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PHTHISIS AND INDUSTRIALISM.
985 and having done so, they have generally acquired was performed, and 15 cm. of the nerve was resected. the right to wear robes of a sort which by themselves the diaphragm was seen two dayslater to have ascended would compel the artist to take an interest in the a hand-breadth and to be completely immobile. Yet work. There are. however, this year only two or there is no record of any great distress or pain, and.
under the category. as Mr. H. Morriston Davies pointed out in THE come portrait of Dr. Matthew Hay, LANCET of Feb. 28th, this freedom from pain and by Mr. Charles Sims, one of Sir Humphry Rolleston, respiratory distress would seem to be the rule rather by Mr. George Henry, and one of Sir Donald Mac_lister, than the exception. Exairesis is evidently a valuable by Mr. Maurice Greiffenhagen. The portrait of Dr. means, in carefully selected cases, of limiting the Matthew Hay is on the wall that bears the Sargent movements of the lung and thus giving it that rest portrait of the Marchioness Curzon and Sir William which is so essential to the healing of tuberculous Orpen’s cryptic "Man versus Beast." The subject lesions. It is, of course, the basal lesion which is most wears scarlet and puce robes to which the artist, as suitable for this treatment, and it is well, as pointed The rather out by the authors of the French paper to which we a brilliant colourist, has done full justice. fixed gaze of the eyes is open to criticism, but it is a have already referred, that the disease should be of striking performance. Mr. Henry’s presentation of a fibrotic character with a natural tendency to healing. Sir Humphry Rolleston is quiet and dignified. It is essentially a pleasant picture. A. characteristic expression of the subject has been faithfully rendered, and the general effect of the dark blue robe is restful THE HARVEY MEMORIAL AT HEMPSTEAD and yet important. Of a very different category is CHURCH. the portrait of Sir Donald MacAlister. This is a FROM 1657 to 1883 the body of William Harvey genuine tour de force in reds, only the face being shown and the shoulder line swathed in the scarlets lay in the vault of the Harvey Chapel in Hempstead and pinks of the Doctor’s gown. The face is presented Church, Essex, whence it was removed in 1883 and to us absolutely full, and the colouring is almost re-interred in a marble sarcophagus, provided by the harsh in its boldness, while not a stroke has Royal College of Physicians of London, within the been inserted that does not in some way help to church. It is now proposed to rebuild the tower of bring out the force and intellectual ability of the church as a further memorial, at a probablethe man. The picture has, of course, been painted cost of .85000, of which M50 have been contributed The parish is small and chiefly agricultural, by an artist who has had every opportunity of locally. and it is hoped that laymen as well as the members of A it is not entitled " his sitter knowing personally ; Presentation Portrait," and many would like to know the medical profession will contribute. The old tower
three
pictures
which
Among them is
a
fell in 1882 and of the five bells the tenor was shattered, the other four escaped injury and are hung in the churchyard. The original tower was a four-sided edifice, somewhat severe in style, in four stories with a battlemented top and two windows with. tracery. Times are hard and taxation is high, but medical men of all nations should feel it a duty to erect a tangible memorial of one of the great men OL their profession, and we earnestly hope that the There is no need to scheme may materialise. emphasise at this date the importance of Harvey’s discovery; suffice it to say that the whole of modern medicine depends upon it. And for those who are Churchmen the restoration of a church tower is an act of grace. Subscriptions may be sent to Dr. Sidney Phillips, Royal College of Physicians, Pall Mall East, to Mr. A. W. Ruggles-Brise, hon.. treasurer, Spains Hall, Braintree, or to the Rev. T. P. Conyers Barker, Hempstead Vicarage, Saffron. Walden, Essex.
what is to be its destination.
