the left eye and in the temple. A week or two later she consulted me concerning the pain, and also diplopia, which was just beginning. I found then that all the branches of the third nerve acted normally. Four or five days later the left external rectus was paralyzed, with marked strabismus. Five days later the inferior rectus also showed slight, though distinct, paresis. The third nerve otherwise remained unaffected. The fundus, vision, kneejerks and facial sensation were normal. There had been no vomiting and no constipation. Nothing was found in the orbits. No scotoma for colors, F. V. full. There was no polyuria.

There was no history of trauma or syphilis, but out of her twelve children four were born dead. I prescribed anti-specific drugs. The pain gradually diminished, and in thirty days from the beginning there was none and the movements of the eye were normal.

Several cases of recurrent paresis of the sixth nerve are included in those gathered together by Drs. Holmes, Spicer and Ormerod. Trans. Oph. Soc. of Great Brit., Vol. xvi, p. 279. Drs. Wissering, Anderson and Ormerod have each recorded cases of one-sided ocular paralysis, associated with edema of the lids and pain.

COMPLICATIONS OF CHRONIC SUPPURATION

OF THE MIDDLE EAR, WITH SPECIAL REFERENCE TO THROMBOSIS OF THE LATERAL SINUS, ITS SYMPTOMS AND TREATMENT.

BY FRANK M. CUNNINGHAM, M.D., MACON.

The development of heretofore neglected fields of work seems to have been more pronounced in the last ten years than in any corresponding time in the history of our noble profession.

The continued advance of surgery, the improvement of facilities for more accurate and searching bacteriological and pathological investigation, the steadily growing belief in the final triumph of serumtheraphy in certain diseases, at least, the success of Roentgen rays and radium in many lines of treatment--all have added to the glory of the work, which will stand forever as a monument to that profession, whose mission is to help his brother man, to prevent disease, to heal the sick, and promote the health and happiness of the human race. Amid the constant growth to a higher standard of proficiency, however, there is one condition which, to my mind, has not received the consideration which its seriousness should command. I refer to the chronic suppuration of the middle ear.

The utter ignorance of the laity, the apparent lack of interest of the general practitioner, in direct contrast with the awful seriousness of the disease, has led to the belief that a few words on this subject might not be out

of place, and perchance be a contributing factor, however little, in placing the general professional man upon a proper footing with the dreaded condition, and pointing out what his relation and responsibility must be in this regard. In the face of the humiliating confession that we have neglected this line of work, what shall be our attitude? Shall we still lie dormant, and let men die from the direct result of a condition which, with a little vigilance on our part, we might prevent? We are beginning to realize the gravity of chronic suppuration; we know the ever-present danger.

Upon you, my friend, the general practitioner and family doctor (that personage of the greatest trust), devolves the prophylaxis of chronic suppuration. When you have cases of acute infectious disease, keep a sharp watch on the drum membranes during the attack, seek for the congestion, redness, swelling, bulging, in fact any of the symptoms of the acute inflammation of this struc

ture.

If you can not satisfy yourself that you know the condition honestly and squarely, do not hesitate to call in a man who can give you a reliable report of the facts of the case. For although you may cure your acute process, and as far as you are concerned, believe you have done your whole duty, you have, in reality, come far short of the mark if, through neglect, your patient has been put in a state which may have a far-reaching and deleterious effect upon the health, to say nothing of the ever-present danger of intercranial complications.

Show me the practitioner who, having a case of a discharging sinus, knowing that necrosed bone caused the trouble, would let that case go unattended, without making an honest effort to effect a cure. There is not a man in the profession who, if he has thought of the condition

at all, does not know that chronic suppuration is most frequently caused by diseased bone, whether in the middle. ear or ossicles. And yet, in many cases this condition is passed as if it were of no consequence. Have we a right to shirk responsibility in this matter? There is nothing to protect our patients except the honor of our individual members. Shall we subject our patients to the constant menace to health, and to chances of most critical seriousness, when a strict attention to careful examination can be preventive? A short reference to the anatomical relations of the middle ear will help us to appreciate how the various complications come about.

The roof separates it from the middle cranial fossa, lodging the temperosphenoidal lobe.

The floor has just beneath it the jugular bulb.
The outer wall has the membrana tympani.

The internal wall, the oval window with the footplate of the stapes in it; also the round window, with the secondary membrane.

The promontory, indicating the first turn of cochlea.

The rounded eminence of the aqueductus fallopi, in which lies the seventh nerve, running just above the oval window.

The pyramid containing in its hollow the stapedius.

The posterior wall has opening or "aditus," which leads directly to the mastoid antrum, the lining membrane of which being continuous with that of every cell in the mastoid apophysis.

The anterior wall, the canal for the tensor-tympani muscle, which is inserted into handle of malleus; the processus cochlearformis and the opening of the eustachian tube, the posterior wall of which is in direct contact with the internal carotid artery.

The closeness of this vessel is important to remember

in curettage of the tympanic orifice of the eustachian tube, a most necessary procedure in the cure of chronic suppuration. With a clearer understanding then of the vital structures in the immediate vicinity of this cavity, we are prepared to accept the assertion of that pioneer of earwork, Prof. Adam Politzer, of Vienna, "that the middle ear is bounded on one side by life, on the other three by death." What are the complications of O. M. P. C.?

(1) Facial paralysis may be caused by a gradual extension of the ulcerative process, finally irritating the canal of the nerve. Or it may result from intercranial pressure, due to extension from otitic trouble. Zuckerkand reports that there is, at times, a dehiscence in the fallopian canal. In such a condition, what would be more easily accomplished than extension to the nerve through this opening? The nerve is superficial in its descending portion just over the oval window, but I can find no report of erosion in this area.

(2) Mastoiditis may result at any time in the course of chronic suppuration. While this condition may remain latent, and apparently without danger, it is always a ready victim to any acute inflammation, starting up an exacerbation of the old process. These cases are most dangerous, and attended, very frequently, with intercranial complications. Given a condition of chronic suppuration of the middle ear, with a sudden suppression of discharge, with increasing pain, I should insist upon immediate operative intervention, in the absence of any other symptoms. It is one of the most imperative conditions I can conceive of, and should be dealt with in a prompt and decisive manner.

(3) Extension of caries into the semicircular canals is fortunately a rare occurrence. The symptoms of disturbance of the labyrinthine fluid, viz. vertigo, dizziness,