ear disease is much more prevalent among the insane than among the sane. In fact, it is the exception not to have some demonstrable functional disturbance of the ear. Bryant found it present in 90 per cent. of the insane examined. In many of these cases a history can be obtained which shows that the ear disease was in existence before the insanity appeared, and in others the condition of the ears is such that it must have antedated the mental disturbance. His summary is as follows:

1. Insanity is usually accompanied by aural disease. In the majority of the insane the two affections are mutually dependent.

2. Hallucinations of hearing arise from tinnitus through the misinterpretation of aural stimuli under psychopathic conditions.

3. Cessation of the tinnitus can be expected to relieve the auditory hallucinations.

Curetting the Lateral Sinus from the Other Side of the Torcular.-Robert Lewis, Jr., New York (Archives of Otology, vol. xxxvi, Nos. 1 and 2), reports a case of mastoiditis complicated by thrombosis of the left lateral, petrosal and cavernous sinuses. On operation, the sigmoid sinus was found absolutely obliterated, not even a clot occupying the former situation of the sinus. This condition extended from a little beyond the knee almost to the bulb. The bone was removed and the remaining portion of the sinus curetted as far as the torcular. The internal jugular vein was removed. A bacterial examination showed a streptococcus infection of the vessel walls. Five days later chemosis of conjunctiva of eye on operated side. Lewis removed the remaining portion of the bone covering. the left lateral sinus as far as the torcular and curetted the sinus on the opposite side. There was no clot, but the flow of blood was not at all free. The patient died in one hour. Lewis believes this sudden death was due to a dislodgement while curetting of a portion of the thrombus in the right sinus, which passed by way of the right internal jugular vein and reached the heart. He therefore believes it is not good surgery to attempt a curettement of the lateral sinus from the opposite side by way of the torcular without first ligating the internal jugular vein on the side to be curetted.

Dr. George I. Dixon, who made the autopsy, does not believe that a detachment of a thrombus in this case had anything to do with death. His description of the condition of the heart is as follows: "The pericardial sac was distended and contained six ounces of clear amber fluid. The heart was soft and flabby. A large, firm thrombus was found

in the right auricle, which extended through the auriculc-ventricular opening into the ventricle, where it was attached to the columnæ corneæ. A considerable portion of the auricular end of the thrombus, and all of the ventricular end, was dense and white. That portion attached to the auricular wall was thick and had evidently been present for a considerable length of time, but the balance of the auricular cavity was filled with a recent red clot sufficiently large to account for the fact that the ventricles were empty. There was also a dense white thrombus in the left auricle.

Meningism.-Chevalier Jackson, Pittsburg (Journal American Medical Association, March 30, 1907), discussed before the Section on Laryngology and Otology the subject of meningism, as distinguished from meningitis, from an otologic standpoint. He enters into the varieties, etiology, pathology, symptomatology, prognosis, diagnosis and treatment, and gives the details of thirteen out of sixty-two cases which he has noted. He concludes:

1. Without lesion of the meninges there may be a syndrome comprising many of the diagnostic symptoms of meningitis. Before recovery, such cases are often indistinguishable from meningitis.

2. The term meningism is, on the whole, the least objectionable that has been applied to this syndrome.

3. Nosologic independence of the condition will stimulate research.

4. According to etiology, these cases may be classified as either reflex toxemic or irritative.

5. In all three classes there are circulatory changes, and in many cases direct action on the cortical and subcortical cells. In the toxemic cases the nosotoxins circulating in the blood act as toxic doses of cerebral poisonous drugs do.

6. As otologists we have mostly to do with irritative and toxemic cases. When any of these forms occur accidentally in a case with middle-ear disease, correct diagnosis becomes of the utmost importance.

7. Any meningitic symptoms may occur, but the erethistic are much more frequent than the depressive. The full development of pressure symptoms or paralysis will usually exclude meningism.

8. The readiness with which the symptoms of meningism may be quieted by small doses of morphine is a valuable diagnostic point.

9. These cases of meningism are distinct from Quinche's "serous meningitis," in that here is no serous effusion.

Anesthesia.

F. H. M' MECHAN, M. D.

Amputation of the Thigh Under HyoscineMorphine-Cactin Anesthesia.-Dr. Henry G. Ebert, in the Military Surgeon, reports an amputation of the thigh in the upper third, under hyoscine-morphine-cactin anesthesia:

"Injections (hypodermic) were given two hours, one hour, and half an hour before operation. Anesthesia was ideal and complete throughout operation and for several hours afterward. No ill effects whatever were noticed at any time. Muscular relaxation was not so complete as in ether or chloroform anesthesia, so that after the operation no subsequent contraction of flaps took place and there was no more tension on the stitches afterward than at the time they were put in.

