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order that the sonorous oscillation may infringe on the fenestræ and promontory with the least loss of intensity. The anterior attachments of the membrana tympani should then be preserved and this part of the membrane trained across the ostium tympanicus tube to close it and prevent infection reaching the middle ear from the pharynx.

5. The tympanum should be kept open and the major ossicles removed if the stapes is out, to allow the freest access of sound waves to the labyrynth. The rapid restoration of the tympanum, together with its function, can sometimes be facilitated by allowing the membrane to heal up quickly while drainage is kept up in some other direction as long as it is required. The necessary drainage may be obtained through the Eustachian tube, the mastoid wound, or, best of all, because there is no disfigurement, through an opening in the posterior membranous wall of the canal just external to the annulus. This method of drainage requires extensive removal of the posterior osseous wall. After the complete radical operation the tympanic drainage through the meatus is perfect. The use of skin-grafts in the tympano-mastoid operations does not seem to lessen the amount of dense tissues covering the stapes. gives the histories of four cases illustrating his points.

Bryant

Skin and Periosteal Flap in Tympano-Mastoid Exenteration.

E. M. Holmes, Boston (Annals of Otology, Rhinology and Laryngology, Vol. xvi, No. 1), proposes a new method of forming a skin and periosteal flap in tympano-mastoid exenteratian. The post-auricular incision differs from that usually made in that the skin only is incised and that somewhat nearer the auricle, care being taken not to injure the periosteum. The anterior skin flap is dissected and carried forward until the posterior and superior portion of the cartilage of the external auditory canal is exposed. An incision is now carried through the posterior and superior wall of the auditory canal and the auricle thus partially detached is carried forward. The anterior and inferior portions of the canal are not injured. An incision is carried through the skin and periosteum of the bony canal from the incision already made, beginning at the junction of the lower and middle third of the posterior wall, extending to near the annulus, then by an upward course parallel with annulus to junction of superior and anterior wall, then outward to rim of bony canal.

From this the periosteum is incised over the linea temporalis as far back as to

give ample exposure of bone. An incision is also carried through the periosteum from beginning of auricular incision below backward and downward to mastoid tip.

Unless there has been very extensive disease this flap covers nearly all of the exposed bone. The attached portion of skin taken from the auditory canal will now cover the area which was the aditus and attic of middle ear. The next step is to adjust the auricle, and in order to prevent the tendency to produce a subsequent occlusion and to get sufficient room for subsequent treatment it seems well to split the posterior portion of the cartilaginous canal, and then, with gut suture, the upper segment to periosteum over the linea temporalis and the lower mastoid segment to that of the tip of the mastoid. The skin can now be closed and sutured. A gauze or gauze-wrapped rubber drainage-tube is now inserted in the canal. Holmes has employed this method in twenty-seven cases and has "obtained excellent results in the majority.

Labyrinthine Suppuration.

E. B. Dench, New York (Annals of Otology, Rhinology and Laryngology, Vol. xvi, No. 1) reported to the Eastern Section of the American Laryngological, Rhinological and Otological Society several cases of labyrinthine suppuration complicating purulent otitis media.

First case, man of thirty-one years. Chronic suppurative otitis media for a period of years. For two weeks he had suffered from severe vertigo and headache. These symptoms had been steadily increasing. Radical operation performed in the usual way. When the horizontal semicircular canal was exposed a carious area was found which involved the entire thickness of the canal wall. Curettage easily opened the lumen of the canal. The carious canal wall was cautiously removed forward to a point just above the oval window. The crura of the stapes were carious. The stapes was removed and the entrance to the oval window enlarged. A narrow strip of iodoform gauze was inserted in the oval window and was also made to cover the opening in the horizontal semicircular canal. An uninterrupted recovery took place and the vertigo entirely disappeared after the operation.

Second case, boy aged fourteen years. Chronic suppurative otitis media for a number of years. There had been no symptoms indicative of labyrinthine involvement. On performing the ordinary radical operation an eroded area was found leading into the horizontal semicircular canal. The outer wall of

the bony canal was removed for a considerable distance until the probe could be passed downward, forward and inward into the vestibule. A narrow strip of gauze was carried into the opening into the semicircular canal. Patient made an absolutely perfect recovery.

Third case, infant ten weeks of age. An erosion of the horizontal semicular canal was found complicating an acute otitis. A simple mastoid operation was done and the eroded area on the outer wall of the canal was curetted, opening the lumen of the canal. The wound was dressed in the usual way, care being taken to shut off the lumen of the canal from the remainder of the wound. Complete recovery.

Fourth case, girl aged twelve years. Chronic middle-ear suppuration with no symptoms of labyrinthine involvement. Radical operation. The region of the oval window was filled with granulation tissue. The curette, although used gently, extracted the stapes. The foot plate was atrophied. The probe could be passed directly into the labyrinth. A strip of gauze was packed into the pelvis ovalis. Persistent nausea for fortyeight hours, but ultimately complete re

covery.

