woman would expose the aditus compara- | with inspissated pus and epidermal scales, tively well, and even expose the upper and which were removed with the curette. medium wall of the antrum fairly well. The auricle and the cartilaginous canal However, in cases in which the antrum is were severed from the long canal and held involved in chronic suppuration, what is forward by an assistant. Between the artiknown as the radical mastoid, or Stacke, ficial opening in the mastoid process and operation, is better calculated to yield the bony canal there remained a ridge of satisfactory results. bone, which was removed by the Rongeur forceps and chisel. The scute, or bony This young man had chronic suppura Figs. 3 and 4.-Sections through the mastoid antrum, aditus, tympanum and Eustachian tube. Median aspect of the specimens: H, horizontal semicircular canal; HN, horizontal portion of aquæductus Fallopii; V.N, vertical portion. In the upper specimen the section is somewhat more median than in the lower, in order to open the horizontal semicircular canal and the aquæductus Fallopii. It will be observed that in the lower specimen the tubercle (H) containing the semicircular canal is more lateral than the hard ridges of bone below it (N) containing the facial canal. In the upper specimen the stapes is in the oval window, and the topography of the inner walls of the tympanum, the aditus, and the mastoid antrum is well shown in the lower figure. (From photographs of specimens belonging to the writer.) tion of his middle ear since childhood. His ear has been treated by several physicians. Failing to bring about a cessation of the discharge by intratympanic syringing, an incision was made behind the auricle down to the bone. After dissecting up the periosteum, by means of a mallet and chisel, the mastoid antrum was exposed in the manner usual in the simple mastoid operation. The antrum was found to be filled floor of the attic, was also removed, and the entire middle ear thus converted into one large cavity. (Fig. 5.) A skin-lining for this cavity was obtained by slitting up the cartilaginous canal and pressing the flaps into place when the auricle was secured in the normal position. This is not quite Stacke's method of operating, but is the manner in which the radical mastoid operation is most frequently performed. The suppuration has ceased. The man hears my watch at about 3 feet. Through the meatus it is possible to inspect all parts of the middle ear, which is apparently completely lined with epidermis. This epidermis will probably exfoliate, and from time The Fig. 5.-The radical mastoid operation, auricle has been turned forward and the cartilaginous meatus detached from the bony meatus. The scute and the posterior wall of the meatus have been chiseled away in order to convert the mastoid antrum, aditus, attic, and atrium into a single large cavity, all parts of which will be easy of inspection and access through the canal when the auricle and cartilaginous canal have been returned to their normal position. In the specimen the malleus and incus have been allowed to remain and are somewhat dimly seen in the figure. (From a dried preparation in the writer's collection.) to time epidermal scales and dirt of various kind will require removal. This, however, can readily be accomplished; and, with a very little care, our patient's hearing will probably always remain good and his ear free from suppuration. IRRITABLE BLADDER.1 BY ELLWOOD R. KIRBY, M.D., Clinical Professor of Genito-Urinary Surgery in the Medico- GENTLEMEN: The case which I shall present to you to-day is one of considerable interest from the fact that the symptom of which he complains is one common to many genito-urinary conditions. 1 A clinical lecture delivered to the third- and fourth- year students of the Medico-Chirurgical College. You will note from his history that the most pronounced symptom is frequency of micturition: commonly, but incorrectly, called irritability of the bladder. The term "irritable bladder" has been used to express a disease rather than a symptom; hence some confusion has arisen in the application of therapeutics to the condition upon which this perverted function depends. Irritability of the bladder is understood to mean that the act of micturition is performed unnaturally often. I shall not attempt to qualify this somewhat broad definition by any statement as to the number of times a healthy person should urinate during twenty-four hours, as there are variations dependent upon circumstances and individual peculiarities which would make such an attempt almost ridiculous. Therefore, unless a person is, in some manner, inconvenienced by the frequency of the act, I hold that he is not suffering from vesical irritability. Irritability of the bladder may be caused. by one or other and sometimes more than one, of