Dercum,' in the excellent chapter on neurasthenia written by him, the subject receives a mention somewhat commensurate with its importance. No treatment of the subject of neurasthenia can be considered complete which omits mention of imperative conceptions as a symptom. CLINICAL LECTURE. BLEPHAROPLASTY, STRICTURE OF THE ŒSO- CASE I.-About ten days ago I performed a plastic operation on this girl's face in order to make a new upper and lower eyelid. Whereas formerly she even slept with the eye open, she can now close the lids. The upper lid was taken from the temporal region, the lower from a V-shaped incision in the cheek. The upper wound was closed by collateral incisions and sliding of tissues, while the lower gap was closed as a linear wound. The scars are at present very noticeable, but they will fade in time. CASE II. This patient, an old man, has stricture of the œsophagus, and he is slowly starving to death; have proposed performing gastrostomy, but he positively declines operation. Seeing the end of life approaching he has yielded so far as to permit me to try electrolysis within the œsophagus. This is a procedure in which I have little confidence, but I shall put it in practice in order to do all possible for the patient's relief and with the hope that if this fails he will consent to surgical measures. The flexible œsophageal electrode is connected with the negative pole of the battery, and a current of twenty milliampères is passed for five minutes. We will repeat this every day. CASE III.-The first operative case is that of a man of fifty-five years, who comes in with an ulcer on the lower lip, not quite in the middle line. It has an indurated base, which flares out so as to make the lip thicker than it should be. The area of infiltration shades gradually into normal tissue. There is no difficulty in making a diagnosis of epithelioma, from the age of the patient, the location of the sore, the refusal to heal itself, and the obvious presence of constant irritation of a pipe. This form of cancer has been called pipe-smokers' cancer. The teeth are badly decayed, foul, and covered with a carbonaceous deposit. There is a notch on the side of the cancer showing where the pipe-stem has habitually rested. The patient has unwittingly favored the growth of the cancer by a variety of applications which he has made. He has also relied on clover tea, and has only sought professional advice within the last few days, when the outlook, though not hopeless, is unfavorable. Epithelioma in this location is almost always seen in men of middle or advanced age; yet not long ago I had to operate on a young woman of twenty-eight who had as typical an epithelioma of the lip as this. So far as I can feel, there is no lymphatic involvement; perhaps after the patient is anæsthetized I may be able 1 Nervous Diseases, by American Authors, p. 65. to find enlarged lymph-nodes, and then it will be necessary to remove them. I have often told you that in operating for cancer you must remove all tissue that is invaded without false mercy, stopping only at organs essential to life. The operation consists in the exsection of a V-shaped piece of the lower lip, and, as the closing of this wound reduces the lower lip so that there is a relative redundancy of upper lip, I shall extend the mouth laterally and close this incision by a sliding of tissues, so as to equalize the two lips. This makes the operation longer and bloodier, but the cosmetic effect is better. It has been customary to dress such wounds with collodion, since the ordinary antiseptic dressing is out of the question; but I have noticed that a little saliva usually works its way under the crust, or else the collodion is raised by an effusion of serum, bacteria enter, and suppuration ensues. Therefore for the last few years I have adopted the policy of allowing the line of sutures to be covered with a scab of blood, perhaps using a little collodion after a day or two, but not at first. CASE IV. This case is one of inguinal hernia, of short duration, in a man of thirty-two years. The tumor is only about as large as a hen's egg when the hernia is down. The intestine is now in the abdominal cavity. Having had the site of operation shaved, scrubbed, and disinfected, and surrounding parts shut off by damp bichloride towels, I shall proceed to cut down over the external inguinal ring. There is undoubtedly a serous sac, and the search for this is not quite so easy as it would be with the hernia unreduced. I shall look for it alongside the spermatic cord, which is easily felt. Having found and isolated the sac, I shall now carry out Kocher's idea, make an opening at the upper end of the inguinal canal, draw the sac up into the opening, and twist it. If this does not make a radical cure of the condition, I do not know what will. The outer wound is closed with a continuous subcutaneous catgut suture. Although it is not so important in this location, the subcutaneous suture has the advantage over the ordinary puncturing suture of leaving no cross-marks, so that after healing only a linear scar is visible. CASE V. This is morphologically an interesting case, that of a little child, with the middle and ring fingers of the right hand united, and with the middle, ring, and little fingers of the left