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tesis must be repeated at the old site. This is sometimes to be repeated four or more times in the same case.

A polypoid protuberance at the site of perforation requires some description. If it prevents the entrance of air by the douche, it should be incised with a scalpel and the opening enlarged downwards, or a new opening should be made in the lower posterior quadrant. If the hypertrophy has grown to some size, it should be removed with Wilde's snare. If this is done properly we find that the hypertrophy stump shows a central opening. In influenza otitides especially this re-formation of the teat-like protuberance is frequently observed and requires to be repeatedly removed.

I have never used cauterization or a galvano-cautery because I do not like the presence of a scab or an inflammatory reaction. Removal with the cold snare and paracentesis, if performed under antiseptic precautions, are never followed by inflammatory reaction and are always sufficient to keep the opening patent until the suppuration in the middle ear has ceased.

The return to the normal hearing distance (whisper in 4 to 5 m) gives us the surest indication when the opening can be allowed to close. After closure, the air douche is to be applied by means of the catheter in adults, and Politzer's method in children, until no noises are perceived by the patient on blowing his nose and the hearing power has be. come normal. Notwithstanding the normal hearing for voice, the tuning-fork applied to the vertex is transmitted to the affected ear and the upper tone-limit in Galton's whistle may be lowered.

In the last five years between three-fourths and four-fifths of my cases have healed under this line of treatment; in the remainder, namely, one-fifth to one-fourth of the acute purulent otitides, the antrum and mastoid cells had to be opened. This, I think, partly depends somewhat upon the broadening of our indications for operation. Without wishing to enter upon the operative treatment of the mastoid complications, I should like to state how my indications have become extended.

If an acute middle-ear suppuration lasts more than two

months, notwithstanding careful treatment, a complication is surely present which will prevent its healing spontaneously. At operation a large cavity of pus is found in the mastoid, or an extradural abscess or gravitation abscess in the neck, etc. I therefore think that the operation is indicated even in the absence of all local and general symptoms. I do not hesitate to proceed to operation if moderate swell. ing and pain are present, especially below the mastoid process. In this case I not only remove the covering of the

. antrum but of the entire mastoid process. The site of perforation in the lower surface is sometimes so deep as to require exposure up to the bulb of the jugular vein.

Finally, I want to protest against two methods of treatment which are recommended in many text-books and are being employed at the present day to a limited extent.

I refer to irrigation through the catheter and to the pack. ing of the ear canal. I have no personal experience with irrigating through the catheter. The fact that the tip of the catheter after its introduction into the mouth of the tube is frequently covered with crusts and tenacious mucus, has been sufficient to show the impropriety of this procedure. These crusts are probably not removed by the air current but would surely be affected by a stream of water and their inflammatory action in the tympanum is very probable.

The reports on this irrigation do not seem to be at all favorable. Buerkner in his text-book cites the statistics of Christianeck, where in the year 1881-82 paracentesis with tubal irrigation was followed by a very severe inflammation and suppuration in 41.2 % of the cases. Hessler also prefers removing the discharge with the simple air douche and has not seen any advantages from tubal irrigation.

In a discussion at the otological meeting in Vienna in 1895, the impracticability of this method in acute suppuration with narrow perforations was agreed to by all. Some of those present also objected to its use in chronic suppurations with large perforations, because the results sometimes could not be controlled and because the injection with the tympanic canula from the ear canal gives better results (Scheibe). This latter opinion is the one which I have always maintained in discussions. Two fatal cases were reported which followed more or less immediately after irrigation.

It seems to me that with our present knowledge and experience the irrigations through the tube, especially in acute cases, should be abandoned.