ARTIFICIAL UNILATERAL PHRENIC NERVE PARALYSIS. THE difference between artificial and " natural " unilateral phrenic nerve paralysis is like that between " an artificial and a natural " pneumothorax. The artificial lesions are almost painless and free from discomfort, whereas when morbid conditions cause either phrenic nerve paralysis or a pneumothorax, the patient is in a parlous state. It is interesting to note in the paper published by Sir Charlton Briscoe in THE LANCET of Feb. 21st, that he finds that " most patients with phrenic paralysis are too ill for prolonged examination, and cannot tolerate the supine posture for any length of observation." The question may be raised : Is the phrenic paralysis per se or are the morbid processes causing pressure on the phrenic a nerve responsible for the patient’s critical condition PHTHISIS AND INDUSTRIALISM. It is noteworthy in this connexion that artificial WE have already referred to the first and second paralysis of one phrenic may not only fail to embarrass Harben lectures for 1924, delivered by Prof. E. L. him but even relieve of a sense of the patient, may Collis. The publication of these has been completed discomfort in the affected side by virtue of section of in the May issue of the Journal of State ;.lledicine. certain sympathetic filaments running in the phrenic. The first two were devoted to determining whether, In a paper published by Dr. C. A. Perret, Dr. C. A.. if so, in what way, the rise of industrialism in and, A. in Presse l6Tedicale for the Piguet, and Dr. Giraud, different countries has influenced the prevalence and April llth, an account is given of the present position age-incidence of phthisis. The lecturer claimed the of artificial phrenic nerve paralysis in the treatment ! to be profound and, from its study, looks I ! influence of pulmonary tuberculosis. Therapeutic the occurrence of the disease as a reflection of in this field have done much to throw light on the upon the existence of malnutrition in early adult life and innervation of the diaphragm by the phrenic nerve. wear-and-tear in later life. The third lecture deals A few years ago the surgeons who performed simple with the question whether an alteration in agedivision or resection of a short section of the phrenic such as has taken place for phthisis, might I incidence, in the neck were surprised to find how little be a manifestation exhibited when epidemics of not diaphragm was affected thereby. Subsequent investiwax and wane. The records of measles, enteric gations have shown that several nerve filaments may fever, whooping-cough, diphtheria, influenza, and join the phrenic below the neck, and that if the particularly of scarlet fever are examined. Influenza phrenic is divided in the neck, and its distal end is provides evidence of an interesting occurrence: pulled out slowly so that the filaments joining it lower previous to 1918 the mortality from this disease had down can be included in the resected portion, almost displayed a normal curve. Then suddenly, in 1918, complete paralysis of the diaphragm ensues. This the curve altered and came to possess a remarkable process, known as exairesis or evulsion of the phrenic, peak in early adult life coinciding with the peak for has been performed by the authors in two cases with which had been growing higher phthisis mortality considerable success, whereas they did little good in and higher at that period of life as food scarcity the three cases in which they performed simple In one of the cases in which exairesis phrenicotomy. 1 THE LANCET, April 25th, p. 880. ____
experiments
the iinfection
I
I
986 The suggestion is made became more pronounced. that the similar phenomena thus exhibited by the two causes of mortality occurring at the same time and under similar conditions had a common origin. Only in the case of scarlet fever is a definite move in age-incidence to later years of childhood found to have occurred in the past half-century, while the mortality both from this disease and from phthisis has been falling. When, however, the age-incidence of attack during the rise and fall of epidemics of this disease was closely examined (for this purpose five years’, admissions to the Glasgow Fever Hospital were employed), no evidence of any significant difference in age-incidence was found ; in other words, no support was forthcoming for the view that the move over 50 years is epidemiological rather than social. The evidence produced in this lecture is at best only evidence by analogy ; it has clearly been collected .at the expenditure of much time and trouble. But whether, if sound, it really helps to assure us that the fall in phthisis mortality is not a mere dip in a long wave which must inevitably rise again is doubtful. Prof. Collis clearly holds an optimistic view and seeks ior foundations for his faith. Possibly others with access to other records will examine them and publish their results, for the matter is one of practical signifiIn any case, cance in efforts to eradicate tuberculosis. the effort shown in these lectures to interpret vital :statistics in the light of social conditions is to be welcomed. ____
THE ALLEVIATION OF DEAFNESS. IT is acknowledged by all otologists that the results of the treatment of chronic otitis media, otosclerosis, and nerve deafness have hitherto been disappointing. Only a few weeks ago Dr. J. Kerr Love,! President of the Section of Otology of the Royal Society of Medicine, said : " Outside of surgical treatment there has not been great advance in otology. We can hardly do more than we -could do fifty years ago for the cure of deafness. We are only beginning to try to prevent deafness, and the consequence is that the management of chronic deafness is largely in the hands of the empiricist and the quack."1
