Chapter II: Part 2

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.”