The case of G. M., aged 21 years, which came under my care early this spring, was one of unusual interest both from the severity of the symptoms and the obscurity of the diagnosis.

The patient, a young woman who had been a wife since her sixteenth year, has a negative family history. Her personal history is of not too robust health but of never having been really ill until the past December, at which time she suffered from a severe attack of the grippe, from which she seemed not to have entirely recovered. No children have been born of this union, but she gives the history of one miscarriage at about the third month, due to the wearing habitually of a cervical dilator.

The patient was first seen by me on February 16, the case having been diagnosed previously as neuralgia by a physician who was at the time attending another member of the family. The treatment having been entirely without effect, I was called. I found her with a pulse of 120, temperature 104.6°.

This was a Thursday evening. Patient stated that the Monday night previous she had attended a reception but had felt chilly all the evening and had been obliged to come home early. Since that time she had grown worse, and two nights before had been kept awake by a severe pain in the right ear. The night previous had suffered severe pain in the right eyeball. The right eyelid was exceedingly oedematous and a slight degree of exophthalmos was present. Later the tension of the lid became so great that the eyelid presented a bluish appearance. The tongue was coated and the throat and tonsils were covered with a dirty white exudate; breath not offensive; examination of heart and lungs negative; constipated.

I at once took a culture of the throat, and the probability of an affection of the sinuses presenting itself, I called Dr. Levy in consultation. He agreed as to the possibility of a sinus trouble; but regarding the throat trouble as of specific

origin, suggested the usual treatment. I was not able to elicit any history tending to support a syphilitic etiology.

The next day the temperature was 103.6° and the pulse 112. The eye was still more oedematous but no longer painful except on pressure. Patient was unable to completely close the lid, however, and fearing for her vision I called Dr. Chase in consultation. He stated that the sight would in all probability be lost unless the tension on the optic nerve was soon relieved, and advised the use of hot fomentations every hour for five minutes both day and night. The condition he pronounced a rare one, being an inflammation of the oculo-orbital fascia known as tenonitis. The ophthalmoscope showed that the nerve had not yet suffered. Mercurial innunctions were used to combat the possible specific affection as well as to hasten absorption of the exudate. Potassium iodide (saturated solution) was given in two-minim doses t. i. d., increasing one minim daily. That same evening the pulse was 125 and the temperature 104.6°.

February 17 the temperature was 103° and the pulse 116. Less swelling of the lid and no pain. Patient restless but hungry. Breath offensive and throat covered with a greenish exudate. Took a second culture.

The culture showed a very virulent streptococcic infection and a number of indeterminate amorphous forms which were sufficiently suspicious to cause Dr. Mitchell to advise the giving of antitoxin, though too uncertain to quarantine. 3000 units. of antitoxin were accordingly injected between the patient's clavicles. The temperature fell that evening one degree from that shown in the morning, and was now 102.4° and the pulse 100. The creamy yellow discharge, which was principally from the left nostril, still continued.

Feb. 19. Temp. 101.4°; pulse 100. The evening of that day witnessed no increase in the pulse rate, but the temperature had crept up to 103.4°.

Feb. 20. Morning temperature and pulse rate same as the previous evening. The afternoon of that day the eye condition showed a decided amelioration. During all this time the motions of the eye had been almost absolutely impossible on account of the swelling, and the lids could not be closed. The swelling now began to subside and a profuse but clear watery discharge of such amount as to call for treatment, set in. This was partially controlled by dropping in the eye morning and evening a mild solution of sulphate of zinc.

Patient expectorated a considerable amount of bloody tenacious mucus and complained of soreness in the region of

the larynx. This discharge evidently came from the head, as a careful examination of the lungs again revealed a negative condition. This expectoration would come on periodically, and after the throat had been cleared it would remain free from the accumulation for some time. The evening of the 20th the eye was so much better as to relieve all apprehension regarding patient's vision. The pulse was now 98 and the temperature 102.4°. But the condition of the throat was still so bad that another injection of antitoxin was given.

Feb. 21. Morning: Pulse 96, temp. 99.4°. Evening: Pulse 100, temp. 102.4°.

Feb. 22. Morning: Temp. 99.4°; pulse 88. Evening: Pulse 90; temp. 102.4°.

Feb. 23. Morning: Temp. 99.4°; pulse 84. Evening: Pulse 84; temp. 100.4°.

Considering the patient now convalescent, I discontinued my visits.

Summary: The case was so obscure, and the condition, as evidenced by the continuous high temperature and rapid pulse, so serious that, like a general who knows not his enemy nor from what source the gravest danger is to be expected, I could but be alert for any ambuscade and endeavor to aid nature in every way in her valiant fight.

The treatment in addition to that already outlined consisted in the giving of 1-60 of a grain of strychnine nitrate every three hours. The bowels were kept open by giving the effervescing citrate of magnesia, and the diet restricted to nourishing liquids. Ten grains of sodium sulphocarbolate were given three times a day on alternate days. Tepid alcoholic baths were given for the fever, and a simple diaphoretic prescribed. The head was cleared every few hours by the use of a saturated solution of boracic acid used in a bulb syringe.

When the fever had completely disappeared I advised the use of neoferrum, a tonic which I have found very satisfactory after long or blood-impoverishing illnesses.

The patient's eye did not regain its contour for some days after convalescence was established; but is now quite normal in appearance and apparently none the worse for the strain. She expresses herself as feeling better than for a long time previous to her December illness, which seems to have been the nidus of her later trouble.

Dr. Levy has since informed me that he has been called in to attend two similar cases since seeing this patient, and declares the diagnosis of sinus infection to be the correct one. In the case of this patient the sinus drained itself, and with proper aid nature was able to effect a cure.