applied to a mucous membrane, always penetrates its epithelial structure and, reaching the coats of the blood-vessels, produces rigid contraction of their muscular fiber, and thereby causes a marked diminution of their caliber. Theory would therefore indicate its use in the first stage of inflammation. Bosworth has shown its great utility in the treatment of acute coryza. Applications to the Schneiderian membrane are accompanied by marked blanching and its characteristic anesthesia.

Rhinologists are loud in their praises of its wonderful virtues.

Bosworth tells us that if called upon to give up either cocaine or the remainder of the pharmacopeia, he would unhesitatingly retain the cocaine.

Otis has ingeniously contrived a plan by which painless circumcision can be performed; he injects under the preputial fold three or four drops of a six-per-cent solution. This little operation is repeated until a circle of blebs is formed around the cervix. He then draws the prepuce forward, and makes a similar subcutaneous ring of injections. The redundancy of tissue can then be painlessly removed anterior to the zone of cocaine injection.

Cocaine is used to benumb the urethra for various operations, such as the introduction of sounds, bougies, and catheters, internal urethrotomy, etc. A personal observation of its use for such purposes has convinced me of its utility. I have repeatedly noted a marked coolness and diminution in size of the dependent portion following the injection.

On one occasion a urethrotomy caused very slight bleeding at the time, but was followed, in the course of an hour, by quite a troublesome hemorrhage.

It seems reasonable to attribute this to the primary astringent action of the drug. Cocaine diminishes the caliber of the urethra. I have not succeeded in passing so large a sound after the use of cocaine as without it.

The profession is indebted to Corning for methods of restricting cocaine anesthesia to the immediate field of operation; by this means many of the larger operations have been successfully done.

By tourniquets, bandages, and compressing

rings, we are able to prolong complete insensibility almost indefinitely with much lower per cents than heretofore used. The thigh has been amputated, supra - condyloid osteotomy and resection of the head of the femur have been painlessly done.

Tumors, abscesses, felons, and ingrown toenails are, in many instances, amenable to the benign influence of this new discovery.

The thorough examination of the more painful fractures and dislocations has been much facilitated by cocaine anesthesia in injured regions. Pharyngeal cocaine atomization has, in one instance at least, mitigated the horrible dysphagia of hydrophobia.

Alexander's operation for extra-peritoneal withdrawal and shortening of uterine ligaments through the inguinal canal, as a mechanical means of relieving procidentia uteri, is at present most warmly discussed, both favorably and adversely. Careful gynecologists will rather side with Emmet, who believes that practically as good results can be accomplished without subjecting the patient to such questionable risks. Polk views the operation with much favor. LEXINGTON, KY.

REPORT ON OTOLOGY.*

BY J. MORRISON RAY,

Demonstrator of Ophthalmoscopy, Largyngoscopy, and Otoscopy, in the University of Louisville.

ments of our art.

During the past year otology has kept abreast with advances made in other departNo great things, it is true, have been accomplished, but valuable additions to our therapeutic and clinical resources have certainly been made. Some new ideas have been advanced, but have not yet had sufficient time for their proper estimation; some old methods have been revived, and may again become the fashion. Notably among these is the operation of incision of the drumhead in the treatment of certain cases of persistent catarrhal deafness. Sir Astley Cooper has been credited with having introduced this operation, but Riolanus had performed it nearly one hundred and fifty years before the time of Cooper. Its application as a thera

*Read before the Kentucky State Medical Society, June, 1886.

peutic measure in the treatment of cases of deafness was first made by Eli, in 1760. Its indiscriminate use, however, naturally soon brought it into disrepute, and for years it was seldom used. Gruber has in recent times advocated multiple incisions in the treatment of progressive catarrhal deafness. In the Medical Record of January 23, 1886, Dr. W. H. Bates revives this method, and reports four cases in which he practiced it with good results. His description of the method is as follows: "The operation consisted in puncturing or incising the drum membrane in from five to ten different places. Simple punctures were made, or the drum was slit in various directions. The operation was repeated as soon as the opening in the drum membrane had healed. The size and freedom of the incision must be determined after the first operation for each case." As to the results of this treatment, he says this "innovation," which has given results as unexpected and satisfactory to me as to the patient, may be fairly presented for future indorsement. At the last meeting of the American Medical Association, Dr. Bishop, of Chicago, reported twelve cases in which he had incised the membrane for the cure of deafness. The cases, however, did not appear to have been well selected, as several, from the symptoms and tuning-fork test, seemed to be cases with at least labyrinthine complications.

