:-K'';r yfe NATIONAL LIBRARY OF MEDICINE NLfl DDSSfifl?! 1 NLM005588719 RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN THE CEREBROSPINAL FLUID; ITS SPONTANEOUS ESCAPE FROM THE NOSE. WITH OBSERVATIONS ON ITS COMPOSITION AND FUNCTION IN THE HUMAN SUBJECT. BY StCLAIR THOMSON, M.D., M.R.C.P.Lond, "" F.RC.S.Eng. PHYSICIAN TO THE THROAT HOSPITAL, GOLDEN SQUARE ; SURGEON TO THE ROYAL EAR HOSPITAL, LONDON NEW YORK: WILLIAM WOOD AND COMPANY. MDCCCXCIX. /S99 c.i mwrni v:r:rrf cf kmuv. oliiiUZA 14, MD. ^—- PEEFACE. Two and a half years ago I discovered that a young woman in apparently good health, and without any tangible cause, was suffering from the escape of cerebro-spinal fluid from one side of the nose. This produced no other symptom than the mechanical one of inconvenience. The flow was at first intermittent in its appearance, but for more than three years it has been continuous both day and night,—with only four intermissions, one of these lasting for sixteen days, two lasting for twenty-eight days, and the other for two months. To all intents and purposes the patient remains in perfect health; indeed, as regards attacks of headache to which she had been subject, she is even better than she was before this flow commenced. An attempt to establish a hitherto unrecognised patholo- gical possibility on the observation of a single case might be met with the objection which occurs in French law, Testis unus, testis nullus. But a prolonged and extensive search through medical literature has convinced me that, while the condition is probably one of exti*eme rarity, still similar cases have already been published, although in the majority of instances the exact source of the fluid which escaped from the nose was overlooked, and the discharge was ascribed to hypersecretion from the mucous mem- brane. I have, however, succeeded in collecting the records of twenty other cases, and their study is made the more interesting by the fact that most of them were asso- IV PEEPACE. ciated with cerebral symptoms and some with retinal changes. In this way the recognition of a single case of cerebro- spinal rhinorrhcea has led to the collection and considera- tion of others occurring in literature, and has enabled me to give a description of a condition which will help to the discovery of other cases, and to a more complete study of the subject. The patient in whom this curious phenomenon occurred attended the clinic of my colleague Dr. J. W. Bond, to whom I have to express my great indebtedness for kindly permitting me to make full observations on the case. Apart from the clinical aspect of the condition, the unique opportunity was afforded for making a series of observa- tions on the composition and function of the cerebro- spinal fluid in the human subject. These have already been published in vol. lxiv of the 'Proceedings of the Royal Society' in a conjoint paper by Professor Halliburton, Dr. Leonard Hill, and myself, and the conclusions arrived at have been incorporated in the following pages. I have to thank Professor Halli- burton most cordially for freely placing at my disposal not only his very special knowledge of the physiological chemistry of cerebro-spinal fluid, but also his valuable time in repeatedly making most thorough analyses of the various samples of fluid I have submitted to him. StCLAIR THOMSON. 28, Queen Anne Stkeet, W. j April, 1899. CONTENTS. Part I.—The Spontaneous Escape of Cerebro-spinal Fluid from the Nose. page Historical . . . . • .3 Escape of Cerebro-spinal Fluid from the Cranium A. From the Ear, after Injury B. From the Ear, Spontaneously Case published by Escat. c. From the Nose, after Injury Case published by Mathiesen ,, „ Vieusse Spontaneous Escape from the Nose not a Recognised Sym- ptom . Author's Case . Complete Analysis of Cerebro-spinal Fluid. The Sterility of the Nasal Fossae . Progress of the Author's Case Intermissions in the Flow Patient's present Condition Other Published Cases: Group A.—Cases in which the Discharge from the Nose was undoubtedly Cerebro-spinal Fluid Case I.—Published by Tillaux . Case II.—Published by Leber . Case III.—Published by J. Toison and E. Lenoble Case IV.—Published by F. "Wallace Mackenzie Case V.—Published by Gutsche. Case VI.—Published by Mermod Case VII.—Published by StClair Thomson Case VIII.—Published by Scheppegrell . Case IX.—Published by Korner Table of Nine undoubted Cases VI contents. PAGE Group B.—Cases in which the Discharge from the Nose was most probably Cerebro-spinal Fluid . 49 Case X.—Published by King . . .49 Case XI—Published by BUiotson . . 50 Case XII.—Published by Paget. . .51 Case XIII.—Published by H. Fischer . . 54 Case XIV.—Published by W. R. Speirs . . 55 Case XV.—Published by E. B. Baxter . . 56 Case XVI— Published by Nettleship . . 57 Case XVII.—Published by Priestley Smith . 59 Case XVIII.—Published by Priestley Smith . 60 Case XIX.—Published by Emrys-Jones . . 62 Case XX.—Published by Berg . . .63 Case XXL—Published by Lichtwitz . . 64 Other possible cases published by Willis . . 67 ,, Morgagni . . 68 Nothnagel . . 68 Groh . . 69 E. Meyer . . 69 >» Berg . . 70 Flatau . . 71 ,, Prosser James . 71 Table of Twelve Probable Cases . . . .76 Summary of Twelve Probable Cases . . .80 Diagnosis from Nasal Hydrorrhcea . . .81 Poulsson's Case of Marked Nasal Hydrorrhcea . . 81 Analysis of Secretion in Nasal Hydrorrhcea . . 83 Chemical Composition of Cerebro-spinal Fluid . . 86 Diagnosis from so-called Dropsy of the Antrum . . 88 Anderson's Case of Nasal Hydrorrhcea . . 88 Serous Accumulation in the Maxillary Sinus . . 89 Diagnosis from "Water inspired and retained . . 94 Diagnosis from Vaso-motor Neuritis . . .95 Diagnosis from Ruptured Lymph Tubes . . .95 Mules' Case of Lymph Naavus of the Eye . . 96 Difference between Lymph and Cerebro-spinal Fluid . 98 Summary of Evidence in support of Group " B " . .99 Clinical Picture of Cerebro-spinal Rhinorrhcea . . 103 Chemical Tests for Cerebro-spinal Fluid . . 104 Pathology . . . . . .109 Hydrocephalus Internus . . . .111 The Cerebral Symptoms in the majority of cases . 114 CONTENTS. VI1 PAGE Pathology: Route of Exit from the Cranial Cavity . 116 Route of Exit through the Lymph Channels 117 Treatment . . . .120 Conclusion ...... 121 Part II.—Observations on the Composition and Function of the Cerebro-spinal Fluid in the Human Subject. Physical and Chemical Properties of Cerebro-spinal Fluid . 125 Sterility of Fluid and Rate of Flow . . . 125 Comparison of the Morning and Evening Fluid . . 125 Intra-vascular Injection of the Cerebro-spinal Fluid . 127 The Influence of Straining and Posture on the Flow and Composition of the Fluid .... 128 Experiments made with Abdominal Compression . . 131 PART I. THE CEKEBBO-SPINAL FLUID; ITS SPONTANEOUS ESCAPE FROM THE NOSE IN TWENTY-ONE INSTANCES. THE CEREBRO-SPINAL FLUID; ITS SPONTANEOUS ESCAPE FROM THE NOSE. Historical. A reference to Landois and Stirling's ' Text-book of Human Physiology,' published in 1885, shows how little was known at that date of the cerebro-spinal fluid, the only notice of it being a quotation from Hoppe-Seyler. Indeed it is remarkable that, until the recent work of Halliburton,1 little has been added to our knowledge of this liquid since 1842, when Magendie published his ' Recherches sur le Liquide Cephalo-Rachidien/ in order, as he writes, to place beyond doubt the normal existence of this fluid. Previous to that date knowledge of the secretion in question had been very confused and un- satisfactory. Galen repeatedly speaks of an excrementi- tial liquid, expressed from several points of the brain into the ventricles, especially into the fourth, where it is stored, and then purged into the nose through the ethmoid bones and infundibulum. It is here curious to note that although Galen was of course mistaken in think- ing that this was a physiological procedure, yet I hope to show the possibility of such a route as he imagined. It is difficult to say if Galen's opinions were the result of direct observation, or if they were merely speculative. After his period, Massa, Vesalius, Vidus-Vidius, and Varoli refer to a watery humour in the brain. In the 1 ' Chemical Physiology and Pathology,' London, 1891, p. 355. 4 THE CEREBRO-SPINAL FLUID. sixteenth century we find Sansovino1 still calling the nasal cavity the " cloaca del cerebro." Schneider2 finally showed how baseless was the fabric of the ana- tomical vision which saw any free communication between the nose and the ventricles of the brain. It was not till the time of our own Willis 3 that the method of direct observation was brought to bear on the question as to what became of the cerebro-spinal fluid, a question which appears to have considerably puzzled the elder anatomists. Willis acknowledges that it is at first sight difficult to see how this fluid passes off through the holes in the cribriform plate, since they are completely blocked during life by the nerve fibres and the prolonga- tions of the dura mater. Yet he holds that it is permis- sible to think that the fluid descends into the nose by openings which are invisible after death, but dilatable during life " by heat and the spirit." But Vieussens 4 points out that the pituitary membrane cannot be the ex- cretory surface for the aqueous humour of the brain. He had opened many crania and found a quantity of water in individuals who had never during life voided anything similar by the nose or mouth. The following experiments confirm this view:—He poured alcohol into the anterior fossa of the skull and left it there some time ; not a drop escaped from the nose, not even when the dura mater was stripped off the ethmoid. Besides, if a living animal is taken, and the two carotids and jugulars ligatured, and coloured alcohol is then injected into the carotids until all the vessels are distended, he found that the cavities of the brain will be flooded, but that nothing will escape from the nose. Cotugno (1736-1822),5 who gave his name to the 1 P. Sansovino,' L' edificio del corpo umano,' Venet., 1550 (ref. in Zucker- kandl). 2 ' Liber de osse cribriformi,' &c, and * De catharris,' Wittenberg®, 1655. 3 'Opera Omnia,' Geneva, 1695, " Anatom. Cerebri," chaps, xi, xii, andxiii. 4 ' De natura et necessitate spiritus animalis et de succo nervoso.' 5 ' De Ischiade Nervosa/ Neapoli, 1764, in Sandifort's ' Thesaurus Disserta- tionum,' Eoterodami, 1769. ESCAPE FROM THE EAR, AFTER INJURY. 5 Liquor Cotunnii, calculates the amount in the cadaver at about four to five ounces; but although he had found the fluid in living fish and turtles, he is sceptical as to its existence in the living human subject. It is interesting to note that the work of Willis, Vieussens, and Cotugno, must have been strangely overlooked for it to be necessary for Magendie to, so to speak, rediscover this fluid. The fact is another con- firmation of the saying that nothing is new except what has been forgotten. Escape of Cerebro-spinal Fluid from the Cranium. a. From the Ear, after Injury. That the cerebro-spinal fluid can escape from the cranium in cases of injury has been known for some time. As early as the year 1727 Stalpartius van der Wiel (' Observat rarior. cent, prior.,' Obs. xv),1 pub- lished a case in which large quantities of a thin, clear, watery fluid had escaped from the ear for several days after a severe injury to the head. O'Halloran and Dease published cases, but these appear to have been lost sight of until Laugier called attention to the co-existence of a watery discharge and rupture of the membrana tympani in some cases of fracture of the base.3 The character of the fluid was not recognised at first, but it was established by Nelaton, Robert, Rabourdin, Chatin, and Deschamps.3 Guthrie 4 held that the fluid probably came from the cavity of the arachnoid, and pointed out that it was symptomatic of great danger. This accident is now, of course, a matter of common observation. 1 Quoted in Holmes' ' System of Surgery,' 3rd edit., vol. i, 1883, p. 592. 2 ' Comp. Rend, de l'Acad. des Sci.,* 1839, p. 240. 3 'Bulletin de l'Acad. de Med.,' xviii, 7 dec, 1852, p. 240. 4 " On Injuries of the Head affecting the Brain," * Med.-Chir. Review,' No. 76, 1841, p. 302. 6 THE CEREBRO-SPINAL FLUID. b. From the Ear, spontaneously. The possibility of cerebro-spinal fluid escaping sponta- neously from the ear had not entered my mind when I first commenced to interest myself in this subject, and it was only during the preparation of this paper that I met with the record of a case published by Escat (of Toulouse)} His patient was a girl aged 10, who eighteen months previously had first noticed the escape of a clear watery fluid from the right ear. The flow was intermitting, it lasted a few minutes, then stopped abruptly, but recurred ten or twelve times in the day. This state of things lasted two months, and then ceased suddenly under no special treatment. A year later the same phenomenon reappeared, and lasted about a month. Finally the flow again appeared eight days before the patient was brought for advice on the 8th May, 1897. There was no previous history of consequence, no ear trouble, no introduction of foreign body, and no history of accident. The flow came on without apparent cause. A few seconds before it appeared there was a whistling in the right ear, which ceased as soon as the liquid began to flow. At each escape about half a tumbler of liquid was lost, and the total quantity in twenty-four hours was calculated at half a litre. The flow con- tinued during the night, and in the daytime the patient was obliged to wear over the right ear a large linen compress, which required frequent renewal. The flow was generally more abundant during the three hours after meals, and the patient noticed that she could increase it by straining. During one flowing 150 grammes were easily collected, and submitted to Professor Gerard, who re- ported as follows: " The liquid is undoubtedly cerebro-spinal fluid, as the following analysis shows: " Colourless liquid, limpid, faintly alkaline, very slight turbidity with heat in presence of acetic acid. " Chloride of sodium . . . 6*3 gr. per litre. Earthy phosphates (or PH205) . 0*4 „ „ Traces of cholesterin and albumin." In spite of this flow the patient's general health was satisfac- tory. She complained of no pain or malaise, and although her parents noticed some lassitude and intellectual torpor during the flow, this was not marked, and she continued her work and play at school as formerly. 1 ' Archiv. Internat. de Laryngologie,' tome x, No. 6,1897. ESCAPE FROM THE NOSE, AFTER INJURY. 