Part 3

2. Painful inflammation in the mastoid process occurring in acute and chronic suppuration of the middle ear, in consequence of growths filling up the external meatus or the tympanic cavity. When attempts to remove the obstacle to the free escape of pus have failed, the operation is imperative. (Grüning). The operation is indicated even though the soft parts over the mastoid are not swollen or infiltrated. (Politzer).

3. When the posterior superior wall of the meatus is bulging, and when after incision the abscess is not emptied and the symptoms of retention of pus continue. (Toynbee, Duplay).

4. Persistent pain and tenderness in the mastoid process lasting for days or weeks, in which there is probably an osseous abscess not communicating with the tympanic cavity. (Politzer).

5. In every suppuration of the middle ear combined with inflammation of the mastoid process in which fever, vertigo and headache are developed during the course of the affection, which may indicate a dangerous complication. In such cases the indication for the operation is vital. (Politzer, Roosa, Buck.)

As to the time when the operation should be performed, writers do not agree. While one proposes that the operation should be done as soon as there are symptoms of inflammation of the mastoid process, another defers it till the dangerous symptoms (fever, headache, vertigo, etc.,) set in. The latter proposal must not be followed, as in many cases it would be too late; on the other hand, many cases will recover without an operation. As far as it can be formulated, I would say that in a given case of acute purulent inflammation of the mastoid process I would first apply leeches, poultices, cathartics, antiflogistics. If the inflammation is not promptly subdued, I would make a Wilds' incision, including the periosteum, if the bone is found softened; or if a fistulous opening is found, this should be enlarged at once. If the bone is found healthy and not roughened, if there is no fever, vertigo, headache, etc., I would wait a few days; if the symptoms, pain, tenderness, etc., do not subside, I would then perforate the mastoid process.

For the performance of the operation trepans were formerly used, which were replaced by drills which are still used by Buck, Jacobi, Lucae and others, but by most operators they have been set aside, owing to their uncertain and dangerous advance in the deep parts, and on account of their soiling the wound with splinters. The most rational and safe method is by means of the chisel, as recommended by Schwartz, and is performed as follows: The patient being anæsthetized, a perpendicular incision beginning a little above the linea temporalis, extending an inch and a half in length immediately behind the attachment of the auricle. Formerly I employed a straight incision, but recently have followed the suggestion of Politzer, and from the superior end of the perpendicular incision a second one is made backward at right angles, thus forming a flap, which I have found to simplify the operation very much, as it affords a better view of the locality and extent of any pathological changes which may have taken place, and gives more room for operative procedures, and the periosteum can readily be removed to any desired extent. The linea temporalis and the more or less strongly developed protuberance on the posterior superior orifice of the osseous meatus, so strongly urged by authors, are very nice guides theoretically or to point out on an exceptional skull in the class room, but practically are seldom well enough developed to be of any use to the operator. The best guide to go by is to take the superior wall of the meatus as the upper boundary, and the angle formed by the plane of the mastoid with the posterior wall of the external meatus for the anterior boundary when opening the mastoid. This is best determined by pressing the finger into the meatus. Often in children, and when the bone is diseased in adults, the cortical plate of bone can be removed with the hand chisel, and we come at once upon the pus cavity, or diplœ, or cholesteatomatous epidermic masses, or a sequestrum of dead bone, or bleeding granulation tissue, or whatever the case may present. Sometimes the external plate is very thick and we have to chisel our way carefully for almost half an inch before reaching the diplœ, or may find the entire mastoid process sclerossed. No absolute rule can be given as to the depth it is safe to penetrate. Schwartz says "never to go deeper than 25 mm." Buck says "it is better to place the extreme limit at 20 mm," about three-fourths of an inch.

Although I do not consider the operation a particularly dangerous one, especially with the chisel where we can watch each step of the operation; and even though we opened into the lateral sinus or the duramater, the injury would not be necessarily fatal. Yet I would not advise any one to attempt it (unless the indications are imperative) who has not performed the operation on the dead subject. Politzer says "no one should operate on the living before having performed the operation at least forty or fifty times on the dead." I cannot close this article better than in the words of Dr. St. John Roosa, to whose admirable work I am indebted for a large portion of this article.

"Yet, hesitation, when the way is plain, or when the chances are largely on the side of the necessity of the removal of pus, cannot be too sternly condemned. No drug has yet been discovered which can be substituted for the scalpel or trephine when pus has actually formed in the mastoid cells. I wish, however, to repeat what I have said before on the subject of surgical operations. I am in full accord with the great English surgeon, Sir James Paget, who, in his admirable lectures, expresses many times his hesitation to perform any surgical operation, however trivial, that is not absolutely required. We have no right, I think, to perform operations to clear up doubtful diagnosis. If in case the operation proves to have been unnecessary, the patient will be decidedly the worse for it. If we put ourselves in the place of our patients, what we may regard as a trifling thing--"a mere cut"--will not be so esteemed. A mere cut, when unnecessary, may have the most serious consequences, and all the history and symptoms should be carefully weighed before even that is undertaken. Such care will never prevent prompt, rapid and thorough surgical interference when demanded.

