laxed when totally cut off from the spinal cord, extends outward to the angle of the jaw, undermines but its contractions are more likely to be irregular the subcutaneous tissue, forms the swelling already and incomplete. mentioned and communicates with the lumen of the The observation of the case reported briefly external auditory canal at the bony margin of the in this paper serves to substantiate many of the latter. The tympanic membrane is now intact, but is retracted and united to the promontory, evidently points to which allusion has been made, and dem- as the result of an old perforation. The tympanic onstrates from the standpoint of a unique patho- cavity and Eustachian tube contain a large amount of logical lesion that uterine contractions may occur exudate, but are free from blood. The ossicles are in without pain; that the fetus may be carried far on situ. Attached to the wall of the tympanum are its way, if not wholly expelled, by a uterus sep-several small polyps. The attic and mastoid cells are arated from its central connections and without filled with exudate, but the bony tissue is apparently the aid of the abdominal muscles; and that its final not necrotic. The lining of the carotid artery, in its contraction after the expulsion of the placenta nearest vicinity to the tympanum and Eustachian may be complete and satisfactory, precluding tube, is smooth and intact. the likelihood of post-partum hemorrhage. Clinical Department. Histological examination (Decalcification in 5% nitric acid, embedding in celloidin): The wall of the external auditory canal shows a marked inflammatory reaction and is giving off an exudation of pus cells. The tympanum shows the appearance characteristic of chronic suppurative otitis media. The submucosa is markedly “A CASE OF CHRONIC OTITIS MEDIA, HEMOR-free exudate consists chiefly of serum and pus cells. infiltrated with chronic inflammatory cells, and the RHAGE INTO THE EXTERNAL AUDITORY The lining epithelium is comparatively normal. CANAL, PERFORATION OF THE WALL OF PHARYNX, WITH FATAL HEMORRHAGE FROM THE JUGULAR VEIN.* BY FREDERICK L. JACK, M.D., BOSTON, AND FREDERICK H. VERHOEFF, M.D., BOSTON. The polyps are found to consist of edematous connective tissue only slightly infiltrated with inflammatory cells. The air spaces leading out from the tympanic cavity are filled with seropurulent exudate. The medullary spaces of the surrounding bone show an infiltration with chronic inflammatory cells, among which plasma cells largely predominate, and occasional foci of pus J. O., two and one-half years old, was first seen at cells. The internal ear is normal. The carotid artery the Massachusetts Charitable Eye and Ear Infirmary itself is normal, but its sheath shows a marked chronic on Jan. 8, 1907, when the following history was ob-inflammatory reaction which extends as far as the first tained. The patient had never had any of the diseases bend in the bony canal, but which is most marked at of childhood, or any ear trouble prior to the present the entrance of the latter. The sheath of the artery attack. For two weeks she had been fretful and evi- for a short distance is also infiltrated with blood which dently in pain. A discharge of pus from the right ear has forced its way from the large hemorrhage beneath had been noticed for several days, and a swelling post- the temporal bone. The soft tissues in which this aural for nearly a week. Considerable coagulated hemorrhage has taken place are involved in a formablood was found in the right meatus. Over the mas- tion of granulation tissue in which occur large areas toid tip, extending about one inch below and one and of pus cells. The wall of the jugular vein, which passes one-half inches posteriorly, was a large fluctuating through this abscess, is completely necrotic, lined with swelling about the size of a tangerine, tender on pres-purulent thrombi and in places perforated. Higher sure. About two hours following admission to the up, where the vein is in relation with the bone, its wall ward the child was taken with severe hemorrhage is normal. Sections of the abscess beneath the temfrom the mouth and nose. When the House Surgeon poral bone, stained by the Gram method, show numerarrived the child was not breathing and was exsan ous streptococci occurring in short chains and pairs. guinated. Clots were found in the mouth and nares, No other bacteria are to be seen. with signs of vomitus on clothing. Adrenalin was given subcutaneously and normal salt solution, to- Diagnosis. Chronic suppurative otitis media, gether with artificial respiration, but without avail. abscess beneath temporal bone, due to streptoAutopsy by Dr. Verhoeff, nineteen hours after death, coccus pyogenes. Perforation of internal jugular head only. Body that of a fairly nourished female vein. Infected hematoma. Hemorrhage into child. Slight rigor mortis. Lividity of dependent external auditory canal. Perforation of