the tendency to enteroptosis and intestinal prolapse incident to the prolonged strain. In other words, the origin of these bands about the ascending colon, hepatic and splenic flexure, sigmoid and so forth, is referred by him to the mechanical factors of chronic obstipation and the upright posture, the strain of persistent enteroptosis being offset by hypertrophy of the membranous supports of the bowel. Jackson very properly emphasizes that "something definitely more than chronic obstipation must exist to occasion either the pathologic or the clinical picture presented by membranous pericolitis;" and as the worst cases of constipation may be and generally are free from changes of this description, he thinks this membrane is something other than physiologic response to mechanical demand. The author's observations on three cases indicate the missing link in the sequence of mechanico-pathological events to be represented by the addition of the traumatic factor, to a pre-existing and long established intestinal stasis. It is suggestive, and probably more than a peculiar coincidence, that all these patients were raised on Western ranches, and were in the habit of spending many hours daily in the saddle. The two women were natives of western Nebraska and rode horseback a great part of the day, while the man had practically lived in the saddle ever since he was able to sit on a horse. (1) Male, age 30. Antecedents negative. He gave a history of irregular habits of the bowels and progressive constipation for five years past; in the last few years the bowels had not moved naturally without the use of laxatives, and remnants of food sometimes appeared in the stools unchanged. The attacks of constipation often required the use of injections, or large doses of salts, four or five tablespoonsful, and were followed by prostration with drowsiness. He did not complain of intestinal gas or pain, but there was occasional painfulness below the umbilicus and in the region of the right flank. Examination showed tenderness in the median line of the epigastrium, also over Morris and McBurney's points, with marked tenderness of the right iliac flank. The patient was very nervous and hypochondriacal. Operation (Dr. Ford) showed the presence of a large patch of pericolitic membrane on the colon, above the cecum, binding the colon down, but not involving the cecum. The appendix was of medium size, inflamed, larger in the middle than at the base, and at this central enlargement was bound tightly down by an old inflammatory adhesion. The patient made a good recovery, and was cured from constipation, after the operation, which consisted in incision and division of the membrane in the middle line, and removal of the appendix, after the membrane had been stripped back. (2) Female, age 35, single. Healthy until five years ago, when intestinal disturbances developed in form of bloating and distension with gas, causing severe pain until the gas had been evacuated. The condition persisted for a number of years, during which time the diagnosis of chronic appendicitis was made by several physicians, including the author. Operative interfer ence was recommended, but not accepted. The patient became gradually worse, and was finally in an extremely nervous state. The author was called to see her on the evening of December 8th, 1912, and found here just recovering from a faint due to pain in the abdomen from gas distension. ated upon the following morning, through She was removed to the hospital and opera right rectus incision. The cecum lower portion of ascending colon were found to be bound down by a membrane, under neath which lay the appendix, fastened up against the cecum and ascending colon. The membrane had exerted so much pressure upon the appendix that it was completely flattened out and kinked, in the form of a Roman S. and (3) Female, age 24 years, single. Fairly well nourished but very nervous. Bad color of skin, face covered with pimples. History of dysmenorrhea and intestinal disturbances in form of abdominal pain with gas distension. The condition gradually became worse, until finally no movement could be obtained without enemas, several of which were sometimes required to produce results. The attending physician referred the trouble to the appendix. The examination of the abdomen proved negative, with the exception of pain in the appendiceal region. At the time of the operation, on November 9, 1912, the author found the lower part of the ascending colon and cecum bound down by thin membranous adhesions, the appendix lying free inside the adhesions, as in a pocket formed by this membrane. The "veil" covered the cecum and part of the ascending colon and could be stripped off, leaving a few bleeding points, but the glistening peritoneum could be made out underneath. Signs of chronic inflammation were persent in the appendix, which was enlarged and filled with fecal matter. Recov ery was uneventful, and the patient's bowels move daily without assistance since the time of the operation. (b) Inflammatory, and infectious