mine the audibility of speech, which also is proportional to the square of the distance.

Even knowing that, to denote it by a simple fraction of the distance is perfectly explicit and available for our purpose, just as the acuteness of sight has been satisfactorily expressed for years. Next in importance is the determination of the field of audition, the upper and lower tone limits and the tone gaps (defects) between the limits. What, if any, influence the clang-tint has on the audibility of speech and music has never been the object of enquiry. Whether the direct measurement of the vibrations of a tuning-fork by Ostmann or the shadow method of Gradenigo will be made available for the daily practice, the future will show. The reviewer is not prepared to endorse the author's negative opinion on Gradenigo's method.

Ostmann's experiments form a new method of exact scientific research, of which good results may reasonably be expected. Thus far it is cumbersome, but what is scientifically correct, though complicated, may with time be simple and easy, and find its place in the consultation room of the practitioner as well as in the laboratory of the university professor. H. KNAPP.

XI.-Diseases of the Ear. By E. B. DENCH, M.D. Third edition. D. Appleton, New York, 1903. 718 pages. Price $5.00.

In the preface to the new edition of this well-known text-book it is stated that owing to the great advances made in otological surgery within the last years a complete revision of the chapters devoted to operative treatment of chronic suppurative otitis media and of the various intracranial complications of middle-ear suppuration has been made necessary.

As this book was extensively reviewed in vol. xxiv. of these ARCHIVES, we will return to the revised part, beginning with chapter xxix., where a very complete and clear description of the so-called radical operation is given. It is to be regretted that the author sees it wise to continue the use of the term StackeSchwartze, a name with which the radical operation has become known in this country, as it is incorrect and therefore misleading, and its use should be dropped. The method of operating practised by the author consists in first exposing the mastoid antrum in the typical manner and then breaking down the partition between this opening and the auditory canal. In cases of unusually small antrum, or where the lateral sinus is displaced forward, this

method may be extremely difficult and a very dangerous one, especially in hands which are not thoroughly trained, and it is just in these cases that the advantage of the true Stacke operation is to be found. It seems to the reviewer, therefore, that the operation which carries the name of Küster-Zaufal, and which consists in an enlargement of the auditory canal in a superior and. posterior direction until the antrum is reached or, in case of the inaccessibility of the antrum, the attic becomes exposed, is to be preferred. On page 548 it is stated that the fibro-cartilaginous meatus, after having been divided by an angular knife, is pulled out of the bony meatus with a strip of gauze. This is not to be recommended, as it is very important to leave the part of the membranous canal which is in contact with the anterior meatal wall as intact as possible. The necrosis of the anterior bony wall, which is otherwise liable to follow, is extremely obstinate and unpleasant to deal with. We find that one point has not been sufficiently emphasized, and that is the importance of making the actual opening into the middle ear as large as possible; in other words, of removing all of the overhanging bone consisting of the posterior margin of the annulus tympanicus which covers the recess in the posterior wall of the tympanic cavity. This recess is developed to a varying extent and is frequently the site of caries; if so, an insufficient removal of the overlying ridge of bone of course renders the result of the operation futile.

A number of plastic operations are given. The author favors the Panse method and sutures the edges of the flaps to the posterior periosteal margin with catgut. The posterior wound is always closed. Primary skin-grafting has been practised by the author with apparently considerable success and satisfaction. It seems to us that the description of this step has received an exaggerated importance and amount of space.

The author's results are: of 70 cases operated on, 53 were healed, 8 improved, 1 unimproved, I unknown, and 7 still under treatment. Nothing is mentioned of the length of after-treatment nor of the final hearing result.

The heading, "Accidents during Operation," include injury to the facial nerve and to the dura. We cannot share Dr. Dench's opinion on the gravity of the latter accident; in many cases it is impossible to complete the operation without exposing the dura, usually of the middle cranial fossa. In regard to injuring the facial nerve, of course the all-important fact is an exact knowledge

of anatomy; then if the operator will conduct his work in such a way that he always sees what he is doing and is not hampered by blood, the danger of injury to this nerve should be avoided except in cases, of course, where it runs an anomalous course. Perichondritis of the auricle is spoken of as an accident, though it is unquestionably a wound infection, and in the reviewer's opinion is chiefly due to an insufficient resection of the cartilage.

It is of course very difficult to describe an operation of this character in a text-book, just as it is impossible to master it from a written description. At the same time it is very interesting and instructive to learn the methods which an operator of the extensive experience of the author has selected as best, though we should have liked to have seen more exact indications given for this operation.

In the chapter on sinus thrombosis the author, for purposes of diagnosis, recommends a "good free incision," preferably below the knee of the sinus. He believes that involvement of the jugular vein is to be diagnosticated more by the severity of the septic symptoms than by local changes in the neck. If free hemorrhage does not occur from below in exploring the lateral sinus, and the tissues behind the middle of the jaw are infiltrated, and the fluctuations in the temperature have been well marked, it is necessary to deal with the internal jugular vein. Instead of ligation, the author prefers resection, which is practised from the clavicle to a point just above the common facial branch. The operation on the neck is very fully described, and the anatomical relations of the great vessels are elucidated by two excellent textplates. Irrigation of the jugular bulb from below is not favored. The wound in the neck is sutured. In nine cases of excision of the internal jugular vein, eight recovered and one died, which is surely a very remarkable result.

In the chapter on brain abscesses the method of operating from the external surface of the skull, i. e., through the squama or through the occipital bone, is still advocated, though it is becoming generally more accepted to be better practice to expose these areas from the walls of the middle-ear cavities. The author recommends that the dura should always be reflected and puncture of the brain substance made with a knife. The abscess cavity is not irrigated and should be packed with gauze. A. K.