have not yet tried. Early incision has done more to relieve the pain of furuncle than any thing else in my hands; but incision does not give the same relief here as elsewhere, because of the cylindrical shape of the canal; keeping the cut surfaces in close apposition; and hence if menthol on further use is found to do what is claimed for it, it will be a valuable addition to our therapeutics.

Acids in Caries and Necrosis of Temporal Bone. Diseases of the ear, complicated by caries or necrosis of the walls of the tympanum or canal, are difficult to cure. Bone disease may be suspected when the odor of the discharge indicates it, and when the case has long resisted all ordinary measures, even although the denuded and rough bone can not be felt with a probe. Among the remedies applied in such conditions acids have held a prominent place. The investigations of Ole Bull encourage us to their further use, and give the preference to a fourper-cent solution of nitric or muriatic acid. The acid may either be dropped into the ear, or a piece of absorbent cotton saturated with it may be placed in the ear for twenty-four hours.

Facial Paralysis Consequent on Otitis Media. Paralysis of the corresponding side of the face sometimes occurs with inflammation of the middle ear. It is generally the result of a violent suppurative process, and due to caries of the bonal canal through which the facial passes and involvement of the nerve. In such cases the paralysis is likely to be permanent.

At the last meeting of the American Otological Society Dr. Holt, of Portland, Maine, reported a case of acute catarrhal otitis accompanied with facial paralysis and paresis of accommodation. Quite recently I have seen a similar case, except that the accommodation was not affected. The patient was a married lady of about forty years of age. After several days of intense earache in both ears, and deafness so great that the voice could be heard only when spoken in very loud tones near to the ear, she observed that she could not close her right eye and that fluids would trickle out of the right side of her mouth on attempts at drinking. The facial paralysis, though not complete, was well marked. There was at no

time any purulent discharge from the ears, though in each drum membrane there was a small opening, giving exit to a little mucous fluid.

After an obstinate course of three weeks the ear trouble was perfectly relieved and the hearing entirely restored. The facial paralysis is much better, and is still improving, though not yet well.

Better Hearing in a Noise. That certain deaf persons hear much better in the presence of a loud noise was observed long ago. The textbooks usually devote considerable attention to a consideration of this symptom and to the theories of its causation. It is not very rare, and it is important to note that when it is present the prognosis as to results of treatment is usually bad. There are exceptions to this rule, but it is sufficiently in variable to make it of decided value in prognosis.

Cerebral Complications of Ear Disease. Another brilliant achievement in cerebral surgery has lately been announced. An abscess of the cerebellum, the result of a suppurative inflammation of the middle ear, was successfully operated on by Macewen, of Glasgow. The patient, a young man seventeen years old, was brought to the hospital in a state of coma; pulse weak and slow, respirations about 10 per second, and marked optic neuritis. Ear disease was detected, and a sinus found behind the auricle. An incision over the cerebellum opened an abscess and gave vent to about four ounces of pus. The patient made an uninterrupted recovery.

Von Bergmann, in his work entitled "The Surgical Treatment of Brain Diseases," asserts that probably one half of all abscesses of the brain are caused by suppurative inflammation of the middle ear, that such inflammation is always chronic, and often the result of a purulent otitis media, beginning in youth. When we remember that abscess of the brain is only one of the many disasters that chronic suppuration of the tympanum may produce, the aurist need surely make no apology for asking of the general profession such attention to inflammations of the ear as will prevent this chronic suppuration, or, should it already exist, the use of all possible means to cure it.

Removal of Ossicles in Chronic Otorrhea. A few years ago Sexton, of New York, proposed to remove the ossicles of the middle ear in cases of chronic suppuration which resisted all other measures. He announced a number of cases showing good results from this procedure. The plan has been adopted successfully by a few other aurists, and several cases have lately been reported where there was good hearing power in the absence of the stapes, as well as the malleus and incus. I have not yet seen a case in which the removal of the bones of the middle ear seemed to me to be indicated.

Perforation in Drum Membrane and Artificial Membrana Tympani. Not only among the laity, but even among otherwise well-informed physicians, there is a prevalent belief that an opening in the drum membrane of the ear causes great deafness. As is well known to aurists, a considerable perforation may exist with excellent hearing. Recent perforations, moreover, are usually quickly repaired, and the discharge attending them cured. To this there is one striking exception: perforations through the membrana flaccida into the attic of the tympanum are exceedingly obstinate, and are very often attended by caries of the walls of the tympanum or canal. Blake's tympanum syr

inge is a useful instrument in such cases; but my own experience has been that patients with this form of inflammation discontinue the treatment before the opening is healed or the discharge arrested.

