for authority must report the case on blanks prepared in duplicate form, stating the nature of the case, similar to accident insurance reports, to the county physician within twenty-four hours, and must at monthly endings submit a report of all such cases with itemized statement of services rendered, signed before Notary Public. The county physician then O. K.'s report, with recommendations, to be presented to the county commissioners or supervisors of the county for payment. These accounts to be charged against the parties who contracted the services, that in case they are collectable the county may be reimbursed and I would recommend that if it is possible to do so they be charged against their personal tax. This payment to go to the physician who rendered the service, payable through the county physician, who should be required to furnish bond, the amount to be determined by the commissioners. I believe this plan to be just and equitable. The county should care for these people, there is no reason, but sentiment, why a physician should shoulder these burdens. They are not our charges, but those of the county wherein they live, vote and receive every other kind of protection at the expense of the taxpayers. The amount that would be spent for this purpose by the county, each year, as compared to the amount that is spent in the general management of other branches of the county, would be a mere bagatelle for the county, but a tremendous sum for a few individuals. And above all it would have an excellent moral effect upon some of our people who are sapping our strength, soul, mind, and body, not to mention the pocket-book which custom has taught should never be spoken of by the physician.

Nystagmus.

*By CLAUDE T. UREN, M. D., Omaha.

Nystagmus as a phenomenon was known long ago, both the spontaneous and the induced. In 1825 Purking discovered that in turning the insane for treatment nystagmus was produced and studied it, considering it wholly as an ocular phenomenon of cerebellar origin. He also noticed the fact that objects seemed to move during the nystagmus. Separately, Flourens in the same year began his first experiments with pigeons. He dissected out the semi-circular canals of pigeons and discovered that he could produce a nystagmus of the whole head and body of the

*Read before the Omaha Ophthalmological Society, April 15, 1913.

pigeon in the plane of that canal experimented upon. Flourens did not realize that the pigeon was dizzy.

After this work comes a long interval and we next find that in 1861 Meinere discovered that dizziness was caused by dusturbances of the canal. He studied one case with symptoms of dizziness, nausea and falling sensation in whose canals a mass was found posteriorly. Meinere was at this time 61 and too old to follow up his discoveries. Goltz in 1870 advanced the idea the the function of the canals is as a sense organ for the position of the head and maintaining the body in an upright position or rather in equilibrium.

Brener, Mack, Crum, Brown discovered that canals are sense organs for turning sensations and when irritated produce reflex movements or nystagmus. Many others became interested and prominent among them was Jansen of Berlin and Ewald of Strassberg, who began experimenting with pigeons in 1906 and worked out Ewalds law which we will consider later.

It had long been known that patients at times became dizzy while having their ears syringed, and one day Barany noticed while syringing a person that with this dizziness was nystagmus. He began syringing all patients and soon discovered that in any normal person nystagmus could be produced by syringing with water either above or below the body temperature.

Brief Anatomy of the Canals: Roughly the canals lie in the petrous portion of the temporal bone with relation to its axis as follows: Anterior vertical at angle of 45 degrees with anterior plane and the posterior vertical is at an angle of 45 degrees with the cross plane. Thus the anterior vertical plane is at right angles with the plane of axis of the pyramid and the posterior vertical canal is parallel with the plane of axis. The anterior vertical canal is marked by a slight eminence on the superior surface of the pyramid. Each bony canal though very small contains a membranous canal which is as much smaller in comparison as the lead of a pencil is smaller than the pencil itself. Each canal opens into the utricle separately at either end, except the smooth ends of the anterior and posterior vertical which join shortly before entering the utricle. Each canal has a dilated end known as the ampulla which contains the end organ of the vestiblar nerve known as the crista-ampullaris.

Tracing the vestibular nerve back through its canal we find it leaving the internal meatus in the sheath of the 8th nerve and with it entering the medulla-oblongata. Before doing so we find upon it a ganglion known as the vestibular ganglion, one

of the spinal ganglia. In the Medulla the vestibular nerve terminates in the nucleus of Bechterua. From Bechterua's nucleus a new neuron passes out dividing so as to reach the nuclei of the 3rd and 6th nerves. Hence a stimulus received by the end organ of the vestibular nerve passes along the nerve to the Medulla and is transmitted from here to the nuclei of the 3rd and 6th nerves causing a movement of the eyes to the opposite side. This is a slow movement and is known as the slow component. Now if the stimulus be of sufficient strength the overflow of stimuli causes the supernuclear center to respond and a reflex quick movement of the eyes is brought about. This is known as the quick component.

laws:

Ewald, by his experiments on pigeons made the following

(a)

1. For the horizontal canal. The movement from the smooth end to the ampulla is so called effective movement and produces nystagmus to the same side. (b) Movement to the smooth end is less effective and produces nystagmus to the opposite side.

