
  were seen on each side of the nose, looking somewhat like small
  eggs. They were oval in shape, with the long axis directed downwards
  and outwards. The left measured two inches by two inches and the
  right three inches by two and a half inches. A profile view showed
  that they were slightly concave on the side towards the orbit. They
  did not affect the orbital or nasal cavities, nor did they project
  into the mouth or affect the nasal ducts or the cartilages of the
  nose. They were attached to the nasal bones, the nasal process of
  the superior maxilla, and to the superior maxilla itself. They were
  smooth, but on the left side the tumor rose to a central ridge. The
  skin over the swellings was quite normal and was freely movable. In
  order to see clearly, the patient often had to bend his head
  somewhat. The growths were removed by operation.

  CASE IV.—The patient was an Akwapim woman, aged about twenty years.
  This case was similar to Case III., but the swellings, which had
  started when the patient (who had suffered from yaws) was seven
  years of age, were rather more rounded. She would not consent to
  operation.

  _An Advanced Case._—CASE V.—A man, a native of Appolonia, about
  forty years of age, stated that the swellings began with pain in the
  nose after yaws, when he was about six years old. They grew steadily
  and slowly till eight years ago, when they stopped, and they have
  not increased in size since then. On inspection there were two oval
  swellings situated on each side of the nose, the left measuring two
  and a half inches by one inch and the right three-quarters of an
  inch by half an inch. They projected upwards over the orbit, the
  long axis in each case being directed downwards and outwards. They
  did not project into the mouth, the nose, or the orbit, and the
  nasal duct was free. They were attached to the nasal bones, the
  nasal process of the superior maxilla, and to the maxilla itself.
  The skin over the tumor was normal and it was freely movable. The
  patient complained of headache and found that the swellings
  interfered with his vision considerably, particularly on the left
  side. He refused to submit to operation.

  _An Asymmetrical Case._—CASE VI.—An Ashanti boy, aged six years,
  from Donkeo Inquanta, had yaws, and while suffering therefrom, just
  a year previous to his consulting me, the swelling appeared on one
  side of the nose, and had been growing ever since. There was no sign
  of any lump on the other side. He was advised to go to Kumassi for
  operation.


                             THE TREATMENT.

I have attempted to reduce these swellings by the administration of
iodide of potassium, but have not met with any success. The only
treatment appears to be the removal by operation. The method I adopt is
as follows. The eyes being protected by a pad over each, an incision is
made along the long axis of the tumor and the skin is freed on all sides
so that its base is exposed. If the swelling is very small in a child it
may be necessary to make a cross cut through the skin as well, in order
to get sufficient room to work in. The bone being exposed, a portion of
the swelling can easily be cut away by bone forceps, because it is very
soft. If large, a few nicks with a Hey’s saw are found most useful in
enabling a large portion of the mass to be removed entire. After as much
has been removed as possible with the bone forceps, more may be got away
by means of the gouge or the gouge forceps or the nibbling forceps. I
have experienced difficulty in removing the deeper portions,
particularly those close to the orbit. I need hardly say that in the
latter the eye has to be carefully guarded from injury. After removal of
the bone the wound is well washed out with an antiseptic lotion. The
bleeding is slight and is easily controlled by pressure. The wound is
closed by a continuous suture and it heals up readily.


                          THE MORBID ANATOMY.

I have never had any chance of examining the growth _post mortem_, but
the portions which I have removed _en masse_ by operation have enabled
me to make some investigations. The periosteum strips off readily, and
under this is a thin shell of compact bone, which appears somewhat
ridged on the side towards the periosteum. The rest of the tumor
consists of cancellous bone. The whole swelling cuts readily with bone
forceps and consists of quite soft bone. On making microscopical
preparations there were signs of ossification in membrane proceeding
under the periosteum, and the rest appeared like ordinary wide-meshed
cancellous bone. The whole process appeared to be that of a slow
“osteoplastic periostitis.”


                               ÆTIOLOGY.

Two views on the ætiology of this disease have been brought forward up
to the present time, as far as I know—viz., that the swellings were of a
racial character and that the process was started by the larva of some
insect. With regard to the first I have only to mention that the disease
is found in Ashantis, Grunshis, Fantees, Abantas, the Ga people, etc.,
races quite different from one another, to show that this cannot be
entertained. As to the second, I have never met with evidence which
would support the idea that the disease was started by a larva. On the
other hand there is always the history of yaws and of the tumor starting
during the attack of yaws—_i. e._, during the period of eruption or soon
after. Then, again, the patients complain of pain in the nose with, in
some cases, distinct history of a sore and sometimes discharge preceding
the swelling. This might be due to some irritation or ulceration of the
nasal mucous membrane by the yaws. I have never had the opportunity of
examining any person at this stage of the disease, but in the more
developed cases I have examined the nose for marks or signs of old
ulceration, but have not found them. If, however, the nasal process of
the superior maxilla be examined a few foramina are to be seen, and
these are often joined together by a small groove indicating the
position of a bygone suture. The foramina are for small bloodvessels,
which are said to communicate with those of the mucosa of the nose. The
site of these foramina is the situation where henpuye starts, and I
venture to bring forward the theory that the causation of this peculiar
disease is due to an osteoplastic periostitis brought about by the
absorption of the poison of yaws from the nasal mucous membrane through
the small vessels (or lymphatics) keeping open the foramina which
indicate the suture above mentioned.


                     THE GEOGRAPHICAL DISTRIBUTION.

I am only aware of cases reported from the Gold and Ivory Coasts of West
Africa and the West Indies. I never met with it in Mamprusia, nor have I
met any trader coming from Moshi with it, nor have I met with it in Fra
Fra, and I can find no one who has seen it in the eastern parts of the
colony. But in the following districts it has been noted: Ahanta,
Appolonia, Fantee, Accra, Aquapim, Akim, Assin, Sefwhi, Ashanti,
Attabubu, Kwahu, Kintampo, Berekum, Gaman, the Neutral Zone, and Wassaw.
It is perhaps most common in the Sefwhi, Wassaw, and Appolonia districts
which adjoin the French Ivory Coast, where cases are also known.

I look upon henpuye as a localized osteoplastic periostitis in the
region of the nasal process of the superior maxilla, generally
symmetrical, due to yaws, and found among the natives of West Africa and
the negroes of the West Indies.



                THE MADDOX ROD OR THE PHOROMETER; WHICH?


In the last issue of the Journal there appeared an abstract with the
above title, and believing the subject to be of much interest at the
present time, our readers have been invited to send us their opinions on
the matter, as based on the experience obtained in practice. The
communications below have been received and are presented in the order
of their reception. We shall be glad to hear from any physicians who are
interested [ED.].


  DEAR DR. DEADY: In reply to your favor requesting my opinion
  regarding the respective merits of the Maddox rod and the diplopia
  test, I wish to say that my experience leads me to rely more and
  more upon the obscuration test, and while I have not followed out
  the comparison to any great extent, such as is shown by your tables,
  results obtained by relying upon the rod test in the detection of
  heterophoria, as well as in determining when the weak muscles have
  been sufficiently developed, have been such as to warrant my
  continuance of its use.

                                                         E. D. BROOKS.


  I have with interest watched the discussions of late, as to the
  relative value of the Maddox or Stevens tests for heterophoria, as I
  have for years used them both.

  My muscle tests have been made for the last five years at least,
  with a Risley phorometer, which combines both tests upon one arm and
  has proven for me a most satisfactory instrument.

  I am sorry to say that I have not kept any comparative statistics of
  my examinations; at the same time they have all left an impression
  upon my mind, which is this: that I feel more confidence in the
  results obtained from the use of the Maddox test in the routine
  tests that I always make of refractive cases. If this test shows any
  marked degree of heterophoria it has been my habit to retest the
  patient by the Stevens method, which is usually the same, provided
  the patient has a sufficient amount of intelligence to give correct
  answers to the questions put to him. During this test the patient is
  allowed to sit for some time in front of the prisms, and the eye
  muscles allowed to relax from that first impulse at muscular effort
  that follows the placing of the prisms in front of the eyes.

  To my mind both tests are good and fairly accurate in the hands of
  one who is thoroughly familiar with their use and shortcomings,
  provided your patient is able to answer correctly.

  Many times, on re-examining a patient, I have discovered what
  appeared to be a great change in the muscular conditions, but after
  repeated examinations I have usually found it was the patient, and
  not the muscles, that was erratic.

  When Dr. Hubbell speaks of ¼° of difference between the Maddox and
  Stevens tests, he has more confidence than I have in the average
  judgment of patients that come under our care.

                                                      SAYER HASBROUCK.


  DEAR DOCTOR: Your note asking my opinion of the comparative
  usefulness of the Maddox rod and the phorometer is at hand.

  In the detection of heterophoria I regard the rod as the most
  convenient and trustworthy instrument used.

  The distance at which the test is made and the dissimilarity of the
  images seen usually eliminate all actual effort to hold the eyes in
  any particular position other than that in which they stand the most
  easily. Accordingly the deviation is quickly noted and readily
  measured.

  So satisfactory has this modest little instrument been in my
  examinations that I now rarely resort to other methods. The amount
  of deviation sometimes shown between this and other instruments is
  so slight as to make little or no difference in the measures
  employed for correction.

  It is to be noted that cases not unfrequently occur in which a
  hyper-sensitive, or, on the contrary, an enervated condition exists,
  which is not fully indicated by any instrument. An educated judgment
  will here have to supply conclusions not to be drawn by any
  hard-and-fast rules.

  After the rod and the phorometer came into use and an opportunity
  was presented to compare the results obtained by each, I made a
  careful test of eighty pronounced cases of errors of refraction
  accompanied by heterophoria. Of this number only nine showed a
  persistent difference of deviation and in none of them a difference
  greater than 1½°. But this was not always on the one side or the
  other, as six out of the nine showed a higher degree of deviation by
  the rod than by the phorometer. Eighty cases may not be enough upon
  which to base an orthodox conclusion; but my experience with the rod
  has been so satisfactory that I now seldom use the phorometer at
  all. It appears quite possible practically to estimate the degree of
  heterophoria as accurately with the one instrument as with the
  other; and while it is true that a correction of the error of
  refraction will commonly correct the deviation, still all cases of
  optical defect should be tested with the rod or phorometer before
  the lenses are prescribed.

                                                      WM. A. PHILLIPS.


  MY DEAR DR. DEADY: Dr. Hubbell limits the discussion “to the
  comparative value of the diplopia test, by Stevens’ phorometer” and
  the Maddox rod test.

  It would be interesting to follow out the idea with other
  phorometers,—and with the Wilson phorometer my records do not show
  quite such a marked difference in results,—but I have not taken
  pains to get comparative results in any considerable number of
  cases.

  Dr. Hubbell says: “In the diplopia test, the dissociation is
  effected by changing the visual axis of one eye by means of a prism.
  The displacement of one image cannot be done without associating
  with it, more or less, an impulse to some form of ocular effort....
  In the obscuration test (Maddox rod) no such effort is invited, no
  change of innervation takes place.” But in the rod test the light
  seems nearer to the patient than in the prism test. This may account
  for much of the difference in results and amount to “an extraneous
  impulse to muscular contraction.”

  Dr. Hubbell is entirely justified in his conclusion as made upon
  experiments with the Maddox rod and the Stevens phorometer. I shall
  watch cases along similar lines with the Wilson phorometer and
  report later.

  In the mean time the rod and the prism tests may well be taken in
  each case and let judgment decide as to treatment.

                                                     THOS. M. STEWART.


  I agree with the writer that the rod test is the more scientific
  test for heterophoria, and of late years have virtually discarded
  the prism test, except in special cases. The tables are interesting,
  but their value would be materially increased if the author would
  supplement them with tables showing the refraction, and inflammation
  or its results.

  Was it an accident that Stevens’ phorometer showed the same amount
  of right hyperphoria in one-ninth of the cases, and in thirteen of
  thirty-three cases of left hyperphoria? In which of these cases was
  there anisometropia and of what kind was it?

  What was the refraction of the two cases of exophoria, two of left
  and one of right hyperphoria by the phorometer; and was the
  refraction the same in the six cases which were orthophoric by both
  rod and prism?

  Such studies are necessary to a clear understanding of the relative
  value of these tests.

                                                       JOHN L. MOFFAT.


  DEAR DR. DEADY: Your letter and inclosed article on “The Maddox Rod
  or Phorometer; Which?” has been received and examined with interest.

  I have examined a good many cases in my office by both methods and
  find variable results, but where there is a radical difference I
  have found the Maddox rod the more accurate, and from experience I
  have learned to rely upon it instead of the phorometer, as in
  prescribing prisms in hyperphoria in connection with glasses for
  constant use I rely wholly upon the rod test.

                                                        J. M. FAWCETT.


  DEAR DOCTOR: Concerning the discussion of Maddox Rod vs. Phorometer
  about which you wrote me—can say that I believe that the Maddox rod
  is the more reliable test. My reasons on theoretical grounds for so
  believing are briefly these.

  Given a case for examination; the test which _least disturbs_ the
  muscular co-ordination under investigation must give the best
  result. Now I think that when we throw the images into
  non-corresponding retinal points that we almost certainly cause some
  tension of certain muscles, because it is putting the eyes in an
  _unnatural_ relation with one another; and this is done by the
  phorometer. The Maddox rod is theoretically free from this
  objection.