It is an interesting fact that to a New York merchant we are indebted for the idea of an

artificial drum membrane. In 1841, a gentleman from New York consulted Dr. Yearsley, of London, in regard to his ears. He incidentally mentioned and demonstrated that so long as he kept a piece of moistened paper in his ear in a certain position his hearing was quite good. From this originated the application of the artificial drum membrane. It is a device occasionally of great use, both in improving the hearing and aiding the repair of perforations. It is, however, so often applied to cases in which it can not possibly be useful, and may perhaps be injurious, that on the whole it may be questioned whether it has not caused more disappointment and harm than benefit.

When it does good, it is probably by giving support to and holding in position the ossicles of the middle ear. Much disappointment might be saved, and irritation of the ears avoided, if deaf persons would consult their physicians before investing in an artificial drum membrane.

The Causes of Total Deafness. My attention. has been called to this subject by having seen in the last few weeks three cases of almost absolute deafness.

The first was a little girl seven or eight years old, seen May 1st. She was absolutely deaf, and had been so for a year. Her mother said the deafness followed brain fever; and it seems probable that there had been a meningitis, followed by inflammation and consecutive atrophy of the auditory nerve. Sight was good, and except for the loss of hearing the recovery had been complete.

The second case, also a little girl, lost her hearing from scarlet fever. A deep sinus opened at a point back of the center of the auricle, and the contents of the tympanum were destroyed. There had probably been also an invasion of the labyrinth. This child, too, had been deaf for a year or more.

The third case was a young lady of about seventeen years of age. Her uncle told me that she had been almost absolutely deaf for three years; that her ear disease had reached its climax within two months of its beginning, and had been stationary ever since. Such a history at such a period of life was at once suggestive of inherited syphilis, and the diagnosis was not far to seek. Corneæ still marked by diffuse interstitial keratitis; upper incisor teeth of the typical Hutchinson variety; a doughy skin, with peculiar scars about the angles of the mouth and forehead, together with a deep and ragged ulcer of the side of the pharynx, and almost absolute deafness, presented a picture of inherited syphilis in a form fortunately not often seen. The ulcer of the throat healed very rapidly under iodide of potash and mercury and tonics. The hearing is, of course, lost forever. The tuning-fork test gave a negative result. Such a case is all the more melancholy because there is reason to believe that its true nature was not recognized in the incip

iency of the deafness, and thus the patient was deprived of whatever benefit might have been obtained by prompt and energetic treatment.

LOUISVILLE.

WOUND DRAINAGE.*

BY AP MORGAN VANCE, M. D.

As late as ten years ago it was thought that the most important element in wound management was to secure good and sufficient drainage. This axiom has been less dwelt upon as our knowledge of asepsis has increased,

and the ideal treatment of wounds should be without drainage, but until the aseptic details are better understood we will be compelled to use this safeguard in a certain proportion of cases. The perfecting of the means by which drainage will be best accomplished has been the subject of considerable thought by modern 'surgeons. As the result, we have the soft and hard rubber, decalcified bone, and the glass drainage-tubes; on the other hand, as capillary

drains, we have the gauze, the catgut, the horse-hair and silk, all good in their proper places and when properly prepared, but each falling short of an ideal drain. An ideal drainage tube should be non-irritating, aseptic, and absorbable, the time required for its absorption being regulated by its preparation, and no residue should be left behind. This has never been accomplished. It was thought that the decalcified bone filled the conditions, but experience has proven otherwise. This form of tube is unreliable, though acting almost perfectly at times. This is the only example of an absorbable tube yet suggested.

The great advantage of the absorbable drain is that the case may go through with one dressing, a great advantage in many ways. Now it is to suggest a possible method of attaining this object, at the same time using unabsorbable material, that I write this paper.

