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arates the successful from the fatal cases. The latter are then redivided into (1) those in which death was produced by the operation in the labyrinth, (2) those in which the labyrinth suppuration led to death, notwithstanding opening of the labyrinth; (3) those in which the cause of death was independent of the labyrinth suppuration, (4) those in which a fatal complication existed before the operation in the labyrinth. Of interest are those in which a diseased labyrinth was exposed. Of the 102 cases 70 belong to this class. In only one of these was death presumably brought about by the opening of the labyrinth. This gives the very small mortality of 1.4 per cent. The regular opening of a non-infected labyrinth seems to be relatively without danger; nine operations of this kind have been performed on account of Meniere's disease without purulent otitis, and in all cases recovery took place.

moid Sinus and Internal Vein, of Otitic Origin.

The Operation for Frank Allport, ChiThrombosis of the Sig- cago (Journal of the American Medical Association, April 25, 1908). In the mind of the author these complications occur with sufficient frequency to demand a careful study of them. In his article he takes up the following points: (1) Risk in sinus operations, (2) the appearance of the uncovered sinus, (3) the problem of diagnosis, (4) the removal of granulations, (5) location of the sinust (6) treatment of the thrombus, (7) ligation of the internal jugular, (8) excision rather than ligation, (9) anatomic relations, (10) treatment of wound, (11) treatment of shock.

The opening of the sinus, with its possibilities of infection through the already infected mastoid cavity, is an operative procedure of importance and danger. In

the opinion of the writer the sinus should usually be opened in the face of mastoid disease, either acute or chronic, accompanied by the characteristic phlebitic symptoms, but too energetic operative procedures should be avoided without quite positive indications. The color or physical examination of a sinus does not always clear up the pathology; however, a non-compressible or darkened sinus is fairly presumptive evidence of a thrombus. The author is opposed to the use of the aspirating needle, and also to the stroking method of Whiting, for diag

nosis. The author believes in the removal of granulations from the surface of the sinus in that a better inspection of the sinus can then be made. He advocates removing the bony covering by means of a small rongeur in preference to any other instrument. The location of the sinus is uncertain, though it is usually found about one-half inch behind the posterior bony meatus. The sinus is opened longitudinally, care being exercised to avoid cutting through its inner layer, thereby entering the brain. Plugs of gauze should be inserted in the ends in the event of free bleeding. One plug is placed above and one below the incision. Hæmorrhage from the sinus from both directions would indicate the absence of a clot, or, at least, any loose clots expelled by the flow of the blood. Absence or slight hæmorrhage indicates a clot in the direction of absence of flow. Ligation of the jugular is performed by some surgeons before proceeding to open the sinus, while others never ligate the vein unless there is lack of free flow of blood from below when the incision is made into the sinus. The author recommends this latter procedure, and after ligating the vein he excises it. Some operators ligate the vessel and do not excise it.

Aural Complications E. B. Dench, M.D., of Grip. New York (New York State Journal of Medicine, April, 1908). Epidemics of grip are characterized by aural complications of greater or less severity, but there is no aural condition which is absolutely characteristic of the grip infection. The middle ear is the portion of the organ almost invariably attacked, but there are instances where the auditory is involved primarily. The middle-ear condition may vary from a mild congestion of the Eustachian tube and tympanum to an exceedingly virulent inflammation of the middle ear, with rapid extension to the mastoid cells, and sometimes to the intracranial structures. Sudden onset and severe pain seem to be the rule in grip cases of acute otitis media. Some grip epidemics occasion much more ear affection than others, and likewise during some epidemics extension of the disease to the mastoid cells seems to be

the rule rather than the exception. Early and free incision of the drum membrane in these cases will, as a rule, prevent further operative interference. Abortive measures in cases of grip otitis are almost never successful, and it should be made a rule to incise these cases early. The after-treatment is the same as in other cases of otitis. When the aural inflammation has extended to the mastoid it is wise to operate very early as soon as there is distinct evidence of mastoid involvement-for once the mastoid is invaded, the involvement seems to spread with great rapidity in grip cases, so that the sooner that the mastoid cavity is opened and the pneumatic thoroughly ablated the more chances we have of avoiding serious intracranial complications. In many cases of severe grip infections there is no question but that the involvement of the middle ear and the mastoid cells is simultaneous.