After a thorough review of this subject, I must repeat what I said in the discussion of the paper of Dr. Bishop, at St. Louis. My personal experience, which has been that of Schwartze and Von Troltsch, of twenty years back, leads me to say, "that, among the many reports of favorable results from this operation, none of them can be said to give sufficient evidence of its real value unless the patients have remained for a long time under observation after the operation."

Another operative procedure on the drum membrane, that has been advocated during the past year, is the division of cicatrices in the structure in cases of chronic otorrhea, where the membrane has healed and the perforation closed. Prof. Politzer speaks favorably of this procedure. Mr. Bendelack Hewetzon reported two cases in which the results were most encour

aging. He says: "I feel quite sure that although this treatment is really only in embryo, the records of two cases are of interest. . . My fear, however, is that there will be a tendency to after-contraction and return of the deafness."

The mechanism of these operations is quite apparent and rational. In old cases of catarrhal deafness, the drumhead becomes relaxed. The proper tension necessary to keep the chain of ossicles in their normal relationship is lost. The cicatrization following the multiple incisions relieves this relaxation, and the proper tension is again established. In those cases where there has been suppuration, and in the healing process, the drum-head has adhered to the inner wall of the cavity, the excursions of the long arm of the lever of the bony chain becomes limited, and the incisions are made to free this and allow the proper motion.

The varied aspects in which syphilis affects the ear is a question of much interest. Mr. Edward Woakes considers its influence as a factor in the maintenance of persistent otorrhea. He states the principal diagnostic features "to be corresponding lesions in both ears, with limited caries of the fundus, which does not yield to the dilute sulphurous-acid treatment. The diagnosis of these cases is of importance, for without specific treatment they will not recover. It has been suggested that in cases of persistent chronic suppuration of the middle ear in children, inherited syphilis is often the cause of its chronicity, and that the intelligent use of mercury alone, or combined with potassium iodide, will bring about a speedy cure. A case kindly sent me by Professor Cottell bears on the question. Mrs. X. had chronic ear trouble for several years, the hearing distance being reduced to At times tinnitus was very annoying. The ears have been treated by several otologists without availing much. Two months ago she become infected with syphilis, and when I saw her, April 2, 1886, she had a well-marked secondary eruption. Since its appearance the ear trouble has been much worse, and there is pharyngitis, with mucus patches in the mouth. A diagnosis of catarrhal inflammation of the middle ear was made out. The prognosis was

guarded, but treatment advised. Dr. C. had placed her under the proper treatment for her constitutional disease. In two weeks the ears had greatly improved, and at the last examination all noises had disappeared and the hearing was perfect. The constitutional treatment must have been an important factor in bringing about so favorable a result in this case.

The influences of malaria on ear diseases have been studied by Dr. O. D. Pomeroy, who, having secured the opinions of prominent men in different parts of the country, and made a thorough analysis of them, concludes that, while malarial ear diseases do not exist, the malarial poison exerts a modifying influence on the cause of pre-existing ear disease.

Dr. Burnett reports several cases of hernial protrusion of the mucous membrane of the middle ear through a perforation in the membrana tympani. A case much resembling those reported came under my care. The patient, a male, aged fifty-six, had an attack of earache after an exposure during the early winter. The membrana tympani ruptured, and suppuration has been going on since, not withstanding it has been vigorously treated. The hearing distance was reduced to. On inspection I found a round perforation situated below and behind the tip of the handle of the hammer. Through this projected a reddish mass. On inflation, air and pus bubbled through the opening around it. It was not large enough to grasp with the snare. I informed the patient that there was a polypus in the ear, and that its removal was necessary before the ear could be restored to a healthy condition, and ordered a solution of boric acid, alcohol, and water. In two days the patient returned, when I found the mass had disappeared, and by inflation nothing could be made to protrude through the perforation. I ordered boracic acid, in fine powder, to be in sufflated daily; and in a month the discharge had ceased, leaving a small circular perforation in the membrane. The prompt disappearance of this ma-s surprised me. I had seen small granulations disappear under the application of alcohol, but never one so large as in this case, and my only explanation was, that the supposed polypus was a prolapse of the mucous-membrane covering of the promontory.

