atively slight irritations, it is impossible to explain, according to Witmaack, the contract that exists in many cases of nervous deafness, where a more or less complete loss of function of the cochlea may be taken for granted, without disturbances of any kind on the part of the semi-circular canal apparatus either objective or from the patient's history. These cases seem more plausible when the pathologic-anatomical examination in a few cases have shown isolated fibres, degenerative neuritis of the cochlear nerve involved. Of a predilective disease of the vestibular nerve nothing is known, either clinically or from a pathologic-anatomical standpoint. These isolated disturbances of hearing with. out disturbance of equilibrium are used by Witmaack as differential diagnosis in diseases of the labyrinth. Nevertheless all patients with only slight static disturbances must be thoroughly examined for any possible phenomena of irritation or prolapse. To illustrate the differential diangosis from his visual point Witmaack shows a number of cases of nervous deafness without disturbance equilibrium, disease of the acoustic nerve, in which the hearing tests indicated disease of the inner ear and where the exploration for a fresh or a past involvement of the semi-circular processes were negative. In such cases the nerve is damaged by poisons allowed to enter the body, as nicotine, alcohol, salicylic acid, etc., or more often to anomalies of assimilation, as in diabetes, Basedow's disease and gout; or to disturbances of circulation, as in arteriosclerosis and myodegenerative cardis. As opposed to this, such cases of nervous deafness with pronounced vestibular disturbances, labryinthian disease, are reported. Often after lues and nephritis, disturbance of the semicircular canal apparatus (vertigo, disturbance of equilibrium) appear besides the deafness and tinnitus.

of

The

difference between the two group of cases just reported, the disease of the acoustic nerve on the one side and the labyrinthian disease on the other are as follows: 1. Absence or presence of symptoms of involvement of the semicircular canals. 2. Rapid or slow but constant increase of the symptoms in disease of the acoustic nerve, periodical attacks of exacerbation with remissions in labyrinthian disease. 3. Difference in the pitch of hearing. In disease of acoustic low tones are heard better than the high tones, continuous decrease for the high toes. In labyrinthian disease low tones not markedly better than high tones, especially falling off in the middle toes. One point that should be emphasized, is Witmaack's contrast in the indication of the hearing pitch as compared to Gradenigo's who takes Wit

maack's typical hearing pitch for labyrinthian disease, as a disease of the nerve itself. According to Witmaack the following division should be made: 1. Degenerative neuritis-tabes, alcoholism, diabetes and arteriosclerosis. 2. Labyrinthitis-syphilis, leukemia, etc. Witmaack predicts that in the near future in the study of diseases of the ear it will be possible by more accurate functional examination and diagnosis of diseases of the inner ear and the auditory nerve, as in diseases of the eye, to diagnose nervous and general diseases that may not have been recognized before. Witmaack has succeeded in discovering tabes in three cases, that had not been diagnosed before. The deafness of old age and of occupation Witmaack also classes as a neural process on the basis on the basis of his functional examinations. The elective vulnerabiilty of the ramus cochlearis, he thinks is due to its anatomical position, imbedded in a rigid bony tissue and nourished by terminal arteries. Moreover the ganglion cells and their medullary sheath are of such a construction, as to indicate in the foundation of the sprial ganglion an arrest at a very low stage of development. This circumstance and the unfavorable condition of the nourishment of the nerve make it an easy victim to the noxious poisons, be this through lack of nourishment (arterio-sclerosis) or due to over-exertion of the nerve.

Facial Paralysis in a Case of Bezold's Mastoiditis. (Barth, Zeitschrift fuer Ohren heilkunde.)-Facial paralysis in Bezold's mastoiditis is contrary to theoretical consideration, very rare. This case, a farmer of twentyone, developed a mastoiditis which was oper ated on and the paralysis receded in a few days. The reason that facial paralysis is comparatively rare in Bezold's mastoiditis is that the rupture usually takes place in posterior section of the digastric fossa.

