rupture may be converted into a tedi- permanent deleterious effects. ous and dangerous suppuration. 5. In fractures of the temporal bone, or base of the skull, the diagnostic significance of a serous discharge from the ear depends on the time of its appearance; if it occurs immediately it is probably cerebro-spinal fluid, if only after twenty-four hours or longer it is probably from inflammation of the middle ear. DISCUSSION. DR. ADOLPH O. PFINGST: The essayist has presented many points of interest not only to specialists in this line, but to surgeons and general practitioners, as the latter often see these injuries. To consider first the variety of injuries to the membrana tympani which are the result of direct tarumatism by perforating wounds, I believe much of this might be avoided if we would be a little more careful in impressing our patients as to the manner of cleaning their ears. It has been my practice in adults, where there was sufficient discharge to call for irrigation, to use a plain rubber tube on a fountain syringe instead of a glass tube; the glass tube, especially the medicine dropper which is ordinarily used, is very dangerous. Injuries of this kind are usually brought about by persons while cleaning their ears with toothpicks, matches, hairpins, etc. Their attention is suddenly called to something else, or they are frightened, they turn their head, strike their elbow against something, and the instrument with which they are attempting to clean their ears is driven through the drum membrane. I re member one case where a lady was cleaning her ear with the point of a pencil; her attention was called to something quickly; she turned her head and drove the pencil through the drum membrane into the middle ear. As to the variety of cases that come from fractures and thus extending into the drum membrane: We sometimes have quite extensive fractures around. the petrous bone without causing any I will cite one case briefly, which was rather out of the ordinary: A young boy of 12 years on roller skates had hold of a rope; his playmate threw him around and his head was struck against a telegraph pole; he was unconscious for a few minutes, was carried into the house, and blood was coming from the external auditory canal and also from the pharynx; a physician called in at the time of the accident thought there had been some internal injury and supposed the blood came from the stomach. Upon examination the blood was seen running down from the posterior pharyngeal wall. The boy recovered promptly without any apparent permanent injury. I As to the variety that come from a blow directly upon the ear: It is these cases that are more particularly of interest from a forensic standpoint. remember such a case which I saw in Berlin, in the clinic of Dr. Lucae. In these cases not infrequently you will find calcareous deposits in the drum. membrane; where rupture occurs from noises or slight blows the drum membrane is often the seat of calcareous deposits, and is thereby rendered more inelastic and more liable to rupture. In Germany it is the custom of the master mechanics to box the ears of their apprentices in reprimanding them. The case I refer to had received an injury of this kind, and evidently rupture had followed, but unfortunately for him he did not appear at the clinic for several days thereafter, when all signs of traumatic injury were obscured. I may again call attention to the point made by the essayist as to the danger of syringing in these cases; they ought to be left alone; this boy had syringed his ear, and after a few days had passed there was suppuration, and at that time it was hard to make out whether the injury resulted from the blow he had received or whether it was an old otitis. As to involvement of the labyrinth: These are the cases that possess the greatest forensic interest if you can make out that there is involvement of the labyrinth. If there is but partial loss of hearing, it is sometimes hard to tell whether or not the patient is malingering, but if there is complete loss of hearing the difficulties are not so great. If the patient has complete loss of hearing upon one side, by the practical methods now in use, by means of the stethoscope, we can easily determine the question, having the side extending into the good ear closed unknown to the individual and talking through the other side. Before closing I want to make one more point, that is the lax idea the laity have in general in regard to perforation of the drum membrane: If you say anything to the laity about a hole in the drum membrane they think "it is all off." We know, however, that the drum membrane heals readily where no infection has occurred. DR. WM. CHEATHAM: One cause of rupture of the drum membrane which the essayist did not mention, and which I have observed in two or three cases, is pulling the ear, especially in children; catching hold of the auricle and pulling it down and forward; this may tear it from its attachments. Schrapnell's membrane is simply a continuation of the wall of the external auditory canal, and by pulling the ear you can tear the membrane loose. I have seen one case of rupture of the drum membrane from a candle fly; a lady came to me one morning and said she had gotten a fly in her ear the night before. I found that the fly had scratched a hole in the drum membrane nearly the size of its body, and was lying buried in this perforation dead when I saw the patient. It looked a little remarkable to me that the soft feet of a candle fly could tear a hole in the drum membrane. I have seen two cases where doctors had pushed a foreign body into the middle ear cavity, rupturing the drum membrane, by their efforts to extract the foreign body. They had used for ceps, probes, etc., in their efforts to extract the foreign body, instead of depending upon the syringe. Of course, where the foreign body is a bean, piece of paper, or anything that will swell quickly when it comes in contact with hot water, it is better not to syringe the ear, but pick out the foreign body with an instrument. I have seen two cases caused by a knitting needle in the manner described by Dr. Pfingst. An old lady sitting in a chair picking her ear with a knitting