-a razor, scalpels, dissecting-forceps, scissors, hemostatic forceps, a pair of long-handled sharp retractors, needles-these have been sterilized at home and enclosed in a clean towel or canvas bag. We also carry a nail-brush, soap, a pint of strong alcohol, two ounces of flexible collodion, a five-yard package of aseptic or antiseptic gauze, and a half pound of absorbent cotton, also half a dozen clean towels wrapped up in a towel and this again in a piece of strong wrapping-paper. We have the necessary suturing and ligature material, prepared in the manner already described. All of these things can be carried in a moderate-sized satchel.

Arriving at the house, we place a tea-kettle full of water on the stove to boil; then we place the kitchen or dining-room table near a window, spread a quilt over this, and place a pillow at one end. All of this is covered with an oilcloth, if one is at hand, and this with the cleanest sheet that can be obtained, or with one of our towels at the point where the operation is to be performed.

We next scrub our hands in the manner described, and treat the patient's abdomen and thighs in the same manner, carefully shaving the skin in. the vicinity of. the operation. For washing we use the water which has in the meantime been boiled. A pad of absorbent cotton saturated with strong alcohol is placed over the area to be operated upon, and left in place until the beginning of the operation in order to dissolve the fatty material contained in the upper layers of the epidermis.

Four plates are now found and thoroughly scrubbed with soap and hot water and then with strong alcohol. On one of these plates we place our instruments; on the second one, pieces of aseptic gauze to be used as sponges; on a third one, ligatures and sutures already threaded; on the fourth one, the dressings to be applied when the operation is completed. All of these preparations have occupied less than half an hour, and still they are as perfect as though the whole shanty had been turned upside down and every nook and corner had been disinfected.

The patient is now placed on the table and anææsthetized. The field of operation is once more scrubbed with water and then with alcohol, and surrounded with four clean towels. We wash our hands once more with alcohol and with boiled water, and ask our colleague to do the same. From this time until the operation is completed and the wound dressed, we touch nothing but our sterilized instruments, sponges, sutures and ligatures, and the wound. Should our colleague forget himself and touch any unsterilized substance, he must scrub again. The four plates with their aseptic contents are carefully placed where no one can reach them except the operator.

Our colleague is on the opposite side of the table and can assist us very materially by keeping the wound open with the long-handled retractor while we do everything ourselves. The operator is responsible for the wound and must see that no one else infects it. At the same time, he must not offend his colleague, because it will very materially enlarge his sphere of usefulness if he can gain both the good-will of his colleague and his admiration for skill and care.

After closing the wound it is well to seal it by placing strips of gauze two inches wide over the incision and fastening down the edges by applying an abundance of flexible collodion. A large absorbent-cotton dressing is applied over this and held in place with adhesive plaster and with a spica bandage in a manner which will prevent the patient and his or her friends from touching and thus infecting the wound.

Now the patient is ready to be returned to the filthy bed. Notwithstanding this and all other undesirable conditions, we can feel certain that the wound will heal primarily, and that the result of the operation will be perfectly satisfactory from the standpoint of aseptic surgery. The microbes in the bed, or on the ceiling or the floor, have not been disturbed in the least, but we are certain that no dirty hands or instruments have come in contact with the wound, and consequently it must be aseptic.-Medicine.

FOR SALE.

PRACTICE FOR SALE:-I offer for sale my practice in the county seat of one of the best counties in Iowa. Have been here for twelve years; am surgeon of the leading road entering the town; am medical examiner for six life insurance companies, etc. I simply require that my successor buy my office fixtures,-mostly new-worth $700. Purchaser must be reliable physician with few years' practice. Address "Z. V.," care RAILWAY SURGEON, Chicago.