OBSTETRICS AND GYNECOLOGY

W. H. VOGT, M. D.

Etiology and Diagnosis of Early Tubal Pregnancy.-W. E. Ground (American Medicine, Sept. 2, 1905) has operated on 28 cases of tubal pregnancy. Of these seven were operated on before ruptured, and 21 before rupture had occurred. Abdominal section was done in all unruptured cases. All the cases recovered. Post-puerperal lesions and gonorrheal infection were the most frequently noted causative factors.

Care of the Perineum with a Description of a New Method of Delivery of the Shoulders.—

(H. K. Kerr, Medical News, Sept. 2, 1905). -The patient being placed on her left side, the head being delivered and rotation affected, the author places his left hand on the right side of the child's head and presses back firmly. This stretches the perineum from its circumference, laterally and posteriorly, toward the center and anteriorly. Muscular contraction is thereby almost entirely overcome. The perineum is temporarily paralyzed and is elastic like rubber, and can hardly be made to tear. By carrying the left shoulder back into the perineum the right shoulder is lowered into the public arch. When a pain occurs the left shoulder cannot descend, because it is held well back and high up in the perineum. The right shoulder, on the other hand, descends, and as it does so it describes part of a circle around the left shoulder held as a fixed point high up in the perineum, so that the course of the right shoulder is downward and slightly backward, bringing the prominence of the shoulder well back into the vulvo-vaginal outlet, and the right arm below the shoulder into the pubic arch. One pain is usually enough to bring down the right shoulder, and cause it to bulge well out of the vulva. This accomplished, the fingers of the left hand, with which backward pressure is being made, low down on the back of the neck or upper end of the spine, are closed and the physician presses up. This increases the space between the back of the child and the maternal soft parts on the left side below and also opens the right axilla. Through this opening in the axilla the forefinger of the right hand is passed and hooked around the arm, close to the shoulder, bringing it down behind the child's back out of the rulva and sweeping it over the pubic arch. Then, before relaxing the grip with the left hand, the right and is placed on the left side of the child's head and, with the left supporting the perineum, by a downward, forward and slightly upward movement, delivery is effected. Thus before there is the slightest strain on the anterior part of the perineum, the long diameter, from the tip of one shoulder to the tip of the other, is exchanged for the shorter diameter, from the axilla to the tip of the opposite shoulder, as a presenting part, the difference again between laceration and no laceration. This procedure can be employed in most forceps cases by removing the instrument.

Cases Illustrating Some of the Difficulties in Abdominal Diagnosis.-E. E. Montgomery (American Medicine, Sept. 9, 1905) cites the history of six cases, illustrating some of the difficulties of diagnosis. The errors of diag

nosis are frequently the result of careless habits of investigation and failure to utilize all means at our command to illuminate the subject under investigation. The cases, according to the author, may be divided into: (1) Those in which the solution has to do with the existence or non-existence of pregnancy; (2) those in which ovarian tumor may be in question; (3) those in which the condition may make us doubtful as to the existence of a myoma; (4) those due to other growths.

Myoma and Menopause.-(Winter, Berliner klinische Wochenschrift, No. 27).-In 718 cases of myoma the menopause did not occur until after 55 years of age in one-third of the cases. Of 437 patients under 45 years only 9 were in the menopause, only 15 in 170 were between 45 and 50 years, while the menopause had just commenced in 37 out of 111 over the age of 50 years, Fully 17% of his patients. had to submit to an operation after the age when the menopause usually commences in normal women

The symptoms observed

from the myoma in the menopause may be due the expulsion of a submucous myoma, or to an increased tendency to sarcomatous Myomata degeneration, or to hemorrhage sometimes continues to grow after the menopause.