the following conditions: Nervehabit, reflex action; structural changes, including tumors and calculi; and, finally, abnormal states of the urine. In the study of any given case of vesical irritability, permit me to call your attention to an important point: carefully and consider these headings; systematically you will then probably succeed in doing that which others have failed to elucidate. If you do not study these cases in some such methodical manner, it is not at all improbable that you will miss your mark, and will then be obliged to fall back on empiricism. Now, you may possibly ask: what do I mean by nerve as determining an irritable condition of the bladder? I mean just what you do when you make use of the term in its ordinary acceptation: "a nervous man." You will find a certain proportion of cases of vesical irritability simply due to this condition. It is a common complaint among students when about to enter the "green room" to pass their examinations. Irritability of the bladder dependent upon reflex action is most commonly met with in children and young persons. Illustrations of this class are furnished by the irritability that occasionally attends the presence of intestinal worms. In the young, particularly, and even in those of a more advanced age, a constant desire to urinate may be kept up by an elongated or adherent prepuce. The retention and decomposition of the smegma, by setting up inflammation, indicates this as the probable cause. Certain forms and stages of purely renal affections frequently give rise to this symptom. Whether, in these instances, the irritation is merely reflex or is directly due to some alteration in the urine is an inquiry I do not intend entering upon; it is sufficient here to remember that such may be the cause, whatever may be the explanation. Passing to the bladder, we find that in some period of their course all growths give rise to irritability in addition to other symptoms indicating their presence. In the early stages the irritability is probably mechanical in its origin, and in the later stages to cystitis or secondary calculous formation. Similarly, irritation is provoked by enlargement of the prostate, particularly in the early stages of the disease. The irritability connected with prostatic engorgement shows itself chiefly at night. The patient may be perfectly well during the day; but, as soon as he gets into bed, he experiences a desire to pass water, which further disturbs his rest by provoking another call after intervals of varying extent. It is very difficult to explain some of the forms of irritable bladder that are connected with prostatic hypertrophy. I believe, however, that it is more mechanical in its production than is generally supposed. | atony of the bladder with the presence of residual urine. In these cases the irritability is worse by day, as in the case of calculus. I will now finally consider the irritability that is due to altered and abnormal states of the urine. The secretion least irritating to the urinary passages is that which most nearly approximates that which we have taken as a healthy standard. The low specific gravity of the urine that is passed so frequently and abundantly by hysterical females no doubt causes the vesical irritability from which they invariably suffer. Water is more irritating to those passages of the body over which it is not intended. to flow than a saline solution of some density. The abundance of urates and oxalates undoubtedly explains the extreme irritability of the bladder seen in gouty and dyspeptic objects. The treatment of frequent urination is founded on the detection and removal of the cause. There is, however, one form of frequent urination which, apparently, is purely functional. In the absence of urethral lesions or pathological conditions of the urine the patient is unable to retain his water more than one or two hours at a time. The desire to urinate, if not immediately gratified, becomes irresistible. The bladder is completely emptied at each act of micturition. There is usually moderate polyuria. This condition may be due to masturbation, may follow sexual excess or prolonged sexual excitement, or it may develop without apparent cause. Irritability of the bladder in children and adults is a common symptom of stone, The treatment of this purely functional although it varies much both in kind and frequency is at first mainly hygienic and degree. It is simply due to the mechanical dietetic. Since the desire is often not felt. irritation occasioned by the presence of the when the mind and body are actively enstone in contact with the neck of the blad-gaged, riding the bicycle seems particuder; hence this symptom is most pronounced during the day, and more or less absent at night, because, with the patient in the recumbent posture, the stone naturally falls away