He had noticed that the inflammatory attacks in the metatarso-phalangeal articulation had never occurred at the same time as the attacks similar to that for which he now sought relief, and further, it was his fixed conviction that such inflammation migrated from his foot to his throat.

On consideration, the diagnosis rested between a syphilitic gumma and a lesion due to gout. The former is by no means rare, but the latter is exceedingly so. The history and the appearance pointing against the possibility of this tumor being luetic in origin, the patient was treated for gout, which was followed almost immediately by a marked and rapid resolution of the tumor and all symptoms then present. This case is of interest from a diagnostic standpoint, as the similarity of the tumor to a gummatous infiltration was most marked, and indeed it is quite unlikely that the diagnosis made would have been possible, although one could not help noticing the extraordinary coloration quite characteristic of gouty lesions of these parts, if it had not been for a strong anti-venereal history, combined with one typical of what is commonly known as gout.-The Montreal Medical Journal.

OPTIC ATROPHY DUE TO MUMPS.-H. Dor (Lyons) reports two cases of optic atrophy following mumps, in which no other probable cause could be discovered. In one, the visual disturbance was not noted for several months after the attack of mumps. In the other, vision was markedly reduced in one month, and two months later the case had gone on to advanced atrophy.-Transactions of the Thirteenth International Medical Congress.

Special Notice.

PEPSIN is undoubtedly one of the most valuable digestive agents of our Materia Medica, PROVIDED A GOOD ARTICLE IS USED. ROBINSON'S LIME JUICE AND PEPSIN AND AROM. FLUID PEPSIN (see fourth cover page, this number) we can recommend as possessing merit of high order.

The fact that the manufacturers of these palatable preparations use the purest and best Pepsin, and that every lot made by them is carefully TESTED before offering for sale, is a guarantee to the physician that he will certainly obtain the good results he expects from Pepsin.

THE

VOL. XXXIII.

"NEC TENUI PENNÂ.”

LOUISVILLE, KY., JUNE 15, 1902.

No 12.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

PERNICIOUS VOMITING OF PREGNANCY (Hyperemesis).*

BY J. M. KRIM, M. D.

Hyperemesis, or the pernicious vomiting of pregnancy, is fortunately a condition which is not of frequent occurrence, and the physician who is unfortunate enough to be called upon to treat such a case, or otherwise gets such a one under his care, would be many times thankful had he never seen the case.

I can not conceive any condition which in the course of events confronts the practitioner or obstetrician that is more trying or exacting. in regard to management or medication than a case of pernicious vomiting in pregnancy, and I am sure that the members of the Society will agree with me after I give the brief details of three such cases that have come under my care.

CASE 1. Mrs. E. V., aged twenty-seven years; married five years; second pregnancy; height five feet nine inches; weight one hundred and fifty-four pounds. She had been in perfect health up to the second month of this pregnancy, when moderate nausea and vomiting began. As she was feeling fairly comfortable at this time, no medication was deemed advisable.

Beginning with the third month, nausea and vomiting increased; there was almost complete loss of appetite; pulse 100; temperature normal; sleep restless. Various medicines usually recommended in such cases were given at this time, with no beneficial results. Absolute rest in bed was advised, with ice, iced milk, and champagne as *Read before the Louisville Clinical Society, April 22, 1902. For discussion see page 472.

indicated. Various methods of medication were continued, without any favorable effect being obtained. The patient began losing flesh, pulse 100 to 120, temperature normal.

After various consultations being held, and the failure of all manner of medication and other means used in an effort to alleviate the condition, as the patient was losing ground rapidly-pulse 140, temperature 99° F., with continuous nausea and retching-abortion was decided upon, which was refused by the husband. However, he yielded the following morning, and dilating the os with my fingers I introduced a sound and ruptured the sac, and in about ten hours the abortion was completed.

The patient made a good recovery in about two months, and has borne two children since that time without any difficulty, and without any nausea or vomiting during the course of the gestations.

CASE 2. H. P., aged thirty years; married five years; first pregnancy; height five feet six inches; weight one hundred and thirty-four pounds. This woman was in perfect health up to the fifth month of pregnancy, when moderate nausea and vomiting began, with some impairment of appetite. The condition was apparently controlled by medication up to the latter part of the fifth month, when increased nausea and vomiting set in, which it was absolutely impossible to alleviate or control by any method or procedure. Rest was only procured by means of hypodermatic injections of morphine, retching even manifesting itself during sleep. Anorexia was now complete; temperature 99 1-5°, pulse 130. Rectal alimentation with beef peptonoids, bovinine, milk, and panopepton was practiced for a time, but with no good results, nor was there any improvement in her condition.