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.

Phlegmonous Tonsilli- Ila de Angelis, tis-Its Mode of Form- .. "Phlegmonous Ton

ation.

sillitis and Its Mode of Formation" (Arch. Ital. di Laryng.). The author gives a full account of the minute anatomy of the soft palate and the tonsil, giving stress on the convergence of the lymph system of the former toward the palatine recess. The author then made examinations of the canine pharynx to determine how far its palatine tonsil resembled that of the human. In the dog the palatine recess differs from the human only in so far that it is placed in front of instead of above the tonsil. There is a certain resemblance in the ar

rangement in both species of the glandular structure and the invagination of the mucous membrane. There is, however, in the human tonsil a true diverticulum of the mucous membrane, in which the investigator found more of tonsillar tissue than has been heretofore described. Mucous glands are separate and above the hilum of the tonsil. The passage of micro-organisms in the dog always took place from the hilum to the tonsillar tissue proper, and not to the mucous glands.

He concludes as follows from his experiments: Phlegmonous tonsillitis has located always outside the tonsil proper as the result of the invasion of micro

organisms into the crypts of the hilum, which have become cicatricially united or are the seat of inflammatory reaction. The organisms advance toward the recessus palatinus. Because of this the tonsil proper escapes, even though the first

effects of the infection are felt at the hilum. The absence of organisms in the mucous glands demonstrates that these resist infection, although in the later stages these structures may be attacked.

theria.

Pathogenesis of Diph- Scheller and Stenger, "A Contribution Toward the Study of the Pathogenesis of Diphtheria" (Berl. klinische Wochenschrift, No. 42).

The authors call attention to the fact that the nose is more often the point from which the invasion of the diphtheria bacilli proceeds than is commonly supposed. They found the bacilli in the nostrils of persons about the sick patients for quite at time without causing any symptoms in the carriers of these organisms. Only after a while during a period of lessened resistance could such persons develop real attacks of diphtheria. The report is of importance from a prophylactic standpoint, in that it warns of a possible danger to such as might be brought in intimate contact with attendants of diphtheritic patients.

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3 to 14. The infection usually takes place in early adolescence, although two patients were seen giving their ages as 50 and 60 years, respectively. The author was unable to determine whether in the

given case the infection of the nasal mucous membrane was primary or not, and he leaves this question open, because he could not rule out tuberculous involvement of other organs in all the cases.

The site of origin was found usually to be the anterior portion of the septum, and only in advanced cases was the posterior septal region found to be involved. In one case an isolated tumor of tuberculous character was found located upon the middle turbinate. Diagnosis was substantiated in all the cases by histological examinations. Tubercule bacilli

were found in only two cases. The course of the disease differed individually; mostly the tumor was of an inoffensive variety. The prognosis is not good in these cases, especially so where other organs are found to be involved.

The Treatment of W. Posthumus Stuttering. Meyes (Tydschr. v. Geneesk). The author calls attention to the fact that physical influence has significant bearing on the heredity, and he holds that stuttering and backwardness when combined with the presence of adenoids is suggestive of degeneration. There are at present four methods of treatmment: (1) The method of Gutzmann (classical), in which conscious exercises of respiration, speech and movements of the muscles of articulation are made in harmonic co-operation; (2) Liebmann's method, which is a suggestive or physical method by which the fear of speaking is combated; in the Liebmann system only one person is treated at a time, and self-confidence is

thus gradually established; (3) the method of Chervin, which enforces silence upon the student outside of the lessons, so as to suppress the spastic movements of the face muscles; (4) the combined whisper and respiratory method, which contains principles from each of the previously enumerated systems.

As a causa morbi is often different in individual cases, no single method can be designated as the best one. The chief

point in the treatment of stuttering is a good instructor. The teacher must be one who can get the pupils under his personal influence. Every interference with normal nasal respiration must be corrected. Stammerers are benefited by extra instruction in speaking after the usual school hours. Stutterers should be sent to special institutions where they are taught how to speak in addition to the usual instruction.

PUBLIC HEALTH AND FORENSIC MEDICINE.

UNDER THE CHARGE OF

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

Medical Expert, New York State Department of Health.