from the vesical neck. Stricture of the urethra is not uncommonly attended with some degree of irritability. This arises at first from the change in relation between the expulsive efforts of the bladder and the resistance offered by the urethra; afterward from the extension of inflammation backward by continuity until the vesical neck is involved from cystitis; and, finally, from larly serviceable, both for its direct effect and for its general influence on the health. All causes of prostatic congestion or hyperæsthesia must be removed. Sexual excesses, prolonged sexual excitement, and constipation are to be avoided carefully. Cold water should be applied daily to the anus and perineum. Hæmorrhoids should be cured, a redundant foreskin removed, varicocele relieved by suspensory or radical operation; in fact, every possible cause of reflex excitability should receive attention. The local treatment has for its object the relief of hyperæsthesia and congestion of the prostatic urethra. This is accomplished by the use of full-sized, cold, steel sounds; the direct application of electricity; instillations; and prostatic massage. The medicinal treatment should be confined, in the main, to constructives, tonics, and stimulants. Hyoscine, in doses of 1/200 grain thrice daily, and belladonna suppositories, 1/ grain each, give the best results. It should be clearly recognized that this affection, when it has been of long standing, is extremely obstinate to treatment, and that cure, if it can be accomplished at all, is at the expense of months of patient, and not too officious, treatment. In conclusion, permit me to call your attention to the fact that, although an irritable bladder may be purely a functional disturbance, you must not forget, however, that the constant contraction of the bladder may produce changes behind it, which follow as a consequence of urinary pressure. I refer to dilatation of the ureter and pelvis of the kidney. 1202 SPRUCE STREET, PHILADELPHIA. This disease is known as sycosis, and consists of an inflammation of the hair-follicles. It commonly attacks only the face, but may occur upon any part of the body provided with hair. Sycosis begins in the form of one or more papules, which are often more or less rapidly converted into pustules. Some increase to the size of tubercles. Adjacent lesions may or may not coalesce. The pustules do not rupture unless the inflammatory process is rather severe. In some cases, however, the skin becomes riddled with little abscesses and the hairs are matted together by the viscid discharge. Sycosis is sometimes termed non-parasitic in order to distinguish it from sycosis parasitica, or barbers' itch. The latter is due to a definite microphyte, the trichophyton fungus, and is the disease which is transmitted by unclean tonsorial utensils. In this man's case the disease has no such direct dependence upon the barber-shop. Shaving may act as a source of irritation, but no specific parasite acts in conveying contagion. An important clinical distinction between sycosis and tinea barbæ relates to the respective effects upon the hair. In Original Communications. sycosis the hairs remain fixed in their folli NOTES ON SKIN DISEASES. BY JOHN V. SHOEMAKER, M.D., LL.D., Professor of Skin and Venereal Diseases in the MedicoChirurgical College and Hospital of Philadelphia. SYCOSIS. A MAN, 26 years of age, came to the clinic on account of an eruption upon the face. The disease is strictly confined to the bearded portion of the face and neck. He depends upon a barber, and the skin became affected a few days after being shaved. The eruption began in the form of small, round, red spots. These caused much pain and itching. They rapidly grew in size and became filled with pus. He squeezed the pustules, but this practice aggravated the trouble. At the present time there is, upon the neck below the jaw, a series of large pustules and tubercles. The skin is red, swollen, and infiltrated. There is also a number of enlarged lymphatic glands in the neck. The hairs are normal. They are free from a stubbly or nibbled appearance. The lesions are not arranged in circles or semi circles. cles until loosened by suppuration. They retain a normal appearance except as they may become matted together by inflammatory material. In barbers' itch they lose their lustre, become dry and brittle, and break soon after they emerge from their beds. This gives a ragged, nibbled, or stubbly appearance to the affected spots: an aspect found in no other disease. Pustular eczema may attack parts supplied with hair and simulate sycosis, but eczema spreads from a hairy part to a surface destitute of that covering. The perforation of the lesions by hair is distinctive of sycosis. In eczema the hairs very seldom become loosened. Sycosis is generally associated with a depressed condition of