Any new method, therefore, which afforded a chance improvement of chronic deafness would be welcomed. Up to the present the treatment of deafness by so-called re-educative methods has not been received with general approval by otologists either in this country or abroad. There have been, it is true, a few enthusiastic protagonists of the method, such as Dr. J. Helsmoortel, of Antwerp, who published in 1913 a pamphlet on his successful results, .and Dr. A. Raoult,2 of Nancy, who reported in 1913 good results in 35 cases. At a meeting of the Scottish Otological Society in June, 1914, the late Dr. W. G. Porter3 reported favourable results in a few cases, but the outbreak of war left unredeemed his promise to report further. The method of treatment has laboured .and labours under several disadvantages. When it was first introduced into this country it was in the hands of medically unqualified persons. The instrument most commonly employed, the electrophonoide, was sold at what appeared to be an extravagant price ; though we are willing to believe that when the intricacy of the mechanism is considered the price is not an extravagant one. It is impossible to give a prognosis regarding the possible success with any deaf patient until a preliminary course of treatment has been undergone. Even after a full course of treatment the improvement in the hearing is not usually permanent ; in favourable cases it may continue for two or three years, but more commonly, even according to its most enthusiastic advocates,
of the
sion exists that in the camp of re-education the smoke of the incense burned to the Golden Calf Dr. A. A. is just a little too plainly discernible." Gray4 has dismissed the electrophonoide method as negligible because of the results in three of his patients who were treated by it ; in two there was no improvement, and in the third the improvement In this was so slight as to be of no importance. country the most important study of the method previously published has been that of Mr. F. F. Muecke,5who reported in 1914 that his experience with re-education had not been satisfactory. He treated 36 cases ; one was cured (a case of neurasthenic deafness) ; in three there was definite improvement ; ten improved but relapsed later ; and 22 remained in statu quo. The article by Mr. George C. Cathcart in this issue of THE LANCET has, therefore, some importance as being the first categorical summing-up in favour of this method of treating chronic deafness to be published in this country. The instrument he has employed is the " electrophonoide" of Mr. ZundBurguet, who, we believe, is a teacher of the deaf in Paris. The principle of this instrument is explained in the article, and the treatment apparently consists in vibration of the tympanic membrane, vasodilatation of the vessels of the tympanic membrane and the middle ear, and stimulation of the nerveendings in the internal ear, by vibrating ear-pieces which convey sounds corresponding to the registers of the human voice. Mr. Cathcart makes the very definite statement that of his 100 cases of chronic progressive deafness, selected only in the sense that each had been examined and dismissed as incurable by two or more fellow otologists, 68 per cent. have improved after treatment with the electrophonoide. Making every allowance for possible error, this is not a statement that can be gainsaid wholly by such a suggestion as that " the improvement in the mental condition is produced by such an imposing apparatus."6 In face of Mr. Cathcart’s figures and his restrained presentation of the case in favour of the method, the treatment of chronic deafness by mechanical " re-education " does indeed appear to deserve some serious consideration by
otologists. THE
____
ENDOCRINE FACTOR ARTHRITIS.
IN
CHRONIC
EXPONENTS of the septic-focus theory of the chronic arthritis can point to a long series of cases which have been markedly benefited, if not completely cured, by the removal of some hidden source of toxicity. Opponents of this theory can indicate an equally large army of sufferers who continue in the same condition despite ruthless extirpation of teeth, tonsils, appendix, and every other potential lurking place of bacteria. A possible reason for this discrepancy is put forward by Dr. A. K. Thompson in the Boston Medical and Surgical Journal of April 2nd. He points out that focal infection may lead directly to an arthritis, but that it may also produce an endocrine disturbance which causes joint affections in its turn. If this interference with the endocrine system has been induced, the removal of the primary focus will have no effect on the arthritic condition, which is maintained by the failure of the internal secretions. Various observers have noted the association between arthritis or rheumatism and modifications of the thyroid function, either of defect or of an incomplete Basedow’s syndrome. Lancereaux and Paulesco have recorded remarkable success it does not last for more than six to nine months, through the administration of thyroid in chronic Dr. Thompson divides arthritis into The method rheumatism. when a further course is necessary. In the " isotrophic group " he includes three groups. bear had to such adverse comments has, therefore, all cases which are not manifestly atrophic or as that of Dr. Dan McKenzie, that "the impreshypertrophic ; for these the method of treatment 1 Jour. Laryngol. and Otol., February, 1925, p. 110. 4 A. A. Gray, Otosclerosis, 1917, p. 165. 2 Arch. Internat. de Laryngol. d’Otol., et de Rhinol., July5 Jour. Laryngol. and Otol., November, 1914, p. 524. August, September-October, 1913. 3 6 Jour. Laryngol. and Otol., September, 1914, p. 470. Jour. Laryngol. and Otol., September, 1914, p. 469.