7 Direct examination of the right ear showed that the tympanic membrane, including Shrapnell's membrane, was quite intact, and the Eustachian catheter indicated that the middle ear was free of liquid. The external two thirds of the auditory meatus showed nothing abnormal; but in the inner third, on the upper wall, a fine white line was detected. This did not disappear after cleansing; and although suction with Siegle's speculum failed to draw any liquid from it, and a fine probe could not detect any corresponding crack or depression, yet Escat decided that this spot indicated the point of escape of the fluid from the cranial cavity. He applied the galvano-cautery to it, and the flow ceased and had not recurred two months later. In his conclusions from this case the author excluded traumatism or any ulcerative process. He regarded it as due to a congenital defect, or at least predisposed to by a congenital atrophy of the upper wall of the external auditory meatus, which became more marked in the course of the development of the temporal bone and ended in a genuine partial absorption of the floor of the temporal fossa. When compared with the cases I have been able to collect there can be little doubt that this was indeed an instance of spontaneous escape of cerebro-spinal fluid from the external auditory meatus. Although the analysis does not give the specific gravity, nor mentions the substance which reduces Fehling's solution, it is yet sufficiently complete to exclude the question of its being other than arachnoid fluid. I am inclined to ask for some reserve in attributing a cure to the sealing of the cuticular opening with the cautery. If the bone is really defective it is likely that the fluid will break its way through the cicatrix whenever the pressure becomes increased. For we must note that the flow had on two previous occasions ceased spontane- ously, once for a whole year. c. From the Nose, after Injury. The escape of the fluid from the nose as a consequence of injury does not appear to have been so frequently observed. The first suggestion of such a condition is 8 THE CEREBRO-SPINAL FLUID. given by Bidloo the elder,1 a medical writer who lived in the second half of the seventeenth century and wrote a work on surgery. In this he reports the case of a patient who had an accident to the bridge of the nose, followed by a continuous flow of a clear watery secretion from the right nostril in such quantity that within twenty-four hours 20 ounces (600 c.c.) of this fluid escaped. Later on the discharge became purulent, splinters of bone came away, and the patient died seven months after the receipt of the accident. Blandin2 in 1840 opined that he himself was the first to note an enormous serous flow from the nose in certain cases after injury. He pointed out the great importance of this new symptom for diagnosis, and especially for prognosis. A confirmatory observation is given in full by Robert.3 That recovery in such cases may be complete and satis- factory is shown by a case of Hector Cameron's.4 A man aged 75 was thrown down stairs and suffered from " profuse bleeding from his left ear and nostril, followed by the discharge of large quantities of clear fluid. The discharge of cerebro-spinal fluid continued for several days, ceasing from the ear before it did so from the nostril." The patient recovered completely. In the following case the discharge persisted for much longer, viz. for two months, before it finally ceased. It is important to recognise that a cerebro-spinal rhinor- rhcea, if I may be allowed the term, could persist so long, as patients might present themselves for the nasal dis- charge some time after the receipt of the accident, to which they might possibly omit any reference. This case is recorded by Mathiesen.5 1 Quoted by Morgagni,' De sedibus et causis morborum,' liber i, epist. xiv, art. 21. 2 ' Gazette des Hdpitaux,' 1840, p. 205. 3 ' Archives generates de Medecine,' 1845, tome ix, p. 389. 4 ' Brit. Med. Journ.,' May 17th, 1884, p. 886. 5 'Norsk. Magazin for Laegevidenskaben,' p. 241, January, 1887 (from abstract in Bosworth's 'Diseases of tbe Nose and Throat,' vol. i, 1889, p. 266). ESCAPE FROM THE NOSE, AFTER INJURY. 9 Traumatic Cerebro-spinal Rhinorrhcea lasting Two Months. The patient was a boy aged 13, who had a severe fall on the left temple, following which he Avas unconscious for some time. The following night he suffered from vomiting and epistaxis. About two months after the accident he came under observation on account of the discharge of a thin watery secretion of a salty taste from the left nasal cavity. In the course of two hours 25 centi- metres of this fluid were collected. His general health was good. Five days later the discharge ceased. Microscopical examination of the fluid revealed white blood-corpuscles, a few threads of mucus, and pavement epithelium. The fluid was of a specific gravity of 1*006, and of alkaline reaction, contained albumen, salt, and sugar, and otherwise corresponded to a cerebro-spinal fluid. The writer was in doubt if the source of the discharge was the cerebral or the nasal cavity. It is well known that fractures of the base of the skull sometimes escape attention, and from this point of view it is advisable to bear in mind that when the anterior fossa of the skull is involved, a cerebro-spinal rhinorrhcea may not only be an important symptom, but even, as in the following case, the only one. The patient in this instance, after receipt of a fracture through the cribriform plate and the left middle fossa, was able to drive his bullock cart, partly on foot, a distance of twenty-five miles; in- deed he did not seek advice until eight days after the accident, and then he only came on account of a clear watery discharge from the nose. The case is thus reported by Yieusse :1 A man aged 46, immediately after a fall from a bullock-cart, was stunned, and although there was a blood-stained discharge from the left ear and from the nose, he was able to continue his journey of 40 kilometres, part of it on foot. Eight days afterwards he pre- sented himself with a dropping of very limpid fluid from the nose at the rate of about two drops per second (? per minute). On lying down this flow quite ceased, and was replaced by a similar 1 ' Gazette Hebd. de Medecine et de Chirurgie,' tome xvi, 1879, No. 19, p. 298. 10 THE CEREBRO-SPINAL FLUID. discharge from the left ear. By placing the patient in a sitting position and then in a horizontal one, these discharges could be made to alternate regularly. The liquid was not collected; the author was so convinced of its nature that an analysis appeared useless. Eighteen days after the accident the patient died with symptoms of meningo-encephalitis. This was confirmed at the autopsy, which revealed a fracture of the base in the anterior fossa, involving the cribriform plate, and the middle fossa on the left side through the temporal bone. Spontaneous Escape fkom the Nose not a Recognised Symptom. But although this escape of cerebro-spinal fluid from the nose in traumatic cases is a recognised occurrence, and reference to it is to be found in most surgical text-books, I was chiefly interested in seeing whether a case under my own observation was unique in its spontaneous character, or whether there were already records to supply the points which are wanting to make a complete picture of this patho- logical condition. So far as many well-known text-books are concerned this search has been fruitless. Such classical systems of medicine as Ziemssen's (' Cyclopaedia of the Prac- tice of Medicine,' 1881) and Russell Reynolds' (' A System of Medicine,' 1872) have no mention of such a possibility, and there is no reference to it in the text-books of Bristowe (' Theory and Practice of Medicine/ 1890), Osier, or of Hilton Fagge and Pye-Smith (' Principles and Prac- tice of Medicine/ 1891). Although, as I will show later on, this symptom appears to be frequently associated with nervous symptoms, there is no hint of it in Gowers' well- known work (f Diseases of the Nervous System/ 1893) nor in the large ' Text-book of Nervous Diseases by American Authors ' (edited by Francis X. Dercum, Edinburgh and London, 1895). It is remarked by von Jaksch (f Clinical Diagnosis/ third English edition, 1897, p. 108) that "oc- casionally, as in cases of wounds perforating the cranium and in brain tumours, cerebro-spinal fluid may be dis- spontaneous escape from the nose. 11 charged through the nose. Under such circumstances, chemical analysis showing the absence of albumen and the presence of sugar, or at least of a reducing substance, will determine the diagnosis." Here, as elsewhere, it is evident the idea is not even entertained that cerebro- spinal fluid can be discharged from the nose except as a result of injury or brain tumour. Turning now to publi- cations dealing specially with diseases of the nose, I find that the subject is in no way referred to by Morell Mackenzie ('Diseases of the Throat and Nose/ 1884, vol. ii) or Lennox Browne (' The Throat and Nose/ 5th edition, 1899). In the German edition of Mackenzie's work (' Die Krankheiten des Halses und der Nase/ Morell Mackenzie and Felix Seinon, Berlin 1884) reference is made to the cases of Morgagni (p. Q8), Bidloo (p. 8), and Elliotson (p. 50), and also to those of Paget (p. 51), Nettleship (p. 57), and Priestley Smith (p. 59), without suggesting the possibility that the watery flow was caused by escape of cerebro-spinal fluid. Bosworth gives in- stances of several cases which were obviously escape of cerebro-spinal fluid through the nose (' Diseases of the Nose and Throat/ vol. i, 1889), but he does not appear to have realised the origin of the fluid, and he groups these cases under the heading of " Nasal Hydrorrhcea" with cases of nervous coryza, suppuration in the antrum, and various other diseases of the nose. He ascribes the con- dition to a vaso-motor paresis of the nasal mucosa occur- ring in subjects of an intensely neurotic temperament. The excellent text-book of Moritz Schmidt (' Die Krank- heiten der oberen Luftwege/ Zweite Auflage, 1897) has no reference to the question at issue. Rosenthal (' Die Erkrankungen der Nase/ Berlin, 1897) does not mention it, but under the title of " Rhinitis Chronica Simplex " he includes some cases which later on I will claim to be possible examples of the condition I am considering. The very encyclopaedic work by various German authors, which is now issuing from the press in three large volumes (' Handbuch der Laryngologie und Rhinologie/ edited by 12 THE CEREBRO-SPINAL FLUID. Paul Heymann, Wien, 1896-7-8), gives no reference to the occurrence of spontaneous flow of cerebro-spinal fluid from the nose, but simply a mention of hydrorrhcea nasalis as a watery flow which may be symptomatic of injury of the skull, of hydrocephalus, or of affections of the accessory sinuses. Spencer Watson (' Diseases of the Nose/ 2nd edition, 1890, p. 38) gives a careful considera- tion to the question of watery discharge from the nose, but he comes to the conclusion that " there is a possibility of the fluid being cerebro-spinal and that it escapes through a fissure in the cribriform plate of the ethmoid. That such an origin is the true one can only be after a severe injury and as a consequence of a fracture of the base of the skull." Summary. This last quotation summarises the generally accepted view as to the question of the escape of cerebro-spinal fluid from the nose, viz. that while it may occur as consequence of injury, and is a rare accompaniment of brain tumour, its spontaneous escape is unknown. So far from being a recog- nised possibility, it remains unnoticed in many of the best known and most recent publications on general medicine, nervous diseases, and affections of the nose. The ' Journal of Laryngology ' in twelve years does not mention it. The thirteen volumes of the ' Centralblatt fur Laryngologie' contain in the index only three references under the title of "Cerebro-spinal Fliissigkeit." It is evident that the condition is most exceptional, or else that its true nature is very rarely recognised. However, by the help of these and other references I have succeeded in tracing eight other cases where an analogous condition was undoubted, and twelve cases where it was most probable. None of these cases have had the advantage of being so thoroughly investigated as one I am able to record, either because the opportunity did not offer, or because physio- logical chemistry was not till recently sufficiently advanced to speak authoritatively on the composition of the fluid. I author's case. 13 think it will be better, therefore, to report this case in its entirety, and then refer to those which help to make up the parts in the clinical picture of the affection. Author's Case. My patient, R. W—, is a single woman aged 25. She has been born and brought up in the country, where she has attended to the domestic duties of her mother's cottage. She first attended the Throat Hospital, Golden Square, in April, 1896. She was seen to be a healthy-looking young woman, presenting no exophthalmos, nor any striking feature suggestive of disease. Two and a half years pre- viously she had gradually become aware of an increasing tendency to drip from the left nostril. This would occa- sionally stop for a week or even a month at a time, but since Christmas, 1895, it had been continuous both day and night. The nature and source of the fluid were overlooked at first, and she was treated with iron tonics, and locally with alkaline nose lotions. There was no cessation of the flow, and on May 20th, 1896, some post-nasal growths were scraped away under nitrous oxide gas. The dripping con- tinued as before, and it remained unaltered by nasal lotions of extract of hamamelis, and a long course of Fowler's solution. In October, 1896, the intractability of the flow caused me to give the case a fuller examination, and my interest was keenly aroused on finding that when the patient inclined her head forwards a clear watery fluid fell from her left nostril in a steady drip, much as the blood does in epistaxis. The following observations were then made. This dripping—which had at that date been unabated for ten months—runs forwards as a rule, and it escapes more rapidly when she bends her head. When she inclines her head backwards, or when she lies on her back, the liquid runs down into her throat, and she then has to swallow it. At night it sometimes runs on to her 14 THE CEREBRO-SPINAL FLUID. lip, and so on to the pillow; this especially occurs if she is lying on the left (i. e. the affected) side. When she is in bed it also runs into her mouth and causes her to swallow, but she says that it never gives rise to choking attacks. However, her mother states that when sleeping in the same room with her she was frequently alarmed by the gurgling and choking noises