A CASE OF ACQUIRED NYSTAGMUS.

928 young woman, twenty-one years of age, who had suffered about four years altogether from chronic gastric ulceration with two acute and several slight subacute attacks. She was of a highly neurotic disposition, which made one all the more careful and discriminating in making a diagnosis at these times. On the day mentioned above I found her to be in violent pain. Her mother had given her some chicken

Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL,

AND

THERAPEUTICAL.

jelly, which she had immediately vomited, and complained of excruciating pain in the stomach which did not leave her. The muscles of her abdomen were tightly contracted, examination of that region was so that any special extremely difficult. There did not appear to be much abdominal distension. Her pulse was quick and small, but not, to my mind, typically peritonitic." I explained to the patient’s parents the dangerous significance of the symptoms and told them that probably nothing but an operation would save her life. Mr. William Thorburn of Manchester, who happened to be in the immediate neighbourhood at the time, kindly met me in consultation , over the case. He confirmed my diagnosis of perforation and on summing up the case we told the parents that if left alone she would most probably die in about three days ; if operated upon (stitching up the perforation) the probability would be that she might also die, as the percentage of the mortality after operation in these cases was also very high, but that operation would, on the whole, give her the best chance. After some reflection the parents decided not to have her operated upon. We accordingly followed the usual principles of treatment in these cases-viz., (1) injected morphia subcutaneously at stated times; (2) applied hot, light belladonna stupes to the abdomen frequently ; (3) gave nothing but a little ice by the mouth ; and (4) fed the patient entirely per rectum. Happily for her an adhesion took place, probably to the liver, and after seventeen days the muscular rigidity of the abdominal walls had entirely disappeared. As things were going on so well I decided to miss seeing her on Jan. 20th, intending to call in as usual

A

ACQUIRED NYSTAGMUS. BY A. S. PERCIVAL, M.B., B.C. CANTAB.,

CASE

OF

OPHTHALMIC SURGEON TO THE CHILDREN’S HOSPITAL, NEWCASTLEUPON-TYNE.

interested in the subject of "miner’s two main reasons have been deficient illumination and’ fatigue of the ocular muscles. The latter view as to its’ essential cause has been ably supported by Snell, Nieden, Dransart, and others. I bring forward this case as it tendsr to corroborate this view. A man came to me at the beginning of this year complaining of dimness of sight. On ophthalmoscopic examination, no abnormality was discovered; there was no refractive’ error, and with test types he readwith each eye; his. sight was made worse by giving him weak convex glasses.. I questioned him as to his work and learnt that he wae a railway clerk engaged in adding up figures in a large folioaccount book in a well-lighted room. I then got him to elevatehis eyes to see if that movement induced nystagmus. No nystagmus was seen. On putting a large book i& front of him and directing him to adopt the attitude which he usually assumed when at work he bent his’ head over the book and keeping it fixed raised his eyes slowly, examining the edges of the page from below upwards. A vertical nystagmus was manifest as soon as his eyes were on the 21st, but this little detail I omitted to menI left the rotated upwards, increasing in extent as his eyes assumed a, tion to both the mother and daughter. more strained position. He then complained that what he village on the 20th without seeing her and proceeded looked at appeared to dance up and down and that what on my usual round. On reaching another village where he meant by dimness of sight was the dancing of thethey knew I would call I found a telegram awaiting figures during his daily work. On inquiry as to the occur. me telling me to return immediately as the case had again assumed a dangerous aspect. Although in my own mind I rence of any night-blindness he said he did not think he saw quite as well as other people when the light was’ was convinced there was nothing very seriously amiss, as the defective. I took him therefore into the dark room and on was still the mouth and little patient having very by everydown the gas I found that when I could thing she did have in that way was carefully peptonised, I gradually turning hurried home as quickly as I could. I found the patient lying: just discern "brilliant" type he could only read °6pearl"° in bed with her knees drawn up making agonising noises:: type at the same distance. My light-sense is presumably her face was contracted as if in great pain and on examining; normal, so it is fair to assert the presence of some degree of As I have no photometric* her abdomen she made an attempt to wince as if she couldl hemeralopia in this case. not bear it to be touched. During the examination, however, apparatus I was unable to say whether his hemeralopia had’ of she partially arched her back so that her attempt to simulate the peculiar features which are said to be characteristic abdominal tenderness was completely frustrated as she that form of it associated with miner’s nystagmus." r him that if he gave up his work and got some other pressed her abdominal wall against the examining hand. assured The abdominal wall was perfectly flaccid, being free from employment which did not involve similar ocular fatigue* all his troublesome symptoms would disappear. every trace of rigidity. One of her drawn-up legs was3that The case is interesting as showing what little reliance call’ : on shaking and being commanded to put her legs down she be placed on the unconfirmed complaints of patients, did so at once and the shaking ceased. I ordered her a rectal injection of bromide of potassium and chloral and soonalso for the fact that in this case nystagmus only appeared’ after she fell into a comfortable sleep. I found on question- when the patient put himself in the position ordinarily assumed him when at his daily work. It seems not iming the mother that the attack had commenced suddenly,, probable by that many cases of asthenopia in which glasses areas on the previous occasion, but not after taking food. " It commenced immediately her mother told her I had leftt of no service may be due to a muscular asthenopia"crto a nystagmus that has never been detected. the village so probably would not be calling that day. Thee N ewcastle-UDon-Tvne. interesting points of this case, therefore, seem to beshe was told I the commenced was attack directly firstly, probably not going to call, showing that I considered she NOTES ON A CASE OF EXTRADURAL CEREBRAL was getting better, and this undoubtedly led her to think she would as a consequence be deprived of that extra symABSCESS OF AURAL ORIGIN WITH THROMBOSIS OF THE LATERAL SINUS, IN WHICH THE pathy she had been having from all her friends during the time she was really in danger; and secondly, she as nearly SINUS WAS NOT OPENED; OPERAaa possible imitated the onset of her previous dangerous TION; RECOVERY. attack when actual was THOSE who

are

nystagmus"will know that assigned for its causation

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.

and

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perforation

indisputably present.

The value of the various symptoms she fully understood as I had explained the reason of each of them to her mother at various timea during the previous eighteen days. This I had, perhaps, rather foolishly done before the patient. The two important points, however, which she failed to simulate were (a) rigidity of the abdominal walls and (b) sickness, both of which omissions helped me in no small way in

betweenperforation"and its neuromimetlc blance. Youlgreave,

deciding

sem-

BY ADOLPH

BRONNER, M.D., M.R.C.S.,

SURGEON TO THE BRADFORD EYE AND EAR HOSPITAL; LARYNGOLOGISTE TO THE BRADFORD ROYAL INFIRMARY.

A BOY, aged fourteen years, saw me on Nov. 18th, 1897. There had been an occasional discharge from the right ear for several years, but for the last seven months the discharge had been constant. Six days previously the ear became and a swelling appeared behind the ear. The boy

painful

I