conjunctival test (Calmette) in all diseased eyes, even though the process is healed, and in the healthy eye, when there is active disease of the cornea in the

other. The older subcutaneous injection also is likely to light up a fresh reaction in an eye previously tested, and may keep the eye inflamed over a long period of time. The cutaneous test is of great value, because it seems to be specific of tuberculosis. It is in our author's experience more sensitive than the conjunctival test, which it will displace in all probability.

Radical Mastoid Operation for Cure of Chronic Suppurative Otitis Media.

Wendell C. Phillips, New York. (Medical Record, October

10, 1908). After briefly mentioning the causes, pathology, symptoms, diagnosis and prognosis, the author takes up the subject of treatment of chronic suppurative otitis media and classifies the treatment under three general heads, depending upon the extent and location of the disease: (1) Local measures; (2) Intratympanic operation; (3) The so-called radical operation, the present status of which he makes the subject of his paper. Under local treatment he claims its applicability to cases of the simple variety, or, in other words, cases wherein the necrosis is localized, and in those in which the disease is aggravated by adenoids, or hypertrophied tonsils, or poor hygienic surroundings, or impoverished condition of the patient. Here the removal of the adenoids or tonsils or attention to the proper care of the patient's nutrition and general condition will no

doubt occasion a cure without radical measures. Local treatment consists of cleansing the canal and tympanum of its pus and providing free drainage for the pus that is formed. Removal of any obstruction in the canal or tympanum is necessary, and then the douching of the ear. The author makes claim that 50 per cent. of cases thus treated will be cured of the chronic suppuration without recourse to operation. Under the second head of treatment is mentioned the intratympanic operation, also called ossiculectomy. While this operation requires much skill and an accurate knowledge of the anatomy of the ear, it is much less. formidable than the radical mastoid operation. It is also simpler in technique, and occasions no posterior incision. It is necessarily limited in scope to the membrana tympani, soft tissues of the tympanic cavity proper, the ossicles. the tympanic ring and walls. It is worthy of a trial in almost all cases of chronic otorrhoea where there is not too

much apparent necrosis, as its results are often surprisingly good. The purpose of the radical mastoid operation, briefly stated, is to convert the external auditory canal, tympanic cavity, attic, aditus ad antrum, mastoid antrum and mastoid cells into one cavity, removing all granulations, diseased bone and detritus.

The technique of the operation is described in his paper. The dangers of the operation are injury to the facial nerve, involvement of the labyrinth from operative disturbance, intracranial conditions stirred into activity as a result of instrumentation during the operation; in fact, complications that are liable to occur as a result of unskilled operating. According to figures of the author not more than 65 per cent. of the cases operated upon are cured by the operation, but a great benefit accrues, even in cases in which the discharge continues, and that is wide-open drainage, which favors final healing, lessens the tendency to extension of the disease, and also lessens the dangers of serious complications. Dr. Phillips wishes to be classed among those who believe that the operation is justified and necessary in a limited proportion of cases of chronic purulent otitis media. The indications for the radical operation are as follows: (1) When a permanent cessation of the purulent process has not been effected by prolonged local intratympanic treatment combined, if necessary, with such minor operation as removal of granulations, enlarging perforation, etc. (2)

When the cure has not been effected by the removal of necrosed ossicles and curettage of the middle ear. (3) When symptoms of acute mastoiditis are present. (4) When a sudden cessation of pus discharge produces vertigo, pain or other unusual symptoms. (5) The appearance of facial paralysis during the course of chronic purulent otitis media. (6) Attacks of vertigo, indicating that the necrotic process involves the labyrinth. (7) In all cases where intracranial or lateral sinus involvement has already appeared. (8) Where there are positive symptoms of cholesteatoma in the mastoid antrum. (9) Where there are fistulous openings in the cortex of the mastoid process or in the osseous canal wall. (10) Whenever extreme depression or other symptoms of disturbed mentality accompany the disease. The operation is contraindicated: (1) When the purulent process is tuberculosis and accompanied by general advanced tuberculosis. (2) In advanced pernicious anæmia or albuminuria and in cachectic diabetes. (3) It is usually contraindicated in young children. (4) In all cases where the disease is confined to the ossicles and the tympanic cavity. (5) In adults who have scanty otorrhoea without odor, with improper opening in the drum membrane, behind which are retained masses of secretion. (6) In all cases where it is possible to effect a cure by any of the other methods described.