theory; subdivided into endogenic causes, or peritoneal reaction from infection within the colon, and exogenic infection transmitted from some inflamed organ in the immediate vicinity. The membranes are interpreted by Pilcher as the result of long continued or oft repeated mild infections of the peritoneal covering of the cecum and appendix transmitted through the intestinal wall." Gerster assumes a reaction of the peritoneum to infection and chronic inflammation of the colon, in form of "characteristic vascularized transparent membranes (pseudoperitoneum) which take their origin along the external lateral aspects of the cecum, ascending colon and hepatic flexure on the one side, and the sigmoid flexure, descending colon, and splenic flexure on the other." In two cases reported by Duval, the inflammatory origin is indisputable, and the pericolic adhesions had the configuration of pericolic strands rather than that of a membranous veil. He suggests the possible existence of two different varieties of pericolitis, one described by Jackson (the veil type) which is not referable to an inflammatory reaction towards a colic infection, nor a preceding peritonitis; and another variety, which has long been known, and which includes pericolic adhesions, in form of bands, strands, sheets, etc. The second type is evidently of inflammatory origin, and represents the residue of an extensive peritonitis, or the expression of an entirely local reaction of the peritoneum towards a slight colonic infection. The possible persistence of pericolitis in form of bands and adhesions, after the subsidence of the initial attack of appendicitis, is emphasized by Carwardine. Pericolitis according to him is also a frequent accompaniment of inflammatory affections of the gall bladder, and post-inflammatory pericolonic adhesions may result from wandering kidney. (3) Embryonic or congenital theory. According to Mayo, the bands and veils in certain cases may be the sequelae of late rotation of the bowel and descent of the cecum from its hepatic position, after the formation of the peritoneal portion of the peritoneal cavity in the fetus. He points out that failure of the colon to rotate should be considered as a possible cause in cases of obscure inflammatory conditions in the left or middle pelvis, or in the left iliac fossa. The first type of pericolitis, as propounded by Duval, and characterized by its extent, the formation of a veil, and the absence of inflammatory phenomena, is perhaps a peritoneal malformation, analogous to the malformations met with on the left border of the left lumbar iliac colon, and which mark its belated attachment to the posterior abdominal wall. A movable and elongated cecum,or cecum mobile, described by Wilms, in Germany, which is congenital in the majority of the cases, and apt to give rise to symptoms resembling those of membranous pericolitis, is not admitted by Carwardine as a pathogenic factor, in the production of pericolonic membranes. The assumption of congenital factors in the pathogenesis of membranous pericolitis is entirely compatible with the traumaticmechanical view advanced by the author. Constant traction upon the bowel by the dead weight of retained feces, assisted by the regular shaking up of the rider's viscera through the movements of the horse, may certainly be conceived as a source of irritation to a congenital pericolonic membrane, which under more favorable conditions might never have led to the clinical symptoms of intestinal obstruction. The following illustrative cases from the recent French and German literature, may prove of interest, as not included in Jackson's latest contribution, in the Annals of Surgery, March, 1913. References to a number of case reports in the American literature are included in the bibliography. The diagnosis of membranous pericolitis, in three cases reported by Duval, was based upon the symptom-complex of slight transitory intestinal occlusion, with fecal retention. Palpation of the cecum showed an intestine distended by gas, instead of a very limited painful point, as in appendicitis; the pain on palpation was present along the entire course of the ascending colon. The first patient, a woman of forty years, had a history of vaginal hysterectomy, twelve years previously complicated by severe peritonitis. Her intestinal symptoms consisted in obstinate attacks of mucous diarrhea, a constant pain in the right part of the abdomen, and considerable distension of the cecum, most marked at the time of the attacks. Laparotomy was performed, and showed the existence of pronounced veil-like pericolic adhesions, especially at the level of the hepatic flexure, with a free and distended cecum. Resection of the adhesions was followed by recovery, which had persisted three years at the time of the report. The second patient was a girl of 17 years, who suffered from painful attacks in the right half of the abdomen. She gave a history of having inserted a needle in the right iliac fossa. Lateral laparotomy was performed, and the needle was found in the