In teaching medical students, I have always found them, when fully awakened to the dangers of neglecting certain diseases, to be more apt to do too much than too little, especially with the knife and active drugs. It is possible, also, that the crying ignorance and neglect of the previous decades in regard to the treatment of aural disease has had a tendency to cause us, who see many of the afflictions of the ear, to lean toward the side of surgical operations upon the drum, head and mastoid. This is a leaning no less dangerous to the cure of some cases than was the steering toward Scylla or Charybdis to the safe navigation of ancient mariners."

A CASE OF ANOMALOUS DEVELOPMENT OF THE ANTERIOR PILLARS OF THE SOFT PALATE.

BY B. L. MILLIKIN, M. D.,

Oculist and Aurist to Charity Hospital, Cleveland, O.

Some time since, Mrs. G. D., age about 23, applied to me on account of deafness and tinnitus of both ears. In pursuing my examination I found the following unusual anatomical relations of the anterior pillars of the soft palate, which I deem not unworthy of record.

The uvula and posterior border of the soft palate are normal in appearance and formation; but, beginning about the middle of the anterior pillars, these gradually widen out into thick, heavy, broad, muscular folds, which attach themselves firmly to the sides and dorsum of the tongue, extending two or three lines upon the dorsum. They seem to be intimately connected with the muscle of the tongue itself, making them very firm. The posterior pillars are much less well developed than the anterior, and do not control or prevent the drawing forward of the soft palate when the tongue is protruded. The tonsils are small in size but normally located.

The attachments of these bands give a peculiar appearance to the throat. When the tongue is in a state of rest, in the bottom of the mouth, or, better still, when the tongue is depressed, these bands hang like two large curtains, narrowing very much the faucial opening. When the tongue is protruded they are put upon the stretch, and narrow very greatly the faucial opening by drawing forward and downward the whole of the soft palate, so that the posterior border of the soft palate and uvula rest firmly upon the dorsum of the tongue. When the tongue is thus protruded the attachments of these membranes are brought forward almost to the teeth.

In a state of relaxation there is formed back of these folds, on either side, quite a deep cavity, which often collects quantities of solid food, to the great annoyance of the patient. She even sometimes is obliged to remove these obstructions with the fingers, or, by gulping or swallowing frequently, is able to dislodge them. She has no difficulty in swallowing liquids.

There is some impediment in her speech, a peculiar lisping as if she did not have good control of her tongue, which she has always attributed to the fact that she is of German parentage. Her English is, however, very good, other than as above indicated.

In looking up what anatomical literature is at my command, I find no reference to any anomalies of this kind, although I have been able to consult the standard French, German and English works on general anatomy. I myself have never seen a case with an anatomical construction approaching this, so I, therefore, present it for record.

HINTS ON VOCAL TRAINING--THE BREATH.

By BERNARD W. FISHER, A. M.

The prevalence of throat troubles is so marked in America, and by no means least so in this city, that if one hundred individuals, collected at random, had their throats examined, it is probable that four out of every five would be found to have these delicate organs more or less affected. Whatever cause may be assigned by the medical expert in each particular case, the importance of a thorough mastery of the art of correct breathing can hardly be insisted upon too strongly. If it be urged that the widely distributed works of Behnke and others must have put an end to any general ignorance of the importance of this branch of vocal training, I can only reply that a defective style of breathing is by no means uncommon even in public singers, while among amateurs it is so rare that a perfect management of the breath excites in a critical observer a feeling of gratified surprise. The name and works of Behnke have, of course, been known in this country for a considerable time, but some of his statements are too striking to be omitted in an article on this subject. When lecturing at the Tonic Sol-fa College, London, he took ten students and measured their lung capacity in cubic inches, by means of the spirometer, with wrong or "collar-bone" breathing. He then showed them how to breathe correctly, that is, midriff and rib breathing. The average increase among the ten was twenty-five cubic inches of air; the least increase twelve inches, and the greatest forty-five. He adds: "I imagine that these figures are more eloquent than any words, and I think it superfluous to make any further comment on them."--('Mechanism of the Human Voice,' page 20.) Now, putting aside the extreme increase of forty-five inches, let anyone consider what an increase in lung capacity of twenty-five cubic inches of air must mean to the vocalist in the execution of difficult passages, to the speaker using his voice by the hour, and, lastly, to the running athlete. It will surprise a young man commencing vocal training to inform him that, at the same time, he will become a better man in the gymnasium and the race; but unless good lungs are an advantage to the athlete in name only, the above figures tell their own tale. I may add that, in teaching young men and boys, I always put this view of the subject before them, knowing that it will be an incentive to their acquiring a thorough mastery over the interesting art of "taking breath."

