after thorough lavage of the diverticulum, showed the existence of erosions in the wall of the sac.

The author now raises the question as to the classification of the demonstrated case and refers to the recently published monograph of von Starck. This writer classifies them into traction and pressure diverticula, and suggests even the possibility of the occurrence of a combination of the two forms. Pressure diverticula may be pharyngeal, pharyngo-esophageal or completely esophageal. Pharyngo-esophageal (Zenker'sche Pulsionsdivertikel) he claims as the form occurring with relative frequency and generally as the result of some severe trauma. The completely esophageal forms are extremely rare, and only thirty cases have been found described anatomically and clinically. They are almost always located in the anterior wall, and it has not been demonstrated that trauma can be accepted as the causa prima in their development.

In the above mentioned case the condition is an unusual one, as the diverticulum is seated in the posterior wall, is completely esophageal, and the result of severe trauma. It is to be supposed that the primary effect was a rupture of the mucosa, or only a partial tearing of some layer or layers composing the wall of the esophagus, with the production of a condition favorable to the later development of a diverticulum.

Treatment instigated consisted of systematic lavage of the diverticulum and nutrient enemata. The introduction of a permanent tube was not considered warrantable on account of the possibility and added danger of development of pressure necrosis.

Death of the patient occurred as the result of an acute pneumonia, autopsy being as follows: the orifice of the sac was found to be located at the junction of the pharynx and esophagus (Zenker 'sches Pulsionsdivertikel) approximately 2 cm. below the cricoid cartilage, which had a distance of 17 cm. from the line of the teeth. This location does not allow it to be classified as a complete esophageal diverticulum and the author explains the error in having classified it primarily as a complete esophageal diverticulum, in the following manner: he could locate the lower border of the orifice of the diverticulum at a depth of 23 cm. by means of the esophagoscope, but was unable to locate its upper border in the much dilated funnel of the pharynx. The sac being filled at the time of examination, the traction caused by the weight of its contents occasioned a lower seat of the orifice than was demonstrable in the pathological specimen. The sac measured 6 cm. in both its transverse and long axes. The wall showed numerous erosions and was formed of dense connective tissue and scattered bands of muscular fibres. Located at the lower point of the sac was found a turgid varix, of the diameter of a goose-quill. An injury to this, during the daily lavage of the sac, could have led to fatal hemorrhage. Immediately below the cricoid cartilage a small warty excrescence had developed, which on histological examination proved a beginning carcinoma. This is explained as the result of the continual irritation of this esophageal segment during the act of deglutition. The walls of the esophagus were very thin and its lumen decidedly narrow-atrophy due to inactivity. Stomach―atrophic. Striking and unusual were the changes found in the spinal column. The bodies of the 2-5 (inclusive) dorsal vertebræ showed extensive absorption due to pressure; the intervertebral cartilages showed no change whatever. The dorsal spine in this region showed a scoliosis with

the convexity to the left. The absorption of the vertebræ here, is analogous to that occurring with some forms of aneurysm.

The case teaches that the classification of the seat of the diverticulum should be determined by the location of the upper border of its orifice.

DISEASES OF EYE, EAR, NOSE AND THROAT.

C. Zimmermann, M.D., G. E. Seaman, M.D., H. B. Hitz, M.D., N. M. Black, M.D., J. S. Barnes, M.D.

Transillumination of the Antrum.-DR. C. ZEIM, Leipzig, (translation by Ant. McCall, M. D., Journal of Laryng., Rhin., and Otol., June, 1903) enters into a free discussion of the subject, citing numerous careful experiments which entirely disprove the claims of those who place great faith in transillumination as a means of diagnosis of suppuration in the antra. He ends his study by saying that he "cannot even claim for it, any reliable diagnostic value, except in distinguishing solid tumors from cysts of the jaw." The article is well worth perusal. (H. B. H.)

Argentum Catarrh of the New Born.- DR. C. W. BISCHOFF (Centralbl. f. Gyn., No. 10, 1903). Although Crede's method is unanimously acknowledged as an excellent prophylatic, its irritating influence has often been emphasized. Cramer, e. g., observed the latter in 96 per cent. of cases. Dr. C. W. Bischoff therefore studied the reaction of Credé's method, carried out strictly according to Crede's directions, on 100 newborn children of the University obstetrical clinic at Bonn. The degree of irritation was measured by the secretion following. No severe reaction occurred in any case. On the first day it was moderate in 20, slight in 21, minimal in 38, none in 20; on the second day slight in 6, minimal in 22, none in 72; on the third day slight in 1, minimal in 10, none in 89; on the fourth day none in 100.

