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involved, and as this was only to be ascertained by free exposure, the question still remained. He considered it wiser to make an ossicu. lectomy as a preliminary, followed later by the radical operation if the discharge did not cease, and gave as his experience in twenty cases only one in which the second operation was required.
Another important point he brought up was as to what promises could be made with regard to hearing after operation. He cited a case seen in consultation in which other physicians had promised improvement; he was not so hopeful, and as the case turned out the hearing was worse after than before operation. He was in favor of a guarded prognosis.
Dr. WENDELL C. Phillips presented the case of a young man with a history of chronic otorrhoea for twelve years past, following an attack of pneumonia. Until last January there had been a continuous discharge with evidences of necrosis of the ossicles and the annular ring. An ossiculectomy was performed. For two months after operation there was some little pus but since then the discharge has entirely ceased. The treatment of the case was most carefully followed out. The entire surface is now dermatized and there is very little connective-tissue formation. There is considerable depression of the oval window. The case is presented on account of the very good hearing results, this being no doubt due to the favorable conditions in the region of the oval window.
Dr. T. P. BERENS asked Dr. Toeplitz if, in the case he cited, he knew that other physicians had promised good hearing. He considered this a very important point, as patients have been known to state that certain promises were made which the physician did not make at all.
Dr. TOEPLITZ said he could vouch for one as he heard the statement made to the patient in his own office.
Dr. BERENS asked Dr. Phillips if he knew whether he had removed the stapes and entered the foramen ovale.
Dr, Phillips had not entered the foramen ovale and could not be sure whether he had gotten the stapes or not.
Dr. TOEPLITZ asked Dr. Dench's opinion of ossiculectomy.
Dr. DENCH thought that if the tuning-fork examination before operation showed the lesion to be limited to the conducting mechanism almost invariably good hearing would result. The statement was qualified because of the possibility of accident. He also thought that where the tuning-fork reaction demonstrated middle-ear lesion without existing labyrinthine lesion the hearing is almost always improved, sometimes marvellously so. He did not think the depression marking the site of the oval window mentioned by Dr. Phillips uncommon.
Dr. H. L. SWAIN stated that he had recently observed a case where, twelve years ago, the ossicles had been removed by the late Dr. Sexton, who had said at the time of operation that whatever hearing was possessed after operation would be retained. During the twelve years the hearing has on the whole improved a little. He considered this valuable in making a prognosis. He had also had another case in point in a man, aged eighty-four years, in whom the drum and ossicles of one ear were lost in youth and who now hears only in that ear, the other one having become totally deaf, from middle-ear sclerosis.
Dr. LEDERMAN spoke of two cases in which the malleus and incus had been removed from chronic suppuration, and the hearing was lowered for six weeks after operation, but improved after this period; consequently we may anticipate a temporary lowering of the hearing power in a certain number of such cases.
Dr. E. L. MEIERHOF spoke on the controlling of suppuration. He believed that every case of chronic suppuration in the middle ear was accompanied by suppuration in the mastoid antrum, and thought there was reason to believe that if we could bring about a healthy condition of the tympanic cavity and accomplish drainage from the mastoid antrum a cure could be brought about in many cases where the radical operation seemed to be indicated.
Dr. McKennon asked Dr. Phillips if the hearing in his case was better four months ago than at the present time.
Dr. Phillips could not speak positively on that point, but said that the hearing when last tested was decidedly better than before operation.
Dr. Meierhof presented a case of absolute occlusion of the external auditory canal from an exostosis and ecchondrosis from the anterior wall of the canal, an unusual position for such growths. According to tests the ear seems normal, sound conduction is good, and some hearing is present. He has hesitated about rendering the canal patent by operating, but the patient now complains of neuralgia radiating from that side on the head. He has not been able to determine whether or not operation is advisable, owing to the unknown depth of the exostosis and possibility of completing the operation so as to have a successful result.
Discussion.—Dr. Dench thought that the exostosis should be taken off. He thought it difficult to tell how far the growth extended, but considered that if at any time the patient should have middle-ear suppuration, occlusion of the canal would be a serious matter. He thought the exostosis should be removed, bearing in mind the fact that it is wiser to take off a thin layer of normal bone underneath. He had seen several cases in which removal of the growths was followed by excellent results.
Dr. Thomas R. POOLEY spoke of a case reported by him in the Transactions of the Medical Society of the State of New York, where an operation for exostosis of the auditory canal had become necessary on account of pain in the head, as mentioned by Dr. Meierhof in his case. The operation was performed by means of a drill, worked by an electric motor, set to cut to a given distance. The growth was removed without damage to the membrana tympani. The occlusion in this case was not absolute, a small probe could be passed.