The Treatment of Eclampsia. (Newell, American Jour. of Obstetrics, Sept., 1905). -Eclampsia is now regarded as one of the toxins of pregnancy, the particular toxin depending for its production on the development of the ovum. The toxins may be due to faulty maternal metabolism with accumulation of the abnormal products in the circulation, to abnormal conditions at the placental site, or they may be produced during the development of the ovum, and pass into the maternal economy through the placenta. The severe cases show involvement of the liver, the less severe show kidney lesions. The danger to the patient arises from failure of the circulatory apparatus. The treatment must be directed to removal of the source of the toxemia, to relief of the heart by stopping the convulsions, and by relaxing the vasomotor spasm, to securing the elimination of the toxins in the system, and to the support of the patient, until the results have been obtained. The earlier the uterus is emptied the better for the patient. Delivery may be effected by mechanical dilatation of the cervix, or by vaginal Cesarian section if the cervix is very rigid. A loss of 16 to 30 ounces of blood post-partum may be beneficial. The prognosis is better. post-partum than in antepartum convulsions The convulsion may often be controlled by

morphine, or hydrobromate of hyoscine. Salt solution may be injected subcutaneously or into the veins. Purging should be effected by magnesium sulphate or croton oil.

Alexander's Operation Through the Median Incision.-K. T. M. Sandberg (Amer. Jour. of Obstetrics, Sept., 1905) devised this method, to be employed in cases of retrodis. placement of the uterus complicated with prolapse of more than moderate degree. In case of prolapse the sacro-uterine ligaments are shortened, the fundus of the uterus is then brought up and the round ligaments are pulled out through the inguinal canal. The deeper layers of the abdominal wound are then sutured, and the round ligaments are pulled out to the extent indicated by the previous test and fastened by silk sutures, four on each side. The skin and adipose tissue are then closed leaving the wound open just enough for drainage. The author advocates this method because of the following reasons: (1) There is only one incision. (2) This is located where it gives the best access for examination of the pelvic organs and for work

in the pelvic cavity. (3) The abdomen is opened with must less hesitancy when all work can be done through a single incision, and many of the causes of failure of the Alexander operation may be ascertained and avoided by an exploratory opening of the abdomen. (4) The intra-abdominal work is limited as much as possible, stitching the uterus or the round ligaments intra-abdom. inally being avoided. (5) It leaves no adhesions or bands between the abdominal wall and the uterus to interfere with the expansion of the bladder, or growth of the uterus in pregnancy, or to cause obstruction of the bowels. (6) The intra-abdominal relations (7)

are left in an almost normal condition. The thickest and strongest part of the round ligaments is retained.

Indications and Contraindications for Vaporization of the Uterus.-K. Baisch (Thera

pie der Gengenwart, No. 7, 1905)-This procedure which was introduced by Snequireff and advocated by Pincus is unreliable, the action may be too severe, then again too slight. The success of the method depends too much on chance since the thickness of the uterine mucosa is variable. In chronic metro-endometritis, uncomplicated, previous to the menopause, the procedure may be of some benefit. In this condition it may answer the purpose of a hysterectomy. All malignancy must be excluded before it is used.

Salpingitis: Tuberculous and Otherwise.Pearse (Inter. Jour. of Surg., Sept., 1905)

comes to the following conclusions: (1) Tuberculous disease of the tubes occurs in many women and young girls; (2) it occurs in the virign where it is unsuspected, and it attacks the best specimens of our womanhood; (3) its course is so chronic and insidious, that we are apt to overlook it nnless constantly on the watch for this particular disease; (4) its early recognition and removal is usually followed by success. Its ultimate results when neglected are terrible and farreaching.

NEVER incise a swelling in the course of a large artery without making sure first that it is not an aueurism.