2. Anterior vertical canal. (a) Movement to the ampulla is less effective and produces nystagmus to the opposite side. (b) Movement to the smooth end more effective and produces nystagmus to the same side.

3. Posterior Vertical. Same as No. 2.

The two posterior vertical canals cannot supplement or reinforce each other, as by their positions the others do, so that in testing these canals we are dealing with but one at a time and either the more or less effective movement of the lymphi. Methods of Physiological Irritation:

1. Turning.

1. Turning. During turning because of irritation the movement of the lymphi is opposite to the direction of turning and nystagmus results to the same side as the direction of turning. That is turn to the right with head erect the lymphi moves toward the left or towards to ampulla of the right horizontal canal and towards the smooth end of the left horizontal canal. After stopping, the lymphi having picked up the motion to the right continues moving to the right with regards to the canals and a nystagmus results in the opposite direction. The effectiveness of the movement of the lymphi in the two directions;

that is to or from the ampulla, is in the ratio of about 2 to 1. For example:

As we have to take both canals into account it works out as

follows:

L. H. Canal:

T. R. during nystagmus

T. R. after nystagmus

R 14"-1

..L 28"-2

So that we have a during nystagmus of 14 plus 28 or 42′′ and an after nystagmus of 42". The average time in many cases. It has been learned from many turning tests that: Time varies from 5 to 120". That old destruction of a labyrinth equals nystagmus to the opposite side never longer than 25",

If nystagmus to the diesased side lasts longer than 25", the labyrinth is not completely destroyed, that is, there is a compensation in old cases of complete destruction of the labyrinth on one side which takes place and the duration of the nystagmus to both sides becomes equal and shortened.

The nystagmus remains always horizontal to the plane of turning or floor of room, regardless of the position of the patients head.

During nystagmus is always with the direction of turning. After nystagmus is opposite.

Caloric Reaction.

It has been learned that syringing the ear with water the temperature of which is either above or below the body temperature causes a nystagmus, and that the nystagmus caused by using cold water is opposite to that caused by the hot water.

The direction of the nystagmus produced by the caloric test differs with the position of the head of the patient.

Galvanic Reaction.

If a cathode is placed before the ear and the anode in the mid-frontal region we get a nystagmus toward the cathode. Nystagmus Flows With the Current.

If a double cathode is used so as to equally irritate both ears, normally no nystagmus results, but if the labyrinths are unequal nystagmus results toward the more irritable ear.

Other phenomena combined with vestibular nystagmus. 1. Impression of movement of objects with the nystagmus. 2. Closed eyes, have impression of turning with the nystagmus.

Reaction movements against the nystagmus. (Pointing, head, etc.

These reaction movements come from the cerebellum and may be explained as follows:

The vestibular nerve has very intimate connection with the cerebellum.

Cagal has shown that every vestibular fibre before entering Bechterua's nucleus sends a collateral fibre to the cerebellum and sends other fibres to both hemispheres and the vermis.

The moss fibres terminate about the cells in the granular layer of the cerebellum; from these cells fibres called climbing fibres, enter the outer layer of the cerebellum and end around the cells of Perkinje. From Perkinje's cells axons go out to the subcortical nuclei and new neurons carry the impulses from here to the cerebrum and cord. Thus we have a double chain to the cerebellum, a voluntary and vestibular.

If we produce on a patient a horizontal nystagmus to the right and order the patient to move the arm, when the arm moves impulses travel by the climbing fibres to Perkinje's cells and there results a deviation to the left. Thus we can conceive that there is a tonus center in the cerebellum for movement to the left and to the right. The tonus centers are always acting equally under normal conditions and hence movements are well balanced and accurate. These tonus centers only act as regulators of accurate movements when both voluntary and vestibular ennervation are acting.

Barany locates these tonus centers as follows: The centers for movement upward and downward, lie posteriorly near the upper margin of the cerebellum. Centers for right and left movement are more anteriorly.

With every form of nystagmus we get a pointing reaction opposite to the nystagmus. The fault depends upon the direction of the nystagmus and the position of the head.

Points for examination in a labyrinth case:

1. Spontaneous nystagmus.

2. Nystagmus behind spectacles.

3. Attacks of nystagmus by rapid head movements.
4. Big attacks of dizziness. (History.)

5. Spontaneous pointing.