knife is necessary in order to accomplish the desired result. There is no danger of wounding the membrana tympani secundaria as, from its position, it lies in nearly the same plane as the blade of the knife.

While the procedure, as described above, may seem visionary, the results obtained constitute the proof of its practical value. I would not be understood as saying that it is possible in every case to secure a favorable result by a single operative procedure. In order to restore the equilibrium of the stapes and to enable it to perform its function in the best possible manner, repeated operations may be necessary. It is important to test the hearing frequently in order to ascertain the result of each successive synechiotomy. In connection with the quantitative tests it is also important to determine the lower tone limit, as this should fall steadily as the conducting apparatus is rendered less rigid. Operative procedures about the stapes may immediately be followed by an impairment of the hearing on account of the formation of blood-clots, or because of the reaction incident upon such measures. siderable interval should therefore be allowed to elapse before the patient is subjected to a second operation in order that the parts may return to their normal condition.

A con

Great patience on the part both of the surgeon and the patient is necessary to secure a successful result; but if this rule is followed both will feel amply repaid for their persistence.

The author's results are as follows:

Otitis Media Purulenta Residua. -For improvement of hearing, 20 cases. Synechiotomy performed in 18—17 improved, 1 unimproved. Ossiculectomy performed in 2 cases-1 improved, I unimproved.

In conjunction with operative measures, it may not be amiss to call attention to the mechanic treatment of defective audition in the residual suppurative cases. This term includes those cases in which the suppurative process has run its course and has undergone spontaneous cure. We have then simply to deal with the results of a former suppurative process instead of an active purulent inflammation.

The author claims no credit for original investigation in this line. The use of certain mechanic devices to replace the drum-membrane was employed by the earlier otologists. So far as I know, Dr. Clarence Blake of Boston was the first to use a pledget of sterilized cotton moistened in borated vaselin for this purpose. In many of the residual suppurative cases, when a small perforation exists in the lower portion of the drum-membrane, or when there is a perforation of considerable size in the

posterior and upper quadrant which exposes the head of the stapes, the hearing can often be improved by the application of a pledget of sterilized cotton in such a way as to either close the perforation or to press upon the head of the stapes. In the latter instance the efficacy of the cotton disc depends upon the presentation of a larger surface to the sound vibrations, in this way augmenting the impulse conveyed to the labyrinthin fluid. In many cases the improvement following the use of this simple device is astonishing. It would at first seem that the patient must be constantly under the care of the surgeon in order to derive any benefit from this method of treatment. The patient himself, however, soon learns to apply the cotton pledget. As soon as he is conscious that the pledget has become displaced he syringes the ear, removing the former pledget, and then inserts a new one, the increased power of audition enabling him to recognize the fact that the artificial drum is correctly placed. In fact, patients who have followed this treatment for some time become more expert in executing this manipulation than the surgeon himself.

When we come to the consideration of the nonsuppurative form of the inflammation, and the operative measures which are deemed advisable for its relief, the same care must be observed in making a proper selection of cases subjected to operation. I am not infrequently requested to operate upon an ear because it is absolutely worthless and consequently cannot be injured. Unfortunately, many accept this view in selecting their operative cases, and it is for this reason that middle ear surgery has so few advocates. No argument seems necessary to prove the utter absurdity of such a practice. A careful functional examination will always enable the surgeon to determine whether the labyrinth is involved or whether the disease is confined to the

middle ear. In the former instance surgery is of no avail; in the latter it almost invariably promises a certain amount of relief. In a few cases the results of functional examination may not be conclusive, and in such an event it is always advisable to open the tympanic cavity by turning down a flap of the drum-membrane so as to ascertain the extent of the middle ear lesion, and to determine to what degree it causes the impairment of function. Such an operation is easily performed under cocain. A large flap of the membrana tympani may thus be reflected downward and forward, exposing the upper posterior quadrant of the tympanum. The stapes may be separated from the other elements of the ossicular chain and freed from adhesions in the manner already described If the tests are repeated, we are able to exactly determine the importance of the

middle ear lesion; if there is no improvement, the flap may be replaced and the ear restored to its original condition. On the other hand, the labyrinthin involvement may be of less importance than was at first supposed, in which case the two larger ossicles, together with the membrana tympani, may be removed and the improvement following the exploratory tympanotomy be maintained.

cases.

An example of this occurred in one of my own The history of the case led me to believe that the labyrinthin involvement-of which there was decided evidence on functional examination—was dependent upon a pre-existing middle ear lesion. After an exploratory operation, the hearing was markedly improved, and on the following day the operation was completed. The result was eminently satisfactory. The hearing in the ear operated upon was considerably improved, while the effect upon the opposite ear was even more noticeable. Before the operation, the impairment in hearing had been so considerable as to deter the patient from performing his ordinary social duties. At the present time he experiences no difficulty in mingling in society, and the slight impairment in hearing from which he suffers is not apparent.