aetiology of
under the category. as Mr. H. Morriston Davies pointed out in THE come portrait of Dr. Matthew Hay, LANCET of Feb. 28th, this freedom from pain and by Mr. Charles Sims, one of Sir Humphry Rolleston, respiratory distress would seem to be the rule rather by Mr. George Henry, and one of Sir Donald Mac_lister, than the exception. Exairesis is evidently a valuable by Mr. Maurice Greiffenhagen. The portrait of Dr. means, in carefully selected cases, of limiting the Matthew Hay is on the wall that bears the Sargent movements of the lung and thus giving it that rest portrait of the Marchioness Curzon and Sir William which is so essential to the healing of tuberculous Orpen’s cryptic "Man versus Beast." The subject lesions. It is, of course, the basal lesion which is most wears scarlet and puce robes to which the artist, as suitable for this treatment, and it is well, as pointed The rather out by the authors of the French paper to which we a brilliant colourist, has done full justice. fixed gaze of the eyes is open to criticism, but it is a have already referred, that the disease should be of striking performance. Mr. Henry’s presentation of a fibrotic character with a natural tendency to healing. Sir Humphry Rolleston is quiet and dignified. It is essentially a pleasant picture. A. characteristic expression of the subject has been faithfully rendered, and the general effect of the dark blue robe is restful THE HARVEY MEMORIAL AT HEMPSTEAD and yet important. Of a very different category is CHURCH. the portrait of Sir Donald MacAlister. This is a FROM 1657 to 1883 the body of William Harvey genuine tour de force in reds, only the face being shown and the shoulder line swathed in the scarlets lay in the vault of the Harvey Chapel in Hempstead and pinks of the Doctor’s gown. The face is presented Church, Essex, whence it was removed in 1883 and to us absolutely full, and the colouring is almost re-interred in a marble sarcophagus, provided by the harsh in its boldness, while not a stroke has Royal College of Physicians of London, within the been inserted that does not in some way help to church. It is now proposed to rebuild the tower of bring out the force and intellectual ability of the church as a further memorial, at a probablethe man. The picture has, of course, been painted cost of .85000, of which M50 have been contributed The parish is small and chiefly agricultural, by an artist who has had every opportunity of locally. and it is hoped that laymen as well as the members of A it is not entitled " his sitter knowing personally ; Presentation Portrait," and many would like to know the medical profession will contribute. The old tower
three
pictures
which
Among them is
a
fell in 1882 and of the five bells the tenor was shattered, the other four escaped injury and are hung in the churchyard. The original tower was a four-sided edifice, somewhat severe in style, in four stories with a battlemented top and two windows with. tracery. Times are hard and taxation is high, but medical men of all nations should feel it a duty to erect a tangible memorial of one of the great men OL their profession, and we earnestly hope that the There is no need to scheme may materialise. emphasise at this date the importance of Harvey’s discovery; suffice it to say that the whole of modern medicine depends upon it. And for those who are Churchmen the restoration of a church tower is an act of grace. Subscriptions may be sent to Dr. Sidney Phillips, Royal College of Physicians, Pall Mall East, to Mr. A. W. Ruggles-Brise, hon.. treasurer, Spains Hall, Braintree, or to the Rev. T. P. Conyers Barker, Hempstead Vicarage, Saffron. Walden, Essex.
what is to be its destination.