hand webbed together, with a supernumerary finger between the last two. This condition is known to the laity as web-fingers, technically as syndactylus. Sometimes one sees a complete webbing of all the fingers, when the hand looks as if it were covered with a skin mitten. The condition is an evolutionary relic, a reversion to the condition of united phalanges as seen in many of the lower animals. The condition normally disappears early in the life of the human foetus. There is nothing difficult about the diagnosis, and the general indication for treatment is plain, for parents do not wish this interesting condition to remain. The separation of the fingers is not, however, so easy as the separation of two pieces of candy that have become stuck together, and it is not sufficient simply to make longitudinal incisions without preventing the raw surfaces from again cohering. Whenever possible we make an oblique compound dissection between the bones, so that there remains on each finger a thin flap which can be wrapped around and sutured to the skin on the opposite side. Sometimes there is not | ing after finding a clot, in order to meet particular indienough skin to permit this, and then we must simply spread the bones apart and pack in enough antiseptic material to prevent adhesion, and allow the surface to heal by granulation and subsequent cicatrization. A condition resembling syndactylus may be seen from burns or other traumatism and ulceration. When the syndactylus is congenital, it is an advantage to operate as early as possible, for parts thus bound together do not grow so rapidly as those which are free to move. cations. So far the operation is purely exploratory. It is possible that a localized meningitis could have produced some of the phenomena noted here, but hardly the aphasia. The patient's skull is thick-though this is no index as to his mental abilities. The dura is not bulging, but it is discolored by a clot beneath, and on incising it the clot is gradually pushed out by the pulsations of the brain. The clot is quite tenacious, showing that it is not very fresh. I have caught a small bleeding vessel with a hæmostat. Further oozing I shall endeavor to check by using this antipyrin spray. The clot is removed partly by the sharp spoon and partly by wiping with aseptic gauze, which has almost supple Supernumerary fingers are not uncommonly seen on the outside of the hand. Sometimes there will be two thumbs or a bifid terminal phalanx of the thumb. Similarly there may be two quite perfect little fingers or the sixth finger may hang like a flail on the little finger.mented the sponge in modern surgery, the latter being This is a relic of the time when some animals had six digits. No congenital defect or anomaly is ever found which has not its analogue or explanation either in fœtal life or in some of the lower forms of the animal kingdom. On the right hand I am having some difficulty in coaptating the skin about the little finger. On the left hand the removal of the supernumerary digit will allow plenty of tissue to cover the little finger. It will be interesting to note whether Nature, in supplying an extra finger, has provided it with flexor and extensor tendons. Such proves to be the case. The extra finger is smaller than the others and its bones are more slender. There are only five metacarpal bones, the extra finger sharing the articulation of the little finger. To-day I shall not try to separate the ring and middle fingers, but will wait till the wounds on the adjacent sides of the ring and the little finger have healed. The skin-flaps are sutured, the parts are anointed with antiseptic vaseline which has also been sterilized by heat, iodoform is dusted on, and the fingers are separated with iodoform gauze. CASE VI.-This patient is a young man who fell on the sidewalk night before last, striking the back of the head. He was quite rational until last night, when he began to talk strangely and to make queer movements of the arms and thorax, and then he had a shivering of the entire body. Before the clinic I could get no answer to my questions, and I concluded that he was aphasic. Since then he has spoken brokenly and without finishing his sentences. His right arm seemed to be in a cataleptic state, staying wherever I put it. While waiting in the anaesthetic room he has had two convulsions, and on account of the irritative character of the symptoms I believe that the lesion is cortical and superficial, and having come on after an interval it is probably of the nature of a hemorrhage. On inspecting the head since it has been shaved, I note a recent bruise in the middle line, a little above the occipital protuberance. A blood-clot here would not account for his symptoms, especially not for the interference with speech. I shall, therefore, trephine over the motor area of the left side of the brain, following symptoms rather than external appearances. A semi-elliptical incision exposes the left parietal region. The periosteum is retracted, and a chisel-wound made to catch the centre-pin of the trephine. I have endeavored to approximate the speech-centre, not by measuring by a scale, but from a general remembrance of anatomy. If the clot is large enough to require removal, I can get near enough to it in this way, and we