In reference to the first point, I would remark that the human body furnishes us with undoubted instances of hypertrophies, proving themselves to be not only necessary, but precisely compensatory, relative to what is required. If, as I have urged, the chief function of the prostate consists in providing a retentive as well as a supporting appar atus for the contents of the bladder, there is no reason, when the time comes for substituting quantity for quality, why the provision should not prove to be permanently compensatory. The conditions under which muscular hypertrophy exists, as observed about the neck of the male bladder, seemed to indicate that, should circumstances arise to render the necessity for such increase inoperative, the structural excess then undergoes degenerative changes, and assumes properties in accordance with that type of tissue with which it has thus become assimilated. And it appears to me that in the study of hypertrophies there yet remains some interesting work to be done in connection with those transitional changes which depend upon the suspension of, or alteration in, the conditions which in the first instance rendered the overgrowth a necessity.

We have seen that the large prostate is able to perform its function just as perfectly as the smaller one of earlier life. Taking, however, those instances where such is not the case, and where the large prostate proves to be a serious detriment to the individual, it seems to me that in the greater portion the development of symptoms are about coincident with that physical change in the shape of the bladder which we know by the name of "pouching," where a depression is formed above the prostate in which urine may lodge. It has been generally taught that this pouching of the bladder is a direct consequence of enlargement of the prostate, the supposition being that as the latter grows towards the bladder cavity, where there is the least resistance, a depression is left above the growth. Now though this may in some degree be true, it does not represent what commonly occurs. My observations lead me to believe that this pouching, or space for residual urine, is caused by the sinking of the bladder wall itself away from the prostate as the result of urine pressure on the part, and not in the first instance by the encroachment of the prostate upon the interior of the viscus. It is quite easy to demonstrate this upon the dead subject. When this occurs with a large prostate which hitherto has been performing its functions in a natural manner, the immediate effect is to cause a prominence which previously had no existFollowing upon this, we have the conversion of the prominent prostate mass into a fibroma, with the gradual acquisition of those properties which such a structure possesses. In the bladder we see this taking the form of fibrous masses, which cause obstruction and excite mucous exuda

ence.

tion and cystitis. To attribute the latter symptoms to the mere presence of a few ounces of urine in the bladder, which cannot be spontaneously voided, is certainly not warrantable. Passing to points in practice, it is evident that if a person has a large prostate, however well it may be working, it behoves him to be careful that the bladder is not submitted to such a kind of usage as either may gradually or suddenly alter its relations to the outlet. All those circumstances which by their degree or continuance throw an undue strain upon the bladder at a time of life when the tissues begin to lose somewhat their power of resistance, should be studied with the view of avoiding them. In the next place, when these strains do come by the wear and tear and accidents of living, we should be prompt in recognizing them and giving the necessary assistance, either mechanically or by medicines, as the case may be, to prevent permanent damage being done.

I would say a few words, in conclusion, as to the treatment of prostatic hypertrophy when the part has to a large extent assumed the structure and properties of a fibroma. The degree of vesical

irritation and obstruction under these circumstancs is sometimes very intense, and various means have been proposed to deal with this condition by operative procedures, having for their object either the section of the obstructing part with provision for the more perfect drainage of the bladder by artificial means, or the removal of more or less of the prostatic mass. In both of these directions considerable relief has been afforded. Having regard to the fibroid condition the part assumes, I have thought, if there is any truth in Apostoli's treatment, that it is possible it might under these circumstances prove serviceable. I have now this subject under consideration, but at present I have not sufficient material for our purpose of to-day. I am aware that electrolysis has been practised both in this country and in America, but I cannot say that as yet we have sufficient evidence to warrant its more general adoption. I would lay stress on the examination of the prostate from the rectum as determining our views in reference to the patient's future when retention of urine is due to this cause. When this happens in a person with a hard nodulated prostate, where there is evidence to the touch that fibrous tissue predominates largely over the muscular, the power of the bladder seldom returns, and the use of the catheter is generally perpetual; and when, on the other hand, the prostate is found soft and yielding to the touch, indicating that muscle still prevails, we may as a rule anticipate complete restoration of function. I attach importance to the distinction, as in most cases of acute retention due to prostatic enlargement it enables us to form reliable opinions relative to the probable duration of catheterism.Reginald Harrison, F. R. C. S., in Lancet.