made by the patient in her sleep. She had noticed that the flow was invariably from the left side; it appeared to her to be worse when she had a cold; it had never been blood-stained nor offensive; was free from disagreeable taste and odour; its escape gave rise to no sneezing or irritation, and her sense of smell had remained quite unaffected. She prefers to let the liquid flow forward, and in order to arrest it from dropping on to her clothes or the work she may be engaged on, she is compelled to carry a handkerchief in her left hand from morning to night. When working at a table she simply places a handkerchief directly under her nose, and allows the fluid to drip on to it. She uses five to six handkerchiefs a day, and these handkerchiefs on being dried are found to be quite pliable, and do not dry stiff as they would in cases of mere increase of mucous secretion. This point has some importance in reference to the consideration I purpose giving later on to previously recorded cases in which this fact was observed, although the indication it afforded was not appreciated. Coming now to the examination of the nose, it is seen that there is very slight excoriation of the left upper lip and vestibular orifice. With the exception of slight con- gestion along the margin of the left middle turbinal, the inside of the nasal fossa is quite normal. The septum is slightly deviated, and there is a small spur on each side, though nothing but what is quite physiological. The post- nasal space is quite clear; the veins on the posterior wall of the pharynx are larger than usual. In the right nasal fossa no discharge of any kind is to be detected. If the left side is examined in the ordinary manner—i.e. author's case. 15 by tilting the head somewhat backwards,—no fluid can be detected, for in that position it runs into the naso- pharynx, and, as is evidenced by the movement of deglu- tition, it is then swallowed. But if the patient stands up with the head bent forwards, and the physician remains seated in front of her—as in Killian's position for viewing the posterior laryngeal wall—he will be able to see with a nasal speculum that the fluid collects between the septum and the middle turbinal, and that when this space (the olfactory cleft) is filled the liquid runs forwards between the agger nasi and the septum until it gains the upper part of the vestibule, whence it drops from the tip of the nose. There are no carious teeth in the upper jaw; no differ- ence between the two sides of the face is noticeable on transilluminating the head from the mouth; and there is no suspicion of any of the accessory cavities of the nose being affected. The patient's general health is good, and she has always been considered healthy. She eats and sleeps well, does not suffer unduly from thirst, the bowels act regularly, the urine is healthy, menstruation takes place naturally, and the heart and lungs are normal. The thyroid gland is not enlarged. There is no affection of motion or sensation ; the reflexes are normal; she is not subject to giddiness or vomiting. The hearing is normal. The fundus of each eye was examined, but there was no trace of retinitis or optic atrophy. This observation was kindly confirmed by Mr. Adams Frost and Mr. Vernon Cargill. The former reported her eyes to be in every way normal. Her intelligence is good and her memory is clear; she is somewhat shy and nervous, and it would appear that she dislikes being in public as she fancies that people notice her complaint and the constant use she is compelled to make of her pocket handkerchief. As to her previous history, she has never had influenza that she knows of. She states that four years ago she was in bed for fourteen days with headache and vomiting ; but her family attendant, Dr. Eadie of Yeovil, informs 16 THE CEREBRO-SPINAL FLUID. me that this illness was of a bilious character, and that he remembers nothing about her case out of the ordinary character, except that her convalescence was rather pro- tracted. She had measles and congestion of the lungs three years ago, and suffered, so she says, from a good deal of headache afterwards. Dr. Eadie was told that she fainted or had " fits/' but he never saw her in any of these attacks. He writes that the headaches under treatment got better, and he formed the opinion that she was rather hysterical. I have inquired carefully into the history for indications of attacks of convulsions, de- lirium, or unconsciousness, but there appears never to have been anything of the sort. She has never met with any accident to her head, nor had any operative treat- ment to her nose. In her family there is no trace of any similar affection. Her father was found dead on the roadside; he was a rather heavy drinker, and had twice had rheumatic fever. Her mother is alive and well, and as I have fully inquired into the rest of her family history, I need only say that it presents no bearing on her condition. The patient informed me that she had been subject to headaches ever since childhood ; these were always better when the fluid was escaping from the nose, and since the flow has become continuous the headaches have been most remarkable by their absence ; indeed, now they occur only rarely and are very slight. The headaches used to last sometimes for weeks; they were most intense over the left eyebrow, outer side of left orbit, and the centre of the occipital region. This history when considered with the one-sidedness of the flow, the absence of other possible sources, and the macroscopic appearance of the secretion, suggested to me the possibility that I had to do with a case of escape of cerebro-spinal fluid from the nose. I therefore directed the patient to " drip" for ten minutes into a sterilised glass capsule. It was observed that in the first minute the number of drops was seven, COMPLETE ANALYSIS. 17 in the second minute six, and in the third minute five. After this the dripping continued without decreasing frequency, at the rate of five drops per minute. This average would amount to five drachms in an hour, and fifteen ounces in twent}r-four hours. The fluid was sent to Dr. Hewlett, the pathologist of the Throat Hospital, who kindly sent me the following report: "British Institute of Preventive Medicine; " Slst October, 1896. " The specimen of nasal fluid forwarded by Dr. StClair Thomson has the following reactions : " 1. With acetic acid it gives no precipitate, indicating absence of mucus. " 2. Boiled with Fehling's solution it gives a distinct reduction. " 3. Proteids are practically absent. "In these reactions it resembles cerebro-spinal fluid rather than nasal mucus. " Cultivations made from the fluid and incubated at 22° C. and 37° C, four in number, were all negative." Four days later the same quantity of fluid was collected in a sterilised capsule, and again examined by Dr. Hewlett with exactly the same results. There was no longer any doubt that the case was as I suspected. I therefore availed myself of Professor Halliburton's kindness, and of his special knowledge as the leading authority on the chemistry of this fluid. He confirmed Dr. Hewlett's report. Complete Analysis of the Fluid from the Nose. " Report on fluid received from Dr. StClair Thomson, 16th November, 1896. " The fluid was received in sterilised glass vessels in two portions. One portion stated by the patient to have been collected in the course of one hour measured 4 c.c. The other portion collected under Dr. StClair Thomson's immediate supervision in ten minutes measured 39 c.c. If the fluid is secreted at this rate all day, the B 18 THE CEREBRO-SPINAL FLUID. total quantity in twenty-four hours would be 561-6 c.c, or over half a litre. '• The fluid is perfectly clear and colourless. It looks like water. The reaction of the fluid is faintly but distinctly alkaline. The specific gravity of the fluid, estimated by weighing, is 1005. It contains a trace of proteid coagulable by heat and acetic acid; but the quantity is too small to give more than an opalescence. " In another portion of the fluid it was ascertained that this proteid is practically all precipitable by saturation with magnesium sulphate; it is therefore a globulin. The fluid contains a substance which reduces Fehling's solution. This substance is not sugar, as it does not ferment with yeast. A portion of the fluid was treated with excess of acidified alcohol; the proteid was thus precipitated; this was filtered off. The filtrate was evaporated to dryness over a water-bath; the dry residue was again taken up with alcohol, filtered, and again evaporated to dry- ness. Part was evaporated to dryness on a glass slide; the residue, examined microscopically, was seen to contain the needle-like crystals, single and in bundles, similar to those previously de- scribed and figured by me (' Journal of Physiology,' vol. x, p. 248) as obtainable from cerebro-spinal fluid (Vide Plate). The residue had also the characteristic pungent taste of pyrocatechin. " The remainder of the dry residue was dissolved in water, filtered, and the filtrate reduced Fehling's solution well, but did not ferment with yeast. A control experiment showed that the yeast used was active on a sugar solution. " The quantity of material at my disposal did not admit of a more thorough examination of it than is described above; but I have no hesitation, from what I have done, in pronouncing the fluid to be cerebro-spinal fluid. " It is like cerebro-spinal fluid in appearance, reaction, and specific gravity. " It is like cerebro-spinal fluid in its low percentage of proteid matter (globulin) and in its absence of albumin. " It is like cerebro-spinal fluid in containing a reducing substance which is not sugar, which is soluble in water and alcohol, which does not ferment with yeast, and which, on account of these properties together with its taste and crystalline form, is a member of the aromatic series, probably pyrocatechin or some derivative of that substance. " W. D. Halliburton. " King's College, London ; " 18th November, 1896." Crystals of Pyrocatechin. R5 m.m. Crystals from Cerebro-spinal Fluid. 20 THE CEREBRO-SPINAL FLUID. " Examination of other specimens of the same fluid at a later date confirmed the foregoing conclusions. I was able to determine that the reducing substance does not give the phenyl hydrazine test for sugar, and that creatinine is absent.—W. D. H. " February 28th, 1899." The Sterility of the Nasal Fossa. In parenthesis, I would here venture to call attention to the fact that cultivations from the secretion showed that the fluid was absolutely sterile. This confirms in a remarkable manner the results of the experiments which I had some time previously made with Dr. Hewlett, and which we had the honour of bringing before the Royal Medical and Chirurgical Society on the 28th May, 1895.1 We there showed that nasal mucus is generally free from organisms, that it exerts an inhibitory action on their de- velopment, and that, as a rule, the interior of the healthy nose is absolutely sterile. In the case under consideration it might,of course, be advanced that infection of the subarach- noid space had not taken place as the flow was under a positive pressure, and that the outward stream of cerebro- spinal fluid would prevent the entrance of organisms. Magendie has, indeed, shown that in animals the cerebro- spinal fluid is under such considerable pressure, that when the spinal cord of a living animal is exposed and the dura mater punctured, the fluid will spurt out, sometimes to a considerable height.2 This, of course, rapidly diminishes as the pent-up fluid escapes, though doubtless a certain pressure outwards always continues. But when cerebro- spinal fluid escapes from the external ear it is under the same amount of pressure, and as the external auditory meatus is unprovided with the methods of defence which are to be found in the nasal fossae, infection of the fluid 1 " Micro-organisms in the Healthy Nose," by StClair Thomson and R. T. Hewlett, 'Med.-Chir. Trans.,' vol. lxxviii, 1895. a Magendie, ' Recherches sur le Liquide Cephalo-Rachidien,' Paris, 1842, p. 6. INTERMISSIONS IN FLOW. 21 and consequent meningo-encephalitis only too frequently ensue—at least I understand that it used to be so in the pre-Listerian days. Certainly I think it is almost with- out record that the cerebro-spinal fluid can trickle from the ear for two months, as the result of an accident, and yet no infection take place ; but this is what happened with the escape from the nose in the case of Mathiesen (p. 9), and in my case it has been escaping from the nose for more than five years without becoming septic. This appears to me to be a remarkable clinical confirmation of our results, and strengthens us in our conclusion that the interior of the nose is automatically aseptic, and is far from being the nest of microbes which it was considered to be before our researches were published. Progress of the Author's Case. To return to the progress of the case. As soon as the nature of the nasal discharge had been positively deter- mined, no intra-nasal medication whatever was attempted from fear of infection, and the patient was strongly ad- vised to avoid all nasal lotions, sprays, &c. The patient was shown to the Laryngological Society on November 11th, 1896.1 From the date of the analysis—16th November, 1896—to the present date, no nasal treat- ment has been employed, some general tonic treatment was prescribed, and the patient in the early part of 1897 returned to her home in the country. Her health re- mained good, and the flow was reported to be the same as before. Intermissions in the Flow. Only four times has it quitted her. On the 30th August, 1897, i. e. after it had been dripping continuously day and night for twenty months, the flow ceased, and, as she wrote, " it stopped for a clear month to the day." 1 ' Proceed. Laryngol. Soc..' vol. iv, 1896. 