The fact that it is better to remove the drain sooner than it is at all necessary, or best to

change the first dressing, is a well-known fact, and has suggested to me two methods of getting rid of the tube without interfering with

*Read at the May meeting of the Kentucky State Medical Society, 1890.

the dressing. The first I may call the self-removing tube. It is arranged after the following plan :

Take ordinary rubber drainage tubing of proper size for the wound that you wish to drain (amputation for example), cut and perforate two pieces which are each in length one third the extent of the wound, then tie them together with a very fine catgut suture so that the two extremities that are free will correspond to the angle of the wound. To these fasten small rubber bands, to the other end of which a

piece of rubber adhesive plaster is attached. This plaster is to be fixed to the limb at a sufficient distance from the wound to put the rubber bands on the stretch, so that when the catgut yields on account of weakening by absorption the short tubes will be teased or drawn into the dressing. To be sure that the close fit of the dressing will not prevent this, a gutter-like shield of hard rubber may be placed in such a way as to form a little cell for the re

ception of the tube. The size of the catgut

suture will regulate the time at which the wound will be freed from the tube. The gauze, horse-hair, or silk could be used in like manner when the hard rubber shield is not necessary. The second method is to dispense with the catgut connection between the two short tubes or capillary drains, and simply fasten to the outer ends a stout ligature, or, better, a piece of gauze long enough to extend beyond the borders of the dressing; and when you desire to get rid of the drain, make steady traction, when it will easily slip into the soft dressing. I know that we all have found the tube, as ordinarily used, out of the wound from shifting the dressing, which proves the ease with which it slips out; the seepage keeps the parts moist and aids the removal. The short tubes used in the ordinary way are to be preferred to the old way of having one tube extend through the wound. In this way you have two open ends in the wound besides the opening on the sides, which nearly always become stopped with coagule or tissue. By using two short tubes you also get rid of the necessity of drawing the long tube through the wound with the chance of infection from material which has been exposed.

These suggestions apply only to ordinary

wounds. To meet the special requirements for drainage about the chest, abdomen, etc., dif ferent methods must be followed.

LOUISVILLE.

A REPORT ON PATHOLOGICAL HISTOLOGY AND URINALYSIS.*

BY SIMON FLEXNER, PH. G., M. D. Demonstrator of Microscopical Technology, Medical Department University of Louisville.

In presenting this report I desire to state that it is not my intention to record the progress which has been made in the last year in the branches of research with which it is concerned. Its scope is much narrower than this, comprising as it does only a partial record of such pathological work as has come under my own observation.

In this connection I first of all call your attention to the importance of the clinical examination of the blood. The blood is in two ways a factor in disease, according as it is itself the seat of the lesion, or as it reflects abnormal conditions existing elsewhere in the economy, or both. Hence arises the necessity for careful examination of the blood in the first place. Moreover, as it is a fluctuating factor, subject to alteration in quantity and quality from time to time, repeated examinations are demanded as the disease progresses.

Doubtless frequent examinations of the blood will lead to clearer views of the pathology of certain lesions, now still obscure; provide us with more reliable means of diagnosis, and, by exhibiting with accuracy the progress of disease and the effect of treatment, guide us to a more rational therapeutics.

I report two cases only, to emphasize what has been said as to the value of such examinations. The first case reported has great interest aside from its use in this connection, and I hope will be reported fully at an early date. It is the record of a case of progressive perni

cious anemia:

Mr. L., age thirty-five, a patient of Dr. J. A. Ouchterlony, resided in the interior of the State. Eight months ago while West he began to fail in health. When I first saw him, which was early in December, 1889, he was appa

*Read at the May meeting of the Kentucky State Medical Society.

rently bloodless; conjunctivæ, lips, and nails colorless; complexion waxy; he could not have his head raised from the pillow without fainting. The examination of his blood at this time gave the following results: Hemaglobin, 15 per cent; red corpuscles, 750,000 to cubic millimeter.

The next examination was made on December 30, 1889, with the following result: Hemaglobin, 25 per cent; red corpuscles, 1,325,000. At this time color was beginning to show under his nails. He was still very weak.

His urine was examined on December 6, 1889. It was as follows: Color, yellow; reaction, highly acid; specific gravity, 1.014; urea, 2.5 per cent; indican, marked reaction; albumen, .5 of 1 per cent; casts, none.

A few weeks after this examination of his blood he returned home feeling much better.

April 20, 1890, he returned to Louisville, as he had suffered a relapse. His condition on the 26th, when his blood was examined, is represented by the following: Hemaglobin, 10 per cent; red corpuscles, 425,000. April 27, 1890, his urine was again examined: Color, pale yellow; reaction, acid; specific gravity, 1.014; urea, 1.5 per cent; albumen, of 1 per cent; casts, hyaline and finely granular.

