peripheral cases, it has been the habit of surgeons to employ eserin, with the hope that under the influence of the contraction of the pupil the iris will be drawn from its attached position in the corneal periphery. My experience, however, is that eserin is very apt to increase ciliary irritation, and is not an accept able drug in traumatic prolapse of the iris. I make exception of a few cases of prolapse after cataract extraction, in which I have seen it act very favorably. Moreover, abscission of an extensive prolapse across the corneal breadth results not in a small, smooth coloboma, but in a more or less unshapely loss of iris tissue. Touching this point, the following illustrative case may be introduced: CASE IV.-Mary H., a child about one year of age, was brought to the Jefferson Medical College Hospital on March, 24, 1897, with the history that she was struck in the eye with a piece of metal attached to a window blind. The accident occurred four days before her entrance into the hospital. She had been under treatment in another institution, but the parents becoming dissatisfied, they had sought other advice. The wound extended from a half millimeter in the upper ciliary region, in a ¦ curvilinear manner, downward across the cornea, terminating a little beyond its middle. The iris was extensively prolapsed and the eyeball congested, but as far as could be seen there was no injury of the deeper structures. The treatment consisted entirely of pressure bandage and atropin, and resulted in a steady subsidence of the prolapse, so that at the present writing the eye is nearly white and quiet, with a small, non-protruding attachment of the iris near the center of the wound, with the indications that it will be entirely withdrawn into the anterior chamber, the drag on the iris by means of the atropin toward the periphery having been sufficient to draw this tissue out of the lips of the wound, except at the point mentioned. Bacteriologic examination is an important factor in deciding whether or not there should be surgical interference in cases of prolapse of the iris seen late --that is, after closure of the wound by adhesive inflammation. As has been pointed out by Knapp, the surrounding cornea is infiltrated with microorganisms, although the iritic tissue itself may be free from them. A case in point is the following: CASE V.-A boy about ten years of age came to me ten days after he was struck in the right eye with a sharp stick, which cut a ragged wound at the inner side of the cornea, extending vertically across its entire breadth. The iris tissue was clamped in the wound and protruding, and a grayish line was manifest about the center of this tissue and extended somewhat into the corneal area. to be partially opaque. The lens appeared Inoculations from the conjunctiva, which had been frequently washed with a saturated solution of boric acid by the attending physician and had been cleansed only a short time before the inoculation was made, proved to be sterile. Inoculations from the grayish line previously described, which, it should be understood, was not in the iris tissue itself, but on the surface of the lymph which covered it, and in the surrounding corneal tissue, yielded a perfectly pure culture of staphylococcus cereus albus. Although the child was brought with the expectation of operative interference, advice against reopening the wound and abscissing the prolapsed iris was given. The situation of the prolapse was such that the favorable action of atropin could be obtained; there were no marked signs of bandage irritation or ciliary congestion; and opening of the wound would, it seems to me, only have liberated, as it were, staphylococci and presented to them paths for en trance into the deeper ocular structures. Hence, the advice of expectant treatment, with the suggestion that probably later the case would have to be dealt with on the principles which govern the management of traumatic cataract. III. Cases of Prolapse of the Iris Through a Corneal or Corneoscleral Wound, Associated with Lesion of the Underlying Structures, Generally the Crystalline Lens.-Certainly no hard and fast rule can be given to cover all cases, which, however, naturally divide themselves into two chief classes: 1. Those cases in which the lesion is so extensive that conservation of the eye is problematical. With these instances we are not specially concerned this evening. 2. Those cases associated with injury of the lens and followed by opacification and swelling of its tissue. The urgency of the symptoms and the age of the injury must decide action. Some of these cases must be relegated to the class already referred to and illustrated by an example to which expectant and primarily non-operative treatment is suited. others, both lesions may be dealt with at one sitting. In CASE VI.