omentum. Pericolic adhesions were present and were resected, the cure persisting at the time of the report, five years after the operation. The third case concerned a woman of 30 years, extremely thin and neurasthenic, with painful crises in the right side of the abdomen and temporary retention of gas and feces. Right-sided laparotomy, with removal of the appendix and resection of the pericolic adhesions, was followed by recovery, which had persisted two years at the time of the report. In two cases reported by Hagenbach, concerning women of 27 and 23 years, respectively, the symptoms consisted in abdominal pains and colics, disturbances in the evacuation of the bladder, and dysmenorrhea. The cured patients were presented by him before the Basel Medical Society, on July 6th, 1911. In the first case, the diagnosis lay between cystitis, nephritis, oophoritis, and nephrolithiases. Hagenbach assumed perity phlitis, and laparotomy showed pericolitic adhesions of the colon, involving the ascending colon and the right half of the transverse colon. Detachment of the adhesions brought relief for three months, then the old trouble returned. Others rendered a diagnosis of gastric ulcer and bile stones. Another laparotomy was performed and an anastomosis was applied between the ileum and the left side of the transverse colon. The outcome was complete and permanent recovery. In the second case, the symptoms led first to resection of the ap· pendix, then to ovariectomy, first on the left then on the right side. At this time the patient entered the author's clinic, and he made the diagnosis of pericolitis. Laparotomy was performed and extensive adhesions were found in the ascending, transverse and descending colon, as far as the sigmoid. Ileosigmoidostomy was accordingly performed, with unilateral exclusion of the colon. The patient felt well for three months; at the end of this time, colics appeared again with blood and mucus-stained evacuations and distinct inflation of the cecum. Retrograde impaction in the colon was assumed, and could be demonstrated in a series of radiographs of the bowel, with bismuth filling. Particles of the bismuth shadow reached as far as the transverse colon. The backward damming of the gas caused a considerable inflation of the colon. The entire excluded colon was resected, to insure the patient's radical recovery. Since the operation there are daily spontaneous formed stools, without pains. Neither bacteriological nor histological changes could be demonstrated on the resected intestine. The Transactions of the New York Surgical Society, February, 1912, contain a case operated upon by Parker Syms, for appendicitis, which showed a typical Jackson's membrane enveloping the ascending colon and spreading from the parietes over the colon, which was freely movable be neath. BIBLIOGRAPHY. Jackson, Jabez N., Membranous Pericolitis and Allied Conditions of the Ileocecal Region, Annals of Surgery, March, 1913, p. 274. Carwardine, T., Pericolitis, Brit. Med. Jour., January 18, 1913, p. 101. Mayo, C H., Failure of the Colon to Rotate, Medical Record, Pilcher, J. S., Surgical Aspects of Membranous Pericolitis, Hagenbach, Zwei Falle von Pericolitis, Correspondenz-Blatt Wilms, Fixation des Zoecum mobile bei Fallen von sogenannter chronischer Appendizitis; Zentralblatt fur Chirurgie, No. 37, 1908, p. 1088. Simmons, C. D., Jackson's Membrane, New Orleans Medical Dolbey, Pathology and Treatment of Membranous Pericolitis, Northwest Medicine, August, 1912, p. 131. DISCUSSION. DR. C. H. MAYO, Rochester, Minnesota: I do not believe these membranes are common. Practically all such conditions are congenital and can hardly be called defects. Fortunately, the large bowel will stand a great deal of manipulation-a great deal of surgery. If one is not satisfied with the position of the colon, it may be put in some other place without any particular inconvenience to the individual. We are by no means at the end of our resources so far as surgery of the large bowel is concerned, though I believe we have overstepped the bounds in some instances. If one reviews the history of the development of surgery, it will be found that there has been quite as much enthusiasm over the movable kidney as there now is over the large bowel. The reference to movable kidney immediately suggested the idea that it should be fixed. We now know this condition to be normal. In every branch of the development of surgery, there has always been some fad for discussion. Just at present, it is the question of surgery of the colon. It is undoubtedly true that disorders of the intestines are caused by over-eating. It has been demonstrated that the healthy working man eats two and one-half times more meat than he can take care of. Arbuthnot Lane is treating certain diseases by removing the colon. He is treating all varieties of diseases in children by removing the colon. Just how much there is in this treatment is difficult to determine at the present time, but I should say that Lane is on the track of something which is of great importance. Subscribe for the Medical Herald. EXTERNAL EYE DISEASES OF APPARENT NASAL ORIGIN.