Desiring to remove to the Pacific Coast, I offer my well-established practice of over 20 years to any physician who will purchase my real estate, situated in one of the most beautiful and thriving towns in Southern Michigan, and surrounded by a very rich farming country. The town is intersected by two important railroads, for one of which the subscriber is surgeon. The real estate consists of a fine brick house of eight rooms and two fine offices besides, attached to, and a part of, the residence. A fine well of the purest water, two cisterns, waterworks, etc. Fine garden filled with choice fruit in bearing, peaches, pears and apricots and small fruits, raspberries, currants, etc. Fine barn and other outbuildings, comparatively new and in the very best condition, all offered with the practice and goodwill at a very low figure for cash. Address "MACK, Surgeon," care RAILWAY SURGEON, Monadnock Block Chicago, Ill.

By reason of failing health, physician wishes to dispose of real estate and practice. Practice amounts to nearly 84,000 per year. No charges except for real estate. Address WM. D. B. AINEY, Montrose, Pa.

Desiring to remove to a warmer climate, owing to poor health. I offer my well-established practice of 11 years to any physician who will purchase my real estate; situated in one of the most thriving towns in the Platte Valley, in Central Nebraska, on main line of Union Pacific R. R., on which road 1 am the assistant surgeon.

The real estate consists of 2 lots "on corner," on which there is a fine artistic "modern" frame house. 8 rooms; stable 20x30, wind mill, tower and 30-barrel tank; nice blue grass lawn. trees and fine garden (all new); and all offered with my $5,000 practice and good will, at a very low figure. A part cash, balance on time. A very thickly populated country. Address 'BOVINE," care RAILWAY SURGEON, Monadnock Block, Chicago, Ill

First Vice-President..

Second Vice President. Third Vice-President..

F. J. LUTZ, St. Louis, Mo.

167

167

W. R. HAMILTON, Pittsburgh, Pa.
J. H. LETCHER. Henderson, Ky.
..JOHN L. EDDY, Olean, N. Y.
Fourth Vice-President. ...J. A. HUTCHINSON, Montreal, Canada
Fifth Vice-President...... A. C. WEDGE, Albert Lea, Minn.
Sixth Vice-President... .RHETT GOODE, Mobile, Ala.
Seventh Vice-President... E. W. LEE, Omaha, Neb.

Secretary..
C. D. WESCOTT, Chicago, Ill.
Treasurer.
..E. R. LEWIS, Kansas City, Mo.
Executive Committee:-A. I. BOUFFLEUR, Chicago, Ill., Chair-

man:

J. N. JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo, O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa.

No. 7.

EYE SYMPTOMS OF BRAIN TUMOR.*

BY JAMES MOORES BALL, M. D., OF ST. LOUIS.

The eye symptoms caused by brain tumor are numerous and include paralysis of the third, fourth or sixth nerves, uni or bilateral exophthalmus from pressure on the cavernous sinus, changes in the fundus oculi, diminution of visual acuity, concentric limitation of the visual field, and hemianopic contraction of the field of vision. It will be sufficient for our purpose to divide the topic into:

(1) Changes in the fundus oculi, and

(2) Derangement of sight.

At the outset, we must remember that there are a few cases of brain tumor in which there are no symptoms, ocular or other. These are rare cases in which a brain tumor grows slowly, without increase of intra-cranial pressure, and without irritation in the vicinity of the lesion.

I. CHANGES IN THE FUNDUS.

Of all the symptoms of brain tumor double optic neuritis is the most important in diagnostic value, because, (1) it is an objective. sign, (2) it is present at some period in the great majority of cases, (3) the most common cause of double optic neuritis is brain tumor. While in the vast majority of cases of intracranial tumor the optic neuritis is bilateral, the degree of inflammation is rarely, if ever, the same on the two sides at the same time. Cases of one-sided optic neuritis in brain tumor do occur, however, and in these rare instances Dr. Hughlings Jackson believed that the disk on the side opposite to the brain lesion is the more frequently afflicted; but, as Bramwell has remarked, the number of these unilateral cases is entirely too small to permit us to draw definite conclusions.

