response to the use of iodides. Recently he had observed labyrinthine symptoms in persons suffering from hypermetropia, who have said that tinnitus occurred when the eyes were strained. He also reported the case of a young man with muscular asthenopia, who stated that he had ringing in the ears whenever he read in a bright light. Dr. Claiborne wished to know if other members of the Section had observed similar cases.

Dr. SWAIN replied that he had seen several cases where the ear symptoms disappeared after proper glasses had been prescribed. He considered the symptoms due to hyperæmia. He also reported an interesting case of internal-ear disturbance in an old man who was suddenly conscious of blurred hearing following simple influenza. After ten days the "nerve deafness" was so marked that the tuning-fork c (128) could not be heard at all on the deaf side by bone-conduction. For five or six days there was a maximum of deafness, after which the hearing improved to the former status. He considered this due to rise of pressure in

the internal ear, as the deafness cleared up so well under treatment, exactly as we explain the blindness from increased intraocular tension in acute glaucoma.

Dr. MCKERNON extended the thanks of the Section to Dr. Pooley for his paper.

He mentioned a series of cases showing another form of labyrinthine affection due to excessive use of alcohol. The symptoms disappeared under the use of pilocarpine, rest, cuppings, and withdrawal of the cause.

MEETING OF DECEMBER 11, 1902.

PRES. DR. JAMES F. McKERNON, IN THE CHAIR.

Exhibition of New Instruments.

Dr. LEDERMAN presented a portable acetylene lamp, known as the Puritan, for use of the physician, giving a steady light and being a convenient article to carry. The fuel consisted of calcium carbide from which a gas was generated (by the action of water), which, escaping through an automatic valve regulated by a movable diaphragm, furnished a steady flame. The length of time which the lamp will burn without replenishing varies with the size of the lamp; the one exhibited burned four hours on one charging. The price of the lamp is five dollars.

Dr. F. J. QUINLAN stated that he had used this lamp with great

satisfaction, and that he considered it an ideal one for illuminating purposes. Its light resembles a pale sunlight, and the flame was steady. He thought it was just what the physician needed, and that, all things considered, it was not an expensive article, and was always ready for use with little cost and slight attention.

Dr. CARL KOLLER presented a case of sinus thrombosis, followed by hypoglossal paralysis, in a girl, G. S., twenty-one years old, who was admitted to the Mt. Sinai Hospital June 30, 1902. For two weeks she had, after some tonsillitis, been suffering with pain in the left ear, general headache, and high fever with chilly sensations. Four days later paracentesis of the left drum was made in the dispensary; no pus. On admission some tenderness was found over the mastoid tip and antrum and over the posterior part of the mastoid. Pronounced tenderness along the upper course of the jugular. Wry-neck of moderate degree. The drum was not thickened but of a pale greenish color, as if a green exudate adhered to it on the inner side. No discharge. The fundus in both eyes showed marked venous congestion. On the next day this had progressed so much as to leave no doubt about papillitis developing.

Operation on July 1st.-Preliminary paracentesis; considerable serous discharge. After the first removal of bone a minute quantity of pus was found. Sinus was accordingly opened, its wall being exceedingly thin. It was situated very superficially and well forward, overlapping the antrum. It bled freely. It was exposed for about one inch; it was blue in color, narrow and bulged considerably. Some granulations were found in the antrum and the posterior cells; those of the tip were free of pus or granulations. Iodoform gauze dressing. The subsequent course was that, after a short intermission, the temperature continued septic in character. Patient complained of severe headache in the left side and occiput, and extreme tenderness in the upper course of the jugular. Papillitis increased visibly so as to deserve the name of choked disc. Blood culture sterile.

Operation on July 11th.—(1) Curettage of sigmoid sinus; (2) ligature and excision of the jugular. The dura mater of the median fossa was exposed over the tegmen tympani and antri; it did not bulge and appeared normal. Then the sinus was exposed in its entire length, going as near as possible toward the bulb. It was thrombosed. Upon curetting it bled freely from above, but the bleeding from the region of the bulb was not satisfactory. Then the

jugular was tied and dissected as high up as possible; about 1 inches of it were excised. It was not thrombosed. A culture of the thrombus found in the sinus was sterile. Temperature in the next days ranged somewhat over 102°. Some tenderness over the wound in the neck and in the upper part of the posterior cervical triangle. On July 14th the patient complained of severe pain in the head and pain on swallowing. The general condition was not so good, the patient being weaker and paler. On July 16th, gauze packing was removed from the sinus, and from its lower end some pus escaped with distinct pulsation. A rubber tissue drain was introduced toward the bulb and kept in that position. From now on till July 27th the temperature was almost normal, there was no pain, and the general condition was very good. On July 27th the temperature rose again, and from now on kept intermittent; patient began again to complain of severe headache. No pus came from the sinus from the direction of the bulb. A tender, diffuse swelling appeared in the upper third of the posterior cervical triangle. A communication existed between this swelling and the jugular bulb, for on pressing upon the swelling pus escaped from the lower part of the sinus. On August 4th, the deep abscess situated between the deeper muscles of the neck and near the base of the occiput was opened and drained. With the probe one could feel a spot of the occipital bone near the condyles denuded. However, fever and pain continued. The presence of another abscess near the bulb of the jugular was decided on, and on August 14th this second abscess was searched for and found at very great depth. It was reached from behind after having tried in vain to reach the bulb of the jugular through the old wound in the neck. On August 16th, two days after this last operation, it was noticed that the tongue, when protruded, deviated to the left. On the next day the complete symptoms of hypoglossal paralysis were present on the left side. Besides, patient complained of difficulty in swallowing. When the sense of taste was examined it was found diminished in the posterior thirds of the the left side. Temperature remained high. The discharge of pus was very profuse for a few days, then it stopped almost suddenly about one week after the last operation. Temperature became and remained normal and the patient made a quick recovery. The papillitis cleared up gradually; however, it took many weeks to disappear. The hypoglossal paralysis improved more slowly, and traces of both can be recognized to this day.