AN IMPROVED TONSILOTOME.

Any physician who has had a considerable experience in tonsilotomy, with the various tonsilotomes, will not be likely to deny that these instruments are generally too complicated. They are armed with needles, barbs, or sharp-toothed forceps for piercing the tonsil and dragging it through the fenestra before any cutting is done by the blades. A tonsilotome constructed after the pattern I have made renders the barbs, etc., unnecessary. It reduces the painfulness of the operation by one-half; it divests the procedure of any danger of an accident to the operator or patient; it makes a skilful and easy operation possible with a minimum amount of experience; it resembles a large folding tongue depressor so closely that children usually offer no opposition to its introduction for the removal of the first tonsil: and it combines strength and compactness with simplicity of construction. It is made on the principle of the guillotine, the blade of which is propelled by the thumb of the same hand which grasps the handle. The latter is set at such an angle to the shaft as will permit the most perfect coördinate action of the muscles of the hand and arm of the operator. All the work may be done with one hand. This advantage is not a small one for two reasons: The powers of coordination and antagonism of muscles are far more perfectly under control in operating an instrument that requires but one hand, than they are when both hands must coöperate; and one hand of the operator is left fee to hold the head of the patient, if necessary, as the dentist does in extracting a tooth. The advantages of a tonsilotome that can be operated entirely by one hand are about the same as in a tooth forceps which does not require two hands to manipulate.

I have had two sizes manufactured, the smaller having a fenestra of the calibre ordinarily found in such instruments, the larger supplied with an aperture larger than the largest Mackenzie tonsilo. tome, while it is so compactly constructed as to require less space in which to operate. I have used the larger size to extirpate enormously hypertrophied tonsils in children as young as two and one-half years, where it was impossible to insert the Mackenzie instrument of the necessary size. The smaller one is sufficient for the majority of cases, but the fenestra is not capacious enough to admit the bases of the extraordinary glands we occasionally see. It is advisable to remove the whole tonsil, and as the tops only of the largest tonsils can be severed with the smaller instruments, it may be better to have the larger size if but one size is to be kept.

The blade is so protected as to make it impossible to wound the ascending pharyngeal, or the internal carotid artery. The shaft that propels the blade is of such width as to make the use of a

gag unnecessary, for it protects the finger of the operator from the patient's teeth, if it is placed in the mouth to ascertain when the fenestra is in such position as to embrace the whole tonsil, as it is necessary for one to do when operating in children Since I have used the with other tonsilotomes. guillotine I have not had my finger bitten, while it was not an uncommon occurrence before to come off second best, as far as pain was concerned. With the shank wide enough to afford protection it is unnecessary to introduce the finger into the mouth, for the teeth and lips cannot close enough to prevent the operator from seeing plainly the field of operation. There is no working in the dark, or fear of damaging structures you do not

wish to attack.

TRUAX & Co.

The handle is firmly fixed to the shank with a hinge-joint and self-acting spring-lock, so that the fenestra can be pressed down around the base of the gland with any degree of power desired. This feature dispenses with any necessity for hooks, forceps, needles, or barbs for spearing the tonsil. The latter being a soft, fleshy mass, adapts itself to the shape of the fenestra and protrudes through it the instant its base is pressed about. The pain of spearing or tearing the tonsil by toothed or barbed accessories, designed to drag the gland through the fenestra before the blade cuts, excites the most vigorous struggling and resistance on the part of a child. Even when the utmost care has

been exercised, the barbs have pierced the soft palate, or the surgeon's finger, instead of the tonsil. Moreover, the gland always comes out with the instrument, the same as though barbs were used. There is another important advantage in having the handle attached to the shank with a hinge provided with an automatic lock, for the cutting extremity of the instrument cannot be thrown out of your control by a disturbance of the coaptation of its parts. The last time I operated with a Mackenzie tonsilotome the child jumped just as I was placing the fenestra about the tonsil. The shank revolved upon the handle, leaving the latter in my hand, while the cutting end was entirely displaced and removed from the vicinity of the gland. It is impossible for this improved tonsilotome to play you such a trick. The handle is made of rubber, knurled so as to afford a firm grip, and it contains a concealed spring-lock operated by a convenient thumb-plate. When this is moved downward the hinge-joint is unlocked, and the instrument folds upon itself like a pocket-knife, occupying the space of about an inch and a quarter in width and thickness by six and one-half inches in length.