  _Practically_ the deviations are more certainly measured, because a
  patient _knows_ when the streak cuts the light; and you cannot trust
  their eye alone to tell when the lights are exactly in a line. Have
  used _both_ tests in every case I have examined in my private
  practice, and I find the Maddox the more reliable test. It is more
  to be depended upon.

                                                    EDW. HILL BALDWIN.



                   ABSTRACTS FROM CURRENT LITERATURE.


=Grant, Dundas.—Case of Emphysema of the Orbital Wall of the Anterior
Ethmoidal Cells, Caused by blowing the Nose.=—_Jour. Lar., Rhin. and
Otol._, March, 1900.

This case was shown to the British Laryngological, Rhinological and
Otological Association.

W. M., twenty-eight years, came under my care yesterday on account of a
sudden swelling of his eye which had taken place two hours previously,
and which had occurred suddenly as he was blowing his nose without a
handkerchief, and which gave him the impression as if something were
running out of his eye. The swelling crackled in a manner characteristic
of emphysema, and the first suspicion was that he must have had some
disease of the orbital wall of the anterior ethmoidal cells, and that on
examination there would be found some evidence of ethmoidal disease.
None such was to be elicited, and the only history obtainable was that
he received several kicks on the nose and back of the ear two months
ago. This has probably resulted in a fracture of the orbital wall of
certain of these cells.

                                                                 PALMER.


=Lack, Lambert.—Case of Nasal Polypi, with Suppuration and Absence of
Maxillary Sinuses.=—_Jour. of Lar., Rhin. and Otol._, April, 1900.

A man, aet. twenty-eight years, complains of nasal obstruction and
purulent discharge, with a disagreeable odor in the nose. The polypi
having been removed, the pus appeared to flow from under the anterior
ends of the middle turbinates. After wiping the discharge away and
bending the patient’s head forward, it reappeared in large quantity. On
transillumination the cheek on both sides appeared quite dark, and the
patient had no subjective sensation of light. The diagnosis of antral
suppuration was now considered almost certain, and the patient was
advised to have both antra punctured from the alveolar margins. This was
accordingly attempted under gas, but although the antrum drill was
forced in for its full length, no cavity was reached.

Puncture from the inferior meatus was next attempted, and considerable
force was used in two different points; but with no better result. It
would seem therefore that the antra must be very small, if not entirely
absent.

_Discussion._—Mr. Spencer thought it might be one of those convoluted
inferior turbinals which form a gutter in which pus collects. The
majority considered it suppuration in the ethmoidal region.

                                                                 PALMER.


=Lawson, Arnold.—Cicatrix Horn Growing from the Cornea.=—_The Lancet_,
February 3, 1900.

The patient was a female child, aged eight years, a hydrocephalic idiot.
The history given was that about one year previously a white spot had
appeared on the right eye and that the eye began to project. Six months
later a growth was first noticed on the right cornea, and this had
constantly increased in size. Latterly a white spot had appeared on the
left eye. On examination of the eyes there was seen a large conical
tuberculated excrescence protruding between the lids of the right eye.
It was half an inch in length and its base attached to the cornea
covered about four-fifths of its surface. The left cornea exhibited a
yellowish infiltration just below the pupil, over which the cornea was
bulging; the anterior chamber was deep, the iris was immobile, the
tension was slightly raised, and the eye was quite blind. Both globes
were very anæsthetic, and there was considerable muco-purulent discharge
from a chronic inflammation of both conjunctival sacs. The growth upon
the right eye was accidentally detached a few days after admission into
the hospital, and it was then seen to have been attached to the cornea
at the apex of a central staphyloma, which was left covered by a fleshy
soft core which had formerly been embodied in the center of the growth.
The cornea was entirely opaque, and the eye was quite blind. After
removal of the right eye a few days later examination of the globe
revealed a co-arct retina with evidences of chronic degenerative changes
in all the various structures. The anterior chamber was completely
abolished, the iris throughout its extent being firmly adherent to the
back of the cornea, which was bulging centrally. The apex of the corneal
staphyloma had evidently been the site of a large perforation, which was
closed by the fleshy granulations which formed the core of the growth.
The growth itself measured half an inch from apex to base and one and a
half inch around its base.

The interior portion was soft and crumbling, but the external layers
were hard and horny and cut with difficulty. A wedge-shaped piece was
cut away from the growth and specimens were cut and stained with
carmine. The microscope showed that the external layers consisted of
several faintly fibrillated strata of a dense, homogeneous nature. The
layers occupied about one-quarter of the entire thickness of the walls,
the rest being entirely composed of small nucleated cells, those most
external being stratified. Adopting Mr. Bland Sutton’s classification of
human horns, this growth would be an example of a cicatrix horn, the
rarest of all varieties of horn, and one which had been usually found in
connection with cicatrices of burns and scalds. The probable ætiology in
this case was an overgrowth of granulation tissue closing the
perforation in the cornea, which, owing to an unhealthy condition of the
wound and eye, which was anæsthetic and atrophic, had become exuberant,
simulating exactly the condition known as “proud flesh” elsewhere. By a
process of accumulation and heaping up, the granulations gradually
formed a cap over the cornea, whilst the external layers gradually
became stratified and horny from the pressure of fresh growth from the
central core and by the action of the air. The nature of the growth was
evidence that the corneal epithelium bore no share in its production and
discounted the possibility that it might be due to a huge crust of
inspissated conjunctival discharges.

                                                                  DEADY.


=Lodge, Jr., M. D., Samuel.—A Case of Fatal Sphenoidal
Suppuration.=—_The Laryngoscope_, March, 1900.

W. S., aet. thirty-one years, admitted to Royal Halifax Infirmary May
15, 1899, complaining of pain in right ear and right side of face of six
months’ duration. For two months right side face swollen and copious
bloody, purulent discharge from right nostril. Nine years ago had
syphilis. Insomnia from pain.

On admission: Temperature 100°; skin over right superior maxilla red and
œdematous; thick purulent discharge from right superior meatus,
sequestrum in region of right cribriform plate; naso-pharynx, chest, and
abdomen normal; urine, sp. gr., 1014; trace of albumen. Fundi (of eye)
normal.

May 16—No pus found in antrum on exploration and flushing. Patient
taking 60 grs. pot. iod. (t. i. d.) and mercurial inunction. Temperature
in ear usually higher than that in mouth until just before death. June
8.—Mortuus est.

_Post-mortem Examination._—Skull. Base of brain was bathed in thick
greenish pus, principally in the neighborhood of the pituitary body, the
pus extended back over the pons and medulla. No brain abscess.
Ventricles contained more than normal quantity of fluid. Frontal sinuses
and cribriform plate of ethmoid and ethmoidal cells normal.

To right of the sella turcica there was some necrosis of the walls of
the sphenoidal sinus. Probe readily passed from base of skull through
sphenoidal sinus into the nose. Large free opening from said sinus into
nose, which sinus was full of muco-pus. Cavernous sinus not thrombosed.
Right antrum of Highmore contained about a dram of thick glairy mucus.

                                                                 PALMER.


=Killian, Prof. Gustav.—Case of Acute Perichondritis and Periostitis of
the Nasal Septum of Dental Origin.=—_Münch. med. Wochen._, No. 5, 1900.

There have been recorded two cases of perichondritis of the septum due
to alveolar periostitis. Suppuration of dental cyst was cause in the
following case.

A young man had pain in second left upper incisor; two days after
obstruction of nose supervened, with pain in forehead and high fever.
There was a sudden copious discharge of fetid pus from right nostril
seven days later. The entire mucosa of the septum was raised from the
cartilages, etc. It is considerably swollen over right side of the
triangular cartilage, but less so posteriorly. Severe headache in
forehead and frontal eminence, and still little fever. The pus was
escaping through a small hole into the left nostril. It was freely
incised. The triangular cartilage was disintegrated, and the pus had
burrowed between the soft tissues and vomer and vertical plate of the
ethmoid. The choanæ were constricted by thickening of the septal mucous
membrane. The wound healed in a fortnight without sequestrum, while the
toothache lasted but two days.

Six months later the patient had recurrence of pain in the same tooth of
two months’ duration; it was extracted and pus continued to exude from
the socket. A probe, passed 2½ centimeters to the floor of the nose and
septum, showed a cavity covered with membrane in the anterior parts of
upper jaw, which was a cyst at the root of the tooth. The anterior cyst
walls were removed with bone forceps, and the remainder scraped. The
cavity gradually healed.

The cyst probably broke through under the septal mucous membrane. In
exceedingly few cases of perichondritis does the process extend to the
osseous septum. Only once has the author seen record of a case which was
as extensive as this. The offensive odor also points to a dental origin.

                                                                 PALMER.


=Hawthorne, C. O.—The Eye Symptoms for Locomotor Ataxia, with a Clinical
Record of Thirty Cases=.—_Brit. Med. Jour._, March 3, 1900.

It is now generally recognized that the disease known as locomotor
ataxia may include among its clinical manifestations symptoms other than
those which depend on pathological changes in the spinal cord. A number
of these are associated with the functions of the eyeballs. The
Argyll-Robertson pupil is universally admitted as valuable confirmatory
evidence of a diagnosis of locomotor ataxia; ocular paralyses, if less
frequent, are certainly not less significant; and optic nerve atrophy is
at least so well known in connection with the disease that its
occurrence in any individual case would hardly call for comment.

A further step forward in our knowledge of the clinical possibilities of
locomotor ataxia has been the recognition of the fact that ocular
disturbances may precede the evidences of any spinal lesion. This
advance necessarily means that the occurrence of any one of the ocular
events above mentioned must, unless otherwise explained, generate the
suspicion that the case may in its later events display the phenomena
known to depend upon sclerosis of the posterior columns of the spinal
cord.

It is very difficult to collect the evidence necessary to show in what
proportion of cases this suspicion is justified by the event. For it is
certain that ocular disturbances may long precede the manifestation of
spinal symptoms. In the case of optic atrophy the interval may,
according to Gowers, extend even to twenty years. Thus it can only be in
very exceptional instances that one and the same physician will have the
opportunity of observing at least a number of these cases through all
the stages of their progress. Yet, if true, it is of manifest
importance, for the sake both of exact knowledge and of accurate
prognosis, that it should be clearly recognized that an optic-nerve
atrophy, an ocular paralysis, or a loss of the pupil light reflex,
unless capable of other explanation, belongs in all probability to the
order of events incident to locomotor ataxia, and that any one of these
may well be the introduction to a more widely-spread manifestation of
the disease.

For reasons stated above, the collection of complete histories necessary
to afford actual demonstration of the truth of these propositions is
difficult; and all the more so as there is reason to believe that in
those cases in which the early stress of the disease falls upon the
nervous apparatus of the eyeball the spinal symptoms are apt to be
slight in degree as well as delayed in development. This is certainly
the case when the ocular disturbance takes the form of optic-nerve
atrophy. “In a large number of such cases,” says Gowers, “ataxy never
comes on, the spinal malady becoming stationary when the nerve suffers.”

Of course, in a given case of optic-nerve atrophy without spinal
symptoms the question may fairly be raised whether it is right to place
such a case in the locomotor ataxia group. All that can be said in reply
is (1) that from cases of optic atrophy pure and simple one passes by an
unbroken series of steps through cases with more and more distinct
evidence of locomotor ataxia to, at the end of the series, optic atrophy
in association with characteristic ataxic symptoms, and (2) that, as
already stated, a simple case of optic atrophy may remain unchanged for
many years, and yet in the end display undoubted evidence of the
development of a spinal lesion. But if optic-nerve atrophy may be the
primary symptom in the disease, if the occurrence of spinal symptoms may
follow it after an interval of many years, and if again it may remain
without at any time any existing ataxia, it is not unreasonable to
presume that both the Argyll-Robertson pupil and an ocular paralysis may
each have exactly corresponding relations to the development of the
spinal evidences of locomotor ataxia. The collection of evidence to
support this suggestion is even more difficult than in the case of
optic-nerve atrophy. The latter condition must ere long compel the
patient to seek medical advice, and thus the opportunity for a complete
investigation of the state of his nervous apparatus is afforded at a
relatively early date. But an Argyll-Robertson pupil may exist, and
presumably exist for years, without any inconvenience to the patient.
Such a patient, therefore, will not consult his medical adviser until
spinal or other symptoms display themselves, and thus the precedence of
the pupillary condition cannot be determined. In the case of an ocular
paralysis medical assistance is, no doubt, usually promptly invoked. But
such an occurrence is open to a number of ætiological explanations, for
example, rheumatism, cold, etc., which it is difficult to exclude with
confidence. Hence it is much less precise in its significance than
either a double optic atrophy or the Argyll-Robertson pupil. It must be
by the collection of observations extending over a long term of years
that actual demonstration of the relationship of the ocular disturbances
now in question to the occurrence of spinal disease can be established.
But while falling short of the merit of actual demonstration, the
presentation of the facts displayed by a number of cases which could
only be observed over relatively brief periods is not without value. If
no one case affords a complete history of all the stages of the disease
the picture presented may none the less be fairly complete, provided the
cases are sufficiently numerous, and they are seen at different points
of development. It is believed that in the present series these
conditions are fulfilled. The conclusions they afford, as far as the
present purpose is concerned, are: (1) That an optic-nerve atrophy, an
ocular paralysis, or an Argyll-Robertson pupil may exist as an isolated
symptom for a considerable time, presumably for years; (2) that any two
of these may be associated together, with a correspondingly increased
presumption that the diseased process causing them is of the locomotor
ataxia order; (3) that any one of the three, or a combination of two or
all of them, may exist in conjunction with a greater or less degree of
evidence of spinal disease; and (4) that occasionally a case which
commences with purely ocular symptoms may be seen to develop with
comparative rapidity characteristic symptoms of the spinal lesion of
locomotor ataxia. The cases therefore may be held to justify the view
that an optic-nerve atrophy, an ocular paralysis, or the
Argyll-Robertson pupil (not capable of other explanation) must be
regarded as affording a definite basis for suspicion in reference to a
possible development of spinal disease. On the other hand, it must be
admitted that the prognostic indication, so far as spinal disease is
concerned, is not an absolute one, for the ocular defect may exist
certainly for many years without any evidence whatever of the
involvement of the spinal cord.