Any inflammatory reaction following an exploratory tympanotomy invariably results from imperfect technic. With a sterile field of operation, clean instruments, and proper attention to asepsis during the operation, no inflammatory reaction occurs. If the operation is to be completed, i. e., both the membrana tympani and the two larger ossicles removed, the technic is, briefly, as follows: A small pledget of sterilized cotton saturated in a sterilized twentyper-cent. solution of cocain is introduced through the exploratory opening to secure anesthesia. When the parts are no longer sensitive, a sharp knife is made to puncture the drum-membrane at its inferior pole, close to the tympanic ring. A blunt-pointed knife is inserted through this perforation, and the membrana tympani is divided anteriorly as close to its attachment to the ring as possible as far as the anterior fold. If perfect anesthesia has not been obtained, the operator should immediately stop and apply a cocain solution to the margins of the incision so that the procedure will be entirely painless. The drum-membrane is then divided in the opposite direction until the entire membrana tensa is detached from the tympanic ring. It is then wise to insure complete anesthesia of the upper portion of the tympanic cavity by several applications of cocain by means of a cotton-tipped probe. By winding the cotton firmly upon the applicator, and then bending the pledget at a right angle, it is possible to introduce the instrument for a considerable distance into the tympanic

vault, so that the division of the deeper tissues may be accomplished without pain. The probe-pointed knife is then introduced just below the posterior fold and is carried upward, dividing the posterior ligament and the posterior part of the external ligament. In the same manner the attachments to the malleus are divided anteriorly. It is seldom possible to unite these two incisions above the short process of the malleus, a small strip of the membrana flaccida still remaining intact. To completely free the ossicles, it is most frequently necessary to carry a strong, sharp knife upward and inward into the tympanic vault, directly over the short process, dividing the remaining fibers of the external ligament and the overlying part of Shrapnell's membrane. In some instances the tensor tympani muscle will displace the malleus forward as soon as these ligaments have been divided, and render its seizure with the forceps difficult. In such an event, an angular knife should be introduced behind the shaft of the malleus, and made to sever the muscle by rotating the instrument backward. The ossicle is then grasped near the short process with a pair of strong forceps, and extracted in the manner previously described in detailing the technic in suppurative cases. The incus is then removed, as already stated, this step of the operation ordinarily being less difficult than in suppurative cases. After thoroughly drying the parts, the usual dressing is applied.

After an operation upon the middle ear, it is impossible to prevent the formation of a blood-clot within the tympanum. In suppurative cases the presence of the clot interferes with free drainage, and in non-suppurative cases acts as a foreign body, causing a certain amount of inflammatory reaction. To avoid the formation of a clot, a long, narrow pledget of cotton should be carried into the meatus as far as the fundus. This will act as a drain, and prevent the accumulation either of blood or of inflammatory products within the canal. The distal extremity of the pledget is folded upon itself at the entrance of the meatus, so that it cannot be displaced by the patient. The canal is then occluded by a large pledget of sterilized cotton. As soon as this becomes saturated, it may be changed by an attendant, or even by the patient himself. The deep drain is removed twenty-four hours after operation. The canal will then be found to be perfectly free, and all portions of the middle ear can easily be seen upon speculum examination. It is seldom necessary to introduce the deep drain a second time, all hemorrhage usually having ceased at the end of twenty-four hours. I consider this procedure as one of great importance, both in suppurative and nonsuppurative cases.

and all the parts except the peritoneal cavity were liberally irrigated with 1-1000 bichlorid solution, then thoroughly dried with sterilized gauze, the rectum packed, and the usual dressing applied and held in position by a large sized T-bandage.

Owing to the frequent evacuation of the bowels and the necessity for catheterization, the frequent removal of the dressings and their reapplication was required. The drainage tube was removed on the third day. The future history of the case was uneventful, the temperature never going above 100° F., at any time. At this writing the patient is able to walk about and do light work, the only trouble being some rectal incontinence. Liberal administration of the iodids was resorted to at intervals during the progress of the after-treatment.

Two methods of surgical treatment presented themselves as being applicable to the relief of this poor woman's condition, namely, the one adopted, and the other an ab

master and the tunica vaginalis, the sac is isolated as high up as possible, and is drawn outward through a small opening in the fascia of the external oblique muscle onehalf an inch above Poupart's ligament and one-half to one inch externally to the region of the internal ring. If the sac is large, and on account of its funnel shape a recurrence is feared, a small opening is made into the peritoneal cavity to the outer side of the internal ring, and a curved clamp is passed through this opening and down to the lowest limit of the sac. When it is withdrawn, the sac is inverted like the finger of a glove and drawn outward through the incision, tied, and cut away. The incision is closed by a couple of stitches through muscle fascia. Of the 197 cases operated upon, primary union was obtained in 91.3 per cent. All but twenty of the patients were over fifteen years of age. Of 111 cases, which could be followed, there were four recurrences, that is, 3.6 per cent. No patient died from the operation.

