pletion of the operation and loosening the bandage, ioud cries from the patient, whereupon a few drops of chloroform were put upon the mask. Soon after the patient seemed to be awake, but did not respond to questions. Sudden cyanosis and cessation of breathing; death. Section showed opacity and thickening of the pia mater; moderate internal hydrocephalus, with granular thickening of the ependyma. No other abnormality found. Ledderhose held the changes in the brain, together with the chloroform and the alteration in the circulation on loosening up the Esmarch, responsible for the death.

In two other cases, in which the elastic tube was used, a paralysis of the sciatic lasting several months occurred in one, and in the other (suppurating compound fracture of the leg) gangrene of the foot. From his own experience and from that of others Ledderhose believes that Esmarch's method should be used only where it is necessary and that the tube should be replaced by the elastic bandage wherever possible. In the discussion of Ledderhose's paper Madelung insisted on the danger of Esmarch's method in operation for phlegmonous processes; also in amputations on diabetics with whom arterial sclerosis is so common. In paralyses following the use of the constricting rubber tube his experience leads him to give a favorable prognosis.-Western Med. Rev.

ADRENALIN IN UROLOGICAL PRACTICE.

BY PROF. A. VON FRISCH.

Advantageous use can be made of the blanching or hemostatiic action of adrenalin when performing operations on the urethra and bladder. I shall briefly set forth the manner in which I used the preparation in several cases in which it rendered me good service, and I hope to stimulate further experiments in the same direction.

It is sometimes desirable to make a cystoscopic examination in cases of vesical hematuria, in which the preliminary irrigations always cause a renewal of the hemorrhage and in which a clear idea of the conditions is sometimes obtainable for a brief moment only with the aid of the irrigation cystoscope. In such cases I have filled the bladder with 100 to 150 cc. of a solution of adrenalin, 1:10,000, leaving the liquid three to four minutes in the bladder and only then beginning the irrigations. By taking this precaution I avoided all hemorrhage, or else it was so slight that the clearing up of the contents of the bladder was readily effected and the cystoscopic examination could be executed with perfect suc

cess.

In operating on tumors of the bladder and in performing suprapubic cystotomy, after opening the bladder, I make several applications of the solution, 1:1,000, to the tumors and their immediate neighborhood, using a cotton pledget for the purpose. This renders possible the extirpation of the tumor in the blanched tissue almost without any loss of blood. In this way the thorough removal of the base of the tumors is assured, and there is no danger, when dealing with multiple papillomata, of leaving a little of the soft minute new formations behind, since the field remains almost completely dry and free from blood. Inasmuch as the anemia of the mucosa persists for a comparatively short time, and the contraction of the

vessels seems to be followed by considerable dilatation, if one does not wish to stitch up the incision in the mucous membrane, the, wound should be carefully packed and the bladder also tamponed. In one case in which I failed to carry out these precautions I had to deal with very unpleasant secondary hemorrhage. For the endoscopic removal of papillomata of the bladder it is sufficient to fill the bladder with adrenalin solution, 1:10,000, as in the performance of cystoscopy.

In very narrow strictures, which are difficult to enter, application of a few drops of adrenalin, 1:10,000, at the entrance to the stricture, materially facilitates the introduction of the sound.

In difficult catheterism of hypertrophied prostates, a preliminary instillation of 1 to 2 cc. adrenalin, 1:1,000, into the prostatic urethra is of great advantage. The introduction of the catheter is more readily performed and usually without bleeding, even when the prostate is congested. In the same fashion we have heretofore made the most of instillations of cocaine in strictures and hypertrophy of the prostate. This drug also produces a transient anemia and reduces the swelling of the mucosa, but adrenalin works far more promptly.