ARTIFICIAL UNILATERAL PHRENIC NERVE PARALYSIS. THE difference between artificial and " natural " unilateral phrenic nerve paralysis is like that between " an artificial and a natural " pneumothorax. The artificial lesions are almost painless and free from discomfort, whereas when morbid conditions cause either phrenic nerve paralysis or a pneumothorax, the patient is in a parlous state. It is interesting to note in the paper published by Sir Charlton Briscoe in THE LANCET of Feb. 21st, that he finds that " most patients with phrenic paralysis are too ill for prolonged examination, and cannot tolerate the supine posture for any length of observation." The question may be raised : Is the phrenic paralysis per se or are the morbid processes causing pressure on the phrenic a nerve responsible for the patient’s critical condition PHTHISIS AND INDUSTRIALISM. It is noteworthy in this connexion that artificial WE have already referred to the first and second paralysis of one phrenic may not only fail to embarrass Harben lectures for 1924, delivered by Prof. E. L. him but even relieve of a sense of the patient, may Collis. The publication of these has been completed discomfort in the affected side by virtue of section of in the May issue of the Journal of State ;.lledicine. certain sympathetic filaments running in the phrenic. The first two were devoted to determining whether, In a paper published by Dr. C. A. Perret, Dr. C. A.. if so, in what way, the rise of industrialism in and, A. in Presse l6Tedicale for the Piguet, and Dr. Giraud, different countries has influenced the prevalence and April llth, an account is given of the present position age-incidence of phthisis. The lecturer claimed the of artificial phrenic nerve paralysis in the treatment ! to be profound and, from its study, looks I ! influence of pulmonary tuberculosis. Therapeutic the occurrence of the disease as a reflection of in this field have done much to throw light on the upon the existence of malnutrition in early adult life and innervation of the diaphragm by the phrenic nerve. wear-and-tear in later life. The third lecture deals A few years ago the surgeons who performed simple with the question whether an alteration in agedivision or resection of a short section of the phrenic such as has taken place for phthisis, might I incidence, in the neck were surprised to find how little be a manifestation exhibited when epidemics of not diaphragm was affected thereby. Subsequent investiwax and wane. The records of measles, enteric gations have shown that several nerve filaments may fever, whooping-cough, diphtheria, influenza, and join the phrenic below the neck, and that if the particularly of scarlet fever are examined. Influenza phrenic is divided in the neck, and its distal end is provides evidence of an interesting occurrence: pulled out slowly so that the filaments joining it lower previous to 1918 the mortality from this disease had down can be included in the resected portion, almost displayed a normal curve. Then suddenly, in 1918, complete paralysis of the diaphragm ensues. This the curve altered and came to possess a remarkable process, known as exairesis or evulsion of the phrenic, peak in early adult life coinciding with the peak for has been performed by the authors in two cases with which had been growing higher phthisis mortality considerable success, whereas they did little good in and higher at that period of life as food scarcity the three cases in which they performed simple In one of the cases in which exairesis phrenicotomy. 1 THE LANCET, April 25th, p. 880. ____
experiments
the iinfection
I
I
986 The suggestion is made became more pronounced. that the similar phenomena thus exhibited by the two causes of mortality occurring at the same time and under similar conditions had a common origin. Only in the case of scarlet fever is a definite move in age-incidence to later years of childhood found to have occurred in the past half-century, while the mortality both from this disease and from phthisis has been falling. When, however, the age-incidence of attack during the rise and fall of epidemics of this disease was closely examined (for this purpose five years’, admissions to the Glasgow Fever Hospital were employed), no evidence of any significant difference in age-incidence was found ; in other words, no support was forthcoming for the view that the move over 50 years is epidemiological rather than social. The evidence produced in this lecture is at best only evidence by analogy ; it has clearly been collected .at the expenditure of much time and trouble. But whether, if sound, it really helps to assure us that the fall in phthisis mortality is not a mere dip in a long wave which must inevitably rise again is doubtful. Prof. Collis clearly holds an optimistic view and seeks ior foundations for his faith. Possibly others with access to other records will examine them and publish their results, for the matter is one of practical signifiIn any case, cance in efforts to eradicate tuberculosis. the effort shown in these lectures to interpret vital :statistics in the light of social conditions is to be welcomed. ____
THE ALLEVIATION OF DEAFNESS. IT is acknowledged by all otologists that the results of the treatment of chronic otitis media, otosclerosis, and nerve deafness have hitherto been disappointing. Only a few weeks ago Dr. J. Kerr Love,! President of the Section of Otology of the Royal Society of Medicine, said : " Outside of surgical treatment there has not been great advance in otology. We can hardly do more than we -could do fifty years ago for the cure of deafness. We are only beginning to try to prevent deafness, and the consequence is that the management of chronic deafness is largely in the hands of the empiricist and the quack."1
