Chapter LI: Introduction: The object of the following essay is to give, as far as (7)

(_b_) ABSCESS OF THE BRAIN.--With the exception of wounds and injuries, chronic purulent middle-ear inflammation is the most frequent cause of brain abscess. Meyer, in a collection of 89 cases of brain abscess tabulates the causes as follows: Typhus, 1; intercranial tumor, 2; disease of nasal mucous membrane, 3; disease of the blood-vessels, 5; inflammation of neighboring parts of the brain, 5; unknown causes, 11; suppuration of distant organs, especially the lungs, 19; caries of the petrous bone, 20; injuries, 21. Lebert collected 80 cases of brain abscess, and found that one-fourth were caused by purulent middle-ear inflammation, caries of the petrous bone being frequently present; in one-seventh of the cases the brain abscess appeared before puberty, in the remaining cases mostly between the sixteenth and thirtieth years; also, that in some cases the abscess developed in the part of the brain lying over the bony roof of the middle ear; in other cases it was found in a distant part of the brain or the cerebellum, probably developing as a metastatic abscess. Toynbee considered the retention of purulent products in the middle ear or mastoid cells as the chief cause of brain complications from ear sources: he also endeavored to show that an inflammation of the external auditory canal will tend to implicate the cerebellum and lateral sinus--that inflammation of the middle-ear cavity would extend to the cerebrum, and that of the labyrinth to the medulla oblongata. But, practically, such a rule will not hold good, and Gull has modified Toynbee's law as follows: The cerebellum and lateral sinus may suffer from mastoid disease, while the cerebrum is threatened by caries of the roof of the tympanic cavity.

Brain abscess is generally located in the medullary substance, very rarely in the cortex. The middle portion of the brain hemisphere is the most frequent seat of abscess, and very often in that part adjacent to the diseased ear. The abscess may be located directly over the diseased bone, so that the dura mater forms its covering on one side and the brain tissue on the other, or it may be located in the brain parenchyma with perfectly healthy brain tissue between it and the diseased bone. Meyer traces the {832} origin of a brain abscess from ear disease in this manner: A chronic catarrh of the middle-ear mucous membrane results in an hypertrophy of the mucosa on one side and a chronic inflammation of the neighboring bone on the other side. Caries of the petrous bone, so caused, produces inflammation and adhesion of the dura mater, and from here as a starting-point the inflammation spreads into the brain tissue. In rare cases the brain abscess has been found connected by a fistulous tract with the diseased bone.

SYMPTOMS.--Headache is generally present in varying degree, often of a lancinating character. Vertigo frequently present. Fever generally present, with or without chill. Convulsions frequent, with loss of consciousness and unsteadiness of gait, and often paralysis of different parts of the body. The pupils are often contracted, and not unfrequently this disease may closely resemble typhus fever. Lebert noticed in his cases that failure of the intellect was not the rule, but paralysis of sensibility occurred in two-thirds of them. It is also to be noted that cases occur where all these symptoms are absent. This disease can run an acute or chronic course. In the acute condition a fatal termination is caused by the great destruction of brain tissue involved in the suppurative process. In the chronic cases the abscess becomes encapsulated, but finally terminates by rupture of the abscess and escape of pus into the ventricles or over the surface of the brain. In Lebert's cases the fatal termination occurred in half of them during the first month, in one-third of the remainder toward the end of the second month, and in the remaining cases in a varying time between the third and eighth months.

(_c_) PHLEBITIS WITH THROMBOSIS.--This sequela of middle-ear suppuration is not infrequent. Von Dusch in 32 cases of phlebitis with thrombosis found that purulent middle-ear disease was the cause of 20 of them. It is frequently found in the venous sinuses in proximity to the petrous portion of the temporal bone, especially in the lateral and petrosal sinuses, and often caused by caries of the petrous bone.

Phlebitis with thrombosis of the lateral sinus is characterized by a swelling of the mastoid region which extends downward into the neck, due to an extension of the phlebitis from the lateral sinus along the veins leading from that sinus through the mastoid process to the exterior of the skull. Giddiness and unsteady gait are often present. If the inflammation involves also the superior longitudinal sinus, it will cause symptoms such as epileptic convulsions and violent hemorrhage from the nose. Wreden considers that the epileptic seizure is due to a capillary hemorrhage in the cortical substance of the posterior cerebral lobes, caused by obstruction of the veins passing over the brain substance. The nose-bleeding is due to the fact that a part of the blood circulating through the veins of the nasal passages, and then through the superior longitudinal sinus, is hindered by the sinus obstruction and accumulates in the veins of the nasal passages, and finally causes a rupture in some part.

Phlebitis with Thrombosis of the Cavernous Sinus.--Urbantschitsch gives the following summary of this complication:[10] A thrombosis of the cavernous sinus can be caused by a thrombus in the internal jugular or facial veins or by a clot passing from the superior petrosal sinus into the {833} cavernous sinus, or, finally, by inflammation and thrombosis in the venous circulation of the carotid canals.

[Footnote 10: Vide _Textbook_, p. 367.]

PROMINENT SYMPTOMS.--Retro-bulbar oedema and exophthalmos, caused by stoppage of the blood from passing from the orbit into the cavernous sinus. This may result in a mechanical compression of the retinal vessels and temporary blindness; also, occasionally swellings appear about the eyelids and nose. Compression of the oculo-motor and abducens nerves as they pass along the outer wall of this sinus may cause paralysis of these nerves, and consequent inward turning of the eye, with ptosis of the eyelids; also, pressure on a branch of the fifth pair of nerves as it passes along the outer wall of the sinus may cause neuralgia in the parts supplied by the branch, or neuralgia in the supraorbital region.

Phlebitis with thrombosis of the internal jugular vein is marked by a well-defined swelling extending from the angle of the jaw downward along the line of the sterno-cleido-mastoid muscle, painful on pressure, with marked distension of the veins of the face and neck, especially the external jugular vein. Later on, when the collateral circulation is established, the superficial veins are apt to return to their former calibre. If the inflammation extends downward, it can involve the vena cava; and if upward, the facial veins, causing a swelling of the cheeks and eyelids. The process can also extend from the facial to the orbital veins, and thence into the cavernous sinus. Pressure of the thromboid mass on the internal jugular vein, on the glosso-pharyngeal hypoglossus and pneumo-gastric nerves at the opening of the jugular foramen, will cause nervous symptoms corresponding to the nerve involved.