*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May 1, 1896.

OPHTHALMOSCOPIC APPEARANCES.

In brain tumor we find either papillites or optic nerve atrophy. Papillitis is evidenced by a swelling of the intra-ocular end of the nerve. The clean-cut boundary line between the optic disk and retina is lost, the nerve seeming, on account of exudation, to overlap the adjacent retina, or the change may not be so well marked, the only abnormality noticed being a slight engorgement of the veins without swelling of the disk and with blurring of its edges. As a rule, however, the neuritis of brain tumor is a pronounced condition known by the term "choked disk." In typical cases the picture, when once seen, is easily remembered. The swelling of the papilla, great enlargement of the veins from compression by the swollen nerve fibers, the arteries diminished in size, the change in color of the nerveall are present in a marked case. This disease runs a chronic course and after many months the signs of inflammation are succeeded by those of atrophy. In atrophy the ophthalmoscopic appearance is the very opposite of that of papillitis. In atrophy the nerve head presents different appearances according as the atrophy is simple, i. e., non-inflammatory, or secondary, i. e., inflammatory. As we may be called upon to examine a case in the atrophic stage, it is of great importance that the ophthalmologist be able to distinguish the simple from the secondary form of optic nerve atrophy.

In simple atrophy the optic papilla is pale, often of a bluish-white color, its edges well defined, the gray dots of the lamina cribrosa are distinctly seen over a large area, and the retinal vessels are unchanged in size. The optic nerve head presents the excavation of atrophy. This excavation is to be distinguished from the excavation of glaucoma on the one hand and from a physiological cupping of the disk on the other. The physiological excavation can be at once excluded by stating that it never involves the entire papilla; if there be an excavation involving the whole papilla, it is either glaucomatous or atrophic. If glaucomatous, there will be recession of the lamina cribrosa, and the central retinal vessels are seen climbing over the edge of the excavation, but they cannot be focused at this point, and also at the bottom of the excavation at the

same time. The edge of the excavation in glaucoma is overhanging. The tension of the eye is increased except in glaucoma simplex and the retinal arteries either pulsate spontaneously or on moderate pressure. The atrophic excavation, while involving the entire papilla, is not so deep as that of glaucoma. There is no recession of the lamina cribrosa; the optic nerve is white; there is no increase of tension; the arteries do not pulsate spontaneously.

In inflammatory atrophy the papilla is traversed by connective tissue formed by the organization of an exudate. At first the papilla is grayish white; its margins hazy; the veins distended and tortuous; later the papilla is bluish-white or pure white, but the lamina cribrosa is not exposed to view (Fuchs).

At

this stage the papilla is small, irregular and shrunken; the arteries and veins are contracted and often enclosed in white streaks (Fuchs).

The causes of simple atrophy are, (1) spinal disease, particularly locomotor ataxia, which also generally presents the Arglyll-Robertson pupil and absence of patellar reflex; (2) brain affections, among which are disseminated sclerosis, tumor, and progressive paralysis of the insane, and (3) orbital disease, as orbital tumor, fracture involving the optic foramen, etc. In injuries to the nerve there are at first no ophthalmoscopic signs except the site of the lesion be so far forward that the central vessels are severed. In that case the picture is similar to the one found in embolism, viz., the retina is bloodless.

Valuable as is the ophthalmoscope in brain affections, the information it conveys is general, not localizing. Although double optic neuritis is present in 80 or 90 per cent of all cases of brain tumor, its absence does not exclude brain tumor, for these reasons: (1) the eyes may not be involved, the growth being remote from the optic tracts; (2) optic neuritis may have been present and have disappeared before the ophthalmoscope is used.

Other conditions causing optic neuritis are meningitis, lead encephalopathy, Bright's disease, cerebral abscess, hypermetropia, ovarian and uterine derangements, exposure to great cold, anæmia, acute infections, febrile diseases, syphilis, heredity, hydrocephalus, inflamma

tory processes in the orbit (caries, erysipelas extending from face, periostitis, orbital cellulitis), rheumatism, multiple sclerosis.

