practice, I have found strychame to be of value. Old people need strychnine now and then if you want them to live.

Do not use strychnine too long or spinal irritation will follow and here is the trouble with strychnine: The physician uses it too long, has destroyed its therapeutic value and lost confidence in the drug, so study this most congenial drug and your confidence will grow. Study the law of strychnine.

Strychnine arsenate in respiratory troubles; S. nitrate in kidney affections; S. sulphate in bowel disorders; S. valerianate in nervous disorders. Strychnine is the best vital tonic known.

Richmond, Ind. M. W. YENCER, M. D.

EDITOR MEDICAL WORLD:-This is in response to your call for opinions on the value of strychnine (December WORLD, page 406).

Strychnine has been used very freely by countless physicians for many years, and now we are told by conscientious scientific leaders that it is therapeutically worthless.

I believe these statements are made in good faith. There is a reason for the conclusion. I believe that the drug in doses of 1-60 to 1-30 grain is of some value as a tonic if the term be permitted, and if not given to cure a disease. I think it is beneficial in such dose in treating conditions following acute illness, as a stomachic, etc.

But the question seems to be "Is it a stimulant?" The answer is decidedly yes, but not in the tonic dose.

Perhaps it may not often cause a rise in blood pressure, but in certain cases of surgical shock and in other cases where stimulation is indicated, it will certainly produce results if given in proper dosage. That dosage, for an adult, is 1-15 or 1-10 grain hypodermically, repeated in 2 hours if needed.

I might say that sparteine sulphate is in the same position at present as is strychnine-condemned as no good. Again, 1-10 or 1-4 grain given as a stimulant means time wasted, but 1% or 2 grains every 3 or 4 hours will occasionally bring about cardiac compensation after digitalis has fallen down.

Tonawanda, N. Y. H. B. DEEGAN, M. D.

I have been practicing medicine nearly thirty years, and if I had to give up that drug I would quit medicine and, I reckon, join the "Chiros."

I do know I have never killed anyone with it, but instead, have saved several lives by using it. Its usefulness is too great to mention in this connection, but for a uterine tonic, after ergot and viburnum, etc., have failed, don't forget strychnine. When your pneumonia patient begins to cyanose don't forget strychnine. When you are trying to keep some aged pioneer or ex-inebriate with us longer, don't let the price of strychnine interfere.

If you have almost let your "flu" patient get by-leave him some strychnine tablets so he will be alive in the morn when you get back. If you have a heart flicker or flutter and don't know which valve, whether either or neither, give some strychnine. In fact, my brother, don't go off without some in your grip. Success to THE WORLD. Hawkins, Texas.

W. L. BEAVERS.

some form or compound is prescribed oftener than any other drug.

A mechanic that repairs old machinery cannot well get along without his monkey wrench. I suspect the monkey wrench is the most useful and the most essential tool the old machinery mechanic has need for. When all the tires and taps of an old buggy are tightened up, the rattle and wabble is all gone and it runs like a new buggy for a time.

Strychnine is the doctor's monkey wrench and perhaps the doctor needs his monkey wrench as often and as constantly as the mechanic.

Strychnine, according to size of dose, I think, puts more or less tone and tension in every organ and muscle of the body, and perhaps this tension at times in creases the functions of the organs. Strychnine produces a clonic, tonic, perhaps more tonic, spasm of the muscles, and, like ergot, on uterine contractions, it is so tonic as to continue its rhythm, and so does not produce a real, natural increase in function. Yet small doses, I think, do tone up with not enough spasm to interfere with natural function very much.

In atonic heart conditions, in atonic breathing troubles, in atonic bladder troubles, in atonic colic, in atonic stomach and bowel troubles, strychnine is often useful and reliable, according to my logic and observation.

From the foregoing statements it seems that I cannot see much in strychnine but a tonic remedy. It surely does not act on any germ theory like quinine in malaria, and it does not affect the circulation like veratrum, etc., etc.

To illustrate my idea further, strych nine is to the doctor what the fiddler's key is to the violin. Turn the key just enough, and the violin is in rhythm and tune and makes fine music-but turn on too much tension, and the thing squeals and squeaks and next a string snaps.

In sthenic conditions with high fever and a dry tongue and skin, I think strych nine should be used very cautiously, if at all. W. CELSOR, M. D.