PROGNOSIS of a phlebitis with thrombosis, as a rule, is unfavorable. Chronic middle-ear suppuration can also form a starting-point of metastatic abscess, also of tubercular formations in the lungs and other organs of the body. I have also been much impressed with the frequent occurrence of kidney complications, such as granular nephritis, in this disease. A gradual absorption of pus will develop a general bodily weakness, and it is a fairly well established fact that, as a rule, patients suffering from chronic middle-ear suppuration are not apt to be long lived: many life insurance companies now order that this disease will prevent the case from being considered a first-class risk.

II. Mastoid Disease.

The mastoid process of the temporal bone presents an outer convex with an inner concave surface. On the upper and posterior borders of the bone are found several canals, through which the external vessels form a union with those of the dura mater; also, by which the outer cranial veins form a union with the transverse sinus. There is also an important suture--the petro-squamous suture, which admits of the passage of blood- and lymph-vessels. These vessels furnish a channel for the spread of inflammation from the antrum outwardly, involving the tissues of the neck, and inwardly to the brain membranes and brain tissue proper; phlebitis with thrombosis of the lateral sinus can also occur. The interior of the mastoid process contains one large opening, the antrum, with numerous communicating air-cells, and all lined with {834} an extension of the tympanic mucous membrane. Inflammation of the mastoid process, as a rule, is an extension of inflammation from the middle ear. The cause will be found in an obstruction to the free escape of the purulent products from the antrum out through the middle ear. It is also found that in a great number of cases of purulent middle-ear inflammation the air-cells are closed by a process of sclerosis. There are two forms of mastoid disease--1, periostitis of the bone; 2, inflammation of the mucous membrane of the mastoid cells.

1. Periostitis of the Mastoid Bone is caused either by external injuries, or more frequently by inflammation extending from the mastoid cells outwardly to the periosteum.

SYMPTOMS.--Pain, severe in character, also fever. Redness over the mastoid and great sensibility to the touch, followed by marked swelling, which may extend far down the neck, involving the lymphatic glands. Later, pus will be found between the periosteum and bone, and in a few cases caries of the bone.

2. Inflammation of the Mucous Membrane of the Mastoid Cells is caused generally by extension of inflammation from the middle-ear cavity, either of a catarrhal or purulent character, causing the cell-cavities to quickly fill up with the inflammatory products which escape through the antrum and middle-ear cavity into the external canal. If this way is closed, the fluids accumulate in the mastoid cells and form conditions favorable to involvement of the internal organs.

SYMPTOMS.--Severe pain, tenderness, and redness of skin over mastoid, but not the marked swelling that is found in periostitis. During such an inflammation facial paralysis may develop, showing that the inflammation has extended into the bone itself. Delirium is occasionally met with, probably due to a more or less circumscribed meningitis; coma is also occasionally noted, caused by effusion into the lateral ventricles. In many cases of antrum inflammation there is a marked swelling of the upper and posterior cutaneous covering of the osseous part of the external canal, making it a valuable symptom in determining the degree of the inflammatory action.

Caries and necrosis of the mastoid bone are resultants of the above-described conditions, and are especially found in early childhood, and generally caused by retention of pus in the mastoid cells and breaking down of their walls. This process can be limited to the cell portion of the bone or can also involve the cortex, with formation of an external fistulous opening.

TREATMENT.--Use of heat and moisture, either by hot-water fomentations or warm poultices, like flaxseed, over the entire temporal region of the head on which the diseased mastoid is located. The flaxseed poultice is to be covered with oil silk and changed as often as needful to keep it warm. The use of leeches to the mastoid is indicated by tenderness of the part to the touch, with heat and swelling of the tissue covering the bone. Two or three foreign leeches can be used, and if the abstraction of more blood is desired the after-bleeding is to be encouraged by warm moist applications. If the disease advances notwithstanding this treatment, an opening down to the bone is indicated. The incision is usually described as the Wilde incision. The length of the cut is to be from a half to one inch, down to the bone, the point of the knife entering the {835} skin on a level with the upper wall of the auditory canal, about half an inch behind the auricle. Occasionally the posterior auricular artery is cut, but hemorrhage is readily controlled by pressure over the artery. During the entire treatment the external auditory canal is to be cleansed from time to time of the purulent secretions, so as to facilitate the discharge of pent-up fluids from the middle ear and antrum. Also, the condition of the pharynx is to be noted, and treated if needful. Finally, if all these measures fail to relieve, and the patient shows signs of meningeal or brain involvement, together with marked redness, tenderness, and swelling over the mastoid bone, showing that pus is being retained in the mastoid cells, there only remains the making of an opening into the mastoid process and antrum by means of a bone-drill or gouge. This is best done by a free vertical incision through the skin and periosteum covering the mastoid process. Examine then the bone, and a fistulous opening may be found which can be enlarged by a probe, and so allow the free escape of pus. If such does not exist, apply a drill to the bone at a point a quarter of an inch posterior to the external canal and just below a horizontal line drawn tangent to its upper wall. The instrument is to have a direction inward, upward, and slightly forward. The depth to which it should penetrate varies: usually cell-structure is reached at a slight depth, when the drill should be withdrawn. If sclerosis of bone exists, it will be necessary to go deeper, but never more than three-quarters of an inch, or about 20 millimeters. This is Buck's rule. Schwarze says, never go deeper than 25 millimeters, otherwise there is risk of plunging the drill into the labyrinth. Also, during the drilling process Buck recommends keeping the fore finger of the operating hand constantly pressed against the neighboring bone, so as by counter-pressure to reduce to a minimum the risk of wounding the lateral sinus if it should lie in an abnormal position in the path of the drill. After-treatment consists in keeping the canal open by gentle washing. The use of a bone-gouge is preferred by some to the drill, as being a less dangerous instrument.

Diseases of the Internal Ear.

ANATOMY.--The internal ear consists of a central cavity, from one end of which arise the semicircular canals, and from the other the cochlea. The interior of these contains the membranous portion and fluids of the internal ear. The cochlea contains the most important part--namely, the terminal endings of the auditory nerve. Sound-vibrations pass through the external canal and strike against the tympanic membrane, throwing it into vibration. The vibrations of this membrane are carried across the middle ear by the chain of small bones to the membrane closing the foramen ovale of the internal ear, throwing this and the labyrinthine fluid also into vibration, and these latter vibrations, impinging on the terminal endings of the auditory nerve in a way as yet unknown, produce sound.

Vessels of the Labyrinth.--The labyrinth obtains its blood partly from the arteria auditiva interna, a branch from the basilar artery which comes from the vertebral, and partly through vessels communicating with the middle ear viâ the round and oval windows, and through others passing {836} through the long walls themselves. The arteria auditiva interna divides in the internal meatus into a vestibular and cochlear branch. The former is distributed to the soft structures of the vestibule and semicircular canals. The cochlear branch is distributed to the modiolus and layers of the lamina spiralis. The venæ auditivæ internæ empty into the inferior petrosal sinus or the lateral sinus; other branches empty into the superior petrosal sinus.