almost always have to enlarge an open so difficult to render aseptic. I am glad to give Dr. Weidenbauer credit for sending this case to the hospital. He recognized the condition present, realized the importance of surgical relief, and has done everything possible except performing the mechanical part of the treatment. It is quite probable that as the patient recovers from the anesthetic, the relief of pressure will be manifested by speech and the rapid recovery of consciousness. The wound is dressed antiseptically, without complete closure of the scalp-wound, as we wish to provide for the easy evacuation of any further blood-clots that may be formed. CLINICAL MEMORANDA. CASE OF TRAUMATIC SEPTIC MENINGITIS. BY ANDREW J. MCCOSH, M.D., OF NEW YORK. THE following case is of interest for three reasons: First, the marked improvement which followed the opening of the skull and drainage of the meninges, resulting apparently in cure or at least in the temporary recovery of the patient. Second, the persistence of the sepsis within the cranium for a period of four months without constitutional or local manifestations. This was proved by the presence of the same species of bacilli at the two operations. Third, the existence of an enormous cerebral abscess (eight ounces) and the absence of grave symptoms. There were no paralysis, no convulsions, no delirium or subnormal temperature, neither was there marked elevation of temperature. The only symptoms were moderate pain, a slight stupidity, and finally vomiting, but for ten days or more the patient had walked about as usual, had eaten with a good appetite, and had been fairly intelligent in spite of the presence of a large collection of pus in his brain. The fatal result due to pneumonia is another example of the close connection between sepsis in the brain and sepsis in the lungs. H. H., aged thirty years, was struck or kicked on the forehead in a fight on October 1, 1894. He walked home, and made no special complaint until the following day, when he suffered from headache in the frontal and parietal regions, and felt so feverish and weak that he remained in bed. Toward evening he became restless. On the following morning (October 3d) he was rather apathetic, and his restlessness had increased. His symptoms became worse during the day, and in the evening he was brought to the hospital in the ambulance. On admission he was stupid and complained of severe headache. Temperature 102°, pulse 80, respiration 30. The pupils were contracted and regular, There was no paralysis. At times he was very restless. Knee-jerks unaltered. 4th. Stupor had increased. He could be aroused with difficulty, and would then moan and show great irritability for a few minutes and again lapse into stupor. Temperature 100°, pulse 44 to 58, respiration 16. Operation was advised, as it was thought that there was a blood-clot pressing on the brain and probably a meningitis. | 101°. The pulse varied between 80 and 100. At times he talked intelligently, and would answer questions, though for the greater part of the time he was noisy and delirious. Fourth and fifth weeks (October 28th to November 12th) improvement continued in his mental condition, but not in temperature. During the day he was comparatively quiet, though often irrational, and always noisy at night. Sixth to eighth weeks (November 12th to December 3d) his mind gradually became clearer, he talked intelligently with his friends, and manifested interest in his surroundings. At night he was still restless. Temperature remained between 100° and 102°. On December 6th he was out of bed, and soon began to move about the ward. His memory was not good, occasionally irrational at night. After December 11th his temperature remained below 991⁄2°. On December 24th his fever had entirely disappeared. Appetite good. No headache. Wound completely healed. Discharged apparently cured. Two weeks later he returned to the hospital on a visit, and talked intelligently with the patients, and, while somewhat sluggish yet, he seemed comparatively well mentally and physically. For four months after he left the hospital he was entirely free from pain, fever, or sign of mental aberration. He was able to do light work, and seemed happy, though his wife noticed some loss of memory and occasional attacks of stupidity or indifference to his surroundings. About the first of April he began to complain of pain in the region of the right trephineopening, and noticed a bulging outward of each opening. A few days later he felt sharp pain in his right eye, and also some pain on the left side of the frontal region. He also appeared rather stupid. He was readmitted to the hospital on April 15, 1895. He complained of severe pain in the right eye, over the right tre 5th. Complete coma. Temperature 101°, pulse 40 his mental movements were sluggish, and he was still to 50. Consent to operation was obtained. Operation, October 5th. Chloroform. A semicircular flap with the apex just above the brain-line was dissected downward and the frontal bone exposed. A linear fracture one and one-half inches long was seen running in a vertical direction from left to right almost over the longitudinal sinus. There was no depression of bone. A one-inch trephine was applied just to the right of the median line, and