22 THE CEKEBRO-SPINAL FLUID. At the end of this month it gradually returned, and in the course of a fortnight it was flowing as much as ever. There does not appear to have been any cause for the cessation, nor any for the reappearance of the dropping. It could not be ascribed to any particular circumstance, nor to any treatment, for she was not having any. The flow again ceased during the months of January and February, 1898. The cessation took place gradually, and the flow roturned in the same manner. For the third time it ceased during the month of April. From the 5th of May, 1898, it continued day and night until the 18th February, 1899, when it ceased for sixteen days. The patient states that during these cessations in the flow she was not ill ; she was able to continue her work, and was not sick, giddy, or faint. But on inquiring closely it is clear that she was more subject to headache when the dripping ceased, chiefly over the left eye and the top and back of the head. The headaches did not recur immediately on cessation of the flow, but after two or three days. They appear to have been less severe than in former years, before any dripping showed itself; but still, just at the end of February, 1898, she wrote that she had " most severe pains over the left eye and most dreadful at the back of the head." As soon as the drop- ping commenced again the pains ceased. With reference to the last cessation, the patient wrote : " When it was stopping I had no headache, and was in good health. Two or three days before the water returned I was in agonies of pain." The nuisance which this constant dripping is to the patient may be judged from a letter in which she wrote to say " no one knows the misery I'm in, so if you could possibly send me anything you thought would stop it I should be so glad." Patient's Present Condition. The patient came under observation again in October 1898. When examined on the 6th October her general OTHER PUBLISHED CASES. 23 condition was found to be as previously described. The dripping was taking place entirely from the left side, and in the same manner. Her eyesight remains unimpaired, and there is no fresh observation to add except as regards the left nasal cavity. Here a small polypus, presumably an cedematous fibroma, has formed, and is seen descend- ing between the left middle turbinal and the septum. This has probably formed from the continuous soaking of the spongy tissues, as suggested by Bosworth in analogous conditions. The escape of fluid was reported to be as bad as ever on the 18th March, 1899. Other Published Cases. Before drawing the conclusions which are justified by this exceedingly curious case, and venturing on a few speculations, I think it would be well to first place on record the cases already recorded in literature, which appear to me to resemble it, although in the majority of instances they were ascribed to some other condition than that of the escape of cerebro-spinal fluid. The com- parisons which will then be available may help towards an explanation of the phenomena. I must ask indulgence for the space which these records will take up. My excuse is that I know of only one other attempt to bring together the records of several cases to show that spontaneous cerebro-spinal rhinorrhcea is a clinical possibility. This was done by Leber * in 1883 ; but, with the exception of his own case, all those he quotes are cases which I only include in a second group under the title of " most pro- bably cerebro-spinal fluid," and six of the eight un- doubted cases to which I am able to refer have occurred since the publication of Leber's paper. Bosworth's collection of cases under the heading of " nasal hydror- rhcea " contains too great a variety of pathological i Von Graefe's ' Archiv fur Ophthalmologic,' xxix, 1883, p. 273. 24 THK CEREBRO-SPINAL FLUID. conditions to be of help in elucidating the phenomena in question. I have placed the cases in two groups (A and B), and have numbered them in chronological order. Group A.—Cases in which the Discharge from the Nose was undoubtedly Cerebro-spinal Fluid. Case I.—Tillaux. c Traite d'Anatomie Topographique/ Paris, 1877, p. 56. Tillaux in recording his case remarks that the obser- vation is extremely rare, if not unique :— " An optician presented himself to me in December, 1872, for a discharge from the nose. The latter caused him no pain, but having his head constantly bent forward over his work, he was extremely inconvenienced by the incessant dropping of liquid. I thought at first of a pituitary hypersecretion produced by a coryza, and men- tioned this idea to the patient; he vigorously opposed the idea, asking me to note that he had no symptoms of a cold, that the flow was not of recent date, and that it was continual, especially when he bent his head forward, a statement which he illustrated on the spot. When asked if he could supply some of this fluid the patient replied, ' A litre, if you wish it.' He calculated the amount of flow at a quarter of a litre in the day; a few days later he brought two bottles containing 200 to 300 grammes each. The fluid was analysed by M. Mehu, who reported that it was pure cerebro-spinal fluid. " On inquiring as to the patient's previous history, I learned that he had twice been operated on for nasal polypi. I had no longer any doubt that the liquid escaped from the cranium by an opening in the roof of the nasal fossa?, on the plane of the lamina cribrosa. Further information showed that the position of the head had a considerable influence on the flow; on holding it forward, the flow was incessant; it diminished as he raised his head, and completely disappeared in the horizontal position. I have followed the patient Bince that period; there are variations in the flow of the liquids which has even ceased for several months without any treatment. Except for some headache from time to time the patient does not experience the least trouble, neither physical nor mental; he enjoy, all his faculties, and, as formerly, occupies himself with his business. I saw the patient last on September 20th, 1873, when the flow was as abundant as ever." CASE by tillaux. 25 In this edition of his book the conclusion of the case is not given, but Lichtwitz1 states that in a later edition (4e edition, 1884, p. 54), which I have not been able to procure, Tillaux adds a note to say that he had learnt that the patient had died with convulsive symptoms. A few points are wanting in this description. We are not informed if the flow was one-sided; if the interior of the nasal fossas was healthy ; if the headache varied in relation to the flow. It is to be presumed that both eye- sight and smell were intact, since the patient " enjoyed all his faculties." As to the disappearance of the flow when in the horizontal position, this statement probably depended entirely on the patient's assertion, and is to be accepted with reserve. In my own case the p;itient was under the impression that the flow sometimes ceased during sleep, but the evidence of anyone sharing the same room is that she is continually making swallowing movements in her sleep. The full analysis of the fluid is not given, but Mehu was a well-known chemist, and his researches on the composition of cerebro-spinal fluid are so frequently quoted (his supply of the liquid probably coming from this case) that I think there need be no hesitation in ac- cepting his positive report as absolutely conclusive. I would note that the flow was continuous, although subject to variations, and that during the ten months the patient was under observation it sometimes ceased entirely and quite spontaneously for months at a time. It is also par- ticularly noteworthy that the patient died with cerebral symptoms. Tillaux evidently connects the escape of cerebro-spinal fluid with the operation for the removal of polypi. I am surprised at this, for we know clinically, and from Zuckerkandl's researches,2 that the roof of the nose is never the point of origin of mucous polypi. If the occur- 1 'Archives Cliniques de Bordeaux,' No. 12, December, 1892. 2 ' Anatomie Normale et Pathologique des Fosses Nasules/ Traduction Franchise, 1895. 26 THE CEREBKO-SPINAL FLUID. rence of nasal polypi in this case was not merely coinci- dental, it is much more likely that they were the result of the constant soaking of the mucous surfaces in watery fluid, and not the cause of its flow ; unless, indeed, it is sug- gested that the cribriform was accidentally damaged by the surgeon. Case II.—Th. Leber (Gottingen). "A Case of Hydro- cephalus with Post-neuritic Atrophy of the Optic Nerves, and Persistent Dropping of Watery Fluid from the Nose." Von Graefe's ' Archiv fur Ophthal- mologic/ xxix, 1883, I, p. 273. A girl aged 15 § first came under notice in 1877 on account of failing vision. Hydrocephalus from birth; always weakly and undersized, with large head; vision and intelligence good in child- hood; vision good until fifteen years old ; during the last year great failure of vision ; latterly frequent short attacks of giddiness, with- out loss of consciousness ; occasionally severe headache; two epileptic seizures. Post-neuritic atrophy in both discs ; exterior of eye normal; pupils react promptly ; vision reduced to counting fingers and seeing movements of hand. Stature small; with fairly well-marked hydrocephalus; circumference of head 61 cm.; nasal catarrh, enlarged tonsils, coryza, indurated cervical glands, carious teeth. From March 12th, 1877, to end of 1881 she remained in much the same condition; there was no improvement in vision; the epileptic attacks recurred at intervals of six to eight weeks; also much oftener paroxysms of giddiness and headaches. Towards the end of 1881 all these manifestations showed themselves less often, and at Christmas, 1881, continual dropping of watery fluid from the nostril began. Up to February 5th this flow only ceased once during a period of two days. The fluid was watery, slightly dull (from bacterial development), neutral, no mucin, only traces of albumen, little organic matter, some salts, including NaCl; except bacteria, no formed elements. In December, 1881, as already remarked, dropping of fluid began from the nose, and in February, 1882, she presented herself again for examination. Vision had deteriorated, so that the right eye was quite blind, and with the left she could count fingers. Eye move- ments normal; viscera normal; urine free from sugar and albumin : intelligence intact; no motor or sensory disturbance, except loss of CASE BY LEBER. 27 sight and complete loss of smell. A watery fluid constantly dropped from the left nostril, especially when the head was bent forwards ; when the head was held up, and during sleep, nothing was noticed, perhaps because the fluid flowed backwards. The flow was more plentiful in the morning than in the afternoon. Both nasal fossa? were free, nothing in the throat except enlarged tonsils. The quantity varied ; once in the morning 15 drops fell in a minute; in an hour 22 c.c. were collected ; in six hours 76 c.c. escaped; in seven hours and fifty minutes 32 c c. The secretion therefore fluctuated in an hour between 4-08, 12*6, and 22 c.c. 76 c.c. escaped in six hours. Analysis of fluid.—Sp. gr. 1007-8, feebly alkaline, perfectly clear and free from odour, slightly salty to taste; gave no deposit on standing; contained a very few lymph corpuscles, which in freshly- caught drops still made distinct amoeboid movements. Certain rounded cells showed in their interior very active molecular move- ment. On boiling, even on addition of acetic acid, no opacity; with nitric acid, slight opalescence. Trommer's test gives a very slight separation of oxide of copper. Boiling with Liquor Potassa^, a yellow colouring, which disappears on further boiling. Silver nitrate solution gave a white precipitate; on evaporation common salt crystals were obtained; on heating the slight residue on porce- lain it became brown. Occasionally the dropping ceased for periods varying from eight days to four weeks. It was reported as still present when the patient returned home. For awhile it was from the right nostril, but afterwards from the left, as before, and her general condition continued better than in previous years; headache and giddiness ceased; convulsive seizures still occurred from time to time; they were not more apt to occur during the periods of arrested dropping than at other times. Yision remained the same. The following analysis was supplied by Professor Tollens: The fluid turns the ray of polarised light slightly to the left. It reduces Fehling's solution very slightly (1 c.c. Fehling's solution is reduced by 6*5 cc. of the fluid). This gives, reckoning for sugar, 0*077 per cent, sugar (?). "Whether the reducing substance is really to be looked upon as sugar, remains, according to this, certainly rather doubtful. In addition were found chlorides of soda and potash (shown by flame tests), traces of sulphates. Mixed with five volumes of absolute alcohol, slight fine-flaked opacity. The fluid eva- porated to dryness and the residue dissolved in water leaves a little soft flaky substance, which is insoluble in water, alcohol, ether, and diluted acetic acid, and with Millon's solution gives a fine red colour (protein material). Finally, the fluid contains traces of an acid 28 THE CEREBRO-SPINAL FLUID. substance which is uncrystalline, oily, and with solution of per- chloride of iron, as with chloride of lime, gives a deposit, and so very likely is a fatty acid which is in solution in combination with an alkali. From the fulness and care with which Leber records his case I gather that cerebro-spinal rhinorrhcea is not a frequent concomitant of the hydrocephalus of children. The analysis leaves no doubt as to the fluid being cerebro- spinal. In the following case the completeness of the analysis leaves nothing to be desired; unfortunately, however, the clinical history is most meagre. I have written to Paris, but have been unable to obtain further particulars. Case III.—J. Toison and E. Lenoble. ' Comptes Rendus de la Societe de Biologie/ tome iii, Serie 9, 1891. Seance du 23 Mai. A young woman, aged 28, had four years previously had a violent fall on a staircase. The injury affected chiefly the nape of the neck. Afterwards the patient appeared to recover completely; but about four months previously (to the first date of observation, February 22nd, 1891), that is to say, towards the end of November, 1890, she was suddenly seized with a nasal discharge which was more or less abundant, at times very considerable, and which she regarded as the beginning of a coryza ; but later on no other of these symptoms appeared, and the flow persisted in varying quantity. When examined for the first time on February 22nd, 1891, the liquid which escaped was found to be limpid, colourless, free from odour, very fluid. The patient complained of its saltish taste. There was little doubt that the case was one of escape of cerebro-spinal fluid. Besides, a hasty examination of a few drops of the liquid showed that it gave an abundant precipitate with nitrate of silver (chloride of sodium), and that it gave nothing with nitric acid. The patient collected all the liquid which escaped during six consecutive hours; it amounted to 75 c.c. The patient thought that on that particular day the flow was less than usual. However, if it had continued at the same rate during the whole day, the total amount for the twenty-four hours would have amounted to 300 c.c. The following very full analysis is given: case by toison and lenoble. 