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Un daa symbolaa suivants apparaitra sur la damiira imaga da chaqua microficha, salon la caa: la symbola — ^ signifia "A SUIVRE ', la symbola V signifia "FIN". Laa cartaa, planchas, tablaaux, ate, pauvant dtra filmAa jk daa taux da reduction diff«rants. Lorsqua la documant aat trop grand pour dtre raproduit an un saul clichA. il ast filmA A partir da I'angia sup^riaur gaucha, da gaucha i droita. at da haut an baa, an pranant la nombra d'Imagas nteassaira. Las diagrammas suivants illustrant la m^thoda. 32X 1 2 3 4 5 6 'mflF « CjJdecl Two Cases of Is ""* rhoej BT T. MELVILLE HAR PBOmSflOK OP HHWOI.OOV AN PUDT-OBADUAta MEDICAL With a Jieport on tl BT CASEY A. WOO] msvmvcTOR in oph»hai.moi.i •OB(K RtPRlMTM Stit ^feto ¥otlt j for Septembt ^/•'?: CjJderf^ C^^.f^ h Two Cases of Nasal Hydror- rhoea. .«C.^ BT T. MELVILLE HARDIE, B. A., M. B., PHOKSnSOR OP BH!»tOI,nOV AND I.AB"liaOLOOY IK lUR POHT-OBADPATl MlDICAt WSHOOI. OF CBIOAOO. Witl a Heport on the Eye Symptom», BT CASEY A.WOOD, M.D.,C.M., INIvmVCTOK IN OPOTHALMOtOOr AMD OIOLOOY IN THK ■OHOUU BBPRIIIT4D FBOM Stc Neto yorft HJUWcal Jlounwl for September 6, 1890. W^' ^0'' / Z''' f «'''*- \ H^/*'Q.V*^ / MEPICAl FACULTY, Reprint TWO CASJ By T. PROFESSOR OF WITH A By INSTRUCTOR Case I. — Mi child, aged fon; came to Ameri living for two w oped a cough, w andJulv. She particularly in her medical att her to bed for ; ing in the ears during the sev has suffered at ally recurs. Ii from the nose < lacrymation pi for three or foi a few days, an( and absence o two years and * Read b< Wl ■1 ^v ■'- '^■■v.^- -MIFI. *5K|lft;:f»->i!«r" ■ Reprinted from the New York Medical Journal for Septemher 6, 1890. CompiimentB of LR.CASEY A. WOOD. dr.T. M.HARDIE. 204 Daark>orn 6t, THB AUDITORIUM, C-«l^*rO CHICACN). ij TWO CASES OF NASAL HYDROERIICEA.* ^ By T. MELVILLE HARDiE, B. A., M. B., PROFEeSOB OF RUINOI-OUT AND LABYNOOI.OGY IN THE P08T-0BADUATB MEDICAL SCHOOL OF CHICAGO. WITH A REPORT ON THE EYE SYMPTOMS, By CASEY A. WOOD, M. D., C. M., INSTBUCTOR IN OPHTHALMOLOCIY AND OTOLOGY IN THE SCHOOL. Case L — Mary S., aged forty-three, German, married. Las one child, aged fourteen, healthy. Until nine years ago, when she came to America, she had always enjoyed good health. After living for two weeks in a haseinent, in Fehruary, 1881, she devel- oped a cough, which became asthmatic some time between March and July. She had had occasional attacks of a.sthnia ever since, particularly in cold, dam]) weather. In July she received what her medical attendant told her was a sunstroke, which confined her to bed for some time. Some pills prescribed caused a buzz- ing in the ears with deafness for several days (quinine?), and during the severe headaches, usually vertical, from which she has suffered at intervals since that time the deafness occasior- ally recurs. In August or September, 1881, a watery discharge from the nose commenced, the conjunctiva being reddened and lacrymation profuse at the same time. The discharge lasted for three or four days, stopped for a month, came on again for a few days, and again intermitted. Similar periods of discharge and absence of discharge alternated continuously until about two years and a half ago, since which time the discharge has * Read before the Chicago Medical Society, July 7, 1890. ^j^ 2 TWO CASES OF NASAL HYDRORRHEA. occurred daily, usually for tliree or four hours in the morning. The patient reports that it begins just as soon as she rises in the morning, whether that be at 4.30 or 6.30. Excepting on one or two occasions, no discliarge has been noticed at night. She can not remeuiber whetber tiie discharge occurred on days on which she was confined to bed. IJas never attenjpted to stop the discharge by lying down in the morning after the com- mencement of the flow. As a usual thing the tiuid comes from both nostrils (sometiiues from one), and drop by drop. Shortly before stop[)ing for the day the clear water, whitish and opal- escent when in (lunntity, becomes thicker and viscid, resem- bling ordinary mucus. Sneezing and formication are somewhat frequent accompaniments