From this Bischoff infers that the severe irritation observed by Cramer must be due to faulty methods. If, however, further experiences with 1 per cent. solutions of nitrate or acetate of silver should prove the latter to be just as effectual as the 2 per cent. solutions, they would be preferable on account of the slighter reaction of the eyes after their use.

(C. Z.)

Surgical Relation of the Facial Nerve.-HUGH E. JONES (Journal of Laryng., Rhin., and Otol., June, 1903) after careful study of many temporal bones, lays down the rule that that part of the Fallopian canal in which the facial nerve is embedded is entirely internal to the highest part of the floor of the meatus and below a line running from this upwards and inwards at right angles to the plane of the tympanic ring. We may, therefore, fearlessly chisel away all the posterior osseous wall lying external and superior to this line. (H. B. H.)

Remarks on Injuries of the Eye by Chemicals.-E. SCHWARZ, Aussig, (Beitr. z. Aug., Heft 55) sums up the results, which were rather favorable, in

the treatment of 75 cases of injuries from chemicals. The chief point is the use, as soon as possible, of a chemical antidote and then energetic irrigations with water. When the offending agent is an alkali he uses acetic acid 1 per cent., or diluted hydrochloric or citric acids; when an acid, 2 per cent. solutions of carbonate of soda; when a salt, oleum olivarum.

(C. Z.)

Orbital Cellulitis as a Sequel of Scarlatina.- BURTON K. CHANCE (American Medicine, June 13, 1903) reports two interesting cases both of which occurred during convalescence. In case 1, a youth, age 17, a diffuse cellulitis suddenly developed in the right orbit. The unusual complication commenced with violent pains in the orbit and neighboring parts, accompanied by a chill, succeeded by a marked elevation of temperature which was soon followed by an effusion of fluid into the areolar tissues with protrusion of the globe. The eye lids were red and excessively edematous; there was great tenderness of the hard and tense orbital tissues. The media remained clear, affording ample opportunity for the study of the interior of the eye. There was at first a blanching of the fundus, followed by intense redness and fine hemorrhages scattered throughout the fundus; also marked swelling of the disc, overdistention of the veins and contraction of the arteries. There was excessive edema of the conjunctiva and lids. A day or two before death the exposed cornea became dry and insensitive; necrosis speedily followed and the eye was lost. Case 2, was a boy of 10, whose right orbit was also affected. The localized symptoms were in general similar to those present in the first The cornea remained unaffected; the media clear and no evidence of intraocular exudation at any time apparent, although the disc was swollen and intensely congested, as was the choroid. On the eighth day, without premonitory symptoms, the patient was seized with a general convulsion and died.

case.

Wide and deep incisions were made into the periocular tissues in both cases but only blood tinged serum escaped. Suppuration had not taken place. The course in each case was rapid, death taking place within ten days after the appearance of the special symptoms. No evidence of any affection of the surrounding cavities or contiguous sinuses was discovered. The vision was impaired and later entirely lost by the changes produced by the pressure upon the optic nerve.

In conclusion Chance considers it not unreasonable to advance the hypothesis that there had been so great a massing together of the morbid hemic elements as to produce a phlegmon of the orbit which need not necessarily have undergone degeneration or have given rise to suppuration. In the case of the older boy, it is probable that the local affection had produced a fatal septicemia; while in that of the younger, death may have been due to the sudden passage of an embolus, detached from a heart-clot. Again, death may have followed the formation of a thrombus passing either from the ophthalmic vein to one of the communicating vascular sinuses or in the connections between the cervical veins. (J. S. B.)

Toxic Amblyopia from Coffee.-P. B. WING (Annals of Ophthalmology, April, 1903) reports an interesting case of toxic amblyopia from coffee in a

boy 8 years old who had been in the habit of taking six to eight cups of strong black coffee daily. His vision had been failing for six months and at the time the author first saw the case the pupils were dilated and sluggish, the optic disc much congested and the outline could hardly be distinguished; the retinal veins were large and the arteries small. V 20/200 in each eye, visual field contracted.

The coffee was at once stopped, and strychnia, gr. 1/50, t. i. d., prescribed; at the end of one month vision=15/20. Field had increased. The case had practically recovered. (G. E. S.)

HYGIENE AND PUBLIC HEALTH.