SHE MUST "MAKE GOOD" OR QUIT.-A Los Angeles woman physician advertised widely to cure cases of cancer and, on account of such advertising, her certificate was revoked by the California State Board of Medical Examiners. One of the provisions of the California medical practice act is that a certificate may be revoked if the holder is guilty of uttering grossly improbable statements in regard to his or her healing powers. The disbarred physician will now take action in court to prove that her assertion that she can cure cancer is not "a grossly improbable statement." The California courts may now mediate and decide if cancer is curable by the methods of the enterprising Los Angeles physician.

ENDOMETRITIS.-E. F. Tucker, Portland, Ore. (Jour. A.M. A., Nov. 11), remarks that in six text-books he finds 27 varieties of endometritis described, no single one of which is found in all six. This ought to be discouraging to the student did these varieties really all exist. Tucker states that the endometrium is a tissue, the main function of which is undoubtedly connected with the development of the fertilized ovum, and its pathology is limited. He quotes from Emmett and Howard Kelly as to the rarity and limitations of endometritis, and says that a true endometritis can only exist as a result of a direct irritant to the structure of

the endometrium, either microbic or otherwise, and such is rare.

The endometrium may be affected by conditions affecting the uterus, but this does not represent a diseased The only successful condition by itself. treatment is removal of the cause when this can be discovered and local measures directed to the endometrium alone will be of little avail. He does not believe in a gonorrheal, condition of the endometrium proper, a part from the cervix, though he says this is a disputed point.

SOCIETY PROCEEDINGS

MISSISSIPPI VALLEY MEDICAL ASSOCIA

TION.

(Continued from page 563.)

Thirty-first annual meeting, held at Indianapolis, Ind., October 10, 11 and 12, 1905. The Presidena, Dr. Bransford Lewis, of St. Louis, in the chair.

SURGICAL SECTION.

Prostatectomy. Dr. W. D. HAINES, of Cincinnati, O., said that two patients, aged respectively 42 and 59 years, with small indurated prostate with obstruction, did well after perineal section and the removal of the gland, in that the catheter was abandoned and a troublesome cystitis relieved. One of the men suffered incontinence for a period of three months after the operation, and the cure was incomplete as residual urine was found in both cases, and this despite easy bladder access by the sound or catheter. The author condemned the use of metallic instruments in prostatics for diagnostic purposes, or for the relief of urinary retention, as the danger of perforation and infection far outweigh the meager information or temporary relief thus obtained. One could confidently hope for complete cure in 30 per cent of the cases submitted to prostatectomy, namely, released from catheter bondage, relief from bladder complications and restoration of

DR. S C. STANTON, Treasurer.

urinary functions. In his experience with perineal prostatectomy seven cases had been functionally cured, nine showed residual urine, some of whom had attacks of cystitis and dribbling, and five of these were suffering from incontinence six months to one year and a half after operation. Two cases required secondary operation, one for stone, and one for perineal fistula, making a total of sixtéen cases, with ages ranging from 42 to 79 years, without mortality. While these results were far from ideal, the unfavorable physical condition present in the majority of them would in a measure militate against criticism as to the final outcome of this series.

President's Address. Dr. BRANSFORD LEWIS delivered his address, a synopsis of which appeared in the last issue of the FORTNIGHTLY, page 524.

Present Status of Surgery of the Stomach. -DR. W. D. HAGGARD, Nashville, Tenn., said that a discussion relative to operation for stomach lesions now is similar to that in regard to appendicitis twelve or fifteen years ago. Then only the desperate cases were submitted to operation. It is so now with many stomach cases. This, however, must yield to the logic of results, and in a short time the profession generally will advise early operation as they now well nigh universally do in appendicitis. Improved technic, low mortality and satisfactory end results will inevitably