Finally I used the drug in three cases of acute and complete suppression of urine, due to hypertrophied prostate. Each time I was confronted with initial complete prostatic retention in the first stage. The suppression had been so complete that the patient had been unable to void a single drop spontaneously for days or weeks. After instilling 2 cc. of adrenalin, 1:1,000, into the prostatic urethra, I waited three to four minutes and then requested the patient to try to empty the bladder. The result was, of course, very imperfect, but the patients were able to void a small quantity of urine, at least drop by drop, immediately after the application. In such cases there is no depreciating the moral effect of a result, be it ever so slight, which follows immediately on the surgeon's intervention, for the patient is usually much depressed over his condition, and you thus give him hope that spontaneous urination is among the possibilities. But in my cases I observed that the first painfully voided drops of urine were followed by a fairly quick return of the normal function, very much after the manner in which the same result may be observed when Bottini's operation is successfully performed. is successfully performed. The instillations were continued for several days. The quantity of the spontaneously voided urine (which in one case amounted to 500 cc. on the first day) increased steadily and satisfactorily -indeed, faster than we have been wont to observe in such cases when the acute edema of the prostate is reduced.

These further results from the injection of adrenalin are certainly not to be explained by the quickly subsiding hemostasis of the mucosa, but they are very probably in direct relation to the immediate effect of the interven. tion. I have always been under the impression, and I have on various occasions expressed the opinion, that in many cases of retained urine, following prostatic hypertrophy, in addition to the mechanical impediment caused by the enlarged gland, a certain part is played by the excessive muscular tension of the internal sphincter. Inasmuch as in the act of urination the relaxing of the sphinc

ter is always primary, and this (as is not seldom the case in neuroses without change in the volume of the prostate) causes the patient the greatest trouble, it is at all events conceivable that th psychic impression produced by the first spontaneous urination, be it ever so slight, helps the patient afterward by facilitating the relaxation of the sphincter, which induces micturition.-Wiener Klin. Woch.

MAINTENANCE OF ASEPSIS IN SURGICAL WORK.

BY G. B. MURRAY, GREENWICH, N. Y.

Case No. 1.-I was called to attend a farm hand who, during a quarrel, was stabbed by a manure fork, the four tines, reeking with filth, penetrating about two inches. into his glutei muscles. We gave the man a complete bath to begin with. Syringed out the deep-punctured wounds with equal parts of glyco-thymoline and warm water, then with peroxide of hydrogen, then once more with the solution of glyco-thymoline, one part to two of water, syringing out the wounds once daily with same solution.

The man was not confined to his bed or even to his room for a single day. The wounds are almost entirely healed at this writing, and during the process of healing I have failed to detect sufficient pus to make a spot on a white handkerchief. This is about as severe a test as anyone would be likely to give any remedy in regard to its antiseptic and healing qualities.

Case No. 2.-Through our town an extension of the railroad is being built, which necessitates the employment of a large number of Italians.

They have differences which usually end in going to a doctor and getting patched up. I was called one night about 2 a. m., and found a man with a cut reaching from the top of shoulder, running straight along the upper surface of arm to elbow, and in some places reaching the bone. These laborers are horribly filthy, and this was a pretty nasty looking mess. I made the wound as surgically clean as possible, but at best it was far from strictly antiseptic, and closed the incision with twenty interrupted sutures, applied a dry dressing and directed him to call at office on second day. Did not show up for nearly a week. There had been no attempt at union. The stitches had all cut out and the gaping of wound was as great as at first; the odor was something awful and the arm from shoulder to elbow was covered with blisters. I tried my best to persuade him to go to a hospital, and he promised to do so, and I dressed the arm, hoping it would make a little better appearance at the hospital. I first gave it a very thorough cleansing with very hot 1 to 2,000 bichloride solution. Then I literally drenched it with, equal parts water and glyco-thymoline, of which I had obtained a good supply at the druggist's, then wrapped the arm in several layers of sterilized gauze, saturated with the glyco-thymoline solution, applied a gauze handage as snugly as I dared, and after once more getting his promise to start for the hospital the next day, and giving him a pint of solution, with directions to keep the dressing wet with it, I turned him loose once more. I heard nothing from him until two or three days ago,

when he came into my office. He had not been to the hospital, and the same old dressing, just as I put it on, was still there, as black as dirt could make it.

