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jugular then the bulb should be looked after, for it is more likely that the bulb be affected rather than the sinus.

Dr. LEDERMAN presented a case which he had shown a year ago, of a young man with chronic suppurative otitis, who was struck over the ear, with the result that the disease was augmented and symptoms of mastoid infection and jugular thrombosis arose. The usual operation was done, the mastoid opened, and carious tissue and pus removed; sinus thrombosed; the jugular was then tied one inch above the clavicle and a portion was resected. The tributaries were not ligated. The sinus was then opened and scraped. The parts were then curetted and the patient was in good condition. All went well for about five days, when chill and high temperature developed, and pus was found in the lower portion of the sinus wound. The wound was opened, but no pus was found, and it was concluded that the parts drained through the antrum. In five more days the temperature again rose; then it was found that the posterior sinus wound was infected. An inch and a half of bone was chiselled away, and the wound curetted till good return of blood was obtained. The patient did well and was shown as cured. For five months he was all right, when the ear began to discharge and a little granulation tissue and a portion of the incus were found to be present in the middle ear. These were removed under cocaine. Three months ago the patient returned with a little fistula in the scar over the mastoid which led into the antrum. Probing disclosed bare bone. The Schwartze-Stacke operation was done, and the result up to the present time is good. However, there was marked facial paralysis, which has slowly improved. The case is somewhat remarkable for the number of serious operations undergone. Dr. Lederman also thought the case illustrated the necessity of exercising great care in the thorough removal of all diseased tissue. He asked the opinion of the members of the Section as to the chance of complete recovery from the facial paralysis. The whole cavity has healed over, though the last operation was performed two months ago, and no sign of suppuration is present, though moisture occasionally comes through the Eustachian tube.

Dr. Berens asked when the facial paralysis had developed.
Dr. LEDERMAN replied: Three days after operation.

Dr. BERENS stated that he had at present under observation a similar case, in which, seven days after operation, facial paralysis began and is now complete. He was sure he did not touch the facial nerve. He thought Dr. Lederman's case was sure of some improvement, but that complete recovery was unlikely for a long time to come.

Dr. T. J. HARRIS thought the subject of facial paralysis following these operations was interesting and very important. He did not believe that any one doing otological work was exempt from this unfortunate result. He did not think it was an accident in most cases, but that it was the result of the thorough removal of tissue which advanced cases required, and he considered that the surgeon should not be blamed. In private practice it presents a serious question, and he thought it wise to present to the patient the fact that such a result is a possible sequel of the operation, as well to guard the patient against dissatisfaction and disappointment as to protect the operator. In reference to the ultimate result, in two cases in children with partial paralysis he had gotten complete recovery; also in another case in which the facial was wounded with resulting marked paralysis, the recovery has been complete. He did not believe that the nerve was often cut, but that it might be wounded, and he thought complete recovery was to be looked for.

Dr. LEDERMAN stated that he felt more hopeful in regard to the facial paralysis in his case, as some improvement had occurred. He mentioned another feature of the case, namely, the presence of moisture in the Eustachian tube. He spoke of another case under treatment, in which after operation the result was good, but from time to time re-infection occurs whenever the patient takes cold. The Eustachian tube has been curetted several times without permanent closure of same.

Dr. McKERNON presented a case showing the result of the combined operation, which he had spoken of several times. This operation consists in the removal through the canal of the ossicles, granulation tissue, and superior part of the tympanic ring, all the dead bone, cleaning out the mastoid antrum and cells, going through into the middle ear, widening the aditus, and then, instead of taking away the posterior wall of the middle ear, removing it and making a typical Stacke, he simply cuts a quadrilateral window through the posterior wall, through which the interior of the middle ear is plainly visible and can be cleaned out. Afterwards a piece of gauze is passed through the canal and out into the mastoid wound. Dr. McKernon has done

several such operations in the past two and a half years. In the second case atresia resulted and a second operation was required.

The case presented had suppuration since infancy.