The cases here recorded have all been the subject of detailed and in
most cases repeated examination, and unless the contrary is stated, it
may be taken for granted that the thoracic and abdominal viscera are
normal, to physical and other methods of examination. In all cases, too,
in which no specific statement is made, it is to be understood that the
visual acuity, the visual fields (both for white and colors), and the
fundus oculi have been proved to be normal. This last statement of
course does not apply to cases in which optic atrophy exists. Particular
care has been taken to be accurate in regard to the condition of the
pupils and the knee-jerks. In nearly, if not absolutely in every
instance where a departure from the normal is chronicled, the record has
been confirmed by more than one observer, and in the case of a deficient
knee-jerk the conclusion stated has never been formulated until the
conditions insisted on by Gowers, Buzzard, and Jendrassik have been
fulfilled. With a few exceptions in which only a single observation was
possible, the patients have been watched for months, and in some
instances for several years. The cases are arranged in series, with a
view to show how, from a purely ocular condition, one may pass through
gradually accumulating evidence to the same ocular condition in
association with the characteristic signs of the spinal lesion of
locomotor ataxia.


   I.—CASES IN WHICH OPTIC-NERVE ATROPHY IS THE PRIMARY OR DOMINATING
                               CONDITION.


       (_a_) _Optic Atrophy, without Other Evidence of Disease._

CASE I.—W. T., aged twenty-five. Failure of vision extending over two
years, with reduction of visual acuity to the power of counting fingers
at three feet. Double optic atrophy; pupils medium, with distinct light
response; knee-jerks distinct and no evidence of spinal disease, and no
cerebral symptoms other than one or two attacks of giddiness.
Urethritis, but no syphilis.

CASE II.—F. R., aged thirty-eight. Double optic atrophy, with almost
complete loss of vision, the defective sight having been observed for at
least eighteen months; pupils dilated and immobile; no evidence of
spinal disease, unless possibly some degree of failure of sexual power;
no cerebral incidents; no history or evidence of syphilis.


(_b_) _Optic Atrophy, with Other Ocular Evidence Suggestive of Locomotor
                                Ataxy._

CASE III.—(By permission of Mr. Ernest Clarke, F. R. C. S.) R. C., aged
thirty-nine. Double optic atrophy, reducing right visual acuity to the
power to count fingers at four feet, and left to mere perception of
light; right pupil dilated and three times the size of the left; neither
any light response, but free movement on convergence; entire absence of
symptoms and objective signs of spinal disease; “gleet” twenty years
before, no syphilis.

CASE IV.—A. S., aged twenty-five. Double optic atrophy, with observed
failure of vision for twelve months. V. A. right-hand movements only;
left, 6/18 part; pupils 2.5 mm., no light response, but contract on
convergence; knee-jerks difficult to obtain, but movement, though
possibly wanting in promptness, is normal in extent; no ataxia or other
evidence of spinal disease; mother of three healthy children, no
miscarriages.


      (_c_) _Optic Atrophy, with Some Evidence of Spinal Disease._

CASE V.—W. A., aged thirty-seven. Double optic atrophy, with reduction
of visual acuteness to “hand movements;” pupils dilated and immobile;
knee-jerks absent, but no other evidence of spinal disease; venereal
sore when aged twenty; no recognized secondaries, and father of four
healthy children.

CASE VI.—J. G., aged thirty-five. Failure of sight (six months); optic
atrophy, gradually increasing whilst under observation of twelve months;
pupils not definitely abnormal; knee-jerks absent throughout, but no
further appearance of spinal disturbance; urethritis, but no history of
syphilis; father of two healthy children, wife no miscarriages.

CASE VII.—F. L., aged thirty-nine. Double optic atrophy, reducing visual
acuteness to 6/24, pupils very small, and with Argyll-Robertson
phenomenon; subsequent to failure of sight (twelve months) has had
shooting pains in thighs, and failure in retention power of bladder;
knee-jerks distinct; no ataxia or sensory defect in lower limbs;
venereal sore twenty years before; no recognized secondary syphilis;
wife healthy: seven pregnancies, five miscarriages.


  (_d_) _Optic Atrophy, with Distinctive Evidence of Spinal Disease._

CASE VIII.—C. H., aged thirty-eight. Failure of sight (two years) from
double optic atrophy; pupils medium, with Argyll-Robertson phenomenon;
moderate double ptosis, but no ocular paralysis; shooting pains in lower
limbs (eight years); knee-jerks absent; considerable ataxia and failure
of control over bladder; syphilis at nineteen years.

CASE IX.—G. S., aged forty. Pallor of disks and peripheral contraction
of visual fields; four months later loss of knee-jerks and gradual
development of ataxia; pupils normal throughout; death at the end of
twelve months with symptoms of meningitis; syphilis at twenty-five
years.


              II.—CASES WITH ARGYLL-ROBERTSON PHENOMENON.


(_a_) _Argyll-Robertson Phenomenon, without Other Evidence of Disease._

CASE X.—A. L., aged thirty-three, the subject of slight hypermetropic
astigmatism. Pupils small, not quite circular, with Argyll-Robertson
phenomenon; no other ocular defect, and no evidence of a spinal lesion.
No history of syphilis.

CASE XI.—K. S., aged forty-three. Pupils rather small, unequal, quite
destitute of light response, though moving freely in convergence; no
other ocular defect except some presbyopia; no evidence of spinal
disease, though left knee-jerk not easily obtained. Unmarried; syphilis
seems highly improbable.

CASE XII.—G. G., aged sixty. Pupils small, with distinct
Argyll-Robertson phenomenon. Knee-jerks, not easily obtained, but not
definitely abnormal, and no other evidence of spinal disease. Patient
suffers from defective vision, probably from tobacco poisoning (central
scotoma for red); no history or evidence of syphilis.


   (_b_) _Argyll-Robertson Phenomenon, with Other Ocular Disturbance
                    Suggestive of Locomotor Ataxia._

CASE XIII.—D. T., aged forty-two. Pupils below medium size, destitute of
light response, with free movement in convergence; had for seven days
suffered from diplopia, and under observation gradual development of
complete paralysis of right external rectus; no other ocular defect.
Knee-jerks distinct, and no suggestion of spinal disease; chancre of lip
and secondary syphilis nine years before.


  (_c_) _Argyll-Robertson Pupils, with More or Less Evidence of Spinal
                               Disease._

CASE XIV.—T. F., aged fifty-five. Right pupil 2mm., left 3 mm., each
with Argyll-Robertson phenomenon; no other ocular defect except
presbyopia. Ten years ago had difficulty in passing urine, and since
then occasionally voids it involuntarily, and for eighteen years has
been liable to seizures of pain in calves, insteps, and heels;
knee-jerks normal, and no objective signs of spinal disease. Venereal
sore when aged twenty, but no secondary symptoms, and father of six
healthy children.

CASE XV.—H. W., aged thirty-eight, is the subject of hypermetropia, 4.5
D. Pupils very small, especially left; neither moves under light, but
distinct contraction during convergence. Admits recent difficulty in
descending stairs, saying he “frequently misses the bottom step,” and
has suffered from “sciatica” for two years. No objective evidence of
spinal disease, and urinary and sexual functions undisturbed. Admits
gonorrhea, but denies syphilis. Wife miscarried eight months after
marriage; no further pregnancies.

CASE XVI.—R. S., aged forty-three. Hypermetropic and presbyopic. Pupils
small, unequal, not quite circular, and with definite Argyll-Robertson
phenomenon. Knee-jerks cannot be obtained (confirmed on three different
dates), but no other sign or symptom of tabes dorsalis, unless
“rheumatic pains” in lower limbs for several years. Unmarried; no
history of syphilis. Four years ago had, after “catching cold,” to have
urine withdrawn by a catheter, but no subsequent disturbance of bladder
function.

CASE XVII.—E. W., aged forty-eight. Myosis with Argyll-Robertson
phenomenon; right ptosis and crossed diplopia (one month), without
obvious ocular paresis; absence of right knee-jerk (confirmed on two
occasions), and failure in retention power of bladder (six months), but
no other evidence of spinal disease; vulvar sores and skin eruption six
years before.


 III.—CASES IN WHICH AN OCULAR PARALYSIS IS THE EARLIEST OR DOMINATING
                                SYMPTOM.


       (a) _Ocular Paralysis, without Other Evidence of Disease._

CASE XVIII.—(By permission of Mr. J. T. James, F. R. C. S.) F. D., aged
thirty-seven. Dilated and immobile pupils, without any other ocular
defect. No evidence of spinal disease; syphilis nine years ago; no
change while under observation for three years.

CASE XIX.—K. K., aged twenty-eight. Iridoplegia, double, followed by
paralysis of left external rectus, the condition being under observation
for nearly a year, but without the discovery of any satisfactory
explanation. No evidence of spinal disease. Married, four healthy
children, no miscarriage; during one pregnancy very free loss of hair
(now grown again), but no other occurrence to suggest syphilis. No
family or personal history of gout or rheumatism.

CASE XX.—G. H., aged thirty-three. Dilated and immobile pupils, with
incomplete ptosis and divergence of eyeball on each side. Present
condition of four years’ duration, and separated by an interval of three
years from venereal sore and skin eruption. No other ocular defect; no
evidence of spinal disease, and general health good throughout. No
change while under observation for three months.


    (b) _Ocular Paralysis, with Other Ocular Evidence Suggestive of
                           Locomotor Ataxia._

CASE XXI.—E. S., aged forty-three. Diplopia from paralysis right
external rectus, pupils small, each with Argyll-Robertson phenomenon;
visual left acuity only 6/12, and small but distinct central scotoma,
with some contraction of the peripheral field; knee-jerks distinct, and
no ataxia or other evidence of spinal disease. Three early miscarriages,
no full-time child. No change while under observation for nine months,
but on two occasions severe attack of vomiting and abdominal pain,
extending over several days and without recognized cause (? gastric
crises).

CASE XXII.—A. M., aged fifty-five. Left ptosis and paralysis of external
ocular muscles supplied by third nerve in 1887, the pupils being normal,
followed by incomplete recovery. In 1897 development of identical
condition on the right side, and pupils found to be small and with
Argyll-Robertson phenomenon; knee-jerks very slight and with great
difficulty, but no other evidence of spinal disease. No history of
syphilis.

CASE XXIII.—H. F., aged thirty-seven. Right ptosis with diplopia (seven
days) and defective inward excursion of right eyeball; pupils very
small, not quite equal, and with Argyll-Robertson phenomenon; optic
disks pale and marked contraction of visual fields, but normal central
vision; knee-jerks scarcely to be obtained, but no other evidence of
spinal disease. No history of syphilis. Father of four healthy children.
Seen after a month’s interval, paralysis of all external right ocular
muscles supplied by third nerve, and knee-jerks absent.


 (c) _Ocular Paralysis, with More or Less Evidence of Spinal Disease._

CASE XXIV.—G. S., aged forty-one. Ptosis and complete ophthalmoplegia
externa on left side, with dilated and immobile pupils and some degree
of right ptosis, these conditions or some of them having been present
for five years. Knee-jerks distinct, and no ataxic phenomenon, but
imperfect control over bladder, and failure of sexual power during last
six months. No admitted syphilis.

CASE XXV.—J. L., aged forty-two. Diplopia and drooping left upper eyelid
for four years. Ptosis left side, and marked defect of ocular movements
in each eye; left pupil dilated and immobile; right small, contracts
during convergence, but no light response; no other ocular defect.
Knee-jerk scarcely obtained on either side; no ataxia, but attacks of
“twitching pains” in lower limbs, and for some time difficulty in
starting the flow of urine. Venereal sore in 1882, and subsequent loss
of hair, but no other secondary symptoms. Patient watched for twelve
months without appreciable change.

CASE XXVI.—L. D., aged forty-four. Crossed diplopia (one month), without
obvious ocular paralysis, and pupils small with Argyll-Robertson
phenomenon. Knee-jerks absent; no ataxia to usual test, but has noticed
tendency to stagger in the dark; is troubled with pains in the knees,
has difficulty in commencing the act of micturition, and recent marked
failure of sexual power; venereal sore at twenty years, and subsequent
sore throat, but no skin eruption or loss of hair. Father of three
healthy children.