the wall parts. Both nostrils and right external auditory of the pharnyx, with fatal hemorrhage from intercanal are filled with clotted blood. Below and slightly nal jugular vein. behind the meatus there is a swelling about the size of an olive, over which the skin shows ecchymosis. Meninges and brain are normal, no evidences of tuberculosis. The venous sinuses are free, including the right lateral sinus and bulb. The whole temporal bone, with a large amount of the soft tissues beneath it, including a portion of the wall of the pharynx, removed and hardened forty-eight hours in 10% formalin. A stream of water can be forced through the carotid canal without any of it finding its way into the tympanum. The soft tissues beneath the bone, which contain the carotid artery and jugular vein, are infiltrated with blood from a large hemorrhagic extravasation. This is in communication with the pharynx a short distance below the mouth of the Eustachian tube. It also BIBLIOGRAPHY. Hessler: Arch. für Otol., vol. xviii. Grossmann: Casuist, Beitr. z. Ophth. und Otiatr. Rest, 1879. Pilz: Dissert. inaugur., Berlin, 1865. Sokolosky: Centralbl. für Chir., 1881. Toynbee: Dis. of the Ear, 1860. Prescott-Hewett: Arch. Gén, de Méd., vol. xiv, 1837. Hermann: Wien. Med. Wochenschr., 1867. Ward: Transactions of the Pathological Society, 1846. UNDER the title of the Hippocratean College of Medicine, a night school for the study of medicine * Read before the American Otological Society, Washington, D. C., has been opened in St. Louis.- Medical Record. May 8, 1907. BY FARRAR COBB, M.D., BOSTON, A STRANGE REASON FOR PERSISTENT increasing in severity, but the patient had done her ABDOMINAL PAIN. INTESTINAL ADHE- usual housework until two weeks ago, when it became SIONS CAUSED BY A PIN WHICH HAD so intense that she could not stand. From the beginning her appetite had been poor and there had been PENETRATED THE UMBILICUS WITHOUT some nausea, but no vomiting. She had slept poorly THE KNOWLEDGE OF THE PATIENT. and had had more or less headache. She noticed that she was compelled to pass urine frequently, as often as once an hour during the day and more than twice Assistant Visiting Surgeon to the Massachusetts General Hospital. during the night, and that for a few weeks before enIT is recognized that intestinal adhesions, with trance the act of urination had been painful. The or without abscess formation, may be caused by bowels had moved daily and the movements were dark the migration from the stomach or intestines of in color; she had noticed no blood. She thought she sharp foreign bodies, such as pins, needles or had lost weight, but did not know how much. She fish bones, which have been swallowed. Occa-vented her from earning her living as housemaid. was very anxious to be relieved from pain, which presionally such cases have been reported. detailed here is probably unique because of the location and method of entrance of the pin and the entire ignorance of the patient in regard in it. Because of the very unusual condition found at operation, it is thought worth while to report it. The case Examination showed a well-developed and nourished young woman. Nothing abnormal in the chest. Urine normal. Leucocyte count, 18,000. Hymen present. Uterus small, anteflexed, movable. Left kidney palpable. Palpation of the abdomen developed tenderness at the umbilicus, most marked on the patient's left and running into the left hypochondrium, with slight muscle spasm. Nothing abnormal in the appearance of the umbilicus was noted. The patient was kept in bed under observation for four days, during which time the evening temperature was 100° F. daily. Pulse and respiration were normal. During this time she complained constantly of pain in the region of the umbilicus, with nausea, but nothing abnormal was found upon examination except the tenderness mentioned above. Operation was determined upon because of the pain, which was manifestly severe at times. No certain diagnosis of the cause for the pain seemed possible. The case was operated upon by me on Oct. 13. The anesthesia was nitrous oxide gas followed by ether. Bimanual examination after the patient was under ether revealed nothing abnormal in the pelvis save marked anteflexion of the uterus. After dilating and curetting the uterus, to correct to a certain degree the anteflexion, the patient was placed in the Trendelenberg position and the abdomen opened in the median line for the purpose of exploration. Upon opening the peritoneum the following conditions were found: The urachus was much larger than usual, fully the size of a pencil. The bladder seemed normal in size, but apparently was held partially out of the pelvic cavity by the large urachus. For the space of one to one and one-half inches above and below the umbilicus the omentum was firmly adherent to the anterior parietes and to the small intestine; the omental adhesions surrounded the urachus and bound