Another pertinent point that should not be neglected in this age of antisepsis, is the provision for cleansing and disinfecting the three pieces of which the instrument consists. By raising the proximate end of the horizontal top-spring of the shaft and swinging it 90° to either side, it becomes disengaged from its lock and it liberates the blade from the shank. This arrangement makes it as simple as possible for taking apart, cleansing and putting together again.

In amputating the apex of a relaxed and elongated uvula the tonsilotome should be used with the handle directed upwards. It should occupy just the reverse position as a uvulatome to the one it occupies when used as a tongue depressor.

Another merit that is not too small to mention is that its simplicity of construction renders it inexpensive. Dr. Seth H. Bishop in Jour. Am. Med. Association.

eotomies performed at the Boston City Hospital was twenty-nine per cent. In about 100 cases of intubation performed at the same institution the rate of recovery was twenty-six per cent., showing a slightly smaller percentage than the old operation. It is not claimed that these figures and facts are conclusive. The number of intubations is, as yet, too small to settle the question. The recovery of patients under three years of age was in the same proportion after each operation, namely, twelve per cent. O'Dwyer, Brown, and Waxham save about one in four after intubation; Huber and Montgomery save one in two; Northrup and Denhard save one in five; Jenning, one in ten ; Chatham, one in fifteen; and A. B. Strong, one in thirty-one. This variation of results in the experience of different operators, proves conclusively that the type of the disease determines the result to a great extent-far more, in fact, than any mode of treatment. The conclusion on this point is that the new operation saves nearly, or quite as many patients as did the old.

In regard to the facility of doing intubation, it may, like tracheotomy, be easy or difficult, according to the age of the child, the condition of the larnyx, and the strength of the patient. Both operations are difficult in children under three or four years of age, and both are attended with some danger. In tracheotomy the risk lies principally in hemorrhage and collapse. In intubation, it lies in pushing membrane, etc., down in front of the tube, producing more or less complete obstruction. In very weak children, collapse may result from prolonged efforts at placing the laryngeal tubes. Under these circumstances the surgeon should choose the operation with which he is most familiar. The old operation can be done with one good assistant. Intubation requires at least two fairly good ones. Unless great care be taken, the operator's finger may be severely bitten, which, in at least one case, has resulted in death.

HEOTOMY AND INTUBATION IN THE TREATMENT OF CROUP.

Dr. O'Dwyer's method of intubing the larynx, he said, has now been before the profession in a prominent manner about three years, and it is surely gaining favor, as its merits and its limitations are being more clearly understood. The operation has its advantages and its disadvantages. It gives relief to the dyspnoea and it saves lives. The statistics of recovery vary much, as in tracheotomy. Twenty-six per cent. is a fair average after intubation. The recovery rate in 327 trach

a physician who can place O'Dwyer's tube, then the old operation is better, there being less danger of fatal obstruction, and the question of feeding giving less anxiety. The weight of testimony goes to prove that it is less work to take care of intubated than of tracheotomized patients. The time occupied in caring for the tube in the latter class is largely taken up in feeding the former class of patients.

Northrup's statistics of 107 autopsies, performed at the New York Foundling Hospital, go to prove that there is no such thing as "food pneumonia," as in no instance were signs of food found in the

smaller bronchi. Dr. O'Dwyer advances the opinion that the secondary lung affections, especially pneumonia, are due to retained secretions, which, owing to the presence of the tube in either operation, cannot be ejected by coughing. Others hold that this complication is due to the fact that the air enters the lungs without first being warmed and moistened by passing through the nasal chambers. The author ascribes these affections to the natural tendency of exudative processes to extend in all directions, basing the opinion upon the fact that pulmonary complications are as frequent in cases not receiving surgical treatment, run the same course, and are as fatal as in those in which operation is resorted to.

