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duction of a convalescence from a minimum of three to four weeks and a maximum of several months to 48 to 96 hours, exclusive of the middle-ear condition.

The gain from a cosmetic standpoint is also very great. There is no displacement of the auricle and no unsightly depression back of it. The cavity in the bone is entirely filled up, the contour restored, and all that remains to show that the operation has been performed is a faint linear scar. Reik says that in such a comparatively small cavity as the mastoid it is probable that in some cases the fibrous tissue is entirely converted into bone by the osteoblasts.

Three illustrative cases are included in the paper.

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which appears in the New York State Journal of Medicine, June, 1908. The observations are based upon 10 cases observed by him, a history of which is a part of the paper.

After reviewing the different channels by which gas reaches the cranial cavity, the author says:

"We are all familiar with cases which have had a middle-ear suppuration for many years without at any time in their course evidencing the slightest symptom of intracranial involvement. In such cases, after the advent of an acute inflammation, intracranial complications are somewhat common. The determining factor of the acute exacerbation is likewise the important element in producing the intracranial lesion. Any element which impedes free drainage of the middle-ear spaces is thus of moment, because tending to cause pus retention. Among such may be enumerated medicinal powders which cake in the external auditory

canal, exuberent granulations, foreign bodies, aural polyps, impacted cerumen, exostoses, etc. Furthermore, in case of long-standing middle-ear suppuration, the eburnization of the mastoid is quite a common finding. This hardening of the mastoid cortex, the effort of nature to shut off the purulent process, thus making egress of the pus more difficult externally, favors its advance inward toward the cranium. In addition, the eburnization is very rarely observed at the tegmen. The eburnization of the temporal bone is, therefore, a significant factor toward the production of intracranial lesions.

"It seems, therefore, at the present state of our knowledge of these lesions, that a meningitis produced by contiguity offered better prospects for ultimate recovery after operation than one which follows an invasion of the labyrinth. Disease in the middle cranial fossa gives a better prognosis as to eventual recovery after operation than obtained from a purulency in the posterior cranial fossa. Furthermore, disease in the posterior cranial fossa, when operated upon, will not yield to treatment unless the labyrinthine purulency is first eradicated.

"In conclusion, he urges that expectant treatment in the face of post-mastoidal intracranial symptoms be limited as much as possible, and that as soon as diagnosed, or even a well-founded suspicion of purulent involvement of the meninges is entertained, that a systematic exploration of the meninges and labyrinthine capsule be undertaken.

"The operation on the labyrinth should not be deferred until meningeal symptoms intervene, as then the symptoms from the latter overshadow the former, and the chances for eventual recovery are lessened.

"The establishment of early meningeal drainage will save many cases which

otherwise would develop general meningitis and terminate fatally.

"Finally, even the most desperate cases from the clinical standpoint should be subjected to exploratory operation, because occasionally surprising results will follow, and the exception to the generally fatal rule may save a patient who otherwise would die.

"Summarizing our conclusions, we

find

"I. That intracranial complications result from contact of diseased bone with dura, or they come about from an invasion of the cranium through the labyrinthine or other anatomical channels.

"2. That trauma, either accidental or surgical, may arouse into activity latent intracranial lesions.

"3. That intracranial lesions are generally, although not invariably, the result of an engrafted acute process upon a chronic middle-ear suppuration, especially if the chronic suppuration is a disease of the bone.

"4. That the intracranial invasion, when located in the posterior cranial

fossa, generally will first have involved some part of the labyrinthine channels.

"5. That involvement of the middle. cranial fossa is more amenable to surgical treatment than when the posterior cranial fossa is the seat of the lesion.

"6. That the earlier the surgical intervention the better the prospects of ultimate recovery.

"7. The evacuation of pus from the posterior cranial fossa without surgical relief of the purulent labyrinthitis is useless (when labyrinth is involved).

"8. That lumbar puncture, as an aid to surgical treatment, is of undoubted value.

"9. That no case should be considered too hopeless to submit to operation, as sometimes surprisingly good results are obtained even in such.

"10. Finally, that surgical trauma, in the form of the radical mastoid operation, should only be imposed on patients in whom the positive diagnosis of bone necrosis, unyielding to other treatment, is made, and that the radical mastoid operation should not be undertaken simply to attempt a cure of a persisting purulent otorrhoea."