it and the small intestine firmly against the abdominal wall in the M. H., single, nineteen years old, entered the West umbilical region. Palpation of the omental adhesions Surgical Service of the Massachusetts General Hospital detected a hard mass the size of a large English walnut on Oct. 8, 1902. Dr. Beach, the senior surgeon of the buried in the adhesions just under the umbilicus and service, very kindly turned the case over to me. For in the center of this a sharp object like a pin or a needle two weeks she had been under observation in the Out- was felt. The omental adhesions were tied off with Patient Department and was recommended to the wards catgut. After separating the intestine with some for operation because of a suspected abdominal neo- difficulty the urachus, which was found to be patent, plasm or tubercular peritonitis. The family history was tied off and excised. The sharp object was diswas unimportant. She had always been in good covered to be a common pin which had penetrated the health until the onset of the present trouble about abdominal cavity by transfixing the umbilicus. For three months ago. Catamenia began at sixteen years, the sake of showing the pin in situ, as well as adopting at first profuse, but in the last two years scanty and the best method of removal of the infiltrated area (see accompanied for one day by much pelvic pain, requir- illustration), the umbilicus, with a moderate amount ing her to go to bed. There had been considerable of neighboring tissue, was excised, after which the irregularity, but none for several months. Three abdominal excision was closed in layers. Examination months before entrance, without known cause, she of the excised tissues showed that the pin had entered began to be easily tired and to have constant pain at the umbilicus and had become buried in omental in the abdomen, most severe in the region of the umbilicus and in the left hypochondrium; it was sometimes sharp and darting and ran into the pelvis and up to the region of the left breast. This pain had been slowly adhesions, but no point of entrance on the external skin could be found. The urachus in the inflammatory mass excised was practically obliterated. In all probability the urachus had been patent up to the skin covering the umbilicus previous to the reaction caused by the pin. The patient made an uneventful recovery and was seen by me three years after the operation, when she reported herself as in good health, with no abdominal pain and regular catamenia. She occasionally was bothered by frequency of micturition, but not nearly so much as before the operation. Neild: Visible peristalsis; tumor. No improvement on bismuth and soda with breast feeding. Onesixtieth minim of tincture of opium twenty minutes a.c. Much improvement in a week. Opium stopped in five weeks. Recurrence of vomiting. Opium resumed and vomiting relieved. Dose gradually diminished. Recovery complete and lasting. No Visible peristalsis; tumor. Same diet. One-eightieth minim tincture of opium twenty minutes a.c. In the illustration is shown in a semi-diagram- improvement in a week. Then one-fortieth minim matic way the condition found at operation. given. Marked improvement in a week. Continued The patient at all times denied all knowledge of to do well. how the pin gained entrance into her abdominal Third case doing well under same treatment cavity, but on close questioning after the opera- also referred to. tion she remembered that she had fallen down a months later. Im flight of stairs shortly before the onset of the Rob: Visible peristalsis; no tumor. No benefit abdominal pain. The fall was a bad one and from changes of food and lavage. One-eightieth she suffered from painful bruises. It is possible minim tincture of opium twenty minutes a.c. that at this time a pin in her clothing may have provement in one week which continued. Well five been forced through the tissues of the umbilicus, which were thinner than normal by reason of the patent urachus, and the pain of her other injuries prevented her noticing the minor wound. It is interesting to note the frequency of micturition associated with the abdominal pain. This may have been caused by a certain amount of shortening and contraction of the patent urachus due to its involvement in the mass of adhesions; on the other hand, it may have been a purely reflex nervous manifestation. Medical Progress. PROGRESS IN PEDIATRICS. BY THOMAS MORGAN ROTCH, M.D., BOSTON, AND JOHN LOVETT MORSE, A.M., M.D., BOSTON. STENOSIS OF THE PYLORUS IN INFANCY. Sutherland, however, gave up to seven minims daily of the liquor opii sedativus for some time without any effect on the peristalsis. In speaking of the medical treatment of pyloric stenosis Sutherland remarks that the pylorus has two functions, — one of contraction and one of relaxation. The latter has been pretty generally overlooked. The fact that the muscular fibers are hypertrophied is