on removing a button of bone an extradural blood-clot was seen alongside of the longitudinal sinus and evidently caused by a rupture of its wall. The opening was enlarged by rongeur (Lüer) forceps. On removing the clot the hemorrhage from the sinus started afresh, but was easily controlled by pressure. When the dura was exposed it was seen that there was no pulsation. As soon as the knife punctured this membrane a stream of turbid serum spurted out with considerable force. Two ounces of fluid escaped. Another blood-clot was found under the dura, and it was scraped away. The pia mater was then seen to be gray, cloudy, and without lustre, and was in astate of inflammation. Another trephine-open-phine-opening, where there was a pulsating swelling the ing for the sake of drainage was made over the left frontal eminence, and in this side there was also found both an extradural and intradural blood-clot. Irrigation with salt solution was employed. Horsehairdrains were inserted inside the dura through each opening. The scalp-flap was loosely fastened in place by a few sutures and strips of gauze inserted on each side. During the operation the pulse had risen from 38 to 85. The bacteriological examination of the fluid showed numerous colonies of streptococci and staphylococci. 6th. Coma not complete. He could be aroused, and he began to be delirious. Temperature 100° to 102°, pulse 86 to 100, respiration 24. 7th. Very noisy and delirious. Temperature 101° to 1021⁄2°, pulse 80 to 90, respiration 18. During the first week after the operation he continued very noisy with almost constant delirium. Temperature 100° to 102°, pulse 75 to 80. The wound was dressed on the fifth day, and the dressings found soaked with considerable serous discharge. Second week (October 12th to 19th) there was but little change. Temperature ranged between 100° and 102°, pulse 80 to 100. Third week (October 20th to 27th) there was a slight improvement. The temperature was lower-99%° to size of a small egg. There were also a bulging of the left trephine-opening and some pain in the left eye. Pressure on the projecting masses increased the pain in his eye and produced dizziness. There was no paralysis of motion or sensation. The patient walked about the ward, and conversed intelligently, though his reasoning-power was slow in its action. He was not restless, but was rather torpid. Temperature 981⁄2°, pulse 100, respiration 24. Diagnosis, probable cerebral abscess. 16th. Temperature 99°, pulse 70 to 80. Pain less severe when he remained in bed. 17th. Temperature 99° to 99%1⁄2°, pulse 80 to 96, respiration 20. Complains he cannot sleep. 18th. Patient walked over to the dispensary and back (quarter of a mile) for an examination of his eyes. Slight congestion of the right fundus was found. Temperature 991⁄2°, pulse 80 to 90. Pain more severe. Vomited several times. 19th. Vomiting. Bulging through trephine-openings increased. Stupidity more marked. No paralysis. When spoken to answers questions intelligently. Special senses not affected. Pupils react regularly. flexes lost. Knee-re 20th. Operation. Chloroform-anesthesia. A semilinear skin-flap was dissected from the frontal bone and THE COLON AT THE ILEOCÆCAL VALVE. BY CARL WEILAND, M.D., OF PHILADELPHIA. As cases of congenital occlusion of the intestine are very rare, only two such cases in 111,451 patients having been recorded at the Vienna Foundling Hospital, according to E. Theremin,1 it would seem of interest to put on record the following example of this hemiteratic anomaly: from the dura mater which bulged out of the trephine- | A CASE OF CONGENITAL OCCLUSION OF opening, to which the flap was very adherent. The dura was much thickened. An aspirating-needle passed into the brain substance drew out pus. The dura was incised around the upper margin of the right opening, and under it was found brain-tissue mixed with granulations. This was scraped away with a sharp spoon, and immediately a jet of thick greenish pus spurted out to the distance of two feet. The opening in the brain was enlarged, and the pus continued to flow until eight ounces had escaped. It was then seen that the bulging over the left trephine-opening had collapsed. The finger passed into the abscess-cavity found it lined with a smooth, uniform membrane which bled but slightly. The cavity was as large as a man's fist, and occupied apparently the entire frontal lobe on the right side, with the exception of a thin shell of cerebral tissue which formed its wall. The cavity also extended into the left frontal lobe. The dura was opened on this side, and the finger thrust through a thin layer of granulating cerebral tissue passed into the abscess-cavity. This was then gently washed out with boric-acid solution, and drained through each trephine-opening by a rubber tube and strips of gauze. Before the operation, temperature 99%1⁄2°, pulse 80. Two hours after operation temperature 102°, pulse 120. 21st. Temperature 100° to 102°, pulse 80 to 100, respiration 16 to 20. Free from pain. Mind brighter. 22d. Temperature 100° to 101°, pulse 9ɔ. No paralysis. No vomiting, Rather restless. Wound dressed. 23d. Temperature 100°, pulse 80 to 90. Takes more interest in surroundings. No pain. 24th to May 8th. Temperature 100° to 101°, pulse 80 to 100. Occasionally very restless. Takes nourishment. No paralysis. Hernia cerebri springing out of wound. Very little discharge. 