CASE XXVII.—J. H., aged forty-seven. Double vision of two months’
duration; similar attack three years ago, with complete recovery.
Paralysis of right external rectus; pupils, visual acuity, and visual
fields normal. Knee-jerks absent, but no other evidence of spinal
disease. Patient the subject of albuminuria, and presents physical
evidence of an aneurism of the ascending aortic arch. Youngest child has
marked evidence of inherited syphilis.

CASE XXVIII.—W. M., aged thirty-five. Paralysis of left third nerve,
without iridoplegia or cycloplegia; pupils normal. Knee-jerks absent,
but no ataxia or other evidence of spinal disease. Several venereal
sores ten years ago, but no recognized secondary syphilis. There is,
however, evidence of a former iritis.

CASE XXIX.—M. C., aged fifty-four. Paralysis of left external rectus,
with history of two previous attacks of diplopia during last four years;
no other ocular defect, unless some imperfect light response in left
pupil; knee-jerks absent, and complaint of “sciatica” for two years, but
no other evidence of spinal disease. Albuminuria distinct, and physical
signs of hypertrophy of left ventricle. No history of syphilis.

CASE XXX.—(By permission of Mr. N. M. MacLehose, M. B.) H. Y., aged
thirty. Homonymous diplopia observed over a period of six months without
appreciable ocular paralysis; pupils of medium size, with definite
Argyll-Robertson phenomenon; knee-jerks absent, and in later months
decided ataxia and sensory defects in lower limbs; visual acuity
unaffected to ordinary test, but gradual contraction of visual fields,
especially on right side; chancre and secondary syphilis four years
before.

There are in these series of cases many facts which might reasonably be
made the subject of remarks, and several of the cases are certainly of
great individual interest. But they are here displayed in the above
grouping for the purpose of illustrating the clinical order and sequence
in which, as a matter of actual experience, the ocular disturbances of
locomotor ataxia may manifest themselves in relation to the spinal
evidences of that disease. Of course, in those cases in which there
exists only a single ocular symptom unaccompanied by any sign of spinal
disease, it may be objected that it has yet to be demonstrated that such
cases are of the nature of locomotor ataxia. It is doubtless to be
desired that such cases should be under exact observation as long as the
opportunity for further developments exists—that is, for the entire life
of the patient. But to insist upon such a condition is a mere counsel of
perfection. One must make reasonable use of such evidence as the brevity
of life and the exigencies of practice permit. And the evidence here set
forth affords at least a very strong presumption, to say the least of
it, of the truth of the doctrines stated in the earlier paragraphs of
this paper. Probably the particular proposition which is most likely to
be contested is the one which places the Argyll-Robertson pupil equally
with optic-nerve atrophy, and an ocular paralysis, as a possible first
event in the eruption of the phenomena of locomotor ataxia. But on
turning to the records it will be found that the facts support this
suggestion almost as strongly as they support the corresponding
suggestion in reference to optic-nerve atrophy and ocular paralysis.
Attention in this respect may be particularly given to Case XIII. The
man complains of a quite recent diplopia, and he has undoubtedly had
syphilis; the pupils show the Argyll-Robertson phenomenon. It is in the
highest degree probable that, had the patient been under observation a
week or two earlier, the condition of the pupils would have been the
sole existing ocular abnormality. Yet in the light of the development of
an ocular paralysis, it can scarcely be doubted that, whether he develop
spinal symptoms or not, his nervous system is the site of diseased
processes of the locomotor ataxia order. When to these facts there are
added, as in Cases XIV. to XVII., illustrations of the various forms and
degrees of evidence of spinal disease that may be associated with the
Argyll-Robertson pupil, it seems impossible to resist the conclusions
that the condition of the pupil so named may be the first evidence of
locomotor ataxia; that it may precede by varying intervals other
evidences of the disease; and that at least very probably, in a certain
number of cases, the symptomatology of the disease may be permanently
restricted to this one event. In some examples of its spinal form
locomotor ataxia is undoubtedly an extremely chronic disease, with few
and imperfectly developed symptoms; and it is thus not unnatural to
expect that similar limitations may obtain in the ocular manifestations
of the disease. That evidences of grave nervous disease may be limited
to the pupil is well seen in Case XVIII., where a syphilitic patient was
under observation for three years without the discovery of any
abnormality other than paresis of each sphincter iridis. There is
certainly no obvious reason why a similar restriction should not
determine the Argyll-Robertson pupil as a purely isolated phenomenon
with, it must be added, the same unfortunate possibilities that are
undoubtedly attached to the patient whose case has just been quoted. The
conclusions above adopted in reference to the Argyll-Robertson pupil are
applicable, _mutatis mutandis_, to optic-nerve atrophy and to ocular
paralysis, as is abundantly demonstrated in the corresponding series of
the cases recorded in this paper.

                                                                  DEADY.


=Menzies, J. Acworth.—Detachment of Corneal Epithelium (?).=—_British
Med. Jour._, March 17, 1900.

The following case seems to be worthy of record because of the long
duration of the symptoms and the immediate relief ultimately obtained.
Mrs. W. consulted me on August 4, 1899, and gave the following history:
Five years previously the right eye was struck and “cut” by a cricket
ball. Since that time there had been pain exactly as if there was a
foreign body under the lid or embedded in the cornea. There was a
pricking feeling on winking, and the patient could not bear to have the
upper lid touched in its outer half. She could only obtain ease by
keeping the eyes closed and perfectly still, or wide open with the lids
motionless. On examination no foreign body could be seen, and the lids
were normal. In the lower outer quadrant of the cornea careful
observation showed that the epithelium was ruffled and freely movable
over a small area, and in part of the same area was a tiny circular,
slightly opaque, raised patch of the corneal tissue. Nothing more could
be made out. I prescribed a bandage and some boric lotion with cocaine.
Two months later, on October 6, I again saw the patient, who was then in
precisely the same condition as before, and had been so during the two
months’ interval. She was in such misery that I decided to adopt
surgical measures at once. Accordingly, after instilling cocaine, I
carefully explored the painful area with a needle, but could detect no
foreign body. I then scraped the part thoroughly with a sharp spoon,
removing the epithelium for some little distance around, and a fair
amount of corneal tissue in the affected area. The following day there
was some smarting, but the eye could be moved freely under the lid, and
there was no pain on pressure over the previously tender spot. Progress
was uninterrupted. The epithelium grew over the denuded surface, and no
opacity resulted. The eye now is perfectly right and the vision is
normal.

I should have put the difficulty I had in making a diagnosis down to my
having overlooked some detail, had it not been that the patient was for
a considerable time under treatment at an eye hospital. The explanation
I am inclined to adopt, for want of a better, is this, that the original
blow caused the anterior elastic lamina with the epithelium to become
detached. The nutrition of the epithelium might thus be kept up, and
every movement which pressed upon the surface would bring the detached
membrane down on the corneal nerve filaments. But it must be confessed
it is not easy to understand how this condition could remain stationary
for five years.

                                                                  DEADY.


=Hines, M. D., Oliver S.—Iodide of Stannum in Tuberculosis.=—_The Amer.
Hom._, March 15, 1900.

The author thinks iodide of stannum often preferable to stannum in
tuberculosis. He uses it when the patient has a clear complexion and
long eyelashes and where the progress of the disease is rapid. He
reports a case for which the 2x trituration was given, in which there
was “a marked tubercular affection of the chest, increased vocal
fremitus, an abundance of thick yellow and sweetish sputum, sweat at
night, and rapid emaciation.” The result was encouraging.

                                                                 PALMER.


=Kyle, M. D., D. Braddon.—Initial Forms of Tubercular
Laryngitis.=—_Inter. Med. Mag._, March, 1900.

The enumeration and exact description of these prodromal symptoms are so
important that we copy them in full.

The following, which is a translation of an article by Monsarrat of
Paris (_Rev. Hebdom. Laryngol., d’Otol., et de Rhinol._, No. 43, October
28, 1899), covers the ground so thoroughly that it is worthy of
repetition:

“Laryngeal phthisis completely developed presents multiple and varied
symptoms, some more characteristic than others. In one patient are found
symptoms functionally grave, out of proportion to the lesions relatively
benign. In another, physical signs take first place; there may be an
ulceration completely obliterating one cord, or considerable œdema of
the arytenoids and vestibule, which closes the opening of the glottis.
Having reached the period when tuberculosis is easily recognized, the
various patients are able to date their laryngitis from diverse
pathologic beginnings. This one will present solely the history of a
cough, the other a raucous voice, in another pain will take precedence.
In mentioning these various modes of commencement we insist on the
connection which may exist between each of them and the localization at
the beginning of tuberculosis, on one or the other parts of that complex
organ known as the larynx. Let us divide the symptoms into the
functional and the laryngoscopic. The connection or antithesis between
them will be noticed.

“An initial symptom, quite frequent in tubercular laryngitis, is,
without a doubt, cough. This symptom, common to all maladies of the
respiratory tract, would have no diagnostic value, except that it is
characteristic. On it alone the diagnosis of laryngeal phthisis could
never be based. At the beginning, cough puts us on our guard, especially
when it is causeless; that is to say, when auscultation of the chest
fails to reveal anything abnormal. This cough is always persistent,
sometimes violent, hawking, and provoking.

“The physical signs of the chest do not correspond to the tenacity of
the cough; it is therefore possible for the larynx to be accused. As
regards this cough, the ‘hemming’ so often described, and which draws
attention most often to a possible rhinopharyngitis, may cause us to
think at the beginning of tuberculosis, but only after examination of
the rhinopharynx has established its integrity. There is a cough, well
known at the beginning of tubercular laryngitis, a little dry cough,
commencing insidiously, often at the moment when the patient is about to
speak, which the individual himself does not notice, but to which his
friends attach an importance too often justified by the outcome. The
cough may be hacking, followed or not by expectoration, and often
accompanied by vomiting. It is certainly right to consider it as a
symptom of the beginning of the disease.

“The speaking voice is often altered, dysphonia appears, and the patient
who is attacked presents little alteration in his larynx; no ulceration,
the cords accurately approximate, and they are very slightly congested;
the laryngeal image does not reveal anything by which this profound
alteration in the voice can be explained. There is no cough. There will
come a time in the disease, however, which will cause us to see that
this, too, is an initial form, and oblige us to give a prognosis
exceedingly guarded.

“The voice may be eunuchoid. Castex has noted it among the tuberculous.
The raucosity of the voice should also recall the statistics which
demonstrate the fact that a fifth of the cases of this condition are
tubercular. But these three symptoms, dysphonia, raucosity, eunuchoid
voice, are also found in other maladies of the larynx; conditions,
however, easily diagnosticated by the laryngoscope. If nothing justifies
these affections of the voice, one should think of tuberculosis. It is
these initial forms, apparently paradoxical, but analogous to that,
which we are going to mention under the subject of pulmonary lesion not
sufficient to provoke cough in the beginning if the larynx has not been
initially affected. The forms that are recognized in the mirror are
evidently very numerous. We will mention some: Congestion of the cords,
monocorditis, recurrent laryngitis, and a nodular form at the free
border of the vocal cords. We do not take into consideration any variety
of ulceration, no matter how insignificant, as for the most part the
velvety aspect of the cords leads us to think at once of laryngeal
phthisis. But this has not appeared at the beginning, and we are only
considering initial forms. The symptoms which we are attempting to
describe are those suggestive of tuberculosis, and we only say that
tuberculosis of the larynx may begin by a nodule, by a congestion, by a
monocorditis, etc.

“Congestion of the vocal cords, whose ætiology is difficult to explain,
often coincides with slight dysphonia, with cough. This congestion,
fugacious, if not tuberculous, disappears with rest, if it is not
aggravated by a chronic rhinopharyngitis. In the majority of cases the
patient returns. Despite a treatment, properly instituted, the
congestion persists; it extends on the cords; it may remain there, or it
may reach over the ventricular bands to the arytenoidal apophyses; this
is a form of commencing laryngeal phthisis, especially if, after a
period of calm, there is found in a patient a new congestion. It is
recurrent laryngitis, another form of initial tuberculosis more grave
than the first. Against laryngitis of this form treatment is of no
avail.

“Another variety of initial tuberculosis is monocorditis. The patient
becomes suddenly aphonic; laryngoscopic examination shows a cord
perfectly red, congestion of which is evident, not only by the color,
but by its altered volume. Contrast with the sound cord is often
striking. Movements of the affected cord may be observed, but it is
generally paretic. Acute monocorditis should cause us to think that it
is an initial form of tuberculosis. This monocorditis often corresponds
to the side of the lungs which is afterward or at that time attacked by
the bacillus. Certain authors admit that this relation is absolutely
constant, and their statistics allow no exception to the rule. On the
other hand, Bayle’s theory, setting forth the direct penetration of the
tubercular infection, becomes less often justified. It is the lymphatic
route which most often produces bacillary infection.