LARYNGOLOGY AND RHINOLOGY.

UNDER THE CHARGE OF

S. J. KOPETZKY, M.D.,

Assistant Surgeon, Manhattan Eye, Ear and Throat Hospital, New York (Ear Department); Attending Otologist, N. Y. Children's Hospital and Schools, R. I.

The Laryngeal Compli- Rieser, W. (Amer. cations of Typhoid Journ. Med. Sci., Fever, with Report of February, 1908).

Two Cases.

The lesions met with in the larynx are submucous laryngitis, ulcerative laryngitis and perichondritis. The site of lesion, as found postmortem, does not agree with what has been observed clinically. In 4000 autopsies the posterior wall at the insertion of

the vocal cords and involving the cricoid cartilage was the seat of the lesion in 60 per cent., the arytenoid cartilages and interspace the next, the ary-epiglottic folds, epiglottis and thyroid cartilage being least affected in the order named; whereas Chevalier Jackson found in 360 routine laryngoscopic examinations ulceration to be present in 68 cases, involving the epiglottis 42 times, ary-epiglottic folds 22,

interarytenoid space 18, and ary-tænoid cartilage 10. Inflammation may occur any time between the first and the tenth weeks. Over 70 per cent. of reported cases occurred after the third week. The onset is insidious. Extreme dyspnoea and spasm may be the first intimation, and the first attack may end fatally. In the greater number of cases these complications occur when the patient is convalescent and all danger supposed to be past. The symptoms begin mildly and in the following order of frequency: Hoarseness, aphonia, stidor, dyspnea, metallic cough, dysphagia. Any of these symptoms may be overlooked or misconstrued until, with tragic suddenness, an acute œdema of the glottis supervenes, or an asthenic apnoea, without the slightest warning of its approach, may terminate life. Therefore the slightest hoarseness, cough, pain in swallowing or breathing should immediately arouse suspicion and lead to a laryngoscopic examination being made.

The prognosis, if we judge from 243 collected cases, is very bad, as 65 per cent. in all died; of those operated on 58 per cent., and of the unoperated 76 per cent.

In the first of the author's two cases, which are recorded in detail, the patient developed in the third week a parotitis with œdema of the pharynx and larynx. Tracheotomy was performed with relief to breathing, but the patient died the next day without recovering consciousness. Cultures for Klebs-Loeffler bacillus were negative, and at the post-mortem "the cartilaginous box of the larynx and the trachea were found absolutely normal.

The second case was admitted to hospital convalescent in the fourth week, after a mild attack without complications. Eight days later, though the temperature remained normal, he developed hoarseness with slight cough, and at times inspiratory stridor. Laryngoscopic exami

nation showed congestion of the cords, but no impaired movement or any ulceration. Under treatment symptoms improved; only aphonia remained. Twelve days after admission the patient developed respiratory obstruction, so sudden and complete that the house surgeon had to perform laryngotomy with an ordinary penknife. Cultures for Klebs-Loeffler bacillus were negative. A month later it was still impossible to remove the tracheotomy tube.

Inferior Turbinal Bodies.

A Fatality Subsequent Thooris, A. (Samto Cauterization of the pigny) (Revue Hebd. de Laryngologie. d'Otologie et de Rhinologie, January 11, 1908). A man. aged 35, apparently in robust health. suffered from intermittent nasal obstruction, caused by turbinal hypertrophy. Eighteen days after galvanocauterization of the left inferior turbinal body severe hæmorrhage took place from the left nostril, chiefly into the pharynx. It was not controlled until the whole choana was methodically plugged. Several attacks of syncope followed, and, although bleeding did not recur, the patient died about 30 hours after the cessation of the hæmorrhage. In the absence of an autopsy it was thought that, besides the great loss of blood, fatty degeneration of the heart was the cause of the fatal syncope.