Dr. Burnett read a paper, before the American Otological Society, on the relation between chronic otitis, media-catarrhalis, and chronic rhinitis. In a country where the latter disease is so prevalent as in the Mississippi Valley, the frequency with which incurable cases of deafness are met with can be easily understood. Cases of obstruction to free nasal respiration, or the so-called mouth-breathers, almost invariably suffer from dulless of hearing. This is due to the fact that the normal balance of

air pressure on the two sides of the membrana tympani is destroyed and its free vibrations interfered with, or the disease extends to the delicate contents of the drum cavity, there often giving rise to permanent pathological changes. My own observations allow me to state that excellent results are obtained from prompt surgical treatment of the nasal stenosis by means of the galvano-cautery.

Dr. Roosa, in 1885, proposed the term, presbykousis, to designate the hearing of old per

sons.

He says "it is produced by a physiological or senile rather than a pathological change in the ear, and for this reason is fairly analogous to presbyopia." It is distinguished from catarrhal deafness by means of the tuning-fork. The latter cases hear a vibrating fork relatively better by bone conduction, while the presbykoustic hears its vibrations better through the air, thus showing that the condition is due to changes in the acoustic

nerves.

A continued report on the examination of the auditory organ of school-children has been furnished the Archives of Otology by Bezold. It will be of great value to statisticians. Children furnish a large percentage of our ear patients, and among the incurable affections of adult life the seeds are often laid in the exanthematous fever of childhood. In closing his report, Bezold makes the following significant. remark: "My statistics show that the mental development of the individual suffers a limitation corresponding to the degree that his hearing power is diminished."

New remedies are constantly finding their way into otological practice. When cocaine was first introduced much was expected from it in alleviating the pain of acute ear troubles,.

and in operations on the drum-head.

It has not, however, been as great a boon to the sufferers from aural diseases as it has been to those with eye troubles. In operations on the auricle and auditory canal, it is valuable as a hypodermic injection. Locally, it is said to allay the pain in operations on the drum. My experience, so far, does not verify the statement. Dr. Baldwin, of Montgomery, reported two cases of myringitis in which it promptly allayed the pain. It is said to act more quickly and surely when injected into the middle ear through the eustachian catheter. Holt claims, however, that the after-effects of its application are prolonged congestion. Burnett and Zeiss recommend a solution of brucine, five per cent, as a local anesthetic. They claim. that while it is longer in producing anesthesia, the effects are more lasting than those of cocaine. Peroxide of hydrogen was first recommended and is now extensively used by Landolt, Paris, in the treatment of purulent inflammations about the eye and its appendages. Dr. W. A. Dayton recommends its use most favorably in the treatment of suppuration of the middle ear. He "it will be found to be a most marsays velous cleanser; and if cleanliness is the desideratum in middle-ear suppuration, we have a servant par excellence in the peroxide." Since this report others of a similar character have appeared, which entitle it to most favorable consideration. I have used it in a number of cases with good results. The active effervescence destroys every particle of pus that may lie beyond the reach of the syringe, and by repeating the application of three or four drops, the fundus of the ear becomes perfectly free from pus accumulations, thus putting it in the best condition for the healing forces to

to promptly stop acute suppuration, and, being a slight local anesthetic, will supersede to a great extent boric acid in the dry treatment of purulent middle ear disease.

LOUISVILLE,

ON ORTHOPEDIC SURGERY OF TO-DAY.* BY AP MORGAN VANCE, M. D.

What is orthopedic surgery? The general surgeon would answer: The treatment of human deformities by the use of mechanical apparatus. And when an orthopedist excises hip joints, knees, or ankles, he feels that the orthopedist is infringing on his field.

The orthopedist will answer very differently. He would say it was that branch of surgery which takes into consideration all diseases which tend to produce deformity or crippling; the prevention of deformity as far as possible, from whatever cause; the cure or palliation of the same whenever possible.

Thus you will easily see the magnitude of this department of the surgeon's art. It is really very often difficult to define a line between it and the work of the neurologist, general surgeon, or the practitioner of medicine; as nearly all diseases of bones, particularly about joints, congenital deformities, and those from nervous causes, as well as deformities caused by burns, together with the various troubles of rheumatic origin, may all present conditions requiring his special skill.