of the discharge, but they are by no moans constant, nor does the formication appear to precede the discharge, as one might expect. Jt quite as frequently follows The patient avers that this symptom has been more annoying since treatment was begun. While the asthma is ordinarily troublesome only in cold and damp weather, she is not sure that tiie hydrorrh(t'a is appreciably influenced by matters meteoro- logical, lias not noticed that it is worse on damp days. Thinks it IS as bad in July as in November. Jt varies in amount from time to time, but without reason, so far as the patient could de- termine. IIHonj since coming under Ohervation.—\n October 1889 " could not see to sew," and attended Dr. Coleman's eye'clinic' where glasses were prescribed. She was then referred to me! Lxaraination of her nose siiowed slight posterior hypertrophy of the right inferior turbinated and a dropsical condition of the middle turbinated bodies right and left. Ridge on septum high up on left side. No polypi. Sense of smell unimpaired. No marked departure from normal sensibility of nasal nmcous mem- brane as tested by probe. Satisfactory posterior rhinoscopic view not obtainable, tongue depressor causing gagging Pa- tient says this is produced by holding anything (.. rj, candy) in the mouth for a minute even, but she has no such sensation wfien masticating and eating ordinary food. General health not very good. Burning pain in epigastrium after eating not infrequent. Painful and hyperajsthetic spot TWO ver the loft eig ears ago. No clinic for lacorat during the past practitioners an< Tuoval by snare with the interna donna extract (^ Treatment was 1 until the (5th o nienced. This 1 but little sleep companied by a the 10th and 111 charge or heada pleasant aympto bas had an aim resent time (7t time. Patien eginning of Ju: In view of itrophy with n t careful exanii by Dr. Casey ^ >' The fluid 1 iblorides, trace gion, and an Ikaiinc in reac Case II.— T i the case whose 1 Mrs. K. K., ( gave a history o has lasted for egan the pati( basement tenem profuse, but in TWO OASES OF NASAL HYDRORRFICKA. 8 ver the loft eif^hth rih in front, wlilcli first l)ecarne painful five years ago. No neiiralgiaa. Is being treated in gynrocological clinic for laceration oftlie cervix. The patient has been treated -during tlie past ten years by a sufficient number of regular practitioners and quacks, but without marked benefit. The re- oval by snare of portions of the middle turbinated bodies, Iwith the internal administration of zinc oxide (gr. f) and bella- donna extract (gr. J , markedly diminished the flow for a time. Treatment was begun on the 10th of April, with good results nntil the (Uh of May, when a day and night discharge com- ;jinenced. This lasted until the flth of May, the patient getting Ubut little sleep in the interval. The nasal discharge was ac- '^^ompanied by a fiow from the eyes and a severe headache. On Ahe lOth and 11th of May she had asthma; there was no dis- *^"harge or headache. She was then almost free from any un- loasant symptoms until the 3d of June, since which time she as had an almost daily recurrence of the discharge until the resent time (7th of July), with asthma and headache from time time. Patient's attendance has been very irregular since the ginning of June. In view of the not infrequent association of optic-nerve trophy with nasal hydrorrh(ra (seven cases are recorded), careful examination of the eyes was made at my request Dr. Casey Wood, whose report is appended. The fluid had a specific gravity of 1-006, contained iloridcs, traces of mucin, a few cells from the olfactory 3gion, and an occasional flat epithelial cell. It was feebly ilkaiine in reaction. Case II.— I am indebted to Dr. Lackner for the discovery ot ^he case whose history I shall now give. Mrs. K. K., German, aged forty-two, married, two children, fave a history of profuse watery discharge from the nose which las lasted for ten years. Six months before the discharge )egan the patient suffered froni "malaria" when living in a )asement tenement. The flow was at the beginning not very Iprofuse, but in a short time was troublesome throughout the Ml 4 TWI. CASES OF NASAL UVi)H(.U|i|Iu.;A. day «„,1 froq„e„Hy all ni^ht a, «M. si,o wa.s often wakened by It, and ,t w„, ,H.ea,,i„nall, «, „r„f„,„ a» to ,.r„vent" iZ, „ to getlier. The intor,ni,»io„., have been rare , „,1 „f ' |, ''.!' , °" .ion Patient „,,er„ that th „„i„, haf r „ 'I twenty-tour honrs ,l„ri„„ the ten year,, the amou, r ,f fc J..