no reason for assuming that only the power of contraction is retained. In fact, the hypertrophied pylorus has been seen to relax during an operation. The variation in the severity of the symptoms shows that even in marked cases it relaxes at times. The difficulty is that it does not do so enough to allow sufficient nourishment to pass through. The aim of medical treatment must be, therefore, to restore the function of relaxation of the pylorus, which has been in abeyance to the more powerful action of the constrictor muscular fibers. All sources of irriIt is evident from these cases that the majority tation in the stomach which may maintain of authors disagree with Heubner as to the best pyloric spasm must be removed. It must be method of feeding these cases. They almost all kept free from irritating food. Small amounts agree that it is better to give small amounts often must be given at a time, in order to secure comrather than large amounts at longer intervals. plete digestion. Lavage must be used daily They also almost unanimously favor lavage. for a long time, best at a time when, under Most of them believe that breast milk is the best normal conditions, the stomach is empty. food in this condition, although some believe Breast milk is the best food. Fats, in artificial in giving it diluted. Some give alkalies, believing that the condition is due to hyperacidity. Marx used them in one of his cases in which the acidity was high with good results, but did not use them in another in which the acidity was low. The Germans, led by Ibrahim, use poultices to the abdomen and feel that they are of considerable value. [The writers are somewhat skeptical as to the efficacy of poultices in these cases.] (Concluded from Vol. clvi, No. 26, p. 854.) foods, are likely to cause trouble. Finally, he expresses "the hope and belief that as our knowledge and experience of the medical treatment advance there will be fewer and fewer cases in which surgical intervention is called. for." Very little work has been done in most cases as to the chemistry of the gastric digestion, and what little work has been done has given varyVery few opinions have been expressed as to ing results. It is safe to say that nothing of what happens when recovery occurs since importance has been learned in this line. Ibrahim summed up the subject in his paper. A whole session of the Section on the Diseases Marx, however, believes that recovery takes of Children at the Toronto meeting of the British place largely as the result of compensatory Medical Association, last summer, was devoted to hypertrophy of the other muscles of the stomach. this subject, and several valuable papers were Several cases have been treated by small doses presented, notably those by Cautley and Stiles. of opium before feeding, with apparently good Many valuable points were also brought out in results. These cases are as follows:the discussion of these papers. Cautley distinguishes between functional brings forward various arguments against spasm pyloric spasm and congenital hypertrophic as the cause of the hypertrophy. stenosis. He says that there is a group of cases In speaking of the diagnosis between spasm in infancy which shows a combination of symp- of the pylorus and hypertrophic stenosis, he toms which are extremely liable to give rise to says that in the former the vomiting is different an erroneous diagnosis of congenital hyper- in character, peristalsis is slight or absent, the trophic stenosis and to which the name of pyloric stomach is rarely dilated, pronounced constipaspasm may be given. He admits that there is tion is unusual, there may be diarrhea and no absolute proof that there is spasm of the there is no tumor. It is rare for two or more pylorus in these cases, but says that he can put feeds to be retained and then vomited. In case forward no other plausible explanation. The of doubt the effects of medical treatment are of main feature of this condition is severe and con- value. There is greater danger of pyloric spasm tinued vomiting. The food is usually brought being diagnosed erroneously as pyloric hyperup at once, but sometimes a considerable quan- trophy than of the opposite mistake being made. tity is kept down and then violently ejected. The outlook is extremely bad if treatment is Constipation may be present. Some of his purely medical even when the obstruction is cases had visible peristalsis and dilatation of incomplete. He believes in early operation and the stomach. He makes no mention, however, that the prognosis depends mainly upon the of tumor. He thinks that these cases prove general condition of the infant. He believes that spasm of the pylorus is not the cause of that pyloroplasty is the best operation. the marked hypertrophy of the pylorus seen in congenital hypertrophic stenosis. Stiles quotes Professor Cunningham at considerable length with regard to the musculature He has had sixteen cases of