“Tubercular laryngitis may often begin by a nodule situated on the border of the vocal cords. It is important not to confound it with singers’ nodules, these latter being more conical and more rounded. The tuberculous nodule may grow slowly, not ulcerate for a long time; interfering so little with the speaking voice that the patient often refuses any intervention. But the day comes when we see this nodule desquamate, and we may observe the evolution of the tuberculous ulceration which displaces it. We make no mention of the other forms of commencement characterized by a congestion of the entire organ, by œdema of the epiglottis, by a lividity quite characteristic which invades the entire endolaryngeal mucosa, forms most usual for the tubercular involvement of the larynx. A form especially noticeable is that which begins with a sensation of a lump in the throat. It is true that this variety is not observed except in the nervous; it is not, however, to be compared to the globus hystericus. Tuberculous patients, in whom the tuberculous process in the larynx begins with a sensation of a lump in the throat, may be in very good health, but this particular impression is often the first symptom which they observe in a laryngitis, which finally becomes tuberculous. At the moment when the patient complains of this symptom it may happen that laryngoscopic examination fails to detect any lesion. It is useless to add that this form is especially met with in the female. It most nearly resembles that form that begins with a dysphagia that persists to the end; but at the beginning of tubercular laryngitis this dysphagia alone is noted without any other symptoms.” So it can be seen that laryngeal phthisis may begin by a variety of symptoms, some common, the others rare. It is needless to insist upon the importance of an early diagnosis.
Palmer.
Ball, James Moores.—On Removal of the Cervical Sympathetic in Glaucoma and Optic-Nerve Atrophy.—Jour. A. M. A., June 2, 1900.
I propose to consider the surgery of the cervical portion of the great sympathetic nerve in certain ocular diseases. European oculists and surgeons have performed sympathectomy for glaucoma and exophthalmic goiter. I have gone further, and in one instance removed the superior cervical ganglion for simple atrophy of the optic nerve. I have performed sympathectomy four times up to July 20, 1899. First the cases will be reported; then the conclusions will be drawn.
CASE I.—EXCISION OF SYMPATHETIC FOR GLAUCOMA ABSOLUTUM.
Mrs. B. S., aged thirty-six, has had pain in and around the right eye for two months, and examination showed vision in this eye reduced to light perception; tension + 3, and the pupil widely dilated. The anterior chamber was shallow, the cornea cloudy and slightly anæsthetic, the media slightly cloudy, still allowing the fundus to be seen. The episcleral vessels were enlarged. Circumcorneal injection was present and the optic nerve cupped. A diagnosis of chronic irritative glaucoma was made. The left eye presents immature cataract, and vision in this eye is 20/70.
Knowing of the flattering results obtained by Jonnesco and others, by excision of the superior cervical ganglion in absolute glaucoma, I explained the operation to the patient, and obtained permission to operate. On May 15, 1899, the patient was anæsthetized, chloroform being employed. An incision four inches in length was made on the right side downward from the mastoid process, extending along the posterior border of the sterno-cleido-mastoid muscle. The external jugular vein was cut and tied. The sterno-cleido-mastoid was then separated from the trapezius muscle, and the spinal accessory nerve was cut. A deep dissection was then made, exposing the carotid sheath. This was opened to enable us to locate the pneumogastric nerve beyond question. The carotid, internal jugular vein, and pneumogastric nerve were then pulled forward, enabling us to see the rectus capitis anticus major muscle, on which the superior cervical ganglion rests. Tearing through the fascia, the ganglion was found and stripped. The ganglion was then cut high up with curved scissors and all its branches severed. About one inch of the trunk of the sympathetic below the ganglion was removed. The wound was closed with interrupted sutures and the neck placed in a plaster cast. The time required for operation was fifteen minutes, and immediately after it was noticed that the right eye was suffused with tears, the right conjunctiva much injected, and the right nostril moist. The intra-ocular tension was + 2. The patient slept well all night, without medicine, being free from pain for the first time in over two months. Tension had steadily decreased to + 1.
On May 16, slight ptosis was noticed on the right side. This symptom is yet present. On May 19 the circumcorneal injection was much less; the conjunctival hyperæmia and lachrymation were still present, while the ptosis was slightly increased and tension was + 1.
At the present date—July 23, 1899—this patient has no pain. The retinal arteries are increased in size. Tension is + 1. Vision has increased from light perception to ability to count fingers at three feet. The conjunctival injection which followed the operation has disappeared; the optic nerve has a color more approaching the normal. The ptosis is less.
This was the first sympathectomy made in America for glaucoma.