* JAS. M. PATTON, M. D., Omaha, Neb. It is within comparatively recent years that oculists have recognized the influence of intranasal pathology as a causative factor in diseases of the eye. No ophthalmic examination is now complete without a thorough examination of the nose and accessory sinuses, with the result that many of the formerly so-called idiopathic cases of optic neuritis, atrophy, uveitis, cellulitis and even muscle disturbances can be traced directly to the nose or sinuses. When we remember the intimate relation of the sphenoid and post ethmoid cells to the optic tract, and consider that the orbit is only separated from the nasal structures by the lamina paprica which is not infrequently perforated by dehisences, the surprising thing is that in the presence of such large amount of nasal infections the eyes are not more frequently involved than they are. a Thus the responsibility of the nose in the deeper ocular affections is easily accounted for and we are surprised that this relation was not determined earlier, but when we come to the external inflammatory conditions the analogy is not so clear and many have been slow to admit that such a relation really existed. We have all experienced the reflex irritation of the eyes from the inhalation of irritating gasses, and the sneezing that sometimes accompanies the presence of a foreign body in the eye. An acute coryza or a mechanical irritation of the nasal mucosa quickly stimulates an involuntary flow of tears with congestion of the conjunctival tissues. Remembering these common experiences we can readily appreciate the possibility of intra-nasal pathology as an etiological factor in the more serious of the socalled external diseases of the eye. Anatomically the external portions of the eye and the intra-nasal structures are rather intimately related through the arterial and nerve supply. The lids, conjunctiva, eyeball and deeper structures are supplied by the ophthalmic branch of the internal carotid artery which also supplies the nasal mucosa. Again the nasal mucosa and the eye-ball, lids, conjunctiva and cornea derive their sensory nerve supply from a common source, the fifth cranial. Whether these relationships have anything to do with the conditions that we see clinically remains to be proved. There is a possibility that the Read before the Medical Society of the Missouri Valley, Omaha, Neb., September 19, 1913. lymphatics are the real communicating structures but this has not been as yet definitely determined. Disregarding lachyrymal disturbances caused by obstruction of the lower end of the lachrymal duct, we occasionally see cases of conjunctivitis apparently secondary to a primary infection in the nose, whether this infection was car-. ried through the lachrymal apparatus or by means of the handkerchief is uncertain. Campbell (Canadian Practitioner and Review, XXXV, page 625) reviews the bacteria of the eye and nose and found the staphylococcus, pneumococcus, bacillus of Morax-Axenfeldt and others, to be more frequently found, e.g., in the eye, if the nose was infected and vice versa. We all know how difficult it is to cure a case of phlyctenular keratitis without first relieving the irritating nasal symptoms. In fact the nasal treatment in many of these cases is almost as important as the ocular and has led some to the opinion that the intranasal infection may be an etiological factor in this distressing disease. But it is not the direct infections that I wish to bring to your notice so much as the indirect or reflex symptoms, e. g., the asthenopia, pain, muscle weariness, conjunctival irritation and corneal erosions, occurring without sufficient cause locally, and clearing up on intranasal therapy. Benham (St. Paul Medical Journal, XVIV, 163) reports a case in which the patient presented the usual symptoms of eye strain, with irritation of the conjunctiva. Refraction and muscles were normal, but the doctor found a heavy septal spur which was pressing on the turbinates on the affected side. The nasal conditions were corrected and the ocular symptoms disappeared without further treatment. He quotes Dowling, who has made extensive experiments, and is of the opinion that irritation of the ciliary nerves will only excite sneezing, etc., when there is an abnormal condition of the ethmoids. And that the wearing of properly fitted lenses will frequently relieve ethmoidal irritation and that cases in which correction of the refractive error does not give the desired relief, are often made com. fortable by reducing the size of the middle turbinates. Foster (Ophthal. Year Book, Vol. VIII, 356) reports five cases in which asthenopia was apparently due to pressure between the turbinates and septum, clearing up on correcting the intra-nasal condition. Kyle (Ibid. page 355) had several cases of severe eye pain relieved by intra-nasal treatment without operation. Dupuy (ibid) reports a case of conjunctival hyperemia and De Schweintz (Ibid) several cases of so-called