tion of the hepatic veins, in this manner of opening into inferior vena cava. As to angioma of the liver, such a condition is practically unheard of, except in childhood.

Dr. Myer said it was not his intention to tear down the diagnosis. He merely expressed his opinion that it was impossible to say definitely in any case just what kind of tumor one may find in the abdominal cavity. He thought the vomiting could be very easily explained for he had seen very much less pressure within the abdominal cavity produce more persistent vomiting than was seen in this case. Had the patient vomited blood there might be other reasons to think there was congestion in the liver. With reference to the enlarged spleen he had simply said that in the cursory examination he had made, he did not make it out, he did not mean to say that there was no enlargement. There are no pulmonary symptoms in this case, the patient stating that he has not been coughing, and yet cough almost invariably occurs in marked regurgitation.

THROUGH the streets of Berlin doctor's carriages have the right of Even the Emperor's carriage must pause when a doctor's vehicle is about to cut cross its path.

way.

CHOLERA AND PLAGUE IN THE PHILIPPINE ISLANDS.-During the four weeks ending July 18, 1903, the average of new cases of cholera reported is 9 a week, nearly all of which were outside of Manila. The totals for cholera and plague are as follows: Cholera, 3,238 cases and 2,160 deaths; plague, 15 cases and 13 deaths.

BUTTERMILK.-Buttermilk as a remedial agent cannot be praised too highly. The lactic acid, the sour of the buttermmilk, attacks and dissolves every sort of earthy deposits in the blood vessels. Thus it keeps the veins and arteries so supple and free running there can be no clogging up; hence no deposit of irritating calcareous matter around the joints, nor of poisonous waste in the muscles. It is the stiffening and narrowing of the blood vessels which bring on senile decay. Buttermilk is likely to postpone it ten or twenty years, if freely drunk. A quart a day should be the minimum, the maximum according to taste and opportunity. Inasmuch as gouty difficulties arise from sluggish excretion, buttermilk is a blessing to all gouty subjects. It gently stimulates all the excretories-liver, skin, and kidneys. It also tones the stomach and furnishes it the material from which to make rich, red healthy blood. If troubled with gout avoid meat, sweets, pastry, wines, spices, hot rolls, bread of all sorts and everything belonging to the tribe of ferments. Eggs, game, fresh fruit, vegetables, especially salads, may be eaten with impunity. If any one has a creaky joint or a swollen and aching one, he should drink all the buttermilk he can relish whenever and wherever he can, but it should be fresh churned and wholesome. -How to Live, August, 1903.

Reports on Progress.

COMPRISING THE REGULAR CONTRIBUTIONS OF THE FORTNIGHTLY DEPARTMENT STAFF

DEPARTMENT OF OTOLOGY.

BY A. F. KOETTER, M. D.

ST. LOUIS.

On the Use of Eustachian Catheter.-Dr. B. St. John Rossa ( The Post-Graduate, July, 1903) deprecates the use of cocain as a preliminary to passing Eustachian catheter in the mouth of Eustachian tube; the operation if done with proper instruments may be an almost painless procedure, especially after the first few introductions. Constant use of cocain may cause the nasal mucous membrane to become hyperemic and sensitive and nasal canal may be injured. Author advocates the use of the hard rubber catheter, as the silver catheter with its large curve invariably requires the use of cocain being accompanied by considerable pain. Patient should have good support for head and back, the point of instrument introduced vertically, quickly turned horizontally, then passed to wall of pharynx and back to mouth of tube. Author improved on rubber catheter by having guide near proximal end a solid piece of hard rubber instead of steel ring which was apt to slip from its place and thereby lose its value as guide.

Ab

A Case of Teratoma of the Ear.-Dr. Wm. C. Braislin in a paper read before the American Laryngological and Otological society and reported in Brooklyn Medical Journal, a case of teratoma of the ear. The patient, a woman fifty years of age, came to his office complaining of_tinnitus of the left ear so severe that she was unable to sleep at night. Itching, which was present had been aggravated by frequent use of hair pin. No pain at any time. Symptoms had been persisting for two years. solute deafness on affected side had latterly developed; watch placed against ear could not be heard. Obstruction which prevented introduction of finger tip or small pin was very evident. A probe of smallest diameter could not be introduced along the floor or walls of canal beyond the obstruction. Growth had appearance of sebaceous cyst, but not probable owing to its density. Exploratory thrust caused brisk and presistent hemorrhage which led to diagnosis of angioma, the presence of several dilated branches of the post-auricular vein behind the ear at the attachment of the auricular cartilage, favored this conclusion. At the operation done several days later a wide incision, as in classical mastoid, was made to allow the auricle to be drawn well forward, causing no especial hemor rhage, though vessels in this region were all larger than common. The tumor was attached to periostium of bony canal filling it entirely. It was inclosed in a capsule and was dissected out entire. Deep in the bony meatus it was attached by a sort of pedicle. In dissecting tumor from interior

