LARYNGOLOGY.

WILLIS SIDNEY ANDERSON, M. D.

ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

THREE CASES OF ETHMOFRONTAL SINUSITIS WITH SPONTANEOUS EVACUATION THROUGH THE

ORBITAL REGION.

SAINT-CLAIR THOMPSON (Revue Hebdomadaire de Laryngologie, d'Otologie et de Rhinologie, June 30, 1906) calls attention to the comparative rarity of sinusitis opening into the orbit.

The first case reported was that of a woman aged eighteen, who had an abscess at the level of the left eye following influenza. The symptoms were those of ethmoid, frontal and maxillary sinus suppuration. Incision and evacuation of the pus cured the patient without further operation.

The second case was that of a boy, aged eleven, who had an abscess of the frontal sinus following a cold. An incision was made, and pus evacuated containing the micrococcus catarrhalis in pure culture. The sinus was drained through the anterior wall and cure resulted. There was no pus found in the nose.

The third case was that of a woman, aged twenty-five, who had chronic sinusitis with acute frontoethmoidal exacerbations. The external abscess was incised, a fistula remaining. Two months later an operation demonstrated that the fistula led to an anterior ethmofrontal cell. Several operations were necessary before a complete cure resulted.

The author compares these cases with abscess in the mastoid region. If the infection is recent, then incision is sufficient as in the first case. More severe cases require incision and drainage as in the second, while severe cases require radical operative treatment, as in the third. Transillumination was of value in the first case, where only one side was involved. The absence of fever and general symptoms were characteristic of these cases.

PROCTOLOGY.

LOUIS JACOB HIRSCHMAN, M. D.

CLINICAL PROFESSOR OF PROCTOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

THE OFFICE TREATMENT OF INTERNAL HEMORRHOIDS BY OPERATION.

IN the March, 1906, number of The Therapeutic Gazette, Tuttle states that the operative treatment of hemorrhoids in office practice resolves itself into excision with suturing of the edges, or ligature with or without transfixion. He discards the cautery on account of the radiation of heat beyond the anesthetized area. The ligature is the easiest, quickest and most satisfactory in the majority of cases.

He

describes his technique thusly: After the parts are thoroughly sterilized, he injects twenty or thirty minims of a half per cent solution of cocain into the region of the lesser sphincterian nerve on either side. of the posterior commissure. After waiting three minutes a duckbill speculum is introduced into the anus, and with this held firmly at the anterior commissure, the sphincter is massaged with the finger for five minutes, until it becomes loose and placid. Care should be taken to avoid traumatism to the mucous membrane. After dilatation is accomplished, the hemorrhoids are caught one by one and injected with a one-tenth per cent solution of cocain, and dissected up until a narrow pedicle is formed well within the rectum. If the blood-vessels are large, he transfixes with a double-threaded needle and ties on either side, otherwise a single ligature around the mass suffices. The tumor is then cut off below the ligature. After all the hemorrhoids have been removed, he applies adrenalin solution to prevent subsequent oozing, and the patient is allowed to go after a few minutes rest. The operation may be modified by suturing the edges of the mucous membrane, but Tuttle sees no advantage over the ligature, and he rarely employs it.

NEUROLOGY.

DAVID INGLIS, M. D.

PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE DETROIT COLLEGE OF MEDICINE.

AND

IRWIN HOFFMAN NEFF, M. D.

ASSISTANT PHYSICIAN AT THE EASTERN MICHIGAN ASYLUM.

MULTIPLE SCLEROSIS: A CONTRIBUTION TO ITS CLINICAL COURSE AND PATHOLOGICAL ANATOMY. TAYLOR again states (Journal of Nervous and Mental Diseases, June, 1906) the now well-recognized fact that multiple sclerosis is more common, especially in this country, than we have formerly supposed. He gives a résumé of the reports on this disease, and also reports twelve cases illustrating some of the difficulties of diagnosis. and exemplifying the necessity of a thorough consideration of every case before the diagnosis of multiple sclerosis is excluded. Separate paragraphs are devoted to the frequency, diagnosis, prognosis, and pathological anatomy of the disease. Taylor believes that the diagnosis of multiple sclerosis is often absolutely impossible to make with assurance during life, even in advanced stages of the disease. He furthermore says that it is likewise possible that the diagnosis made relatively early in the disease may give place to another as the process extends. The writer also inclines to the view that the etiology of the disease is still obscure and ventures the supposition of a selective poison acting through the blood-vessels. Our chief interest, he says, still centers, as it has in many years past, in the pathologic anatomy of the condition, and in this field much interesting and important work has

been done, with an alteration of opinion regarding the character of pathologic process. The article is a valuable edition to this supposedly rare disease and an extensive bibliography appended enhance the value of the paper.

The general conclusions given by Taylor are as follows:

(1) The rarity of the disease in this country has been overestimated. A more careful examination of atypical cases and a more open mind in diagnosis is desirable.

(2) The importance of observing and properly estimating minor symptoms of the disease, particularly unexplained spasticity and ocular disorders, must be emphasized.

(3) The etiology remains obscure. The pathological anatomy is still a hopeful field for study. Present evidence points towards a primary destruction of the myeline with either a secondary or coincident proliferation of the neuroglia.

I. H. N.

"THE ADVISABILITY OF ELIMINATING THE TERMS MENIERE'S DISEASE AND MENIERE'S SYMP

TOMS FROM OTOLOGIC NOMENCLATURE."