needle, being suddenly attracted by something, in turning her head drove the needle through the drum membrane. I have seen one case from a twig; a man was riding through the woods and the twig of a tree entered his ear and ruptured the drum membrane. I have seen one case from a hairpin, also one from a piece of stiff paper which was rolled up in the form of a pencil, the sharp point rupturing the drum membrane. I have seen two cases from openhand blows over the ears, and have seen several from head injuries. We have all read of the dangers of sepsis in cases of rupture of the drum membrane associated with fracture of the bone at the base of the brain, etc. I have seen a good many of these cases and have never seen any fatal results from it. I remember one man who had his ear crushed, so to speak, between two logs; both drum membranes were ruptured; he had paralysis and several other complications, but finally made a good recovery. As to the escape of the cerebrospinal fluid in the cases, i. e., whether it is really cerebro-spinal fluid or not: I saw an article some time ago which gave a formula for testing this fluid to determine whether or not it was cerebrospinal. We sometimes have the escape of fluid from the nose following injuries which is said to be cerebro-spinal fluid; they make what is called a sugar test to differentiate this from serum. Dr. Dabney spoke of the tuning fork: I do not think he carried it far enough for differentiating between involvment of the petrous portion, where the internal ear is more liable to be involved, and simple involvement of the tympanic cavity. When the internal ear is injured deafness is great; you will find the drum membrane ruptured and the middle ear filled with blood. The differential diagnosis with the tuning fork can be readily made. DR. A. M. VANCE: I was interested in that part of Dr. Dabney's paper referring to fractures at the base of the brain: I do not agree with him that the cerobro-spinal fluid is poured out within twenty-four hours after the injury; my experience is that this fluid first appears not earlier than two or three days, and it is usually much later. DR. JAMES HEFFERNAN: I have seen two cases of perforation of the drum membrane; one of them I saw directly after it occurred. Two little boys, brothers, were playing together, and by some means one of the drum membranes was ruptured. I saw the case immediately afterward; hemorrhage was rather profuse; I did nothing for it except to put in some antiseptic cotton; the child recovered promptly with apparently good hearing. The second case was a man 40 years of age, who gave the history that he was riding through the woods and a short twig penetrated his ear. He said he fell from his horse, pain was intense, and he seemed to lose consciousness. For a number of years after that he had occasional seizures resembling epileptiform attacks. After a time these attacks ceased, and when I saw him he had some function in the injured ear, but could not locate sound. I could see a cicatrix in the left drum membrane. If the right ear was closed and he was spoken to, he could hear with the left ear, but could not locate the sound. Hearing in his left ear was reduced probably one-half. I have often wondered what was the cause of his inability to locate sound. occur to me, both of which have already been spoken of. The first was the point the essayist made as to the danger of infecting the middle ear cavity by washing out the ears. The first impulse of the layman, following an injury to the internal ear, is to wash it out; and in washing things out he almost necessarily washes things in. Most of these injuries that the general surgeon sees are associated with more serious injuries, and the injury to the ear itself loses much of its importance on account of the greater gravity of the other conditions. I believe it seldom happens that following injuries of this kind infections are observed which seem to have had their origin in the auditory canal through any fracture which has gone through the base of the brain. I take it this is largely for the reason that treating them on general surgical principles they have no good avenues for infection; that is, nearly all surgeons in a case of this kind would simply wipe away the blood or fluid with gauze or cotton without making any effort to wash it out thoroughly. Another reason would be that you have nature's method of cleansing the wound in nearly all of these cases—a stream of aseptic fluid (blood) which washes through the channel, and which apparently would do the work very well if left to itself. It has seemed to me in the cases I have seen of this nature, that the escape of the cerebro-spinal fluid is not as apt to occur at once as it is to occur later, as Dr. Vance has stated. My own explanation of that would be that nearly always where a fracture of this kind has occurred you first have a decided hemorrhage; on the cessation of this hemorrhage you have the formation of a blood clot; this blood clot acts as an occluding agent for some little time, and when this breaks down and comes away then any fluid behind it comes away with it. Certainly as we see granulating or healing wounds, which are healing by first intention, DR. J. B. BULLITT: Only two points without infection in other parts of the body it would be exceptional to see any large amount of fibrinous material thrown off, and why it should occur here more than other places would be hard to understand or explain. It would be easy to understand how a large amount of fluid could be thrown off secondarily after the blood clot had broken down and had been thrown off. As the general surgeon sees these cases, it seems to me that the hypothesis on which the essayist spoke is probably not the correct one. DR. S. G. DABNEY: I believe Dr. Cheatham said that he had only seen two cases of rupture of the drum membrane from boxes on the ear; I have seen a number of them, I believe six in all. Another rather curious thing is, that Bacon in a recent report states that puncture of the drum membrane by a twig is very rare, and mentions one case; yet three such cases have been reported here to-night. Though my experience with injuries from boxing blows on the ear