Any new method, therefore, which afforded a chance improvement of chronic deafness would be welcomed. Up to the present the treatment of deafness by so-called re-educative methods has not been received with general approval by otologists either in this country or abroad. There have been, it is true, a few enthusiastic protagonists of the method, such as Dr. J. Helsmoortel, of Antwerp, who published in 1913 a pamphlet on his successful results, .and Dr. A. Raoult,2 of Nancy, who reported in 1913 good results in 35 cases. At a meeting of the Scottish Otological Society in June, 1914, the late Dr. W. G. Porter3 reported favourable results in a few cases, but the outbreak of war left unredeemed his promise to report further. The method of treatment has laboured .and labours under several disadvantages. When it was first introduced into this country it was in the hands of medically unqualified persons. The instrument most commonly employed, the electrophonoide, was sold at what appeared to be an extravagant price ; though we are willing to believe that when the intricacy of the mechanism is considered the price is not an extravagant one. It is impossible to give a prognosis regarding the possible success with any deaf patient until a preliminary course of treatment has been undergone. Even after a full course of treatment the improvement in the hearing is not usually permanent ; in favourable cases it may continue for two or three years, but more commonly, even according to its most enthusiastic advocates,
of the
sion exists that in the camp of re-education the smoke of the incense burned to the Golden Calf Dr. A. A. is just a little too plainly discernible." Gray4 has dismissed the electrophonoide method as negligible because of the results in three of his patients who were treated by it ; in two there was no improvement, and in the third the improvement In this was so slight as to be of no importance. country the most important study of the method previously published has been that of Mr. F. F. Muecke,5who reported in 1914 that his experience with re-education had not been satisfactory. He treated 36 cases ; one was cured (a case of neurasthenic deafness) ; in three there was definite improvement ; ten improved but relapsed later ; and 22 remained in statu quo. The article by Mr. George C. Cathcart in this issue of THE LANCET has, therefore, some importance as being the first categorical summing-up in favour of this method of treating chronic deafness to be published in this country. The instrument he has employed is the " electrophonoide" of Mr. ZundBurguet, who, we believe, is a teacher of the deaf in Paris. The principle of this instrument is explained in the article, and the treatment apparently consists in vibration of the tympanic membrane, vasodilatation of the vessels of the tympanic membrane and the middle ear, and stimulation of the nerveendings in the internal ear, by vibrating ear-pieces which convey sounds corresponding to the registers of the human voice. Mr. Cathcart makes the very definite statement that of his 100 cases of chronic progressive deafness, selected only in the sense that each had been examined and dismissed as incurable by two or more fellow otologists, 68 per cent. have improved after treatment with the electrophonoide. Making every allowance for possible error, this is not a statement that can be gainsaid wholly by such a suggestion as that " the improvement in the mental condition is produced by such an imposing apparatus."6 In face of Mr. Cathcart’s figures and his restrained presentation of the case in favour of the method, the treatment of chronic deafness by mechanical " re-education " does indeed appear to deserve some serious consideration by
otologists. THE
____
ENDOCRINE FACTOR ARTHRITIS.
IN
CHRONIC
EXPONENTS of the septic-focus theory of the chronic arthritis can point to a long series of cases which have been markedly benefited, if not completely cured, by the removal of some hidden source of toxicity. Opponents of this theory can indicate an equally large army of sufferers who continue in the same condition despite ruthless extirpation of teeth, tonsils, appendix, and every other potential lurking place of bacteria. A possible reason for this discrepancy is put forward by Dr. A. K. Thompson in the Boston Medical and Surgical Journal of April 2nd. He points out that focal infection may lead directly to an arthritis, but that it may also produce an endocrine disturbance which causes joint affections in its turn. If this interference with the endocrine system has been induced, the removal of the primary focus will have no effect on the arthritic condition, which is maintained by the failure of the internal secretions. Various observers have noted the association between arthritis or rheumatism and modifications of the thyroid function, either of defect or of an incomplete Basedow’s syndrome. Lancereaux and Paulesco have recorded remarkable success it does not last for more than six to nine months, through the administration of thyroid in chronic Dr. Thompson divides arthritis into The method rheumatism. when a further course is necessary. In the " isotrophic group " he includes three groups. bear had to such adverse comments has, therefore, all cases which are not manifestly atrophic or as that of Dr. Dan McKenzie, that "the impreshypertrophic ; for these the method of treatment 1 Jour. Laryngol. and Otol., February, 1925, p. 110. 4 A. A. Gray, Otosclerosis, 1917, p. 165. 2 Arch. Internat. de Laryngol. d’Otol., et de Rhinol., July5 Jour. Laryngol. and Otol., November, 1914, p. 524. August, September-October, 1913. 3 6 Jour. Laryngol. and Otol., September, 1914, p. 470. Jour. Laryngol. and Otol., September, 1914, p. 469.
aetiology of