do away with the empirical treatment of occult intractable stomach troubles. The typical indication for operative interference is obstruction of the pylorus from an open or cicatrized ulcer causing dilation of the stom. ach, with stasis of food. The short circuiting operation of gastroenteric anastomosis finds its ideal operation here, and has given the most beneficent results. It is the fons et origo of the present group of drainage operations, as well as other gastric procedures, and is altogether the most perfected and satisfactorily employed operative device. The other complications of ulcer requiring operation were pointed out, as (1) perforation, (2) hematemesis of chronic ulcer. Operation is advised in repeated acute hemorrhage or in constantly recurring small hemorrhages. Other indications are found in the following groups of cases: (3) Obscure and persistent stomach troubles, with a long history of dyspepsia culminating in hemorrhage after it has been controlled by medical means and the patient put in the proper condition for operation. (4) Cases of chronic intractable dyspepsia, even without dilatation, which fail to yield to proper medical treatment and are not due to a general visceral ptosis. Aside from malignancy, chronic ulcer and its complications furnish most of the indications and the majority of cases. It is not impossible that the bulk of cases of inveterate dyspepsia is really due to ulcer. That it is found postmortem very many more times than it is recognized clinically.

General Blood Poisoning Emanating from the Nose and Pharynx.-DR. J. HOLLISTER, Chicago, stated that micro-organisms of the nose and pharynx were formerly considered harmless. A great many diseases can be directly traced to them. Fatal cases of blood poisoning occur, but are not very frequent. With the decrease in the number of streptococci in the pharynx all general symptoms not only diminish but disappear. The connection between acute rheumatism and tonsillitis is well known. The tonsil receives its lymph from the nose and pharynx, and may, therefore, become secondarily inflamed in cases of infections located in the nose and pharynx. There is a difference in the course of the disease, whether the infection dates from the nose and pharynx, or directly from the tonsils. The most striking example is diphtheria. Histories of cases are given by the author where chronic rheumatism of many years' standing, which had been treated with all kinds of medicine, massage and Xray, disappeared when the suppurative processes in the nose and its sinuses were cured. The mixed infections of tuberculosis of the

lung and bones may be avoided, in the opinion of the author, if the pharynx and nose whence they start are treated. As to treatment, very little is accomplished by sprays. Washes with boric acid solution are used in the nose, and in the pharynx paintings with solutions of iodin and iodid of potash and glycerin.

Cancer of the Rectum.-DR. E. B. SMITH, Detroit, made a special plea for extirpation in the treatment of cancer of the rectum as

being the only procedure that will give He spoke of colotomy as hope of a cure. the operation of necessity rather than of choice, and urged examination in all cases where the rectum is involved, as in cases of hemorrhage, where there are bloody stools, where there is painful defecation, and where there is constipation, and advised a microscopical examination in all cases where the neoplasm is developed. The author shows that the extirpation of a part or the whole of the rectum by the Kraske method is the ideal operation, and should be practiced only by those who have had expereince in capital operations.

Surgery of Visceral Injuries from Violence to the Abdominal Wall.-JOHN Wall.-JOHN YOUNG BROWN, St. Louis, called attention to the mortality in such cases, and emphasized the importance of their early diagnosis and prompt surigcal treatment. He reported a series of six cases, in all of which abdominal resection was done. Of the six cases, one recovered and five died. An analysis of cases. confirms the importance of early diagnosis and prompt surigcal treatment by abdominal section in all cases of abdominal contusion in which there were present the slightest symptoms pertaining to injury to peritoneal viscera.

2. It

Intraperitoneal Tuberculosis.- DR. F. F. LAWRENCE, Columbus, Ohio, drew the following conclusions: 1. Intraperitoneal tuberculosis is frequently a local disease. probably occurs much more frequently in the female than in the male. 3. In a large ma. jority of cases it is primarily visceral and the general peritoneum is secondarily involved. 4. The surgical treatment is rational, some times agreeably surprising in results, and again bitterly disappointing. 5. In this, as in many other surgical conditions, early diagnosis and early operation will bring more certain results. 6. In this condition the greatest obstacle to overcome is the idea that it is a secondary condition. 7. No case of intraperitoneal tuberculosis should be denied. the benefits of operation, no matter how extensive, as long as there is no positive pul