patient returned and a difference was found in the refraction that it was due to an error in the first determination; or when changed by a colleague that it was due to careless and inaccurate work; and while believing in the vast majority of instances there are no changes in the static refraction of healthy eyes, admits there are numerous exceptions to this rule. Several cases are reported in which the amount of astigmatic correction was increased, the angle changed, and in one case in which a quite marked degree of hyperopic astigmatism later developed into simple hyperopia. The cases reported rigidly exclude from consideration any which involve a stretching or distention of the ocular tunics. SKIASCOPY AS A METHOD OF PRECISION. EDWARD JACKSON (Journal of the American Medical Association, September 5, 1903) prefaces his paper by the following remarks: It is difficult to realize how one may understand the theory of a method, and may employ it habitually in practice, and yet may attain results of insignificant value, as compared with what might easily be reached by a little more exactness. The difference between a loose method and a method of precision may be nothing in theory and trifling in detail, but enormous in practical usefulness. A scientific method becomes a method of precision, and attains practical value by comparatively slight modifications, but these may be made or adopted very slowly. He then reviews some common clinical methods discovered years before they became generally used, showing that it was inevitable that skiascopy should pass through a period of development. Continuing, he says: For skiascopy this stage of development has not yet passed, but it has gone far enough for us to place the shadow-test among our methods of precision. The time for being content with a general comprehension of its theory, and teaching it in a rude, diagrammatic way has passed. Recognition of it as a practical test should be given henceforth only as it takes the form of a method of precision. If one has no tape measure he may estimate length by spanning with his hand or counting paces. If the conditions for accuracy are for the time impossible, one may practice approximate skiascopy. But it should be recognized that this is not all that skiascopy might be. The first step towards rendering skiascopy a method of precision is the shortening of the distance between the patient and the surgeon. The shadow-test is practiced with a pupil of from four to eight millimeters in diameter. A letter inscribed in a circle of that size would be recognized at a distance of two to four meters in a good light. With the strongest illumination of the pupil the movement of light and shadow can be recognized readily at the same distances. But the strongest illumination is not available for accurate skiascopy. The conditions which give the most brilliant reflex from the pupil differ essentially from those under which the refraction can be exactly measured. As the point of reversal is approached the illumination of the pupil becomes feeble, and for a fair approach to exactness, say within 0.25 diopters, the light of the pupil becomes so feeble that the direction of its movement cannot be recognized at one meter, even when the movement extends over the whole width of a pupil six or eight millimeters in diameter. Skiascopy at one meter cannot be certain. The correctness of measurements made at that distance cannot be relied on. They may be accurate by chance, but they are not accurate with certainty. Moreover in the great majority of eyes, the movement of light and shadow has to be determined, not in the area of the whole pupil, but in an area much smaller, a circle of three to five, instead of six to eight millimeters in diameter. Then in this smaller circle one has to watch the movement in a comparatively dim light area, while around it a larger and more brilliant area is also moving. The distance between the patient and surgeon must be measured exactly. But if the surgeon goes far enough away from the patient's eye, it makes very little difference whether his source of light be large or small, and he need not measure the distance from the patient at all, but merely guess at it or make a fixed deduction. The need of measuring the distance between surgeon and patient has already been alluded to. When the distance is so great that a foot added to it will mean but 0.25 diopters difference in the refractive power, such measurements are unnecessary. But when a single inch means more than 0.25 diopters of the refractive power, the need for exactness is obvious. For working at one-quarter meter the source of light should be 2.5 millimeters in diameter. The reduction in the size of the source of light renders necessary a reduction in the sight-hole, which should be not more than half the diameter of the source of light. The room must be dark. The light must be so thoroughly cut off that no reflection of the surgeon's hand or face can interfere with clear view of pupillary movement. The source of light should be as close as possible to the mirror. In conclusion, he says: We would indicate by the term exact skiascopy,— The working at a distance of one-quarter to one-half meter. The adaptation of the source of light and the sight-hole to this distance. Care to bring the source of light close to the conjugate focus of the retina. Means of fixing exactly the direction of the principal meridians. Control testing, by departure both ways from the lens' strength, focal distance, or merdian fixed on. And, in general, precision and exactness in every detail. LARYNGOLOGY. BY WILLIS SIDNEY ANDERSON, M. D., DETROIT, MICHIGAN. ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE Detroit COLLEGE OF MEDICINE. THE SUBCUTANEOUS INJECTION OF PARAFFIN FOR THE CORRECTION OF DEFORMITIES OF THE NOSE. F. GREGORY CONNELL (Journal of the American Medical Association, September 19 and 26, 1903) in a carefully prepared article, gives the history of the various methods of this procedure, together with the dangers. uses and technic. Among his conclusions he mentions that the method is still in its experimental stage, but that its use is rapidly increasing. Harmon Smith (Journal of the American Medical Association, September 20, 1903) gives an excellent summary of the method and describes a special syringe devised by himself which has proven useful in the hands of a number of physicians. REPORT OF CASES OF PYOGENIC BRAIN DISEASES, ASSOCIATED WITH OR CAUSED BY ACUTE AND CHRONIC NASAL SUPPURATION. THOMAS HUBBARD (The Laryngoscope, September, 1903) reports. five cases. In three of the cases the middle ear and mastoid were involved. In two the sinuses of the nose were involved. The author's comments on the cases are as follows: This group of case reports lack that accuracy of detail which is essential to the scientific study of such an important subject. But one lesson is clear, and it emphasizes what we see every day in the practice of otology. Nasal