Valuable as is double optic neuritis as a sign of brain tumor, we must remember that in some few rare instances all the rational signs of cerebral tumor have been present during the life of a patient on whom post mortem examination failed to reveal anything wrong. Such a case occurred in the practice of Dr. Hughlings Jackson, and Dr. Sutton made the autopsy.

Double optic neuritis does not help us in localizing the growth. Bramwell says: "Perhaps tumors of the medulla are less often attended with double optic neuritis than tumors in other parts." Starr's opinion is that: "Tumors of the cerebellum and corpora quadrigemina, and tumors upon the base of the brain and in the basal ganglia, produce optic neuritis more constantly and earlier in their course than tumors situated in the cortex or centrum ovale. Optic neuritis is usually double, though it always appears first in one eye, and is rarely equally intense in both eyes, but in a few cases it has been found in one eye only, and then is thought to indicate disease of the nerve in the orbit or in front of the optic chiasm, rather than a distant tumor." (Am. Text Book of Nervous Diseases, p. 484.)

11.

DERANGEMENTS OF SIGHT.

In many cases of double optic neuritis vision is absolutely normal, both as regards visual acuity and the field of vision. Hence, it is not sufficient to use the test types and record the visual acuity. The ophthalmoscope should be used in every case of suspected brain disease. The derangements of sight which occur in brain tumor may be classified as follows: 1. Diminution of visual acuity. 2. Restriction of the field of vision. 3. Hemianopic contraction. of the visual field.

Of these the first and second have no localizing value, being found in many and diverse conditions. Hemianopic contraction of the visual field is a localizing symptom of great value in brain tumor. Hemianopsia is met with, also, in hysteria and hemicrania.

Hemianopsia, in order to be understood, presupposes a knowledge of the anatomy of the optic tracts. Remembering this, and re

calling the partial decussation of fibers in the chiasm, we are prepared to profit by a study of hemianopsia in brain tumor. Hemianopsia. is a deficiency of one-half of the field of vision, the dividing line being vertical. It is called homonymous when the same side of each field is lacking, and the terms right and left are further descriptive of the part of each field which is blank. If both temporal fields are wanting, we speak of temporal hemianopsia; if both nasal, nasal hemianopsia. We speak of superior and inferior hemianopsia when the dividing line is horizontal. Such hemianopsias are due to local causes, i. e., plugging of the artery supplying the upper or lower half of the retina. Inasmuch as rays of light cross in the eye, inability to see objects in the right half of the field indicates a lesion of fibers supplying the left half of the retina, and vice versa. In superior hemianopsia the lower half of the retina is at fault.

The localizing value of hemianopsias may be expressed as follows: Bilateral temporal hemianopsia indicates an antero-posterior division of the chiasm, as occurred in Weir Mitchell's case, in which an aneurism had entirely divided the chiasm in the median line. The outer half of each retina retained the power of vision. Quite a number of cases of this form of hemianopsia have been published. Hemianopsia, however, is rare in diseases of the chiasm, and then is sharply defined only for a time, since we have to deal with progressive processes, as tumors, syphilitic and tubercular growths. (Kines.)

Nasal hemianopsia is extremely rare, as may be judged from the anatomical facts. A single lesion could produce it only under very peculiar conditions. It might result from bilateral symmetrical lesions. Nasal and temporal hemianopsias, so far as known, are due to lesions in the anterior fossa of the skull, involving the chiasm. One-sided nasal hemianopsia would come from a lesion of the outer part of the chiasm on the same side as the eye affected.

Lesion of the optic tract, between the optic chiasm and geniculate bodies would cause lateral hemianopsia. Lesion of the central fibers of the nerve between the geniculate bodies and cerebral cortex would produce lateral hemianopsia. Lesion of the cuneus causes lateral hemianopsia. Lesion of the an

gular gyms may be associated with hemianopsia, sometimes crossed amblyopia, and the condition known as mind blindness. (Osler.)