While a wound in the skin is objectionable on general principles, yet the wound of tracheotomy gives little trouble and does little harm. The diphtheritic poison gains admission to the system before the wound exists, and the course of the disease, as regards sepsis, is the same after as before the operation. In only 6 of the 327 operations at the City Hospital of Boston was diphtheria in the wound noted; 3 of these cases recovered. Both tubes may produce ulcerations in the trachea, but the result is seldom serious.

Conclusions.-1. Intubation may be tried in all cases of croup. 2. It is preferable in young children, and in cases in which the tube must be left entirely to itself. 3. It may be resorted to for euthanasia, provided the operator is reasonably expert and can do it without producing collapse. 4. Tracheotomy is called for in those cases in which intubation cannot be done, or in which it fails to give relief; or in which the laryngeal tube is repeatedly ejected, or requires frequent removal for cleansing. It may also be required in those cases in which sufficient food cannot be given while the O'Dwyer tube is in position. It is also preferable in cases situated at a distance from a surgeon capable of introducing the laryngeal tube. 5. The tracheotomy instruments should always be at hand in intubation in cases of emergency.-Dr. Gay in Med. News.

TIGHT LACING.

Amongst the various subjects to which the members of the British Association directed their attention at the late meeting at Bath, and upon which the ladies attending the Biological Section may fairly be regarded as competent to express an opinion, was the custom of women to wear stays. The discussion might have been considered a mere playful interlude introduced by Professor Roy and Mr. Adami to enliven the proceedings, were it not that trival subjects-trival, that is, from the Association's point of view-are most likely to excite the bitterest feelings. The wearing of corsets has really two aspects, which deserve separate consid

eration--the hygienic and the æsthetic. From the hygienic point of view, the question resolves itself into one of the degree to which the compression, or, as women say, the support, of the chest is carried, and the rapidity with which that degree is attained. The body as a whole, and the several organs composing it, have a wonderful power of accommodation to surrounding circumstances, permitting changes of form and even of position that appear at first sight incredible, without material impairment of function. If the form of so unyielding a part as the head can be greatly altered, with preservation of ordinary brain power, as occurs amongst many savage tribes, by pressure begun early and steadily continued, we may be sure that much more might be accomplished if similar pressure were applied to so mobile a part as the chest without greatly impeding the function if respiration. Such moulding of the form of different parts is familiar to all as effect of disease; and many a man or woman, after an attack of pleurisy terminating in empyema and adhesions, possesses an unsymmetrical thorax, which nevertheless serves him or her well throughout a long and active life. The body, in other words, permits considerable liberties to be taken with it without serious impairment of health; and if pressure of the chest were commenced in early childhood, and steadily persisted in, no doubt still greater deviation than is commonly seen could be induced. As a matter of fact, however, in this country such pressure is not applied; the stays given to girls by sensible mothers up to the age of fourteen or fifteen are soft, and exert little more pressure than the waistcoat of a boy. At that age, when the figure naturally changes, the firmer support is taken into use, and the amount of harm it occasions is dependent on the degree to which support becomes compression. There are no doubt many girls who, desirous of making themselves conspicuous and, as they foolishly believe, attractive, tighten their waists to such an extent as to incapacitate them for taking exercise and for the necessary ingestion of food; they consequently become weak, pallid, and chlorThese evils are, moreover, intensified by the rapidity with which the compression has been applied, and all who are interested in their welfare should exert themselves to point out the egregious folly of such a practice. Upon the æsthetic side of the question there is little to be said; here, as in so many other controversial questions, de gustibus non est disputandum. Amongst the Greeks, for ages the arbiters of taste, the women wore an apology for stays, and we are told that at a very early period the girdle was strengthened by metal, and long before the Christian era a broad band or belt was worn next the skin to support the breasts. According to Planche, the practice of tight lacing appears to have been introduced by the Normans as early as the twelfth century, and

otic.