health. When this is the case we should aim, by hygienic and medicinal means, to improve the functions of digestion and assimilation. Massage and static electricity are beneficial. Mild local treatment will usually yield better results than active medication. If the hair is long it may be trimmed short, but it is not necessary to have the patient shaved. Crusts, if present, may be removed by the use of an oil. When the surface has been cleared we may make use of various antiseptic, astringent, or demulcent reme- | of the disease to the face preclude the idea dies, according to the activity of the disease. of syphilis. In so late a case of syphilis we They may be employed as ointments or should observe larger and more destructive lotions. Lead, bismuth, zinc, calomel, and lesions. There would be ulcerations and ammoniated mercury are among the sub- the formation of thick crusts. There would stances often prescribed with benefit. Lo- probably be found cicatrices upon different tions are used either warm or cold accord- portions of the body indicative of the ing as one or the other is most grateful to former presence of ulcerated lesions. the feelings of the patient. Lead-water and Neither the history of the case nor the laudanum, weak solutions of acetate of zinc, aspect of the eruption suggests the influcorrosive sublimate, and witch-hazel are ence of syphilis. In eczema of the papular remedies which are employed with success. form there is infiltration of the skin beIn the later stage of the affection, when tween the papules. a chronic inflammation lingers and infiltration is present, it is well to make cautious use of more stimulating substances, as tar, carbolic acid, resorcin, salicylic acid, etc. When there is much engorgement and suppuration, incisions with the use of hot water to encourage bleeding answer an excellent purpose. In private practice the local use of strong galvanism is the treatment to be preferred. The present patient shall be given internally the wine of antimony, which stimulates the glands of the skin, the liver, and primæ via and relaxes the capillary blood- | vessels. It shall be administered in 5-, increasing to 10-, drop doses four times a dav. Locally he shall use R Olei cadini, 3j. Unguenti hydrargyri nitratis, 3j. The quantity of oil of cade in the ointment may be gradually increased to 2 or 3 drachms. ACNE. A woman, 25 years of age, has suffered for six years past from red papules scattered over the forehead, cheeks, and chin. Her skin is harsh, dry, and irritable. Occasionally the eruption disappears. The lesions upon the cheeks are quite closely aggregated. A few pustules are also present. Upon her chin, just below the angle of the mouth upon each side, the papules are particularly large. The tongue is coated, the bowels constipated, the appetite capricious, and the digestion is seriously disordered. tion of the liver is defective. The ac The long duration of the case, the sluggish course of the eruption, the periods of temporary improvement, and the limitation The locality affected and the age of the patient indicate that the case is one of acne. This is an inflammatory affection which involves the sebaceous glands. It, therefore, occurs most frequently and typically upon the face, as the sebaceous glands are there most abundant. Acne generally commences in youth, especially at the period of puberty. Its lesions usually consist of papules and pustules, though tubercles may form and the spots of suppuration may be of sufficient dimension to constitute abscesses of the skin. Papules and pustules usually co-exist in cases of acne. According to the predominance of one or the other it is customary, for convenience of description or classification, to speak of papular or pustular acne. Aggravated cases of the disease give rise to hypertrophy of the sebaceous glands, with roughness and greasiness of the skin. Acne sometimes occasions cutaneous atrophy. In anæmic and scrofulous patients the lesions are of a dark-red or purple color, extremely indolent, and are often situated upon the trunk or extremities. Acne is often co-existent with comedo and seborrhoea. It is produced by internal or external causes of irritation. The use of irritant soaps and cosmetics and the effect of chemicals employed in industrial occupations are apt to cause this disease. As a rule, however, it is due to some internal cause. The physiological changes which take place at puberty are very commonly attended by the development of this malady. At a later date disorders of the genital apparatus in either sex give rise to the lesions of acne. Digestive disturbances of all kinds are very prone to occasion acne. This is undoubtedly the origin of the present case. In any patient affected by acne we must, consequently, direct our treatment particularly against its exciting cause. Local treat |