Total Deafness Follow- L. J. Goldbach, M. ing Infectious Diseases D. (Laryngoscope, July, 1908). The disturbance of hearing or absolute total deafness following as an after-complication of the infectious diseases occurs quite frequently. Meningitis, with its division of encephalitis and basilar meningitis, seems to predominate; typhoid claims a goodly number, as well as diphtheria, parotiditis, hydrocephalus, syphilis, scarlet fever and measles. These cases usually occur in childhood. Nerve deafness is usually bilateral. A unilateral nerve deafness is usually due to a parotiditis or to a scarlet fever. Infection may follow a train of symptoms, bringing about total destruction of the organs of hearing, and consequently incurable deafness following. The pathological condition may go further and bring about deafmutism. Such conditions occur usually in childhood; yet there is no exemption for the adult. The sequelae of labyrinthine involvement leaves the diseased organs of hearing (the predilection seems to be for the auditory nerve) in an incurable state. The pathological condition. existing may be an exudate, causing either a primary or secondary atrophy of the auditory nerve or its nucleus, or in the aquæductus cochlea or labyrinth, or a chemical change of the perilymph. To bring forth this pathology, showing the destruction brought about by the different micro-organisms of these various diseases, is a difficult proposition. Perhaps their attack is on the nerve fibers through the aquæductus cochlea or the labyrinth,

or the weight of the infection may fal in particular on the endothelial covering of the labyrintheal cavity. How shall we decide when it shows itself by the different intensities through the severity of its infection? Do we have, in the severest forms, the necrotic falling off of the soft parts of the labyrinth, or a labyrintheal deafness, due partly to the direct influence of the toxin, thereby leaving a cellular and fibrinous deposit on the endothelium of the bony framework, or the purulent exudate dwindling to a small collection and covering the space cavity in the labyrinth to a more or less degree?

What, then, in summing up the pathological condition, takes place? Are the results of such inflammatory reaction the following:

First. A degenerative or intracellular change of the auditory nerve sheath?

Second. A perverted chemical change in the perilymphatic spaces of the labyrinth, partly destroying its membranous structure?

Third. A secondary inflammatory exudate near or on the floor of the fourth ventricle, leading to secondary atrophy of the auditory nuclei?

Fourth. A pathological condition of the blood taking place-a toxæmia?

Fifth. An inflammatory exudation of the meninges extending to the acoustic nerve?

Sixth. Why is not the facial nerve involved in such violent inflammatory con

ditions, especially when it is in such close. proximity to the eighth nerve?

The author reports eight cases.

it was entirely blocked by a severe swelling, starting from the anterior lower wall of the auditory meatus, corresponding to the boundary of the cartilaginous and

mon.

Bezold observed only two corresponding cases among 20,000 affections of the auditory meatus. Hasslauer, in 1899, was enabled to compile 30 cases from the literature, including three personal observations. At a later date four cases came under treatment in the practice of Dr. Passow, one of these patients being the subject of the present demonstration (meeting of Berlin Otological Society, November 13, 1906):

Man, age 28 years. Had a bad fall on October 27, striking with the chin upon the pavement. When he regained consciousness after 15 minutes' syncope he noticed blood coming from his chin and his right ear. There were no vertigo and nausea, and he was able to walk to his home, about half an hour's distance. bandage was applied at the time, but had to be changed very soon on account of recurrent hæmorrhage from the right ear. The patient was admitted to the author's clinic on the first day of November. The right auditory meatus was filled with pus;

A

which is possible without pain to a slight extent only a movement toward the surentirely bare of epidermis. This motion face is seen within the swelling, which is increases in proportion to the opening of the mouth, and is certainly referable to the detached fragment of bone. At the time of admission to the clinic the surroundings of the right maxilla were still swollen and the chin on the left side presented a wound 2 cm. in length. Hence the left lower maxilla seems to have borne the brunt of the violence; the inferior maxilla at this instant presumably made a forcible movement toward the right side, the fracture originating in this manner. The inferior maxilla is most readily driven against the lower wall of the auditory meatus, when the violence does not come directly from the front, but acts laterally. The presence of simple fracture of the wall of the auditory meatus, instead of fracture at the base of the skull, was indicated by the absence of cerebral manifestations and of the discharge of cerebrospinal fluid. The treatment consists in fixation dressings and suitable diet. Hearing does not appear to be affected in this type of fracture. F. R.

the soft parts and the periosteum from the facial side of the maxillary antrum follows, i. e., from the bone underlying the cheek. The mucous membrane of the lateral wall of the nasal cavity is then lifted off.

The aperture is now enlarged by removal of surrounding bone, and the bone of the nasal and the facial walls of the · maxillary antrum as far as reachable is removed. Flaps are cut from the mucous membrane having bases toward the rear, and the after-treatment is by the open method.

The author suggests that all these procedures are possible under local anæsthesia, using the following mixture: Cocaine hydrochl.....