Vitality of the Uterine Mucous Membrane.-JUNG (Centralbl. für Gynek., May 8, 1897) had an excellent opportunity to observe the remarkable vitality of the mucous membrane of the uterus in the case of the wife of a man treated for gonorrhea and syphilis. She had had seven children and four miscarriages, and on account of profuse and repeated hemorrhages, her uterus was curetted and touched with carbolic acid. The good effects of this treatment had worn off in a month, and the cervical canal was dilated and the cavity of the uterus filled with a paste made of one part of chlorid of zinc and two parts of rye flour. The result apparently was a perfect one, the treatment reducing the size of the uterus, and obliterating the cervical canal. However, in three-months' time the patient was back again complaining of the same old trouble. The uterus was then removed, and examination of its nearly obliterated cavity showed a regeneration in part of its mucous membrane, the new epithelium showing the same pathologic changes as the old layer.

Stone in the Bladder Broken Spontaneously. SEVEREANU (Centralbl. für Chirurgie, May 8, 1897) mentions a unique case in which a stone in the bladder was broken spontaneously. The patient was a man, aged eighteen, who suffered from his second until his ninth year from symptoms of stone in the bladder. From his ninth year until three months before his entrance into the hospital, he was perfectly well and could run and ride without the least pain. One night he fell into a grave and experienced immediate and severe pain in the lower part of the abdomen with a return of the old bladder symptoms. There was no blood in the urine.

By examination through the rectum, and by means of instruments, the bladder was found to contain at least two calculi which moved one upon the other. Suprapubic cystotomy was performed and the two halves of a calculus, which together weighed about an ounce, were removed. Each presented a broken surface which fitted exactly into that of the other half so that there was no doubt that a single stone had been broken into two parts by the fall, possibly, as a result of a powerful contraction of the bladder. The calculus was composed of urates.

THE BILL BEFORE CONGRESS ABOLISHING ANIMAL EXPERIMENTATION IN THE DISTRICT OF COLUMBIA.

THIS is not the official title of Senate Bill No. 1063, but indicates the intent of its originators in framing it, as well as the practical effect of its execution. The bill, as originally worded and in its present form before Congress, has all the silky softness of a kitten's paw to the casual observer; but sharp and vigorous claws lie concealed within its insinuating fairness, which await only the legalization of its provisions to assert themselves in their destructive work. The measure is entitled "A Bill for the Further Prevention of Cruelty to Animals in the District of Columbia," and it is in this harmless guise that the Humane Society of Washington is endeavoring to usurp to itself the power of controlling all animal experimentation, not only in the Government laboratories, but also in those of the medical schools and of private individuals. The advocates of the bill are most specious in their arguments in favor of abolishing imaginary cruelties of a most horrifying character and preventing their occurrence by means of carefully issued licenses and a system of regular and

irregular inspection. The harmful character of the bill, as an entering wedge in the hands of visionary enthusiasts destined to prevent all animal experimentation, and so striking at the root of all progress in organic medicine, has been clearly pointed out by the scientific members of the medical profession resident in the city of Washington. This view of the measure has been confirmed by numberless memorials to Congress from all the prominent medical and scientific gatherings which have convened in this country for the last two years, and yet the measure is constantly gaining in strength and steadily approaching the goal of its final passage. It is one of the many illustrations of the fact that a small association of persistent individuals, especially if it contains within its number a few visionary women, can, by gaining the adherence of two or three strong advocates, carry almost any measure through any State Legislature or even through the National Congress, unless it is met and opposed by some scheme of what is known as practical politics. "Practical politics" means the

control of a certain number of votes.

Up to the present time, the great brotherhood of medicine and allied sciences has rested upon the belief that its opinions carried weight with the politicians, because it believed the politicians had respect for the opinions of men who must know more upon the subject under discussion than anyone else. Medical societies have therefore contented themselves with simply embodying their opinion in the form of resolutions and presenting them to Congress. It is becoming daily more clear, however, from the progress of this matter, that he who counts upon a politician taking up a cause and throwing the weight of his influence and effort into the fight in its behalf, is certainly reckoning without his host. Sad though the conclusion may be, there no longer exists in our legislative halls a single champion of truth for truth's sake, or of justice for the sake of right. sooner the medical profession acts in accordance with this understanding, the sooner will it be able to accomplish its end, in caring for the welfare of the community as well as its own safety and progress. Every question before Congress must be put upon the basis of practical politics. In the question at issue, the medical profession is practically unanimous in its opinion of the harmfulness of the pending measure. The only way to make that influence tell, is for

The