The second therapeutic procedure-namely, the packing of the auditory canal — is designated as the “ dry method," as no use is made of the syringe. The thorough cleansing of the ear canal cannot be obtained by this method because for this irrigation is essential. In the first days, after a severe acute otitis, the discharge is so free that a cotton plug placed in the meatus becomes saturated in ten minutes. The packing under these conditions can only act as a poultice. If subsequently the discharge becomes less, the gauze packing permits the fluid constituents of the discharge to be taken up somewhat externally, while the pus cells and the bacteria are caught in the meshes of the innermost layer, just as in a filter. In the external part of the tampon the discharge becomes dried in crusts and the innermost part is saturated with pus so that the action can only be compared to a hot application and the absorbing conditions are far from ideal. It is said that this packing of the canal depends upon surgical principles. If we are dealing with deep wounds we use a drainage tube. Where wound edges are to be kept apart, gauze packing is introduced. In the suppurating tympanum we have a deep-seated suppurating process; can we find a more natural drainage tube than the auditory canal? It surely would not occur to any surgeon to obstruct this drainage tube with gauze.

In the last years we have frequently had occasion to observe cases which have been treated for some time with packing and these have increased so much within the last years that I have had sufficient experience to judge of their unfortunate effects. Dr. Doelger has collected twenty-two cases which had previously been treated by gauze packing. The appearance of the gauze plug is similar to what I have just described. In eleven cases it was of a disagreeable odor and in five very fætid. The canal and drum-membrane had an entirely different appearance from what we are accustomed to see. The bony canal was narrowed by the concentric swelling and the drum-membrane was covered with thick, irregular, epidermis scales. This thick accumula. tion of epidermis which frequently occludes the entire recess is not without import. The collections of epidermis, the cholesteatoma, and the simple diffuse external otitis show how rapidly softened epidermis undergoes putrefaction.

The continual accumulation of epidermis by means of gauze packing explains why in half of the cases the discharge was found to be fætid, a condition which in the spontaneous course rarely occurs, but under treatment with boric acid is practically unknown.

These putrefactive products found collected in the audi. tory canal have not been without influence upon the middleear process. As a survey of the complications which these twenty-two cases with packing show, there were:

4 cases of empyema of the mastoid.
2 cases of gravitation abscess in the neck.
2 of empyema and caries of the mastoid.
I of labyrinth necrosis.

In eight of these nine cases the mastoid had to be opened. The ninth case (labyrinth necrosis) did not come to operation.

I think that the increase of operative cases of purulent otitis in recent years is partly due to the practice of this method.

The result of the tampon in two cases of traumatic rupture of the drum-membrane is very instructive. In both cases purulent discharge and inflammatory signs did not appear until the tampon had been introduced, as the ear remained dry and free from irritation during the first days. The appearance of suppuration after the rupture of the drum where the ear has remained dry during the first few days is such an unusual occurrence that its connection with the em. ployment of the tampon cannot be overlooked. I do not wish to say that the treatment with packing is always followed by such bad results. I can only give my experience with the cases which I have seen and in these its action has been very unfortunate.





Dr. Max TOEPLITZ presented two cases of ossiculectomy for chronic suppurative otitis media,-one, a boy, who had been operated on a year ago at the Montefiore Home, who had had a running from the right ear with considerable odor for several years. There was perforation and the use of the probe in the attic showed considerable grating. There was some hesitation as to whether the operation should be the radical operation or ossiculectomy, but the latter was finally deemed more advisable and was performed. The ossicles on removal were found carious. After operation the otorrhea and the odor ceased and the boy appeared well. He passed from observation and has since not been seen until quite recently. At present there are some odor and a few granulations on the posterior wall of the meatus. It was consid. ered probable that a radical operation would have to be done in this case.

The second case was in a child, aged eight years, operated on four weeks ago at the Post-Graduate Hospital; giving the history of continuous discharge for six years, much odor, and examination with the probe revealed grating in the attic. The ossicles were removed, the incus was normal, and the malleus was carious. Discharge and odor ceased, the ear is now perfectly dry, and the general health of the patient improved.

The question seemed to be as to when the ossicles should be removed and when not. Dr. Toeplitz thought that if diagnosis could confine the disease to the middle ear an ossiculectomy would be sufficient, but inasmuch as other parts were often

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