The auditory nerve or portio mollis of the seventh nerve arises by two roots in the medulla oblongata. One ganglionic nucleus of origin is in the floor of the fourth ventricle, the other is in the crus cerebelli ad medullam (Stieda). The nerve winds around the restiform body, and passes into the meatus auditorius internus, and finally divides into a vestibular and cochlear branch. The vestibular branch divides into three branches: the superior is distributed to the utricle and ampullæ of the superior vertical and horizontal semicircular canals; the middle to the sacculis, and the inferior to the ampulla of the inferior vertical semicircular canal. The cochlear branch enters the modiolus and breaks up into smaller branches, which radiate fan-shaped into the lamina spiralis, and are then distributed between the two plates of the lamina spiralis through all its turns.

TINNITUS AURIUM.--It may be assumed that the normal ear is filled with continuous sound. The blood flowing through the large arteries and veins in close proximity to it (such as the carotid arteries and jugular vein), as well as the blood flowing through the vessels of the internal ear, will give rise to sound by throwing into vibration the soft tissues surrounding them, including also the walls of the vessels themselves. This motion is sufficient to excite the auditory nerve-elements by causing vibrations of the intra-labyrinthine fluids, and so produce sound; which, being a normal condition, and one to which the ear is accustomed, will remain unnoticed.[11]

[Footnote 11: To Theobald we are indebted for the vascular theory of sound.]

The arterial system of the body throws the neighboring tissue into vibration, but this is not recognized unless our attention is particularly directed to it; or, in other words, the entire body is filled with movement as a normal condition, and therefore attracts no attention. But let this movement be increased--for instance, by violent muscular exertion, increasing the arterial action--or lessened, as in syncope, and at once an abnormal condition draws our attention to it.

In the same way the ear is filled with continuous sound as a normal condition, and therefore it is not perceived, these sound-vibrations escaping out through the middle ear and external canal. This can be readily proved. Let the external auditory canal be obstructed artificially, either by the finger or by a cork. At once a tidal tinnitus, so called, is produced, this being caused by the normal sound-vibrations being impeded in their outward passage and being thrown back again to impress the nerve-elements for a second time. This, being an abnormal condition, is at once recognized.

Different Varieties of Tinnitus Aurium.--I. Tinnitus caused by obstruction of the normal sound-vibrations in their outward passage through the middle ear and external canal; tidal tinnitus, so called from a resemblance to the noise of the ocean. Such obstructions may exist in the middle-ear {837} cavity, as thickening of the soft tissues of the middle ear, exudations and adhesions, as found in chronic catarrh, or in the external canal, as impacted cerumen, a swollen canal, etc. The effect of such obstruction would be to interrupt the normal sound-vibrations and cause them to be reflected back again to impress for a second time the auditory nerve-elements, causing an abnormal and therefore recognized condition. This is the most frequent variety of tinnitus, and for the reason that it is produced by the more ordinary ear diseases.

II. Tinnitus caused by abnormal sound-vibrations produced either by increase or by decrease of intra-labyrinthine pressure. In a normal condition the auditory nerve-elements are subjected to a given intra-labyrinthine pressure; now, if this pressure be altered (either by being increased or diminished) an abnormal condition ensues, and is noted as such.

_a_. Tinnitus produced by increased intra-labyrinthine pressure may be caused by increase of the intra-labyrinthine fluids (by effusions, hemorrhages, etc., as in Menière's disease), or can be caused by increase in the amount of blood flowing through the arteries and veins of the internal ear. In either case there will result an increase of pressure that is exerted on the auditory nerve-elements. Also, another result of such increase of pressure on the arteries of the labyrinth would be to throw them into more active pulsation, and so cause greater movement on the intra-labyrinthine fluids. These abnormal vibrations impinging on the auditory nerve-endings would be noticed as such, and give rise to tinnitus of a pulsating character corresponding to the movements of the pulsating vessels. Such a condition is noticed in an eyeball afflicted by glaucoma, or can be artificially produced by finger-pressure on a normal eye. The veins of the retina will be first thrown into movement, and as the pressure increases the arteries will show marked pulsation. Why should not a similar set of conditions in the internal ear produce similar results?

_b_. Tinnitus produced by a lessened intra-labyrinthine pressure may be caused either by loss of intra-labyrinthine fluid or by a lessened blood-supply to the internal ear. The latter cause being the most frequent, a familiar example of this would be the tinnitus experienced by a fainting person, a common sensation being a swimming head accompanied with strange whizzing noises in the ears. The tinnitus of anæmia is of this class, and frequently of the pulsating variety. Another explanation might be given: an anæmic heart murmur might be conveyed along the blood-vessels as through a speaking-tube, and in that way impress the auditory nerve. In this variety of tinnitus it is supposed that the sound-conducting apparatus of the middle and external ear is normal; if any obstruction exists, it would cause increase of tinnitus of this variety.

III. Tinnitus caused by a diseased condition of the auditory nerve, either in the part lying between the internal ear and brain or in the brain-centre itself--pure subjective tinnitus. Here we enter upon a subject obscure from the fact that so little pathological research has been made in this direction; but, reasoning from analogy, why cannot the auditory nerve be subject to as many diseased conditions as the optic nerve, where the ophthalmoscope has clearly shown the existence of neuritis, atrophy, and many other pathological changes, caused, it may {838} be, by disease of the retina, or it may exist as an inflammation of the nerve itself exterior to the eyeball, or it may be due to a brain tumor pressing on the optic nerve or optic tracts, also basilar meningitis? Gummata, osseous growths, etc. have in turn caused optic neuritis; finally, lesions at the optic nerve-endings in the brain itself have caused well-defined pathological changes in the optic nerve, which by the aid of the ophthalmoscope are recognized. Now, if these changes exist in the optic nerve, why may not the same conditions be present in connection with the auditory nerve, although from its anatomical location they are not capable of demonstration, as in the case of the optic nerve? And, as in the latter phosphene symptoms are common, due to nerve-irritation, so in irritation of the auditory nerve tinnitus would be developed, but of a subjective character. (In this connection it is not out of place to remark that in obscure internal ear disease examination of the optic nerve will often give valuable information toward clearing up the ear complication.) This variety of tinnitus may in some cases be due to a reflex nerve-irritation.