Correct breathing cannot _cure_ disease. The medical expert must do that. But it will _prevent_ disease; and when the throat, under proper treatment, has been brought to a healthy state, it will assuredly be the chief means of keeping it in that condition. The following is a striking instance to the same effect:

Some years since, an English clergyman had to give up all ministerial duty from "Clerical Sore Throat." Acting under the absurd advice of a London teacher of elocution, he resided in Spain for five years without the slightest benefit. He then returned, and at the house of the elocutionist who had made him an exile saw a copy of Behnke's celebrated work. Coming to the conclusion that the author must be rather clever, he at once consulted him. Following his advice he had his throat made medically sound by Lennox Browne, and then took the usual course in breathing and voice production under Behnke. A short time after I was with Herr Behnke, when a post card arrived from the clergyman: "I preached yesterday in Chichester cathedral, and was congratulated on the strength of my voice and the ease with which I filled the building."

A few weeks since I heard a sermon in a Cleveland church. The preacher took short "collar-bone" breathings, using twice the power necessary for the building, and towards the conclusion was in evident distress (which naturally communicated itself to his hearers), a failing voice and perspiring face. If before entering the ministry he had learned to breathe and use his voice properly, such troubles could never have existed.

There is yet another unpleasant affliction which correct breathing will rarely fail to cure, a high-pitched and effeminate voice in a man. I quote again a case from the same work:

Mr. M----, a tall, thin young man, engaged in evangelistic work, suffered from "weakness of voice." He spoke chiefly in a "child voice," over which he had very little control. His breathing power increased by sixty cubic inches in two lessons. "In one week more," adds Herr Behnke, "I could dismiss him with a full, sonorous man's voice in place of the uncertain child's squeak with which he had come to me."

I must lastly point out that the cure of stammering often entirely depends on the management of the breath, and in all cases it must be an important agent.

The limits of this paper allow but a brief notice of the best course for a breathing instructor to follow. Let the pupil lie down on his back, place the hand lightly on the lower part of the lungs, and tell him to inhale easily through the nostrils, allowing the air to fill the lower part of the lungs, avoiding all motion of the shoulders and heaving up of the chest. When the lungs are fully inflated count four with deliberation, and let the pupil inhale all the air as suddenly as possible. Gradually increase the counting week by week up to twelve, which marks a real control over the unused muscles. The next course is for the pupil to inhale suddenly and exhale slowly. The instruction given is of necessity meagre, but it need hardly be pointed out, no written directions can take the place of personal teaching. From four to six weeks is usually sufficient for the young and vigorous to gain command over the breathing apparatus; older pupils have sometimes great difficulty in mastering the muscles, unruly through disuse.

Herr Behnke allows no use of the voice beyond ordinary speaking while the breathing exercises are going on. I have followed this rule much modified, and do not find the results unsatisfactory.

The total neglect of this important subject in both American and English schools is to me perfectly astounding. Half an hour a week for three months would be ample for the purpose. These few hours would confer a benefit of the highest value, and lasting a lifetime.

The Cleveland Medical Gazette.

_A MONTHLY JOURNAL OF MEDICINE AND SURGERY._

One Dollar per Annum in Advance.

All letters and communications should be addressed to the Cleveland Medical Gazette, No. 5 Euclid Avenue, Cleveland, Ohio.

A. R. BAKER, M. D., _Editor_. S. W. KELLEY, M. D., _Associate Editor_.

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EDITORIAL.

We have mailed the Gazette regularly to a number of our friends who have not remitted their dollar. We hope they will do so soon.

MEDICAL DEFENSE ASSOCIATION.

Last month we urged the necessity of the profession organizing a medical defense association. We publish this month the proceedings of the Chicago Medical Society, in which the same question is discussed very fully.

STATE SOCIETY REORGANIZATION.

The editor of the Cincinnati Medical Journal asks the secretaries of local societies to bring the matter before their respective organizations, and suggests that they invite expression upon the following propositions:

1. To so change the constitution of the State Society as to make the members of county societies members of the State Society simply by virtue of their local membership.

2. Present members of the State Society to remain members without reference to membership in local societies.

3. All members to stand upon an equal footing, thus doing away with the delegate system.

4. All papers to be presented to the State Society must first be presented to the local society, by which it may be referred to the State Society.