April 30, 1890, his blood was again examined. It was: hemaglobin, 10 per cent; red corpuscles, 400,000. May 3d, it was: hemaglobin, 10 per cent; red corpuscles, 600,000. That day he was feeling much more comfortable. On May 6th he died suddenly of heart failure.

The next case is one of simple anemia. It is unnecessary to go further into the details of the condition of the patient prior to the date of the first examination, than to say that she had been a well-nourished, vigorous person, who had withstood large demands on her physical and emotional powers in the performance of the duties of a trained nurse, and that her

failing health followed attendance on a pro

tracted and unusual trying case of illness.

Miss X, a patient of Dr. D. W. Yandell, was examined on the 15th of December, 1889. At this time she was very pale, lips and conjunctivæ pale. Her face looked full, but her body is thin; had lost weight quite rapidly; her blood was as follows: Hemaglobin, 45 per

cent; red corpuscles, 1,325,000. While, at this time, she was not necessarily confined to her bed, yet the least undue exertion was followed by dizziness and fainting. January 20, 1890, she was again examined: hemaglobin, 70 per cent; red corpuscles, 4,000,000. She had gained strength, and thinks weight also; has better color. At the time of the first examination she could not walk more than a few minutes at a time. Now, January 20th, she is attending to quite arduous professional duties.

The last examination was made on May 10, 1890. She is attending to her professional duties, but is still much more easily exhausted than formerly. She had gained considerably in weight, and her color is better. She had been much better until some weeks ago, when she had an attack of la grippe, from which she has not quite recovered. This examination showed: hemaglobin, 75 per cent; red corpuscles, 3,900,000.

Of the cases reported I think it can be safely said that repeated examinations of the blood threw much light on their course and tendency, and in a large measure directed their treatment. There is an impression that this purpose is equally well served by examining at thin layer of the blood under a microscope. This is certainly not to be relied upon, for it. is manifestly impossible to obtain a layer of uniform thinness, and, furthermore, it is the picture presented to the eye, not the number of the corpuscles, that determines the result where this method of examination is employed. And even if this method gave results approaching the truth, which clearly it can not, it would leave the hemaglobin unestimated. In the examinations here detailed the hemometer of Fleischl and the hemacytometer of Thoma-Zeiss were employed. These instruments are placed before you, and your inspection of them is invited.

Before closing this part of my paper it may be well to remark that it is possible to estimate the white cells and their relation in number to the red. Finally, the relations of all the elements of this tissue can be determined as related to one another, and in their absolute amounts.

I turn now to the consideration of another branch of clinical microscopy, the bacteriologi

cal examination of secretions and excretions. That such examinations are capable of aiding the diagnostician in many ways, and that they often furnish him infallible evidence of the presence or absence of certain diseases can not now be questioned. Such, for example, are the examinations of sputa for the bacillus tuberculosis; for the coccus of pneumonia; of pus for the gonococcus in supposed gonorrhea; of the evacuations for the bacillus tuberculosis; the urine for the bacillus tuberculosis, and the splenic blood for the bacillus of typhoid fever. I may also mention that by means of microscopical examination the presence of Laveran's organism (protozoa) in the blood of patients suffering from malaria has been abundantly confirmed and their causal relation to the disease all but established.

These examinations can be made immediately; that is, directly from the materials containing the organism, without any of the delay which would be caused were cultivations of the organisms necessary. Again, an unexpected advantage may be realized by such examinations, as, when in searching for one organism another is found, probably the source of the disease. Such a case is illustrated by the following: Some sputa was sent to be examamined for the bacillus tuberculosis. After a careful search none were found, but instead, cocci of pneumonia were observed. The physician in attendance, when informed of this, told me that the patient had had pneumonia some weeks before, and, as he had not convalesced, he suspected tuberculosis. From this result it is probable that the pneumonia was still present. Some weeks later another examination of his sputa was made, and this time bacilli of tuberculosis were found. This was evidently a case in which pneumonia predisposed to tuberculosis. Again, the pus organisms have, by their presence in unusual numbers in sputa, or as one or the other predominated, been used to differentiate suspected tuberculosis from abscess or gangrene of the lungs. This operation is not always possible; it is indeed attended by grave difficulties such as require considerable skill and experience in investigation. Yet I wish to emphasize strongly the fact that a safe inference may frequently be drawn from such examinations.