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Bucknill, Isidor Zeifert was charged with the manslaughter of Jane Farvish by administering cocaine with a view to performing a dental operation. The prisoner, who was a Russian, said that no communication had been made to him that the deceased was suffering from her heart. He administered to her one-third of a grain of cocaine in 10 minims of water. He denied that he said the dose he gave was half a grain in 10 minims of water. The learned judge, in his summing up, referred to the evidence that cocaine was extensively used by dentists, and very often without an examination being made as to the state of the patient's health. He also alluded to the difference of opinion which exists among doctors as to what is an excessive dose. The medical works quoted for the defense state that a stronger dose than that which the defendant was alleged to have given would not be too much. It was also stated that cocaine is a most uncertain drug, and that it is impossible to say what its effects will be on any particular

person. The jury found the prisoner "Not guilty."

Several cases have come before the criminal courts at different times when the prisoners have been charged with manslaughter by administering noxious drugs. In R. v. Chamberlain the prisoner, an herbalist, was indicted for the manslaughter of a woman suffering from a tumor, to whom he administered an arsenical ointment without giving her any caution or directions as to the use of it. The deceased, thinking the more she rubbed in the better, rubbed and rubbed until she absorbed so much of the poison that she died. Justice Blackburn told the jury that if the prisoner, by culpable negligence, caused the death of the deceased, he was guilty of manslaughter, but not if death occurred through mistake or misfortune, otherwise no medical man would be safe. There must, however, be competent knowledge and care in dealing with a dangerous drug; and if a man is either ignorant of the nature of the drug he used or is guilty of gross want of care in its use, there is criminal culpability. All the direction he could give them was that if the prisoner administered the ar

senic without knowing or taking the pains to find out what its effect would be, or if, knowing this, he gave it to the patient to be used, without giving her adequate directions as to its use, there was, in either view of the case, culpable negligence, and the prisoner ought to be convicted; but if otherwise, the prisoner ought to be acquitted. It appeared to him that a medical man who should administer such a drug or allow a patient to apply it without taking care to observe its effects, or guard against them, would be gravely wanting in due care. A verdict of "Not guilty" was returned.

When, however, a blacksmith, by applying corrossive sublimate, caused the death of a man suffering from cancer, he was convicted of manslaughter. Baron Watson told the jury to find the prisoner guilty if they thought he took upon himself the responsibility of attending to a patient suffering from cancer without being qualified for the purpose. If he used dangerous applications, he was bound to bring skill in their use, and in this case the prisoner's education and employment made the use of these highly dangerous substances almost amount to a want of skill (R. v. Crook).

In R. v. Webb the prisoner was convicted of manslaughter in causing the death of a patient suffering from smallpox by administering large doses of Morrison's pills. Lord Lyndhurst said: "If, where proper medical assistance can be had, a person totally ignorant of the science of medicine takes upon himself to administer a violent and dangerous remedy to one laboring under disease, and death ensues in consequence of that dan gerous remedy having been so administered, then he is guilty of manslaughter. I shall leave it to the jury to say, first, whether death was occasioned or accelerated by the medicines administered, and

if they think it was, then I shall tell them that the prisoner is guilty of manslaughter if they think that, in so administering the medicines, he acted either with a criminal intention or from very gross negligence."

In R. v. Spencer the prisoner, a dulyqualified medical man, was indicted for the manslaughter of a patient by administering a mixture which contained strychnia instead of bismuth, and was acquitted. It was held by Justice Willes that the jury, before they could convict, must be satisfied that the circumstances showed such gross and culpable negligence as would amount to a culpable wrong and show an evil mind. That a blunder alone would not make the prisoner criminally responsible, nor the accident of someone else, and that the prosecution could not assume, but must prove, that the prisoner (who dispensed his own medicines) kept his ordinary drugs and his poisons in such a way that he could not tell which he was using. That the prisoner, being a competent person and properly educated in his profession, this was not like the case of a quack, who had not skill to master what he had undertaken, or who, from any bad motive, committed the act with which he was charged.-The Hospital.

The Bedroom.

Too often a bed is made up in a slipshod manner without being thoroughly aired. This should never be allowed. The covering should first be stripped back over two chairs set at the foot of the bed. The mattress should then be doubled so that the air may get to all parts of it, and left so for from half an hour to an hour. In very severe winter weather the time may be lessened. Each piece of bedclothing should be well shaken before it is restored to its place, and the pillows

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