Finally, tinnitus may be noticed in cases of inflammation of the middle ear where fluid has collected, and is caused by the bursting of air-bubbles in their passage through this fluid, the air gaining access to the middle ear by way of the Eustachian tube. Tinnitus so produced resembles a bubbling or crackling sound. Hinton draws attention to certain cases where the tympanic membrane has lost its normal elasticity and become stiff, any movement of such a membrane causing a crackling sound. Also, there are some cases of tinnitus produced by foreign bodies being deposited on the tympanic membrane, such as cerumen, pieces of hair, etc., making a rustling or rasping noise.

Tinnitus produced by abnormal contractions of the tensor tympani or stapedius muscles has been thought to exist. Tinnitus may be intermittent or continuous. It also has an endless variety of sound, from one almost unrecognizable to a roar so loud as to render the patient nearly distracted.

Location of the Tinnitus.--Those varieties due to a diseased external or middle ear locate the sound, as a rule, in the ear itself. Subjective tinnitus is often located in the frontal and occipital regions; often also in the ear itself. It is also to be noted that marked tinnitus may be associated with a low degree of deafness, and the converse is true: slight tinnitus may be associated with a high degree of deafness.

PROGNOSIS.--The removal of tinnitus depends entirely upon the cause of it and the possibility of its removal. Continuous tinnitus is always to be regarded as a more pronounced symptom than the intermittent form.

The TREATMENT will be directed to the removal of the cause. If the disease is located in the external canal or middle ear, or in a diseased condition of the naso-pharynx, these irritating causes should be removed by treatment already laid down in previous pages. The treatment of subjective tinnitus will be guided by the same principles. Determine the cause and seek for its removal. As to whether any particular drugs exist peculiarly adapted to the removal of tinnitus, I would say that in tinnitus of a subjective character or due to nerve-irritation the bromides are indicated in appropriate doses. Inflation of the middle ear with air impregnated with ether (a few drops of ether dropped into a Politzer air-bag {839} and the inflation made by the Politzer method), at intervals of three or four days, in some cases proves of benefit.

Deafness after Cerebro-Spinal Meningitis, Scarlet Fever, Mumps, etc.

This opens up a chapter in which our knowledge derived from post-mortem examination is very limited. In a given number of such cases the inflammation probably extends from the brain to the labyrinth; in others the changes that are found exist chiefly in the middle ear, so that it must be supposed that the inflammation in such cases has originated in the middle ear, and has secondarily invaded the labyrinth. In some cases, such as deafness after mumps, Toynbee is of the opinion that the peculiar poison of that disease affects the nervous apparatus of the ear, as the deafness comes on suddenly, and is usually complete, without evidence of disease in any other part of the ear. In this class of cases the prominent symptoms are deafness--which is total--and staggering gait, with vertigo. This symptom may last many weeks, and then cease. As a rule, examination of the tympanic membrane is negative, and the seat of disease is to be sought for in the labyrinth, whether it may be an inflammation of the soft structures or an effusion, causing increased intra-labyrinthine pressure. In many cases the suddenness of the attack would point to an effusion as the more probable cause.

Brunner in a comparison of five cases of deafness after mumps[12] gives the following symptoms and course of the disease: 1. The nervous deafness after mumps can be one-sided or double-sided, the former being more frequent. 2. It is complete, and, according to past experience, incurable. 3. It develops rapidly, with vertigo and subjective noises, the later symptom lasting a long time. 4. There is little or no fever. 5. Pain is never or very seldom present. 6. Consciousness is not lost; excessive vertigo a prominent symptom. 7. It happens both in children and adults.

[Footnote 12: _Archiv Otology_, vol. xi., No. 2, p. 103.]

Menière's Disease.

A. Guye of Amsterdam has published a very full summary of the history of this disease.[13] The following is extracted from it: Under the head of Menière's disease is included those cases of inflammatory processes in the semicircular canals or in the middle ear producing vertigo, which is either continuous, or caused by normal movements of the head, or appearing only at intervals of weeks or months; also, that this disease is of a secondary nature, and is due to inflammatory processes in the tympanum or antrum. In typical cases the vertigo is accompanied by sensations of rotation: first a sense of rotation about a vertical axis and toward the affected side; this is followed by a sensation of rotation about a transverse axis forward and backward. The vertigo then becomes complete, and is followed by fainting, with or without loss of consciousness and vomiting. The attack in some cases may last for a few minutes to a half hour; in others every movement will tend to produce vertigo for {840} several days. In chronic cases the feeling of vertigo to a slight degree persists between the attacks. Guye considers the causes of middle-ear catarrh as the factors most likely to cause Menière's disease. Syphilis is also noted in some cases.

[Footnote 13: _Ibid._, vol. ix., No. 3.]

TREATMENT.--In some cases an alterative treatment is most serviceable, such as iodide of potassium, also the bromide of potassium; quinine is also by some recommended. The use of alcohol and tobacco is to be forbidden.

The disease known as boiler-makers' deafness, because generally found among men laboring in machine-shops, where they are subjected to loud noises connected with the work they are engaged on, is thought to be due to a paralysis of the terminal endings of the auditory nerve due to concussion. The middle ear sometimes shows some thickening of the tympanic membrane. Treatment is without avail.

In internal-ear diseases a few common symptoms can be noted. All cases show deafness, and in most of them of an absolute degree. And here is where the tuning-fork proves a valuable aid in diagnosis of deafness due to middle-ear disease, in which cases the tuning-fork is heard best on the deaf side, and to deafness due to internal-ear disease, where the tuning-fork is heard the least on the deaf side. Vertigo and a staggering gait are quite common symptoms, probably due to irritation of the semicircular canals. Prognosis as a rule is bad, as far as recovery is concerned, and an alterative treatment is often indicated. Electricity, I would state, in my experience has not proved to be of any avail.

Deaf-Mutism

may be either congenital or acquired. Two-thirds of all cases will come under the first class, and often depend upon a mal-development of some part of the central nervous system or the ear itself, or may be due to intra-uterine disease of the ear. There is a strong tendency for this disease to be inherited, and particularly in children where there exists a blood-relationship between the parents. The acquired cases may arise from defects in the central nervous system or in the internal ear, or may be due to diseases affecting the middle ear, such as purulent inflammation; and this latter cause is to be noted, as no doubt proper treatment of the middle-ear disease in many cases would have prevented such a result.

All deaf cases become mute, unless the disease has occurred in adult life, when the patient has already acquired the power of language. A deaf-mute does not speak, because he cannot hear, and therefore speech is an unknown quantity.

The TREATMENT would consist in treating any middle-ear disease that might exist, such as the sequelæ of purulent inflammation, and the instruction of the patient in acquiring the power of intercommunication either by the methods long employed of finger-reading, or, much better, by the lip method, so called, where the power of speech is given to the patient. Such cases should attend schools where such instruction is given, commencing at five years of age, and many cases now attest the value of the latter method of instruction.

