apex or of the whole lung which anatomically corresponds to thickening of lung tissue; and (4) proof of the existence of peribronchial enlarged glands. In conclusion, they state that the clinical and X-ray findings have agreed in the main; but in the majority of cases the X-rays afforded valuable information as to the extent of the lesions-which were often more widespread than the ordinary cilnical evidences seemed to suggest. Where the diagnosis was in doubt on account of absence or insufficiency of clinical signs, the X-rays showed a peribronchial or bronchial gland affection-the value of which in prognosis, as well as in diagnosis, is of enormous importance. In a few cases, involvement of the apex evident clinically was not recognizable by the X-rays, because recent infil. tration, though sometimes sufficient cause clinical signs may not be sufficiently dense to produce a shadow or haziness on the X-ray plate or screen.

to

A Case of Rupture of the Heart.-Casassus (Jour. de Med. de Bordeaux, Sept. 9, 1906) details the history of a man seventy-one years old, who sought hospital relief for a generalized eczema. In spite of his age he appeared to be robust. While taking a nap half an hour after his noon meal, he suddenly awakened with extreme pain in his precordial region, began to vomit, the face was pale and the expression evidenced an agitated appearance. The forehead was covered with a sweat and the extremities were cold. There was slight dyspnea and the pulse was small, irregular and sometimes intermittent. The cardiac sounds were completely muffled and there was a certain degree of arhythmia. The patient died at the end of eleven hours. At the autopsy there was found a rupture of the heart muscle on the anterior surface, the tear measuring one and one-half centimeters in length. The pericardium contained a large effusion of blood.

OTOLOGY.

ALBERT F. KOETTER, M. D.

Labyrinth Suppuration.-(Hinsberg, Breslau. Compilation in Internationales Centralblatt fuer Ohrenheilkunde.)- Pathological Anatomy. Of the different routes of infection to the labyrinth those going out from the middle ear have a practical significance, namely: (a) the existing vascular connection between middle ear mucous membrane and labyrinth; (b) congenital dehiscence in the labyrinth wall; (c) breaking through the labyrinth wall, be it from trauma or inflam.

matory process; (d) invasion of deep extra dural abscess through posterior surface of pyramid. pyramid. Of less practical significance, because with them no operative interference comes in question, are the labryinth conditions that arise metastatically through the circulation, for example parotitis epidemica, as also those from the cavum cranii through mediation of the aqueducts or the nerves. With the labyrinth suppurations caused by traumas as fractures of the base of the skull, foreign bodies, injury by shooting, especially those suppurations arising from operative opening of the labyrinth are of interest, be it that labyrinth opening is intentional, as in stapes extraction to improve hearing, puncture of the fenestra rotunda, be it unintentional as in extraction of foreign bodies, middle ear operations.

Most often the labyrinth suppurations arise through destruction of the bony capsule following middle ear suppuration, and indeed less frequent from acute than from chronic (cholesteatomas, tuberculosis). As places of perforation most frequently considered, are the windows, then the promontorium and the horizontal semicircular canal, very seldom the infection comes from the tube or the facial canal. A semicircular canal fistula as

place of infection has more favorable prognosis than perforation through the windows, this explains the phenomena that such solitary semicircular canal fistulas are frequently found in the living, but seldom in autopsies. It must be remembered that a part of the gaps or defects may come from a rupture multiple fistula occur. from within, especially is this the case where

Often these perforations, if observed closely, may be discovered macroscopically during the operation, which practically is of utmost importance, because through careful observation of the findings of the operation, under circumstances, disclosures as to the extent of the suppuration and indication as to therapy may be gleaned. The extension of the suppuration in the inner ear may involve the whole labyrinth (diffuse labyrinth suppuration), or on account of formation of protective adhesion limit itself to one part (circumscribed labyrinthitis), both forms cannot absolutely be separated from one another, as the second form may go over into the first, but in practice they are judiciously differentiated from one another, because they demand a different therapy.

Microscopically we find in the early stages an exudate rich in cells, that may change, first, into granulation tissue, then into dense connective tissue, and finally into bony tissue. Besides this there may be ossification of the bone, and in this way cause breaking

through from within. In other cases large portions of the labyrinth frame-work may necrose (labyrinth sequestrium).