“Tubercular laryngitis may often begin by a nodule situated on the
border of the vocal cords. It is important not to confound it with
singers’ nodules, these latter being more conical and more rounded. The
tuberculous nodule may grow slowly, not ulcerate for a long time;
interfering so little with the speaking voice that the patient often
refuses any intervention. But the day comes when we see this nodule
desquamate, and we may observe the evolution of the tuberculous
ulceration which displaces it. We make no mention of the other forms of
commencement characterized by a congestion of the entire organ, by œdema
of the epiglottis, by a lividity quite characteristic which invades the
entire endolaryngeal mucosa, forms most usual for the tubercular
involvement of the larynx. A form especially noticeable is that which
begins with a sensation of a lump in the throat. It is true that this
variety is not observed except in the nervous; it is not, however, to be
compared to the globus hystericus. Tuberculous patients, in whom the
tuberculous process in the larynx begins with a sensation of a lump in
the throat, may be in very good health, but this particular impression
is often the first symptom which they observe in a laryngitis, which
finally becomes tuberculous. At the moment when the patient complains of
this symptom it may happen that laryngoscopic examination fails to
detect any lesion. It is useless to add that this form is especially met
with in the female. It most nearly resembles that form that begins with
a dysphagia that persists to the end; but at the beginning of tubercular
laryngitis this dysphagia alone is noted without any other symptoms.” So
it can be seen that laryngeal phthisis may begin by a variety of
symptoms, some common, the others rare. It is needless to insist upon
the importance of an early diagnosis.

                                                                 PALMER.


=Ball, James Moores.—On Removal of the Cervical Sympathetic in Glaucoma
and Optic-Nerve Atrophy.=—_Jour. A. M. A._, June 2, 1900.

I propose to consider the surgery of the cervical portion of the great
sympathetic nerve in certain ocular diseases. European oculists and
surgeons have performed sympathectomy for glaucoma and exophthalmic
goiter. I have gone further, and in one instance removed the superior
cervical ganglion for simple atrophy of the optic nerve. I have
performed sympathectomy four times up to July 20, 1899. First the cases
will be reported; then the conclusions will be drawn.


        CASE I.—EXCISION OF SYMPATHETIC FOR GLAUCOMA ABSOLUTUM.

Mrs. B. S., aged thirty-six, has had pain in and around the right eye
for two months, and examination showed vision in this eye reduced to
light perception; tension + 3, and the pupil widely dilated. The
anterior chamber was shallow, the cornea cloudy and slightly anæsthetic,
the media slightly cloudy, still allowing the fundus to be seen. The
episcleral vessels were enlarged. Circumcorneal injection was present
and the optic nerve cupped. A diagnosis of chronic irritative glaucoma
was made. The left eye presents immature cataract, and vision in this
eye is 20/70.

Knowing of the flattering results obtained by Jonnesco and others, by
excision of the superior cervical ganglion in absolute glaucoma, I
explained the operation to the patient, and obtained permission to
operate. On May 15, 1899, the patient was anæsthetized, chloroform being
employed. An incision four inches in length was made on the right side
downward from the mastoid process, extending along the posterior border
of the sterno-cleido-mastoid muscle. The external jugular vein was cut
and tied. The sterno-cleido-mastoid was then separated from the
trapezius muscle, and the spinal accessory nerve was cut. A deep
dissection was then made, exposing the carotid sheath. This was opened
to enable us to locate the pneumogastric nerve beyond question. The
carotid, internal jugular vein, and pneumogastric nerve were then pulled
forward, enabling us to see the rectus capitis anticus major muscle, on
which the superior cervical ganglion rests. Tearing through the fascia,
the ganglion was found and stripped. The ganglion was then cut high up
with curved scissors and all its branches severed. About one inch of the
trunk of the sympathetic below the ganglion was removed. The wound was
closed with interrupted sutures and the neck placed in a plaster cast.
The time required for operation was fifteen minutes, and immediately
after it was noticed that the right eye was suffused with tears, the
right conjunctiva much injected, and the right nostril moist. The
intra-ocular tension was + 2. The patient slept well all night, without
medicine, being free from pain for the first time in over two months.
Tension had steadily decreased to + 1.

On May 16, slight ptosis was noticed on the right side. This symptom is
yet present. On May 19 the circumcorneal injection was much less; the
conjunctival hyperæmia and lachrymation were still present, while the
ptosis was slightly increased and tension was + 1.

At the present date—July 23, 1899—this patient has no pain. The retinal
arteries are increased in size. Tension is + 1. Vision has increased
from light perception to ability to count fingers at three feet. The
conjunctival injection which followed the operation has disappeared; the
optic nerve has a color more approaching the normal. The ptosis is less.

This was the first sympathectomy made in America for glaucoma.


          CASE II.—DOUBLE SYMPATHECTOMY FOR GLAUCOMA SIMPLEX.

Miss M. E., a German, aged forty-three, was sent to me on June 14, 1899.
For two years sight had been failing, until at this time vision was as
follows: R. E. = 0; L. E = light perception. Tension was + 3. Both optic
nerves showed marked cupping of the disk; the vessels were pushed to the
nasal side. She stated that she had never had pain in the eyes, and had
not consulted an ophthalmic surgeon.

I advised her to submit to an excision of the left superior cervical
ganglion; she consented, and on June 15 the operation was performed by
myself, assisted by Dr. E. C. Renaud, at St. Joseph’s Sanatorium, in the
presence of Drs. J. C. Murphy, A. R. Kieffer, and S. A. Grantham. The
operation was difficult, owing to the abnormal position of the vagus
nerve. This was outside of and external to the carotid sheath, and was
much smaller than normal; it was not larger in diameter than the head of
a pin. It was identified by irritating it and watching the effect on the
heart. The superior cervical ganglion was removed and one-half inch of
the trunk of the sympathetic below. Shortly after the operation there
were lachrymation, ocular congestion, and contraction of the pupil on
the corresponding side. On the second day she counted fingers at 2½, and
on the third at 3½ feet. Slight ptosis was present.

She left the hospital on the eighth day. At this time she counted
fingers at four feet. There was only slight, if any, reduction of
tension during the eight days she was in the hospital. In counting
fingers she saw with the nasal side of the retina—temporal field. I did
not see her again until June 30, and she was then counting fingers at
five feet. Tension on that day was normal. She had light perception in
the right eye.

On July 16 I excised the right superior cervical ganglion without
difficulty, and on July 7 she counted fingers at seven feet with the
left eye, and could see the hand at four inches with the right. I
examined her on July 20, when vision remained the same, the tension of
the right eye was + 1, and of the left + 2. She was well pleased to have
the small amount of vision she possessed.


            CASE III.—SYMPATHECTOMY FOR OPTIC-NERVE ATROPHY.

T. J., aged forty-six, an inmate of the St. Louis City Hospital, a
laborer, was admitted on account of blindness. There was no history of
syphilis, rheumatism, nor any systemic disease. The patient was of
limited mentality. No history of his family could be obtained. He
claimed to have had good health all his life, with the exception of an
attack of malarial fever several years ago. The patient had been a
moderate drinker of alcoholic beverages. In appearance he was robust,
and he complained only of loss of vision which, in the left eye, had
been failing for eleven months, in the right for seventeen weeks,
according to his statement. Until seventeen weeks before this he could
see enough with the right eye to get around. Since then vision had
steadily declined until he had light perception only—and this only
apparent when light was concentrated on the eye by the ophthalmoscopic
mirror. Vision of the left eye = 0.

The pupils were widely dilated. The ophthalmoscope showed, in the right
eye, a white disk, particularly on the temporal side; the arteries
slightly reduced in caliber, veins normal. There was shallow, atrophic
cupping of the nerve head. The retina and choroid were normal, the
vitreous and lens clear. The left eye showed a disk of a dead white
color throughout the whole area, arteries very small, atrophic
excavation pronounced, veins reduced in caliber, and choroid normal. The
macula was not visible in this eye, owing to the much-reduced
blood-supply. The vitreous and lens were clear. Vision was as follows:
R. E. = perception of concentrated light. L. E. = 0.

_Diagnosis._—R. E. = optic-nerve atrophy. L. E. = complete atrophy of
optic nerve and retina.

_Treatment_: Resection of the right superior cervical ganglion of the
sympathetic was done. The operation was followed by conjunctival
congestion, lachrymation and contraction of the pupil, slight ptosis and
hypotonia.

No appreciable change in the patient’s vision followed, and
ophthalmoscopic examination made two weeks after operation showed no
change in the appearance of the fundus, except that a cilioretinal
artery in the upper part of the disk had doubled in caliber.

So far as I know, Case III. is the first instance in the history of
medicine of an excision of the superior cervical ganglion, or of any
part of the sympathetic system, for the relief of optic-nerve atrophy.
Although the operation was not of benefit in this particular instance,
yet I am not willing to concede that it will prove valueless in cases of
non-inflammatory atrophy in which vision is not entirely lost. In truth,
I expect it to prove beneficial in such cases, sufficiently often to
justify the procedure.

I was led to make this experimental operation for several reasons: 1.
The use of glonoin is often followed by an improvement in vision in
cases of simple atrophy of the optic nerve. 2. Glonoin enlarges the
retinal vessels, as has been proved by ophthalmoscopic examination. 3.
There is no question that in glaucoma simplex—a disease in which there
is an atrophy of the optic nerve—improvement in vision follows
sympathectomy. 4. Excision of the cervical sympathetic is followed by an
increase in the blood-supply of the orbital contents.


               PATHOLOGIC CHANGES IN THE EXCISED GANGLIA.

The microscopic examination of three of the excised ganglia was made by
my friend, Dr. Carl Fisch, of St. Louis. The specimens were those from
Cases I., II., and III. Of the two ganglia removed from Case II. only
the first one—the left—was examined.

Transverse and longitudinal sections of the three specimens were studied
microscopically, by means of a great number of different staining
methods. Owing to the method by which the ganglia had been
preserved—weak formalin solution—the employment of the Golgi—Marchi—and
the more delicate Nissl stains was rendered impossible. In general it
may be said that the pathologic changes found were the same in the three
cases, although a little less pronounced in No. 2 than in 1 and 3.

Most striking of all was a very marked hyperplasia of the connective
tissue, which in some places resulted in dividing up the ganglion into
small groups of nervous elements separated by broad bands of fibrous
elements. The walls of the vascular structures showed decided sclerosis;
the connective-tissue sheaths of the ganglionic cells were much
increased in thickness. In Case I. small foci of round-cell infiltration
were seen in this hyperplastic growth, of an inflammatory character. No
plasma nor mast cells could be demonstrated.

The ganglionic cells were markedly pigmented. Together with a number of
cells normal to all appearance there were great numbers showing
different stages of degeneration. As a rule the nucleus, besides having
lost part of its peculiar staining property, had assumed the parietal
position; the nucleus was reduced in size or even missing in a large
percentage of the cells. While in some cells the chromatic elements were
well preserved, in others the process of chromatorhexis and
chromatolysis could be followed up through all of its stages. Only
comparatively few cells were seen showing the normal dendriform
processes; very often the processes were short, ending bluntly, or they
had even disappeared altogether. The general peripheral network of
processes was much reduced in volume and compressed by the pressure of
the connective-tissue formation. Only very few medullated fibers were
seen. Unfortunately it was impossible to study their structure with the
Marchi method.

The general pathologic aspect was that of a decided sclerosis,
originating in inflammatory processes going on in, and starting out
from, the walls of the vascular structures. The changes of the nervous
elements were most likely not idiopathic, but due to pressure and
inhibited nutrition.

The plates accompanying this paper have been made from drawings of
sections of superior cervical ganglia.


                      TECHNIQUE OF THE OPERATION.

The ordinary precautions for surgical cleanliness are to be observed,
and general anæsthesia employed. The incision should be made along the
posterior border of the sterno-cleidomastoid muscle, starting at the
mastoid process and running downward to within an inch of the clavicle.
The sternomastoid is separated from the adjacent muscles, the spinal
accessory nerve cut, and the carotid sheath reached. This dissection is
made with the fingers. The carotid sheath should always be opened in
order to locate the pneumogastric nerve. I consider this very important
because: 1. The nerve is sometimes outside the sheath, as happened in my
second case, in which the pneumogastric was much atrophied and was
external to the sheath. 2. Differentiation of the cervical sympathetic
from the vagus is sometimes difficult. Often, in operating on the
cadaver, I have found both nerves inclosed in the same fascia. It is
needless to say that excision of the vagus instead of the sympathetic
would not only defeat the object of the operation, but would add a
serious complication. Differentiation of these nerves after opening the
carotid sheath is not usually difficult, for in working upward the
operator comes upon the ganglionic expansion of the sympathetic. The
ganglion is seized with forceps and stripped. Its branches are cut
first, then the cord passing below is severed, and lastly the ganglion
is cut above, as high as possible. It is best to use curved scissors and
to have the finger under the ganglion while traction is made, thus
cutting on the finger and avoiding injury to the underlying structures.

If the middle ganglion is to be removed, it will be best to excise it
first and then work upward. If the entire chain of the sympathetic is to
be removed, as is done for epilepsy, and as is now advised in
exophthalmic goiter by Jonnesco, the operation is one of great
difficulty, owing to the location of the inferior ganglion. This is
situated near the neck of the first rib. One of my friends, who is a
skillful surgeon, in removing this ganglion ruptured the vertebral
artery near its origin and was obliged to tie the subclavian to check
the hemorrhage. After the latter has ceased the wound is closed with
superficial sutures. The hemorrhage in removal of the superior ganglion
is usually trifling, only a few small vessels being cut. The external
jugular vein was cut in my first case, but not in the others. The
patient leaves the hospital on the eighth or ninth day.