has been perhaps a little more than the average, I know nothing practically from my own experience about the point the general surgeons have spoken of. I put in quotation marks that portion of my paper in regard to discharge of the cerebro-spinal fluid from the ear. The quotation is from one of the latest English writers, Hoevel. From a medico-legal standpoint it is important to know whether there was any pre-existing disease of the drum membrane, because in that case it would be far more easily ruptured. Dr. Bullitt is familiar with the case of the young man referred to in this pa loudly in the defective ear when placed on the vertex. If the disease is in the labyrinth it will not be heard so well. I do not believe the labyrinth is quite as liable to be injured when the drum membrane is ruptured as when it is not. I have only seen one case of disease of the labyrinth from loud noises; a gentleman in this city was spending the summer at Petoskey; he was standing near a cannon when it exploded, and from this he evidently had disease of the labyrinth. The prognosis is more serious in these cases than when the drum membrane is involved. THE LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.* Stated Meeting, April 18, 1902, William Cheatham, President pro tem., in the Chair. UTERINE FIBROIDS; TUBO-OVARIAN ABSCESS; DERMOID TUMOR. DR. L. S. McMURTRY: I have selected four pathological specimens from operations done during the past ten days to present to the Society this evening. These specimens are all fresh and illustrate some most interesting features of pathology connected with the pelvic organs. The pathology of no other region of the body gives such endless variety of lesions as may be found in connection with the pelvic organs in women. The first specimen is from a case operated on before the class of the Hospital College of Medicine at the Graystreet Infirmary on Wednesday last. It is a very large multi-nodular fibroid tumor of the uterus, weighing 18% pounds. The tumor is interstitial and subserous, growing from the uterus as a center and leaving that organ in partial integrity so as to render the operation exceedingly easy. The patient was a married woman, 35 years of age, Stenographically reported for this journal by C. C. Mapes, Louisville, Ky. sterile, and the growth was first observed about four years ago. It will be observed in the specimen that the mucous membrane of the uterus was not molested by the tumors, and consequently menstruation was not excessive or abnormal. The patient's nutrition was consequently maintained fairly well and her symptoms were altogether those of pressure. Emaciation has increased markedly during the past year, and the interference with digestive functions and respiration impelled her to seek operative treatment. The omentum was adherent to the anterior aspect of the tumor, and presented the largest venous sinuses in its meshes that I have ever observed. The tumor also was engorged with blood, and large sinuses may be seen coursing through and between the nodules. I am sure the tumor was very materially fed by its vascular connections with the omentum. I need not dwell upon the operative procedure beyond a brief allusion to the technique applied to the pedicle. The evolution of the operation for fibroid uterine tumors has centered about the treatment of the pedicle, which is the cervix uteri. After havAfter having practiced the extra-peritoneal method with the neude and total hysterectomy (removing the cervix entirely), I have for several years practiced almost exclusively the method of supra-vaginal amputation with extra-peritoneal pedicle. Indeed, this is now the method generally practiced in America, and ast perfected leaves little to be desired. The mortality of this operation has been reduced to as low a rate as in the operation of ovariotomy. It has been a question of much difficulty to prevent infection about the pedicle, which is sequestrated beneath the pelvic peritoneum. It will be remembered that with careful hæmostasis this pedicle is anemic and left in the loose space beneath the peritoneum that is stitched over it across the floor of the pelvis. The cervical canal may be infected at the time of operation, and communicates with the vagina. The sub-peri toneal space in which the pedicle rests is frequently a dead space, and fills with serum and effused blood to stand there inviting infection and abscess. I have never lost a patient from such an abscess about the pedicle, but convalescence is always delayed and much distress produced by this condition which formerly occurred in a certain proportion of my cases. I adopted a method which is not peculiar to myself, but I think I have modified a very important feature for preventing this complication of suppuration about the pedicle. After amputating the tumor low down by a wedge-shaped incision, and securing thorough hæmostasis by a few cat-gut sutures upon each side, I take a small knife and enlarge the cervical canal by cutting away the mucous membrane, thus making a free opening into the vagina. The vagina, I should say, is always thoroughly cleansed and disinfected preparatory to this operation. Through the opening thus made in the pedicle I pass a small wisp of gauze into the upper vagina, leaving sufficient in the sub-peritoneal space to facilitate capillary drainage. The modification I have made of gauze drainage as generally practiced here is to enlarge the cervical canal and lessen the quantity of gauze. This drain is permanently removed at the end of forty-eight hours by introducing one finger into the vagina and making gentle traction. I have practiced this method in a large proportion of all my cases during the past two years, and have not had suppuration about the pedicle in a single case in which it has been applied. The second specimen is also one of uterine fibroid tumor, and from another patient. It illustrates an entirely separate and distinct pathological picture and clinical manifestation of this class of uterine tumors. You will observe that it is a small interstitial and sub-mucous fibroid growth which has distorted the cavity of the uterus and very greatly expanded the mucous. membrane lining the uterine cavity. It |