leucocyte count, a factor which the neurologist takes into consideration. In otitic abscesses there is, of course, a high grade of leucocytosis, but in trying to distinguish between abscesses and tumors and spots of softening this was an important help in nonotitic abscesses at least. He referred to a case of supposed tumor recently seen in which the leucocyte count of thirty thousand caused hesitation as to operation, and the case was still being watched. He also referred to the value of the X-ray photographs as demonstrated by Dr. Mills, of Philadelphia, who believes that it may be possible to photograph brain abscesses sometimes as well as brain. tumors. The photographs are made while the patient is under anæsthesia. Such a process can only rarely be employed in otitic abscesses. Dr. Dana also remarked on the fact that the otologists in their histories did not make the same status" as the neurologists did, and it seemed to him that no very definitive account of the cerebellar functions was given in otological reports. The neurologist has a definite category of symptoms referable to cerebellar disease and patients suspected of such trouble are most rigidly examined as to their points. Recent investigations in symptomatology have enabled the neurologist to detect disease of this region rather more certainly than heretofore, and he thought that a careful investigation of the cerebellar functions would be an interesting addition to otological case histories. He spoke further of a symptom recently brought out by a French otologist, Dr. Babinsky, of Paris. Dr. B. states that there is a static volitional equilibrium" and a "motor or cinetic volitional equilibrium," and that the motor equilibrium is maintained longer than the static. It has been found that in locomotor ataxia a person loses both motor and static equilibrium, but in cerebellar disease the patient loses only his cinetic equilibrium—that is, he staggers only while walking; he has the symptoms of what is ordinarily known as cerebellar ataxia-staggering gait, irregular innervation, but when he is put on his back in bed he is very quiet. When told-while in this position-to hold up an arm or a leg he will make many inco-ordinate movements getting the extremity in position, but once raised he can hold it still, the static equilibrium being rather increased than destroyed; hence in some cases of cerebellar disease there is even a tendency to catalepsy. He referred to a case reported by Babinsky, of cerebellar abscess in which the presence of this static equilibrium was marked, almost to the point of catalepsy, while the motor volitional

66

equilibrium was much disturbed; Babinsky also cites two other cases reported by otologists, in which patients with cerebellar abscess had this static equilibrium to the point almost of catalepsy.

Dr. McKERNON thought that cerebellar abscesses caused by ear disease were rarely diagnosed before mastoid operations. In two cases of his own experience the diagnosis was made after the mastoid operation. He considered the definite cardinal symptom was localized, persistent head-pain. In a paper read five years ago he detailed from three cases the symptoms encountered and they agreed with those mentioned by Dr. Bacon. In regard to opening the abscesses, he spoke of two cases he had operated on, in which he had used with great success an instrument devised by Dr. Whiting, the encephaloscope, which enabled him to see the bottom of the cavity clearly. In regard to the cause of the abscess in the case presented by Dr. Eagleton, he was inclined to think that the otitis was the exciting cause, and referred to a similar case of his own, in which the patient was injured while skating. There was no optic neuritis in his cases, and he thought that unless the lesion caused pressure on the optic centres, in recent cases the eyes were not affected. In regard to opening the abscesses, he advises opening as low as possible on account of drainage.

Dr. EAGLETON did not agree with Dr. Collins as to the advisability of at first using the finger for exploration in all cases. In the majority of cases in which operation is undertaken early enough to promise good results, it is impossible to make an exact diagnosis whether the abscess is in the cerebellum or the cerebrum. In these cases the knife should be used; but when it is possible to make an exact diagnosis, or if the knife has either failed or has located the abscess, the finger should be introduced. Replying to Dr. Bacon's question as to whether the mastoid was examined, he said it was not; there was no tenderness in that region, and in his opinion there was no time to be lost in draining the abscess, so the mastoid was not opened. He believed that the important things were to find the pus, drain, and then open the mastoid. He had used the encephaloscope in two cases, and while he appreciated the fact that it might be a very useful instrument in skilled hands, where there was a limiting membrane, it had rendered him no assistance.

Dr. T. R. POOLEY read a paper on affections of the labyrinth resulting from general and organic diseases (omitted from