29 '• Microscopical examination.—Very few white blood-cells; no red discs, but a few short bacilli and one or two micrococci. " Chemical analysis. — Colourless, odourless, perfectly limpid, alkaline, and measuring 75 c.c. " With heat a faint cloudiness which does not disappear on the addition of a few drops of acetic acid, and which is produced even when the liquid has been acidified beforehand. " Acetic acid produces a development of carbonic acid. " Nitric acid gives no precipitate. '• Acetic acid and ferrocyanide of potassium give no result. " Neutral acetate of lead gives a white precipitate, soluble in excess of the reagent. " The liquid does not give the biuret reaction'; but with iodide of potassium and Millon's reagent2 it gives a yellow precipitate (reaction of Randolph); this precipitate easily becomes red under the influence of a slight excess of the reagent. " The density taken with the specific gravity bottle is, at + 10°, 10076. (Weight of the liquid, 62*791 gr.; weight of the water, 62*315 gr.) " The proportion of fixed matters was made on 5 c.c, and gave— Organic matters .... 00065 gr. Mineral matters .... 00440 ,, Total solids at 100°—110° . . . 0*0505 „ or per litre— Organic matters .... 1*30 gr. Mineral matters .... 880 „ Total solids.....10*10 „ The chlorine directly measured corresponds to 6*84 gr. of chloride of sodium per litre. " The greater part of the liquid was treated with an excess of alcohol at 95°; after twenty-four hours' rest the precipitate was collected on a filter, washed with weaker alcohol, dried, and dissolved in a small quantity of water. " The solution became opalescent under the influences of heat. It gave a precipitate with acetic acid and ferrocyanide of potassium; it did not reduce the cupric sulphate and caustic potash, but it gave most distinctly the reaction of Randolph (or what we call Millon's reaction). " This solution, therefore, contains an albuminoid material soluble in water after precipitation with alcohol, and giving the reaction 1 That is, violet colour with copper sulphate and caustic potash. 2 A mixture of the nitrates of mercury and excess of nitric acid. 30 THE CEREBRO-SPINAL FLUID. which is said to be characteristic of peptones (reaction of Ran- dolph).1 " The alcoholic liquids used in the preceding steps are distilled in order to collect the alcohol. The residue is taken up with water. The watery solution reduces Fehling's solution; therefore it con- tains the reducing substance whose presence had been observed at the beginning of the analysis. " All the efforts made by one of us to isolate this reducing body have been fruitless, as it occurred in too small a quantity in the liquid. Bat we have, however, been able to show that it both reduced ammoniacal nitrate of silver, at the same time giving a metallic mirror as aldehydes do. It also deviated the ray ol polarised light to the right. The deviation observed in a tube of a decimetre = +> 1° 15'." On another occasion [it is not mentioned at what later date] the quantity collected during eight consecutive hours only amounted to 62 c.c, which would on!}* give an average of 186 grammes for the twenty-four hours. This leads the authors to remark that this shows that the flow had actually diminished; but the only conclu- sion it may justify is that the flow varied in quantity. "This second sample is less transparent than the preceding, less fluid; it contains slight clouds of mucus, but is colourless. " Microscopical examination.—Few white blood-discs; few short bacilli, one or two micrococci; no red blood-discs. " Chemical examination.—This liquid contains a larger proportion of organic matter, and the albuminoid matter, which was isolated, as on the former occasion, does not give clearly the reaction of Randolph. " The density at +10*5° is 10076 (weight of the liquid, 62*8010 gr.; weight of the water, 62*325 gr.). The fixed matters include— Organic matters .... 0*0035 gr. Mineral matters .... 0*0175 ,, Total of solids .... 00210 „ Per litre the fixed matters amounted to— Organic matters . . . . 1*75 gr. Mineral matters . . . . 8*75 „ Total of fixed matters . . . 10*50 „ The proportion of chlorine carried out on the ashes of 2 c.c. gave 0*033 gr. of chloride of sodium, which corresponds to 6*72 grs. of chloride of sodium per litre. " Conclusions.—The results obtained may be summarised in the 1 This reaction is not characteristic of peptones, but :i pink instead of a violet biuret reaction is.—W. D. Halliburton. CASE BY WALLACE MACKENZIE. 31 form of the following conclusions, which agree generally with those of Mehu, except in regard to the reducing material. " A. Cerebo-spinal fluid appears to normally contain some white blood-globules, a fact which is easily explicable, since the white blood-cells are found in nearly all parts of the organism. "B. From the chemical point of view it is characterised in the fresh condition— " 1. By its alkaline reaction and by the absence of odour and colour. " 2. By a low density varying round 1007. " 3. By the constancy of its richness (a) in mineral matters, and amounting in our cases to between 8*30 gr. and 8*80 gr. per 1000 c.c; (&) in chloride of sodium (from 6*62 gr. to 6*84 gr.). " 4. By the variability and weakness in organic and albuminoid material. Probably, also, even the nature of these albu- minoids is subject to variation. " By the presence of a reducing body not pointed out by Mehu but already suspected by Bussy, of which we have always been able to prove the existence without being able to determine its nature." Unfortunately there are no clinical details with regard to this case, other than those given in the above report. We are therefore without information as to whether the flow was continuous day and night, if it was one-sided or not, if it was accompanied by any cerebral or ocular sym- ptoms, as to the condition of the interior of the nose, and as to the conclusion of the case. Case IV.—F. Wallace Mackenzie. " A Case of Atrophy of the Optic Nerves, with dropping of Watery Fluid from the Left Nostril." ' Transactions of the Inter- colonial Medical Congress of Australasia,' Third Session, held in Sydney in 1892, p. 500. A well nourished, healthy-looking, intelligent lad at the age of seventeen began to suffer with severe headaches and gradual failure of sight, together with attacks in which the patient used to fall down in a sort of fainting fit. There were apparently no convul- sions. Well-marked optic neuritis was found in both eyes. The sight continued to get worse, and at the end of a year a watery dis- 32 THE CEREBRO-SPINAL FLUID. charge began to drop from the patient's left nostril. Coincident with this the fits ceased, and there had not been any return since (i. e. after the elapse of two years). At the age of twenty—on April 8th, 1890—he presented himself to the author on account of blindness and a continual dropping of a clear watery fluid from his left nostril. There were no nasal polypi, and no diseased condition could be detected in the nose or naso- pharynx, nor was there any evidence of a diseased condition of the accessory cavities. The eyes were wide open; the pupils were partly dilated, equal, and slightly sensitive to light. V = p. 1. with both eyes. There was atrophy in both optic discs, the margins being sharply defined. There were no retinal haemorrhages. A clear watery fluid dropped continuously from the left nostril at the rate of about one ounce in an hour. On examination the fluid was found to be clear and transparent; sp.gr. about 1006. On boiling with acetic acid there was a slight cloudiness. There was a con- siderable proportion of chlorides and a trace of sulphates present, and the salts were principally those of potassium. In three different specimens examined there was no reaction of sugar in any. Wallace Mackenzie is of opiuion that in his case the fluid was derived from the subarachnoid space. He adds " I look upon the early symptoms and condition as being analogous to an attack of glaucoma, and the relief caused by the escape of fluid through the nose may be compared to the relief of the increased tension in the eye by the escape of fluid through the canal of Schlemm." The above is a most carefully recorded case, and although deficient in some details it is the most com- plete I have yet come across in my bibliographical search. There is a distinct record of the condition of the eyes and of the interior of the nasal fossae. I have no doubt that Wallace Mackenzie was right in regarding his case as one of nasal escape of cerebro- spinal fluid. The history of headache and failure of vision, of " fainting fits " which entirely ceased on the establishment of the flow, and the one-sidedness of the discharge, all tend to confirm this opinion. It would have been interesting to have heard if, when the loss of vision first came on, the left eye—the one on the side of the dis- charge—was affected before the right. The low specific CASE BY GUTSCHE. 33 gravity of the fluid, and the absence of mucin, eliminate the possibility of an intra-nasal origin of the liquid. The analysis is particularly valuable from the negative value it brings to bear on other cases in my bibliography. The " reaction for sugar " was not obtained, although three different specimens were tested. Now the negative result of this " sugar test " is adduced by Mr. Priestley Smith for abandoning the hypothesis that the nasal fluid was cerebro-spinal in his own two cases, as well as in Mr. Nettleship's and Sir James Paget's. If it is agreed that the fluid in the present case was really of cerebro- spinal origin, it is evident that the negative finding of the " sugar test " is not to be regarded. Besides, in examin- ing cerebro-spinal fluid the test with Fehling's solution has to be applied with some delicacy, so that the reaction might be overlooked in the hands of observers who were not used to the refinements of physiological chemistry. Case V.—Gutsche. Dissertation, Erlangen, 1894, " Zur Pathogenese der Hypophysistumoren und iiber den nasalen Abfluss, sowie das Verhalten des Liquor Cerebrospinalis bei einer Struma pituitaria." Abstract in ' Centralblatt fiir Laryngologie/ Bd. xi, 1895, S. 460. " The case concerns a man, aged 34, who, being in otherwise per- fect health, observed that a clear fluid flowed from his left nostril, the quantity in the course of a day amounting to about 250 c.c. When lying down it flowed into the throat. It is remarkable that in other cases this striking symptom of the flow from the nose of the cerebro-spinal fluid was never mentioned. Death ensued in about fifty-eight days after the first appearance of illness, with the phenomena of cerebro-spinal meningitis. The post-mortem showed struma pituitaria (swelling of the pituitary gland and of the chiasma nervorum opticorum), empyema of the sphenoidal sinuses and of the left maxillary antrum, and arachnitis purulenta. " The chemical analysis of the fluid showed that it was rich in albumin, and contained a reducing substance, which, however, could not be described as sugar." C 34 THE CEREBRO-SPINAL FLDID. To the inclusion of this case amongst those of " spon- taneous " dropping of cerebro-spinal fluid it might be objected that there was a gross lesion at the base of the brain, but here again the connection between the lesions found post mortem and the cerebro-spinal flow is not very evident. The analysis is not opposed to the view that the fluid was cerebro-spinal ; indeed, the presence of " a reducing substance " supports it. The large amount of albumin is explained by the admixture with inflammatory products in the accessory sinuses. Case VI.—Mermod. " Meningoencephalitis consequent on the exploration of a supposed Frontal Sinus." (Annal. des Mai. de l'Oreille et du Larynx,' tome xxii, No. 4, April, 1896. A man aged 36 had suffered for several years from painful tickling in his nose, especially towards the root, with considerable muco- purulent secretion, which was increased in cold, damp weather; nasal respiration was frequently interfered with. The continuous current, electrolysis, and application of the galvano-cautery to the hypertrophied inferior turbinals only produced momentary relief. When examined on July 15th, 1S95, he was complaining of head- ache, frontal or occipital, or sometimes generalised; at times it was a general heaviness of the head, which was very troublesome when he was at work. He ran much from the nose, requiring two or three handkerchiefs a day, and many more when the weather was cold or damp; the secretion was the same on both sides; he had the con- stant sensation of being stopped up in the nose. The nasal mucous membrane was generally very red; the inferior turbinals were not very large, their surface rough and unequal, probably the result of previous treatment. The middle turbinals were very irregular, and presented that appearance of polypoid degeneration which is habitu- ally observed in long-standing suppuration of the accessory sinuses. The meatuses were full of muco-pus, of which it was difficult at first to discover the source, which was probably multiple. During the summer of 1895 the following treatment was carried out in various sittings:—Resection of the middle turbinals, extraction of large polypoid masses on each side from the neighbourhood of the infundibulum ; opening of the right maxillary antrum by the alveolar border, and of the left sphenoidal sinus, which was found full of pus and large granulations, so that the anterior wall was resected in order to throw the sinus and the nose into one cavity. CASE by mermod. 