Laryngeal Affections A. Iwanoff (Zeitin Syringobulbia. schrift fuer Laryn., Vol. 1).

The author terms certain laryngeal symptoms always seen in cases of syringobulbia as pathognomonic. Of 28 cases in

which there were laryngeal symptoms, seven showed typical recurrent paralysis, either upon the right or the left side. The remainder of the cases, namely, 21, showed quite a different condition, the paralysis being incomplete on one or both sides of the pharynx, and of such a kind as to show a departure from Semon's rule, that the musc. posticus is the first to

be involved. In these cases, some other muscle, at least in the majority of cases, at least one other was found involved. This was usually found to be the thyro-arytenoideus internus or the arytenoideus transversus, the crico-arytenoideus posticus remaining intact. The author finds this a typical onset in its manner of involving the muscles that is characteristic of the dis

nasal origin are distinguished by the author: (1) Headache, with permeable choanæ, almost continuous, appearing in the morning as soon as the patient wakes up, subsiding at meal-time and returning with greater severity in the course of digestion. The bromides are useless in these cases, whereas the patients are often relieved by menthol valerianate. (2) Headache in the presence of acute rhinitis. The pain is located at the root of sociated with nasal obstruction. Quinine the nose and in the forehead, and is ashydrobromate is recommended as beneficial. (3) Headache in the presence of nasal stenosis. The pain is unilateral, and occurs especially in the morning hours. It subsides after painting the mucous membrane with cocain-adrenalin. A useful sedative in these cases is citrated caffeine (60 centigrammes four times daily, alone or combined with suitable agents). (4) Headache in the presence of acute sinusitis. The pain is continuous, and localized in the affected side. of calomel (10 centigrammes in the mornIt may be relieved by the administration ing on six successive days). In the presence of maxillary disturbances aconite. should be prescribed (1⁄2-2 mg).

Chronic sinusitis, syphilis and tuberculosis of the nose likewise give rise to characteristic forms of reflex headache. F. R.

year, but 13 less than 1906. Of this number there were 55 deaths, besides which there were 108 deaths from other causes; or, altogether, 163 persons lost their lives as the result of our present unspeakable Independence Day. Blank cartridges caused 76 per cent, of all cases of tetanus,

while the majority of deaths other than from tetanus were caused by gunshot wounds and giant crackers. Twenty-two persons were burned to death by fire resulting from fireworks. Besides the fatal injuries, there were 5460 non-fatal accidents, the largest number yet recorded; II people were blinded and 93 lost one eye each; 57 persons lost a leg, an arm or a hand, while 184 had one or more fingers blown off. The cause of the most mutilating wounds was the giant cracker, which this year caused 1793 accidents, including 23 deaths and five cases of tetanus; 194 persons were injured by stray bullets from the reckless discharge of firearms by others. Chicago and Cleveland each had 12 persons killed during this year's celebration, while New York had II. The largest number of injuries in any city was 426, in Philadelphia. New York had 316, St. Louis had 229 and Chicago had 202 non-fatal injuries. Although the number of tetanus cases resulting remains about the same as the last year or two, the number of tetanus cases from other causes is on the increase, there being 166 such cases reported this

year as compared with 94 last year, and 60 in 1906. This emphasizes the fact that in the treatment of all penetrating wounds, the possibility of tetanus should be borne in mind, and prophylactic measures employed. Reports show that ordinances are being adopted by more city councils each year restricting the use of fireworks. Many cities prohibit the toy pistol, many limit the size of the giant. cracker, and many limit the use of fireworks to one or two days. Toledo and Baltimore have rigidly enforced prohibitory ordinances, with the result that very few accidents are reported from those cities. St. Paul, Detroit and other cities tried to change the form of celebration by substituting children's meetings, picnics, etc., in place of the use of fireworks. The plan is suggested not only to have parades, picnics, children's outings and the exhibition of flags and bunting, but also to prosecute those who continue to recklessly discharge firearms and giant. crackers, or who persist in other deathdealing methods of celebration. This is a plea for a more sane and, therefore, more patriotic celebration.