Dench thinks it possible that in many of the cases where we have suppuration after a complete radical operation we have to do with a suppuration of the labyrinth. If it is necessary to remove the stapes in order to free this portion of the tympanum from granulative tissue, the stapes should be removed. If pus is seen to flow from the oval window it should be enlarged forward and downward. In these four cases the hearing was made considerably worse; for this reason the surgeon should avoid opening the bony labyrinth unless he is absolutely certain that disease exists in this region.

Rapid Convalescence After Mastoid Operations.

W. S. Bryant, New York (The Laryngoscope, Vol. xvii, No. 4), in a paper on rapid convalescence after mastoid operations, gives the following brief instances of his methods:

Case 1.-Child four years. Chronic purulent otorrhea. Mastoiditis. Extensive mysingotomy and a half-inch post-aural incision. General osteitis; gouge, rougeur and curette used. Wound cleansed with physiological salt solution and closed without sutures. Gauze wick in canal. Operation lasted twelve minutes. Wound healed by first intention. Fourth day, middle ear dry and post-aural wound dry. Post-aural scar scarcely percep

tible.

Case 2.-Child three months. Purulent otorrhea two weeks. Mastoid abscess four

days. Extensive mysingotomy. Half-inch incision; retraction of periosteum; bone and antrum opened with curette; wound washed with salt solution. Cigarette drain in wound and gauze drain in meatus. No sutures. Operation lasted six minutes. Second day, middle ear practically dry and post-aural wound healed.

Case 3.-Child four months. Purulent otitis and mastoiditis. Mysingotomy. Postaural incision five-eighths of an inch long opened subperiosteal abscess. Bone excavated with curette. Wound washed with saline solution and closed with cigarette drain. No sutures. Operation lasted fifteen minutes. Third day, wound swollen and discharging; cleansed with peroxide of hydrogen. day, false membrane covered wound. oxide of hydrogen. Ninth day, wound healed and middle ear dry. Scar scarcely perceptible.

Fifth

Per

Case 4.-Girl, sixteen years. Chronic purulent otitis. Pain, headache and dizziness one or two weeks. Short incision. Pus in antrum and cells. Radical operation done. Dura exposed over tegmen antri. Meatus flap cut. Wound washed with salt solution and closed without sutures. Gauze wick in meatus. Operation lasted forty-five minutes. Third day, wound healed by first intention. Seventeenth day, middle ear practically dry. Twenty-first day, middle ear epidermized. Post-aural scar scarcely perceptible.

Case 5.-Woman, twenty-seven years. Chronic necrosis tympanum and mastoid. Short post-aural incision. Short post-aural incision. Sinus and dura of middle cranial fossa were uncovered. Usual radical operation. Wound washed with salt solution and closed without sutures. Small cigarette drain removed on second day. Operation one hour. Sixth day, post-aural wound healed and middle ear practically dry. Twentythird day, tympanum epidermized and scar scarcely perceptible.

Case 6.-Girl, twelve years. Chronic otitis and mastoiditis. Radical operation. Dura uncovered, Wound washed with salt solution and closed with subcutaneous silver wire. Operation forty minutes. First day, changed outside dressing. Second day, wound and meatus foul. Third day, wound foul, but healing at angles. Fourth day sloughing, peroxide of hydrogen. Fifth day, wound breaking down. breaking down. Seventh day, wound clear. Thirteenth day, middle ear practically dry and post-aural wound healed.

Subacute

Case 7.-Girl, sixteen years. otitis and mastoiditis. Complete mysingotomy.

One and a half inch post-aural incision. Epidural abscess. Sinus granulating from knee to jugular bulb. Large amount of bone removed and broad extent of dura exposed. Wound washed with saline solution and closed with subcutaneous silver wire. Operation forty minutes. Third day, wound healed by first intention. Fifth day, middle ear dry. Suture removed. Thirty-first day, only a

faint linear scar visible.

All of the above are examples of Bryant's modification of Blake's blood-clot operation. The Differential Blood Count in Aural Surgery. W. P. Brandegee, New York (Annals of Otology, Rhinology and Laryngology, Vol. xvi, No. 1), reports a case of acute otitic brain abscess and one of acute double mastoiditis in which Sondern's differential blood-count were of great practical value. In the abscess case the polynuclear percentage coincided accurately with the clinical picture, increasing with the increasing severity of the symptoms and declining after operation upon and evacuation of the abscess and the establishing of the period of repair. The mastoid case is especially interesting because the polynuclear percentage fell sharply from 77 per cent. to 65.9 per cent., while the local and general symptoms of the patient, a boy of twelve years, were still severe. Brandegee, who had made all preparations for an operation, postponed this latter when the drop in the polynuclear percentage took place, and forty-eight hours later, with a declining leucocytosis, the general and local symptoms of the patient began to improve.

