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Observation on the InComplica

tracranial

tions of Middle-Ear Suppuration, with a Report of Ten Cases.

OTOLOGY.

IN CHARGE OF

R. JOHNSON HELD, M.D.,

Assistant Surgeon, Manhattan Eye, Ear and Throat Hospital, New York (Ear Department); Attending Otologist, New York Red Cross Hospital.

S. J. Kopetzky, M.D., New York (an abstract of a paper read at the annual meeting of the Medical Society of the State of New York at Albany January 30, 1908). The paper is introduced by a brief resume of the anatomical routes traveled by the purulent process from the middle ear to the cranium. The role played by the radical mastoid operation in arousing into activity latent brain or meningeal lesions is discussed.

A citation of the cases follows. These cases under observation within the last 18 months. The intracranial lesions followed, or were found at the time of operation in four simple mastoidectomies and six radical mastoid operations.

In age the cases ranged from one year to 52 years. Both sexes were represented, there being six females and four males. The left side was diseased four times, the right six times.

The duration of the ear trouble prior to coming under observation ranged, for the acute cases, from two to four weeks, and for the chronic cases from 18 months to 17 years. The acute cases mostly occurred in childhood.

In two of the acute cases an interval of time elapsed between the first operation and the advent of the intracranial lesion. The latter was ushered in with sudden facial paralysis and high fever. Gastrointestinal disturbances and the absence of otorrhoea masked the progress of the lesion in a third case among children until the advent of facial paralysis and the simultaneous appearance of otorrhoea

drew attention to the ear. In these three cases the intermediate lesion was a purulency of the labyrinthine channels.

In three cases there was presented all the external evidence of retro-auricular subperiosteal abscess, yet upon incision of the integument no fluid pus was evacuated. The superficial tissues overlying the mastoid process was found to be indurated, oedemateous and friable.

The mastoid cortex was found to be perforated four times-three times among children, once in an adult aged 38 years.

Marked albuminuria presented in a case of sinus thrombosis.

Inequalities in the size of the pupils was noted. In two cases the larger pupil corresponded with the diseased side.

The middle cranial fossa was invaded alone four times; the posterior cranial fossa was involved alone four times, and both middle and posterior fossæ were found involved twice.

In a general way two routes were found to have been traveled by the pathologic process to the cranium.

1. The direct route; this method of intracranial invasion is by contiguity, the disease spreading from the middle ear to the inner mastoid table, and by contact involving the dura, of either the sinus, or directly overlying inner table or tegmen. Meningeal inflammation follows. This was the finding in seven cases.

2. The indirect route; the disease spreads from the middle to the internal ear, involving the meninges and brain. only after first invading the labyrinthine channels. This was the finding in three

cases.

Cases occurred in which the advance

ment of the disease was discovered at op-
eration at various stages, different com-
binations of lesions being presented. The
following pathological lesions were rep-
resented in this series of cases:
1. Pachymeningitis externa (extra
dural abscess, including peri-sinus ab-
scess), seven times.

2. Pachymeningitis interna (intra dural abscess, both cerebral and cerebellar), four times.

died before the result of the operation was determinable, probably from shock. In the remaining fatal cases the disease progressed in spite of the surgical measures undertaken.

2. Evacuation of extra dural and intra dural meningeal pus collections, evacuation of brain abscesses and the establishment of meningeal drainage.

3. The maintenance of the intracranial pressure as near normal as possible, through repeated employment of lumbar puncture. Additionally, if the disease, as evidenced by the symptom complex, is found to be advancing through the labyrinthine channels, the exploration of the internal ear becomes imperative.

The results from operation were as follows: Of the ten cases, six died and four recovered. Of those terminating fatally, one died of septic pyæmia, the operation having been undertaken too late. to permit recovery from the profound general sepsis. A second case, in a child,

The extent of the lesion does not seem necessarily to cause a fatal outcome, for in one of the cases which recovered pus was evacuated not only extradurally and intradurally, but also from the lateral ventricle, by ventricular puncture and from the subarachnoidal space by lumbar punc

3. Purulent labyrinthitis, three times. 4. Cerebellar abscess, one time.

ture.

5. Cerebral abscess, one time.

6.

Sinus thrombosis, one time. 7. Ulceration on the brain cortex, one time.

8. Pus in the lateral ventricle, one time.

It seems that at the present state of our knowledge of these lesions a meningitis produced by contiguity offers 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 obtains from a purulency in the

A brief outline of the surgical therapeutics is given. The indications for intracranial surgery call for three objectives:

1. Eradiction of the causative disease posterior cranial fossa, and furthermore,

I.

in the temporal bone.

the disease in the posterior cranial fossa when operated upon will not yield to treatment unless the labyrinthine purulency is first eradicated.

The paper concludes with a plea for early surgical intervention at the first sign of labyrinthine involvement, and for the systematic inspection of the meninges in all cases evidencing suspicious symptoms during the post-operative period.

The operation on the labyrinth should not be deferred until meningeal symptoms supervene, 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 would otherwise develop general meningitis and terminate fatally.

Finally, even the most desperate cases

from the clinical standpoint should be subjected to exploratory operation, for occasionally surprising results will fol

LARYNGOLOGY AND RHINOLOGY.

Experience with Kill- L. Mader (Archiv
ian's Radical Operation für Laryngol., Vol.
for Chronic Empyema 20, Part 1).
The
of the Frontal Sinus.
author gives the fol-
lowing account of the results he obtained
in 14 cases of disease of the frontal sinus
with the Killian radical operation. The
time of his report is six months after
these operations were undertaken.
found as follows:

He

UNDER THE CHARGE OF

S. J. KOPETZKY, M.D.,

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

unfavorable results which some surgeons have obtained.

