the age of four years. The bones, joints and lymph glands are the parts most frequently affected. Its great prevalence in children during the milk-drinking age and the predominance of other types than the pulmonary would seem to indicate a bovine origin and in communities where the milk was Pasteurized the percentage of intestinal forms was less than in districts where the milk was fed raw. The British Commission found that the tuberculosis produced in cattle by material from human and bovine sources was identical in its general effect and in detail. Walbach and Ernst came to the conclusion that there was no difference in the specificity between tuberculin made from human and bovine bacilli and that there was no essential difference in the disease processes caused by bacilli from these sources. Rau believes that primary intestinal tuberculosis and tabes mesenterica are of bovine origin and conveyed by milk. Woodhead believes the same. Still thinks that tuberculosis of the intestines is often secondary, caused by the swallowing of the sputum. Behring says "The milk fed to infants is the chief cause of consumption." The evidence as to the communicability of bovine tuberculosis to infants is so conclusive that there is no longer any room for doubt. The only point in question is as to the comparative frequency of this mode of infection. This source of infection is no doubt very frequent. It is our duty to guard against tubercular infection in every possible way and to insist on milk absolutely free from tubercle bacilli for infant feeding. The cows should be tested with tuberculin and those which react positively should be separated from the herd.

ORTHOPEDICS.

BY IRA DEAN LOREE, M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN SURGERY IN THE UNIVERSITY OF MICHIGAN.

SOME DEFORMITIES AND THEIR PREVENTION. DAVID T. BOWDEN, M. D., in the International Journal of Surgery for February, 1906. Under this heading he describes some of the more common congenital deformities of the lower limbs, their causes, and treatment; also some of the acquired forms of deformity, in different parts of the body.

The valuable part of the article must be summed up in the paragraphs devoted to the responsibility in neglected cases. The family physician as well as the parents must be educated to know the value of early intervention in all cases of deformity, especially those of congenital origin. Much can be gained even in those cases that reach the orthopedic surgeon late, yet complete obliteration of the marks of neglect is often impossible. The surgeon must be given the best chance and this necessitates early supervision of the treatment. The inconvenience and mental suffering of these patients should be impressed upon the parents and the family physician should be in a position to detect these abnormalities at once.

OPHTHALMOLOGY.

BY WALTER ROBERT PARKER, B. S., M. D.

PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF MICHIGAN,

INJURIES OF THE EYE FOLLOWING PARAFFIN INJECTIONS IN THE NOSE.

PROFESSOR W. UнTHOFF, of Breslau (Berliner Klinische Wachenschrift, December, 1905), gives the following reports concerning frequently practiced injections of paraffin in the nose.

A married woman, aged forty-five, exhibited saddle-nose. While there was a history of traumatism, examination rendered a specific origin not improbable. There was a history of rheumatism. The heart was normal. In all there had been three injections of paraffin, at intervals of eight and five months, for the treatment of the nose deformity. During the third injection the patient suddenly noticed the left eye becoming blind. There was no pain, but some lachrymation and several attacks of vertigo were experienced on her way home. There were no material inflammatory manifestations, but there was, however, on the day following the injection, an ophthalmoscopic picture of embolism of the central retinal artery. Vision nil. The diagnosis was confirmed eight days later. A puncture on the left side of the anterior chamber, followed by massage of the globe, did not change the findings of the examination.

Doctor Uhthoff thinks there is no doubt that a small particle of paraffin was the real obstacle that beclouded the arteria centralis retinæ, and it must be assumed that the foreign body passed through the pulmonary circulation prior to entering the artery. Cases of this kind must be regarded as exceedingly rare occurrences.

An analogous case is that reported by Hurd and Ward Holden (“A Case of Blindness Following a Paraffin Injection Into the Nose," New York Medical Record, July 11, 1903), in which, after the third injection, loss of vision likewise occurred in the corresponding eye under the picture of embolism of the central retinal artery. In explanation of this case Hurd and Holden are inclined to presuppose a persistent foramen ovale between the two atria, enabling the particle to pass from the right atrium into the left, thus obtaining direct access to the arterial circulation.

This assumption seems to Uhthoff somewhat arbitrary, and he does not claim the same for his case. The most probable explanation, according to the writer, is that in this case paraffin found its way during injection into the venous system and after passing through the pulmonary circulation entered the arterial system and consequently also that particular arteria centralis retina.

A similar case was reported by Moll (Ann. des Mal. d'Orielle du Lar. et du Phar., 1902), also one by Rohmer (Ann. d'Occuliste, 1905). In Leiser's case, which was reported in the Deutsche medicinische

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 inflammatory 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.

OTOLOGY.

BY R. BISHOP CANFIELD, A. B., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN,

AND

WILLIAM ROBINSON LYMAN, A. B., M. D., ANN ARBOR, MICHIGAN.

DEMONSTRAtor of OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN.

ACUTE BILATERAL MIDDLE EAR SUPPURATION FOLLOWING AN INTRANASAL OPERATION, AND RESULTING IN DEATH FROM PYEMIA.

I.

OTTO J. STEIN, M. D., in The Laryngoscope, Volume XVI, Number 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.

(8) Diarrhea.

(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 cochleæ, or along the veins leaving the inner ear.

LARYNGOLOGY.

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.