To sum up, we may say that there are two operations which have proved fairly satisfactory for approaching the pituitary fossa, the Hirsch-Cushing submucous nasal method, and the fronto-orbital method of Frazier. Though it is not possible yet to decide finally between these, the opinion can be expressed that the fronto-orbital route is more suitable in the great majority of cases. In the three cases which the speaker has operated on this method has been adopted with success. All three of these

more »

... ses were almost blind before brought for operation. In the first case a portion of an endothelioma was removed and the general condition improved, though the sight did not improve. The third case obtained great improvement of vision after a cyst was evacuated. The second case proved to be one of syphilitic meningitis, and though the patient said he was a little better after the operation there was no obvious improvement in his condition. Now that the mortality of the operation has diminished surgeons can more readily urge that patients with oncoming blindness due to pressure on the chiasma should be treated by operation more early than is now the case. An extended and more fully illustrated account of the whole subject III1 ; IN my first communication on this subject I described three of the earliest cases of severe shell shock I had seen, which were characterised especially by defects of memory, vision, smell, and taste. Among the large number of cases which have since come under my observation I have met (in about 25 per cent.) with various disorders of cutaneous sensibility, some distinctive features of which form the subject of the present contribution. Over-reaction anct " Hyperœsthesia." The following is a pronounced instance of general over-reaction:-CASE 9 (Case-number 227). -Stretcher-bearer, aged 19, with 18 months' service, and 6 months' service in France. Was seen by me on the day after admission to a base hospital. Four days before admission he had been " blown up three times by aero-torpedo trench mortars," while attending to the wounded in the trenches during an enemy attack. He said that one had blown him in the air, that another had blown him into a dug-out, and that the third had knocked him down, but that nevertheless he continued his work of carrying away the wounded to the dressing station. Two or three hours later, after he had finished, he was resting in a dug-out when everything seemed to go black " (probably he had a hysterical " fit ") and he became " shaky," and had remained so ever since. He said that he had hardly slept for seven days before he "gave in." He appeared an honest, courageous lad, but was obviously in a very "nervous" condition, making irregular spasmodic move-ments of the head, arms (especially the right), and legs 1 The first of these communications appeared in THE LANCET of Feb. 13th, 1915, p. 316, and the second in the issue of Jan. 8th, 1916, p. 65. especially the left). There were well-marked coarse tremors. ,nd incoordination during voluntary movements of the arms. He touched his nose with far greater uncertainty when his yes were closed. The lightest touch of cotton-wool on the imbs or head provoked very lively movements ; obviously helreaded the next touch. "I I was always ticklish," he explained, "but never like this. I can't stand it, sir." A )in-prick produced a series of most violent spasms, almost mounting to a convulsion. He sweated considerably during' examination. There was much rigidity in the legs, and so nuch spasm that a knee-jerk was unobtainable until my second visit, the sixth day after admission. Plantar stimulasion gave a flexor response. He suffered from visual lallucinations of bursting shells ; he also heard them when lozing. The patient improved considerably with rest and treatment. but 17 days after admission, lying asleep in bed outside his tent in the sunshine, he woke to find himself being carried back in his bed owing to a sudden shower of rain. This brought about a recurrence of such terror that a special nurse was considered necessary that night. On the next da3P he was still very " jumpy " and alarmed, even at the sound of a footstep ; he complained of severe headache. Three days later he had again improved and was transferred to England, where, after two months in hospital and one month's leave, he returned to light duty. Cases like this, of general sensori-motor overreaction, appear to be rare after shell shock. But I believe that they may be regarded as an extreme form of the far commoner condition of unilateral or otherwise more restricted " hypera&sthesia," and for this reason (based on considerations which will appear immediately) I place the word in inverted commas. Such local "hyperoesthesia" was specially apt to. occur over areas which were the seat of spontaneous. (subjective) painful sensations. Unilateral "hyperaesthesia" was combined in several cases with contralateral anaesthesia or hypæsthesia. In others it was sometimes difficult to be sure whether one side of the body was subnormally sensitive orwhether the opposite side was supernormally sensitive, although as a rule the patient's " jumpiness" " and muscular over-reaction afforded a. sufficient clue to the latter condition. The nature of the hyperœsthesia."-Several cases of " hyperæsthesia" presented features recalling to, my mind those which have been emphasised by Head and Holmes in their observations on lesions of the optic thalamus, and which have been attributed by them to a loss of the inhibitory control normally exercised by the cerebral cortex over the activity of the thalamus. They compare this loss Qf cortical control over the thalamus to the loss of cortical control over the bulb and cord; just as the latter manifests itself in muscular rigidity, increased reflexes, &c., so the former results in sensori-motor and affective over-reaction. In such thalamic over-reaction a cutaneous stimulus produces abnormal motor response, excessive tingling and diffuseness of sensation, and increased affective reaction of pain or pleasure. With the most careful avoidance of suggestion on my part, various patients suffering from local " hyperæsthesia" after shell shock have given me