Hartsville, Tenn.

EDITOR MEDICAL WORLD:-Inclosed please find check for $4 for which continue sending THE MEDICAL WORLD to my address, 4 years from January 1st, 1922. I like THE WORLD Very much. Harrison, Ark. J. B. DODGE, M. D.

Syphilis of the Nervous System.

Difficulties in diagnosis. General symptoms. Ocular symptoms. Oculocardiac reflex. Ophthalmoplegia interna. Argyll-Robertson pupil.

BY F. L. JACKSON, M. D. Westbrook, Maine

In

We are all more or less familiar with the clinical pictures characteristic of syphilis. General cutaneous eruption, mucous patches and condyloma found on the mucous membrane, glandular enlargement, iritis and falling out of hair, as seen in the second stage of the disease. the third stage the symptoms take on a more advanced aspect and include gummata, ulcers, localized skin lesions, thickening of arteries, sclerosis of liver, kidneys and of the central nervous system, particularly the cord. Were this all, the problem might not be so perplexing, but there are other syphilitic lesions which are not so easily discovered and, when they are, it is often difficult to differentiate them from lesions having an entirely different etiology. The form of syphilis I have under consideration at the time of writing is syphilis of the nervous system.

General Remarks.

The variety of clinical pictures which this form of syphilis presents is quite as varied as the disease itself and the fact that they in no wise differ from those due to other causes, as cerebral tumor, meningitis, occlusion of a cerebral vessel from any cause, renders it even more difficult to make an accurate diagnosis. Did I say in no wise differ from symptoms of cerebral diseases? It is true that their in

ception is more gradual, it requiring at least a week for their development. It often happens, however, that the symptoms are not sufficient to arouse the curi

osity of the patient; so by the time they are brought to the attention of the physician, something quite serious has developed.

A history of the case when it can be correctly obtained is of great diagnostic value. But this is often difficult, and since cerebrospinal syphilis may develop anywhere from ten to thirty years after inoculation, the patient may believe that he was cured by some specific treatment

years before, so the original trouble has long since been forgotten. The Wassermann reaction then is often negative. In such cases, if the symptoms are of such a character as to cause one to suspect syph ilis of the nervous system, the cerebrospinal fluid should be used.

General Symptoms.

Of great diagnostic value is the grouping of symptoms as originally suggested by Hubner:

1. Basal strain symptoms or gummy meningitis. They include such general symptoms as intense headache, often worse at night, loss of memory, somnolence and stupor, all of which more or less characterize the typical tumor of the brain. Maniacal excitement, imbecility and great physical weakness may super

vene.

2. Gummy meningitis and symptoms of the convexity in neighborhood of the fissure of Silvius. This group includes hemiplegia or monoplegia, paresis, cortical derangements of speech, such as motor aphasia and the like. Perhaps the symptom belonging to this group which is of the greatest diagnostic value is epileptic convulsions. They may be local or general, and, as a rule, are not preceded by an aura. When occurring in patients over thirty years of age, and alcohol and ure mia can be excluded, they are of syphilitic origin.

3. Syphilitic disease of the walls of the arteries. The most frequent symptom seen in this group is hemiplegia, which 18 due to the sudden closure of a vessel by thrombosis; convulsions may occur, but

are rare.

4. Cases of combined cerebral and spin al syphilis and which may include any on€ of the three forms just considered, associated with a more widespread disease.

Ocular Symptoms.

A glauce into the eye will often aid greatly in the diagnosis of syphilis. There are sometimes seen ulcers of the eyelids, accompanied by induration of the preocular and submaxillary glands, which distinguishes them from tubercular ulcers and ulcers of vaccinia. Ulcers of the conjunctiva are rare, but, when found, soon disappear when potassium iodide is given. Gummatous inflammation of the iris is more common, one or more yellowish

brown or reddish brown nodules being present and varying from the size of a pin's head to that of a pea. They may either be found in the ciliary or pupillary body or midway between. Those skilled in the use of the ophthalmoscope may detect a dust-like opacity in the posterior portion of the vitreous, blurring and redness of the optic papilli and alterations in the macular region and in the vessels (the diffused syphilitic choroiditis of Foster). Other forms of retinitis which may be discovered: (1) Relapsing syphilitic central retinitis, (2) syphilitic hemorrhagic retinitis, (3) syphilitic arteritis of the retina, and (4) perivasculitis of the retina. For a more detailed description of these diseases, I would refer the reader to "Modern Ophthalmology," by James Moores Ball."