MEDICAL PRACTICE BILL.

A bill to establish a medical board of examiners and licenses, and to regulate the practice of medicine and surgery in the State of Ohio, and to define the duties and powers of such board, will be presented to the Legislature of Ohio. It provides for:

1. A mixed board so far as schools are concerned.

2. No attache of a medical college is eligible to a place on the board.

3. All candidates for the practice of medicine in Ohio shall submit to an examination by this board.

4. None but graduates in medicine and surgery shall be eligible to examination.

5. Licenses may be refused or revoked for criminal or dishonorable conduct.

6. Graduates at present practicing in the State may continue without submitting to an examination, but must register in the office of the probate judge.

These are the essential features of the bill, and on the whole good. It does not interfere with physicians already in practice, which has caused the failure of nearly every bill presented to the Ohio Legislature becoming a law. Excluding college professors from becoming members of the board is fair to the profession, and saves the bill from being the tool of the medical colleges, unlike the Pennsylvania law, and yet it does not ignore the medical schools entirely as educational and graduating bodies, like the Illinois and West Virginia laws. It is impracticable, even if desirable, to ignore denominational lines in medical legislation.

PHYSICAL EXAMINATION OF YOUNG GIRLS.

The following remarks were made by the president of the Royal College of Physicians, December 28, and were the result of an inquiry into the conduct of Dr. Haywood Smith, by the college, for having physically examined the girl, Eliza Armstrong, without the consent of parent or guardian:

"It is, in the opinion of this college, a grave professional and moral offence for any physician to examine physically a young girl, _even_ at the request of a parent, without having first satisfied himself that some decided medical good is likely to accrue to the patient from the examination, and, also, without having first explained to the parent or legal guardian of the girl the advisability of such examination in general and the special objections that exist to their being made. Moreover, the college feels that a young girl should on no consideration be examined, excepting in the presence of a matron of mature age, and, so far as the physician knows, of good moral character...." The rest of the remarks were put direct to Dr. Smith, and are of no general interest.

The decision of the college was favorable to Dr. Smith; his name was _not_ erased from the roll.

SUET BANDAGES.

"These are admirable for dressing. You can make them by melting mutton tallow over a slow fire. Have your bandages of close cloth, ready cut the proper length and breadth, dip them into the suet; when saturated, hold them so as to let them drip off, or the grease may be spread upon the cloth. Hang them over a line where they may be protected from dust; let them cool, fold them, put away for use. These bandages are especially adapted to dress old ulcers and wounds. They are smooth and adapt themselves perfectly to the surface; are agreeable to the patient, and can be medicated with any therapeutical agent you wish."--_American Medical Digest_, quoting Dr. Edwin Brock in _New England Medical Monthly_.

A disadvantage of the tallow bandage is its becoming rancid. Vaseline, not becoming rancid, has been tried, but melts too easily. For most purposes the wax bandage is as good as the tallow, perfectly smooth and does not become rancid, but cannot very well be medicated. A useful material for a bandage of this kind is the paraffine, as recommended by Tait.

The tallow bandage can be put to another use by those who do not live convenient to an instrument dealer. When made wide the tallow bandage can be rolled into a very good rectal bougie, large or smaller as you wish by a few more or less thicknesses of the cloth. By the same means a very good vaginal dilator can be extemporized for cases of stricture or vaginismus. But where it is to remain long _in situ_ for these cases beeswax or a mixture of beeswax and tallow, which are generally available in the country, make a better substitute. "Cere cloth" was formerly much used by gynecologists.

We observe that Dr. Piffard has retired from his editorial connection with the Journal of Cutaneous and Venereal Diseases. The Journal will be continued under the sole editorial charge of Dr. P. A. Morrow. We may remind our readers that this is the only publication in the English language devoted to Skin and Venereal Diseases, and during the three years of its existence it has won for itself a high reputation for scientific excellence as well as practical utility. In addition to presenting all that is new and valuable in these special departments, the colored lithographs and wood engravings with which the original articles are illustrated are worth more than the price of subscriptions. Judging from the handsome appearance of the January number, which is enriched by an admirable chromo-lithograph and a number of well-executed woodcuts, and the eminently practical character of its contents, this high standard will be maintained in the future.

SOCIETY PROCEEDINGS.

CHICAGO MEDICAL SOCIETY.

OFFICIAL REPORT.

_Stated Meeting, January 18th, 1886._

President pro. tem., D. W. Graham, M. D., in the chair.

Dr. E. J. Doering read a paper entitled

MUTUAL PROTECTION AGAINST BLACKMAIL.