He said he thought his arm was nearly well, as it gave him no pain and was not painful on moving. He said he called for some more of the solution, as he had used the last the day before. I removed the dressings, and much to my surprise the wound was doing finely, fast closing by granulation. The blisters had all gone and everything was looking favorably for a speedy recovery and a perfect arm. Now I used nothing on this arm but what I have mentioned.-Ex.

RESULTS FROM THE ADMINISTRATION OF IRON IN A READILY ASSIMILATED FORM AFTER GYNECOLOGICAL OPERATIONS.

BY C. A. VON RAMDOHR, M. D., PROFESSOR OF OBSTETRICS IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL, GYNECOLOGIST TO ST. MARK'S HOSPITAL

AND THE GERMAN POLIKLINIK.

Some few months ago I had the misfortune of having a patient lost a comparatively large amount of blood after a trivial operation. In spite of the weakened condition of her stomach I tried iron, as the quickest acting tonic, to counteract her anemia. The results were so extraordinarily good and her general appearance improved to such a degree that I decided to put all my patients on the use of the same preparation after any operation, and to carefully note the good or bad results of its administration.

To further guard against making any allowance to my enthusiasm, I had the blood of some patients at the New York Post-Graduate Hospital tested by Dr. H. T. Brooks, the director of its pathological laboratory, and similar tests at St. Mark's Hospital made by the pathologist, Dr. George Lindenmeyr. Some cases were kindly loaned me for observation by Dr. H. J. Boldt, Dr. J. R. Nilsen and Dr. Carl Beck, to all of which gentlemen I hereby once more acknowledge my indebtedness.

The preparation used in all cases was the peptonate of iron and manganese, made according to Dr. tiude's formula and known for short as "Pepto-Mangan Gude." The results as found have shown me and will convince you that it is not only possible but highly beneficial to feed a patient on this tonic immediately aftter an operation and during her convalescence, as a routine treatment. In only one case, that of a twelve-year-old girl, referred to me by Dr. Beck, an account of which is appended here, had the administration to be suspended because it was nct well borne.

In no case was constipation observed, nor was the Pepto-Mangan taken with aversion.

The period of trial varies from twelve days to fortyfour days. Quite a number of patients disappeared before the second examination of blood could be made. There have been examined twelve gynecological cases, among which is one check case. I append, however, as long as the examinations have been made by the pathologist, two general surgical and five medical cases. Case I (Post-Graduate Hospital), patient aged twentyseven years. Ovariotomy. Time of administration, seventeen days. First count, 5,050,000 red corpuscles

to the cubic millimeter; second count, 5,312,000 to the cubic millimeter. Case II (Post-Graduate Hospital), patient aged twentythree years. Laparotomy. Time of administration, sixteen days. First count, 3,600,000 red corpuscles to the cubic millimeter; second count, 3,870,000 to the cubic millimeter.

Case III (Post-Graduate Hospital), patient aged twentyseven years. Alexander's operation. Time of administration, twelve days. First count, 4,437,500 red corpuscles to the cubic millimeter; second count, 5,670,000 to the cubic millimeter. Case IV (Post-Graduate Hospital), patient aged thirty years. Oophorectomy. Time of administration, twelve days. First count, 5,250,000 red corpuscles to the cubic millimeter; second count, 5,400,000 to the cubic millimeter.

Case V (St. Mark's Hospital), patient aged thirty-eight years. Excision of fibroid of cervix. Time of admin

istration, twenty-three days. First count, 2,624,000 red corpuscles to the cubic millimeter; second count, 3,450,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, thirty-five per cent; second examination, sixty per

cent.