The Oculocardiac Reflex.

This reflex consists of a gentle pressure on the globe of the eye with one hand, while with the other the pulse is noted. If the patient be normal, there will be a perceptible slowing of the pulse thru vagus stimulation. This is a true reflex, is easily elicited by the physician, and is of great diagnostic value in syphilis of the nervous system. According to Rose ("Physical Diagnosis"), "the afferent impulse excited by pressure on the globe of the eye is transmitted thru the ophthalmic division of the trigeminal nerve to the Gasserian ganglion, thence thru the large root of the fifth nerve to its root of origin. Thence the impulse is transmitted downward to the root of origin of the vagus nerve, resulting in tonic efferent impulses from this center causing inhibition of the cardiac rate."

Ophthalmoplegia Interna.

This is a paralysis of the internal ocular muscles, and when occurring in one eye and lasting for a long time, is almost without exception due to a luetic nuclear lesion. I have found that an easy method of testing these muscles is to adjust a trial frame to the patient, instruct him to look at a lighted candle which has been placed a few feet away, then put in a prism lens, base outward and note if he is able to see the lighted candle without turning the head. Failure to do this would indicate paralysis of the internal ocular muscles.

The Argyll-Robertson Pupil. This is a condition in which light reflex is lost, but convergence is present. This phenomenon is the result of a break in the reflex arc, and is now generally believed to be in the fibres connecting the primary visual center with the sphincter muscles. In very rare cases this reflex might result from pressure, but almost without exception is a symptom of syphilis of the nervous system.

Conclusion.

Remembering that symptoms syphilis of the nervous system are essentially the same as those of other brain lesions, as tumor, meningitis and occlusion of a cerebral vessel from any cause, it is often a difficult problem to diagnose the disease correctly. But convulsions when not due to uremia or alcoholism, unilateral spasms, particularly the more limited ocular palsies, hemiplegia occurring in persons under 45 when not due to cardiac embolism, point to syphilis of the nervous system.

It often happens that the Wassermann reaction in such cases is negative. When this does happen, a test should be made with the cerebrospinal fluid, which, in the majority of cases will give positive results.

Surgery of the Nose.

Pathological conditions in the nose requiring attention. Turbinates, sinuscs, cells. Test for hearing. Deflected septum. Treatment. Removal of middle turbinate. Results.

BY MILTON MORROW, M. D.
Muskogee, Okla.

In the subject of nasal surgery we have several conditions which cannot be conibated in any other way except by surgical means. Nasal catarrh, and especially the chronic form, is always due to a defect of the anatomy of the nose or throat or to both, or a pathological condition. I examine the patient who gives a complete history of nasal catarrh, viz: the patient catches cold at the least exposure, has hypersecretion of the mucous membranes or the nose, posterior nares and pharynx. He complains of a dripping of mucus into the pharynx, especially when he lies

down or inclines his head backward, causing him to hawk and spit, which bothers him much in public. If in chronic, atrophic catarrh there is a drying of se

cretion in the nose and a bad odor of the

breath, sooner or later there will be a tinnitus aurium in one or both ears, which will last during the acute stage of the cold, and then clear up, but finally the tinnitus aurium will become permanent and his hearing acuity will diminish or he may commence to lose his vision in one or both eyes, due to pressure upon the lachrymal bone, which I would compare in thickness to a cigarette paper.

Now, the important question is what causes these symptoms? Is it the inħalation of irritating substances or catching cold, which is simply a bacterial invasion of the mucous membranes of the nose and throat?

These things may play some part in causing catarrh, but if you will make a thoro examination of the nose and throat you will always find some abnormal condition of the anatomy of the nose or throat, such as a deflected septum, hypertrophied turbinates, septal spur, diseased ethmoid cells, or submerged tonsils, any of which might cause the above-named symptoms, and as long as you let the patient wear this abnormal anatomy he will have catarrh.

es.

