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nosis, he pronounced the mass an inflamed and thickened tube. The first object to present itself to our attention upon opening the abdomen was a perfectly normal tube. The left ovary, however, was prolapsed, cystically degenerated and had growing in it a small fibro-myoma, determined by microscopic section.

In these four cases of ovarian disease we get a diagnosis of lumbago, chronic appendicitis, possible ectopic gestation, simple pregnancy, fibroid tumor of the uterus, and chronic salpingitis. Dudley names 17 intrapelvic and 12 abdominal conditions which may be and have been mistaken for ovarian cyst. Is, then, a correct diagnosis of ovarian disease next to impossible and merely guess work.

If in these cases and all other cases a careful history were obtained and all the factors given due consideration and weight the mistakes would be fewer. For example, in Case IV if the constant extreme tenderness had been given the weight its importance as a symptom demanded ovarian and not tubal disease would be have been recognized. While a diagnosis may not be incorrect it may be woefully incom- . plete. This is well illustrated by the case of Mrs. I, who came to my office complaining that something came down out of the vagina. On the examining chair there presented a prolapsed rectum. The uterus seemed to be in its normal situation though the cervix was considerably ulcerated and the perineal floor had been partially destroyed twenty-five years previously. Treatment was directed to the rectum but the patient came back in a few days and said that was not all the trouble. I then examined her in the erect position and found the uterus half way out into the world.

The examination, therefore, should be systematic and thorough and repeated as often as may be necessary under varying conditions. Anesthesia should be resorted to if need be to secure relaxation and freedom from pain.

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The ovary is best located in the manner described by Kelly. carrying the vaginal finger far up into the lateral fornix posterior to the cervix, and then pushing out toward the lateral wall of the pelvis, while deep pressure is made with the abdominal hand in the same direction through the corresponding semilunar line, the ovary can usually be caught and palpated. It is not sufficient simply to touch the ovary; it must be caught repeatedly and be allowed to slip between the fingers in various directions until it has been thoroughly examined on both surfaces and its free border. The ovary feels like a firm body as big as the thumb, with rounded border and convex surfaces, slightly irregular. It is freely movable in all directions. It requires educated

fingers to palpate normal ovaries, and it is probably safe for the average practitioner who readily locates the ovary to assume that it is enlarged. This organ is a tender one and the tenderness in a diseased ovary is severe, often extreme, and if the examiner locates a tender object anywhere in the pelvis that gives intense pain on pressure it is probably the ovary, no matter if it be in front of, behind or attached to the

uterus.

In acute overitis the pain may radiate to the back, thighs, ischiatic nerves and breasts. Nausea and vomiting are frequent, but fever is not at all constant. Painful defecation, frequent urination, dyspareunia and hysterical symptoms are nearly always present. When the Ovary becomes two or three times its normal size its weight will carry it down into the cul-de-sac of Douglas unless a retroverted uterus opposes its descent, when it will lie low at the side of the pelvis or in front of the uterus.

In chronic overitis the ovaries undergo cystic degeneration. They are usually prolapsed, dragging down and twisting the tube, and they are often closely adherent to the posterior wall of the uterus. In these cases there is a history of long standing pelvic disease, pain or discomfort in the ovarian regions, displacement of the uterus, and chronic leucorrhea. There may be, likewise, a history of celibacy as a casual factor or sterility as a resultant state.

Cystic growths of the ovary are exceedingly common and, as has been indicated, present some difficulties in diagnosis. They occur most frequently during the period of sex activity. It must not be forgotten, however, that dermoid cysts may occur and require removal in early childhood. Pozzi refers to ovariotomy performed by Rochman in a child twenty monthis old; by Bell in a girl 13 years of age, and by Polotobnoff in a child nine months old. On the other hand cysts may not obtrude themselves until late in life. It is to be kept in mind, also, that they are not infrequently bilateral.

When small the cyst is usually hard and inelastic because of the tension of the capsule. When included in the broad ligament it seems to be one with the uterus, but careful examination will reveal a slight groove between the uterus and the mass. This is an important diagnostic point. Here the rectal examination is highly valuable. It is amazing, sometimes, to discover how clearly the pelvic organs may be outlined with the finger in the rectum counter to the finger tips pressed into the abdominal wall.

None of the many symptoms of ovarian cyst are pathognomonic, but they must all be considered as factors in establishing the diagnosis.

Nutritive disturbances, intestinal indigestion and constipation are observed. The latter is due to adhesions to and pressure upon the rectum. These also produce hemorrhoids, which it is useless to attempt to cure until the cause is removed. Other pressure symptoms are urinary disturbances from pressure upon the bladder and ureters.

Menstrual disturbances are not significant. "Menorrhagia often occurs in the case of cysts impacted in the immediate neighborhood of the uterus." (Pozzi.) Sterility is by no means invariable even in bilateral cases. Facies ovariana are not so often observed at present because these cysts are usually discovered and removed when small.

The limits of this paper will not permit us to take up the differential diagnosis of ovarian cyst from other conditions with which it may be confounded. It is merely suggested that the practitioner note on filing cards the cardinal symptoms of the various pathological states. When a case appears for diagnosis there is at hand a ready reference, garnered from various sources, to those conditions which may be mistaken for ovarian cyst.

NEUROLOGY OF OCULAR REFLEXES.*

EDGAR J. GEORGE, M. D., CHICAGO.