In discussing the case, which in many particulars differs from the typical picture of thrombophlebitis of the sigmoid sinus, Dr. Koller wished to say from the beginning that it most likely was a case of primary phlebitis of the jugular bulb. This class of cases has been lately brought into prominence by Jansen and others. The mechanism of infection is not quite apparent yet, but the shortest route would suggest itself as the most likely and that would be directly from the tympanic cavity to the bulb of the jugular, which lies in so close proximity. Perhaps congenital peculiarities would predispose an individual to this danger. The patient exhibited rapidly developing papillitis which does not belong to the typical symptoms of thrombosis of the sigmoid sinus, although it is regularly met with in the thrombosis of the cavernous sinus. But, according to Jansen's statements, papillitis is a common occurrence in the cases of primary phlebitis of the jugular bulb. The conditions revealed by the first operation agree fully with that view taken of the case. The abscess in the bulb must have perforated and burrowed under the deep muscles of the neck until it appeared in the upper part of the posterior cervical triangle. Macewen gives another explanation of these deep abscesses. He states that they owe their origin to phlebitis of the condyloid emissary veins. However this may be, recovery did not take place until a second abscess, which was deeper yet and which was evidently the original periphlebitic abscess, had been opened and drained. There are a number of unusual symptoms connected with the case. Wry-neck is sometimes found in cases of thrombosis of the jugular, and the explanation given by Koerner and others is that, the movements of the head toward the other side being painful, the head is instinctively held in the wry-neck position to ward off pain. It is hard to understand why this symptom should occur only in a comparatively small number of these cases. At different times in the history of this case presented we found noted difficulty in swallowing. A few days after the last operation the disturbed sensation of taste and motility of the tongue made their appearance, proving paralysis of the glosso-pharyngeal and hypoglossal nerves on the left side. It is not impossible that this may have been due to injury, although Dr. Koller felt pretty sure this was not the case. Considering that the function of all the three nerves, the ninth, tenth, and eleventh, leaving the skull through the jugular foramen in close proximity to the jugular bulb, was disturbed, and that the

twelfth, leaving through the condyloid foramen, was paralyzed, it may not be too far-fetched to assume that the periphlebitic abscess was responsible for it, just in the same way as we sometimes see facial paralysis in cases of mastoiditis.

Discussion of Case Presented by Dr. Koller.-Dr. LEDERMAN spoke of a case which showed a number of symptoms similar to those reported by Dr. Koller, from re-infection of the sinus due. to sepsis of the wound. He asked Dr. Koller if in his case he had not found a rather narrow mastoid. The reply was affirmative. Dr. Lederman thought that in cases of narrow mastoids where the sinus is near the posterior tympanic wall infection was apt to occur early in the disease, as the bulb of the sinus projects into the floor of the tympanum. He had seen one case where early in the disease there was marked thrombus in the lower portion of the sinus, and considered this also a case of primary infection of the bulb. He thought it was important to be satisfied that all infected material was removed at operation. He congratulated Dr. Koller on the excellent results in his case. He further recalled a case reported by Kipp, operated on for sinus thrombosis. The sinus was opened and found thrombosed with a septic clot, but the patient showed symptoms of shock, the operation was discontinued, and the jugular was not ligated. In spite of the infective thrombus the patient recovered, though a metastatic abscess appeared in the gluteal region. Dr. Lederman stated that he would feel very anxious with a septic thrombus in the sinus or bulb when the jugular vein had not been ligated.

Dr. T. P. BERENS thought that Dr. Koller's case raised an interesting point in diagnosis: the fact that the patient had severe wry-neck would indicate pressure on the spinal accessory nerve and he thought it would be well to recollect this point. further believed that in all cases of wry-neck we should look about the region of the bulb to see if pus can be detected.

Dr. McKERNON spoke of a patient, aged eleven years, who showed marked wry-neck. There was no sinus involvement, but an abscess low in the neck causing pressure on the spinal accesafter the evacuation of this the stiffness gradually

ceased.

Dr. KOLLER wished to emphasize the difference between thrombophlebitis in acute and chronic cases. In cases of chronic ear diseases we are more apt to have phlebitis of the sinus, but if in acute cases we find symptoms of pyæmia or affection of the