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Wochenschrift, January, 1902, amaurosis of the left eye occurred after the third paraffin injection, there being initial collapse and continuous vomiting, followed by inflammatory turgescence of the palpebræ, lessening of motility, and symptoms of interocular hemorrhage. Leiser here assumes the development of a thrombosis of the vena ophthalmica. After speaking of the dangers of liquid paraffin as compared with semifluid, and mentioning the means of prevention of embolism suggested by Leiser, the author reports his second case.
A male, aged fifty-seven, was kicked in the face by a horse, with the resultant deformity of saddle-nose. Three paraffin injections were made in 1904, and the result was satisfactory until the end of February, 1905. About that time, on a rather warm day, patient had exerted himself to the extent of profuse perspiration. Suddenly he felt an itching and pressure in both eyes which he proceeded to rub. In the course of a few hours they became swollen, and lids and face inflamed. On the following day he was unable to open his eyes. Microscopic examination of a small piece of skin excised from the strongly swollen palpebræ proved that the inflammatory proliferation was caused by penetration of the paraffin into the eyelids. For several months patient was unable to open his eyes. In order to enable him to open his lids at least to some slight extent and to use his eyes, it was necessary to remove the hard, tumor-like proliferation of the lids. Microscopic examination was in harmony with the clinical findings. The inflam-1 matory proliferations are occasionally not sharply circumscribed but coalesce diffusely into the surrounding tissue. Consequently these are not sharply circumscribed and encapsulated paraffin tumors, but infiltrations of the tissue with paraffin particles and strong interstitial inflammatory proliferation. In fact at this time large quantities of paraffin in substance are no longer demonstrable in the newly-formed tissue, but the exceedingly numerous giant cells of foreign bodies indicate that diffuse paraffin particles in the tissue have decided the point of origination for the new formation of the strong inflammatory tissue.
BY R. BISHOP CANFIELD, A. B., M. D., ANN ARBOR, MICHIGAN.
PROFESSOR OF OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN.
WILLIAM ROBINSON LYMAN, A. B., M. D., ANN ARBOR, MICHIGAN,
DEMONSTRATOR OF OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN.
ACUTE BILATERAL MIDDLE EAR SUPPURATION FOL1 LOWING AN INTRANASAL OPERATION, AND RESULTING IN DEATH FROM PYEMIA.
OTTO J. STEIN, M. D., in The Laryngoscope, Volume XVI, Number I. The salient points in this case are:
(1) An acute suppurative process in both ears, following an intranasal operation.
(2) Absence of all pain or tenderness in or about the ears subsequent to the incision of the drum membranes on the third and fifth days respectively.
(3) A profuse aural discharge, showing only diplococci, continuing for sixteen days.
(4) A most profound deafness.
(5) The maintenance of a high temperature for sixteen days, with no decided changes excepting one complete remission on the seventeenth day.
(6) Absence of rigors and perspiration.
(7) Pus in the urine.
(9) Metastasis in the knee-joint and side of the thorax.
(10) A complicating angina of the soft palate and arches, with the membrane showing diplococci catarrhalis infection, the same as found in the ears.
The patient was a female, forty-one years old, thin and weak, but complaining of no particular ailment. Two days after removal of the posterior end of the left inferior turbinate she suffered from earache on the right side. The membrane was incised on the third day. On the fourth day the left ear ached and the membrane was incised. After the incisions all pain disappeared and both ears discharged freely. The temperature from the first remained high with no remissions. Doctor Stein saw the case on the thirteenth day of the first ear symptoms, at which time the temperature was 102°, pulse 120, regular and full, respiration 28. Patient complained of no discomfort but deafness was such that one had to shout into her ears, and there was no history of deafness previous to the operation. She was nauseated and had vomited that morning. There was present a mild diarrhea but no abdominal tenderness. Chest examination was negative. The secretion from the ears ran into the throat and there was a membrane over the soft palate and uvula which was not at all painful. Pus escaped freely from the large openings in the membranes. Exposed bone was detected in the middle ear of the left side. No mastoid tenderness. Temperature 103.6°, pulse 125. Blood examination gave 4,000,000 red, 15,000 white, hemoglobin eighty per cent. Ear examination was negative.