DIAGNOSIS.

Given a case of brain tumor in which there is hemianopsia, where is the lesion? To determine whether the lesion be in the tract between the chiasm and the geniculate bodies, or in the central portion of the fibers between these bodies and the visual centers, Osler says this can be determined in some cases by Municke's hemiopic pupillary inaction. The pupil reflex depends on the integrity of the retina, the fibers of the optic nerve and tract, and the nerve center in the geniculate bodies, which receives the impression and transmits it to the third nerve, along which motor impulses pass to the iris. If a bright light is thrown into the eye and the pupil reacts, there is no question about the integrity of this reflex arc. In lateral hemianopsia the light can be thrown so as to fall upon' the blind half of the retina. "If, when this is done, the pupil contracts, the indication is that the reflex arc above referred to is perfect, by which we mean that the optic nerve fibers, from the retinal expansion to the center itself, and the third nerve are uninvolved. In such a case the conclusion would be justified that the cause of the hemianopsia was central; that is, situated behind the geniculate bodies, either in the fibers of the optic radiation or in the visual cortical centers. If, on the other hand, when the light is carefully thrown on the hemiopic half of the retina, the pupil remains inactive, the conclusion is justifiable that there is an interruption in the path between the retina and the geniculate bodies, and that the hemianopsia is not central, but dependent on a lesion situated in the tract." (Osler, p. 848.)

"In all cases where the defect in the visual field is contained in one eye only, or in which, while there are defects in both eyes, they are not symmetrically situated, the lesion must be situated in the optic nerve itself—that is, in front of the chiasm-since all interruptions on the farther side of the chiasm result in the production of symmetrical defects in the visual fields." (Fuchs.)

"It is not generally appreciated that hemianopsia is a symptom often entirely overlooked by a patient, a case having been recently re

ported by Bleuler', in which, though wellmarked hemianopsia existed, the patient was entirely unaware of any visual defect. It is therefore exceedingly important that the extent of the visual field in both eyes should be carefully tested in every case of suspected brain disease, each eye being tested separately." (Text Book of Nervous Diseases, by American Authors, Philad., 1895, p. 492.)

DISCUSSION OF DR. BALL'S PAPER.

Dr. C. D. Wescott, Chicago: Dr. Ball has given us a most excellent resume of our knowledge of this subject. In fact, he has covered all the points so far as they occur to me, and I have absolutely nothing to add in regard to the eye symptoms of brain tumor. I want to call attention, however, to the fact that this paper emphasizes better than anything else could have done, perhaps, the point that our increasing knowledge of the relation of the eye to the nervous system is augmenting our possibilities of diagnosis in brain and nerve lesions. It also emphasizes the necessity for the study of the ophthalmoscope and familiarity with its use in the practice of general surgery and medicine. When most of us were students we had no opportunity to study the ophthalmoscope; we were not encouraged by our teachers to use it in general diagnosis. To-day in our best schools a practical course in ophthalmology is a requirement for graduation. In Rush Medical College we have had such a course for the last two years, and it has been obligatory. It is surprising with what readiness the students acquire a practical knowledge of the use of the ophthalmoscope. I have risen chiefly to suggest that we all do more in this direction; that we all study the simple means by which we may acquire the use of this important aid in general diagnosis. And while on this point, I want to mention the eye model which has been furnished by Queen & Co. of Philadelphia, as an aid to the acquirement of ophthalmoscopy. This company has put upon the market a paper model, with which we may imitate the various conditions of refraction of the eye and with which, if we are the patient, we may easily acquire the habit of relaxing our accommodation, which is the essence of ophthalmoscopy. After a few hours' practice with the ophthalmoscope and *Archev für Psychiatrie, Vol. XXV. p. 39.