and accessory sinus disease is very commonly associated with, or the cause of, acute and chronic ear disease, and likewise such disease is not rarely the source. of meningeal infection. And yet in serious cases, in which surgical intervention is resorted to, how frequently this cause is overlooked, or at least how rarely reported. Concerning ozena, as a factor in purulent mastoid disease and meningeal infections, I am convinced that it is a very important matter. Simple mastoid operations can scarcely be expected to do well with such a complication; and certainly in pyogenic brain diseases, supposed to originate from the temporal bone, the possibility of direct meningeal infection, from ulcerated nasal mucous membrane and eroded bones, and accessory empyema, should be carefully considered before attempting surgical procedure by way of the mastoid. The prognosis in all such cases is very bad, and is the important thing to take into consideration in deciding on the advisability of mastoid or more extensive operation. In other words, the nares and accessory sinuses should be studied quite as carefully as the temporal bone, as factors in the prognosis of mastoid diseases and as a medium of intracranial infection. DERMATOLOGY. BY WILLIAM FLEMING BREAKEY, M. D., ANN ARBOR, MICHIGAN. LECTURER ON DERMATOLOGY AND SYPHILOLOGY IN THE UNIVERSITY OF MICHIGAN. ENDEMIC AND HEREDITARY SYPHILIS. THE Journal of Cutaneous Medicine and Syphilis summarizes Doctor George Ogilvie's review (British Journal of Dermatology, 1903, XV, page 11) of Professor von Düring-Pascha's "Report on Endemic and Hereditary Syphilis in Asia Minor," culling some most interesting facts, and giving some decided opinions against the position of the French syphilographers, as also against "Profeta's law." The report covered the examination of about sixty-five thousand people and over thirty thousand cases of syphilis. Among the points worthy of notice are that in these cases specific treatment was practically unknown, the preponderance of accidental over venereal infection, and the frequency of tertiaries. In Europe the proportion of accidental venereal infection is not over five per cent, while in Asia Minor, according to von Düring, the inverse is nearer the truth, though he could not give exact figures. Among the vehicles of infection were drinking vessels, the "naigle” or water pipe, the razor, and the cigarette. Although acquired syphilis was quite frequent in children, von Düring was not able to detect the primary lesion in an infant or child. In all previous reports on endemic syphilis the proportion of tertiaries to secondaries is given as about two to one. According to von Düring's opinion one to two would be about the correct proportion. He attributes the errors of former reports to the facts (1) that peasants do not as a rule seek medical advice for secondaries because they do not attach any importance to them; (2) that all people escape registration during the periods of latency; and (3) without the treatment tertiaries persist about twelve times as long as secondaries, consequently the same patient will figure in these statistics for years; (4) in an “extinct focus," that is, where in the course of years all inhabitants are infected-a by no means rare occurrence-only cured people or those suffering from tertiaries, are to be found. As the proportion of tertiaries to secondaries in Europe is about one to ten-estimated—the question arises, What is the reason for this increased frequency? The precocity, gravity and long duration of tertiaries in endemic syphilis are considered to be due to the want of treatment. Destructive processes of the palate, pharynx, and the nose constituted about forty per cent of the tertiaries. In regard to hereditary syphilis, von Düring has collected more than one hundred cases, in which the children of parents who before marriage suffered from acquired syphilis, contracted fresh syphilis, a complete contradiction of Profeta's law. With regard to the infectiousness of congenital syphilis, he expresses himself with great reserve. He does not deny it but he states that he 1 i had never seen an exception to Colles' law. He likewise has never seen a healthy nurse infected by a congenitally syphilitic child, although he knows of several cases in which apparently healthy women have suckled children-not their own-affected with severe congenital syphilis. Professor von Düring failed to find the marked dystrophic influences of hereditary syphilis and its degenerating influence upon rational development, which evidently pleases Ogilvie, as he refers extensively to "the present tendency of the French school towards pansyphilism, which seems itself to be a kind of professional neurosis." The logic of this would seem to be that if all the people became infected and immune the disease would die out! * * * Doctor George T. Jackson (Journal of Cutaneous Diseases, including Syphilis, October, 1903), referring to Doctor Tschlenow's article on "Inherited Immunity to Syphilis and the so-called Profeta's Law" (Montshft. f. pakl. Dermat., 1903, xxxvi, page 489), says the so-called Profeta's law is that children of syphilitic parents, in most cases at least, enjoy for a certain time an immunity against syphilis. This law has many exceptions, especially as far as it concerns the inheritance of the disease from the father. Any immunity that may be acquired. from the father would seem to be exhausted in a short time. It would also seem that tertiary or spent syphilis in the parents confers very much less immunity to the children, than does active syphilis, and that any such immunity is rapidly lost. It is nevertheless true that apparently healthy infants born to syphilitic mothers do not in most cases contract the disease from the mother-which seems to be practically equivalent to saying that the degree and duration of the immunization of the child, corresponds very closely to the gravity and activity of the disease in either or both parents, at the time of conception, and of the mother during gestation, and the evidences of disease of the infant at or soon after birth. NEUROLOGY. BY DAVID INGLIS, M. D., DETROIT, MICHIGAN. PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE Detroit coLLEGE OF MEDICINE. SEVERE PAIN CAUSED BY BLOOD PRESSURE. THERE are many cases of intense pain clearly due to temporary increase of arterial pressure, with localized hyperemia. The unbearable headache of intense cerebral congestion, such as occurs at the time of a sunstroke or as a subsequent effect of sunstroke, is an instance in point. A similar congestive headache not unfrequently follows severe blows on the head. Many cases of migraine are of the congestive type; such patients often show visibly swollen, tortuous, temporal arteries. Neuralgias in all parts of the body, including those of the internal viscera, are often either due to, or at least accompanied by, such arterial tension. Every medical man knows how these conditions |