Tinct, iod. decolor.

Trid. carbol...

Glycerine.

Aqua dist...

1.0

āā 0.3

10.0

100.0

To 1.0 of this mixture there is to be added two drops of adrenalin (1:1000), and of the solution thus combined about 3 ccm. are injected along the lines of in

cision.

The author suggests the following as the points for injecting the anaesthetic: (1) From the mouth directly over the canine tooth into the facial side of the tissue overlying the lateral wall of the antrum, and (2) in the nasal cavity directly around the apertura pyriformis, and upon the lateral nasal wall.

The injection must be subperiosteal. Anæsthesia takes place after 10 minutes. The author does away with the unbearable hitting strokes of hammer and chisel by employing an electromotor and trephine.

Kuttner (Deutsch. Nasal Dysmenorrhoea. Med. Wochen., 1908, page 1050). The author criticises the

views of Fleis and his followers in believing the nose to be a reflex center acting in conjunction with the genital organs, and he takes decided exception to the conclusions drawn by Fleis from the clinical picture of nasal dysmenorrhoea. The article is interesting as an analysis of the entire question.

The Indications for Rethi (Wiener KlinOperations on the ische Woch., 1908, Nasal Septum.

page 873). The author is right in expressing regret at the great frequency with which the various operations on the nasal septum are undertaken without sufficient cause, and he believes that many such operations would not have been performed had the attending surgeon understood the history of the nasal obstruction with which he was attempting to deal. In the latter regard, it is of the greatest importance that the commencement and the variety of nasal obstruction be carefully studied.

The article is timely, in that it calls a halt on the performance of the submucous resection of the nasal septum, which is so often done without bettering the condition of the patient's breathing at all, because other and more urgent conditions are present in the nose demanding correction. The hypertrophied turbinates, the nasopharynx, etc., should all receive attention before the submucous operation upon the septum is performed, if the obstructed. breathing is to be bettered.

evoked by many irritants other than new hay, it is advised that attention should be paid to the pseudoform of the disease, which is provoked by the presence in the nose or nasopharynx of polypi, exostoses, turbinal hypertrophies, etc. These projecting morbid tissues, mainly by irritating the sensory terminals of the surface. opposed to them, render hyperæsthetic not only this surface, but also the center to which the sensory impulses are transmitted, that of the fifth nerve pair. Such cases are often not only sensitive to many pollens, but also to many commonplace. irritants. They are readily cured, he asserts, by properly executed removal of the morbid growths, but in such a way that no adhesion or synechiæ are left between the opposed surfaces. Cauterization of the hyperæsthetic areas caused by them, by the local application of glacial acetic acid, chromic acid or galvanocautery, tends further to insure recovery. In the number of the Monthly Cyclopædia and Medical Bulletin cited he instances cases

of cures effected by caustic applications to the hyperæsthetic areas and describes. the modus operandi of remedies administered internally, first showing how the morbid symptoms are awakened by the atmospheric irritants. When these specific irritants appear in the air, as interpreted from his standpoint, the violent sensory impulses transmitted to the trigeminal center provoke reflex dilation of the arterioles which supply blood to the mucosa of the nose, sinuses, conjunctivæ, etc., and all these structures become intensely congested-the exciting cause of the distressing symptoms. He therefore argues that beneficial effects can be obtained by remedies which either locally or by acting on the sympathetic center provoke constriction of the dilated arterioles.

He condemns the use of cocaine

solutions, which, while effective, are dangerous, owing to their liability to produce a cocaine habit in the patient. Far safer and just as efficient, according to him, is a weak-1 to 10,000-solution of adrenalin chloride, prepared with normal salt solution. This solution, by depleting the engorged mucosa, affords the patient considerable comfort, and this effect may be sustained by spraying over the constricted mucosa a solution of menthol in any light petrolatum oil, of the strength of five grains to the ounce. A saturated solution of quinine used as a spray, followed by the application of an ointment composed of 30 grains of quinine and one ounce of petrolatum, are recommended by Fulton. These measures, however, should only be regarded as palliative, serving to relieve stenosis, allay irritability and control excessive secretion.

As internal treatment belladonna has given Dr. Sajous the best results when used in conjunction with local treatment. To adults he gives 1-120 grain of atropine three times daily until slight dryness

of the throat occurs, when the effect may be sustained by one or two doses daily. When asthma complicates the case he employs instead the following preparation: R Tincture of belladonna.

..ss

Potassium iodide.... .5ii Water....q. s. to dissolve the iodide Syrup of orange peel, q. s. to make iii M. et Sig: One teaspoonful every three hours until the paroxysm is arrested.

Earlier in the article Sajous speaks of the gouty diathesis as being an underlying cause of hay fever, this diathesis being attributed to an inadequate breaking down of wastes. The only remedy which has served him faithfully in counteracting the gouty diathesis is desiccated thyreoid, which acts by enhancing, as do the iodides, the catabolism to toxic wastes. It may be