-For example, in a case not long since under my care, the wound being in the upper portion of the cornea and seen about ten or twelve days after the accident, the lens being opaque and partially protruding into the anterior chamber, a small, upward corneal section was made, the prolapsed iris seized and removed, and the soft lens-matter expressed through the wound. The primary vision, without treatment of the capsule, was 8. Subsequently there was thickening of the capsule and the vision dropped to. The patient declined to allow division of the membrane. Such a procedure, if possible, seems to me more desirable than a primarily non-operative course, for, at all events, operation later on is sure to be needed. IV. Cases of Prolapse of the Iris Through a Corneal Wound, with Prolapse of the Ciliary Body or Process Through its Scleral Extension. - Under these circumstances, my experience coincides with that recently recorded by Dr. Knapp. The iris portion of the hernia may become quiet, or even withdrawn into the anterior chamber, while the ciliary end of the lesion forms a cyst-like protuberance. Therefore, if I see a case of this character, and it is a proper one for this manipulation, I clear the wound of all protruding ciliary tissue, if I may so express myself, and close it with sutures. These sutures are passed, however, through the conjunctiva overlying the wound and not through the sclera; at least, I am disinclined to pass them through the sclera unless absolutely sure that this can be done without inclusion of any uveal tissue in the stitch. If the case is seen late, i.e., after the cyst has formed, the latter is excised and the eye treated exactly as after abscission of pouch-like hernias of the iris already described. While it is true, as pointed out by Knapp, that prolapses of the ciliary tissues "are apt to produce cyst-like ectasias which, for their cure, require thorough excision," this rule also meets with exception. CASE VII. A girl, aged eleven, came to the Jefferson Medical College Hospital in the early portion of 1896, with the history that one year previously she had been wounded in the right eye with the tine of a fork. Downward and inward in the ciliary region, about four millimeters from the corneal margin, was a small, translucent, cyst-like ectasia, with dark-colored base. The eye was otherwise normal. Complaint was made of pain, watering, and photophobia of the left eye, and, apprehensive of sympathetic trouble, the patient was kept under observation for some time. She then disappeared from view, and was not again seen until the present month-more than two years after the injury, when the cyst, about the size of a small pea, was found in exactly the same condition as at her first visit. In the meantime the refractive error had been corrected, and both eyes were quiet and comfortable. V. Management of the Adherent, Non-bulging Cicatrix After Healing of an Iris Prolapse.-As may have been gathered from what has been previously said, one of the chief advantages of operative interference in traumatic prolapse of the iris, under those circumstances in which I believe it to be not only justifiable, but the best procedure, is the securing of a non-adherent cicatrix. Now, although eyes which have healed without infective inflammation and without surgical interference are usually perfectly quiet, non-irritable organs, in a certain number of cases, the slight drag on the attached iris during the movements of the pupil is the cause of pain and discomfort. Therefore, I would like to add one word in regard to what I may call the treatment of the sequel of prolapse of the iris, that is, of the adherent cica trix. Take, for example, the case of the girl detailed, in which the iris prolapsed through a curvilinear wound extending half way across the breadth of the cornea, and was withdrawn into the anterior chamber at all points except one near the center of the scar. At this point the iris was attached and lifted up in a minute tent-like extension, the pupil below it being somewhat ovoid in shape. In cases of this character, I am accustomed to free the attached iris from the scar by the ordinary operation of division of anterior synechia. The method I prefer is the one specially advocated by Mr. Lang of Moorfield Hospital, in which an instrument not unlike the Knapp knife-needle is introduced into the anterior chamber and the synechia divided by a slight lever-like movement. The iris drops back into place, a drop of atropin solution rolls it out of danger of reprolapse, and a circular pupil is secured. It is less easy to accomplish this maneuver when the iris is prolapsed in the periphery or angle of the anterior chamber, although it can also be done there with the same result. I have never seen harm follow this slight operation, and I have more than once seen an eye thus relieved, which had previously been persistently painful, grow comfortable and quiet. The question of prolapse of the iris as the result of perforating ulcers of the cornea is not part of the discussion this evening, but it perhaps is not entirely out of place to say that these cases seem to me to demand the same line of treatment as the traumatic ones, and the management of the case is governed by the same principles as those already enunciated. In a few instances where the prolapse has been an extensive one and has protruded through a large, somewhat irregular opening, which could not be neatly coapted with stitches, I have very successfully planted a flap, after the manner of Gama Pinto. In one instance, associated with the last stage of a gonorrheal conjunctivitis, I took the graft from the opposite or sound eye.1 With reference to prolapse of the iris as a complication of the simple extraction of cataract, my practice is the same, I believe, as that of many surgeons, chiefly Dr. Knapp, namely: If the prolapse is discovered within a few hours after its occurrence, it is cut off and the edges of the iris reduced, exactly as after the operation of iridectomy. If the prolapse is not noted until later, for