The boy was discharged

from the hospital one week later without operation.

Epithelioma of the Ear.

W. C. Braislin, Brooklyn (Annals of Otology, Rhinology and Laryngology, Vol. xvi, No. 1), reports four cases of epithelioma of the ear in a woman aged forty-eight and three men aged respectively seventy-one, seventyfive and eighty years. He prefers partial or complete amputation to cauterization. He gives brief histories and photographs of his cases. He comments especially on the extremely slow course of epithelioma of the ear; one of his cases was stated to have existed for thirty-five years.

B. A. RANDALL, Philadelphia, reports a measure of success with dionin solutions up to 5 per cent. sprayed into the Eustachian tube and middle ear with catheter and atomizer. As this is a preliminary communication he gives no statistics.

Dermatology.

The Barber and Skin Diseases.

An especially remarkable paper on "The Barber and Skin Diseases," by Rollin H. Stevens, was read at the recent meeting of the Ohio State Homeopathic Medical Society. It is printed in full in the Cleveland Medical and Surgical Reporter for August. It deals with a subject which it is to be feared medical men regard too lightly. The education of the barber is a matter of prime importance, since he should be taught "to conduct his business in a strictly surgically clean manner and cease being a distributer of disfiguring, demoralizing, disgusting, yes, even depopulating diseases, such for instance as baldness and ringworm in their various forms, local septic infections and syphilis." Tinea barbæ, alopecia areata, alopecia vulgaris, sycosis vulgaris, syphilis, lupus-this is the formidable array of diseases which find their inception or which are developed in the pretentious tonsorial parlor or the cut-rate barber shop of the slums. Even "epithelioma often gets its start through the picking and cauterizing of moles, warts, pimples and keratoses.

What is society doing to remedy these evils?

"A few States now have barber license laws, including Michigan, Wisconsin, Kentucky, Missouri, Minnesota, Connecticut, Washington, New York, New Jersey and California. In Kentucky, since 1902, the barbering in cities of the first, second and third classes is under the supervision of a State Board of Barbers, which may adopt reasonable rules and regulations and prescribe sanitary requirements. Any shop in which the tools, appliances, etc., are not kept in a clean and sanitary condition may be declared a public nuisance and have its license revoked. To obtain a license the barber must pass an examination and prove that he has sufficient skill in the art of barbering, and have ability to recognize and prevent the spread of infectious diseases of the scalp and skin by means of his tools, etc. The board is composed of barbers, who conduct the examinations and enforce the law.

"This law is planned after the Michigan law, which was adopted in 1901, and is still on the statute books, though the first law in Michigan was passed in 1898, Minnesota having passed one the year previous. A board of three barbers passes upon an applicant's knowledge of the nature and effect of eruptive and other skin and scalp

diseases, whether they are infectious and communicable, and his ability to prevent their spread by means of barber tools and appliances. Every barber is required to sterilize all tools and utensils used by him in the work of a barber, according to approved methods, and all directions or orders of said board concerning the proper method of sterilizing tools and utensils shall be faithfully obeyed by every barber. The proprietor is held responsible for the sterilization of all barber tools, utensils, razors, shears, clippers, etc.

Wisconsin's law is very similar, and some important amendments were passed by the present Assembly in February. The amendments required apprentices to register and serve two years before taking the final examination for a barber's license. The board was authorized to adopt reasonable rules for the sanitary regulation of barber shops subject to the approval of the State Board of Health, and is given the power to enter any barber shop during business hours for the purpose of inspection of such shops. If any shop be found in an unsanitary condition, or if any barber working therein has been charged with imparting any contagious or infectious disease the board shall immediately notify the health officer, and such shop shall be quarantined, and the barber so charged shall not practice his occupation until such quarantine shall be removed by the health officer. The board has the power to revoke the certificate of such barber. The Wisconsin board is composed of three barbers who are very active and progressive. They publish bulletins giving such information as they deem desirable to barbers. Bulletin No. 2 is very elaborate, and gives rules for disinfecting instruments, suggestions for cleanliness, descriptions of infectious diseases of the skin and scalp, and a large number of formulæ for treating those diseases.

"The aim of the laws relating to barbers is the protection of the public health. This, naturally, is the function of the board of health. And the policy of the board of health is largely planned by physicians. Hence it logically follows that the board of health or physicians should have the responsibility of the sanitation of the barber shop. That law which leaves the education and examination of the barber in sanitary matters to the barber, does not protect the public. Barbers' boards, in the States favored with them, are composed entirely of barbers. They are made the examiners of candidates who are presumably just as qualified to practice as the examiners themselves, and in Wisconsin they

attempt to educate in medical matters that which should always be left in the hands of competent medical men. Their little knowledge of the principles of asepsis and antisepIsis and skin diseases is a dangerous thing to the public, and when they attempt to treat difficult and obscure diseases, as they do in Wisconsin, they are going very much too far towards violating the intent of the laws governing the practice of medicine, if not the letter.