Of practical value is the extension of labyrinth suppuration into the skull and this occurs either through destruction of the labyrinth capsule (especially at the superior or posterior semicircular canal) or more often through previously formed paths (spontane ous dehisences, acoustic nerve, aqueducts). By transmisson through the aqueductus vestibuli there appears, first, an empyema of the saccus endolymphaticus, a disease, according to the newer reports, much more common than was previously supposed. All these means of communciation lead into the posterior cranial fossa, a perforation in the middle fossa at the anterior crus of the superior semicircular canal has not been observed to the present time.

Symptomatology and Diagnosis of Labyrinth Suppurations.-The symptoms concern both parts of the labyrinth, the organ of hearing and the static organ, and, namely, as symptoms of irritation (subjective auditory sensation, as vertigo, vomiting, disturbance of equilibrium, nystagmus), or appearance of deficiency (deafness, viz., disturbance of the regulation of equilibrium of a certain kind, absence of physiological nystagmus and rotatory vertigo in deficiency of both sides). It is very difficult to interpret the appearance of deficiency on the part of the static organ where labyrinth disease is unilateral. The test of the nystagmus and rotatory vertigo at present yields uncertain results, therefore an exact test of the equilibrium is in order, namely, static test on a horizontal plane and static test on an oblique plane, dynamic test of von Stein. These symptoms so dominate the clinical picture of labyrinth suppuration that they may be designated directly as labyrinth symptoms. Vertigo may be present in varying degrees, it is strongest in operative opening of the labyrinth. Nystagmus is nearly always present at the beginning of the stage of irritation, but disappears more rapidly than the vertigo, it is mainly horizontal, seldom rotatory. Proof of the presence of static deficiency is often very difficult, sometimes patients rarely notice them, as in the latent stage of labyrinth suppuration he feels well and is capable of working. Fever is absent in uncomplicated labyrinth suppuration; changes in the fundus of the eye abducens paralysis with slowing of pulse indicate infection of cavum cranii.

The course of labyrinth suppuration is sometimes very startling so that between the first appearance of apoplectiform labyrinth symptoms and the death following diffuse meningitis only a short time elapses

2

Because of the frequency of such latent suppurations of the labyrinth it is necessary to closely examine each patient on whom a radical operation is to be performed, regarding the static function as well as the hearing the latter through adoption of an aid in hearing for both ears, use of the Lucae-Dennert method, etc. Besides a thorough revision of the labyrinth wall for fistula, is indispensable at the operation, by careful probing and the use of H2O, and adrenalin. If there exists before the operation deafness besides distinct appearance of irritation, deficiency on the part of the static apparatus; at the operation stapes defect we can surmise a diffuse labryinth suppuration. If there exist before the operation symptoms of irritation with relatively good relatively good hearing, at the operation semicircular canal fistula we have a circumscribed disease of the semicircular canal. If there exists before the operation symptoms of irritation without proof of labyrinth fistula at the operation, we must if there is deafness proven think of breaking through at the fenestra rotunda or at another place not visible. But if in the same case the hearing has been preserved we are dealing either with a labryinth irritation without infection, viz., through pressure on the stapes, or an in. flammatory process in the labyrinth capsule (paralabyrinthitis), or there is present a circumscribed infection cf the labyrinth which cannot macroscopically be proven.

In making a differential diagnosis we must remember that labyrinth symptoms may appear temporarily in acute and chronic middle ear suppurations, especially in pus retention, without any infection of the labyrinth being present, similar conditions may be caused by lues and hemorrhage which may accidentally be present in otitis media. Furthermore, the disturbance of equilibrium show very few points of support regarding the differential diagnosis as compared to abscess of the cerebellum, only when after operative opening of the labyrinth the vertigo still persists in undiminished strength for some time, we can with a degree of certainty attribute it to the cerebellum, the same counts for the nystagmus, this may be considered cerebellum nystagmus, when, in the beginning it persists by looking to the

healthy side, suddenly changes to the diseased side. At all events all doubtful cases should be observed for other symptoms of cerebellar abscess (compression of the brain), likewise meningeal symptoms that are usually absent in uncomplicated labyrinth suppuration.