9th to June 1st. Temperature 100°, pulse 90 to 110. Mental state more clouded. Some weakness. Occasional delirium. Gradual loss of strength. Hernia cerebri increases in size in spite of frequeut clippings. Ist to 7th. Patient somnolent. Refuses food. Delirious at night. Decidedly weaker. Temperature 101°, pulse 88-100. 8th. Distinct change. Unconscious. Temperature 1042°, pulse 120, respiration 36. Labored breathing. Unable to swallow. 9th. Temperature 106°, pulse 120, respiration 40. Comatose. Died in the afternoon. REPORT OF AUTOPSY BY DR. J. S. THACHER. Brain. Abscess-cavity size of fist occupies most of right frontal lobe back to about one inch in front of fissure of Rolando. Wall in front is a thin membrane which becomes gradually reinforced with brain-tissue. The whole anterior part of the right hemisphere was enlarged at the expense of the right temporal lobe and of the left frontal lobe. On microscopical examination abscess-wall composed of granulation-tissue, simple inflammation. A few pea-sized spots of suppuration at tip of left frontal lobe. Lungs. Consolidation of apex of lower lobe of left lung; other patches scattered through the upper and lower lobes. In right lung patches of pneumonia distributed as in left. On October 26, 1895, at 2 P.M., Mrs. Wr., primipara, aged thirty-four years, of Philadelphia, gave birth at full term to a boy of apparently perfect development. Nothing unusual was observed in the infant until October 27th, at 1 A.M., when the child began to vomit a darkish fluid which left only a light-colored stain on the clothing. As the child had been given some tea of a similar color it was supposed to be that; at any rate, no pathognomonic odor could be detected. This vomiting occurred on that day whenever the child was given some nourishment. As toward evening the bowels had not moved, in spite of a little piece of soap that had been put into the rectum, an injection of lukewarm water with a little soap was given, which returned immediately and brought small cylindrical masses of white mucus about 5 mm. in diameter. This, of course, aroused suspicion at once; but the next morning conclusive evidence of an internal pathological condition was furnished by the vomited matter, which now was distinctly fecal in odor and had the appearance of meconium. As the first thought was that of intussusception a soft-rubber catheter was introduced into the rectum, which could be pushed up about eight inches. Then the nates of the | child, who was already very weak, were raised and plain lukewarm water was injected with a Davidson syringe. As the injection returned at once, the anus was gently compressed, and about two ounces of water were again injected. This procedure increased the vomiting of fecal matter very much, and so was stopped at once; but the vomiting continued, respiration became embarrassed, and soon the child died, about forty-eight hours after birth. One hour later Dr. U. W. Vollmer kindly assisted me in making the post-mortem examination, which showed the following condition of the intestinal tract: The small intestine showed great vascular injection and was much distended with gas, especially near the ileocæcal valve. Here the diameter of this viscus was about 18 mm., the same as that of the caput cæcum, with which the small intestine was continuous, as the lower fold of the ileocæcal valve was absent or, rather, very little developed. The upper part, however, of this valve, the ileocolic fold, was developed too much, for it stretched across the whole lumen of the bowel and formed a complete septum between the colon on the one side and the cæcum with vermiform appendix and small intestine on the other side. There was not the slightest chance for a communication between these two parts. Below this anomalous diaphragm the cæcum and small intestine showed well-developed villi, and the entire mucous membrane was stained brown with biliary pigment and showed a small amount of 1 Deutsche Zeitschrift für Chirurgie, 1877, Bd. viii. meconium. Above the abnormal septum the large intestine was very much contracted, having a diameter of only 5 mm. It also had no ascending part, but the transverse colon turned back at once to the posterior aspect of the abdominal cavity and ran transversely as far as the usual position of the splenic flexure, where the descending colon commenced. The whole colon and rectum, about ten inches in length, contained only soft, white mucus, and not the slightest trace of meconium. Its surface looked white compared with the color of the small intestine, and its walls were thin, having apparently been arrested in its development. The time when the septum must have formed we can fix, with great probability, as follows: As meconium appears in the intestine about the end of the fourth month of intrauterine life, and as no meconium was present in the large intestine, it is evident that the septum must have formed before the end of the fourth month. On the other hand, it is known that the transverse colon is developed at the third month, and the ascending colon at the fifth month, from which would follow that the large intestine of this case was arrested in its development at