of canal and leave the skin unbroken it was accidentally button-holed at the deepest portion of canal just external to drum membrane. Soft parts of canal were replaced and held in position by gauze packing. Sutures were used in closing wound behind the ear. Healing was prompt and hearing restored, slight amount of tinnitus still present after three weeks. Tumor on examination showed presence of cartilaginous and myxamatous tissue and abortive glands. Vessel walls show arterio-sclerosis and hyaline degeneration. Fibrous tissue in places. Pathologists who examined microscopical slides of growths differ as to proper nomenclature; one calling it a teratoma, another an endothelioma.

Treatment of Acute Suppurative Otitis Media (Laryngoscope, June, 1903.) S. MacEwen Smith in speaking of treatment of otitis media acuta thinks that early and prompt treatment of acute inflammatory diseases of the ear are the most important duties of every practitioner of medicine. Prompt and proper care of acute catarrhal otitis media will often prevent it from progressing to suppurative stage; but, if it has reached suppurative stage prompt recognition and care will arrest progress and recovery take place without loss of function. If disease should be purulent from inception, immediate evacuation of pus will prevent complications and often loss of life. According to author a great majority of suppurative diseases of tympanum are primarily catarrhal and become purulent from neglect of patient or physician. If there is only hyperemia and hyper-secretion of mucous it can be classified as non-suppurative. Should secretion remain for a time in tympanic cavity, pathological changes take place, bulging and perforation occurs and case is then acute suppuration. Effective treatment of acute otitis media must be directed to cause of disease. Acute otitis media due to coryza usually yields to simple remedies, while acute otitis media due to exanthemata, epidemic influenza or pneumonia require prompt measures for their relief. Mastoid and intracranial involvement are more liable to follow influenza and pneumonia than one of the exanthemata, due no doubt to the virulence of bacillus of influenza and pneumonia. Relapses may oftentimes occur in these cases and sudden death take place during a violent convulsion, as in two cases seen by Dr. Smith last winter. Author speaking of the ineffectual operation known as paracentesis of membrane, and makes an earnest plea for a free incision of membrane, carrying it from most bulging point downward to the lower border of canal, insuring good drainage. Cleansing canal and middle ear with an antiseptic solution and putting in gauze drain to be changed every day are usually satisfactory. Rest in bed, free movements of the bowels and restricted diet aid materially in treatment of acute otitis media.

Symposium - Otitis Media Suppurative (Laryngoscope, June, 1903.)-Norval H. Pierce speaking of etiology, pathology and symptoma. tology of acute suppurative otitis media finds greatest number occur in first three years of life, due he claims to hyperplasia of lymphoid structures of pharynx and post-nasal space and frequency of acute exanthemata at this period. Sex.-In first twelve years more females than males

affected (45 per cent to 32 per cent), later on this is reversed 6 to 4. Season.-Winter and Spring. Climate.-Most frequently seen in parts subject to sudden variations of temperature; cold is predisposing factor in acute ear disease. Germs most frequently found in exudate are diplococcus pneumoniae and streptococcus pyogenes. Staphylococcus pyogenes albus and aureus, pneumo-bacillus, bacillus of Friedlander, bacillus pyoscyaneus, staphylococcus cereus albus and aureus and micrococcus tetiagenes. Micro-organisms are rarely found in pure culture in aural exudate. Kathrack in thirty-one cases of otitis media before perforation occurred, found pure culture in but three cases. According to McKernow most violent and destructive is streptococcus pyogenes. Prognosis should be guarded when this organism is found. Route of Infection.-Tympanic cavity may be infected as follows: 1. Intact drum-head, as in erysipelas, tuberculosis, eczema. 2. Through perforation of tympanic membrane. 3. By way of circulation (a) in congenital otitis media accompanying infectious diseases in utero-variola, typhus diphtheria. (b) Some diseases occurring in extra-uterine life. (c) Endocarditis. 4. By way of eusta chian tube: (a) Indirectly by lymphatic interspaces. (b) Directly by continuity of surface. (c) Through the lumen of tube forcing infectious mucous into ear by coughing, sneezing. The nature of an otitis is dependent on the intensity of bacterial virulence, number of organism, resistance of tissues and rapidity of invasion. Symptomatology.-Pain is the most prominent symptom in acute otitis media suppurativa, a throbbing, burning pain, rise in temperature, sometimes accompanied by delirium and convulsion. Entotic sounds due to labyrinthine pressure or serous exudate and hyperemia in the labyrinth. Hearing is more or less decreased, especially before perforation. Objective Symptoms.-Hyperemia and bulging of tympanic membrane, bulging indicates presence of fluid in cavity. External canal in neighborhood of membrane may be congested. Bulging often assumes nipple-shape at the apex of which perforation takes place through which it discharges with more or less difficulty. Perforations most frequently occur in lower anterior and posterior quadrants. Marginal or multiple perforations in lower quadrant indicate constitutional trouble, usually tuberculosis.

