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disappearance of erysipelas; another, the diminution of pyæmia. The pyæmia to which he refers is the one which formerly was seen following otitis and appendicitis. Otitis cases now being operated on early, pyæmic cases are rare. He thought, as regards appendicitis, that in the last five years a great change had taken place. At the same time, these pyæmic cases, though very grave, do unusually well. He thought that the jugular vein should be operated on first. Some cases of meningitis seem to get well, and it appears to him that the conditions are similar to those in other serous cavities, inasmuch as a certain amount of toxic absorption can be recovered from. He thought it very important to emphasize (especially for the general practitioner) that we should not wait for external mastoid symptoms, as these frequently do not appear at all, owing to the elongated condition. of the bone. As regards closing the wound, he thought that that was against surgical teaching, and he was able to obtain as good a cosmetic result by approximating the granulating surfaces by strapping. At the same time, there was no risk of any infection.

Dr. LESZYNSKY thought a question of some interest was: When should the neurologist be called in to see an ear case? Surely not during the stage of coma. He was firmly of the belief that if the case were studied earlier, conjointly, by the neurologist and the otologist, the diagnosis could be furthered. Unquestionably, the intracranial complications are now comparatively rare, and their diagnosis is often very difficult. Small abscesses may not give any characteristic symptoms at all. Statistics are of no value at the bedside. The Doctor cited two cases which he had recently seen where a correct diagnosis had not been made. In the second, the brain was explored in various directions; no pus was found, and at autopsy a tumor of the pons was found present. He thought that the differential diagnosis between meningitis and abscess may be extremely difficult, because the latter was frequently complicated by the former. The slow pulse is characteristic of an abscess, though it may occur in meningitis. Rigidity of the neck is sometimes present in cerebellar lesions. Serous meningitis can often not be diagnosticated; if the case gets well, it is customary to speak of it as "serous meningitis." Lumbar puncture is of but little assistance, and this step is not without danger. The Doctor was decidedly against indiscriminate exploration of the brain as sometimes practised by otologists. In regard to facial paralysis,

he had seen no advantage from the use of the interrupted current; if in the second week there was an absence of Faradic irritability of muscle and nerve, he thought the question was an open one whether the power would be regained.

Dr. GRUENING wished to call attention to the anatomical formation of the temporal bone and its influence on the course of disease. He showed a specimen where the jugular bulb was unusually large and not only occupied the floor but encroached upon the medial wall of the tympanum. As dehiscences are not uncommon, a case of this kind could easily show signs of pyæmic infection. He also spoke of cases where certain cells in the mastoid become involved and remain diseased while the rest of the process gets well. He referred especially to the cells in the tip. He thought that the anatomical conditions were of much greater importance than the kind of bacilli found present.

Dr. WENDELL G. PHILLIPS thought that if the acute cases were properly treated the chronic cases would not occur. If the chronic suppuration is complicated by mastoiditis, an operation should be performed. He thought that knowledge gained from the bacteriological examination was a very serviceable clue to the proper treatment in acute cases. In conclusion, he wished to enter a very warm plea for early operation in acute mastoiditis. Temperature in adults is of very little diagnostic value. In his experience, meningitis was always fatal, and all operative measures were needless.

REPORT OF THE TRANSACTIONS OF THE NEW

YORK OTOLOGICAL SOCIETY.

BY DR. ARNOLD KNAPP, SECRETARY.

MEETING OF MARCH 24, 1903.

DR. J. B. EMERSON, PRESIDENT,

IN THE CHAIR.

Presentation of Patients.

Dr. DUEL presented a case of secondary operation. The patient had been operated upon by Ballance, of London, eighteen months ago. The case was one of otorrhoea since childhood, and the usual procedure, as described by this author, was followed. Dr. Duel stated that Ballance now has changed his method of operating, and simply splits the canal without removing any of the cartilage in the plastic step of the operation. The patient came to the Manhattan Eye and Ear Hospital five months ago with recurrence of the otorrhoea. The canal was found considerably stenosed. After two months of conservative treatment it was decided to operate. After detaching the auricle, a soft mass, covered with a thick membrane, was encountered, which came from the middle cerebral fossa and was as large as the ball of the thumb. It could be pushed back; there was some necrosis of the cavity and the facial ridge had not been sufficiently levelled down. The cavity was thoroughly curetted and the skin flap was taken by dissecting off the skin from the anterior wall of the canal and the cavum concha. This was then thrown up so as to cover the protruding mass; the cartilage was thoroughly removed, the wound was covered at subsequent operations by skin grafts. Then the case was free from symptoms and now is healed except at one small point in the tympanum.

