roborant treatment. After several weeks the eye became softer, the ciliary injection disappeared, the child grew stronger, and six months later Fuchs thought there was no longer any danger from tumor. After an observant period of one and one-half years the tension was normal, the tumor was atrophic and smaller, and the other patches on the fundus had become paler. The condition of the fellow eye remained the same, except that the yellowish spots had paled perceptibly.

The fact that glioma may begin in the form of white plaques, scattered through the retina, makes the interpretation of such cases difficult. Here, however, the facts that the spots were not elevated, that they were surrrounded with a pigment border, which is absent in beginning glioma, that they were diffusely scattered over the fundus instead of being in groups, and that the retinal vessels passed in an uncurved line over their surface, made the differentiating points. The fact that in the course of one and one-half years they had not grown but had become paler and whiter, made the diagnosis a certain one. Schick reported a similar case in 1900, in which masses of exudate, which he considered fibrinous in character, formed between the choroid and retina, and did not change in the course of one and three-quarters years.

LARYNGOLOGY.

BY WILLIS SIDNEY ANDERSON, M. D., DETROIT, MICHIGAN.

ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE

THE PROPHYLAXIS OF SINUS DISEASES.

D. BRYSON DELAVAN (Journal of the American Medical Association, February 21, 1903) gives, as some of the predisposing causes of sinus diseases: Malformation of the nasal cavities, deviation of the nasal septum, enlargement of the middle turbinal, congestion and hypertrophies of the soft parts. Any of the acute infectious diseases may act as an exciting cause. Influenza is the most common. Dental disease, and the irritation caused by dust are mentioned.

Prophylaxis: The care of simple "colds in the head," and the correction of nasal deformities.

Active treatment: Keep the patient quiet and at an even temperature and treat the exciting cause.

Local treatment: All local treatment applied in these cases must be absolutely unirritating. The nasal cavities should be carefully sprayed with a mild cleansing solution, following which the swollen tissues should be contracted by applications of a mild solution of cocain, not stronger than four per cent, and the approaches to the sinus outlets opened as widely as possible by the action of this drug. The secretions should be removed as far as is possible from the regions before occluded, by means of the cleansing spray; a spray of adrenalin should be applied for the purpose of increasing the power and adding to the duration of

the effect of the cocain; and, finally, the parts should be protected by a light spray of liquid abolin.

If these applications are made with sufficient gentleness and care, the result will be immediate relief to the patient's distress with much ultimate benefit to the inflamed cells. Applied early in the history of the case, an attack which has indications of being severe has been arrested by a single treatment. Several treatments, however, are generally necessary, many may be required, and sometimes it is only after a long course of patient effort that success is attained. When the treatment must be continued the danger of the repeated use of cocain must be recognized and adrenalin substituted. Indeed, in many cases it is better to depend on the latter drug alone. During the height of the attack a recurrrence of the nasal swelling may necessitate the repetition of the treatment several times a day.

The prevention of invasion of the sinuses in the acute infectious diseases already alluded to, is a matter not always within the limits of present knowledge. Thus, in diphtheria, measles and scarlet fever, attended as they are with violent local congestion of the nasal cavities, it is difficult to think of any safe means of treatment. In typhoid fever, smallpox and pneumonia, however, careful systematic cleansing of the nasal passages is most valuable for many reasons, and it is clearly indicated not only for the prevention of otitis, but also for that of analogous inflammations of the accessory sinuses.

To briefly summarize the matter, in the prophylaxis of sinus diseases much good may be accomplished:

(1) By recognizing the conditions under which inflammation of the sinuses is likely to occur and, if possible, removing them.

(2) When removal of the predisposing conditions is not practicable, by guarding the patient against the various exciting causes which may determine an acute attack.

(3) When acute inflammation is already threatened, by applying immediate treatment for its relief.