fugitive episcleritis secondary to accessory sinus disease. Mark (ibid) reports a case of extrinsic muscle disturbance due to an osteoma of the ethmoid cells and Culp (ibid, page 9356) asthenopia secondary to a cystic growth in the inferior meatus. Within the last few years we have had a number of cases of recurrent corneal irritation in a number of which it amounted to an active ulceration. There was no local pathology to account for the condition nor could any definite germ be isolated. The condition would respond rather kindly to treatment but would recur in from one to six months. In spite of the absence of any definite nasal pathology, the removal of a part of the middle turbinate on the affected side has apparently put a stop to the recurrence and the patients have been free from symptoms. We have had twelve to fourteen cases of this type of which the following is a typical example: C.B., aged 45, consulted us in October, 1906, complaining of recurrent inflammation of the right eye. Family and personal history negative as to constitutional diseases. No bad habits. Examination showed marked congestion of the right conjunctiva, moderate iridocyclitis with photophobia, cornea slightly roughened with two small infiltrated areas near limbus.. Nose practically normal. No pressure nor obstruction. The condition responded rather slowly to treatment but finally cleared up only to be followed by a similar attack a few months later, which cleared as before. Finally in 1909 as a sort of a last resort, I removed the anterior half of the right middle turbinate without much hope, I'll admit, of its benefiting the patient, but to my surprise the cornea cleared promptly and in the four years since there has been no evidence of a recurrence of the trouble. This of course led us to employ this same treatment in similar cases with very satisfactory results. In conclusion, it is generally admitted that many of the deeper ocular affections are directly secondary to nasal pathology, and we also know that many cases of asthenopia, discomfort, conjunctival irritation and corneal affections do not respond to local treatment alone, and are greatly improved by correcting nasal defects. 567 Brandeis Building. DISCUSSION. DR. BANISTER : I think that Dr. Patton's paper is too practical and of too much benefit to the general practitioner to be allowed to go by without discussion. The facts that he brought forward will be of great aid to the general practitioner, who cannot get this information from text-books, and I for one think that Dr. Patton is to be congratulated upon the very practical manner in which he has presented his subject. The findings in our office fully confirm his. DR. F. B. TIFFANY: In my experience in Germany, a good many years ago, they made a specialty of the eye, the ear and the nose. They didn't combine them as you do here in America, at that time. I was over there last year and I found that such men as Lindgate of Paris, has added the affections of the ear, nose and throat to those of the eye. They have taken up all of these branches, they recognize that affections of the nose have something to do with those of the eye. DR. J. M. PATTON (closing): I wish to thank the gentlemen for their kind discussion. These cases of eye strain and conjunctivitis that do not respond to local treatment, should always suggest a thorough examination of the nose. In fact oculists are agreed that an examination of the eye is not complete until the nose and accessory sinuses have been examined. FLAVEL B. TIFFANY, M. D., Kansas City, Mo. Entropion is not only a turning-in of the margin of the lid with the lashes resting upon and irritating the cornea, but it is more. The lid in its normal state is wedgeshaped, the thickest portion being at the free margin. But in entropion diseases have produced atrophy; so that the margin instead of being thick has become thinned, the hair bulbs distorted, and the shafts have been drawn so as to strike the ball of the eye. In aggravated cases the intramarginal space is obliterated, the lashes come out from the mucous line, and are often folded under, lying upon the eyeball. There is always more or less contraction. from cicatrices at the retrotarsal fold, which also tends to invert the ciliary margin of the lids. Besides the atrophy of the margin, the portion of the lid a little beyond the margin is frequently hypertrophied-a condition which heightens entropion; and in the upper lid there is a tendency to redundancy of the skin, which is loose and movable. Especially are these conditions found in old people. In fact entropion is usually confined to old people, in whom it is easily provoked. The ophthalmologist knows by experience that it often follows the bandaging of an eye after the extraction of cataract; being caused by the pressure of the bandage on the ciliary margin. But it is to that class of patients who have suffered long from trachoma, with atrophy and cicatrices, with obliteration of *Read before the Medical Society of the Missouri Valley at Omaha, September 18, 1913. |