Jonnesco’s method, according to his latest communication on the subject,
is different. He always employs the premastoid route where only the
superior ganglion is to be removed, reserving the postmastoid for the
excision of the entire chain. The carotid sheath is split, the internal
jugular vein and sternomastoid drawn outward by a retractor; a second
retractor draws the vagus and internal carotid inward. In the space made
the superior ganglion is found. The deep vertebral fascia is opened, all
the branches of the ganglion isolated and cut by blunt, curved scissors;
when this has been done the ganglion is attached only by nerve strands
above, a strong pull is made, and the ganglion gives way. The excision
is then completed by cutting the inferior strands. In closing the wound,
he uses both deep and superficial sutures.

He mentions a transient dysphagia and pain in the cranio-mandibular
joint as occurring after this operation.


           EFFECTS OF EXCISION OF SUPERIOR CERVICAL GANGLION.

The effects of removal of this ganglion are immediate and remote: The
immediate are relief of pain, lachrymation and conjunctival injection,
together with a discharge from the corresponding nostril, unilateral
sweating, and contraction of the pupil. Often there is an immediate
reduction in intra-ocular tension. These effects are noted within five
minutes after the excision.

The remote effects are ptosis, which appears on the third or fourth day,
improvement of vision, and in some instances a tardy contraction of the
pupil and a tardy reduction of the intra-ocular tension. To these there
must also be added a slight sinking of the eyeball into the orbit, and a
feeling of heaviness in the head. What I have just written applies
particularly to cases of glaucoma.

In exophthalmic goiter, after the excision of the ganglia, the
exophthalmus and tachycardia are said to improve almost immediately and
a reduction of the goiter soon follows.

Although Jonnesco speaks of the immediate reduction of the intra-ocular
tension, yet this does not always occur. In my second case, at the end
of eight days the tension was + 2. On the sixteenth day the tension was
normal. In my first case reduction of the tension was immediate. The
relief from pain in the first case was immediate and lasting. This
patient had not been free from pain for two months previously. The
slight ptosis following sympathectomy is to be attributed to paralysis
of Müller’s muscle. Sinking of the eyeball is no doubt due to paralysis
of the unstriped peribulbar fibers found in Tenon’s capsule. Contraction
of the pupil is usually an immediate result; it may, however, appear
tardily. Thus in my first case the pupil was unchanged until the fourth
day after the operation; and it did not become at any time as markedly
contracted as in the other two patients. In the third case—that of
optic-nerve atrophy—the pupil was markedly contracted within five
minutes after the excision.

The lachrymation, conjunctival injection, and nasal moisture are
transient symptoms which are usually absent after the first day.

In this connection it is interesting to note that Mr. Jonathan
Hutchinson, as early as 1866, recognized many of the ocular symptoms of
paralysis of the cervical sympathetic, and wrote a paper thereon.


   HOW DOES EXCISION OF THE CERVICAL SYMPATHETIC REDUCE INTRA-OCULAR
                                TENSION?

This is a question difficult to answer—difficult for the reason that we
are not sufficiently acquainted with the physiology of the production of
aqueous humor under normal surroundings. Panas and Duvigneaud have
assumed rightfully that “If the nervous mechanism of intra-ocular
secretion or, to speak without hypothesis, the action of the nervous
system on intra-ocular tension can be known, the pathology of glaucoma
will be cleared up, iridectomy will be explained, and perhaps a new and
scientific basis for the treatment of glaucoma will be established.”
Many observers have sought to solve the problem. Donders attributed the
hypertension to a neuro-secretory cause and believed the trigeminus to
be the agent of excessive secretion. He held that section of the
trigeminus should relieve intra-ocular tension, while section of the
cervical sympathetic could have no particular influence.

His views were overthrown by experiments made by Wegner in 1866, on
rabbits. By means of manometers placed in the anterior chamber, he
sought to record variations in the intraocular tension. He proved to his
own satisfaction that the trigeminus takes no part, while section of the
cervical sympathetic produces hypotonia, and irritation of its upper end
and causes hypertonia. He held that section of the cervical sympathetic
enlarges the blood vessels of the eye; the blood then flows under
reduced pressure, and intra-ocular secretion is lessened. Almost
identical results were obtained by Adamück—1866‒68—who experimented on
cats.

Von Hippel and Gruenhagen believed that the cervical sympathetic
contains vasoconstrictor fibers for the eye. Their experiments were made
on cats and dogs. They found that irritation of the upper end of the
cervical sympathetic causes in the cat hypertonia, while its extirpation
increases intra-ocular tension. While, according to Wegner, the
hypertonic action proceeds from the enlargement of vessels caused by
cutting the cervical sympathetic, and the contraction of the blood
vessels caused by the irritation of the nerve causes a hypertonic
action, the contrary view is held by Adamück, Von Hippel, and
Gruenhagen.

However this may be, there is no doubt that the trigeminus plays no
great part in the production of ocular tension. Furthermore, the
inefficiency of Bedal’s operation—stretching the nasal nerve—is
explained by the fact that it is the cervical sympathetic, and not the
trigeminus, which influences intra-ocular tension.

Jonnesco believes that the ocular sympathetic fibers from the brain and
spinal cord pass through the superior cervical ganglion; permanent or
intermittent irritation of these is accompanied by dilatation of the
pupil, narrowing of the small intra-ocular arteries, contraction of the
peribulbar muscular fibers, and probably an increased action of the
elements which produce the aqueous humor. “As a matter of fact,” says
Jonnesco, “any increase of the blood pressure will produce a permanent
or intermittent narrowing of the arteries and cause the extravasation
and increase in aqueous humor; then it is probable, although not
definitely settled, that a permanent or intermittent irritation of the
excito-secretory fibers is followed by an increase in the secretion of
aqueous humor; the permanent or intermittent dilatation of the pupil
pushes the iris into the iris-angle, closes the canals of the filtration
zone, and hinders or prolongs the exit of aqueous humor from the eye;
the permanent or intermittent contraction of the unstriped peribulbar
muscular fibers closes the efferent veins of the eyeball, and hinders
the venous circulation of the eye—hence the dilatation of the
intra-ocular veins.”

He holds that excision of the superior cervical ganglion destroys all
vasoconstrictor fibers of the eye. The arteries relax, the blood
pressure is lowered, and extravasation is reduced. This operation
destroys the excito-secretory fibers, thus limiting the amount of
aqueous produced. The fibers which dilate the iris are destroyed, hence
the contraction of the pupil reopens the iris-angle and removes the
obstacle to the outflow of aqueous. The nerve-fibers supplying the
unstriped muscular apparatus contained in Tenon’s capsule are destroyed,
hence the pressure on the efferent veins is removed and ocular
circulation is reestablished.

Jonnesco believes that the starting-point of the nervous derangement
producing glaucoma is central: “When one removes the ganglion the point
of origin of the influence will not be removed, but the communication
between this center and the eyeball is destroyed.”

Regardless of the differing views of physiologists concerning the
mechanism of the reduction of ocular tension, based on experiments made
on the lower animals, there can be no difference of opinion concerning
the effect of excision of the superior cervical ganglion in the human
subject. The operations made by Jonnesco and others on the Continent,
and by myself in America, prove that removal of the superior cervical
ganglion causes a marked reduction of intra-ocular tension in
glaucomatous cases. That the same effect occurs in eyes with normal
tension is evident from my third operation—that done for optic-nerve
atrophy.


             EXTENT OF SYMPATHECTOMY IN DIFFERENT DISEASES.

Up to the present time excision of the cervical sympathetic has been
performed for the following diseases: epilepsy, exophthalmic goiter,
glaucoma, and optic-nerve atrophy. The question naturally arises: How
extensive an operation is necessary in these affections? This I will
attempt to answer:

In epilepsy it is necessary to excise the entire cervical chain on both
sides for the reason that, according to Jonnesco’s theory, it is
necessary to convert a state of cerebral anæmia—which he assumes is the
condition in epilepsy—into one of cerebral hyperæmia. Since the carotid
plexus is formed by branches from the superior ganglion, and the
vertebral plexus arises from branches which have their origin in the
inferior cervical ganglion, it is evident that the entire cervical
sympathetic must be removed.

In exophthalmic goiter, although Jonnesco in his first operation excised
only the superior and middle ganglia, he now believes it necessary to
remove the inferior as well, for this reason: from the superior ganglion
the ocular fibers arise; from the inferior the vasodilator,
cardiac-accelerator, and, probably, the secretory nerves of the thyroid
gland. If eye, thyroid, and cardiac symptoms are to be relieved the
entire chain must be excised.

In glaucoma removal of the superior ganglion alone is necessary. All of
the sympathetic fibers of the eye, with the exception of those which
pass directly from the cerebrum by way of the trigeminus, are connected
with the superior ganglion.

In optic-nerve atrophy, if it should be proved that noninflammatory
atrophy of the optic nerve can be improved by sympathectomy, removal of
the superior ganglion alone will be necessary, for reasons already
given.

If the glaucoma is unilateral, it is necessary to remove only the
corresponding ganglion.


                       HISTORY OF SYMPATHECTOMY.

In 1889 Alexander of Edinburgh resected the superior ganglion on both
sides. In 1892 Jacksh resected the vertebral plexus and cut the cord
connecting the middle and inferior ganglion. The third operator was
Kummel, who excised the superior ganglion on one side only. In 1893
Bojdanik made a bilateral resection of the middle ganglion. In 1896
Jaboulay made a bilateral section of the sympathetic cord, above and
below the middle ganglion. These operations were all made for epilepsy.

In regard to exophthalmic goiter, Jaboulay made a simple section of the
sympathetic early in 1896. In September of the same year Jonnesco
excised the superior and middle ganglia.

Jonnesco was the first, in 1896, to do a bilateral resection of all
three cervical ganglia, though it is claimed by a Polish surgeon,
Baracz, that he proposed the same in 1893. To Professor Jonnesco
furthermore belongs the credit of having first excised the superior
ganglion for glaucoma in September, 1897.

Ball of St. Louis was the first to remove the superior cervical ganglion
for optic-nerve atrophy. The date of this operation was June 24, 1899.

Terrier, Guillemain, and Malherbe, in their “Chirurgie du Cou,” 1898,
were among the first to give the surgery of the sympathetic a place in a
text-book.

Among those who have operated on the cervical sympathetic for the relief
either of glaucoma or exophthalmic goiter, or both, are Abadie, Réclus,
Gerard-Marchant, Chauffand and Quénu, Jeunet, Bled, Ball, Renaud, and
Bartlett.

Panas is opposed to sympathectomy in glaucoma. He reports seeing a
patient in whom, three months after the operation, vision was still
declining.

François-Frank, at a meeting of the Paris Academy of Medicine, held May
22, 1899, spoke of the effect of sympathectomy on the circulation of the
thyroid gland, brain, and eyes, and on the heart. He believes that the
operation can easily produce good results.

Doyon has described the trophic changes produced in the rabbit by
excision of the cervical sympathetic.


                              CONCLUSIONS.

From a study of the cases of sympathectomy made by Jonnesco and others,
and from the observation of my own cases, I offer these conclusions:

1. Excision of the superior cervical ganglion is a most valuable
procedure in glaucoma.

2. It is of more value in glaucoma simplex than in inflammatory
glaucoma.

3. In inflammatory glaucoma, on which iridectomy has been done without
benefit, excision of the superior cervical ganglion should certainly be
tried.

4. In cases of absolute glaucoma with pain, sympathectomy is to be tried
before resorting to any operation on the eyeball.

5. In cases of simple optic-nerve atrophy, sympathectomy may possibly be
beneficial if done before vision is entirely lost.

6. In cases of exophthalmic goiter, which do not improve under hygienic
medicinal and electric treatment, excision of the cervical sympathetic
on both sides is to be advised.

7. In unilateral glaucoma excision of the sympathetic ganglion is to be
done only on the corresponding side.

8. In the hands of a careful operator, excision of the superior and
middle ganglia is a safe operation, but removal of the inferior ganglion
can be done safely only by the most skillful surgeons.

9. The postmastoid route is to be preferred in excision of any part, or
all of the cervical sympathetic.

10. The fact that glaucoma is improved by sympathectomy and the finding
of pathologic changes in the excised ganglia suggest the conclusion that
this affection is due either to a permanent irritation of the cervical
sympathetic, or to an irritation located elsewhere and transmitted by
means of the cervical sympathetic.

I wish to extend my thanks to Drs. E. C. Renaud and Willard Bartlett for
valuable assistance in the preparation of this paper; to Dr. Carl Fisch
for the pathologic report.

                                                                  DEADY.


=Heath, M. D., Charles.—A Case of Sinuses in the Vault of the
Naso-pharynx.=—_The Jour. of Lar., Rhin. and Otol._, May, 1900.