If this anesthetic will work in all cases as well as it did in this and numerous others reported in the medical journals, it would appear to be the ideal anesthetic for field use and emergency work where one may be short-handed, as it does away entirely with the anesthetist and the space and care necessary in the transportation of ether or chloroform.

The absence of inconvenient after-effects is a most valuable feature of this preparation in field work, while the ability to perform serious operations promptly is of particular advantage; but of equal utility in active service is the possibility of securing complete rest and anesthesia in cases of injuries too extensive to permit of immediate operative attentiɔn, such as in visceral injuries of the abdomen, chest or head. It seems a good thing for the military surgeon and should come into favor with him.

Freer's Method of Local Anesthesia.-Dr. J. F. Byington, reporting fifty-six cases of submucous resection of the nasal septum, in the Journal A. M. A., January, 1907, has the following to say about the newer method of rhinological anesthesia:

"Freer's method of local anesthesia was used in each case. Each side of the septum is first swabbed with a 1:1000 solution of adrenalin, and this is followed in about three minutes with an application of pure powdered cocaine rubbed on to the mucous membrane by means of a swab moistened in the adrenalin solution. The absorption of the cocaine is largely prevented by the contraction of the blood-vessels produced by the preliminary application of adrenalin, and thus the effect of the anesthetic is practically limited to the field of the operation, while the use of

the pure cocaine undiluted produces profound anesthesia."

In their recent text-book on "The Treatment of the Diseases of the Nose and Nasopharynx," A. Onodie and A. Rosenberg observe that the possibility of cocaine poisoning is entirely obviated by Freer's method, just described.

The Drop-Method in Ether Anesthesia.Dr. S. G. Davis, writing in the Maryland Medical Journal, advocates the drop-method for ether anesthesia. He uses a large Esmarch inhaler with a capacity of twenty-five cubic inches of air-space, and six thicknesses of gauze. To prevent conjunctivitis he uses

Before bea rubber protective for the eyes. ginning anesthesia, a wet towel is laid around the face of the patient and the mask is placed upon it to insure a close fit. During the course of anesthesia the towel is gradually drawn up or another used to cover the greater part of the mask, leaving only a small opening at the top on which to drop the ether. The ether is dropped only so quickly as not to interfere with breathing. Unconsciousness follows in three minutes, surgical anesthesia in ten. His method is practically that of Dumont as it is practiced on the continent. During anesthesia, respiration should be quiet; panting, irregular or stertorous breathing call for air. The pulse should be full and bounding, the pupils of normal size and responsive to the light-reflex. The principal advantages claimed for this method are the absence of venous congestion, which makes it an admirable procedure in mastoid operations, and the absence of nausea.

Jactatory Movements During Anesthesia.Describing his experience anent jactatory movements during anesthesia, an English anesthetist, writing in The Lancet, May, 1907,

says:

The cases in which I have noticed these jactatory movements have been alcoholics, who have had a good deal of struggling in the initial stages, and in whom the inhibitory powers of the upper motor neurones, weakened by alcoholism, have been cut off, while the lower motor neurones retain their irritability. The same jactatory movements are to be elicited in disseminated sclerosis of the spinal cord."

From personal experience the same observation holds good for neurotics, excessive smokers, and individuals who have indulged in sexual excesses.

THE small pustular syphiloderm sometimes resembles a pustular eczema.

Book Reviews.

The Common Bacterial Infections of the Digestive Tract. By C. A. HERTER, M.D., Professor of Pharmacology and Therapeutics in Columbia University, Consulting Physician to the City Hospital, N. Y. New York: The MacMillan Company, London: MacMillan & Co., Ltd., 1907. All rights reserved.