congenital hyper- of the pyloric canal. Cunningham found great trophic stenosis and bases his conclusions on thickening of both muscular layers in the specithese cases. He believes that it is congenital mens which he examined. Stiles believes, therein origin and that it is rarely compatible with fore, that from the purely anatomical point of long life. He attaches great importance to visi- view the only difference between the normal ble peristalsis and states that it may be visible pylorus and the stenosed pylorus, as met with in only after feeding and that it is best elicited by infants, is that in the latter the muscular coat giving a fair sized meal, by flicking the stomach is greatly thickened. He believes that it is a wall with the finger or by applying a cold object. distinct pathological entity, but admits that Dilatation depends on the duration and degree both in the child and in the adult there is clinical of obstruction. The absence of dilatation is evidence to support the view that cases of pure not a contra-indication in early cases at a time spasmodic stenosis of the pylorus do occur, and when operative treatment gives the best results. believes that the majority of the cases of infanThe diagnosis is certain if the pylorus is felt. tile pyloric stenosis that have recovered without It is greatly to the detriment of the child, how-operation belong to this category. A considerever, if the physician waits until he can definitely able number of cases presenting the symptoms feel a tumor before he ventures to make a diag- of pyloric stenosis have recovered without the nosis. aid of surgical treatment. It rests with the follow up the life history of such infants as are supposed to have been cured of pyloric stenosis without operation. If they again suffer from gastric symptoms pointing to pyloric stenosis surgical treatment will take the same place in pyloric stenosis of the infant that it has taken in that in the adult. He divides the cases into typical and mild. physician to settle whether these recoveries In the typical cases there is characteristic vomit-are cases of spasm without hypertrophy or a coming, constipation, wasting, visible peristalsis, bination of spasm and hypertrophy, the former dilatation of the stomach and tumor. In the predominating. It is of great importance to mild cases the vomiting varies with the diet. If the stomach is washed out daily and a diluted food given, vomiting may be entirely absent for a week or more at a time and the infant may gain in weight. These are the cases which may get well without surgical aid. It is probable, however, that the hypertrophic stenosis of adults is due to the persistence of the infantile condition. He divides the cases of pyloric stenosis into Some may recover; others suffer from chronic two distinct groups, namely, the purely spasgastric trouble; most die from progressive wast-modic without any hypertrophy, and the true ing. He says that although the amount of congenital hypertrophic in which a varying muscle may vary a little in the normal pylorus amount of spasm or tonic contraction is superand in those who apparently suffer from spasm, added. The first group may be expected to get it remains very small and in section roughly well under dietetic and medical treatment, triangular. There are no intermediate stages while the latter group must assuredly die unless between the conditions found in these and those surgical treatment is resorted to. He does not found in hypertrophic stenosis. He believes think that the kind of operation is of much that Nature in her extreme anxiety to provide importance, the main point being to operate a sufficient pyloric sphincter has overexerted early. He believes that there is an intermedherself and produced too great a quantity of iate group in which the hypertrophy, although muscular tissue. There is a true hyperplasia, present, is less marked. It is these cases which a simple redundancy of fetal growth." He have probably led to the confusion and differ Scudder: Jour. Am. Med. Asso., 1905, xliv, 1665. Sutherland: Lancet, 1907, i, 725. Townsend and Scudder: BOST. MED. AND SURG. Jour., 1905, cliii, 669. Thompson: Surg., Gynec. and Obstet., 1906, iii, 521. ence of opinion which exists among physicians regarding the pathology and treatment of infantile pyloric stenosis. He advises a diagnostic incision in all cases in which the diagnosis is doubtful and in which medical treatment is not bringing about an improvement. If the case is one of spasm without hypertrophy the physician and surgeon should together decide as to the advisability of divulsion. If the infant is young and feeble and the hypertrophy not marked he prefers divulsion. If the general condition is satisfactory and there is marked hypertrophy, the choice lies between pyloroplasty and gas-HELD AT WASHINGTON, D. C., MAY 7, 8 AND 9, 1907. tro-enterostomy. Reports of Societies. ASSOCIATION OF AMERICAN PHYSICIANS. FIRST