Case VI (St. Mark's Hospital), patient aged eighteen years. Miscarriage after penumonia at fifth month. Curettage. Time of administration, twenty-four days. First count, 2,432,000 red corpuscles to the cubic millimeter; second count, 3,842,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, thirty-four per cent; second examination, fifty-five per cent.

Case VII (St. Mark's Hospital), patient aged twenty-five years. Vaginal hysterectomy. Time of administration, fourteen days. First count, 2,962,000 red corpuscles to the cubic millimeter; second count, 3.264,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, thirty per cent; second examination, forty-two per cent. Case VIII (St. Mark's Hospital), patient aged twentythree years. Pyosalpinx. Vaginal operation. Time

of administration, twenty-four days. First count, 3,426,000 red corpuscles to the cubic millimeter; second count, 4,280,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, forty per cent; second examination, sixty-two per cent. Case IX (St. Mark's Hospital), patient aged twenty-one years. Emmet's operation. Time of administration, thirty-six days. First count, 2,351,540 red corpuscles to the cubic millimeter; second count, 3,740,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, thirty-five and a half per cent; second examination, seventy per cent. Case X (St. Mark's Hospital), patient aged thirty-seven years. Beck's operation. Time of administration, forty-four days. First count, 2,253,000 red corpuscles to the cubic millimeter; second count, 3,420,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, thirty-six and a half per cent; second examination, fifty-five per cent. Case XI (St. Mark's Hospital), patient aged twenty-one years. Laparotomy for pyosalpinx. Time of administration, twenty-three days. First count, 2,680,450 red corpuscles to the cubic millimeter; second count, 4.758,570 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, thirtythree per cent; second examination, seventy per cent. To convince ourselves that not all gynecological patients would have their blood corpuscles increased at the same rate after an operative interference, as after taking Pepto-Marcan (Gude), Dr. Brooks has kindly made this check test in

Case XII (Post-Graduate Hospital-control). patient aged twenty-eight years. Ovariotomy. Time in hos

pital, fifteen days. First count, 4,368,750 red corpuscles to the cubic millimeter; second count, 4,480,000 to the cubic millimeter.

Case XIII (St. Mark's Hospital), that of a girl, aged twelve years. Resection of tuberculous hip-joint. Time of administration, seventeen days. First count, 1,865,420 red corpuscles to the cubic millimeter; second count, 1,760,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, thirty-two per cent; second examination, thirty-two per cent. This is the only case where the use of the preparation had to be discontinued because the stomach rebelled, and where no improvement was observed. Case XIV (St. Mark's Hospital), that of a boy, aged fifteen years. Large punctured wound of thigh. Time of administration, fourteen days. First count, 2,480,ooo red corpuscles to the cubic millimeter; second count, 3,200,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, thirty per cent; second examination, forty-two per cent. Case XV (St. Mark's Hospital), that of a man, aged thirty-seven years. Anemia. Time of administration, twenty days. First count, 3,586,510 red corpuscles to the cubic millimeter; second count, 4,550,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, fifty-two per cent; second examination, seventy-two per cent.

Case XVI (St. Mark's Hospital), that of a woman, aged twenty-four years. Anemia following malaria. Time of administration, twenty-four days. First count, 3,242,654 red corpuscles to the cubic millimeter; second count, 4.422,500 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, fifty-two per cent; second examination, seventy-five per cent.

Case XVII (St. Mark's Hospital), that of a woman, aged twenty-four years. Professional nurse. Anemia. Time of administration, twenty-eight days. First count, 2,475,216 red corpuscles to the cubic millimeter; second count, 4,060,222 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, forty-two per cent; second examination, sixtytwo per cent.

Case XVIII (St. Mark's Hospital), that of a girl, aged nineteen years. Professional nurse. Anemia. Time

of administration, twenty-one days. First count, 2,640,100 red corpuscles to the cubic millimeter; second count, 4,125,000 to the cubic millimeter. Hemoglobin (percentage of normal amount): First examination, thirty-nine per cent; second examination, sixty per cent. Case XIX (St. Mark's Hospital), that of a woman, aged twenty-five years. Professional nurse. Anemia and gastric catarrh. Time of administration, thirty-five days. First count, 2.563.202 red corpuscles to the cubic millimeter; second count, 3,420,000 to the cubic millimeter. Hemoglobin (percentage of normal. amount): First examination, forty-two per cent; second examination, sixty per cent.