DIFFERENT METHODS OF DETECTING FEIGNED DEAFNESS.--The {841} Moos Method.--Stop the external canal of the sound ear with a cork; place a vibrating tuning-fork on the head. If the person under examination declares that he does not hear the fork with either ear, he is feigning deafness, as it would be heard well by the sound ear.

The Urbantschitsch method makes use of the human voice. First determine that good hearing power exists in the sound ear; then shut the external canal of this ear with a cork and address the individual with a few loudly-spoken words. If he denies hearing at all, he is feigning, as a good hearing ear, by simple closure of the external canal, will be still able to hear loudly-spoken words.

Another method is to determine the distance at which the person can hear certain words and repeat them correctly. Then have the patient close the eyes and let the examiner try by lengthening and shortening the distance, and note the result. Often he will hear and repeat words spoken at long distances, and apparently not be able to repeat words spoken at short distances.

Müller's Method.--Speak into the sound ear through a tube or paper roll different words as softly and quickly as the examined person can repeat; then let a second examiner repeat the same in the deaf ear. Of course nothing will be heard by the person feigning. Then let the first examiner repeat his performance; the feigner will quickly repeat after him. Suddenly begins the second examiner to softly and quickly speak in the deaf ear, but choosing different words from the first examiner. A really one-sided deaf person will repeat the words spoken into the sound ear only, while the feigner will be in doubt, and will not be able to separate the words heard by both ears, so as only to repeat the words heard by the sound ear.

{842}

{843}

INDEX TO VOLUME IV.

A.

ABORTION, 467
Changes in maternal system, 474
Changes in uterus and pelvic viscera, 475
Classification, 467
Criminal, causes of, 493
Course of, 497
Diagnosis, 505
Duration, 503
Hemorrhage, 516
Morbid anatomy of, 494
Pain, 516
Pathology of, 494
Preliminary symptoms, 499
Prognosis, 508
Symptomatology, 497
Symptoms of, 500
Termination, 504
Treatment of, 509
Abortion which is thoroughly inaugurated, 516
After-treatment, 523
Anæsthetics, 514
Antiseptics in, 510
by tampons, 517
Dressing-forceps, use of, 513
in cases of retention of ovum, 519
Instruments, 512
Medication, 512
Preparations for, 509
Preventive, 515
Definition of, 467
Development of ovum, 477
Etiology, 479
Amnion, the, 491
Chorion, 490
Decidua, 488
Exciting causes, 481
Hemorrhage, 490
Local causes, 488
Ovum, the, 489
Placenta, the, 490
Predisposing causes, 480
Umbilical, the, 491
Uterine mucosa, 488
Frequency, 468
History, 470
Importance, 468
Physiology of early pregnancy, 474
Synonyms, 467
Uterine mucosa, 476

Abscess of the brain as a sequel of chronic inflammation of middle ear,
832

Absence of one kidney, 21
of pain in fibroma of skin, 686

Acanthia lectularia, 733

Accidents and complications of ovariotomy, 336

Acne, 641
rosacea, 647

Aconite in the treatment of parametritis, 221

Acquired anteflexion of uterus, 177

Actual cautery in the treatment of the pedicle after ovariotomy, 326

Acute catarrh of middle ear, 821
cystitis, 126
diffuse nephritis, 82
nephritis of scarlatina, 84
endocarditis in pregnancy, 430
endometritis, 460
infectious diseases of pregnancy, 424, 425
lobar pneumonia in pregnancy, 430
metritis, 447
ovaritis, 283
parenchymatous nephritis, 78
pleuritis in pregnancy, 431
purulent inflammation of middle ear, 825
urethritis in women, 353
vaginitis in prolapse of uterus, 158

Affections of the eye caused by diseases of the digestive system, 749
of fifth pair of cranial nerves, 785
of second pair of cranial nerves, 771
of seventh pair of cranial nerves, 790
of third pair of cranial nerves, 780
of twelfth pair of cranial nerves, 790

After-treatment in anterior elytrorrhaphy for prolapse of uterus, 163
of abortion, 523

Age in epithelioma, 709
in progressive muscular atrophy, 542
of menstruation, 182

Albinismus, 676

Albumen in the urine as a symptom of acute diffuse nephritis, 82
of chronic parenchymatous nephritis, 81

Albuminoids in albuminuria, 35

Albuminuria, 34
as a symptom of congestion of kidney, 70
in Bright's disease of kidneys, 73, 75
in calculous pyelitis, 47
in chronic diffuse nephritis, 96
of nervous affections, 40
of pregnancy, 40

Alcohol as a cause of toxic amblyopia, 803
effects of, on the eye, 803

Aleppo bouton as a variety of furunculus, 606

Alimentary canal, disorders of, during the menopause, 440
in pregnancy, 408

Alkalies in treatment of acute cystitis, 127
of chronic cystitis, 131

Alopecia, 678
areata, 680

Alterations in condition of blood as a disorder of pregnancy, 405
in nutrition during menopause, 437
in secretion of kidneys during menopause, 437
of functions of skin during menopause, 435

Alteratives in local treatment of chronic metritis, 459

Alum in the treatment of dilatation of the urethra in women, 359

Amenorrhoea, 183
atrophy of uterus in, 186
chlorosis in, 186

Ammonia hydrochlorate in the treatment of fibrous tumors of the uterus,
259

Amnion, the, as a local cause of abortion, 491

Anidrosis as a disorder of secretion in diseases of skin, 584

Anæmia, pernicious, as a disorder of pregnancy, 406

Anatomical characteristics of seminal incontinence, 141

Anatomy, course, pathology, and termination of parametritis, 210
of internal ear, 835
of middle ear, 817
of syphiloderma bullosum, 705
of vagina, 367
of vulva, 388
pathological, of progressive muscular atrophy, 543

Anæsthetics in treatment of abortion, 512

Aneurism, retinal, 743

Angioma of the skin, 688

Anodynes in acute cystitis, 127

Anomalies of kidneys, 19

Anteflexion of uterus, 176, 177

Ante-locations of uterus, 153

Anterior elytrorrhaphy for prolapse of uterus, 161

Anteversion of uterus, 174

Antiseptics in treatment of abortion, 510

Apiol in treatment of amenorrhoea, 190

Applications in treatment of seborrhoea, 589

Arrangement of tables in ovariotomy, 320

Arsenic as a cause of dermatitis medicamentosa, 602
in the constitutional treatment of eczema, 632
in the treatment of lichen ruber, 624