DAY, TUESDAY, MAY 7. ADDRESS OF THE PRESIDENT. The following summary in an editorial in the British Journal of Children's Diseases sums up the subject very well: "The summary of the DR. F. P. KINNICUTT, New York, referred to the writings and observations of the past year deaths of Dr. Jas. Stewart, of Montreal, and Drs. I. E. indicates that the disease is much more common Atkinson and Thos. Lattimer, of Baltimore. He then than is generally supposed; that operative gave an outline of the work to be done at the present treatment in wasted infants is not often success-session, saying: "The successive meetings of the Assoful; that cases with apparently all the symptoms of its founders. In the twenty-two years since its birth ciation of American Physicians have proved the wisdom of the affection do get well without operation; much of the best work of the laboratories and clinics of that great care is essential in diagnosis before the United States and Canada has been yearly presented accepting a diagnosis of pyloric hypertropy for the consideration, discussion and instruction of its necessitating operation from pyloric spasm, members. Embracing, as it does, in its membership, which is curable by simpler measures." In the pure scientist in medicine, and the clinician in every summing up our evidence it should be said that field of its practice, this body has been an admirable diagnosis in any case not operated on or autopsied is open to question. It is evident that much has yet to be learned concerning these conditions and the diagnosis between them. It is especially important to know what happens eventually to those cases which are supposed to have stenosis and recover under medical treatment. An autopsy on one of these cases dead of some other disease after a lapse of months or years will teach us a great deal. So would an autopsy under similar conditions on a case cured by operation. REFERENCES. Ashby: Brit. Med. Jour., 1906, ii, 949. example of the science and art of medicine walking hand in hand, the one or the other leading for the moment, but always with the willingness and desire to path of truth. Such a union has given the Association have its steps corrected if per chance straying from the its great strength. Only by such union is secure progress in medicine attainable." THE CONNECTIONS OF THE OCCIPITAL LOBES AND THE PRESENT STATUS OF THE CEREBRAL VISUAL DR. ADOLPH MEYER, New York, presented this paper under the following subdivisions: 1. Isolation of the geniculo-calcarine tract (2 cases). 2. Subdivision of sagittal marrows and their course. Marking of the calcarine area. 3. Degeneration of the occipital efferent Audry and Sarvonat: Revue Mensuelle des Maladies de l'Enfance, path and the geniculo-calcarine tract, following de 1906, xxiv, 39. Barling: Brit. Med. Jour., 1905, ii, 1523. Berkholz: Jahrb. für Kinderh., 1906, lxiv, 757. Blaxland: Lancet, 1905, ii, 826. Capps and Beran: Quoted by Thompson. Carpenter: Med. Press and Circular, 1906, n. s., lxxxii, 7. 1905, ii, 408. Med. Journal, 1906, ii, 939. Editorial: Brit. Jour. of Diseases of Children, 1906, iii, 364. Griffith: Arch. of Pediat., 1905, xxii, 721. Harper and Harper: Lancet, 1905, ii, 503. Heubner: Die Therapie der Gegenwart, 1906, viii, 433. Hutchinson: Brit. Med. Jour., 1906, ii, 949. Ibrahim: Congenital stenosis of the pylorus in infancy. Karger. Berl., 1905. Keefe: Providence Med. Jour., 1906, vii, 104. Kimball and Hartley: Arch. of Pediat., 1907, xxiv, 207. Kerley; Brit. Med. Jour., 1906, ii, 950. Marx: Münch. Med. Wochenschr., 1906, liii, 188. Morse: BosT. MED. AND SURG. JOUR., 1906, clv, 343. Morse and Murphy: Ibid., 1905, cliii, 489. generation of the calcarine cortex. 4. Marchi-degenerations from a small wound of the post-parietal cortex, involving the optic radiations: (1) afferent character of the internal sagittal marrow (contributing to the of the external sagittal marrow; (2) efferent character lateral part of the crus); (3) subcortical (external sagittal) fibers towards the motor area; (4) no fibers to the frontal lobe. Anatomical data for clinical co-relations. DR. L. F. BARKER, Baltimore, said we should be grateful for this contribution to our knowledge of the association fibers which connect the primary visual S. centers with the adjacent and more distant centers. These studies were of the very greatest importance for diagnosis in neurology and psychology. It was only by control of clinical observations, by pathological anatomy, that we could hope for better ideas of locali Murdock: Transactions Medico-Chirurgical Society of Edinburgh, zation and association. Rogers: Ibid., 1906, xliii, 763. Rogers and Howland: Arch. of Pediat., 1906, xxiii, 190. Rotch and Murphy: BOST. MED. AND SURG. JOUR., May 9 and 16, neurasthenic conditions, but as affording especially 1907. Sarvonat: Brit. Jour. of Diseases of Children, 1906, iii, 364. good chances for observation, because the whole illness |