These last seven cases do not strictly come within the scope of my paper, but still I was loath not to bring them out, and I am glad that Dr. Lindenmeyr in his zeal picked out these last three cases of hospital nurses for an experiment. You will notice how rapid their improvement was from the objective figures, more so than that of the women operated on, and I think for the reason that a certain amount of exercise in the open air helped, on the one hand, and the direct loss of blood impaired the multiplication of corpuscles on the other hand.

However, from the foregoing you will, I hope, agree with me that, firstly, it is beneficial to immediately put a patient on whom an operation has been performed on the use of an easily assimilated iron preparation, and secondly. Pepto-Mangan (Gude) seems to be such a rational ideal pharmaceutical combination.-New York Med. Jour.

Notices and Reviews.

"The Operations of Surgery." By W. H. A. Jacobson, M. Ch. Oxon., F. R. C. S., Surgeon to Guy's Hospital; Consulting Surgeon Royal Hospital for Children and Women; Member Court of Examiners Royal College of Surgeons, etc.; and F. J. Stewart, M. S. London, F. R. C. S., Assistant Surgeon Guy's Hospital and to the Hospital for Sick Children; Surgeon in Charge of the Throat Department, Guy's Hospital.

Fourth Edition, Revised, Enlarged and Improved. 550 Illustrations. Two Volumes: Vol. I, Operations on the Upper Extremity, Head, Neck and Thorax. Vol. II, Operations on the Abdomen, the Lower Extremity, and Vertebral Column. Philadelphia: P. Blakiston's Son & Co., 1902. Price, $10.00 net.

Nearly five years ago we had the pleasure of reviewing the third edition of Jacobson's "Operative Surgery." At no time since then have we felt that any of the more enlarged and modernized works had quite filled the place which the careful reviewing of the earlier edition of this work had made for it in our estimation. This is not meant as a reflection upon other works, but rather to emphasize the fact that Jacobson's work occupies a peculiar position in many respects covering the same ground, but in his way of discussing and presenting the indications for the various operations and the limitations of operative treatment and weighing their relative merits, it occupies a distinctly separate and characteristic position of its own.

Jacobson's "Operations of Surgery," in two volumes is a broadly conceived, deliberately considered, accurately executed international presentation of the operations of surgery. It is distinctly international, as it recognizes all nations as producers of good operative procedures; in this respect being in marked contrast to many European works. The liberal spirit manifested will be particularly gratifying to Americans, since the genius and teaching of American surgeons are given deserved representation.

While we have taken distinct pleasure in commending the former editions, the present one, in its more elaborated and completed form, makes it even a greater pleasure to recommend it to all practitioners as a, work which discusses the "what to do" in surgery in a clear, sound, logical and satisfactory manner.

To know "what to do" and when to do it is only second to the ability to determine "what is the matter." In fact, from many standpoints-particularly that of the general practitioner, it is often of paramount import

ance.

English authors are to be thanked for the close attention which they give to the presentation of the minute details of procedures, which is of such inestimable value to operators of limited experience.

In a general way one volume is given up to the presentation of the operations on the upper half and the other of the lower half of the body. As an example of the thoroughness of the book and manner of treatment of subjects: Removal of the Breast is discussed in 35 pages; The Indications, Results and Dangers of Improved Operations, Mortality, Local Recurrence, The Importance of Operating Widely, the Selection of Cases, Description of Modern Operation, Removal of Pectoral Muscles and

Clearing of the Axilla are fully discussed and many authors quoted with references. The conciusions impress one as being logical deductions from the evidence presented. The various procedures are well illustrated.

