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namely, the hearing will be much improved, often approaching normal. About the indications for operation he remarks that it is too early to accurately forecast the same, as only an extended experience will afford the data for such a forecast. There are, however, certain broad principles on which the indications may be tentatively based. Based upon therapeutic indications, chronic mastoiditis may be divided into three classes, namely: (1) Those amenable to non-operative treatment. (2) Those amenable to the meatomastoid operation. (3) Those amenable only to the radical mastoid operation. The meatomastoid operation is contraindicated in: (a) All simple cases curable by non-surgical and minor surgical treatment through the external auditory meatus. (b) All cases curable by the

proper surgical attention to the epipharynx and posterior ethmoidal and sphenoidal sinuses. (c) Cholesteatoma of the tympanic cavity. The removal of the cholesteatoma from the tympanic cavity would dislocate the ossicles, and if this is done the radical operation should be performed, as the chief object of the meatomastoid operation would be destroyed, namely, the preservation and improvement of the hearing. (d) Epidural abscess with its atrium of infection through the tegmen tympani. (e) Brain abscess. (f) Infection suppuration and necrosis of the labyrinth. It is, of course, contraindicated in any case in which it fails for any reason to remove all morbid material and secure adequate drainage. It is indicated in other cases in which simpler measures have failed.

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.

A Case of Mistaken Goris (Zeitschr. f. Diagnosis. Laryngol., Vol. I, Part 1, Brussels). The case was that of a man, aged 45, who suffered from severe neuralgia in the right upper incisor teeth. The teeth were removed by a dentist, but were found to be sound. The pain persisted, and a few days later was felt in the upper canine tooth of the same side. This was removed, but without benefit, and subsequently a part of the alveolar margin was chiseled away and the maxillary antrum was opened by a surgeon. The antrum was found to be normal and the pain continued unabated. Analgesic drugs produced only temporary improvement, and the pain, which at first was located only in the front part of the upper jaw, gradually increased and extended so as to involve the whole upper jaw

on the right side. A laryngologist whom the patient consulted discovered and removed some spicules of bone which had been left in the wound by the surgeon, but without benefit. It was now concluded that the neuralgia must be of a hysterical nature, and treatment by suggestion was tried. This seemed at first, in combination with morphia and chloral, to be of some benefit, but the pain soon afterwards returned in its original severity, and was now felt chiefly in the lower jaw on the same side. At this stage -five months after the illness beganthe patient was first examined by the author, who, on digital examination of the nasopharynx, detected a tumor growing from its right lateral wall. This had evidently at first exerted pressure on the nerve branches to the incisors, afterwards

on those to the other teeth from before backward, and finally passing into the zygomatic fossa, had involved the inferior maxillary nerve. No operation was attempted, and the patient died a fortnight later of cerebral embolism. It is reasonable to suppose that had the meaning of the pain been correctly interpreted early in the case relief from the pain, if not a cure, could have been effected by operative treatment.

Webs.

Congenital Laryngeal Hansberg (Zeitschr. f. Laryngol., Vol. I, Part 1). Laryngeal webs of congenital origin are much more uncommon than those which are acquired, and, indeed, only a little more than 20 cases are described in literature. All of these arose from the anterior commissure and extended backward for a variable distance, but not farther than the vocal processes. They were much thicker in front than behind, and ended posteriorly in a concave border. In two cases, in addition to the membrane between the cords, a second was present at a slightly higher level. Suggestions of web formation are not infrequently met with in the form of a curved instead of an angular anterior commissure.

The author's case was that of a female child, aged eight days, who had been quite voiceless since birth and had shown signs of respiratory obstruction. It was not possible to obtain a view of the larynx, but some congenital malformation was suspected. During the first four months of life the respiratory obstruction gradually increased, and eventually necessitated the performance of a tracheotomy, which was delayed until the last possible moment. This was followed a fortnight later by thyrotomy under cocaine and suprarenin. There was found a thick, firm membrane, beginning in

front at or below the anterior commissure, adherent for a short distance to the right vocal cord, and extending backward and upward on the right side to end just in front of the arytenoid at about the level of the ventricular band. The membrane was dissected out and the laryngeal wound closed. Beyond a rise of temperature for a few days, which occurred also after the tracheotomy, the child displayed no adverse symptoms. The cannula was soon left out, and six weeks later healing was complete and the voice was loud, though a little hoarse. The child has since developed excellently and remains perfectly well.

This case differs from others hitherto reported in that the membrane was asymmetrical, being attached to only one side of the larynx. It is further of interest as an example of the survival of a child of four months after tracheotomy and thyrotomy.

A Case of Acute Leukæmia, With Death, Following Adenotomy.

Hug (Fourteenth Meeting of South

ern German Laryngol. Soc., May, 1907, Internat. Ctrlbltt. f: Ohrenheilkd., V, 1907).

The patient was a child three years of age, of delicate appearance, with considerable enlargement of the pharyngeal and palatine tonsils, presenting the ordinary features. The adenoid vegetations were removed without general anesthesia. There was no secondary hæmorrhage, but about a week later the patient became very weak.

The liver and spleen were enlarged, and there appeared small localized petechiæ. At the end of another week the patient died. An examination of the blood, which was made 16 hours before death, yielded the typical findings of acute leukæmia, and this was confirmed by the autopsy. In all probability a latent leu

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

Consulting Dermatologist, New York State Department of Health.