Articles needed for operation of ovariotomy, 318

Ascites in the diagnosis of cystic tumors of ovary, 305

Aspiration in the treatment of ovarian cysts, 308
of pelvic abscess, 225

Assistants in ovariotomy, 320

Associated movements of head and eyes in affections of third pair of
cranial nerves, 782

Astringents in treatment of albuminuria, 42

Atony of bladder, 133

Atresia, 373
hymenalis, 374
vaginal, 376
vulvæ, 373

Atrophia cutis, 683
pilorum propria, 682
unguis, 683

Atrophied tubules in congestion of kidney, 69

Atrophies of skin, 676

Atrophy of bladder in women, 348
of uterus in amenorrhoea, 186
progressive muscular, 540

Atropia as a cause of dermatitis medicamentosa, 602
in polyuria, 34
in treatment of seminal incontinence, 146

Autopsies in nystagmus, 784
of cases of pseudo-hypertrophic paralysis, 558

Axis of arteries, 148

B.

Baldness in tinea tonsurans, 720

Basedow's disease in medical ophthalmology, 799

Baths in the treatment of lichen ruber, 624

Battey's operation, 290

Bearing-down feeling in prolapse of uterus, 158
in retroversion of uterus, 166

Belladonna as a cause of dermatitis medicamentosa, 602
in acute cystitis, 127

Bimanual replacement of retroflexed uterus, 170
of retroverted uterus, 170

Biskra bouton as a variety of furunculus, 606

BLADDER, DISEASES OF, 123
Atony, 133
Causes of, 133
Treatment of, 134
Catheterization, 134
Electricity, 134
Strychnia, 134
Catarrh, 128
Catarrh of, in prolapse of uterus, 157
Cystitis, acute, 126
Causes of, 126
Prognosis of, 127
Symptoms of, 126
Epididymitis as a symptom, 127
Treatment of, 127
Alkalies in, 127
Anodynes in, 127
Belladonna in, 127
Hyoscyamus, 127
Opium, 127
Sitz-baths in, 127
Cystitis, chronic, 128
Causes of, 128
Pathology of, 130
Prognosis, 130
Symptoms, 129
Degrees of, 129
Severe pain in, 129
Treatment of, 131
Alkalies in, 131
Clothing in, 131
Emptying bladder, 132
Hemorrhage from, 134
Diagnosis of, 135
Treatment of, 135
Gallic acid, 135
Ice, 135
Iron, 135
Nitrate of silver, 135
Opium, 135
Tannic acid, 135
Inflammation, 123
Pathology of, 124
Symptoms of, 124
Treatment of, 125
Marriage as a, 125
Ointments in, 125
Passing sound as, 125
Varieties of, 123
New growths of, 136
Neurosis of, 132
Prognosis, 133
Treatment of, 133
Organic diseases of, in wound, 339
Paralysis of (see _Atony of_), 133

Blepharospasm, 790

Blindness after pneumonia, 748

Blistering in the treatment of parametritis, 222

Blisters in the treatment of chronic perimetritis, 236

Blood in Bright's disease of kidneys, 77

Bloody urine as a symptom of acute diffuse nephritis, 82

Boil or evil as a variety of furunculus, 606

Boric acid in treatment of chronic purulent inflammation of middle ear,
829

Boracic acid in the treatment of pyelitis, 55

Borax and water in the treatment of cystitis in women, 346

Bougies in the treatment of seminal incontinence, 144

Brain abscesses as a sequel of chronic purulent inflammation of middle
ear, 832

Bright's disease of the kidneys, 72
as a cause of inflammation of middle ear, 820

Bromides as a cause of dermatitis medicamentosa, 602
of potash in the treatment of seminal incontinence, 145

Bromidrosis as a disorder of secretion in diseases of skin, 584

Bulbar paralysis, 790
in medical ophthalmology, 790

C.

Caffeine in treatment of chronic congestion of kidneys, 72

Callositas, 662

Calorica, 601

Canal of Nuck, cysts of, 397

Cancer of the vagina, 382
of the vulva, 402

Canities, 678

Cannabis as a cause of dermatitis medicamentosa, 602

Cantharidal collodion in treatment of seminal incontinence, 145

Carbolic acid for instruments, 321
in the treatment of pyelitis, 55
spray in ovariotomy, 320

Carbunculus, 606

Carcinoma of the uterus, 274

Cardiac disease in congestion of kidney, 71
diseases in pregnancy, 429

Caruncle, urethral, 403

Cases of hemianopia, 776
of parametritis, 217

Castration for the cure of chronic metritis, 459

Casts as a symptom of congestion of kidney, 70
in calculous pyelitis, 451
in urine in chronic diffuse nephritis, 96

Catarrh of bladder, 128
in prolapse of uterus, 157
of middle ear, acute, 821

Cathartics in the treatment of diseases of kidneys in pregnancy, 419

Catheterization in the treatment of atony of bladder, 134

Cause of elephantiasis, 674
of scabies, 726
of tinea versicolor, 725

Causes of abortion, exciting, 481
local, 488
predisposing, 480
of acute cystitis, 126
of alopecia areata, 681
of albuminuria, 39
of amenorrhoea, 183
of atony of bladder, 133
of carbunculus, 607
of chloasma, 659
of chronic catarrh of middle ear, 824
of chronic cystitis, 128
of chronic purulent inflammation of middle ear, 828
of criminal abortion, 493
of death after ovariotomy, 314
of foetus in pregnancy, 424, 425
of dermatitis medicamentosa, 602
of ecthyma, 653
of erythema nodosum, 596
of herpes zoster, 610
of hypertrichosis, 670
of inflammation of middle ear, 818
of impacted cerumen in the external auditory canal, 812
of impetigo contagiosa, 652
of inversion of urethral mucous membrane in women, 362
of keratosis pilaris, 660
of lupus erythematosus, 690
of menorrhagia, 201
of molluscum epitheliale, 661
of myalgia, exciting, 530
of myalgia, predisposing, 530
of ophthalmitis, febrile, 761
of pelvic hæmatocele, 241
of progressive muscular atrophy, 541
of pruritus, 712
of pyelitis, 53
of pyelo-nephritis, 99
of scleroderma, 672
of sudamen as a disease of the skin, 586

Caustic potash in the treatment of lupus vulgaris, 696

Caustics in treatment of angioma of the skin, 688
of hypertrichosis, 670
of verruca, 664

Cauterization in the treatment of angioma of the skin, 688

Cautery, actual, in the treatment of pedicle after ovariotomy, 326

Cephalodynia as a symptom of myalgia, 531

Cerebral hyperæmia during the menopause, 443
symptoms of acute diffuse nephritis, 82