U. O. B. Wingate, M.D., W. C. Bennett, M.D.

The Pathology of Summer Diarrheas of Children.-G. W. Booт (Jour. Amer. Med. Assn., June 13, 1903) classifies diarrheas of children as follows: Mucous disease.

1.

2. Diarrheas of indigestion.

3.

Diarrheas due to food infection.

A. The result of preformed poisons, e. g., tyrotoxicon, etc.

B.

Diarrheas due to bacterial or other infection in which the medium of infection is the food, and in which the poisons causing the diarrhea are elaborated within the body.

The article deals mainly with the etiology and pathology of summer diarrhea of children and states that while streptococcus infection may be responsible for occasional cases of diarrhea, by far the greater number are due to bacteria of the colon group; from researches made by Celli and Fiocca, Shiga, Flexner, Kruse, Duval and Bassett and others, it appears that Shiga's bacillus, which seems to be identical with the bacterium coli dysentericum is the real offender. This bacillus has been repeatedly isolated from the stools of cases of dysentery, being most plentiful in the fastigium of the disease and diminishing as recovery takes place. It was never found in the stools of healthy infants, and the blood of infants suffering from summer diarrhea agglutinated pure cultures of the bacillus while that from healthy infants did

not.

Shiga's bacillus resembles the typhoid bacillus, but no flagellæ have been

found.

Shiga inoculated himself with dead cultures of the bacillus, the results of which led him to believe that its toxins were more virulent than those of typhoid and cholera. (W. C. B.)

Sterilized Milk, Pasteurized Milk, or Clean Milk?- C. W. M. BROWN (Archives of Pediatrics, April, 1903) after referring briefly to the history

of attempts to improve the quality of milk, discusses sterilization-as the term is usually used, which is by heating once to 212° F., and quotes the changes which occur from such heating, as follows: "(a) Decomposition of lecithin and nuclein. (b) Organic phosphorus is diminished in amount and inorganic phosphorus is increased in amount. (c) The greater part of the phosphates are rendered insoluble. (d) Precipitation of the calcium and magnesium salts. (e) The greater part of carbon dioxide is driven off. (f) Normal lactic acid fermentation is prevented, allowing more deleterious fermentations to follow. (g) Lactose is destroyed. (Not below 230° F.) (h) Caramelization of a certain portion of the lactose. (i) The fat emulsion is rendered imperfect or destroyed by coalescence of the fat globules. (j) Separation of the serum albumin begins at 167° F. (k) Casein is rendered less easy of coagulation by rennet. (1) Casein is slowly and imperfectly acted upon by pepsin and pancreatin. (m) Peptone and toxins can be found after prolonged sterilization. Vaughan says that the toxin of the colon bacillus, which is constantly present in great numbers in unclean milk, is not lessened in toxicity by a temperature of 356° F. One two hundred and seventieth of a grain will kill a guinea pig. (n) The taste is rendered objectionable and the cream does not rise well, although this does not lessen its value as an infant food."

The ill effects of using sterilized milk in infant feeding are due to the fact that the soluble calcium salts which are present in normal milk are rendered insoluble by boiling. The point lies in the fact that, unless soluble calcium salts are present, the coagulation of caseinogen will be arrested or delayed. Scurvy is apt to result. In proof of this he states that "of 379 cases of scurvy brought together in the report of the American Pediatric Society in 1898, sterilized milk was the previous diet in 107."

Pasteurization, if dene at a temperature between 140° and 160° F., 1s not open to the above objections, or if so, to only a slight extent, and if maintained at that temperature for 15 to 30 minutes will destroy tubercle bacilli. The author believes that, owing to the skill and apparatus required in pasteurizing milk, whereas sterilization requires little of either among the poor in cities, the latter is to be preferred.

The most important thing about the preparation of milk is to provide fresh, clean, unadulterated milk from healthy animals. This can be and is obtained in many of the largest cities.

Hastings' experiments in regard to the action of fore milk on the decomposition of the entire milk were mentioned, as they seemed to prove that while the fore milk is richer in bacteria than the entire milk, it nevertheless, in some way, prevents coagulation.

Brown maintains that highbred cows, as jerseys, if properly cared for, are not apt to have tuberculosis, and quotes authorities who aver that such care will not cause an increase in price of more than one cent a quart over ordinary milk. (W. C. B.)

A Mask to Prevent Infection with Tuberculosis.-DR. RICHARD ROSEN in his volume entitled "The Prevention of Diseases,” says that in tuberculosis the infection may be conveyed by coughing, small droplets of fluid carrying tubercle bacilli being cast into the air, and inspired by healthy persons.