On the sixteenth day the patient complained of pain about the right knee. The urine examination on the following day showed pus, albumin, streptococci and staphylococci. The temperature dropped to 96.4°. The left mastoid was opened; the bone was hard and white, showing no signs of necrosis. The sigmoid sinus was exposed throughout its entire length and found apparently healthy; the tip of the mastoid was removed; and cells far into the zygoma taken away. The only evidence of inflammation was in the antrum and middle ear where the membrane was thick and covered with granulations. No openings could be found into the cranial fossa.
The following day the patient was, at times, in a comatose state and
the right mastoid was opened with the hope of finding some avenue of venous infection. A condition similar to the left was found, the sinus was exposed and found apparently normal, so it was not opened. The patient was in her room an hour after leaving it and her condition improved so that she recognized her family, but the coma gradually deepened and she died ten hours later. No autopsy could be obtained.
The most common avenue for septic material to gain entrance to the circulation from the middle ear and antrum is through the large sinuses. This could not be discovered. Septic material has gained entrance to the circulation through the small veins and this has occurred as a result of osteomyelitis of the mastoid, and the question arises whether sufficient absorption could have taken place from the middle ears and antra to have caused the fatal result. On account of the sudden marked deafness the extension of the disease through the labyrinth must be considered. This might have taken place through the internal meatus, or along the aquaeductus vestibuli or aquaeductus cochlæ, or along the veins leaving the inner ear.
R. B. C.
BY WILLIS SIDNEY ANDERSON, M. D., DETROIT, MICHIGAN.
ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE
ORBITAL AND MENINGEAL INFECTION FROM THE ETHMOID CELLS.
JAMES F. MCCAW (American Journal of the Medical Sciences, August, 1905) reports a case in a man, forty years of age, who had had catarrh and nasal obstruction for years. Severe cerebral symptoms developed leading to the patient's death.
Postmortem showed that the infection originated in the ethmoid cells, broke through the os planum, stripping the periosteum from the roof of the orbit, extending outward and downward to the external angular process of the temporal bone, and there passed out to form the subperiosteal collection of pus described in the paper. These cases are rare but nevertheless cerebral infection from the nose takes place often enough to warrant more care on the part of practitioners.
THE TREATMENT OF EMPYEMATA OF THE MAXILLARY SINUS THROUGH THE NOSE.
GEORGE L. RICHARDS (Journal of the American Medical Association, September 16, 1905), divides etiologically these cases into those of nasal and dental origin. The author advises the treatment of the sinus by the nasal route. If of dental origin extract the tooth, treat the infection, and allow the wound to close. When not of dental origin puncture high underneath the inferior turbinal and wash out the antrum. If this does not suffice enlarge the opening sufficiently so that it will remain open during the required time of treatment. The antrum can then be curetted or packed with gauze as the case requires.
BY LOUIS JACOB HIRSCHMAN, M. D., DETROIT, MICHIGAN.
CLINICAL PROFESSOR OF PROCTOLOGY IN THE DETROIT COLLEGE OF MEDICINE.
LOCKING THE BOWELS FOR FROM TEN DAYS TO TWO WEEKS.
HOWARD A. KELLY, in the February, 1906, number of Surgery, Gynecology, and Obstetrics, concludes, after discussing a series of twelve cases of plastic work around the rectum, that an enforced obstipation lasting from eight to fifteen days is of great value in the management of these cases after operation. His patients are put on a diet of egg-albumin and water; this being practically all assimilated, and leaving no residue in the bowel. The first twenty-four hours, the patient receives no food whatever; on the second day one and a half ounces of albumin in water at two feedings; on the third day three ounces divided into five or six feedings about three hours apart; on the fourth day three and a half ounces in the same manner; fifth day and daily till the tenth or fifteenth day, six ounces per diem. The bowel is moved at the end of the period by giving a half ounce of licorice powder, followed in some cases by an oil enema, and perhaps the next morning by a half ounce of salts. One of the most important factors in securing the first evacuation is to have the patient lying in the Sims position, so as to obviate straining. Scybala will not form even after this long period of intestinal stasis, if milk is eliminated from the diet, and a perfectly soft stool is procured from the albumin diet.
