the vessels, and when the dorsal portion of the cord was experimented on we find that both dilatation of the pupils and dilatation of the vessels occurred.

One fact certainly has been satisfactorily established in these experiments, namely, that an irritation of the cord will set up hyperæmic conditions of the optic nerve, although from the varied results of the different experiments it might be objected that the influence from the point of irritation in the cord is not carried to the optic nerve by way of the sympathetic. It cannot, however, be denied that the sympathetic nerve may, under certain circumstances, be the medium through which the eye is reached in spinal diseases, for, in addition to other evidence, we have the observation of Basch,* who has seen the dilatation of the retinal vessels as a result of irritation of the splanchnic nerve; on the other hand, it cannot be claimed that when disease of the cord implicates the eye that it always travels in the same path.

With regard to the differential diagnosis of optic nerve disease as a result of spinal lesions, the great expectations that have been indulged in in reference to the ophthalmoscope have as yet not been realized. And while there are those who speak of peculiarities in the hyperæmic stage, and of characteristic discolorations of the optic disk in the stage of atrophy, there would hardly be one who would venture a diagnosis upon these alone. The examination of the functions of the eye may, however, yield very important data. Prominent among these are the red-green color-blindness, and the contracted field of vision, especially the sector-shaped defects that will frequently be manifested. Another very significant symptom in distinguishing this from other forms of atrophy is the increased sensibility to light. Not only will such patients see better in twilight, but sometimes when they are almost entirely blind they will still complain of the distressing effect of bright light. When spinal symptoms are already developed the diagnosis is comparatively easy; and in the absence of those ordinarily looked for, the examination of the tendon reflex will often lead to the detection of spinal disease, when other symptoms, by which this condition is more commonly attended, may not yet have made their appearance. Westphalt first called the attention of the ophthalmologists to the importance of the tendon reflex as a diagnostic aid in all cases of optic nerve atrophy, and urged its

*Arbeiten d. Leipzigher Physiologischen Instituts, 1875. † Berliner Klin. Wochenschrift, January, 1878.

employment with a view of determining whether it constitutes an early symptom of locomotor ataxy.

Uthoff's investigations incline to this conclusion, and in his cases, in which spinal symptoms were present, the patella reflex was almost invariably absent. In only two of his fifteen cases could the patella reflex be demonstrated, and in these the spinal symptoms were very well marked. In twenty-four cases of progressive optic nerve atrophy, there were seven in which the patella reflex was absent. In these cases there was nothing to indicate that they were due to diseases of the cord, but there was one among them in which, after three months, spinal symptoms became developed. Probably if the others could have been followed, similar results would have been observed. In sixteen cases of atrophy of the optic nerve, due to cerebral diseases, eight of nine in adults showed that the tendon reflex was maintained; in the others the patients were too young for satisfactory examinations.

With regard to the changes noticed in the pupil in spinal diseases, there is nothing that can be pointed out as peculiar when the pupils are dilated; but when the pupils are contracted we find a condition that seems to be quite characteristic. The peculiarity alluded to consists in the phenomenon that this contracted pupil undergoes no alteration whether the patient be brought into a dark chamber or be exposed to the most intense light, but still exhibiting changes with the efforts of accommodation. With regard to the frequency of spinal myosis, Uthoff found it present in nine cases of fifteen. To Argyle Robertson is due the credit of having first pointed out the characteristic features of spinal myosis.† His observations were soon fully verified by Knapp,‡ Leber,§ Hempel,|| and others, and it may be regarded as one of the principal symptoms in the differential diagnosis of optic nerve atrophy due to spinal diseases.

We now arrive at a point in our studies where we must turn our attention to another form of eye symptom in spinal affection, namely, the disturbances of the muscles of the eyeball; and here we approach the most obscure part of our subject. Both the alterations found in the optic nerve and in the pupil can be explained by disturbance of the sympathetic. There is nothing in the nature of the affection of

* Beitrag zur Sehnervenatrophie, Graefe's Archiv für Ophthal.

† Edinb. Med. Journal, 1869.

Archiv für Augen und Ohrenheilkunde, 1872.

? Virchow-Hirsch's Jahresb. 1872.

|| Ueber die Spinalmyosis, Graefe's Archiv, 22 a.

the muscles of the eyeball, however, which points to a similar origin. It has been found that the paralysis of the muscles of the eyeball appears as a very early symptom in the spinal disease; sometimes assuming a very transitory character, at others persisting obstinately. The muscles supplied by the fourth pair of nerves seem to enjoy almost entire immunity in these conditions; those supplied by the third and sixth pairs are attacked with almost equal frequency. Sometimes the motor oculi of one eye will be involved, while the abduceus of the other alone has suffered.

