Part 8

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.