The appearance of Herter's book marks a distinct epoch, both in bacteriology and gastro-enterology. It demonstrates clearly that the bacteriology of the digestive tract has ceased to be an abstract study, and has come to have distinct bearing on the clinic. It also shows the enormous advances which have been made since Escherich's pioneer work. The book is divided into twelve chapters, which exhaustively describe the normal and abnormal flora of the human digestive tract in childhood, adolescence, adult life and old age. The methods of cultivating the microorganisms are well described. The relation of the bacterial flora to fermentation and putrefactive processes is dwelt upon at length. Final chapters are given on the clinical adaptation of this new knowlege. According to Herter, the intestinal bacteria are probably not necessary for the maintenance of healthy life. The chief significance of the intestinal bacteria lies in their potential capacity for checking the development of harmful bacteria. Gastric juice of healthy people protects the intestine against bacterial invasion up to a certain point, but spore-forming bacteria or those taken on an empty stomach or in too great numbers may reach the intestine. The chief obligate bacteria are the B. lactis aerogenes, which inhabit the upper parts of the intestine and grow fewer in number lower down, and the B. coli, which increase in number as the B. lactis diminish. The difficulties of gaining a correct idea of the bacterial life within the intestines are clearly pointed out. They depend upon the fact that certain of the bacteria grow under aerobic and others under anaerobic conditions. The large bowel is most of the time under anaerobic conditions. The initiation of putrefactive processes depends largely, but not exclusively, upon the obligate anaerobes. Ordinary facultative anaerobes, such as B. coli and B. lactis aerogenes, cannot attack native proteids. Here in the intestine the native proteids are decomposed only by the obligate anaerobes. The intestine, however, abounds in bacteria which can attack albumoses and peptones, thus entering into symbiosis with the strict anaerobes. The upper two-thirds of the small intestine contains practically no putrefactive bacteria. The lower part of the ileum contains some anaerobes. In disease these may be greatly increased. In the colon there is always an enormous accumulation of bacteria. Towards the lower part of the colon, the B. coli group tends to die out, chiefly because their soil becomes exhausted, but partly because of the formation of certain inhibitory substances, such as indol, acids and phenol. This explains the fact that the stools following the use of purgatives are often richer in living bacteria than the normal stools. An attempt has been made to place the pathological putrefaction within the intestines upon a solid clinical basis.

Herter recognizes three common types: (1) The indolic type; (2) the saccharo-butyric type; (3) the combined type. In the indolic group there is probably an invasion of the ileum by a member of the B. coli group, which attacks hydrolized proteids and forms indol. This process is common in cases of occlusion of the bile-duct, and probably frequently occurs in childhood. The saccharo-butyric type is common in adults. It is due chiefly to an infection

with the B. aerogenes capsulatus, which may be associated with other bacteria. The stools in these cases are apt to be light in color, due to the admixture of fine air-bubbles; they float on water; they may smell of butyric acid; the reaction may be acid, neutral or alkaline; they contain little or no indol. The patients usually suffer in nutrition; many develop anemia; they cannot tolerate acids or carbo-hydrates. Nervous symptoms, as a rule, are not prominent. There is often a tendency to diarrhea. The combined type includes those cases in which there is a persistent indicanuria. Symptoms of nervous depression and of muscular weakness predominate in this condition, and pernicious anemia may result from it.

The above analysis of the contents of this book reveals both its scientific and practical character. Aside from the rich subject-matter, the work is notable for Herter's well-known charm of style and clearness of description.

HENRY WALD BETTMANN.

Wellcome's Photographic Exposure Record and Diary. Three editions, United States; Southern Hemisphere and Tropical edition, for Tropics and South Hemisphere; Northern Hemisphere edition for Canada, Europe and all countries north of the Tropic of Cancer, except United States of America. Burroughs Wellcome & Co., 45 Lafayette Street, New York City. Price of the United States edition, 50 cents.

This photographic record and diary, published by Burroughs, Wellcome & Co., is a compact compendium of photographic information. The exposure calculator alone is worth many times the price of the book to amateur and even professional photographers. It is accurate, and not a single picture need be lost through wrong exposure when timed by this meter. This little compendium contains, among other valuable matter, a table for focusing by scale, explanations for toning with various methods, plate speed tables, monthly light tables, and temperature chart.

Folia Therapeutica.

This is the title of a new periodical publication appearing in London under the editorship of Professor A. Babinski, Berlin, and Professor J. Snowman, London. It has for its object the recording of the progress of modern therapeutics and pharmacology, and to present in a condensed state methods of treatment and preparation which may be safely recommended and which bear the appearance of real therapeutic advance. Ewald, Senator and Brieger contribute valuable articles. There is an abstract department, a book review and a bibliography. This new publication, in view of the uncertain condition We of our therapeutics, is especially acceptable. commend it to the profession most heartily. There is something more in it than an euphonious name.

of cases we have gall-stone colic, followed with icterus, and the diagnosis is easily arrived at; however, in some cases this is lacking, and even the other common symptoms cannot be found. It has frequently occurred to me that many people who have had gall-stones, and did not have the usual line of symptoms, may have had other distressing symptoms due to the presence of gall-stones in the gall-bladder, gall-duct, cystic duct or common duct.