example, the third or fourth day, it is allowed to remain until the eye is quiet, when, if there is staphylomatous bulging, the protrusion is abscised, or, in other words, treated as is a staphyloma of the cornea. In a few instances I have inserted after this operation one or two delicate silk sutures, and have been 1 Philadelphia Polyclinic, 1896, vol. v, No. 14. pleased with the result. Once I have seen the prolapse entirely reduced by the use of eserin, the iris being withdrawn into the anterior chamber and the pupil becoming perfectly circular on the sixth day after the accident. In the beginning of this paper I said, "Evidently no single rule of surgical conduct is applicable to each case of traumatic prolapse of the iris." But if an attempt to formulate such a rule should be made, which, like all other rules, must meet with exceptions, it would read somewhat as follows: Whenever it is possible to secure clean removal of the protruding tissue operative interference is indicated; when this is not possible non-operative measures, as in the instances already described, are worthy of consideration and adoption. THE OPERATIVE TREATMENT OF SUPPURATIVE AND NON-SUPPURATIVE MIDDLE EAR INFLAMMATIONS.1 BY EDWARD B. DENCH, M.D., OF NEW YORK; PROFESSOR OF OTOLOGY IN THE BELLEVUE HOSPITAL MEDICAL I HAVE SO frequently spoken upon the subject to which I now invite attention, that I feel some hesitation in making it the theme of this article. Were it not for the fact that the surgery of the middle ear is still in its infancy, I should scarcely feel warranted in so doing. Being convinced of the great value of middle ear operations, both in suppurative and non-suppurative otitis media, provided proper judgment is exercised in the selection of cases in which such procedures are to be instituted, I take the liberty of again referring to this method of treatment. Chronic inflammations of the middle ear may be divided into two large classes, first, suppurative inflammation, and, second, non-suppurative inflammation. In suppurative inflammation of the middle ear, operative procedures are demanded for the relief either of a discharge from the ear, or of impairment of hearing which has resulted from a previous purulent process, the otorrhea having ceased spontaneously. A discharge from the ear, of long duration, which has failed to yield to milder measures of treatment, is always indicative of caries within the tympanum. The disrepute into which middle ear surgery, as applied to these cases, has fallen, is largely due to the fact that a careful selection of cases proper for operation has been neglected. When there is extensive caries within the tympanum, and 1 Read before the Southern Section of the American Laryngological, Rhinological, and Otological Society, New Orleans, March 3d, 1897. when this destructive process has extended into the mastoid cells as well, it is evident that the removal of the ossicles only, or in fact any operative procedure through the external auditory meatus, will fail absolutely to relieve the condition. Here a more radical operation, such as the Stacke-Schwartze, is demanded. In a certain proportion of cases, however, we find that the bony involvement is confined either to the ossicular chain or to those parts of the tympanum easily accessible through the external auditory canal. It is in these cases that the removal of the carious ossicles and a thorough curettement of the tympanum effects a complete cure. Statistics show that the percentage of cures following ossiculectomy is about equal to that obtained by the Stacke-Schwartze operation. When we consider that the cases included in these statistics were unselected, the value of the less radical operation is at once demonstrated. A careful reading of the published reports of cases proves that, in many instances at least, an unfavorable result was due simply to an incomplete operation. It is to. be remembered that in about eighty-five per cent. of all cases of caries of the ossicles the incus is involved. In a large number of the reported cases, the remnant of this ossicle was not removed, the operator contenting himself by taking away the malleus. The carious incus was allowed to remain in the middle ear, and hence the discharge was not relieved. I have always insisted upon the importance of removing both ossicles to obtain a satisfactory result. If the incus has been partially destroyed the fragment of the ossicle remaining is often difficult to remove. Its extraction prolongs the operation, but is essential if a successful result is to be obtained. The same rule applies to curettement of the tympanum. The operation should never be looked upon as completed after both the malleus and incus have been excised. Every portion of the middle ear accessible through the canal should be examined either visually or with the probe, and all softened areas should be thoroughly scraped with a sharp spoon. The same instrument should also be carried into the tympanic vault. Run off all softened bone in this region. Conducted in this way an intratympanic operation never fails to diminish greatly the discharge, and in a large proportion of cases, to cause its complete cessation. As the patient is under general anesthesia, there is no necessity for haste at the expense of thoroughness. In my own cases, the operation not infrequently has occupied an hour and a half, most of the time being spent in searching for a small fragment of