of each cornea was opaque with an apparent flattening of the conical projection. The rest of the cornea was clear, and sight continued improved. The patient's health was still poor, and a visit to her country home was deemed advisable.

Eight months afterwards the patient paid me a visit, when I found the cornea very decidedly flattened, and in a good condition to have the subsequent iridectomy performed, with promises of great improvement in vision. Her general health being still very poor she determined to wait some time longer before submitting to the iridectomy.

During the past year I have seen but one other case of keratoconus. He was timid, and declined to be operated on in any way. I have, therefore, had no second opportunity of testing this method. So far it promises better results than any of those previously used, and I would advise its trial for this very intractable disease.

SOME POINTS IN THE DIAGNOSIS AND TREATMENT

OF SYPHILITIC LARYNGITIS.

BY CARL SEILER, M.D.,

PENNSYLVANIA.

SYPHILITIC laryngitis is of so common an occurrence that a few points in regard to its diagnosis and treatment which have suggested themselves to me, may be acceptable to the general practitioner, who frequently must meet with cases in which circumstances prevent his obtaining a specific history, or in which the symptoms are such as to simulate non-specific forms of throat. disease.

As is well known, the symptoms of syphilitic laryngitis are those seen in ordinary catarrhal laryngitis with slight but characteristic differences in the appearances of the parts, and it is these differences which this paper is intended to point out. As in catarrhal laryngitis, so in the specific form of the affection the mucous membrane of the larynx is red, but in syphilitic laryngitis the color is usually peculiar, being of a bright carmine hue, although we occasionally meet with cases in which this is absent and we see instead either the more livid red of catarrhal inflammation or the ashy gray discoloration of tubercular or phthisical laryngitis. These cases are, however, very rare, and the two latter named inflammatory conditions never present the bright carmine color. The inflammation may be a general or a diffuse one, but is commonly localized and confined to certain portions of the larynx when it presents a symmetry in outline as well as in position, which is most characteristic of syphilitic inflammation of the upper portion of the respiratory tract. These symmetrical patches of inflammation seen, for instance, on the mucous membrane covering both arytenoid cartilages or on corresponding parts of the ary-epiglottic folds, are usually sharply defined by a more or less distinct line of demarcation separating them from the surrounding still healthy mucous.

membrane. The same peculiarity in regard to color and distribution of the inflammation is noticed when the pharynx and fauces are also affected; and even when the larynx alone is the seat of the disease we notice two sharply-defined bands of inflammation symmetrically disposed on the free borders of the velum palati. Sometimes cases are met with in which these lines are not at first seen, but they appear after the laryngoscopic mirror has been introduced once or twice, and especially after an effort at gagging on the part of the patient.

In the later stages of the affection swelling of the different parts of the larynx is very common, and especially are the epiglottis and the ary-epiglottic folds the seat of tumefaction. It is often very difficult to decide by the sense of sight alone whether this swelling is due to serous effusion into the submucous tissue, thus constituting localized oedema, or whether it is due to inflammatory infiltration of the mucous membrane, or finally whether it is of a gummatous nature. Under such circumstances I am in the habit of using the laryngeal sound in order to arrive at a correct interpretation of the nature of the tumefactions.

Ulcerations of the mucous membrane are very common in syphilitic laryngitis, and are either shallow, involving very little of the submucous tissue in the ulcerative process, or they are deep. The shallow ulcers are not distinguished from ordinary catarrhal ulcers except that they usually are symmetrical in outline as well as in position, or that if an ulcer is seen on one side of the larynx only an area of most intense inflammation is usually noticed in a position corresponding to that of the ulcer, on the opposite side. These shallow ulcers are to my mind the result of the simple inflammatory infiltration, and are therefore in no way different from the ulcerations seen in catarrhal inflammations: whether they are infectious or not I am not prepared to say, but am inclined to believe that they are not. After healing these lesions leave very small if any scars behind, and yield readily to appropriate treatment.

The deep ulcerations, on the other hand, which occur more frequently in those cases which are remoter in regard to time from the primary infection, and may therefore be considered as belonging to the tertiary manifestations of the systemic affection, are of a more characteristic appearance. Their edges are raised and usually bordered by a line of a bright red hue; they are covered with a grayish pus; they spread very rapidly from a small beginning and attack the deeper seated tissues. Thus they

frequently destroy the perichondrium of the cartilages and cause the necrosis of portions of cartilages, especially of the arytenoid and cricoid, which portions are apt to become detached and may fall into the trachea, when they give rise to very grave complications. On healing, these deep ulcers leave very extensive stellate or radiating cicatrices, which possess considerable contractile power, and often thereby give rise to stenosis of the larynx. My own experience has taught me to consider them to be caused by the breaking down of more or less extensive gummata in the mucous membrane. Both the shallow and the deep ulcerations. of syphilitic laryngitis are generally far less sensitive than the ulcerations seen in any other disease.

Frequently I have seen cases in which a syphilitic infiltration of the lung existed, and in which the lung symptoms were far more prominent than the throat symptoms, so that they might have readily been mistaken for cases of acute tuberculosis. In a paper read before the Philadelphia Laryngological Society, and published in the Medical and Surgical Reporter (April 16, 1881), I have reported two such cases, together with the conclusions arrived at by myself and others in regard to the peculiarities of syphilitic lung disease. The fact of the occurrence of syphilitic infiltration of the lung, which is by no means rare, in connection with syphilitic laryngitis, as well as the great similarity of the symptoms between it and tubercular infiltration, makes it of the greatest importance to the physician to be able to demonstrate with the laryngoscope syphilitic disease in the larynx, for then he will be much more likely to obtain a confession from the patient as to the primary infection, and he will be able to give a favorable prognosis.

The treatment of syphilitic laryngitis should be both systemic with iodide of potassium and mercury, as well as supportive with tonics, cod-liver oil, and nourishing food. If, on account of great swelling or ulceration of the epiglottis, dysphagia exists, I have found inunctions of oil into the skin and nutritive enemata of desiccated blood and beef tea to be very beneficial.

The local treatment should consist in reducing the general inflammation of the laryngeal mucous membrane and in healing up the ulcerations. I am in the habit of using a mildly astringent solution composed of acid. carbol. mm. 45, sodii biboras and sodii bicarb., each 3j; glycerinæ, fl3j, and water pt. j, thrown into the larynx by means of an atomizer, with very happy reVOL. XXXII.-15