35 The anterior and middle ethmoidal cells on the right side were opened, and were also found to contain pus and large granulations. Towards the end of the summer the patient experienced a certain amount of relief, but the secretion was still very abundant. When examined on November 15th the local condition had altered. The nose was completely free ; the aspect of the mucous membrane as a whole was almost normal; there was no vestige of polypus, and no trace of pus. The lining of the left sphenoidal sinus was seen to be rose-coloured, and the right maxillary sinus also no longer secreted pus. But, on the other hand, the patient asserted that he used his handkerchief more than ever, only the secretion had gradu- ally lost its purulent character, and had become absolutely watery ; also it was no longer continuous, but intermittent in character. The headache had become exclusively frontal; it was often most severe, especially on the right side, and it diminished every time after an abundant nasal evacuation of a liquid which was clear as water [the italics are Dr. Mermod's]—a symptom on which the patient particularly insisted. He was persuaded that there was "some- thing " at the base of the forehead, and demanded relief in one way or another, as his work as a printer was b2Coming constantly more difficult for him. As to diagnosis. Thinking that the case might be one of vaso- motor hydrorrhcea, the local action of cocaine, antipyrine, and atro- pine were tried without avail. A cyst of the frontal sinus might be suspected, and the case appeared to coincide best with the two cases of Lichtwitz, where the nasal secretion came from the frontal sinus, and where cure was obtained by a puncture from the nasal cavity (vide p. 64), although, with the exception of sneezing, the nervous symptoms—such as laehrymation, photophobia, temporary hemia- nopsia, convulsive seizures, &c (Lichtwitz)—were wanting. The view of an affection of the frontal sinus was the more probable, as other sinuses were involved; but why should there be pus in the maxillary and ethmoidal sinuses on the right side and the sphenoidal on the left, with serous fluid in the frontal sinus ? The liquid was not thought to be cerebro-spinal, for in the curious case of Tillaux the flow was incessant—a quarter-litre in twenty-four hours—and was not accompanied by any sort of malaise; besides, this quantity varied according to the position of the head. Here there was nothing of the sort. There was no ocular disorder; vision equal on both sides; the papilla clearly limited; no venous stasis. An attempt to catheterise the frontal sinus from the nose was not successful, the curved cannula appearing to be arrested at the entrance of the infundibulum, as if it terminated in a cul-de-sac. Before resorting to Schjeffer's method of puncturing the floor of the sinus from the nose another attempt was made—with every antiseptic precaution 36 THE CEREBRO-SPINAL FLUID. —to pass a fine curved flexible probe up through the fronto-nasal canal. It was remarked with surprise that the instrument entered easily, without meeting with any bony resistance, into what appeared to be a vast cavity, giving the impression of a very exten- sive frontal sinus. On withdrawing the probe, which had penetrated to a depth of 7\ centimetres, from the nostril the patient's habitual headache was much augmented for an hour, and during the night there was an abundant serous flow from the nose. He resumed his work next day, and returned to the clinic in eight days, when the same manoeuvre was repeated; but, in order to collect some of the serous liquid, a small cannula was introduced in the same track as on the former occasion, but only to the depth of 6^ centimetres. Immediately some grammes of liquid, clear as water, escaped from the cannula; the onset of sharp pain obliged the hasty withdrawal of the cannula, and so prevented the collection of the liquid. Meningo-encephalitis followed, and on the sixth day a large opening of the frontal region at the root of the nose showed that the frontal sinus was entirely absent, the position usually occupied by it being entirely taken up by the frontal lobes. A small opening existed on the right side between the skull and the nose. There were the usual indications of meningo-encephalitis, and the patient died in twenty- four hours. At the post-mortem, examination of the base of the skull revealed the existence of two holes. The first, hardly perceptible, was situated in the dura mater, beside the apophysis crista galli, and more than 3 centimetres behind the nasal spine. It was probably through this small slit that the flow of liquid used to take place. The second opening was much further forward in the neighbourhood of the foramen caecum, and 2 millimetres behind the posterior sur- face of the bony wall, or 11 millimetres from the nasal spine, and at least 1 centimetre in front of the lamina cribrosa, which had not been injured. No trace of a frontal sinus was to be found either on the right or the left side. The brain showed no sign of traumatism. At the base, around the optic chiasma and cerebellum, there was a considerable quantity of pus in the subarachnoid spaces, otherwise the base of the brain showed no sign of inflammation. On the right a focus of softening of the point of the frontal lobe invaded the two first frontal convolutions. The ventricles were very dilated and occu- pied with purulent serum; the ependyma was very injected and opaque. On the right the first frontal presented on section some small haemorrhages in the white matter; the centre of softening only concerned the grey matter. The autopsy gives no explanation of the right frontal headache ; evidently, since there was no frontal sinus, the CASE BY MERM0D. 37 liquid could not be anything but cerebro-spinal fluid which collected between the frontal lobe and the dura mater, escaping at intervals. The whole profession must feel extremely indebted to Dr. G. Mermod for his full publication of this most instructive case. In the clinical record only one detail is missing, viz. the analysis of the fluid, and it was only the force of circumstances which prevented this. I cannot refrain from directing attention to some of the most important points in the above case, before passing on to consider the cases together. It shows how a skilled specialist may be misled by reference to only one or two similar cases of a condition of which there is not an established " Krankheitsbild." The example of Tillaux's case (p. 24) did not appear to Mermod to be analogous to the above, because in Tillaux's the flow was incessant and varied according to the position of the head; but my conclusions will point out that cerebro-spinal rhinorrhcea may be constant or intermittent, and that the flow may vary or be the same in different positions of the head. Again, a too close analogy with the description of the case of Lichtwitz (p. 64) helped to mislead Mermod, but when I come to consider that case I will have to point out that it is extremely probable that it also was one of discharge of cerebro-spinal fluid. The importance of Mermod's observation will, 1 trust, excuse me for diverging to call attention to two practical lessons it teaches. One is, that the escape of clear watery fluid from the nose should (in the absence of gross lesions) always raise the suspicion that it may be cerebro-spinal fluid ; and the other is, that it may be a dangerous pro- ceeding to attempt to penetrate the frontal sinus from the nasal cavity. My own case would, in chronological order, rank here as No. VII. The following has been published since my patient was shown to the Luryngological Society. 38 THE CEREBRO-SPINAL FLUID. Case VIII.—Scheppegrell. " Case of Recurrent Head- ache, each attack being relieved by the discharge through the Right Nostril of a Fluid from the Cranial Cavity." ' Journ. Americ. Med. Assoc./ February 26th, 1898, p. 480. In February, 1885, the patient, a female, suffered from a most agonising headache, the pain at times being so severe that she was entirely oblivious of her surroundings. This continued for three weeks, and was relieved by the following accident. While descending a stair the patient fell down a considerable distance, her head striking against a stone jar at the bottom of the staircase. The fall was so severe that the patient was unconscious for several seconds, but when she revived she observed that there had been a profuse discharge of a yellow watery fluid from the nostrils, and that the headache, which had persisted for three weeks, had entirely disappeared. The attacks, however, continued to recur at varying intervals, the intermissions being sometimes only twenty-four hours, and rarely more than two weeks. The headaches persisted from three to five days, and some- times as long as ten days. On each occasion the headache termi- nated with a spontaneous discharge from the nostrils, principally from the right side, and complete relief. This train of symptoms still continued when the patient presented herself to the author in January, 1893. She then " stated that when these headaches commenced there was a feeling of stiffness in the neck near the collar-bone ; then the pain seemed to ascend until it formed a focus in the upper part of the head near the crown, and produced a sensation as if a boil were forming, the pain extending over the whole upper part of the head, and her eyes could be kept open only with difficulty. The face is flushed, but there is no elevation of temperature. An ophthalmoscopic examination gave negative results, and there was no exophthalmos." The right sphenoidal sinus was punctured, but no fluid escaped. The right frontal sinus was opened externally under chloroform, and found to be healthy. The ethmoidal cells were opened without benefit, and the antrum of Highmore was catheterised without giving relief. The various accessory sinuses having now been excluded, the view was entertained that the discharge came from the cranial cavity. Some of it was therefore collected for examination. " The fluid had a specific gravity of 1005, and was slightly alkaline in reaction, and contained a small amount of albumen. Chemically the liquid resembled the cerebro-spinal fluid, and the contents of the cranial lymphatic vessels in this region, which are almost identical in CASE BY SCHEPPEGRELL. 39 character. When this fluid was allowed to settle in a conical glass, there was a heavy white deposit; and the clear supernatant fluid was of a pale straw colour, and did not coagulate. The sediment consisted almost entirely of pavement epithelial cells, some occurring singly, and others in flakes. A few red corpuscles were seen. In a second specimen sent for examination, the admixture of blood was so large that it imparted a reddish tinge to the whole body of the liquid." The author concludes that the fluid, which had caused the first attack of cephalalgia, had accumulated in the cranial cavity, and that the fall had been instrumental in breaking through the barrier which had existed between the liquid and the nasal cavity. But if this fluid were discharged from the subarachnoid space, it was difficult to understand why the same quantity came from the nostrils after each attack, and also why the discharge ceased so abruptly, and did not continue to drip for some time after the first pressure had been relieved. This leads the author to suppose that this peculiarity was due to a cyst connected with the lymphatic circulation in this region, possibly caused by occlusion of the efferent lymphatic vessel of the perivascular lymphatics surrounding the vein which passes from the nose, through the foramen caecum, to the superior longitudinal sinus. " The location of such a cyst in this region would not only cause all the disturbances due to pressure in the subarachnoid space, but would also explain the limited amount of fluid which was discharged after each attack. The flight admixture of blood-corpuscles evidently came from the ruptured point in the upper part of the nasal cavity." Repeated examination has not shown any cyst protruding into the nostril. The above case varies in many particulars from those we have already considered. The details of the chemical analysis are not sufficient, by themselves, to determine the cerebro-spinal character of the fluid, and the author still holds the older views of chemical physiologists that cerebro-spinal fluid and lymph are almost identical in character. Later on I shall point out that this opinion has been abandoned. So far as it goes, however, the analysis of the fluid is not opposed to the claim of the author that the fluid came from the cranial cavity, and his diagnosis is fully borne out by the particulars of the case. The chief point in which it differs from the other seven cases is in the cessation of the flow after a limited amount (mentioned to be about an ounce) 40 THE CEREBRO-SPINAL FLUID. had escaped. As the freedom from headache—and from the nasal discharge—sometimes endured for periods of two to six weeks, it is to be presumed that a certain amount of liquid had to accumulate, sometimes slowly, before it induced headache. The author's suggestion as to how this took place is ingenious and plausible. The following case has only been published since this work was written. It has, however, come to my notice in time to introduce it here before my manuscript was sent to the printer. Case IX.—Korner (Rostock). "Flow of Cerebro-spinal fluid through the Nose with Optic Atrophy, a combi- nation of symptoms probably caused by a tumour of the pituitary body breaking into the sphenoidal sinus." ( Zeitschrift fur Ohrenheilkunde/ Bd. xxxiii, Heft 1, Juli, 1898. The patient was a female aged 37, and came to the clinic on April 8th, 1896. Since the age of ten she had been deformed, and for the last eight years her gait had been weak and trembling. For some years the weakness of her eyes and hands had prevented her from working as a seamstress. About four months ago, after cough and sneezing, she began to suffer from a flow of clear watery fluid from the left nostril. This flow continued day and night uninterruptedly. When lying on her back the fluid ran into her throat and was swallowed. She is seen to be small and thin. She has a marked kyphoscoliosis. Her mental capacities are small; she laughs much without reason, but to simple questions she gives clear and correct answers. As a rule she sits still and holds a handkerchief or a glass beneath her dripping nose. She cannot walk alone without assistance, and has to steady herself against the nearest object. Her movements are not ataxic; it appears rather as if she had a great weakness in her legs. From the left nostril there drops incessantly a clear watery fluid. On different occasions this was collected, and each time it averaged about 15 c.c per hour. On analysis, Professor Nasse found 1*18 per cent, of fixed matters and 0*75 per cent, of ash. The loss on ignition (Gliihverlust) (0*43 per cent.) was reckoned chiefly as albumen. On account of the scantiness of the fluid the mucin could not be reckoned with certainty; the ash contained much CASE BY K0RNER. 41 NaCl. In the right side of the nose nothing abnormal was dis- coverable. In the left side there was a considerable hypertrophy of the anterior end of the middle turbinal. As regards the eyes, there was slight prominence of the eyeball and rotary nystagmus. The right pupil was normally dilated, the left somewhat wider. The right pupil reacted well to light, but the left did not react at all to direct light, although it did so decidedly for accommodation. There was slight insufficiency of both internal recti. The vision on the right was f; on the left, fingers could only be counted when held close to the eyes. On both sides there was decided optic nerve