«h«rge be.ng ahont the ,«rao ,„u„ne ■ an,l winte ,, " i.p Bwollen an,l e.veoriate,.. Watery .lineharj o y e„ ^^t^: oeea„„n„l eonjunctival i,,|e..tion. Knndn. n„r,„,rno „„ te nerve atrophy and , nt,a,.,i„„ „r via„,., mJ' ^.'^ '^^^ l^^n y tuade the exan.in„,i„n of the eye, in thie ca,e aj A r„„l,le,on,6 a, onnnen, ,y,n|,to,n w„. „„..e,in, •• "„ ' ,,, hf ytnne, „ day- hein« th, „,nal thing. I nfortnnateTv , I fluid was not examined, the di„.|,„r.,e oea-in,, I, .^1 ■ ' followed i„,tr„etion, in the inattrrTf le tint i T " ""!"°.' and left, and p„ly„oi.l thiekenin, of hoth middle' tlnlfed Mar,/, «A._.\f,.rked lewening of discharge reported R« maining polyiM removed. '' "^'-P""*"- '*«• 7«/..-r>i,ch„r^>e very slight. No sneezing. nat^i:i:,:'""™"^-"->'-™^"^"'^i«'-niddlot.,rhi. ti.rb1;,t7'''''ptti::l;rr- f *; t""'- '■"""« '^^ '"M'"e tor, i!; itf luol'"""' '," ""■ ''"'■""^'°" "f ''■^•'-"'"™ «■'- sub ecf i, h ''" ™'"''''-""»- T'- literature of' the orted "";'™"'».''-^'--o= about twenty-flve cases reason or other an e..aniinati„n of the nose was not made :p.Cb:::iretri^f::--''"rr'"'^^ cabcs. i„ fact, a perusal of the histories TWO ol rasoH in whi ttose wrts H Hyi mav. like atro groat many
  • r other diseai >een accurate >nythinjT but a is lios worth c 3tioh>gy of tl irho reports tl lroppiiij]j is < )ituitary nieni )pcninf;s." I [a discharge ol * Goz. hrhtf., J Trau.vtftio * Brifhh Me \ Graefe'8 A ^ OphthnlinU lf>i>l., p. 1. \ Treatm ni vol. i, pp. 261, 2 m. Re- TWO CARES OF NASAL IIYDROURIKEA. 5 Ol cftHCH in which a continuous discharge of water from the Hose was a Hyniptom will (ioiupel one to conclude that it may, like atrophy of the optic nerve, be produced by a great many different conditions. One was evidently duo to fracture of the base of the skull (Vicusse's case*) ; it is tn occasional accompaniment of j^eneral anasarca (Ueesf); of meninjxitis (Taj^etl); of trifacial paralysis (Althnus <*) ; «f hydrocephalus interniis (Leber, || who thought there *:ad been bone absorption from pressures with escape of the eerebro-spinal fluid from the openinj^ thus formed); while In some cases (IViestley Smith's,^ Nettleship's^) the brain iymptouis appear to have been very marked. In two cases, on the other hand, reported by Bosworth,| to whose valua- ble paper on the subject I have to acknowledj/e my indebt- edness, there was at the bei«;inninnr apparently no visible nasal or other disease, and, presuminj^ the examinations to have been accurate, the affection can not very well have been tnythinj; but a paresis of the sympathetic vaso-motor nerves, as liosworth concludes. A somewhat novel idea as to the atiology of this affection has been suggested by Mules,^ who reports three cases in support of his theory that "the dropi>iiig is due to overdistended lymph vessels of the pituitary membrane, which by their bursting cause fistulous openings." Jirietly they were : 1. A girl who suffered from a discharge of fluid from the umbilicus for six months; no * ne side. We have not far to look to sec Mules's explanation of the discharge from eye and nose, hut are as far as ever froFu know- ing the cause of the enlarged lyn.ph tui.es. As a corollary to his theorv. Mules conclu.les that the coexistence of optic- nerve atrophy with an abnormal waterv secretion from eye and nose is merely a coincidence. He explains the occur- rence of the atroj>hy by suggesting that it mav sometimes be due to the wasting character of the general disease of winch It and hydrorrho-a happen to be sympton.s. In some cases of hydn.rrliranc of the upper part of the septum, and from the swoUen opales(!ent middle turbinated body opposite. The diseharf^e did not ("ome frotn a polypUH, so far, at any rate, as concerned that oo/inj; from the septum ; nor