All subjects are treated in much the same manner, a liberal allowance of space being made to the most important ones. The statistical data quoted are from reliable sources, and of distinct value.

We cannot well imagine how a work could better cover the scope of these two volumes at this time, and we prophesy for this edition a much greater appreciation than has ever been accorded any work on operative surgery.

The work of the publisher has been well done, and the volumes are of convenient size and weight, while the 500 illustrations are judiciously selected. A. I. B.

"Saunders' Medical Hand-Atlases." Atlas and Epitome of Operative Surgery, by Dr. Otto Zuckerkandl, Private-docent in the University of Vienna. Edited by J. Chalmers Da Costa, M. D., Clinical Professor of Surgery in Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Second edition. Philadelphia: W. B. Saunders & Co. Chicago: W. T. Keener & Co. 1902. $3.50 net.

The aim of this book is to place the subject of operative surgery before the practitioner and student in as concise a manner as possible.

The book is devoted entirely to the methods employed in operations on the various parts of the body, and but little space is given to questions of diagnosis or to indications for operative procedures.

The special value of the book lies in the illustrations. There are 278 wood cuts and 40 colored plates, which abundantly illustrate the anatomic relations of the tissues in the various operative fields. The different steps in operative technic are concisely stated and made plain. by means of the cuts and colored plates.

To the advanced student in medicine and the general practitioner, the book is of great value. D. S. F.

SAUNDERS MEDICAL HAND ATLASES. "Atlas and Epitome of Abdominal Hernias." By Privatdocent Dr. George Sultan, of Gottingen. Edited, with additions, by William B. Coley, M. D., Clinical Lecturer on Surgery, Columbia University. With 119 illustrations, 36 of them in colors, and 277 pages of text. Philadelphia and London: W. B. Saunders & Co. Chicago: W. T. Keener & Co., 1902. Cloth, $3.00 net.

Abdominal hernias are of such comnion occurrence either as congenital defects or acquired through intraabdominal pressure or accident, the sac following the natural canals or openings, and in recent years from accidents in abdominal surgery, that a special work concisely written and abundantly illustrated will be welcomed by surgeons of limited practice and experience.

The book contains 119 illustrations and 36 colored. plates, which beautifully explain the essential anatomic facts, the important points in diagnosis and the various steps in operative procedures.

The great certainty with which hernia can be cured. by operation, and the serious accidents which may occur to one afflicted by hernia makes this branch of surgical work very attractive. work very attractive. While trusses will probably be employed for years to come, yet it may be assumed that

the risk and inconvenience of hernia which cannot be easily and successfully retained by a truss, will lead practitioners to recommend and advise operation.

It

The different varieties of hernias are described, with their anatomic relations, diagnosis, and treatment. would be naturally expected in a modern work that the chief stress would be placed on operative treatment, and to facilitate a clear understanding of what is necessary to a successful result, every step in the most approved methods is illustrated. There are some features of this book which may be especially noticed.

On pages 50 to 58 will be found some interesting observations on the origin of hernias in which previously existing pathologic conditions and congenital conditions are considered. The rare occurrence of traumatic hernias is especially mentioned and the observations by both author and editor will be profitable reading to those who contend that hernias are frequently produced by a single trauma. On pages 135 and 136 will be found a discussion on "Expert Opinions in Reference to Abdominal Hernias," which will be of great value to surgeons of railways and accident companies.

The sections on the operative treatment for the radical cure of umbilical hernia is not up with the latest work in this country. The author's statement that frequent recurrences are observed is true when applied to the older methods. Dr. W. J. Mayo has adopted a method which gives results but little inferior to the results in inguinal hernias. His plan has been described in several papers, and consists in freeing the aponeurotic tissues to the extent. of an inch or two and overlapping them and suturing with mattress sutures, usually in a transverse direction. The overlapping of the aponeurotic flaps gives a broad surface of contact, and when sutured in the line which gives the least tension, is followed by very satisfactory

results.