atrophy. There was no enlargement of the thyroid gland; no signs of acromegaly. It was thought that the patellar reflexes and skin sensibility were normal, but there was no note of it in the case book. The patient was only a short time under observation; she returned home and died four and a half months after the above observations were made. The nasal flow continued up to her death. There was no autopsy. The source of the fluid had not been recognised while the patient was under observation, and hence the observations taken were not as complete as might be desired. The hypertrophy of the middle turbinal was removed without altering the flow; the portion removed was found to be an ordinary hypertrophy. The left maxillary sinus was punctured, but no fluid was discovered in it. It was only when the author became acquainted with the case of Gutsche (vide p. 33) that he realised that in the above case he had had to do with an escape of cerebro-spinal fluid, and he concludes that in his own case, as in Gutsche's, it was due to a tumour of the pituitary body. He has collected the records of eight cases which have been published of optic nerve atrophy with escape of watery fluid from the nose, and suggests that in all of them both these symptoms were due to a tumour of the pituitary body. These eight cases are those of Baxter (p. 56), Gutsche (p. 33), Hardie and Wood ('New York Med. Journ.,' 1890, vol. ii, September 6th, p. 264), Leber (p. 26), Nettleship (p. 57), Priestley Smith (p. 59), and Wallace Mackenzie (p. 31). Although the chemical analysis is incomplete in the above case, yet the physical characters of the flow, its limitation to one side, its continuity night and day, the amount discharged per hour, its association with optic nerve atrophy, and the negative examination of the nasal fossae and their accessory cavities, are sufficient evidence as to the arachnoid origin of the fluid. I caunot agree with 42 THE CEREBRO-SPINAL FLUID. Korner's suggestion that in all the cases he quotes the escape of cerebro-spinal fluid was due to a tumour of the pituitary body breaking through into the sphenoidal sinus. In Baxter's case no such tumour was discoverable at the post-mortem. A study of the case of Hardie and Wood has convinced me that it was one of vaso-motor rhinitis. In Nettleship's case the flow ceased. And in Priestley Smith's the flow lasted from two to four years, which it would hardly have done with a progressive growth at the base of the brain. To facilitate reference and comparison the main points in these nine cases may be recorded in tabular fashion (vide Table A). TABLE A. 44 THE CEREBRO-SPINAL FLUID. Table A.—Cases in which the Discharge from II III IV Author, reference. Tillaux, Traite d'Anatomit Topo- graphique, 1877 Leber, Archiv f. Ophthal- mologic, xxix, 1883 Toison and Lenoble, Comptes Rendus de la Societe de Biologie, tome iii, serie 9, 1891 Wallace Mackenzie, Trans. Iiitercol. Med. Con- gress, Third Session, 1892,p. 500 Sex and M., adult F., 20 F., 28 M., 20 Duration. "Not of recent date." Under ob- servation 10 months Com- menced at age of 20 4 months 2 years Cerebral symptoms, Some headache from time to time, but enjoyed all his faculties. Death with convulsive symptoms Hydrocephalus from birth. Intelligence good in childhood. With failure of vision came onset >f giddiness, severe headache, and epileptic seizures Severe headache at age of 17, with sort of fainting fits; no convulsions. These ceased with the establishment of the nasal discharge at age of 18, and had not returned during the two subsequent years Eye symptoms. Vision good in childhood. At age of 15 failure of vision from post-neuritic atrophy Gradual failure of vision com- menced at age of 17, with well- marked double optic neuritis. At age of 20 atrophy of both optic discs; no retinal haemor- rhages General. Flow continuous, increasing on bending head for- ward, and ceasing in horizontal position Continuous flow, but with intermis- sions of periods of 8 days to 4 weeks; increased on bend- ing head forward; during sleep not noticed, probably because the fluid flowed backwards Onset sudden Well nourished, healthy looking, intelligent TABLE A. 45 Nose was undoubtedly Cerebrospinal Fluid. Nostril affected. ccessory cavities. ft. Both nasal fossae free History. Previously twice operated on for nasal polypi Progress and results. Quantity and character of fluid. Violent fall 4 years previously Left; no nasal jlypi; no disease n nose, accessory r-avities, or naso- pharynx Variations in the flow of the liquid, which even ceased at times for several months without treatment. Death Headache and giddiness ceased when flow was [established. Con- vulsive seizures continued, and were not more apt to occur during periods of arrested dropping i litre in the day. Analysed by M. Mehu, who reported that it was pure cerebro- spinal fluid Fluctuated be- tween 4 c.c. and 22 c.c. per hour; 76 c.c. escaped in 6 hours. Full analysis given; clear, free from odour, alkaline; sp.gr. 1007-8; no albumin 75 c.c. in 6 hours, or 300 c.c. in 24 hours; but on another occasion only 186 c.c. in 24 hours. Very full analysis given; absence of odour and colour; sp. gr. 1007; presence of a reducing body Flowed at rate of 1 ounce an hour; clear, transparent; sp. gr. 1006; no sugar reaction Diagnosis. Cerebro-spinal rhinorrhcea. Cerebro-spinal rhinorrhcea. Cerebro-spinal rhinorrhcea. Cerebro-spinal rhinorrhcea. 46 THE CEREBRO-SPINAL FLUID. Author, reference. Gutsche, Centralb. f. Laryngo- logie, xi, 1895 Mermod, Annales des Mai. de V Oreille et du Larynx, tome xxii, No. 4, 1896 StClair Thomson, The Cere- bro-Spinal Fluid, London, 1899 Scheppe- grell,Journ. Amer. Med. Assoc, Feb. 26th, 1898 Korner (Bostock), Zeits. f. Ohren- heilk., Bd. xxxiii, Heft 1, Juli, 1898 Bex and age. Duration. M., 34 F. F. 58 days Several years 5 years 8 years 9i months Cerebral symptoms. Death from cerebro-spinal meningitis Headache and heaviness, most severe on right side, and always relieved after abundant flow of clear liquid. Death from meningo-encepha- litis following exploration Headache since childhood, but absent since nasal flow was estab- lished; returning slightly during cessation of flow Intense headache; eyes kept open with difficulty; always relieved by flow Limited mental capacities Eye symptoms. No ocular dis- turbance ; vision equal on both sides; papilla clearly defined Eyesight unaffected; no trace of optic atrophy or retinitis Ophthalmo- scopic examination negative; no exophthalmos Slight promi- nence ; rotatory nystagmus; right pupil normal, and re- acted; left larger, and re- acted to acorn- modation, but not to light; marked optic nerve atrophy both sides, worse left General. Otherwise in perfect health. When lying down flow passed into throat General health good Presumably good Small, thin; marked kypho scoliosis; not ataxic, but cannot walk without assistance TABLE A, 47 Nostril affected. •iccessory cavities. Left History. Progress and results. Quantity and character ol fluid. Diagnosis. _ Death. Post- 250 c.c. in a day; Cerebro-spinal mortem clear, rich in albu-men ; contained a reducing substance which was not sugar rhinorrhcea. Both nostrils; — Flow intermittent. Clear as water. During life, a lasal polypi and Death. Post- No analysis cyst of right hypertrophic mortem frontal sinus. dnitis; empyema From the of maxillary autopsy, ntrum and aute- cerebro-spinal or ethmoidal cells rhinorrhcea. n right side, and left sphenoidal sinus Left; nose, No history of Four intermis- 15 ounces to Cerebro-spinal ccessory sinuses, accident sions of 1 to 2 561*6 c.c. in 21 rhinorrhcea. nd naso-pharynx months' duration; hours. All the normal; no otherwise con- characteristics ot leezing or irrita- tinuous day and cerebro-spinal tion ; no loss of night fluid smell tight; accessory Headache Flow ceased after Watery, 1005, Cerebro-spinal cavities on right after lasting an ounce escaped; slightly alkaline; rhinorrhcea. ide all shown to 3 weeks relieved recurred every 24 small amount, of be healthy by flow from nose, consequent on a fall hours to 2 weeks, as conclusion to a headache albumin Left Trembling and Nothing found in Clear watery fluid, Not diagnosed weakness of gait nose or left averaging 15 c.c. while under preceded nasal maxillary antrum per hour; 1*18 per observation. tiow by 8 years; to account for cent, of fixed On becoming weakness of flow matters, and 075 acquainted with hands and eyes per cent, of ash Gutsche's case for some years (No. V) Korner previously concluded that the flow had been cerebro- spinal fluid. 48 THE CEREBRO-SPINAL FLUID. Summary of Undoubted Cases of Cerebro-spinal Rhinorrhcea. From these nine cases the following points may be summarised : Females 5, males 4; therefore both sexes appear to be pretty equally affected. Age from 20 to 37 ; therefore an affection of youth and adult middle life. Cerebral symptoms in Eye symptoms in . Side of the nose affected mentioned in From left side in From right side in From both sides in Intermission in the flow occurred in . „ „ not mentioned in. Continuous flow, day and night pre- sumably, in Not noticed at night No note in Complete disappearance of the flow in Death in . „ with cerebral lesions in Post-mortem in 8 cases. 3 „ 7 „ 5 „ 1 case. I „ 5 cases. 4 „ 1 case. 4 cases. no case. 4 cases. 3 „ 2 „ The first autopsy showed swelling of pituitary body and of the chiasma nervorum opticorum, empyema of the sphenoidal sinuses and of the left maxillary antrum, and arachnitis purulenta. The second autopsy showed that the escape of cerebro- spinal fluid had occurred through a hardly perceptible hole beside the apophysis crista galli. We now come to the cases collected from other observers, which I have placed together in a second group and entitled " Most probably cases of cerebro- spinal rhinorrhoea," although their authors have re- CASE BY KING. 49 corded them under various headings. Several of them have already been claimed by Leber * as being what I esteem them to be, and Wallace Mackenzie 2 expresses his opinion that in six of them the fluid came from the same source as in his own case, viz. the subarachnoid space. In all, I have collected twelve cases in which the proof of the cerebral origin of the fluid is not positively certain ; and although I am of opinion that the balance of evidence would justify their inclusion with the first nine cases, I have thought their consideration would be facilitated by placing them together in this second and slightly doubt- ful group. Group B.—Cases in which the Discharge from the Nose was most probably Cerebro-spinal Fluid. In chronological order. Case X.—King. ' The London Medical and Surgical Journal/ vol. iv, 1834, p. 823. At the Westminster Medical Society on Saturday, January 18th, 1834, " Mr. King related a case which had occurred to Mr. Rees, ot Finsbury Square, who had transmitted the notes to him. A female aged 52 had excessive discharge of clear limpid fluid from the left nostril, to the amount of a quart in twenty-four hours. It had commenced three months before, and was constantly secreted night and day. It became necessary to wear a sponge for the purpose of absorbing the discharge, as, from its constant trickling into the larynx, it had several times threatened suffocation. The patient is stout, but subject to excessive action of the sanguiferous system; her eyelids are puffed; there is a florid state of the countenance, and a pulse of 96. She has a general disposition to anasarca, and the catamenial discharge, which appeared at ten years of age, and which has continued to flow ever since, is quite regular. Her diet consists of vegetables. Hitherto no local or general treatment has been found of avail." 1 Loc. cit. 2 * Transactions of the Intercolonial Medical Congress,5 Third Session, held in Sydney in 1892, p. 500. D 50 THE CEREBRO-SPINAL FLUID. Case XI.—John Blliotson. "Liquid Watery Fluid in very large quantities from the Left Nostril." ' The Medical Times and Gazette,' 1857, New Series, vol. xv, p. 290. On July 19th, 1842, Dr. Elliotson was first consulted by a lady aged 40, in excellent general health, on account of a profuse flow of watery fluid from her left nostril. She had had a similar attack fourteen years previously. One night she had a severe pain in her head, and the next day as the pain declined the left nostril began to run, and by the evening she felt no more pain and the discharge was at its height. It lasted eighteen months, and suddenly ceased without obvious cause one night, after having been as profuse as ever the day, and indeed the evening, before. The second attack had been going on for thirteen months when she first consulted Dr. Elliotson. The fluid was more copious than in the first attack, and as much as three quarts had been discharged in a day. The fluid was colourless, without odour, and so watery that the handkerchiefs dried soft and served again without the necessity of washing. As many as five and thirty were used in a day. When she went to bed a number of towels were placed about her face and neck, and when they became saturated she always awoke from their wetness and coldness. She was compelled to Bleep nearly upright. There was no sneezing, and presumably her sense of smell was unaffected. If she stooped, the fluid streamed from her nose. She felt no thirst, and drank little more than in health. All her secretions and functions were undisturbed. Pulse 80 and good. All causes of debility, excitement, heat, and especi- ally damp, aggravated the complaint. During the two attacks she occasionally had a cold in her head like other people, and lost her voice and sense of smell, and discharged thick opaque mucus from both nostrils, as is usual in catarrh; but then the limpid watery fluid continued to drop from the left nostril just as when she had no cold. This second attack had arisen from no evident exciting cause, had not been preceded or attended by headache, had increased slowly, and arrived at its height in fourteen days. The treatment to which she had been subjected in the first attack was, as Dr. Elliotson justly says, "terrific." "It consisted of repeated very copious bleedings in the arms, cuppings, leeches to the nose, blister- ing behind the ears, each pair of blisters being kept open for a week, strong purgatives, fruitless attempts at salivation by mercury, saline draughts, and low diet." During the second attack she was treated with tannin and gallic acid in increasing doses, and secale CASE BY PAGET. 