even rupture of the wall of the unprepared heart. In the ordinary clinical case the stress is gradual, and the fibre is educated to an increased tonus; but when subsequently accidental overstrain occurs digitalis should be invaluable for the purpose of restoring the vigor of the heart. The simultaneous action of the drug on the right side of the heart is not without influence in the restoration of compensation. In practice, then, it may be inferred that digitalis should seldom, if ever, be given in cases of aortic regurgitation which have developed during or after middle life, since the ventricular wall is seldom perfectly sound.

In aortic stenosis digitalis is contra-indicated apart from the occurrence of cardiac failure. In this lesion an augmentation of the tonus of the heart and peripheral vessels could but increase the work with which the left ventricle has to contend.

In mitral incompetence beneficial results are invariably obtained from the administration of digitalis. On the left side of the heart a rise of tonus and consequential hypertrophy enable the right ventricle to cope with the increased resistance in the pulmonic circuit, and by maintaining the blood pressure in the pulmonary veins and left auricle it resists the reflux through the mitral opening and ensures an adequate supply of blood to the left side of the heart. A rise of tonus in the arterioles and capillaries would no doubt greatly minimize the disturbance in the systematic circuit due to this cause, though the increased resistance to the discharge of the ventricular contents would augment the reflux through the mitral opening. In uncomplicated mitral stenosis the supply of the blood to the systemic circulation tends to become increasingly restricted. A rise in the tonus of the left ventricle and peripheral vessels would still further diminish the charge of blood delivered to the aorta. No doubt the effect of increased cardiac tonus on the right side of the heart would be of benefit provided the blood supply to the left ventricle could be thereby augmented. It may be inferred, therefore, that digitalis can be of no benefit to mitral stenosis in the absence of failure of the right ventricle, and in this event, so soon as the pulmonary blood pressure has been raised to the point at which the maximum charge of blood is delivered to the left ventricle, the drug would again. act prejudicially.--Progressive Medicine, Sept. 1, 1907.

IN CHARGE OF J. PRICE-BROWN.

A Case of Closed Sinusitis of the Ethmoid Labyrinth, with Exophthalmos. Harry Kahn and Mortimer Frank, Laryngoscope, September, 1907.

The patient, a girl of fourteen years, had passed through attacks of nearly all the usual exanthemas. On recovering from chicken-pox, a protrusion of the left eye occurred, becoming gradually more pronounced. There was no headache, no hydrorrhea, no parosmia, no pharyngeal nor laryngeal irritation. The only apparent indication being the pushing of the globe of the eye outwards and forwards.

On rhinoscopic examination the septum was seen to be straight, but a large tumor-like mass, polypoid in character, was found to occupy the position of the normal anterior end of the left middle turbinal, filling the whole of the olfactory space.

On application of cocaine and adrenalin, the mass remained immovable and hard, and there was no pus visible. On resection of the growth, a large volume of white odorless pus escaped, which continued from day to day up to the time of the report of the case, a month later. The ethmoid at the time was cleaned out as fully as possible, and free drainage obtained. The discharge is gradually decreasing, and the protuberant eye returning to its normal place in a satisfactory manner.

That the treatment followed is the appropriate one is borne out by the fact that in the Medical Record, Vol. 70, page 689, Fish reports five cases of enucleation of the eye in patients suffering from closed ethmoid sinusitis. And the writers close with the words: "Warning should be taken by the ophthalmologist not to enucleate an eye of this type without first looking into the nasal condition.”

The Alveolar Route of Operating Upon the Maxillary Sinus. -Melville Black, Laryngoscope, September, 1907.

This article strongly advocates operation through the alveolus as the primary method of treatment in chronic antral disease. He insists that to be effectual, the opening should be large, with an all-round diameter of three-eighths of an inch. He makes the first opening with a quarter-inch trephine and then enlarges it with a burr.

After thoroughly curetting and washing out through the artificial opening, a saddle bridge, made of rubber or one of the finer metals, is adjusted. This can be easily removed and replaced by the patient as required for cleansing purposes. When an artificial plate is worn, covering the part, no other plate is needed.

The treatment consists of first curetting and washing; and subsequently, in addition to the latter, cauterizing the whole of the lining membrane of the antrum, with pure carbolic acid, applied by means of bent cotton-carriers-the effect being immediately neutralized by syringing the antrum with alcohol. This carbolic treatment is repeated once a week. When the artificial opening closes before healing is complete, it is enlarged, under cocaine, by a cataract knife. The rimming out is easily accomplished, and the treatment resumed. The cases usually get completely well in from six weeks to four months; and there is rarely a recurrence. If such a thing should happen, the old cicatrix can readily be reopened and the treatment repeated.

A Case of Sarcoma of the Maxillary Sinus.-F. L. Rogers, Laryngoscope, Oct., 1907.