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amination was made while an emulsion of bismuth was swallowed, and a black shadow was seen to form at the height of the supra-sternal notch. When it had attained the size of a small apple it ceased to enlarge. An incision was made along the inner border of the sterno-mastoid from the level of the thyroid cartilage to the supra-sternal notch; the deep cervical fascia was then split, the tonsils were turned outwards and the thyroid gland inwards. The sac then appeared in the depth of the wound and was found to have a pedicle of about 11⁄2 inches in length arising from the œsophagus at the level of the cricoid cartilage; the overlying muscles were dissected off and then

the pedicle was seized and ligatured; the pouting mucous membrane was cleaned. and then the muscular and other soft parts united by stitches. For two days nothing was given by the mouth, and nutrition was kept up by means of subcutaneous injections of salt solution. On the third day water, and on the fourth milk were given, and on the seventh normal food was taken. In regard to the ætiology, the author considers that the diverticulum began with a softening of the alimentary tube on the left side at the level of the cricoid cartilage, and that this yielded on account of mechanical obstruction to swallowing caused by the hard cricoid cartilage.

PUBLIC HEALTH AND FORENSIC MEDICINE.

UNDER THE CHARGE OF

F. C. CURTIS, A.M., M.D., of Albany,

Consulting Dermatologist, New York State Department of Health.

Dying Declarations.

The Supreme Court of Illinois says, in the case of People vs. Buettner, that dying declarations are such as are made by the party, relating to the facts of the injury of which he afterwards dies, under the fixed belief and moral conviction that his death is impending and certain to follow almost immediately, without opportunity for repentance, and in the absence of all hope of avoidance-when he has despaired of life and looks to death as inevitable and at hand.

The declarant in this case, when asked by her nurse how she felt, replied on two occasions: "I feel good," "Very well." From these expressions it may be assumed that there was nothing in her feelings that presaged her approaching dissolution. Still, if she had abandoned hope of life and looked on death as certain to follow immediately, the declarations would be admissible, even though

she was brought to this state of mind by the statements made to her by her nurse and physician.

The important question was, Did the deceased have a fixed belief that she was certain to die soon? If this was the state of her mind, it was no objection to her declarations that her belief was induced by the statements of her nurse and physician. The fact that the deceased manifested a desire for the consolations of religion, and caused a priest to be sent for. showed that the statements made to her by the nurse and physician had brought her to a fixed belief that death was near at hand.

The expression of the desire of the deceased for the consolations of religion, and especially when the particular religion or church of the deceased provides for the administering of certain rites to its members when, and only when, they are actually in articulo mor

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albumen contents and ashes. The lime contents of the ashes had considerably increased, however. The conditions were still more noteworthy in eggs which had been kept in lime for 35 months. The weight, the specific gravity, albumen contents and ashes of the albumen were diminished, whereas the lime contents of the ashes rose to 15.21 per cent. These figures show that the lime contents increase in proportion to the time of preservation in lime. Compared with non-preserved or fresh eggs, the contents in lime of the albumen and of the ashes present such a marked difference that the determination of the lime would seem to be more reliable in doubtful cases than the physical properties of the eggs. F. R.

MATERIA MEDICA AND THERAPEUTICS.
UNDER THE CHARGE OF

ALFRED C. PRENTICE, A.M., M.D.,

Assistant in Surgery. College of Physicians and Surgeons; Attending Physician, New York Home for Destitute and Crippled Children.

Moser's Serum as

a Egis and Langovoy Scarlet Fever Remedy. (Jahrb. f. Kinderheilkunde, Vol. 66, 1907). The clinical material for these investigations was supplied by the scarlet-fever patients of the Children's Hospitals, "St. Vladimir" and "Morosow," in the city of Moscow, during the years 1904-05. Upon the basis of their very detailed and accurate studies the authors arrived at the following conclusions:

I. In the treatment of severe cases of scarlet fever with Moser's serum the mortality percentage drops from 47.4 down to 16.1.

2. The serum possesses a predominant antitoxic action.

3. The influence of the serum upon the complications of scarlet fever is in

considerable.

4. The serum should be injected in the

course of the first three days of the disease; on the fourth day as an emergency procedure.

5. The temperature drops abruptly in proportion to the timeliness of the injection. In the pure cases the temperature diminishes more rapidly than in the presence of complications.

6. While no method exists for grading the dosage of the serum, 200 c. cm. must be injected at a time, except in the case of very little children, for whom the injection of 100 to 150 c. cm. prove sufficient.

7. The individuality of the horse has a marked influence upon the value of the serum, and it is for this reason that there are more or less efficient sera on the market.

8. In cases of mixed infection (scarlet fever and diphtheria) a noteworthy effect

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