Cerebro-spinal meningitis, deafness after, 839

Cerumen, impacted, in the external auditory canal, 812

Cervix, enlargement of, in prolapse of uterus, 157
erosion of, in prolapse of uterus, 157

Cessation of menstruation, date of, 432

Change in quantity of urine as a symptom of nephritis, 81
in specific gravity of urine as a symptom of nephritis, 81

Changes in dermatitis herpetiformis, 613
in eye-ground and its appendages due to diseases of circulatory
apparatus--heart, blood-vessels, and blood, 738
in maternal system in early pregnancy, 474
in uterus and pelvic viscera in early pregnancy, 475

Chloasma, 659

Chloral as a cause of dermatitis medicamentosa, 602
in the treatment of vaginitis, acute, 372

Chlorosis as a cause of amenorrhoea, 185
and hydræmia as a disorder of pregnancy, 405

Choked disc, 772

Cholera, effects of, in medical ophthalmology, 800
in pregnancy, 428
in relation to diseases of the eye, 800

Chorea in pregnancy, 422

Chorion as a local cause of abortion, 490

Chromidrosis as a disorder of secretion in diseases of skin, 585

Chronic catarrhal endometritis, 462
catarrh of middle ear, 823
congestion of kidney, 69
cystitis, 128
diffuse nephritis, 84
endometritis, 461
heart disease in pregnancy, 430
metritis, 450
ovaritis, 284
parenchymatous nephritis, 80
purulent inflammation of middle ear, 827

Cicatrices, 380

Circulatory disturbances in pregnancy, 407

Circumscribed urethritis in women, 355

Clamp in treatment of pedicle after ovariotomy, 325

Classification of abortion, 467
of seminal incontinence, 137

Clavus, 663

Climacteric neuroses during the menopause, 442

Clinical history of epithelioma of uterus, 279
of fibrous tumors of uterus, 250
of seminal incontinence, 138

Clothing in treatment of chronic cystitis, 131

COLIC, RENAL, 42
Diagnosis, 44
Prognosis, 45
Symptoms of, 43
Treatment of, 45

Coma as a symptom of chronic congestion of kidney, 70

Comedo as a disorder of secretion in diseases of skin, 589

Complications of chronic diffuse nephritis, 94
of myalgia, 534
of ovariotomy, 336
of parametritis, 210
of pelvic hæmatocele, 243
of progressive muscular atrophy, 552
of vaginismus, 384

Congestion and inflammation of ovaries as a cause of disturbed vision,
758
of kidney, 69

Connective tissue in pathological anatomy of pseudo-hypertrophic
paralysis, 571

Constipation during menopause, 440
in amenorrhoea, 189
in pregnancy, 413
in retroversion of uterus, 166

Constituents of urine in chyluria, 115

Constitutional treatment of eczema, 632

Contraindications for ovariotomy, 316

Convallaria in treatment of chronic congestion of kidney, 72

Convulsions as a symptom of diseases of kidneys in pregnancy, 418

Copaiba as a cause of dermatitis medicamentosa, 602

Cornu cutaneum, 663

Corrosive sublimate in the treatment of lupus vulgaris, 696

Course and prognosis of pseudo-hypertrophic paralysis, 568
and symptoms of chorea in pregnancy, 422
of acute purulent inflammation of middle ear, 825
of angioma of the skin, 688
of congestion of kidney, 71
of criminal abortion, 497
of eczema erythematosum, 626
of the auricle, 811
of myalgia, 533
of pelvic hæmatocele, 243
of perimetritis, 229
of pityriasis rosea, 621
rubra, 622
of polyuria, 30
of prolapse of uterus, 158
of pruritus vulvæ, 393
of retroversion of uterus, 166
of tinea circinata, 717
of vaginismus, 384
of vomiting of pregnancy, 409
of vulvitis, 389

Criminal abortion, course of, 497

Cubebs as a cause of dermatitis medicamentosa, 603

Culex, 733

Culex lectularius, 733

Cupping, dry, in retroflexion of uterus, 168

Cups, dry, in treatment of nephritis, 83

Curative treatment of chronic endometritis, 465

Curette, use of, in treatment of epithelioma, 710
of lupus erythematosus, 692

Cystic tumors of ovary, 301
of vagina, 381

Cysticercus cellulosæ, 732

Cystitis, acute, 126
chronic, 128
in pyelo-nephritis, 100
in women, 341

Cystocele in prolapse of uterus, 158
vaginalis, 377

Cysto-vaginal hernia, 377

Cysts of canal of Nuck, 397
of kidney, 63
of parovarium, 293
of terminal vesicle of oviduct, 296

D.

Date of cessation of menstruation, 432

Deaf-mutism, 840

Deafness after mumps, 839
scarlet fever, 839
in acute catarrh of middle ear 821
of cerebro-spinal meningitis, scarlet fever, and mumps, 839

Decidua as the local cause of abortion, 488

Decubitus in treatment of vaginitis, 371

Definition and synonyms of parametritis, 209
of pelvic hæmatocele, 240
of abortion, 467
of acne, 641
of acne rosacea, 647
of albinismus, 676
of albuminuria, 34
of angioma of the skin, 688
of atresia, 373
of atrophia cutis, 683
of atrophia pilorum propria, 682
of callositas, 662
of carbunculus, 606
of chloasma, 659
of chronic diffuse nephritis, 85
metritis, 450
parenchymatous nephritis, 80
of chyluria, 114
of clavus, 663
of cornu cutaneum, 663
of cysts of canal of Nuck, 397
of dermatitis herpetiformis, 611
of dermatolysis, 675
of displacements of uterus, 150
of ecthyma, 653
of eczema vesiculosum, 627
of elephantiasis, 674
of the vulva, 399
of erythema nodosum, 596
of fibroma of the skin, 686
of functional disorders in connection with the menopause, 432
of furuncles of labia, 392
of furunculus, 604
of hæmatoma, 401
of herpes iris, 609
simplex, 607
zoster, 610
of hypertrichosis, 669
of impetigo, 651
contagiosa, 652
of keloid, 685
of keratosis pilaris, 660
of lentigo, 658
of lichen ruber, 623
of lupus erythematosus, 689
vulgaris, 693
of miliaria, 654
of morphoea, 672
of myalgia, 529
of nævus pigmentosus, 666
of nystagmus, 783
of onychauxis, 669
of ovariotomy, 313
of pemphigus, 656
of perimetritis, 227
of phlegmonous inflammation of the labia majora, 391
of pityriasis rosea, 621
rubra, 622
of pompholyx, 655
of progressive muscular atrophy, 540
of prolapsus vaginæ, 376
of prurigo, 639
of pruritus, 711
hiemalis, 714
vulvæ, 392
of psoriasis, 614
of pseudo-hypertrophic paralysis, 557
of pudendal hernia, 398
of sarcoma of the skin, 710
of scabies, 726
of sclerema neonatorum, 671
of scleroderma, 671
of scrofuloderma, 698
of seborrhoea, 586
of seminal incontinence, 134
of sycosis, 649
of syphilis cutanea, 699
of tinea circinata, 717
favosa, 715
sycosis, 723
tonsurans, 720
tricophytina, 717
versicolor, 724
of urethral caruncle, 403
of urticaria, 597
of vaginitis, 368
of verruca, 664
of vitiligo, 677
of vulvitis, 389