"The barber's concern should be only a general understanding of the nature and effects of skin infections, and not with diagnosis or treatment. That is difficult, many times, even for the skilled physician, and it cannot be done by any rule of thumb. The barber should not attempt to practice medicine. Each individual case requires the careful study of an educated and experienced physician; but the barber should be well grounded in the principles of asepsis and antisepsis that he may prevent the dissemination of infectious diseases.

66

But how is he to gain this knowledge and experience? At present there are barber schools in name only, for I am informed these principles are not taught there. Good barber schools should be established and have competent physicians on their staffs who should impart a general knowledge of the infectious nature of skin diseases and the best means to prevent their spread in barber shops. In the absence of recognized barber schools I would suggest the medical colleges giving short couses for barbers. I believe they would be appreciated by the barbers and would be a public benefit. Examinations should be held by the medical teacher and by some competent physician delegated by the board of health. Then, if the barber does not put into practice the principles he has had an opportunity to learn, the present laws could be enforced by the barbers' board in co-operation with the board of health. Then, and only then, can we entrust ourselves to the ministration of the barber without fear of contracting some one of the many skin infections.

Treatment of Itching.

,,

Buckley, in the Journal of the American Medical Association, in an excellent article on the treatment of itching, divides pruritus into the following categories: (1) External, which may be miscellaneous or parasitic; (2) idiopathic, which he divides into the neurotic and senile; (3) constitutional, which may be of two kinds, autotoxic and dermato-pathologic. It is difficult to make an abstract of the article. Suffice it to mention merely his

opinion on the recurrent or increased itching at night:

"Outside influences have something to do with recurrent or increased itching at night. The irritation of the skin caused by undressing and by exposure to the air, which is generally cooler than the surface has been when fully clothed, are efficient causes. Many a patient may be comfortable during the day, but when ready for bed may suffer greatly from itching, which will delay or prevent sleep. Often patients will get up at night to make fresh applications or dressings, but my constant advice is so to dress and treat the affected parts before retiring that this shall not be necessary, and, if possible, that they shall make any additional applications under the bed-clothes so as not to expose the surface again to the chilling effects of the atmosphere."

Scabies.

They do not consider scabies of any particular moment in the Military Hospital at Berlin, according to the British Medical Journal. One day's detention seems sufficient, with a thorough application of balsam of Peru. The cure is absolute.

THE Mayor of Exeter, in welcoming the British Medical Society at its recent annual meeting, gave his medical hearers some advice anent the matter of the ingestion of alcohol. The Mayor said he wondered that the medical profession did not as a whole take up temperance with more vigor and more seriousness than they did at present. Laymen looked to them to give a lead in this matter, for alcohol claimed a larger number of victims than tuberculosis. It lay within the power of doctors to help them to make considerable advance by refraining from recommend

ing to their patients such a dangerous thing as alcohol.
Dr. Davy, the president of the British Medical
Society, while admitting that the evils in crime and
disease arising from the excessive use of alcohol de-
manded the attention of every Englishman, more
especially as the drink habit was increasing among
women in England, proceeded to criticise the ultra
temperance advocates, whose arguments, he said, not
infrequently consisted of "unscientific twaddle."
Lessons on the abuse of alcohol should be given in
the schools, and the children should be taught that
alcohol was not necessary for muscular work.
he continued, "to go on and tell them, as in some
American schools, that you are morally wrong in
drinking a glass of wine and to do so is taking poison
is unscientific twaddle, and is absolutely wrong. If
that is what they are going to be taught I, for one,
prefer to teach them nothing at all.”

But,"

Continuing, Dr. Davy admitted a liking for port wine, of which he said his great-uncle had never drunk less than a bottle every day of his life, and he lived to within four months of being a hundred years old. Two or three pints of beer a day would not injure one any more than tea.

The Feeding of Infants
in Diarrhoea,

Cholera Infantum, etc.

Mellin's Food is a preparation for the modification of fresh cow's milk. In diarrhoea or in pronounced digestive disturbances when milk is contraindicated, Mellin's Food dissolved in water may be used temporarily or Mellin's Food in whey.

As soon as the stomach regains tone, a small quantity of milk should be gradually added, until the proper proportions of Mellin's Food, milk and water, adapted to the age of the child, are reached.

Mellin's Food in these cases is much to be preferred to barley or other cereal gruels, as it is free from starch, and therefore does not set up, but actually allays, intestinal irritation.

We will gladly send samples free to you, Doctor, on request.

Mellin's Food Co.,

Boston, Mass.

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