the incus, and in curetting the intratympanic cavity until all softened bone had been removed. The technic of the operation effects the result to no small degree. If the middle ear is filled with granulation tissue, this must be removed before any attempt is made to excise the ossicles. In suppurative otitis, the lining membrane of the tympanum is exceedingly vascular, and under the most favorable conditions an incision of the tissues is followed by free hemorrhage. When granulation tissue is present, the hemorrhage may be so profuse as to entirely hide the field of operation. Considerable local treatment may be necessary, therefore, before attempting to remove the carious ossicles, although the necessity for surgical interference may be apparent from the outset. It is not possible to perform a satisfactory operation for intratympanic caries under local anesthesia. The removal of the ossicles may be effected without difficulty, but the pain incident to curetting the middle ear cannot be prevented by any local application. The proper illumination of the field of operation is also essential, and no one should operate with a poor light. My own preference is the electric light, although an oil lamp or an ordinary gas jet will afford sufficient illumination. The objection to these last two is the possible ignition of ether vapor by the exposed flame, unless the source of light is above the patient and removed at a considerable distance. With proper precautions, however, this danger can be overcome. The steps of the operation depend largely upon the local condition. When the membrana tympani is almost completely destroyed, and the ossicles are drawn upward into Shrapnell's membrane, the procedure is usually as follows: Any adhesions posterior to the stapes are divided by a sharp-pointed knife inserted between the head of the stapes and the tympanic ring, provided the former landmark is visible. When this cannot be seen, the knife is introduced close to the posterior margin of the tympanic ring, just above the normal situation of the stapes, and is carried inward until its point impinges upon the internal wall of the middle ear. The knife is then carried downward for a distance of about onetwelfth of an inch, completely dividing all soft tis sues. After this incision, the head of the stapes will often be recognized, presenting as a small white spot close to the border of the tympanic ring, the tension of the adhesions between the anterior crus and the adjacent wall of the oval niche being sufficient to pull the ossicle forward. An angular knife is then introduced in front of the stapes to free this ossicle from the incus. The long process of the incus has usually been destroyed in these cases, but it is advisable to take this precaution to prevent the possible evulsion of the stapes when the incus is removed. The next step is to free the malleus by the division of the anterior, posterior, and external ligaments. This is done by carrying the incision from the anterior and posterior margins of the perforation completely about the malleus over the short process. It is well to cut first in front of the malleus from the superior border of the perforation, upward to the short process, and to make a second incision, in a similar manner, posteriorily, the incisions meeting above the short process. The division of the external ligament is somewhat difficult on account of its density. It is best effected by plunging a strong sharp-pointed knife upward and inward into the tympanic vault just above the short process of the malleus, and dividing the dense bands anteriorily and posteriorly. If the manubrium is adherant to the internal wall of the middle ear, it may be separated by the use of the angular knife. The malleus is then grasped just above the short process, and is first pushed inward to dislodge the head from the shelf-like process upon which it rests, after which it is drawn downward and outward. Occasionally, when the caries has not been extensive, the incus may be seen as soon as the malleus has been extracted, and the hemorrhage may be controlled by cotton pledgets. The part presenting is usually the long process or the portion of it which remains. It usually lies close to the posterior margin of the tympanic ring, projecting slightly beyond this. The incus-hook is then introduced into the canal and passed behind the posterior margin of the ring, the concavity of the instrument being directed forward. The instrument is then carried upward, and at the same time is rotated forward so as to displace the incus into the field of vision. As soon as this is accomplished it is grasped by the forceps and easily removed. It is important, however, not to attempt extraction when only a small portion of the bone is visible. If the operator fails to grasp the bone firmly, it is frequently displaced into a remote corner of the tympanic vault, and it is found only with the greatest difficulty. A little careful manipulation at this stage of the operation may save a great deal of time. It should be borne in mind that the incus does not lie close to the internal tympanic wall, but near the tympanic ring, its short process resting upon a ledge of bone just above the superioposterior margin of the meatus. Failure to extract the incus is often due to the fact that the incus-hook is passed too far into the tympanic cavity, and when rotated forward lies to the inner side of the ossicle, and consequently