Degrees of prolapse of uterus, 154

Delhi boil as a variety of furunculus, 606

Dementia in ophthalmology, 792

Demodex folliculorum, 732

Depletion in the treatment of chronic metritis, 458

Dermatalgia, 711

Dermatitis, 600
exfoliativa, 623
gangrenosa, 604
herpetiformis, 611
traumatica, 600
venenata, 600

Dermatolysis, 675

Dermoid cysts of ovary, 299

Descent of uterus, 154

Description of alopecia areata, 680
of cystic tumors of ovary, 301
of dilatation of the uterus in women, 355
of dislocation of the urethra in women, 360
of erythema multiforme, 595
of inflammation of urethral glands in women, 354
of kidneys, 19
of milium as a disease of skin, 592
of ovaries and oviducts, 282

Development of the ovum, 477

Diabetes insipidus (see _Polyuria_), 27
mellitus, effects of, in medical ophthalmology, 796
in pregnancy, 416
in relation to diseases of the eye, 796

Diagnosis of abortion, 505
of acne, 642
of acne rosacea, 647
of acute catarrh of middle ear, 822
endometritis, 461
metritis, 449
purulent inflammation of middle ear, 826
urethritis in women, 353
of alopecia areata, 681
of anteflexion of uterus (acquired), 177
of anteversion of uterus (pathological), 175
of atrophia pilorum propria, 683
of atrophia unguis, 683
of calculous pyelitis, 49
of cancer of the vagina, 383
of carcinoma of the uterus, 276
of chronic endometritis, 464
metritis, 456
purulent inflammation of middle ear, 828
of cystic tumors of the ovary, 304
of cystitis in wound, 344
of cysts of parovarium, 295
of dermatitis herpetiformis, 612
of dilatation of urethra in women, 358
of dislocations of the urethra in women, 361
of disorders of function of uterus, 186
of displacements of uterus, 151
of dysmenorrhoea, 194, 195
of ecthyma, 653
of eczema, 629
of eczema of auricle, 811
of epilepsy in pregnancy, 423
of epithelioma of the uterus, 279
of fibroid tumors of the ovary, 297
of fibrous tumors of the uterus, 252
of floating kidney, 24
of foreign bodies in the external ear, 816
of furuncle of the external auditory canal, 814
of furunculus, 605
of hæmatoma, 401
of hemorrhage from bladder, 135
of herpes iris, 609
zoster, 611
of hyperæmia of bladder in women, 339
of hypertrophy of the bladder in women, 348
of impacted cerumen in the external auditory canal, 813
of imperforate hymen, 374
of impetigo contagiosa, 652
of lichen ruber, 624
scrofulosus, 625
of lupus erythematosus, 690
vulgaris, 694
of malformations of ovaries and oviducts, 283
miliaria, 654
of malignant icterus in pregnancy, 415
tumors of the ovary, 298
of molluscum epitheliale, 662
of morphoea, 673
of myalgia, 537
of parametritis, 215
of pemphigus, 657
of perimetritis, 231
of phlegmonous inflammation of the labia majora, 391
of pityriasis rosea, 621
of polyuria, 31
of progressive muscular atrophy, 552
of prolapse of ovary, 288
of uterus, 159
of prurigo, 640
of pruritus, 712
of pseudo-hypertrophic paralysis, 578
of psoriasis, 616
of pyelitis, 84
of renal colic, 44
of retroversion of uterus, 166
of sarcoma of the skin, 710
of sarcomatous tumors of the uterus, 272
of the vagina, 382
of scabies, 727
of seminal incontinence, 141
of stricture of the urethra in women, 364
of sycosis, 650
of syphiloderma erythematosus, 700
of tinea circinata, 718
favosa, 716
tonsurans, 721
versicolor, 725
of tuberculosis of kidney, 65
of urethral caruncle, 403
of vaginismus, 385
of vaginitis, 371
of verruca, 665
of the vomiting of pregnancy, 410

Diarrhoea during the menopause, 439, 440
in pregnancy, 414

Diet in hygienic treatment of vomiting of pregnancy, 410
in preparation of the patient for ovariotomy, 317

Differential diagnosis of parametritis, 215

Difficulties in diagnosis of floating kidney, 25

Digital uterine examinations, 152
touch in retroflexion of uterus, 168

Digitalis as a cause of dermatitis medicamentosa, 603
in treatment of chronic congestion of kidney, 72

Dilatation of the urethra in women, 355

Dilators in the treatment of vaginismus, 386

Diphtheria as a cause of inflammation of middle ear, 819

Diseases of bladder, 123
in women, organic, 339
of digestive system, effects on eye, 749
of ear, see _Otology_.
of eye, see _Ophthalmology_.
of external auditory canal, 811
of internal ear, 835
of kidneys and skin, affecting eyes, 752
in pregnancy, 416
of liver in pregnancy, 414
of lungs in pregnancy, 430
of middle ear, 817
of nervous system, affecting eye, 771
of organs of respiration, effects of, on eye, 748
of ovaries and oviducts, 282
of parenchyma of uterus, 447
of skin, 583
in pregnancy, 420
of uterus, 67
of urinary organs in women, 339
of vagina and vulva, 367
of vulva, 388

Dislocations of the urethra in women, 360

Disorders of alimentary canal during menopause, 440
in pregnancy, 408
of function during menopause, 432

Disordered functions of uterus, 182

Disorders of liver during menopause, 441
of secretion, 583
of special senses in pregnancy, 423

Displacements of uterus, 150
as a cause of disturbed vision, 757

Distribution, geographical, of chyluria, 115

Disturbances in circulation in pregnancy, 408
of vision caused by diseases of sexual organs, 755

Diuretics in treatment of calculous pyelitis, 51
in medical treatment of diseases of kidneys in pregnancy, 449

Diurnal pollutions in sexual incontinence, 138