THE EARLY APPEARANCE, DIAGNOSIS AND TREATMENT OF TUBERCULOSIS OF THE UPPER AIR TRACT. WALTER F. CHAPPELL (Journal of the American Medical Association, February 21, 1903) divides laryngeal tuberculosis into three stages:

(1) The premonitory or pretubercular stage. (2) The stage of infiltration or thickening.

(3) The stage of ulceration.

The first stage is difficult to recognize, although one may suspect it when a patient has an intractable laryngeal catarrh. Later an edematous, or semisolid, appearance of the mucous membrane is usually a precursor of tubercular ulceration, especially when it occurs over the arytenoid cartilages, aryepiglottic folds and epiglottis, and at times the swelling is so great as to seriously interfere with respiration and

deglutition. Small points of ulceration soon follow, and after coalescing give the so-called characteristic worm-eaten appearance. Pain is an important diagnostic symptom during the ulcerative stage, which is in marked contrast to syphilis which may present marked ulceration without pain. The author takes up briefly pharyngeal, tracheal, lingual and nasal tuberculosis. He divides treatment into medicinal, surgical, and climatic. During the quiescent stage, when marked thickening in the larynx exists, submucous injections of lactic acid or creosote may be used. During the ulcerative stage no applications ought to be used that will irritate. Pain may be controlled by inhalation of menthol and iodoform, later, of cocain and orthoform. Surgical measures, such as cureting, are reserved for selected cases, and should be employed only by experienced operators. A suitable climate is urged for these cases.

TUMOR OF THE PHARYNX: AN ACCESSORY THYROID GLAND. REMOVAL FOLLOWING BY MYXEDEMA.

E. L. SHURLY, Detroit, Michigan (Philadelphia Medical Journal, September 13, 1902). The case reported was a girl aged sixteen, who complained of difficulty in deglutition, constant desire to swallow and some dyspepsia. The family history was good. Examination revealed a globular, smooth, dark-red, broadly pedunculated tumor, about the size of a small hen's egg, firmly attached to the base of the tongue, close to the epiglottis and a little to the right of the median line. No atrophy of the thyroid gland could be discovered. The tumor was removed with a heavy, cold wire snare, while the patient was under chloroform. The hemorrhage was very free and was controlled, after two hours' constant attention, by gauze compresses wrung out of ice water and saturated with adrenalin solution. Myxedema developed three weeks after removal, accompanied by the usual symptoms. Prominent in this case were the swelling of the skin about the eyelids, mental dullness and physical debility. Rapid improvement followed the use of the thyroid gland in two to five grain doses three times daily. Microscopic examination of the tumor proved it to be thyroid in nature.

DERMATOLOGY.

BY WILLIAM FLEMING BREAKEY, M. D., ANN ARBOR, MICHIGAN.

LECTURER ON DERMATOLOGY AND SYPHILOLOGY IN THE UNIVERSITY OF MICHIGAN.

SYPHILIS AND SMALLPOX MISTAKEN FOR EACH OTHER. SCHAMBERG (Journal of the American Medical Association, November, 1902) gives the details of four cases of acute secondary syphilis sent by physicians to the Municipal Hospital, Philadelphia, with the diagnosis of smallpox, which came under his notice at that institution.

In the discussion following this report Gottheil referred to the fact

that during an epidemic in New York some years ago a number of smallpox patients were sent to the venereal wards of the Charity Hospital incorrectly diagnosed as pustular syphilis.

Corlett, Allen, and Stellwagon cited instances of temporary difficulty in such differentiation, the occasional presence of fever and general aching and pain in a varioloform syphiloderm, and the relative absence of such symptoms in some cases of smallpox being the chief sources of the confusion.

Without repeating the differential symptoms in the evolutionary stages of typical cases of each disease, it is important to remember that a single examination in the early stage of either disease may not be sufficient for even experts to determine the diagnosis. (The same statement applies to most of the exanthemata, as measles, rötheln, and to impetigo, varicella, et cetera). Such errors emphasize the need for time to develop essential phenomena of infectious and incubative diseases, and the provision in communities for hospitals for contagious diseases, with detention wards where suspected cases may be isolated without additional risk to themselves or endangering the public health while diagnosis is being determined.