DUDLEY ROBERTS, in the Brooklyn Medical Journal, for March, 1906, claims that this form, in which the retention of feces is due to a spastic contracture of a part, or the whole of the lower bowel, often supervenes upon a long-standing atonic constipation. He quotes several authorities to support his contention that as high as twenty-five per cent of all cases of habitual constipation are of this variety. Usually this spastic condition is due to neurasthenia, hypochondria, or hysteria, or it may be a reflex from disease of other organs. The stools are not hard, are of small caliber, or of a "sheep-dung" shape, and are passed mainly by the pressure of the diaphragm and abdominal muscles. The large balls of hard fecal matter, so common in atonic constipation, are absent in this condition. Palpation reveals some part or even the entire colon contracted to the size of the index finger, and it can be rolled under the palpating hand.
The treatment of this condition is the treatment of the underlying neurotic condition. These patients are usually poorly nourished and undeveloped. Suggestion is of value on those patients who are continually worrying about the action of their bowels. It is stated that
the coarse vegetables and fruits, so valuable in atonic constipation, are strong irritants to the mucosa in this condition. Fats are well borne, as well as sugars and honey. Warm sitz baths and abdominal compresses are of value, while cold applications and massage are contraindicated. All cathartics are discarded, as the intestine has an overplus of contractile force. Hyoscyamus and belladonna in suppositories are of distinct value. Rectal and oral exhibition of olive oil is one of the best forms of treatment. The amount given by mouth is only limited by the patient's ability to digest it, while the enemata vary from five to fifteen ounces, warmed to 99° Fahrenheit and given at night and retained till morning. This is done daily for a week and then gradually "tapered off." Bromides and chloral are given by mouth in some cases, and spasm of the sphincter is relieved by forcible dilatation under gas or ether anesthesia. The cure of the condition may require months of treatment.
BY DAVID INGLIS, M. D., DETROIT, MICHIGAN.
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE DETROIT COLLEGE of MEDICINE.
IRWIN HOFFMAN NEFF, M. D., PONTIAC, MICHIGAN.
ASSISTANT PHYSICIAN AT THE EASTERN MICHIGAN ASYLUM.
BRAIN TUMORS: A STUDY OF CLINICAL AND POSTMORTEM RECORDS BEARING ON THEIR OPERABILITY AND THEIR SYMPTOMATOLOGY.
G. L. WALTON and W. E. PAUL (Journal of Nervous and Mental Diseases, August, 1905) contribute a paper based on a study of autopsy records and specimens of two hundred twenty-one cases of brain tumor. The number of operative cases from the author's point of view was three per cent. The clinical features considered are: convulsions, headache and vomiting, mental symptoms, condition of pupils, and reflexes. As the writers have been concerned particularly in the investigation of various reflexes, their interpretation of the findings of the reflexes is of considerable import. They state that there is need for an enormous amount of detailed labor before an exact idea can be reached of the locations of the mechanism concerned in the various reflexes and their interpretations. Considerable variation was observed in the condition of both the deep and superficial reflexes in brain tumors; and although, as they say, their findings were insufficient, they believe that even the meager findings they noted, suggest that it is worth while to carry on the study of the brain as an important integral part of the reflex mechanism. Concerning the knee-jerk, they believe that the fact is, however, established that the knee-jerk not infrequently disappears in brain tumor; and while confessing their inability to critically analyze all the findings which they recorded, they submit that they are not easily recognizable with any theory which accepts the spine as the sole