about the fourth month. If we further assume, as would seem justified, that both phenomena, the appearance of the septum and the arrest of development of the colon, had one underlying cause and occurred at the same time, we come to the probable conclusion that we had to deal with an infant born with a rudimentary colon and a total occlusion of the intestine which had formed at the fourth month of intrauterine life. 315 NORTH SIXTH ST. FOREIGN BODIES IN THE EAR. BY ROBERT BARCLAY, A.M., M.D., OF ST. LOUIS; AURAL SURGEON, ST. LOUIS CITY HOSPITAL, ETC. THE circumstances and phenomena attending the presence of a foreign body within the external auditory canal are so many and so varied that the condition seems to present endless curious and instructive features. Three cases recently met with seem to possess such features sufficiently unique to entitle them to the consideration of the intelligent readers of THE MEDICAL NEWS, than whose columns can be found a no more lasting nor well-known nook for the preservation of clinical memorabilia. "Invisible hairpin," broken, and caught within ear. -A rare case of ensnared aural foreign body is that of a lady, aged about forty years, who, while picking" her left ear with a so-called "invisible hairpin," several hours before the consultation, had heard a sudden 'twang” and sticking in the ear, as if the hairpin had broken. And so, indeed, it had done; for on the instant as she, startled, had attempted to jerk it quickly from the ear, the sharp extremity of the inner portion of its lower prong sprang away from its fellow, penetrated the soft tissues of the floor of the external auditory canal, and remained imbedded there; the separated end of this prong only coming away in her grasp. Every attempt on her part to remove the hairpin by traction on its projecting prong-she durst not force it inward for fear of wounding the drumhead-had served but to bury the | point of the broken prong more deeply into the flesh of the canal, thereby increasing her suffering. Advised by her family physician not to delay, she forthwith sought advice and aid. On examination, it was found that the lower prong or the "invisible hairpin " had broken at the outer end of its wavy portion, and seemed firmly imbedded in the floor of the auditory canal, now quite inflamed, at a point about one-third of its depth from the outlet of the canal. The loop or turn of the hairpin was about one-half inch from the flaccid portion of the drumhead; and together with the unbroken prong, it lay closely against the roof of the canal. Projecting from the meatus there was enough of this prong to be easily grasped between one's thumb and finger. Removal of the hairpin was effected by first inserting within the meatus a Gruber speculum, encircling the unbroken projecting prong, and then raising the end of the broken one with a long-shanked aural hook, when the hairpin was readily withdrawn. Under one or two applications of a vulnerary, the wound of the canal floor promptly healed. Characteristic effects of bird-shot thrown into an upturned ear. CASE NO. 103,672.—One morning as this young clerk, aged eighteen years, was lying upon his left side, facing the wall, his cousin, from a distance of seven feet, playfully pitched a few—say, ten or twelve-birdshot onto his right ear and face. He felt shot enter the ear and deafen him temporarily; and on turning this right ear downward saw three shot roll out. There was now no pain nor tinnitus; but the ear felt stopped up, "a stuffiness, not a decided deafness," which "opened up whenever he swallowed." Slight headache came on toward evening, but disappeared during sleep. Upon awakening the following morning another shot rolled out of this ear. This settled his determination to consult his physician, who at once referred him to me. On examination, his right drumhead was found a trifle congested, but otherwise normal. A mild tympanic inflation, together with mercurial aperient, effected complete relief from his aural symptom. Hard foreign body adherent to the drumhead. CASE No. 103,687.-A curious instance of foreign body upon the drumhead was that of a retired capitalist, an American, aged forty-six years, who for two weeks had suffered from deafness on the left side, with occasional tinnitus, but without earache. One month before he had had a severe attack of acute coryza, for which he had sniffed up some "Pond's extract of witchhazel," blowing his nose immediately thereafter. Upon development of his aural symptoms, of which pain was one at the onset, leeches had been applied about his auricle, and for two days, morning and evening, for about twenty minutes his ear had been douched with hot water. At the time of our consultation he could hear with the affected ear a forty-eight-inch watch on contact only, and low voice and whisper at a distance of fifteen feet. On examination of the left ear the vibrating portion of the drumhead appeared thickened, opaque, lustreless, and somewhat retracted; the flaccid portion and entire periphery much congested, and the short-process of the handle of the malleus barely recognizable. Just in front of the handle, however, was a dark body, resembling a dried blood-clot, but thicker. This was about three-sixteenths of an inch long, one-sixteenth inch in diameter, |