THERAPEUTICS.

BY DELOS LEONARD PARKER, PH. B., M. D., DETROIT, MICHIGAN.

LECTURER ON MATERIA MEDICA IN THE DETROIT COLLEGE OF MEDICINE.

THE THERAPEUTIC STATUS OF THE COAL-TAR PRODUCTIONS IN GENERAL NERVOUS AFFECTIONS.

DOCTOR F. SAVARY PEARCE (The Therapeutic Gazette, January, 1903) discusses the question of the use of coal-tar products in nervous affections and presents views on this subject well worthy of consid

eration.

In a general way it may be said that the author of this article looks upon the drugs referred to much as the average person looks upon firevaluable when used under proper control, but often quite the reverse when used carelessly.

Doctor Pearce refers to several forms of nervous affection in the treatment of which special care should be exercised in order to avoid the danger of injury being done by the drugs referred to.

The first of these is neurasthenia. In this condition headache is almost always present, and should be treated, if possible, not by unhesitating recourse to the coal-tar products, but rather by the removal of the cause which underlies the condition. Such procedure would of course lead to a form of treatment differing greatly in different cases. Abuse of the coal-tar drugs in the disease just mentioned may add to the miseries of the patient, already usually quite sufficient, by disturbing metabolism, disorganizing the blood and depressing the important centers of the medulla.

Hysteria is another condition in the treatment of which Doctor Pearce thinks the physician should be on his guard in order to avoid not so much the intelligent use, as the unintentional abuse of the coaltar derivatives.

Tabes dorsalis is an affection in which pain may be controlled to a great extent by the drugs under consideration. In fact Doctor Pearce thinks that organic nervous diseases affecting the spinal cord offer one of the best fields for the use of this class of drugs, for the reason that the brain centers being unimpaired are less likely to be affected than they would be if such were not the case.

A prescription he gives for use in controlling pain in tabes dorsalis is acetanilid five grains, phenacetin five grains, caffein citrate two or three grains, given every two or three hours from the beginning of a paroxysm of pain.

Of the drugs themselves Doctor Pearce says that antipyrin is the most depressing of all; that acetanilid comes next in order as to depression. on the nerve centers; and that phenacetin is the drug par excellence which will do yeoman service when indications arise.

Doctor Pearce claims that he has evidence to show that the sales of

acetanilid have increased in the past five years. He also says he believes all will agree with him that the coal-tar derivatives are still employed beyond proper measure.

PSYCHIATRY.

BY WILLIAM MILAN EDWARDS, M. D., KALAMAZOO, MICHIGAN.

MEDICAL SUPERINTENDENT OF THE MICHIGAN ASYLUM FOR THE INSANE.

HYDRIATIC

PROCEDURES IN THE TREATMENT OF
INSANITY.

Emmet C. DENT, Superintendent of the Manhattan State Hospital, West, Ward's Island, New York City (American Journal of Insanity, July, 1902), reviews the use of water as a therapeutic agent in the treatment of insanity, and writes of the present status of hydrotherapy as an adjunct in such treatment. Water is administered in the form of warm and cold full baths, warm and cold packs, sitz baths, ice packs, Scotch douches, needle baths and drip sheet baths in conjunction with the hot-air cabinet. He insists upon a careful technique and that the physiologic and pathologic conditions present must be recognized as well as the individuality of each patient in order to obtain the best results. In cases with insomnia, great agitation with active or painful hallucinations and delusions, he has obtained most excellent results with hydriatic measures. In the treatment of some of these cases the patient is put to bed, given a large simple enema at the temperature of 100° Fahrenheit, and the stomach irrigated with sterilized water at the temperature of 107° Fahrenheit. The patient is then put in a warm wet pack, sheets being saturated in water at 112° Fahrenheit, and covered