was the opalescent polypoid-lookinjj; nuddle turbinated a poly- pus. It became mucii smaller upon use of cocaine and pressure with a probe. The theory that the discliar^o is invariably connected with polypi iuis been several times shown to bo incorrect. Cerebral symptoms likewise are frequently absent, as in Case II. An interesting occasiotuil accompaniment is asthma, as I in Case I. So far as I have seen, it has not been noted as '! ft complication of other cases of nasal hydrorrlwea, but the t frequency of its association with hay fever, and the general tesemblance between the latter and such apparently un- ,j0ompli(!ated cases of nasal liydrurrhd'a as the two reported *1by liosworth, wo»dd at any rate prevent our surprise at inch a complication. It will be noticed tliat the patient reports that the asthma had troubled her chiefly during tlie rinter months, and that its onset did not, s<» far as she had foticed, affect the nasal discharge. My notes of the case fince it came un 180 345 270 235 RIGHT EYE. are shown in the charts. " These charts were carefully worked out several times, and the contractions were found to be fairly regular and symmetrical. This re(?ularity is especially seen in the eft eye, as the right field is more restricted toward the Dasal s,de than was found to be the case in the left eye. The held for red is correspondingly limited in both eyes. The fundus appearances are interesting, although there is nothing abnormal outside of the papilhe. The right due is deeply and centrally excavated, and the blood-vessels come for- ward in a normal manner, but (he whole papilla is very slightly paler than it should be. On the nasal border of the nerve ther^ IIZTZ' ^f^^^t^"^'"'" ^^'*"^' ^""'"°^ '^ '^"-^ situation the r^ of the physiological cup, and occupying about one third of Its circumference. A somewhat similar appearance is to be 1345 N RIGHT TWO CASES OF NASAL HYDRORRHCEA. 11 70 SO lOS 1340 160 180 190 LEFT EYE. DIAGRAMS OF OPTIC DISCS. RIGHT EYE. LEFT EYE. 12 TWO CASES OF NASAL HYDRORRHEA. mm^t seen in the left disc. Here there is no general pallor, and the normal cupping is shallow. At its bottom, however, the stip- pling of the cribriform fascia is to be seen. A band, yellow- ish-white in appearance, longer than but quite as narrow as that visible in the right disc, occupies the lower outer aspect of the left papilla. It does not extend, as in the former case, to the edge of the excavation toward the nerve center, nor does it reach in part of its course the outer rim of the disc. I have endeavored to illustrate this condition of things by the pre- ceding rough diagrams. I have seen a number of similar whitish areas in pa- pillae of eyes otherwise normal which were not accompanied by deterioration of vision or contraction of the field of vision, and I consequently hesitate to regard this picture as evidence of atrophic changes, however limited, of the optic nerve itself, and yet they are certainly not the pale spots on the surface of the disc which one sometimes sees due to variations in the light reflex from an uneven papillary surface. Whether the limited decolorization of the discs is evi- dence of a retro-bulbar neuritic process it would be difficult to say. The history of an attack, occurring six months before and accompanied by absolute central scotomata and great loss of visual acuity, certainly points in that direc- tion, but, in the absence of more positive proof, one can not very well decide. If such has been the case, it is not easy to say why, with some remaining impainnentof vision, there are no central scotomata, not even for colors. Notwithstanding all treatment, the ocular symptoms since the date of writing the foregoing, the epiphora espe- cially, are as pronounced as ever. he Nev Edit Published b; [x. BECAUSE oonUtiiuiinf BECAUSE uedJoaltho BECAUSE cal men of BECAUSE cntific obsc value to thi BECAUSE which are { diB00T«ri9fl written b J BECAUSE peutical N< of the most BECAUSE contains on prominent 1 of certain i BECAUSE desire to p sdence of ; best interei BECAUSE some bearii ralue. 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