fails to displace it. It is better to introduce the hook just within the tympanum and then to draw it outward until its angular extremity engages the tympanic ring. The subsequent manipulation is performed with the hook constantly in contact with this bony ring, and of necessity it must displace the ossicle if it is in its normal situation. While the hemorrhage may be rather profuse during the entire operation, it may usually be controlled by firmly packing the canal with small pledgets of cotton. These pledgets are allowed to remain in position for one or two minutes, and when removed the field of operation is usually found to be perfectly dry. The deepest plug may be pressed firmly against the internal wall of the middle ear without danger of displacing the stapes, the walls of the oval niche sufficiently protecting the ossicle. To thoroughly remove carious bone from the tympanic vault, curettes of various sizes are necessary, the cutting portion of the instrument being placed at right angles to the shank. These curettes are made to cut both forward and backward, and should be used freely in every portion of the tympanum not visible through the speculum. The internal wall of the atrium should also be thoroughly curetted. Here the sense of sight aids us in discovering the carious areas. It is to be remembered, even in the selected cases, that the surgeon should not give a too favorable prognosis as to the complete suppression of the aural discharge following such an operation. He can certainly promise that the discharge will be greatly diminished in quantity, and will be so slight as to cause no inconvenience; and he may confidently anticipate a complete cure in many instances if due care is taken to operate only on suitable cases. One of the most important arguments in favor of such a procedure is the establishment of perfect drainage through the external auditory canal. For this reason, intracranial infection cannot occur, and the danger incident to the suppurative process within the middle ear is then entirely avoided. I append the statistics of my own operations: Operations for Otorrhea.-Ossiculectomy, 61 cases. Cured, 35; improved, 17; under treatment, 1; result unknown, 8; hearing made worse in a single case. Stacke-Schwartze operation, 10 cases. Cured, 6; improved, 4. The effect of such an operation upon the hearing must always be taken into consideration, and no patient should be subjected to operation until a careful functional examination has been made. In a few instances the hearing has been impaired by the operation; in the great majority, however, the hearing is very greatly or moderately improved, or remains the same as before operative interference. The following statistics show the results obtained in my own cases: Operations for improvement of hearing when slight otorrhea was present, 26 cases. Ossiculectomy performed in 22 cases. Improved, 17; unimproved, 5. Synechiotomy performed in 4 cases, all improved. A certain proportion of cases is met with in which the suppurative process has undergone a spontaneous cure, and the surgeon is consulted as to the possibility of improving the function of the organ. Some of the most gratifying results obtained in aural surgery follow operative interference in these instances. The intratympanic condition is very similar to that found in hyperplastic inflammation of the middle ear. When a functional examination shows that the perceptive apparatus has not been involved secondarily, the hearing can almost certainly be improved by the division of adhesions which interfere with the mobility of the ossicular chain. In this connection it is to be remembered that any increased tension in one ear will sooner or later impair the function of the other. For this reason it is the imperative duty of the otologist to relieve the tension of the conducting apparatus in order to preserve the integrity of the opposite ear. Ordinarily the tension can be relieved by exceedingly simple measures, and the removal of the two larger ossicles. and of the remnant of the drum-membrane is sel dom necessary. My own rule in these cases is first to divide any adhesions between the posterior crus of the stapes and the adjacent wall of the oval niche. The stapes should then be completely separated from the long process of the incus either by disarticulation at the incudostapedial joint, if this is still intact, or by division of connective-tissue bands which may have formed after the disintegration of the descending ramus of the incus. The stapes is freed from adhesions, above, below and in front, and is cautiously mobilized by pressing it in various directions with the cotton-tipped probe. In attempting to mobilize the stapes, any undue violence must be avoided as the crura may be easily fractured if too much force is employed. The transmission of sonorous vibrations to the labyrinthin fluid can only take place when both the stapes and the covering of the round window are fairly movable. Although the stapes may be mobilized, sound perception may still be absent. The same process which has caused the rigidity of the stapes may have produced a similar condition of the membrane of the round window. To restore the integrity of the apparatus these adhesions must be divided. To do this, an angular knife is passed into the niche of the round window and is then rotated from below upward so as to sever any adhesions which may be present. Firm pressures upon the |