This case was exhibited to show the condition of the growth after seven months of active treatment.

The patient in early life had syphilis, resulting in destruction of the septum. Many years later, when he presented himself for treatment for swelling of the left upper jaw, a perforation was made through the nose, expecting empyema of the antrum, but nothing was found. Later on, an opening was made through the canine fossa, exposing a growth attached to the anterior wall of the antrum, which so crowded the inner wall of the sinus and the inferior orbital plate, as largely to destroy these bodies. A considerable portion of the growth protruded into both nasal and orbital cavities.

The tumor was removed with the curette as completely as possible. Two months later recurrence took place, followed by very rapid growth. Later on, it was decided to remove the superior maxillary bone, and the operation was commenced. But such extensive destruction of tissue was met with that the operation was abandoned, and the cavity being cleansed out as thoroughly as possible instead. Some weeks later the odor became exceedingly offensive, and various kinds of treatment were resorted to, to mitigate the conditions. Among others,

.

methylene blue, combined with quinine and belladonna, were taken for several months; X-Ray was used, with the effect of destroying the unpleasant odor, but without checking the progress of the disease; the Finsen light was also applied, aiding, the writer believes, in producing an abscess where trypsin had been injected. Latterly, undiluted injecteo-trypsini was injected into the cheek opening, with seemingly better effect than anything else in checking the progress of this,growth and removing fetor. For a month or so, prior to exhibiting the case, there had been no apparent enlargement, and no malodor, the reporter believing that there was even diminution in size.

Several times when the growth has encroached upon the mouth, interfering with mastication and deglutition, portions have been removed, to give relief; but each has been followed by very marked and rapid increase.

The operator asked for further light, but received none.

Primary Melanosis of the Palate: Buccal Fistula of Recent Sarcomatous Origin.-J. N. Roy, Montreal Medical Journal. Nov., 1907.

This is an exceedingly interesting case on account of its rarity, the writer having found only two similar cases on record. The patient, . a blacksmith, when 23 years old, injured his palate somewhat with the stem of a clay pipe. One year later he discovered, in the median raphe of the vault, a small, round spot, three millimetres in diameter. During the following twelve years this spot increased, in diameter to about six millimetres. The only symptoms was slight roughness to the tongue on pressure. About this time iodine was applied, and pain commenced to appear, with gradual extension, of the pigmentation to the surrounding parts,, and dark masses, with a hemorrhagic tendency, began to show themselves. Four years later, all the space within the dental arch of the superior maxilla was filled with melanotic granulations. At the end of another four years, together with the melanotic granulations, depression of the palate occurred, chiefly on the left side, a naso-buccal fistula having formed. This was attended by neither hemorrhage nor suppuration.

Examination now revealed melanosis of the entire hard palate. Granulations of brown or blackish color were scattered all over, the left side being greatly depressed. At a point between the middle and posterior thirds of the hard palate a probe passed readily into the nasal cavity.

There was no dysphagia, but the voice was nasal, and the pharyngeal reflexes absent.

Macroscopic, together with microscopic examinations, led to a diagnosis of melanotic sarcoma, resembling melanotic endothelioma; and as the patient positively refused operative measures, the necessary mutilation, together with possible complications and doubtful prognosis, being explained to him, the case was allowed to progress under resorcin and hygienic treatment, the fatal issue being still delayed.

The writer concludes: "I should like to remark how unusual this case is, presenting a primary melanosis of the palate, without co-existing lesions of the eye or skin, a slow evolution of twenty years, and a recent rapid sarcomatous growth."

Epithelioma of the Larynx: Removal by Thyrotomy; No Recurrence after three and a half Years.-Henry L. Swain (New Haven), Journal of Laryngology, September, 1907.

This was the case of a clergyman, aged forty-seven, who had been complaining of hoarseness for six months. Examination revealed a white papillomatous mass growing from the upper aspect of the left cord, and apparently growing out of the cavity. Nearly the entire cord was covered by the growth. Some time later the whole visible mass was removed in small pieces intra-laryngeally. It was very friable. Microscopical evidence was negative. Two months later recurrence took place, and again the mass was removed. During the next two months the operation was repeated five times.

Six months after the first examination it was decided to operate more radically.

Thyrotomy and resection were then done after the usual modern methods. This time microscopical examination revealed the growth to be epithelioma. Recovery was rather slow but satisfactory. A fairly good vocal band has reformed, and after the lapse of three and a half years there has been no further

recurrence.

Non-Recurrent Carcinoma of the Larynx Removed Through the Natural Passages. Fletcher Ingals (Chicago), Journal of Laryngology, September, 1907.

A laborer, aged forty-four, after being hoarse for six years, presented himself for treatment. For three weeks he had complained of pain in the region.of the left half of the thyroid. No dyspnea, but almost voiceless.