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY.

BY W. H. VOGT, M. D.

ST. LOUIS.

Bossi's Rapid Dilatation of the Cervix.-(R. Cristofaletti, Wiener klinsche Wochenschrift, No. 28.)-Five cases are reported in which this method was used; three were cases of eclampsia. The prolonged narcosis in these three cases seem to have a bad influence on the patient. Injuries can be produced easily and the method of dilatation does not approach the physiological dilatation. He believes the kolpeurynter the least dangerous, and the one method best adopted for the general practitioner.

Concerning the Transverse Fascia Incision above the Symphysis Pubis.-Pfannenstiel's Method.-(By Prof. Menge of Liepzig, Monatsschrift fur Gebsurtshaelfe und Gynaekologie, June, 1903.)-Menge prefers this incision to the usual abdominal incision, and believes if healing takes place per primam hernia can be absolutely prevented. The danger of infection and the difficulty of making the skin in this region aseptic is recognized by him, and he goes into detail regarding the method adopted by him to cleanse the parts. In his first series of 32 cases he had no suppuration, whereas in his second series of 30 cases he had four cases of suppuration, all being due to furunculosis. He also calls attention to the necessity of controlling hemorrhage in the abdominal walls completely. He closes the wound by sewing the peritoneum with a continuous suture; the muscles he sews with interrupted catgut, and the fascia he closes in the center with one interrupted suture, and on each side with continuous.

Clamping of the Uterine Arteries in Cases of Post-Partum Hemorrhage Henkel's Method. (A. Labhardt, Zentralblatt fuer Gynaekologie, July 11, 1903.)-Henkel in his work on hemorrhage following labor and its treatment recommends the clamping of the uterine arteries. He does this on account of the good results which he has had in six cases of bleeding due to cervical lacerations and one of atonic hemorrhage. The cervix is caught with a strong Muzeux forceps and brought down, and by drawing to the right or left the parametrium of either side can be easily caught with another Muzeux forceps. He does not believe the danger of clamping the ureter is very great. Bloody urine he considers a sign of a ureter being caught in the forceps, as has occured in two of his cases without any evil result. The forceps remain in place twelve to twenty-four hours. The slight pressure which the forceps cause does not produce necrosis. Encouraged by these results the author tried this method and reports the case. The woman 37 years old, ten months pregnant was brought to the hospital with the diagnosis of meningitis, which upon examination proved to be correct. She was having convulsions and strong pains every five or ten minutes. The os was dilated sufficiently to admit two fingers. Dilatation was hastened by means of the Bossi dilator, it occupying fifteen minutes to complete dilatation. The child was delivered with axis-traction forceps and the placenta expelled. The uterus was a short time poorly contracted, but soon became well contracted, bleeding, however, persisted, in fact became stronger. Upon examination a large cervical tear was detected and the Muzeux forceps applied as directed by Henkel, to both right and left parametrium; hemorrhage ceased immediately; the patient died, however, and the autopsy showed a leptomeningitis and a cervical tear of 9 cm. in length. The forceps applied to the right parametrium was found to contain within its grasp the uterine artery, and the ureter of that side was close to the forceps but free. the left side the forceps lay somewhat higher and scarcely missed the ureter, and although the artery lay within the grasp of the forceps and the forceps were closed completely, yet the artery was not compressed. The author concludes from this experience that the method deserves further trial, but doubts whether it will ever take the place of sewing in cases of cervical tears.

On