Posey and Spiller preface their book on "The Eye and Nervous System" by saying that "it is generally considered that a knowledge of neurology is indispensable to the ophthalmologist and that an acquaintanceship with ophthalmology is of the greatest service to the neurologist, that there is no book in the English language which covers the ground where the two specialties meet." It has been the aim of the authors to render such a book, not only for the specialist, but to present ophthalmo-neurology in a form that the general practitioner may, without difficulty, become conversant with its symptomatology. In this they have succeeded most admirably, but they themselves have failed to explain clearly how eye strain can be transferred to cause reflex irritation or remote disturbances elsewhere. Reflexes like frontal, temporal, occipital, and general headaches, pain in the cervical region, cranial neuralgia, nausea and vertigo (such as car sickness), insomnia, irritableness of temper, neurasthenia and facial chorea (frequently called habit chorea with children). Of the local symptoms, which are also reflexes, there may be photophobia and lachrymation, conjunctivi* Read before Chicago Homeopathic Medical Society.

tis, inflammation of the margin of the lids, and epiphora (watering of the eyes).

Eye strain, or the reflexes of eye strain, are the result either of an abnormality of the eyeball or a disturbance in the muscular balance of the two eyes, causing a persistent effort to maintain parallelism of the visual lines and, in some cases, both an ocular and muscular defect may be found to exist. The majority of all eyes examined are found to be defective in some form or other, and it is rarely that an absolutely perfect pair of eyes are met with. This can be readily understood when it is known that abnormalities of the eyes are deformities of the eyeballs and congenital more often than acquired. In other words it is almost an impossibility for eyes to develop in their growth to a point of perfection, so delicate are their anatomical parts and functions that the least variation from normal in their anterior posterior diameter or corneal curvature will cause an error of refraction. Muscular imbalance can result from an error of refraction, but observation points to congenitality. Ocular and muscular defects are both hereditary and congenital, consequently it is so with many of their reflexes. Often we have heard a patient say, "my mother or father suffered as I do. I must have inherited this headache," or whatever symptoms they may complain of.

Knowing that the great majority of eyes are defective, in their muscular system or otherwise, the question that would naturally arise would be: "Why do we not all suffer from eye strain in some form or other?" The answer is that it depends upon the temperament of the individual. A highly sensitive nervous disposition will often suffer intensely from the strain of a slight ocular or muscular defect, while with a dull unresponsive person it would give rise to no symptoms whatsoever. However, debility from mental strain, overwork or sickness, may affect the robust and cause eye strain to become manifest at any stage of life under fifty years of age. My discnssion will go no further with the etiology of eye strain, but suffice it to say that any abnormality of the eyeball (excepting myopia) will cause, during the waking hours, a persistent strain upon the ciliary muscle from early youth to the fiftieth year of age, when at that age presbyopia (a sclerosing of the lens) takes place and usually removes the ciliary strain. Presbyopia has caused the disappearance of headaches and other reflex ocular symptoms from sufferers who, in their early years, were ignorant of the cause, they attributing their relief to the fact that they had outgrown them, a common expression with the laity, when, after years, their affliction. leaves them. The ciliary muscle is an involuntary muscle. Its tone

depends upon the general muscular tone of the body. While we are awake it is constantly in the act of accommodation, and if called upon to do double duty, that is to correct an existing ocular defect, after a time it usually becomes fatigued.

In order to understand how reflex disturbances occur from overstrain of the ciliary muscle it becomes necessary to briefly consider its nerve supply. It receives its sensation from the long ciliary nerves through the nasal branch of the ophthalmic division of the fifth and short ciliary nerves from the ophthalmic ganglion. This ganglion is made up of three roots, one from the nasal branch of the ophthalmic division of the fifth, one a motor root from the third nerve, and a sympathetic root, a branch from the cavernous plexus, thus its nerve supply is motor, sensory and sympathetic.

As the fifth nerve is the great sensory nerve of the head, undue strain upon the ciliary muscle can provoke not only a local irritation, but can be reflexed to other branches of the nerve that supplies sensation to the frontal, temporal and occipital regions of the head. Ciliary strain can also give rise to gastric disturbances through its sympathetic connections with the solar plexus. The ciliary muscle is not wholly responsible for all local or reflex symptoms that may come from the eyes.

The ocular muscles when not in balance also have their disturbing influence. A slight variation in the relative strength of one muscle to another, or one set of muscles to another, will cause deviation of the visual lines. The continual effort to maintain parallelism of the visual lines of one afflicted with a muscular imbalance is a strain accompanied with marked reflex symptoms, particularly with those of a highly sensitive temperament. Unlike the ciliary muscle the extraocular muscles are voluntary. They receive their motor influence from the third, fourth and sixth nerves, and, like the ciliary muscle, also receive sensory fibers from the fifth nerve and filaments from the cavernous plexus, a connection with the sympathetic. As the ciliary and majority of the extra-ocular muscles have the same sensory and sympathetic nerve connections a strain, either on the ciliary or extraocular muscles alone can have similar symptoms, although frequently an ocular and muscular defect are found associated.

As the fifth nerve is to blame for the transmission of pain from the eyes to different parts of the head it also must be considered. It is the largest of the cranial nerves and different from the rest, as it is a nerve of sensation, motion and taste. It is the great sensitive nerve of the face and cranium. Its cutaneous branches supply sensation to the skin,

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