The paralysis of the muscles of the eyeball occurring in syphilis bears a great resemblance to that met with in spinal lesions, presenting the difference, however, that complete paralysis of the motor oculi is more frequently observed in the former. Rieger and von Forster have so frequently been able to trace syphilis antedating the symptoms of spinal disease that came under their notice, especially in those cases that were attended by such paralysis, that they were forced to infer that the paralysis had an independent origin in these cases. It might be said, in opposition to this opinion, that in excluding this group of symptoms from the general influence that passes from the cord to the eye, the whole theory of the dependence of the eye complication upon the diseased cord is seriously assailed. It must not be overlooked, however, that the principal support which the theory that the eye symptoms are produced by the spinal lesion, and are not a simple coincidence with it, has been received from what has been observed in acute cases of myelitis, in traumatic lesions, and in the physiological experiments to which the cord has been subjected, and in these cases the oculo-pupilar symptoms alone were manifested. It is to be hoped that further investigation will fully clear up the discrepancy which is noticed in this regard between the acute and chronic forms of spinal lesions.

LARYNGEAL STENOSIS.

REPORT OF CASES, WITH REMARKS ON THE HISTORY AND TREAT

MENT.

BY H. CLINTON MCSHERRY, M. D.

Lecturer in the Spring Course, and Chief of Clinic on Diseases of the Throat and Chest in the University of Maryland.*

This being the first occasion upon which the Medical and Chirurgical Faculty has recognized laryngology even as a part of one of its Sections, and as I have been appointed a representative of this branch, it seems proper for me to make a report, as is the custom of gentlemen belonging to a Section, of something of interest that has occurred during the preceding year in the department I represent. I will therefore select for the subject of my remarks laryngeal stenosis, which will be illustrated by giving the history of two cases that have been under my care during the year, with a passing reference to a third case treated by me some time ago, and the exhibition of a patient showing the result of treatment. I will also give an account of the history and general management of the condition, which may prove not uninteresting.

The first patient was a female, who came to me on the 2d of April, 1882, from Dr. Alex. Tunstall, of Norfolk, who wrote in regard to her previous history as follows: "I have occasionally, over a period of four or five years back, prescribed for her, nearly all her ailments being attributable to the effects of syphilis directly acquired from a worthless husband. Chronic metritis, occasional recurrences of cystitis, pharyngitis, laryngitis, with frequent attacks of aphonia, &c. Last year she seemed much benefited by constitutional treatment, combined with tonics (ol. morrhuae), external use of iodine over the larynx, and spray of carbolic acid, &c., internally. These and a trip

*The plates for this paper were kindly drawn for me by Drs. N. A. S. Keyser and Henry Rolando.

to the mountains improved her so much that the treatment was omitted by her, and she had some five or six weeks back an alarming attack of acute laryngitis, with great dyspnoea, aphonia, and stridulous. breathing, and pain in breathing, and tenderness in swallowing solids. She has again been placed under constitutional treatment of hydrarg. chlo. cor. with potass. iod., externally iodine tr. and steam inhalations, &c. She has much improved, but nearly all her symptoms are occasionally in lesser degree manifested, and I fear, without special local examination and treatment, bad results."

When this patient was brought to my office her breathing was extremely labored and noisy, although she had come in a carriage, and the only exertion she had made was to walk into the house. On laryngoscopic examination I found the whole larynx pale, and the arytenoids particularly were very much enlarged and oedematous looking, not showing any of the contrast of color that is characteristic of phthisis. The ventricular bands also were seen so much thickened and broadened that on attempted phonation they met together, so that the vocal cords were not seen at all. The voice produced was a muffled or choked whisper. On deep inspiration the ventricular bands and vocal cords separated slightly, but not sufficiently to give much breathing space. The left vocal cord was not visible, and only the edge of the right one was in view, as will be seen by referring to the diagram, showing the condition of her larynx.

With the exception of this appearance of the throat the general condition of the patient seemed to be pretty good. She was quite sufficiently nourished and in fact rather fleshy. She remained under my treatment three months, until June the 7th, when I allowed her to return home, and sent the following letter to Dr. Tunstall. "After introducing the laryngeal tubes several times I came to the conclusion that there were no adhesions producing the stenosis of the larynx