Prognosis and Therapy.-As a considerable part of the untreated labyrinth suppurations lead to fatal complications our efforts should be extended by means of operation to create a drainage outward of the inflammatory products from the labyrinth, and on the other hand, prevent entrance of new infectious material from the middle ear. AI. though views differed as to whether the opening into the middle ear is sufficient, or if it is necessary to make a free opening into the labyrinth spaces. Whereas interference in the middle ear which stops before the wall of the diseased labyrinth often causes a breaking out of a previously latent labryrinthitis, a compilation of the cases observed by the author and those taken from the literature show that by the opening of the labyrinth spaces the death rate has been materially deoreased, and that the operation in itself carries slight danger with it. To be sure we must differentiate the diffuse from the circumscribed labyrinth suppuration relative to the indications in the cases. According to Hinsberg the operative opening of the labyrinth is indicated where (a) before the operation, besides deafness, static irritation or deficiency exist, and at the operation a labyrinth fistula is found; (b) also without presence of a fistula at the operation, if labyrinth irritation symptoms that were present before the operation do not disappear after it, or if these symptoms appear only after the operation. (c) If endocranial complications threaten or are already present. (d) In sequestrium formation, to prevent a meningitis, the necrotic parts should be removed as early as possible. (e) In operative injury to the stapes, as soon as a spread of the infection to the inner ear is probable. The operation is unnecessary in circumscribed suppuration of the semicircular canal, but even in this case the patient is to be watched carefully so that if dangerous symptoms set in the labyrinth should be opened immediately.

Technique of the Operation.-It should be our aim to make a wide opening of the labyrinth, as in incomplete interference (curetting of the granulations at the windows, cauterization, etc.) have been proven by experience to be dangerous. Indispensable consideration in interference in the labyrinth is a thorough topographical knowledge so as not to come in contact with the facial or the carotid. To avoid secondary injury it is

THE MEDICAL FORTNIGHTLY

A Cosmopolitan Biweekly for the General Practitioner

The Medical Fortnightly is devoted to the progress of the Practice and Science of Medicine and Surgery. Its aim is to present topics of interest and importance to physicians, and to this end, in addition to a well-selected corps of Department Editors, it has secured correspondents in the leading medical centers of Europe and America. Contributions of a scientific nature, and original in character, solicited. News of Societies, and of interesting medical topics, cordially invited.

Advertising forms close on the first and fifteenth of each month. Time should be allowed to submit proof for correction Advertising rates on application.

Remittances and business communications should be addressed to the Fortnightly Press Co.

Subscription, $2.00 a year, in advance, including postage to any part of the United States, Mexico and Canada. Postage to foreign countries in the Universal Postal Union, including Newfoundland, $1.00 a year additional. Entered at the St. Joseph post-office as second-class matter.

Contributors should understand that corrected typewritten copy is essential to clean proof and prompt publication, and is much more satisfactory than manuscript. Original articles should be as condensed as justice to the subject will allow.

Editorial offices in St. Louis and St. Joseph, where specimen_copies may be obtained, and subscriptions will be received. Contributions and books for review should be addressed to the Managing Editor, 319 and 320 Century Building, St. Louis, Mo.

practicable to work after a certain system, and according to the experience of the author in the following way: after completion of the radical operation with extensive removal of the lateral attic wall and spur of the facial, a fine dental burr is introduced in the fenestra ovalis and removing a considerable part of the lateral wall of the labyrinth to the round window. With this besides the vestibulum the basal convolution of the

cochlea is opened. We must avoid a slipping of the cochlea above (facial) or to the front (carotid). Following this the cavity of the cochlea is scraped with a sharp curette. After introducing Bourguet's protector or a bent probe from the oval window under the facial upwards to get the position of the posterior crus of the horizontal semicircuJar canal and taking away the wall of the semicircular canal from above with the burr, whereby we must avoid slipping down. ward.

Flow of liquor is regularly absent after opening of a diffusely diseased labyrinth also the absence of vertigo, whereas in destruction of parts of labyrinth still capable of function vertigo, nystagmus post-operation are nearly always observed and during the operation flow of liquor.

After Treatment.-Cleansing of the laby rinth cavities with H2O, after completed operation, primary suture of the retro-auricular wound only then if good view can be had through external canal. In stubborn granulation formation there is usually the suspicion that there is sequestrium situated deeply. The duration of healing is somewhat longer than after the radical operation. A functional test of the operated cases usually shows complete deafness and static deficiency in absence of vertigo.

DR. CHAS. WOOD FASSETT,

Managing Editor, ST. JOSEPH, MO.