The use of the Roentgen ray has not been satisfactory to me in making a diagnosis, although I have made three very good skiagraphs of hepatic concretions. There are so many physical conditions present that have to be overcome that it seems to me that the radiograph being negative would not be any evidence that gall-stones were not present.

Another thing that makes the symptoms of cholelithiasis differ in many instances is the various complications. When the common duct is obstructed the colic and jaundice are always present. When the cystic duct is obstructed there may or may not be cramp and jaundice. When the concretion has passed into the ampulla of Votter there is most always an inflammation of the pancreas.

There are cases reported in which the stone has been expelled through the lung tissue, the duodenum and the abdominal wall by the assistance of adhesions. There are instances in which the ulceration and rupture of the cyst are not accompanied with sufficient inflammation to form these adhesions, and the stone is let fall in the peritoneal cavity, often with fatal results.

All of these complications would naturally cause different symptoms, and when we consider all these and others there is little wonder that many cases of cholelithiasis are not properly diagnosed except on the operatingtable or in the post-mortem room. While it is true that many patients have these concretions without any alarming symptoms arising from them, I have had a few cases in which neither myself nor consultants were able to make a diagnosis, and the real cause of the trouble was gall-stone.

CASE I.

Female, married, thirty-two years old. Housewife, well nourished, and without constitutional disease or hereditary taint. One child five years old. In April, 1902, while apparently in the best of health, was seized with violent hiccough, which continued for twelve hours, in spite of the drugs administered, both hypodermically and per orem. A few days following the attack symptoms of a violent gastritis appeared. Nausea and uncontrollable vomiting. A diagnosis of hysteria was made and treatment administered. These symptoms occurred periodically, and in most every attack the hiccough preceded the vomiting.

Physical examination of the abdomen did not

On

show any pathological condition. About July 1 she began to vomit all food and water, and great quantities of bile. Used rectal alimentation until October without any improvement, when the second consultation was called and an exploratory incision advised. After she was etherized I made an incision from the xiphoid cartilage to the umbilicus, in the median line, and examined the stomach carefully. Carefully examined the pylorus and the upper portion of the duodenum without finding anything of importance. examination of the gall-bladder found three stones, and the cyst wall to be infiltrated and thick. Made a second incision over the liver and packed gauze under and on both sides of the gall-bladder and opened it. Only a few drops of bile escaped with the stones. The cyst was so small that it could not be sutured to the peritoneum, so I placed a soft rubber drain in the cystic opening and closed the incision around it. Placed a gauze drain around the soft rubber and closed the abdominal opening around the two. The first abdominal incision was then closed. There was considerable shock and some vomit during the narcosis. The second day the temperature was 103° F. and the patient very restless. The third day the temperature was 1010, no vomit and resting easy. Sixth day, dressed wounds, and

was very uneasy, on account of the absence of a flow of bile from the drain. She was restless and uneasy, and still had some temperature. She was etherized the second time and the wound opened. The drain was still in the gall-bladder, and no bile was to be seen. Removed the drainage and closed the bladder and the abdominal opening. The patient made an uneventful recovery, and did not have any recurrence of the hiccough or vomit. She died from pneumonia in April, 1903.

I believe that the gall-stones were the sole cause of the hiccough and the vomit. There certainly must have been a complete obstruction of the cystic duct from inflammation a long time before operation. There was no bile present in the drainage, and only a few drops in the bladder, before it was opened. During her whole sickness she did not have any colic, and she was not jaundiced. While it is probable that this patient only had hysteria, and the gall-stones were only of secondary importance, I am inclined to believe that this peculiar line of symptoms was caused by certain reflexes, and that the condition in the gall-bladder was the sole cause.

The presence of gall-stones in the gallbladder is not without an element of danger, even when we know that they are there. Many cases have been reported in the journals in the past few years in which carcinoma of the liver was supposed to have been caused by biliary concretions. Whether or not gallstones do this I am unable to prove; however, the supposition that they do bears out the conclusion that interference is indicated whenever and wherever chronic cholelithiasis exists. It is true that nature frequently removes them, and with a great deal of trouble to the patient, so we must conclude in those instances where the colic occurs from time to time