51 cornutum, but without benefit. She then consulted Sir Benjamin Brodie, who prescribed a grain of sulphate of zinc with 3 grains of extract of sarsaparilla three times a day, and an injection of 20 grains of sulphate of zinc and 1£ drachms of tincture of galls in 8 oz. of water. Three weeks after this prescription was begun the discharge declined a little, and it slowly lessened till it ceased entirely in about three months. Hence the first attack ceased spontaneously at the end of eighteen months; the second under treatment at the end of twenty-three months. The first began suddenly and ended suddenly; the second took place slowly and declined slowly. Elliotson doubts whether the prescription effected the cure. When free from her complaint she required much less stimulant. Instead of drinking eight or nine glasses of wine a day, three or four glasses produced just the same comfort. She was free from recurrence at the date of publication, i. e. fourteen years afterwards, although in the meantime she is reported by Dr. Elliotson to have suffered from dropsy of the right ovai*y, a condition which was cured by mesmerism. The following analysis of the fluid is given Specific gravity Water . Mucus . Chloride of sodium Sulphate of soda Soda combined with mucus Traces of lime and phosphoric acid. 1010 98*885 •104 1001 The limpid character of the watery fluid and its low specific gravity point towards cerebro-spinal fluid; the rest of the analysis does not help towards any conclusion. Case XII.—Sir James Paget. " A Case of Polypi of the Antrum in which Watery Fluid dropped from the Nostril." ' Transactions of the Clinical Society,' vol. xii, 1879, p. 43. Read November 22nd, 1878. The debate is given in the ' Medical Press,' 1878, vol. xxvi, p. 432, and in the ' British Medical Journal/ 1878, vol. ii, p. 836. The patient was a lady 49 years of age, robust and healthy looking, and with no signs of general ill-health, or any appearance of disease in the nostrils. There was nothing like polypus or un- 52 THE CEREBRO-SPINAL FLUID. healthy membrane, or swelling as of a cyst; no nasal obstruction or unusual flow of tears, no swelling or tenderness, and nothing to indicate the source of the fluid. The sense of smell was perfect. The secretion never was purulent. This fluid had been dropping from the left nostril, with rare intermissions, for eighteen months. As to her history, it was insignificant. In November, 1876, she received a heavy blow over the left frontal sinus, but it seemed to have done no harm at the time. In January, 1877, she had for one day a severe headache, such as she had never had before or since. In February she had a severe mental shock, and in May, 1877, the dropping began. From that time it had continued up to the date of publication (November 22nd, 1878). Once, in May, 1878, it ceased for a fortnight, when she had bronchitis and took morphia; and once it ceased in the night. It always flowed from the left nostril. The amount was variously calculated at " a drop every five or six seconds;" " four ounces were once collected for me in the course of an afternoon and evening;" and " at the rate of 314 grains in twenty minutes." The quantity was generally nearly uniform, but it was always increased by mental distress or by much exertion, or by straining. At night much of it collects in the nostril and is poured out when the posture of the head is changed. Not a drop has ever come from the right nostril, unless when the left nostril and upper part of the pharynx has become filled with fluid during sleep at night; and then, on turning the head downwards and to the right, the fluid pours through both nostrils. The fluid looked like pure water, or like the fluid of the pia mater or that of an acephalocyst.1 On standing, the slight greyish deposit showed only some granular and molecular matter and a few epi- thelial cells and a few round cells. One analysis reported as follows:—" 100 parts of the liquid contains 1*15 of solid matter in solution, consisting of— 0*965 inorganic matter 0*189 organic „ 1*154 The liquid is slightly alkaline; it contains proteid matter, probably albumen, and there is no indication of grape-sugar in it. The solid residue is probably chloride of sodium, but it contains phosphates and, I think, iron" (Dr. Russell). In another specimen, including a large proportion of fluid which had accumulated in the nostril and above the palate during sleep, the specific gravity was 1*004, and the quantity of debris much larger. An analysis made by 1 In describing the fluid from his undoubted case of cerebro-spinal rhinor- rhcea, Tillaux remarks, "Ce liquide est parfaitement clair et limpide comme de l'eau de roche; il rappelle tout a fait le liquide des kystes hydatiques." CASE BY PAGET. 53 Mr. Thomas Taylor, one year previously, showed that the specific gravity of one specimen was 1009*3, of another 1010*44. The dry solid matter obtained from 100 fluid grains of the former was 12 grains of the latter 1*26. The solid matter consisted of albumin 0*05, other animal matter 0*48, chloride of sodium 0*78, with traces of carbonate of soda and phosphoric acid. Sir James Paget expressed the opinion, though speaking with much doubt, that the fluid was derived either from a frontal or ethmoidal sinus, or from the subarachnoid space or the sac of the arachnoid membrane. He thought, however, that it was doubtful, and even improbable, that the fluid was cerebro-spinal, and it was certainly not a catarrhal affection. Mr. Lawson, who had seen the case, believed that it was cerebro- spinal fluid which escaped. He remarked that during sleep very little came away, and appositely asked, " Was this because less was then secreted, or only because the fluid was swallowed ? " Some time afterwards, when Paget's attention had been drawn to the result obtained by Sir Benjamin Brodie in Case XI, the patient was given one grain of sulphate of zinc three times a day, increasing that dose gradually to twice the quantity, while the nostril was injected three times a day with a solution of three grains of the sulphate of zinc in an ounce of water. This plan was steadily followed for about six weeks, then the dropping of fluid gradually diminished, and in two or three weeks more completely ceased. The patient remained well and active and free from all discomfort till a month after the cessation of the dropping. Then, after exposure to mental distress, fatigue, and cold, she was seized with headache, vomiting, restless delirium ; " her pupils were contracted ; and after this, with signs of acute brain disease becoming gradually more intense, she died comatose three days after the beginning of her illness." At the post-mortem there were symptoms of diffuse meningitis, " and over large portions of the anterior cerebral lobes, and some parts of thebase of the brain and of the cerebellum, the pia mater was almost symmetrically infiltrated with pale greenish-yellow, soft lymph. The whole base of the skull, the cribriform plates of the ethmoid bone, the olfactory bulbs and the dura mater in relation with these, were completely healthy. The examination was made the more carefully because of a suspicion that it might have been subarachnoid fluid which had dropped from the nostril. Nothing in evidence of such a supposition could be found. The lining of all the nasal cavities and sinuses, except that of the left antrum, appeared quite healthy. Of this antrum the bony walls were un- changed ; its shape and size were natural, and nothing external indicated any change within. But its floor was covered with two broad-based convex polypoid growths, deep clear yellow with the 54 THE CEREBRO-SPINAL FLUID. fluid infiltrated in their tender tissue, and covered with exceedingly thin smooth membrane traversed by branching blood-vessels. They were of rounded shapes, about two thirds of an inch in diameter and half an inch in depth; they looked like very thin-walled cysts, but were formed of very fine membranous or filamentous tissue in- filtrated with serum. On the outer wall of the antrum were flattened soft yellow masses, which appeared the residue of one or more similar polypoid bodies collapsed after breaking or accidental injury and the escape of the greater part of the serous fluid." (The specimen is in the museum of the College of Surgeons.) The author concludes that this copious production, whether by secretion or filtration, of a fluid of less specific gravity than any produced either naturally or in disease—unless it be the subarachnoid fluid—was brought about by these polypi in the antrum. He refers to the publications of Giraldes, Luschka, and Yirchow on the disease, and observes that neither in these nor in any other works has he been able to find mention of the dropping of fluid from the nostril as one of the signs of either cysts or polypi in the antrum. No con- jecture is hazarded as to the cause of the fatal meningitis. The physical characters of the liquid and its low specific gravity indicate cerebro-spinal fluid; the analysis shows nothing to oppose this conclusion. Case XIII.—H. Fischer. "Wasserige Ausscheidungen aus einer Nasenoffnung." ' Deutsche Zeitschrift fur Chirurgie/ 1880, Bd. xii, S. 369. " A man aged 42 was in hospital because of a broken leg. The patient was otherwise perfectly healthy, but had suffered from headaches. One morning, without any apparent cause, a dripping of a turbid watery fluid like thin milk began to flow out of his left nostril, and lasted for several hours. It dripped drop by drop as in bleeding of the nose. When I saw the patient the dropping had already stopped. The quantity which escaped amounted to 200 grammes; it had a specific gravity of 1003, and an alkaline reac- tion. The chemical examination showed slight traces of albumin, chloride of sodium, and phosphates; under the microscope the fluid revealed no formed elements, especially no hooklets of echinococcus. The patient stated that he had this phenomenon for the third time and that each time after it his headache was always relieved. " Although there was no outward sign of disease of the sinus frontalis, I nevertheless thought it well to accept hydrops of the CASE BY SPEIRS. 55 same, which emptied itself periodically. He had no neuralgia of the fifth nerve such as Althaus demonstrated in his case (' Brit. Med. Journ.,' December 7th, 1878)." A similar observation to the above was demonstrated by Paget to the Clinical Society on the 22nd November, 1878. The analysis does not contradict the conclusion that the fluid was of cerebro-spinal origin. The descriptions of the fluid as being " turbid " and like " thin milk " do not of course support such an idea, but this appearance might have been brought about by admixture. Case XIY.—W. R. Speirs. " Notes of a Case in which the Principal Symptom was a Constant and Copious Watery Discharge of Watery Fluid from the Nose." 1 Lancet,' March 5th, 1881, p. 369. A man aged 55 had suffered from a constant dropping of a clear watery fluid from the nose. It commenced at first with sneezing, and he was inclined to attribute it to the irritation arising from his occupation as a tailor. Change of work, however, made no dif- ference. There was no history of injury, and there was neither pain nor swelling at any time during the continuance of the flow. The fluid came drop by drop, but at times almost so quickly as to form a stream; an ounce was easily collected in a quarter of an hour, and at times the flow was so copious that any garment he was making became completely saturated in a very short time. The specific gravity of the fluid was not noted, but it was perfectly clear and colourless, free from smell, and, according to the patient, had no taste. It contained no albumin, and a handkerchief saturated with it did not stiffen on drying. It did not excoriate the upper lip. At night the patient was compelled to have his head raised till he was almost in a sitting posture, as when lying down the fluid ran back into his throat and caused a choking sensation. Exercise in the open air seemed to lessen the discharge. The sense of smell was unimpaired. "There was no appearance of disease in the mucous membrane of the nostril, and nothing whatever to indicate the source of the fluid." Local treatment with glycerine of tannin, tannic acid in powder, and various other astringents, and general treatment with purgatives, liquid extract of ergot, and liquor strychnia?, produced no decided variation in quantity. The patient himself experimentally adopted the plan of keeping his nostrils filled with goose grease, and the dropping gradually ceased day by 56 THE CEREBRO-SPINAL FLUID. day, until within a week it had quite disappeared, after lasting for nine months. Speirs considers that the post-mortem of Sir James Paget's case proved that the fluid came from the antrum, and pre- suming that his case was identical he suggests that the goose grease may have filled up the fissure of communication between the antrum and middle meatus of the nose, and thereby so altered the existing condition of the structure lining that cavity as to effect a cessation of the excessive secretion. Case XV.—E. B. Baxter. " A case of Paroxysmal Clonic Spasm of the Left Rectus Abdominis, with Symptoms pointing to the Existence of Gross Intra-cranial Dis- ease." 'Brain,' vol. iv, January, 1882, p. 525. Although the nasal condition is not mentioned in the title of this paper, it was for a nasal discharge associated with "nervous ?Q«f 1^1 & lady aged 35 consult«d Dr. Baxter on November i»th, 1879. It appeared that in November, 1877, after a good deal ol worry and anxiety, she began to suffer from headaches and twitches (as she termed them), and shortly after these symptoms made their appearance, a clear watery fluid, sometimes rather offen- sive, occasionally tinged with blood, began to come from the right nostril. The twitchings occurred almost daily, lasting from ten minutes to a couple of hours. They were due to a violent recurrent spasm of the left rectus abdominis, and were followed by symptoms like those of ordinary hysteria. The headaches, which were most severe, also occurred almost daily. The pain began at the root of the nose spread round to the back of the head, and there was a constant fixed pain on the left side of the occiput. The pains were not at all periodic; they occurred almost daily, were worse during tiie day, and never kept her awake at night. No relation is indicated between the headaches and the discharge from the right nostril. The right nostril was pervious. No ulcera- tion or disease of bone could be detected by examining with the rhinoscope or from the front. The discharge was only sometimes offensive, and Dr. Baxter could never himself perceive any un- pleasant odour when he saw her. The upper jaw was crowded with decayed stumps. There was no impairment of taste or smell There never had been any loss of consciousness or intellectual contusion. /•^^^M0^11 °f the eyesi^fc was in