A short description of the author's method of treating empyema of the maxillary antrum follows. He holds strictly to local post-operative treatment under full control of the eye through a large opening in the nasal fossa, and has obtained good results through exposure of the cavities to the action of the light.

Latterly he has used a galvano-cautery burner of special design for the purpose of thoroughly cauterizing the cavity walls at intervals in the course of from two to four weeks. This produces inflammatory reaction, which is never excessive, and, if painful, is made more comfortable by the application of ice. He has used this method thus far in seven cases, three of which are still under treatment and two are almost cured, there being a distinct diminution of discharge. The remaining two show no discharge, although these were of long standing and had been under treatment for long periods and had never shown even a temporary suspension of purulent discharge.

The pain in all the cases was either greatly diminished or entirely absent. In no instance has it returned to its previous intensity. It is noteworthy to remark that the pain seldom subsided immediately after operation. The discharge ceased in a few cases, but although much diminished in quantity it continues in the majority, consisting mainly of mucus. He finds the reason for this in the preservation of the orbital bridge, which naturally makes the complete obliteration of the frontal sinus impossible. In the vast majority of his cases the cosmetic results are excellent. Some few, with very high and deep cavities, show very pronounced depressions. In all the cases the general health has been strikingly improved. In several cases which he exhibited mild depressions prior to operation became completely normal. All the cases, with one exception, are now following their accustomed occupations.

low, and the exception to the generally fatal rule will save the life of one whe otherwise certainly would die.

The author regards the Killian operation better than any other, and ascribes to incompleteness of operation failures or

Therapeutic Effects of Hector Christian
Thyroid Grafts in Man.
(New York Medical
Journal, April 20, 1907). The author
finds that the grafts transplanted not only
do not deteriorate, but become actively
hypertrophied. They form adhesions
with newly-developed active tissue and

take on fully the character of the normal plant. A myxedema, after two operations, became fully cured in the course of three months. The author tried the treatment in cases of cretinism with good results. The younger the patient, the better the result. Children with late dentition, late development of speech and general undevelopment, although three or four years of age, were considerably influenced and their development improved through the thyroid transplantation.

Solis-Cohen (JourLatent Diphtheria. nal of the American Medical Association, July, 1907). The author uses the term "latent diphtheria" for cases showing no pseudo-membrane, but at the same time demonstrates specific diphtheria infection. He reports on 27 cases in which the diphtheria bacilli were found, mostly demonstrable after culture. There are mild aseptic cases which run their course without any symptomatic symptoms, usually under the form of a mild tonsilitis or pharyngitis. He considers such cases as contagious as those

with fully developed symptomatic effects, and would have them treated as infectious cases, even though no symptomatic symptoms are observable.

Relapses in Diphtheria.

Rolleston (British Journal of Children's Diseases, Vol. 4, p. 332). From his investigations the author concludes that relapses in cases of diphtheria happen in a little more than I per cent. of all cases. They are less frequent than light tonsilitis in convalescence from diphtheria and they usually do not occur before. the third weck. Serum rash, after rein

jection of antitoxin, occurs often. The appearance of the rash is earlier and its volume more intense than usual.

PUBLIC HEALTH AND FORENSIC MEDICINE.

Differential diagnosis between relapses in diphtheria, antitoxin redux, scarlet fever and light tonsilitis is necessary. The relapse in diphtheria is usually more mild than the primary attack and generally of obscure causation. Mild doses of antitoxin are recommended for its treatment.

UNDER THE CHARGE OF

Incineration is as old as the world, and was adopted by the most learned nations. It was the universal custom in the Bronze Age.

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

Medical Expert, New York State Department of Health.

Even the Hebrews resorted to this means, for King Saul and his sons were incinerated.

The Mexicans practice cremation, and when men killed in battle were missing

SANITARY AND OTHER REASONS FOR THE INCINERATION OF THE HUMAN BODY.

BY WILLIAM OLIVER MOORE, M.D., LL.B., of New York, Professor Emeritus, Diseases of the Eye and Ear, New York Post-Graduate Medical School and Hospital, etc.

they made figures of them, and after honoring these burned them and buried the ashes.

Mass incineration has been in vogue for several ages on the battlefield. It was employed before Paris in 1814, at Sedan in 1871, in Russia after Napoleon's defeat in 1813. in the Chino-Japanese war, and recently at El Caney in 1898, and

most recently in the Japanese-Russian conflict.

On the battlefield it becomes a necessity. Why not in private life have the method adopted as promptly?

In Italy incineration has been legal since 1877, and it has 25 places where this process is used; Sweden has three; Germany, six; England, four; France, three; the United States, twenty-six; Canada, one.

Incineration was first scientifically performed in the United States in 1876 at Washington, Pa., and now, 31 years afterward, we have only 25 more. This growth is indeed slow, but in the right direction.

The following table shows the growth and the locations of the cemeteries:

CREMATORIES.

CREMATIONS AND CREMATORIES IN THE UNITED STATES, 1876 TO 1900.

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Since 1900 it is estimated that 10,000 have been incinerated, making, roughly, 24,000 since records have been kept. The latest to be added in North America is the Mount Royal, at Montreal, Canada, in 1901, the gift of Sir William McDonald, now living, and by the bequest of John H. R. Molson. The cost is estimated from $50,000 to $70,000. Sixtysix incinerations have been made.

During the epidemic of yellow fever in New Orleans in 1853 in one district the mortality was 452 per one thousand cases, more than double that of any other. In this district were three large cemeteries, in which during the previous year more than 3000 bodies had been buried.

Pasteur, when investigating an outbreak of splenic fever which destroys

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