The book, while it omits a description of some very important methods of operative treatment of the inguinal hernias, as those of Ferguson and Andrews, which are so well adapted to certain cases, is altogether a most excellent work and cannot fail to interest the general D. S. F. surgeon. Diseases of the Nose, Pharynx and Ear. By Henry Gradle, M. D., Professor of Ophthalmology and Otology in the Northwestern University Medical School, Chicago. Pp. 547, octavo, containing 146 wood cuts and two full page colored plates, comprising 16 figures. Philadelphia and London: W. B. Saunders & Co. Chicago: W. T. Keener & Co., 1902. Price, cloth, $3.50, net.

A characteristic feature of this work is that the larynx is not considered, which keeps its size within reasonable bounds and permits of the other subject-matter being more fully elaborated. This omission is furthermore excusable in this country, wherein laryngeal diseases are far less frequently met with than on the continent. About three-fifths of the space is devoted to the nose and pharynx and the remaining two-fifths to the ear. In addition to the usual division in chapters, there is a further subdivision by numbered paragraphs, which makes cross reference more easy, and tends to thus avoid a repetition of words. The print is particularly clear, and by the frequent use of heavy-faced type the subject-matter is indicated.

Among the wood cuts 32 are reproductions from

Zuckerkandl and are particularly good, though Fig. 34 is a duplicate of Fig. 5. Of the remaining cuts many are indifferently executed, especially several of those showing instruments. No index of authors is given and but few references are cited. The history and literature of the different subjects is from time to time concisely given. The anatomy of the different parts is well presented and the embryology sufficiently considered. The anatomy of the accessory sinuses is particularly well given, as is also the anatomy of the ear and its physiology.

This work is thoroughly original and presents its author's views based upon an experience of nearly a quarter of a century. In the matter of treatment only such procedures are recommended as he has found to be reliable, and descriptions thereof are so clearly worded and exact that they cannot be misunderstood. Particular care is taken to give all details regarding the course, outcome and treatment of those diseases which are most likely to cause the less experienced practitioner the most anxiety.

It is noticed that the author expresses but little faith in the value of oily sprays and nebulæ in the treatment of nasal diseases. His belief in this respect differs from that of most practitioners. As an antiseptic application he frequently recommends the use of Löffler's solution, though two quite dissimilar formulæ for this preparation are given, being respectively on pages 70 and 291.

In the treatment of chronically inflamed tonsils of small size, "which cannot be removed satisfactorily," the author advises ignipuncture so as to "render them harmless." On the other hand, he deprecates the radical use of the cautery point, whereby the entire diseased mass may be thoroughly removed, which process insures an ideal and permanent

cure.

Two pages are devoted to anterior dry rhinitis, though it is stated that the cause thereof is not known. According to the reviewer's observations, picking the nose is the most active cause, while the predisposing cause is either a surface made prominent from septal deformity, which is therefore through increased exposure to the passing air current made dry thereby, or else obstructive irregularities of the septum either back of or above the point of irritation, which cause a sensation of stoppage, and thus induce picking of the nose.

Purulent and inflammatory conditions of the ear are well described and the required treatment clearly outlined. For inflation the author prefers plain air and expresses a doubt as to any increased benefit being derived from the use of vapors or nebulæ. The simple rubber handbag is employed and no mention is made of the more practical and exact method of using compressed air in office practice. Hypertrophic and hyperplastic middle ear catarrh are considered jointly, being regarded as different stages of the same disease.

The author is at all times candid and earnest. In fact, his candor leads him to state in several places (pp. 175, 441, 446 and 452) that no treatment known will do away with chronic inflammation of the nasal mucous membrane, and the consequent secretion, and expresses doubt in the efficacy of intranasal surgery, even when successfully executed, in eradicating the chronic inflammation of the mucous membrane and the co-incident hyper-secretion.

On the whole, the work is a masterly and lucid presenta