After numerous consultations, abortion was decided upon, but was absolutely refused, the patient stating that she was very anxious to have the baby, and if the baby had to die she wanted to die with it, etc. (Incubators had not then come into use in this part of the country, or we might have offered her the inducement that the child might be raised by this method.) All coaxing and pleading on the part of the husband had no effect upon her determination not to have an abortion induced, and she finally succumbed, practically dying of exhaustion at the fifth and a half month of pregnancy.

CASE 3. J. K. S., aged thirty-six years; in the third month of her fifth pregnancy; height five feet seven inches; weight one hundred and thirty-two pounds. This woman had no trouble in her previous pregnancies, beyond slight nausea and vomiting. In this, her fifth

pregnancy, nausea and vomiting began in the ninth week and was progressive from the beginning.

Absolute rest in bed, all medication, and other methods of treatment failed to alleviate her condition; she began to lose flesh rapidly; anorexia complete; pulse 120, temperature 99°.

After consultation, abortion was decided upon. This being late at night, the abortion was to be performed the following morning. About three o'clock in the morning I was called to come at once, as she had decided pain in the abdomen, and it was feared she was dying. Reaching the house within half an hour, I found her laboring with an abortion, which proved to be true. After making a vaginal examination, I found the os slightly dilated, a portion of the membranes protruding, which were very tense, and by barely touching them rupture occurred and a large quantity of fluid came away. In a short time a four months' fetus was expelled and shortly afterward the afterbirth was delivered. Nausea and vomiting ceased that morning, and she began to eat and retain her food without any difficulty. Three weeks later she informed me that there must certainly be another child in her uterus, as she felt something moving. Upon making a careful examination I found that she was correct, and she went on to full term with this child without any further trouble from nausea or vomiting.

I take it that a condition such as occurred in this last case must be extremely rare, and would like for the members in their discussion to state whether they have met such cases.

LOUISVILLE.

CONVERGENT CONCOMITANT STRABISMUS.*

BY BENJAMIN L. W. FLOYD, M. D.

The field of vision of the two eyes overlap everywhere except about 40 degrees on the temporal side of each eye. When we look at a distant object the two eyes are brought into such a relation that the impression of the object is made on the central part of the retina, and we are said to be fixing on the object. Similarly, all other objects within the field of vision of the two eyes are seen by corresponding parts of each retina. The impressions that are made on the retinas are carried to the brain, and we are conscious of seeing only one object with the two eyes. This blending of the two objects into one is called binocular vision.

* Read before the Ohio Valley Medical Association, Owensboro, Ky., May 1 and 2, 1902.

Fuchs defines squint as "the deviation of the visual axis of one of the eyes from the correct position of fixation." Convergent squint, then, is the turning inward of one of the eyes, and divergent squint the turning outward of one of the eyes "from the correct position of fixation." Squint can be further divided into concomitant and paralytic.

The term concomitant is given to a form of squint as a contradistinction to paralytic squint, which is due to paralysis of one or more of the six external ocular muscles. In concomitant squint, the innervation being normal to all of the six external ocular muscles, the squinting eye accompanies the fixing eye in all its movements, and this defect in the parallelism of the two eyes or of their visual axes remains to the same degree, regardless of whatever direction the eyes are moved.

Moreover, if the better eye be covered and the squinting or defective eye be made to fix, the better eye turns inward to the same extent as the squinting eye does when the better eye is fixing. This deviation of the squinting eye is called the primary position of the squint, while the deviation of the better eye, when the squinting eye is fixing, is called the secondary position. The reason that the primary position and the secondary position are of the same degree in the concomitant form of squint is obvious to every one, for the external rectus of the squinting eye being associated in movements with the internal rectus of the fixing eye, the same innervation that caused the squinting eye to turn outward and fix the object when the better eye is shaded caused the fixing eye to turn inward, and hence the fixing eye now presents an internal squint of the same degree that the defective eye does when the better eye is fixing.

This is an important point, for it enables one to differentiate between this form of squint and the paralytic form, in which the secondary position of deviation is greater than the primary position, which is as easily explained as before. Since the external rectus now is paralyzed to a more or less extent, a greater innervation is sent out to the lagging-behind eye in the endeavor to turn the eye outward and cause it to fix the object, and this greater impulse causes the internal rectus of the better eye (which is always associated in movements with the external rectus of the squinting) to turn further inward than was the primary position of the squint.

Therefore, in the paralytic form of squint the secondary position is always greater than the primary position, while in the concomitant form they are of the same degree. There is another striking difference