Case shown at the Lar. Soc. of London:

A woman, æt. thirty-one years, had suffered several years with
discomfort in nose, throat, and mouth, with dyspepsia. Mucosa of nares
and pharynx markedly atrophied. Atrophied condition made post-rhinoscopy
easy. “The eustachian eminences were seen to be enormous, filling the
fossæ of Rosenmüller, and reaching nearly to the pharyngeal roof. Just
behind the upper edges of the choanæ, on each side, there appeared a
transverse elliptical opening, which was about half an inch long and a
fifth of an inch across at the widest part on the left side, and
slightly less in each dimension on the right; a probe apparently extends
about a quarter of an inch into the cavity.” In the discussion following
some thought them to be small recesses formed by cicatricial tissues,
other formed by peculiar distribution of adenoid tissue, and still
genuine sinuses.

                                                                 PALMER.


=Roughton, B. S. (Lond.), F. R. C. S., Edmund W.—The Diagnosis and
Treatment of Chronic Purulent Nasal Discharges.=—_The Jour. of Lar.,
Rhin. and Otol._, May, 1900.

We ascertain by interrogation, (_a_) if the discharge is purulent or
muco-purulent; (_b_) whether it is unilateral or bilateral; (_c_)
whether it is continuous, intermittent, or influenced by change of
posture; (_d_) if there is offensive smell perceived by the patient or
by others; (_e_) pain is not usually complained of unless there is
obstruction to drainage, and consequently retention of pus under
pressure. Unilateral discharge suggests a foreign body in a child or
sinus involvement in an adult. If it is intermittent or influenced by
position probably originates in a sinus. Subjective fetor suggests
sinusitis; while objective fetor, ozena; and combined subjective and
objective is the rule in syphilitic necrosis. Location of pain is of
very little, if any, use in diagnosis.

_Rhinoscopy._—Attention directed to (_a_) situation of the pus; (_b_)
polypi; (_c_) atrophy of the mucous membrane; (_d_) crusts; (_e_)
ulcerations; (_f_) adenoids; (_g_) nasal obstruction; (_h_) foreign
bodies. Under (_a_) beside usual cleansing of nasal cavities and
reexamination to ascertain situation, he recommends “tamponading,” _i.
e._, by blocking up first one part, then another, with pledgets of wool,
and noticing whence the discharge reappears. (_e_) Ulceration may be
syphilitic, simple, tubercular, or lupoid in origin. “It must not be
forgotten that a perforation” of the septum “may be entirely the work of
a misused finger-nail.” (_g_) The normal mucoid discharge damned up by
nasal obstruction frequently becomes purulent.

Special methods of diagnosis as follows are mentioned:
transillumination; examination of upper teeth; catheterization of the
ostium, maxillares, naso-frontal canal, and outlet of the sphenoidal
sinuses; external examination of antrum and frontal sinuses; exploratory
puncture of the antrum through the inferior meatus, alveolar process, or
canine fossa. Diagnosis of ethmoiditis is principally by exclusion.

Treatment of the accessory sinuses may be summed up under the following
indications: (_a_) removal of the cause; (_b_) evacuation and drainage
of pus; (c) antiseptic irrigation; (d) removal of morbid material, when
present. PALMER.


=Williamson, R. T.—Remarks on the Diagnosis and Prognosis in One Hundred
Cases of Double Optic Neuritis with Headache.=—_Lancet_, May 12, 1900.

The detection of optic neuritis is of the greatest importance in the
diagnosis of cerebral affections. Nevertheless, in certain cases of
double optic neuritis with headache considerable caution is necessary
before coming to a conclusion as to the exact nature of the disease.
Though these two symptoms are present in the majority of cases of brain
tumor and are so frequently due to this cause they are also met with in
other diseases. In some cases of granular kidney, for example, the
patient comes under treatment for headache and failure of vision; and
ophthalmoscopic examination may reveal intense optic neuritis like that
of cerebral tumor (neuritic form of albuminuric retinitis). At first the
symptoms appear to indicate cerebral tumor, but a careful examination of
the urine and cardio-vascular system will clearly reveal the cause.
Limited space does not permit an enumeration of all the causes of double
optic neuritis with headache. The results of the examination of one
hundred cases presenting these two symptoms reveal, however, several
points of interest. Most of these cases have been seen by us conjointly;
some were seen separately, whilst others (in Groups I. to VIII.) were
examined by one of us (R. T. W.) whilst holding the post of medical
registrar at the Manchester Royal Infirmary. For permission to include
the latter amongst our cases we are indebted to the medical board of
that hospital.

With respect to the diagnosis and termination these one hundred cases
may be grouped as follows:

I. Brain tumor, verified by necropsy, 27.

II. Cases terminating fatally; probably, majority due to brain tumor;
but no necropsy obtained, 27.

III. General symptoms of brain tumor; but necropsy revealed distention
of the ventricles of the brain with fluid; no tumor (serous meningitis
of ventricles), 2.

IV. Cerebral abscess (fatal), 3.

V. Tuberculous meningitis (fatal), 2.

VI. Chronic interstitial nephritis; neuritic form of albuminuric
retinitis (fatal), 3.

VII. Toxic conditions and blood diseases: Chronic lead poisoning, 3.
Ulcerative endocarditis, (fatal), 1. Purpura hemorrhagica (fatal), 1.
Henoch’s purpura (fatal), 1. Chlorosis with cerebral symptoms
(recovery), 3.

VIII. Headache and double optic neuritis (without localizing symptoms);
probably syphilitic (recovery, with blindness, 2; with impaired vision,
4), 6.

IX. Headache and double optic neuritis (without localizing symptoms); no
evidence of syphilis; duration six and two and a quarter years,
respectively. Termination still uncertain, 2.

X. Headache and double optic neuritis (without localizing symptoms); no
evidence of syphilis; recovery with blindness, 8; with impaired vision,
3; with good vision, 8, 19.

The following are brief abstracts of the notes of the cases in Group X.
which have come under our observation and which we have followed for a
considerable period of time. The number of years during which each case
has been followed is given in parentheses after the brief note.

1. A boy, aged ten years. Double optic neuritis, headache, and vomiting;
slight internal strabismus of the left eye. Recovery with normal vision.
(Seven years.)

2. A young woman, aged seventeen years. Headache, vomiting, and double
optic neuritis. Recovery, but with impaired vision in one eye and
blindness in the other. (Five and a half years.)

3. A young woman, aged eighteen years. Double optic neuritis, headache,
and vomiting; several epileptic fits. Recovery, with useful vision in
one eye; vision in the other is very defective. (Seven years.)

4. A young woman, aged eighteen years. Double optic neuritis, headache,
and vomiting. Recovery, but complete blindness followed. (Four years.)

5. A young woman, aged nineteen years. Double optic neuritis, headache,
and vomiting. Recovery with good vision. (Three years.)

6. A man, aged twenty years. Double optic neuritis, headache, and
vomiting. Recovery, but complete blindness followed. (Two and a half
years.)

7. A girl, aged ten years. Double optic neuritis, headache, and
vomiting; knee-jerks were absent. Recovery, but complete blindness
followed. (Three years.)

8. A boy at the age of thirteen years had double optic neuritis and
headache; recovery ensued. At the age of fifteen years he had a return
of headache and double optic neuritis; also vomiting. At a later date
there was partial anæsthesia in the distribution of the right fifth
cranial nerve; the right cornea was opaque; there was complete blindness
in both eyes. Partial anæsthesia of the face and blindness remained, but
otherwise the patient recovered and felt quite well nine months after
the second attack.

9. A girl, aged sixteen years. Double optic neuritis, headache,
vomiting; slight internal strabismus of the right eye. Recovery with
normal vision. (Four and a half years.)

10. A boy, aged ten years. Double optic neuritis, headache, and
vomiting. The head had increased in size. Recovery, but with complete
blindness. (Three years.)

11. A woman, aged nineteen years. Double optic neuritis, headache, and
vomiting. Recovery with normal vision. (Three years.)

12. A boy, aged fifteen years. Double optic neuritis, headache, and
vomiting. Recovery. (Two and a half years.)

13. A woman, aged twenty-one years. Double optic neuritis, much swelling
of the disks, headache, and vomiting. Complete recovery with normal
vision. (Four and three-quarter years.)

14. A girl, aged fifteen years. Double optic neuritis, headache, and
vomiting. Recovery with good vision. (Five and a quarter years.)

15. A boy, aged twelve years. Double optic neuritis, headache, and
vomiting; slight internal strabismus of the right eye. Recovery with
good vision. (Four years.)

16. A man, aged forty years. Double optic neuritis, headache, and
vomiting. Recovery, but with complete blindness. (Eighteen months.)

17. A youth, aged seventeen years. Double optic neuritis, headache, and
vomiting. Recovery, but with total blindness. (Five years.)

18. A woman, aged twenty-two years. Double optic neuritis, headache, and
vomiting. Recovery, but with total blindness. (Two and three-quarter
years.)

19. A girl, aged fourteen years. Double optic neuritis, headache, and
vomiting; internal strabismus (left) for fourteen days. Recovery, with
normal vision. (Two years.)

The following are brief notes of the cases in Group IX.:

20. A girl, aged twelve years. Headache, vomiting, and double optic
neuritis in December, 1893. Recovery in twelve months, but vision was
much impaired. She remained well with the exception of occasional
headache until December, 1899. Then the severe headache returned. She
became ataxic and optic neuritis reappeared. In April, 1900, the
headache was much less and the patient felt much better, but she was
completely blind. (Six and a half years.)

21. A young woman, aged seventeen years. Headache, vomiting, and double
optic neuritis. Vision was impaired. Vomiting ceased; the headache
continued for over two years, but recently disappeared after lumbar
puncture. (Two and a quarter years.)

In all cases of double optic neuritis a systematic and careful
examination of the patients should be made. The urine and
cardio-vascular system should be examined for signs of chronic
interstitial nephritis; the gums should be examined for the lead line
and other indications of lead poisoning should be sought for; the
question of chlorosis or other “blood disease” should be considered; and
the ears should be examined for signs of otitis. But when all these
conditions have been excluded and when the symptoms are apparently due
to a cerebral affection, there is one group of cases in which localizing
brain symptoms are absent and in which the chief indications of disease
are headache, double optic neuritis, and often vomiting. In most of
these cases syphilis can be also excluded. A diagnosis of brain tumor is
given, and the growth is thought to be situated in some region in which
the localizing symptoms are at first indefinite—cerebellum,
temporo-sphenoidal lobe, or prefrontal region. Such a diagnosis often
proves to be correct. Localizing symptoms may develop later and a
necropsy may show the accuracy of the opinion expressed. But sometimes,
to the surprise of the medical man, a fatal termination does not occur;
the symptoms sometimes disappear and the patient recovers, though very
often impairment or loss of vision remains. The patient may continue in
good health for years or for a lifetime afterwards. Most medical men who
have paid much attention to cerebral diseases will have met with a case
or cases of this kind. The chief object of our article is to call
attention to this class of cases and to indicate the frequency of their
occurrence. Nineteen out of one hundred cases of double optic neuritis
with headache in the table just given could (after careful examination)
be placed in this group (X.).

What is the cause of the symptoms in this group of cases? Possibly in
some cases the symptoms are caused by a non-malignant tumor (or
tuberculous mass) which ceases to extend and becomes quiescent and
encapsuled. One of us has recorded a case in which symptoms of cerebral
tumor (including Jacksonian epilepsy and hemiplegia) gradually subsided
and temporary recovery ensued; but three years later symptoms of
cerebellar tumor developed and death occurred. The necropsy revealed a
recent large tuberculous mass in the cerebellum and an old capsuled
tuberculous mass just beneath the motor cortex in the right cerebral
hemisphere. The latter had evidently been the cause of the early
cerebral symptoms from which the patient had recovered. An instructive
case has been recorded by Dr. T. K. Monro of Glasgow. The patient, at
the age of sixteen years, suffered from severe headache with failure of
vision which passed on to complete blindness. For thirty-three years he
was an inmate of a blind asylum, ophthalmoscopic examination showing
double optic atrophy. He died at the age of sixty-three years, from
cancer of the stomach, and the post-mortem examination also revealed a
large myxomatous tumor in the left half of the cerebellum. In all
probability the early cerebral symptoms had been associated with optic
neuritis which had passed on to optic atrophy and the cause had been the
myxoma in the cerebellum which had remained quiescent for forty-six
years.

In some cases of double optic neuritis with headache and general
cerebral symptoms, when recovery occurs the cause is probably distention
of the ventricles of the brain with fluid—serous meningitis of the
ventricles (Quincke). This condition was present at the necropsy, and no
tumor growth could be found in two out of the one hundred cases
tabulated. It is probable that a number of the cases in which a
diagnosis of cerebral tumor has been made, but in which recovery has
occurred, have been due to this condition—serous meningitis of the
ventricles. Probably the two cases in Group IX. and possibly some of the
cases in Group II., in which death did not occur for several years after
the onset of symptoms, were of this nature. Other cases which recover
may be due to a basal meningitis.

The table given above is instructive both as regards the diagnosis and
prognosis in cases of double optic neuritis with headache. It shows the
necessity for careful examination before giving either a diagnosis or
prognosis, and the clinical group of cases No. X. ought always to be
borne in mind whenever the diagnosis is obscure and localizing symptoms
are absent.