Dr. LEDERMAN thought that the tuning-fork tests were important in these cases, especially if bone-conduction is good. He also thought that in the operation, which in the case presented ought to be performed, the after-treatment was most important in regard to the prevention of formation of an atresia, and suggested the introduction of a tube to keep the canal patulous.
Dr. Duel presented specimens made by Dr. T. Passmore Berens and himself of Wood's metal, showing studies of the accessory sinuses, etc. The formula for Wood's metal is:
C. P. lead....
tin... bismuth...... cadmium...
The lead should be melted first and the other metals added in the order named, waiting till each has melted. Its particular advantage is that it melts at 65° C. and can be melted in boiling water. It is easily handled when molten and when poured into cavities by its weight displaces water or other fluid which may be present and fills the smallest recesses. It hardens quickly, producing a beautiful cast. It is used in making corrosion preparations—the
bone being removed after the cast has been made — and transparencies, the bone being rendered transparent, allowing the metal in the sinuses to shine through. The latter are useful in studying topography and relations, while the former show accurately the details of the cavities. Casts of the larger cavities in their natural state may be made from the cadaver by pouring the molten metal into them, allowing it to harden for twenty minutes and then removing the bony walls by the chisel or rongeur forceps.
The following specimens were exhibited :
1. Specimen made by pouring the molten metal into the external auditory meatus of a cadaver, the ear being previously cleaned and filled with boiling water.
2. Specimen made by pouring the metal into the nares of child, filling the nares and naso-pharynx.
3. Corrosion specimen showing the mastoid cells, the labyrinth with all details, also the ampullary nerve; this illustrates how the metal fills even the smallest cavities.
4. Specimen of the labyrinth.
5. Transparent specimen of the temporal bone of a child injected with mercury.
This illustrates the instability of mercury preparations as compared with Wood's metal.
Dr. Phillips presented a new mastoid retractor, designed as a modification of Allport's retractor. He considers such an instrument will be an advantage in holding the mastoid wound open during operation, so that so much hand retraction as is required by the modern operation could be dispensed with.
Dr. THOMAS R. Pooley read a paper on affections of the labyrinth resulting from general and organic diseases.
Discussion : Dr. Dench considered Dr. Pooley's paper a thorough and excellent résumé of the subject. He thought Dr. Pooley had misunderstood his treatment by pilocarpine as he had not used it hypodermically, but by the mouth. He was glad to hear mention of pain in the side of the head in cases of syphilitic deafness as one such case had recently come under his observation.
Dr. Toeplitz asked if it were possible for disease of the middle ear to be transferred from the middle ear to the labyrinth directly through the walls. His experience was that such could not be done unless there was a traumatic lesion of the outer labyrinthine wall leading to the middle ear. He stated that Politzer's assertion in this regard had since been proven erroneous, namely, that there is no connection between the vessels of the labyrinth and those of the middle ear. Whenever there is inflammation of the labyrinth it comes from the inner side of the labyrinth or by metastasis; infection of the labyrinth from the middle ear is by injury.
Dr. LEDERMAN reported a case of labyrinthine deafness due to typhoid fever in a young female, who was an inmate of a deafand-dumb asylum for seven years. He made careful tests and found that on one side there was marked nerve deafness. Under treatment with potassium iodide, strychnine and pilocarpine, local massage and inflammation, hearing improved sufficiently to allow her to go to work. He thought that when the onset of deafness is sudden it shows direct involvement of the labyrinth. He spoke of three cases under his observation where nausea and vomiting followed surgical manipulation of the middle ear for suppurative disease; vertigo and nausea were so pronounced as to prevent the patients from getting up, one for one week, one for four days, and another for several hours, showing that the symptoms were due to disturbance of the labyrinth. In two of these cases the vomiting was projectile and suggested some central irritation. Dizziness was very prominent immediately after the local treatment and continued for a few days in the first patient.
Dr. MEIERHOF stated that he had examined the inmates of an institution for deaf-mutes of 220 patients. Among them there was no case of deafness from mumps, also the proportion of cases due to cerebro-spinal meningitis was not so large as that given by Dr. Pooley.
Dr. J. HERBERT CLAIBORNE congratulated Dr. Pooley on his masterly contribution to a subject which, though very important, had heretofore not received the attention it deserved. Owing to the fact that he was gradually withdrawing froin otological work, he had had little experience with labyrinth disease. He had observed cases of Ménière's disease, but they showed no peculiar symptoms. He mentioned a case seen sixteen years ago, of a man with complete nervous deafness on one side who lost the hearing of the other ear, suddenly, as if it were by the "explosion of a pistol." There were no symptoms of congenital syphilis in this case and infection was denied. The man had lived a sporting life and was a hard drinker. There was no