To refer to some of the practical points of the subject, I will take up the matter under three heads: Diseases of the bones and joints, congenital deformities and cases of nervous and rheumatic origin, and cicatrization from burns.

First, in the point of frequency, come the diseases of joints, or rather of bones in near proximity to the joints, viz., spinal caries, diseases of the hip- and knee-joints, caries of ankle, elbow, etc. The fundamental indications in the treatment of all cases coming under this head can be easily expressed, viz., mechanical rest to the part, as far as possible absolute and unintermittent, with constant efforts at improvement in general condition, that repair

*Read before the Kentucky State Medical Society, June, 1886.

rather than disintegration may be established; the special diathesis indicating the medication, struma and syphilis reigning supreme as the causes of chronic traumatism, and cold of acute bone and joint lesions. The differential diagnosis of joint diseases is often very difficult. It is only by a large clinical experience that a man becomes an expert. The mechanical treatment is as varied as there are surgeons. All, however, should aim at the same result-rest, rest, rest. Particularly would I emphasize this in regard to spinal caries. What absurd barbarity is the practice of intermittent suspension in this disease!

Lateral curvature of the spine will properly come under this division, which, though not a bone or joint disease, is a joint deformity. This is decidedly the most unsatisfactory of all deformities to treat--that is, the true or rotary curvature of the spine; the other forms are often remediable when the cause can be removed. I am prepared to state that any treatment, other than gymnastic, applied to these cases, is not only unsurgical, but cruel.

Dr. Sayre, in a recent letter to the New York Medical Journal, in answer to a review of an English work, where the absurdity of the use of the plaster jacket in these cases was referred to, defends his treatment in a very weak way, by reporting a typical case where he knows good was done. The case was one of lateral curvature in a patient some thirty years of age, where a plaster jacket was applied, giving comfort; and soon the patient was unable to go without her jacket. Nothing was said about the cure of the deformity, or its partial correction; simply that the patient had comfort, and liked the jacket very much, and in fact could not stand up without it. If we wish to wed our patients with lateral curvatures to the life-long companionship of a plaster jacket, follow Dr. Sayre's advice and plaster them all. But to divorce them is a different matter, requiring twice the time to get rid of the primarily useless support as they have been wearing it, the most active treatment by electricity and massage being necessary during this whole period. Hence the bold statement, that to treat by apparatus true lateral curvature is cruel and unsurgical, as there is no force

applicable other than suspension by the head that can possibly exert any influence upon the rotated vertebræ.

Hip Disease. We understand by this term

osteitis of one or more of the bones entering into the make-up of the hip-joint. The same treatment of rest and improvement of the general condition is indicated-the rest to be absolute in the best position for future usefulness. This can be brought about by whatever method the surgeon pleases, either by one or the other of the so-called extension splints, or by some fixed dressing, with high shoe and crutches. Operative treatment, according to the latest statistics, should be avoided, except as a life-saving procedure; but I think, if it is to be resorted to at all, the earlier the better, as will be shown by the following case:

In September, 1884, W. M., aged fourteen. and a half years, referred to me by Dr. Bodine, came under my care for hip disease. A diagnosis of central osteitis of the femoral head was made at the first examination. The high shoe on the opposite foot and crutches were ordered, with tonic and supportive treatment. At this time the history of favoring this limb for six months previously was obtained. There was inch atrophy of thigh, inch of calf. All the motions were limited, flexion to 90° only being allowed; no glandular infiltration; no sign of abscess or tumefaction about the joint. The crutches and high shoe were used in an imperfect way till January 20, 1886, without pain or any exaggeration of symptoms about the joint, except that the motion became a little less free, and the atrophy increased. On this date acute symptoms appeared in the joint and the limb became fixed. in the straight position. The patient was placed in bed, with weight and pulley attached, nine to twelve pounds being used, and a blister was applied over the joint. This treatment soon quieted the pain, and he remained in bed till April 8th, 1 inches actual shortening occurring during this period. After a consultation with Dr. J. M. Bodine and W. O. Roberts, it was decided to excise the diseased head of the bone as giving the best chance of relief. The boy was now sixteen,