Record Decrease in the The quarter ending Death Rate in England. June last showed the lowest death rate recorded in any second quarter since civil registration was established. The deaths registered in England and Wales were at the rate of 13.8 per 1000 of the population, which is 1.8 per 1000 below the mean rate for the corresponding quarters of the last 10 years. The lowest rates were in the counties of Middlesex (10.8), Essex (11), and Kent (11.2). The three Welsh counties, Glamorganshire, Denbighshire and Carmarthenshire, showed the highest rates, which were 15.7, 15.7 and 18.9, respectively. In the 76 cities with populations exceeding 50,000 there was a marked decrease in the mortality. The rate was 13.7, as against 14.7, 14.8 and 14.9 in the three preceding corresponding quarters. The same holds true of the 142 smaller towns, with populations ranging between 20,000 and 50,000. The rate was 12.9, as against 13.6, 13.4 and 14 in the three preceding corresponding quarters. The birth rate for the quarter shows a decrease of 1 per 1000, as compared with the average for the preceding 10 years.

The Artificial Illumina- Myles Standish tion of School Rooms. (Ophthalmology, October), in the course of an illustrated

article, summarizes as follows the essential facts in the proper illumination of school rooms:

I. The walls should be painted a very light color, preferably an exceedingly pale green or buff.

2.

The wooden finish of the room and desks should be light in color.

3. The windowshades should be able to exclude direct rays of the sun, diffuse daylight freely, and also in the evening reflect a given portion of the light which falls upon them.

4.

Direct illumination is desirable.

5. The lighting stations should be so arranged that no annoying shadows shall fall upon the pupil's desk.

6. The newer forms of incandescent lamps and Zalinsky shades, when properly arranged, can give a candle foot illumination of 2.5 on each and every desk in the ordinary school room; and, finally,

6. That in most cities the expense of electricity used in the manner above described is not so much greater than the cost of gas as to be prohibitive. W. M. C. Protective Inoculation Hutyea, F. ("Zur of Cattle Against Tu- Frage der Schutzimpflung von Rindern gegen Tuberkulose," Zeitschrift fur Tiermedizin, XI, 1907). The experimental

berculosis.

experience gained in the course of four years since the employment of the protective inoculation recommended by v. Behring for the immunization of cattle permits a conclusion to the effect that:

I. The intravenous incorporation, twice repeated, of human tubercle bacilli serves for an immediate and considerable increase of the power of resistance of cattle against a later artificial infection, but 2. This artificially increased resistance is not of long duration, diminishing considerably about the end of the first year after the protective inoculation, and sometimes being entirely lost after six months more.

Since a single subcutaneous injection of human tubercle bacilli is to be ranked as equal in protective power with the intravenous inoculation in two sessions, the

above conclusions presumably apply to this method as well. There are as yet no experimental proofs for the assumption that a single intravenous protective inoculation produces a permanent immunity. Theoretical considerations suggest, on the contrary, that protective inoculation according to this method is inferior to the one first mentioned. These conclusions, based upon experimental findings, show the practical value of the methods hitherto employed in a rather unfavorable light; the more so since in certain cases the power of resistance of the inoculated animals was found to be insufficient also toward infection on the part of tuberculous animals. The autopsy of inoculated animals showed that no immunity was manifested in case of feeding with tubercle bacilli. F. R.

THERAPEUTICS AND RADIOGRAPHY.

UNDER THE CHARGE OF

G. M. MACKEE, M.D.,

Instructor in Dermatology at the New York University and Bellevue Hospital Medical College; Radiologist and Radio-Therapeutist to St. Vincent's and the Red Cross Hospitals.

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this question very intelligently and from a practical point of view. He points out the difficulty of making a correct clinical diagnosis of injuries, especially when in the neighborhood of a joint. Not infrequently an injury is diagnosed as a fracture and the part placed in a plaster splint. Later a radiograph demonstrates the absence of fracture, but the presence of a dislocation which was not suspected and which had been made permanent by failure of reduction, immobilization, etc. There are, in fact, many cases of traumatism where it is impossible to make an early diagnosis on account of the pain and swelling, and very often the injury, even after the swelling has subsided, is of such

nature as to mislead the best surgeons. In these cases it is very easy to establish a correct diagnosis by means of the X-ray, and while a hæmatoma, swelling and pain were formerly accepted by the courts as an excuse for the non-recognition of fracture, etc., such is not the case now. Physicians who neglect to advise the employment of the X-ray in these cases expose themselves to an action for damages in which they will be accused of neglect to exercise the "reasonable care and skill" which is required by law. The physician need not, of course, make the X-ray examination himself, but, to be on the safe side, he should advise the patient or the patient's family to consult a radiographer. It is also advisable to locate foreign bodies by roentgenological means and then to operate immediately. The necessity for this is shown by the following case: A

needle was demonstrated in a child's stomach by means of the X-ray. Three days later an operation was performed, but the

Another examination made after the operation showed that the needle had wandered from its previous position.

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Radiography Amédée Granger,

(Radiographs in Relief) M.D. (Archives of the Roentgen Ray, August, 1908). The

FIG. 1. (MacKee, Dental Digest, May, 1908). Radiograph of Normal Foot.

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