For instance, if your patient has a pair of hypertrophied middle turbinates, you will have interference with drainage from the supra-orbital sinuses, the ethmoid cells and the sphenoidal sinuses, which cause catarrh from pressure of the turbinate bones upon the sinus outlets, effecting a retention of secretion in those sinusThe secretion is retained until it decomposes or there is a bacterial invasion of the secretion start up and this invasion forms gas pressure in the sinuses that forces the secretion out over the enlarged turbinates. The secretion, after decomposition sets in, is a catarrhal discharge. This infected discharge flows backward to the posterior nares and larynx, thereby passing over the opening of the Eustachian tube in the posterior nares and infects the tube lining and the middle ear.

There may be pressure of the middle turbinate upon the lachrymal bone, which, being very light in texture, is pressed outward and makes trouble from pressure

upon the eyeball. The patient may have nasal polypi from pressure of an enlarged middle turbinate bone against the septum or they may be due to diseased ethmoid cells. If there is sinus involvement you may find any of the diseases that are caused from septic absorption or from a focal infection, such as rheumatism, neuroses, heart leakage, irregular heart beat. If from pressure of the turbinates you may find asthma, chronic headaches, or anything that may occur from wearing an ulcerated tooth root or a chronically submerged tonsil.

General practitioners will do well to look up this subject, as these troubles in the nose have a great deal to do with patients being susceptible to grippe infection. In those patients from thirty to sixty, who come to you complaining that they cannot hear as good as they should, you will find a large percentage of them with a middle ear catarrh, and in the ones that haven't middle ear catarrh, a large percentage will have syphilitic infection. Therefore give them a Wassermann test.

TEST FOR HEARING.

Now, in examining one of these patients I always use the tuning fork test, if they are hard of hearing, to determine as to whether I can do anything to benefit their hearing or not, I take a C2 tuning fork and put it in vibration and tell the patient to put his hand up when he can hear the fork no longer. Hold the tuning fork just opposite the external auditory canal. Now, the normal ear should hear the tuning fork 55 or 60 seconds. If they hear it for only 30 seconds you register it 30-60, or they have lost half their air conduction, which can always be returned by putting the anatomy of the nose in a normal condition.

Now, I test the bone conduction by put ting the C2 tuning fork in vibration and placing the handle end over the mastoid process just back of the ear, and tell the patient to put his hand up when he cannot hear the fork. The normal ear bears the bone conduction 30 seconds. Suppose the patient hears the fork 15 seconds. Register it "bone, 15-30," or your patient has lost half his bone conduction. Now, in this case you should not tell the patient that you can help his hearing, for when the bone conduction is lost, there isn't

much hope of restoring it, for the patient has carried a middle ear catarrh which has caused ankylosis of the bones of the ear, and it is like treating ankylosis of the knee joint. But you can tell them that by doing the proper work in the nose you can save the hearing they have and they won't lose any more.

In cases of asthma, where you only get temporary relief from medicine, examine the nose, and in a large percentage of cases you will find a deflected septum. If you do find it, you do a submucous resection of the septum, and you will probably get results; but if you do a resection you must be thoro with your work in order to get results.

The antrum of Highmore drains out just beneath the inferior turbinate bone. Be very careful, in doing work on the inferior turbinate, that if there is any pressure from this bone just remove enough of it to relieve the pressure and no more, for if you remove too much of the inferior turbinate you will do more harm than good, as it will leave your patient with an atrophic catarrh that nothing will cure except the injection of sterile paraffin into the sides of the septum nasi.

After you have put the anatomy of the nose into a normal condition, you may have a sinus that does not clear up. If so, just open it up and give it a good drainage and wash it out until there is no discharge coming from it.

TREATMENT.

As to medical treatment, I cannot recommend it very highly, for the only benefit is temporary relief. The only medical treatment I use is alkaline antiseptic solution, used as a nasal douche in 25 per cent. solution, and I use Felter's thuja, painted upon the mucous membranes once a day. I have the patient blow his nose with both nostrils open after using the nasal douche to prevent blowing infection into the middle ear. If he has a dry atrophic catarrh I have him use chloretone inhalant or Felter's thuja, atomized into the nose; but you must always tell these patients that this treatment will not cure them, because no medical treatment or electric cautery will remove a bony enlargement.

The surgical treatment of catarrh or infection of any sinuses that drain into the