has been in use ever since. We apprehend the ordinary Englishman, though he may wonder at, does not really admire a wasp-like figure. Both hygienically and athetically, tight lacing is a mistake. Yet it must be remembered that, partly as a result of climatic conditions, partly from abundance of food and absence of severe work, and partly perhaps from the hereditary effect of sexual selection, a large preportion of the young women of England, of the middle classes at least, are disposed to the accumulation of fat in the breasts, and though from the age of seventeen to twentyfour the breasts may be firm and prominent, yet after that period they are apt, without artifical support, to become flaccid and pendulous. The advantage of support, however, is no argument for the employment of compression. Dr. Hoyle made a good hit in saying that no woman regarded herself as properly dressed unless she felt a little uncomfortable. He might have added that the proportion of discomfort experienced may be pretty safely taken as the measure of mischief being effected in the willing victim of tight lacing. Lancet.

A LOCAL TREATMENT FOR VAGINISMUS AND VAGINITIS.

Vaginismus, as you all know, consists of a hyperesthesia of the nerves supplying the mucous membrane and muscles of the vagina, and its orifice, which upon being irritated produces a spasmodic contraction of the sphincter and other vaginal muscles. This condition may be due to functional or local causes, more often the latter.

Vaginitis is an inflammation of the lining menbrane of the vagina, and it may be of a specific or a non-specific character. This disease is often connected with vaginismus. In the treatment of these troubles the first step is to remove the cause if this be possible. In vaginismus you are aware that it is not easy to introduce a speculum, or even the finger into the vagina, without considerable pain to the patient.

My method of proceeding in these cases is to place the patient on her back, the pelvis somewhat elevated and the knees flexed. I either introduce a bivalvular or a small cylindrical speculum, I prefer the former as on account of its flatness it is easier introduced. Before introducing it, however, I lubricate it with vaseline, and then take a camel's hair brush and apply a four per cent. solution of cocaine both to the speculum and to the orifice. I then introduce the speculum into the vagina and very gently open the blades. By this means I give the patient very little pain. After placing a small roll of cotton beneath the speculum across the perineum, I pour into the vagina through the speculum, a solution composed of sulphate of zinc, or two grains, chloral hydrate five grains,

one

water and glycerine of each four drams. I wait several minutes and then withdraw the speculum slowly but not completely out of the vagina.

As I withdraw the speculum, the walls of the vagina come together and the solution touches every portion of the mucous membrane. I now push the speculum back again, and introduce a small cotton tampon with a string tied to it, pushing it back with a long dressing forceps, at the same time withdrawing the speculum. The tampon will absorb that part of the solution which remains in the vagina and that which escapes will be absorbed by the cotton on the perineum. I now place a piece of cotton between the labia, apply a bandage and the operation is completed. I let my patient remove the cotton and withdraw the tampon in from four to six hours afterward.

I repeat this treatment three or four times a week. After the first treatment, I have no need for the cocaine, as the finger or speculum can be introduced without giving much pain. In vaginitis I proceed in the same way, except I do not use the cocaine solution. In vaginitis the chlorai acts as an anesthetic to the mucous membrane and vaginal muscles. Between visits I have my patient to use vaginal douches of hot water with a little borax added to it. By this treatment I have secured excellent results, and my patients and their husbands (if they have any) appreciate it very much in vaginismus. Dr. Guhman in Weekly Med. Rev.

INJECTIONS OF OSMIC ACID IN MUSCULAR RHEUMATISM.

In No. 24 of the Russkaya Meditsina, 1886, I published some cases of muscular rheumatism in which I had employed osmic acid in the form of hypodermic injections. These cases, though not very numerous, were tolerably characteristic, and bore out the suggestions first made, I believe, by myself, as to the advantages of a persevering use of this method of treatment.

At the commencement I employed osmic acid in quantities of from three to six drops of a one per cent. solution for a single injection—the same doses in fact in which it is recommended in cases of neuralgia. At the present time the doses given internally are from the one-sixtieth to a quarter of a grain per diem, and the hypodermic doses should therefore be about half as great. A very important case however that has occurred in my practice proves that these doses may with great advantage be increased. The case was that of a patient named Vikulin, belonging to the town of Maikop, a merchant, thirty-three years of age, tall, of good constitution and well nourished, who for the last two years had suffered from severe pains in the dorso-lumbar region, especially on the right side, extending to the lower extremities and