Dr. HARRIS presented some drainage gauze tubes, as devised by Dr. Jack of Boston. These tubes consisted of thin rubber finger-cots which come in a number of sizes. Their principal object is to relieve the pain of the first dressing. According to Dr. Jack, the mastoid incision is partially closed above and below, and this rubber tube is passed down to the depth of the wound and then filled with gauze, which remains in place for twenty-four hours.

Voluntary Contributions.

Dr. QUINLAN spoke of a case of congenitally deformed auricle upon which he had just performed an operation. The auricle was prolapsed. Darwinian tubercle was very well typified, the ear not only stuck out, but was pointed, and the deformity was unusually marked. A posterior incision was made, the skin was dissected from the auricle posteriorly, and this was pulled up and attached by deep tension and superficial sutures. The auricle is now close to the side of the head and the result is very satisfactory as far as it is possible at present to determine.

Dr. QUINLAN also spoke of a child five years of age upon whom he had performed a double mastoid operation. Four weeks. ago the child was admitted to St. Vincent's Hospital. Temperature was high and septic symptoms were pronounced. No cause could be found, though there was some discharge from the ear; Shrapnell's membrane was bulging and the mastoid tip was somewhat tender. At operation the cortex was found apparently healthy, but the entire internal structure of both mastoid processes seemed to be completely disintegrated; the temperature came down completely in about three and a half days; there was some history of a grippe infection.

Dr. HARRIS wished to ask the opinion of the Society upon the significance of tenderness along the posterior margin of the mastoid process. He recently had a case of otorrhoea of three weeks' standing without fever. The posterior margin of the mastoid was unusually tender; there was only slight sensitiveness over the antrum. At operation the antrum was found containing very little disease; the tip was broken down, and a cell situated deep down on the internal table was found full of pus.

Dr. SHEPPARD regarded pain in this locality as a very important symptom, and he thought that it was certain evidence

of pus.

Dr. DUEL had seen this symptom associated with tenderness in other parts of the mastoid process.

Dr. LEWIS remembered two cases of tenderness rather far back at the masto-occipital suture. In one case an epidural abscess was found back of the sinus with a perisinuous abscess. The process in the middle ear in the case healed.

Dr. CLEMENS inquired whether the situation of the sinus in Dr. Lewis's case was normal.-"Yes."

Dr. QUINLAN asked whether the sinus in Dr. Harris's case was exposed. Dr. Harris said it was not exposed, as there were no symptoms pointing to its involvement.

mm,

Dr. WILSON Spoke of a man aged thirty whom he had first seen in 1897. There was a bluish tumor at the junction of the Mt and the posterior wall of the canal, measuring 9 mm vertically, 6 mm laterally, and projecting 2 mm into canal. It was apparently solid, extended outward on the posterior wall of the auditory canal for 10 and evidently contained liquid. The patient disappeared from view; he was seen again in 1899. It was incised and a molasseslike fluid evacuated. The patient was not seen again until a week ago. The outer, incised part of the growth had disappeared, but a smaller mass containing liquid was left at the junction of Mt and canal. On incision, the same character of contents was let out. The fluid was examined; it appeared to be degenerated blood. Dr. Wilson thought that it was a hæmatoma, though he could not explain the reason for its occurrence in such a situation.

Dr. EMERSON inquired whether the sac had any lining, and whether it had been explored.

Dr. WILSON replied that it did not have a distinct lining.

Dr. FRIEDENBERG spoke of profuse, persistent otorrhoea as an indication for the mastoid operation. He had just observed a case where the otorrhoea had persisted profusely for three weeks. There were no other symptoms. The mastoid was opened and granulation tissue and caries were found, but no pus. The case has done well.

Dr. LEWIS inquired what the condition was of the drum membrane." There was a perforation in the posterior lower quadrant; the drum remained red."

Dr. DUEL inquired whether there was any sagging of the canal wall.-"No."

Dr. SHEPPARD remembered a case where otorrhoea had existed

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