There are two other points to which we would draw attention. In ten out
of the one hundred cases the patient recovered completely from the
headache and general cerebral symptoms and regained perfect health, but
the optic neuritis was followed by atrophy and complete blindness. In
the face of this terrible termination we cannot help thinking that
simple trephining of the skull and the removal of bone, without any
interference with the brain, as suggested and practiced by Mr. Victor
Horsley for the relief of optic neuritis and pressure symptoms, is a
method of treatment worthy of more frequent trial when vision is failing
markedly. Dr. James Taylor has published cases which appear to show that
this method of treatment may be of service in checking the optic
neuritis and failure of vision. In the class of cases in Group X. if
there should be a suspicion that the symptoms may be due to serous
meningitis of the ventricles, lumbar puncture appears to be worthy of
trial, since several cerebral cases are now on record in which this
treatment appears to have been of great service, and in which the cause
of the cerebral symptoms was probably that just mentioned.

                                                                  DEADY.


=Murrell, W.—A Case of Double Optic Neuritis from Serous Effusion
(Quincke’s Disease).=—_Lancet_, April 28, 1900.

A schoolboy, aged seven years, was admitted into Westminster Hospital on
January 28, 1900, the only history obtainable being that on the previous
morning he had been brought home in a “fit,” which lasted the greater
part of the day. On admission he was perfectly sensible and talked
freely, but on being put to bed he passed into a condition of
semi-consciousness which lasted for many days. He took no notice when
spoken to, and remained absolutely mute. The face and upper extremities
exhibited choreiform movements of a slow and coarse type. These
movements were apparently purposive in character, and at times he
endeavored to clutch at objects within his reach. Sometimes the arms
were widely extended, and then slowly flexed, as if performing the act
of embracing. Sometimes the movements conveyed the idea that he was
feebly endeavoring to strike those around him. There was no paralysis of
the face or of the muscles of the limbs. The movements were, as a rule,
bilateral, although sometimes the facial movements were unilateral, but
not always on the same side. There was no rigidity of the muscles,
retraction of the head, or opisthotonos. There was nothing to indicate
that the patient suffered from headache, although at times the brows
were contracted and the face wore a worried and anxious appearance. The
bowels were open twice a day and urine and fæces were passed in bed. The
motions were normal in character. The patient was unable to swallow, and
had to be fed by the nasal tube. There was no nystagmus, the pupils were
normal in size and contracted well to light. There was well-marked
double optic neuritis. The temperature was 99.8° F., and the pulse was
108. There was no tenderness or swelling of the joints, and there was no
rash on the skin. No tache cérébrale could be obtained. There was a
little cough, but there was no expectoration. The breath and
heart-sounds were normal. The urine was acid, had a specific gravity of
1018, and contained neither albumen nor sugar. The spleen was not
enlarged. The patient showed no signs of anæmia, but the blood was not
examined. There was no wasting of the muscles, and the knee-jerks were
present, although somewhat sluggish. The tongue was clean, and presented
no sign of having been bitten. The patient would not protrude it
voluntarily, and it had to be examined with the spatula.

The condition of the patient remained practically unchanged for twelve
days. The highest temperature recorded was on the second day, when it
reached 100°; on the following day it was 99.8°, and from that time
onward it was normal. The double optic neuritis continued, and the disks
were observed to be getting paler. On February 13 (the seventeenth day
of the illness) the patient was much more sensible, and recognized his
mother, putting his arms round her neck. He was still unable to talk,
although apparently he endeavored to do so, from time to time uttering a
few unintelligible words. On being asked if he would like an orange he
nodded his head, and he showed some signs of interest in a watch which
was shown to him. The incontinence of urine and fæces continued, but
food was taken with less difficulty. The movements gradually subsided.
On the 17th the patient could say his own name, but beyond that could
utter only inarticulate sounds, and failed to recognize letters or
words, either written or printed. On the 20th he was able to speak
plainly, although incoherently. He endeavored to get out of bed, and
during the night was so noisy that he had to be removed from the ward.
Urine and fæces were still passed under him. On the 22d he was quieter,
and for the first time indicated that he wanted the bed-pan. The optic
neuritis was less marked. On March 1 the patient was able to get up, and
seemed to be quite well. On the 8th the following note was furnished by
Mr. G. Hartridge, who had frequently examined his eyes during the course
of his illness: “Pupils five millimeters each. React well to light, to
convergence, accommodation, and consensually. Right vision 6/6, left
vision 6/9. Right disk getting white; not much swelling of the disk;
edges clearing. Retinal vessels, specially veins, very full and
tortuous. Left disk pale (less so than right), dim; edges blurred.” The
only medical treatment adopted was the administration for a few days of
15 minims of liquor arsenicalis three times a day.

                                                                  DEADY.


=Stephenson, Sydney.—Concussion of the Retina.=—_Brit. Med. Jour.,
January, 1900._

Several years have elapsed since Dr. R. Berlin described a series of
cases in which he had observed a peculiar retinal change after the eye
had been struck with a blunt object, as, for example, a stick or a
stone. Under those circumstances he noticed a cloudiness of portions of
the retina, not involving the retinal blood vessels. The milky
appearance reached its height in twenty-four to thirty-six hours, and
disappeared in two or three days. Berlin pointed out that the rapidity
with which the cloudiness developed, and the length of time that it
persisted, stood in direct relationship with the severity of the
original injury. This curious condition, which Berlin called _commotio
retinæ_, was associated with some reduction of sight, episcleral
congestion, and a difficulty in getting the pupil to dilate when
atropine was dropped into the eye. Small retinal hemorrhages were
sometimes present. Berlin explained the ophthalmoscopic picture by
supposing that a rupture of the choroid was followed by bleeding and
œdema of the retina. This theory has recently been opposed by Denig.
That observer, as the result of experiments upon rabbits, believes that
the blow upon the eyeball causes the vitreous to impinge upon the
retina, to tear the internal limiting membrane, and to force the
vitreous into the nerve-fiber layer. The alternate elevations and
depressions thus brought about in the nerve-fiber layer of the retina
are, according to Denig, the cause of the ophthalmoscopic appearances.

Since the publication of Berlin’s original paper few cases of _commotio
retinæ_ have been recorded. Indeed, the retinal changes are of so
fleeting a nature that an opportunity for observing them must occur
comparatively seldom. This fact leads me to place upon record brief
notes of a somewhat interesting case:

E. S., aged eleven years. First seen on July 25, 1899.

_History._—At 6.45 P. M., on July 24, the patient was struck in the
right eye with a cricket ball, made of cork and covered with rag cloth.

_Present State._—Right eye: Small abrasion of the skin of the lower lid,
with a surrounding area of redness. Some general conjunctival
congestion, with a definite ecchymosis in the ocular conjunctiva,
opposite the lower-outer quadrant of the cornea. Tension minus 1. The
pupil distinctly sluggish and a trifle larger than the other one.
Anterior chamber deep. A narrow line of blood clot lay at the bottom of
the anterior chamber. V. 5/9 (ii. letters). Pupil dilates imperfectly to
a mydriatic. With the mirror alone some parts of the fundus oculi were
seen to be unduly white. When examined more closely with the
ophthalmoscope there was found a wide but defective zone of whitish
fundus, situated peripherally upward, inward, and outward. No such
appearances could be made out in the lower part of the fundus. The
retinal vessels, which lay anterior to the affected areas, showed no
changes. In most places it was possible to get beyond the whitish
patches so as to see the edges of the latter. These margins were
irregular, and showed white, tongue-like projections running into normal
fundus. Some small islands of cloudiness lay, however, beyond the area
of general haziness. Around the yellow-spot region was a white radiating
appearance, but no definite white mass was present in that place. Left
eye: No fundus changes. V. 5/5 (iv. letters). Tension normal.

_Treatment._—Vaseline to abrasion of skin of lid; atropine drops (2 grs.
to the ounce—to each eye twice a day); rest in bed.

_Progress._—July 26. R. V. 5/12; tension still rather low. The blood
clot present in anterior chamber and also on anterior capsule of lens
renders it difficult to see the fundus clearly; but no white patches can
be made out in the fundus.

July 27. A little blood is still present in the lower part of the
anterior chamber. The parts of the retina that were milky have resumed
almost their natural appearance, and the changes above mentioned are now
represented merely by a faint, whitish, ill-defined stippling of the
areas in question. Around the yellow spot is a system of fine radiating
lines, which extend for some distance into the surrounding fundus. This
is doubtless due to œdema of the retina.

July 28. R. V. 5/6 (i letter); tension still slightly _minus_.
Ecchymosis present in ocular conjunctiva, but the blood has disappeared
from the anterior chamber. Pupil not so wide as that of the left eye,
although atropine is being used to both. Faint cloudiness lower third of
the cornea, made up of almost transparent dots, as may be seen with a
+20 lens in certain positions of the eye. Fundus changes have
disappeared; faint radiating lines, however, may still be seen around
the yellow-spot region.

July 29. R. V. 5/6 (ii letter) T—I. Pupil now as large as that of the
other eye. Yellow-spot region still surrounded by a wide band of fine,
closely set, radiating gray lines. It may be noted that the
corresponding region of the left (unaffected) eye is encircled by an
ordinary oval reflex.

August 1. R. V. 5/6; (Tn.). A small ecchymosis still present in the
ocular conjunctiva on the outer side of the cornea. No blood in anterior
chamber; no corneal cloudiness. Radiating appearance still present
around yellow spot of fundus.

August 9. R. V. 5/9, L. V. 5/9; (Tn.).

August 12. Vision unaltered. Radiating lines still present around
yellow-spot region of affected eye.

September 5. The right pupil rather larger than its fellow, but no break
in the continuity of the edge of the iris can be discovered to account
for this. The action, both to light and to accommodation, of the pupils
is equal. The radiating lines formerly present around the yellow spot of
the right eye have been replaced by an ordinary oval reflex, like that
present in the other fundus. Tn.; R. V. 5/6 (i letter), L. V. 5/6 (i
letter); No. 1 Jaeger read easily.

September 7. Under atropine. R. V. = 5/18 + 1.5 D. Sph. = 5/5. L. V. =
5/12 + 1.0 D. Sph. = 5/5.

                                                                  DEADY.



                              BOOK REVIEW.


  DISEASES OF THE NOSE, THROAT, AND EAR. Part I. Diseases of the Nose
    and Throat. By S. H. VEHSLAGE, M. D., Assistant Surgeon to the New
    York Ophthalmic Hospital (Throat Department). Part II. Diseases of
    the Ear. By G. DE WAYNE HALLETT, M. D., Assistant Surgeon to the New
    York Ophthalmic Hospital. New York: Boericke & Runyon Co., 1900.
    Price, cloth, $3.00.

We are glad to receive this volume, for which we have been looking for
quite a while; because it fills a vacancy in our homeopathic literature
which has long needed filling.

It will be found a clearly and concisely written volume, very
instructive and advantageous to the student and busy practitioner; it is
not intended to be exhaustive enough for the specialist in these
branches.

Among the many commendable points, we would call attention to thorough
consideration of the subject of Diphtheria, and we are glad to say that
the treatment of this disease is sufficiently broad to include
antitoxin,—let it be rational, allopathic, or whatever we may denominate
it. While, on the other hand, we regret not to see the appreciable doses
of iodide of potash more highly recommended as antidotal to the
syphilitic poison, when manifest in these localities.

The manner in which the general, topical, or mechanical and hygienic
portion of the treatment is handled is to be strongly approved. The
homeopathic indications are well written. Like almost all books by
homeopathic authors, it shows the peculiar bent of the homeopathic
physician’s mind is upon the therapeutics or cure of the patient rather
than upon the fine development of the pathology, ætiology, etc., of the
disease.

The publishers have done well in the binding, selection of type, and
leading,—making it easy to read, but we are sorry to notice a number of
small typographical errors have crept in, to mar it for a somewhat
critical eye.


                            BOOKS RECEIVED.

The following books have been received and will be reviewed in the next
issue of the journal.

Sajous’ “Annual and Analytical Cyclopædia of Practical Medicine.” Vol.
V., “Methyl-Blue to Rabies.” The F. A. Davis Co.

“Diseases of the Eye,” Nettleship; Sixth American from the Sixth English
edition. Lea Bros. & Co.

“Injuries to the Eye in their Medico-Legal Aspect.” By S. Baudry, M. D.
The F. A. Davis Co.

-----

Footnote 1:

  Read before the New York State Homeopathic Medical Society at the
  annual meeting, held in Albany, February 13 and 14, 1900.

Footnote 2:

  Presented at the Annual Meeting of the National Society of
  Electro-Therapeutists, Atlantic City, N. J., September, 1900.

Footnote 3:

  Published by the permission of Sir Frederick Hodgson, Governor of the
  Gold Coast Colony.

------------------------------------------------------------------------



                          TRANSCRIBER’S NOTES


 1. P. 201, changed “glycerine, aa 2 drams” to “glycerine, at 2 drams”.
 2. Silently corrected typographical errors.
 3. Retained anachronistic, non-standard, and uncertain spellings as
      printed.
 4. Footnotes have been re-indexed using numbers and collected together
      at the end of the last chapter.
 5. Enclosed italics font in _underscores_.





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