EMIL AMBERG (American Journal of the Medical Sciences, July, 1906). Amberg's article is made up largely of excerpts from contributors to this disease. The concluding paragraph quite well expresses the author's opinion of the symptom complex, and is as follows:

"We do not speak nowadays of heart disease or of heart symptoms, of lung disease or of lung symptoms, nor of kidney disease or of kidney symptoms. We are expected to diagnose and name a recognizable affection of these organs more definitely, and if this is impossible, in some instances, we leave the question open with the understanding that further investigation is required to clear up some dark points. The same rule, I think, should be followed in otitis interna."

The author furthermore believes that the "Meniere's symptom" can be produced: (1) Through influences from the external and middle ear; (2) through diseases of the labyrinth; (3) through diseases of the brain and of the acoustic nerve; and (4) through neurosis, for example, of the sympathicus (angioneurosis).

The author's conclusions are as follows:

(1) The triad-hardness of hearing, vertigo, and tinnitus-is given as constituting the functional disturbance observed in the so-called Meniere's disease.

(2) These symptoms occur also in numerous affections which are not based on the pathologic finding as described by Meniere in his historic case.

(3) The observation that not always a typical picture is present has led to the introduction of other terms, such as "Meniere's symptoms," et cetera, which has proved to be confusing.

(4) Even affections of the middle ear, of the outer ear, or of other

parts of the body can cause the symptoms described by Meniere. (5) These latter causes can be diagnosed in many instances and prove the existence of a great group of affections characterized by functional disturbances of the inner ear.

(6) By abandoning the terms "Meniere's disease" and "Meniere's symptoms" a more definite nomenclature can be introduced. This is important not only from a physiologic and pathologic, but also from a clinical standpoint. By using, for instance, the terms "otitis interna syphilitica," or "leukemica," or "angioneurotica," or "gastrica" a clear conception of some affections would ensue.

(7) The various terms should be agreed upon. The many international medical meetings give ample opportunity for such a procedure.

THERAPEUTICS.

DELOS LEONARD PARKER, PH. B., M. D.

LECTURER ON MATERIA MEDICA IN THE DETROIT COLLEGE OF MEDICINE.

I. H. N.

ATROPIN AND STRYCHNIN COMBINED, A SPECIFIC FOR

SEASICKNESS.

BRIGADIER-GENERAL ALFRED C. GIRARD, United States Army, retired (Jama, June 23, 1906), in a paper presented to the International Medical Congress held at Lisbon in April of this year, sets forth his ideas, which he has held since 1888, concerning the value of atropin and strychnin in seasickness. At the outset, Doctor Girard says:

"For many years I had believed that I was the original discoverer of this treatment, but it seems that other physicians have used it at times independent of my investigations, and I, therefore, do not pretend to absolute originality, but I believe this report represents the views of many observers working subject to my instructions under various. circumstances, and more than any individual views will establish the value of the treatment."

The treatment consists of hypodermic injection of atropin sulphate grains 1/120 (0.0005 milligrams) with strychnin sulphate grains 1/60 (0.001 milligrams). This should be administered at the beginning of a voyage, or when the sea begins to be rough, or at the advent of a storm when the motion of the water causes nausea. In persons not readily affected by belladonna the dose may have to be repeated once or twice at hourly intervals. The signs for stopping further use of the drugs are dryness of the throat and disturbances of vision. Practically always, however, the seasickness is corrected, if not before, at least by the time incipient symptoms of the effects of the belladonna are made to appear.

The advantages claimed for hypodermic medication in this disease are the rapidity and certainty with which effects are produced, and

the control it gives over the amount of drugs actually taken up by the circulation. Medication by mouth is uncertain, not only as to retention by the stomach, but also as to absorption by the blood even when retained.

As a rule a single dose is sufficient for a voyage, but on long trips or trips beset with severe weather the medication may have to be repeated.

"The rationale of the treatment may be found in the stimulating effect of the atropin on the circulation in the brain, while the strychnin causes a similar action through the spinal cord in the respiration."

Doctor Girard says that from his own experience and observation, and from the reports of medical officers that have made use of the treatment, he is satisfied the remedy is a specific. He concludes his paper with a long list of letters and reports from medical officers serving on army transports and on other ships, and the tone of these reports shows that actual experience with the remedy has converted them all into believers in its efficacy.

EDITORIAL COMMENT.

DISCORD AMONG DOCTORS.

INDICATIONS of dissatisfaction are quite apparent in various sections. of the country regarding the management of the American Medical Association, and in certain sections the reaction has been so intense as to force expression in effort to establish independent organizations. It would be absurd to deny that some cause for provocation exists. It would likewise be absurd to decry a laudable movement because affairs are not managed in accordance with individual idea. Organizations are generally conducted for the benefit of the majority, and no very substantial reason obtains to prove the American Medical Association an exception to the rule, notwithstanding a feeling prevails that the national guild is being manipulated by a selfish minority. However this may be, grievance has certainly been incited, as is evidenced by complaint from every point of the compass, as well as by contention in several quarters for secession from the parent body and inauguration of an entirely new régimé.

*

Michigan has recently declared for "quality" in contradistinction to "quantity." The pronouncement emanates from Grand Rapids doctors, and proposes a State Society wherein "the advancement of the science. of medicine and surgery will be the paramount purpose." The instigators of the scheme advocate allegiance to the Code of Ethics adopted by the American Medical Association in 1847, and disclaim, in the following terms, intention to antagonize existing organization: ¶"We