November report). He classified these diseases as follows: cerebral anæmia and hyperæmia, seldom causing serious ear changes; hemorrhagic pachymeningitis, cerebro-spinal meningitis, of which the latter is given as the most common cause of acquired deafmutism; cerebral vascular lesions which may involve the auditory centres; tumors of the brain in which hearing is affected in one thirteenth of all cases; syphilitic growths, to be again mentioned, and spinal-cord diseases which occasionally gave rise to disorders of hearing. The affections of the inner ear attend more or less frequently upon the acute infectious diseases, diphtheria, scarlatina, and measles, which are considered together. Cases of uni- and bi-lateral deafness following these diseases are reported. Influenza also has a tendency to involve the inner ear. The occurrence of ear affections in parotitis has but recently received attention, and Hinton is quoted as saying that the occurrence of deafness from mumps is next to that from scarlatina; other observers, however, do not bear this out. Numerous cases are cited from various observers under this head. Deafmutism is also sometimes attributed to mumps. Aural complications in connection with typhoid, typhus fever, and variola are referred to, and cases are cited illustrating the particular affections which complicate these diseases. In hemorrhagic smallpox the labyrinth is sometimes affected. In considering the subject of inner-ear disease in malaria it is a question as to how much these affections are due to the use of quinine, as this drug has a decided action on the auditory nerves. Syphilitic affections of the labyrinth may be due to both acquired and hereditary syphilis, far more frequently to the latter. They may occur coincident with the eruption or not till many years after, and may also coexist with middleear disease of catarrhal origin, this is specially true of the hereditary form. It is the unanimous observation of many authors that in the course of syphilitic affections the development of disturbance of hearing is very rapid. Syphilitic affections formerly ascribed to scrofula were dwelt upon in detail and many authorities cited. The prognosis for hearing in acquired syphilis is better than in the hereditary form. Cases of affections of the inner ear have also been observed in acute and chronic Bright's disease, and Dr. Pooley refers to a case of his own, previously reported. The only statement found as to the frequency of ear disease in nephritis is that by Dieulafoy, who gives 50 %. Uterine disease, hysteria, and some nervous affections are briefly referred to as causing disturbance of hearing.

MEETING OF FEBRUARY 12, 1903. THE PRESIDENT, DR. E. B.

DENCH, IN THE CHAIR.

The Exercise of Common Sense in the Practice of Aural Surgery. By Dr. SAMUEL THEOBALD, Baltimore, Md.

Dr. THEOBALD stated that he wished to speak on a few points in regard to common sense, more properly common surgical sense, in otology.

As regards instruments, he thought that the conical nose-piece was very much better adapted for the Politzer bag than the catheter-tip. The latter instrument is likely to give pain or injure the patient's nose. The opening of the bag should be large enough to permit a free current of air. The kidney-shaped pusbasin, as it is generally used, is very bad, because it presents a concave surface where a convex surface should be applied. Again, most of these basins are too shallow. The angular instruments are somewhat faulty, inasmuch as the angle is a bad one, being 140°. He had found that it was very much more serviceable if the angle was 105° or 110°. The reader thought that nowadays the catheter was used too much. This instrument is always very unpleasant, and sometimes painful to the patient. He thought that the old plan of using the Politzer bag should not be given up. The prejudice against syringing in ear disease was without foundation. The younger men of the day are apt to follow certain antiseptic precautions out of proportion with the object sought for. It should not be forgotten that daylight furnishes excellent illumination, and that a dark room with artificial light is not essential. The Doctor thought that the tendency at present was to give the tympanic cavity too much direct treatment, forgetting that most affections in this region are secondary, and that it would be very much better to treat the naso-pharynx and the patient's general condition. Constitutional treatment is very important. It is a fault which the specialist is very apt to commit-namely, to regard all troubles as local.

He had had very good results from home treatment in chronic cases, and thought that very much could be accomplished by proper directions to the patients regarding the use of the syringe, spray, gargle, constitutional remedies, and Politzer bag.

The Valsalva method is at present being less used than it seems right, because the Doctor had found it of value, with the use of the auscultation tube, to detect the patency of the Eustachian tube

Cerumen can be removed in

or the presence of fluid in the ear. no better way than by the use of the syringe after the instillation of sodium-bicarbonate solution. The unwisdom of applying irritants to the ear in middle-ear and external-ear troubles is often forgotten, especially in the treatment of aspergillus, where the insufflation of equal parts of boracic acid and oxide of zinc powder has given the reader excellent results.

The reports of monolateral deafness when the other ear hears well are invariably incorrect, as under these circumstances the hearing of the healthy ear cannot be excluded.

In regard to operations, inasmuch as carious bone is not always necrotic, vigorous curetting need not be resorted to, and that by overcoming the cause, instituting proper drainage, antiseptic precautions, and building up the general system, the bone often recovers and an operation is made unnecessary.

The Doctor thought that ossiculectomy should not be done when the hearing is good. He had recently observed a case where the vertigo, nausea, and tinnitus had been relieved by correcting an error of refraction. He thought that the mastoid was being too much operated upon, and that it had become more or less a fixed habit with aural surgeons. He thought that a great many cases did not require operation under the proper treatment. He also wished to protest against the frequency of radical operations where the ear, as far as hearing was concerned, was often made useless.

Discussion.-Dr. J. W. BRANNAN responded to "The General Practitioner's Point of View," and spoke how ten years ago he was struck by the lack of attention and care that was given to ear affections in infectious diseases, especially scarlet fever. He remembered that in his connection with the Board of Health, he had been instrumental in appointing a consulting aurist with great benefit to the ear cases, and at the Minturn Hospital one of the first appointees was a consulting aurist. His house physician in the latter hospital had looked over the records and had found that of the scarlet-fever cases in the first three years 20% were complicated with otitis, notwithstanding that the best attention was given to the throat. In 1901, 15 % of ear cases occurred, and in 1902, 8%. The decrease in percentage, he thought, was due to the less severe throat infection. One half of the patients were adults. Ear disease was present in 12% in the adults and 25 % in the children.