Radiographic Diagno- Lewis Gregory Cole, sis of Renal Lesions. M.D., (New York Medical Journal, April 25, 1908).

The author of this interesting and instructive paper has successfully attempted the difficult task of writing both a technical and practical article, combining the two in such manner as to be understood and appreciated by the general practitioner. He first calls attention to the fact that in the early years of radiography many serious errors were made in diagnosing renal calculi, and as a natural consequence the method fell into disrepute,

and it has been with considerable difficulty that it has become reinstated in its proper place. He believes that it is now possible, in the vast majority of cases, to obtain enough detail in the plate to warrant a negative or positive diagnosis, as the case might be.

The author considers that the proper seasoning of the tube to be one of the most important points in the Roentgenological technique. Several years ago he noticed that while some tubes would produce a plate containing a great wealth of detail, others, especially new ones, would

fail to give the required definition. As a result of considerable experimenting, he has been able to separate the X-ray into three distinct varieties: First, the direct ray; second, the indirect ray, and third, the secondary or Sagnac ray. The purely direct ray, when it can be obtained, gives, on a well-timed and properly-developed plate, the greatest amount of detail, not only the structure of the bones, but the muscles, fasciæ, fat, and even the blood in the veins show distinctly. The indirect rays from the average tube are equally as powerful and abundant as the direct rays, and their effect is simply to fog the plate and obscure the detail of the direct rays.

It has been demonstrated by Prof. J. J. Thomson that the secondary or Sagnac rays are generated in and emanate from all substances under the action of the X-rays, in inverse proportion to the density of the substance, and the writer is convinced, from his own experiments, that they are produced to a greater extent by the indirect than by the direct rays. It is, therefore, advisable to obtain tubes and apparatus that will produce a maximum of direct rays, and when a tube fails to do this it should be used in connection with a diaphragm in order that most of the indirect rays may be prevented from reaching the plate.

In making renal or ureteral plates the author's technique is as follows: The patient should be prepared for the radiograph by thorough cartharsis the night previous, and an enema just before the exposure is made. The bladder and stomach should also be empty. The clothing should be removed so as to overcome the possibility of error from the presence of buttons, pins, etc. The subject is then placed with his back flat upon the radiographic table, with flexed thighs and raised head and shoulders, so that the lumbar region is brought in contact with

the plate. If one desires to employ one large plate (11x14) to include both kidneys, both ureters and bladder, the tube is placed vertically over the umbilicus at a distance of from 20 to 22 inches from the plate. The tube should be tested before adjusting the plate, which should be arranged so as to include the 11 and 12 dorsal vertebræ, and should extend about one inch below the tip of the cocyx. To assure good definition and the absence of blurring the exposure, which varies between from 10 to 30 seconds, should be made during suspended respiration. With the use of a compression blend (and diaphragm) one may obtain more detail, and the compression of the parts holds the patient quiet and prevents, to a large degree, abdominal breathing. But at the same time the blend limits the field of exposure, so that it is often necessary to make five plates in order to cover the entire genito-urinary tract. The necessity of making a full set of plates cannot be too strongly urged, for, in about onefourth of the cases the calculus is found to be on the side opposite from the pain.

The interpretation of the plates is more important and more difficult than making them, and lack of care and experience in this is the cause of most of the errors that have been made in the X-ray diagnosis of ureteral calculi. One is not justified in making a negative diagnosis of renal or ureteral calculi unless the plate possesses the following detail: (1) The spine and transverse processes of the vertebræ should show distinctly all the way their tips. (2). The outer border of the psoas must show. In some flabby or stout individuals this may not appear as strongly as the shadow of the kidneys. (3) The eleventh and twelfth ribs should be distinctly seen. (4) In about 75 per cent. of the cases the kidneys may be seen more or less distinctly, and if especial care in