Dr. McKERNON thought it easier to remove the ossicles by way of the canal, and by taking away the superior and posterior portion of the tympanic ring he thought a better exposure was obtained. The case shown does not differ as to results from many others. He thought in this operation there was little danger of wounding the facial nerve, unless it were necessary to go down very deep. In a series of twelve cases, lately done, he had not found it necessary to carry the operation so as to expose the nerve.

He thought the particular point of advantage was the firm cicatricial condition of the middle ear as compared with the results, in many cases, of the Stacke operation, and the absence of mastoid disfigurement.

Dr. R. C. Myles asked how he removed the inner-upper part of the osseous canal.

Dr. McKernon replied, Through the external auditory canal.

Dr. W. C. Phillips asked whether after opening the mastoid antrum, Dr. McKernon carried the opening in the external table directly through the aditus to the attic.

Dr. MCKERNON replied that he took in that portion underneath the roof of the posterior canal, simply taking out a quadrilateral section.

Dr. Phillips thought that, if he rightly understood the operation described by Dr. McKernon, it was favorable in that it caused less deformity. He had not done the operation after this method, but he had done similar ones. He had had more cases in which he felt that the mastoid cells were not particularly involved, in which event he did the typical Stacke operation.

Dr. R. C. MYLES asked Dr. McKernon what caused the atresia in the case he mentioned.

Dr. McKERNon said it was due to an attempt, after the quadrilateral window was made, to split the cartilaginous portion of the canal instead of taking out a V-shaped flap.

Dr. LEDERMAN asked how long it took these cases to heal and what drainage was used.

Dr. McKennon said it required about the same time as any other mastoid operation,- seven to twelve weeks; the case presented healed in nine weeks. As to dressing, for the first week a wick of gauze was passed from the posterior wound through the middle

ear and out through the canal. The mastoid wound was packed. Afterwards through drainage was discontinued and the mastoid and middle ear packed posteriorly.

Dr. W. C. PHILLIPS read a paper entitled “A Brief History of Bacteriological Examination in Suppurative Otitis Media, with Remarks upon the Relative Virulence of the Various Microorganisms ” (p. I of this number).

Discussion.—Dr. LEDERMAN mentioned three cases in which the diplococcus intercellularis meningitidis was present, but the pathologist had pronounced this insignificant. The usual mastoid operation was performed without untoward symptoms. He was pleased to know that the subject had been further studied.

Dr. McKennon asked Dr. Cunningham the result of his investigations in the statistics collected at the New York Eye and Ear Infirmary.

Dr. CUNNINGHAM stated that he had collected statistics for Dr. Dench at the New York Eye and Ear Infirmary. The most frequent bacteria only were considered. From the collection it was inferred that the ice-coil was practically useless in 90% of cases of acute streptococcic infection as a means of abortion, whereas in pneumococcic infection alone the ice-coil would probably cause resolution in 86%. In mixed infections the conclusions were about the same in accordance as to whether or not the streptococcus was present. The inference was, therefore, that the presence of the streptococcus indicated a very virulent type of inflammation, while the pneumococcus indicated a milder form. Dr. Cunningham stated that these statistics only apply to cases which are strictly in the acute stage of inflammation.

Dr. McKERNon said that several years ago at a meeting of the American Rhinological and Otological Society he brought out the fact, in a series of fatal cases of brain abscess with middle-ear disease, that in all cases bacteriological examination should be made and if streptococci predominated a guarded prognosis should be given. Many others now concur in this opinion who at the time thought it far-fetched. He further wished to state that infection resulting from the diplococcus intercellularis meningitidis is far more active in his experience than the streptococci. He reported a case, seen in April, in which the first pain in the ear occurred at 11 A.M. At 2 P.M. the drum-membrane bulged. The membrane was opened and the discharge (serous in character) examined and revealed the diplococcus meningitidis in great abundance. The patient was immediately put to bed and watched carefully for four hours; he then had a tender mastoid and pus discharging from the middle ear. Between 10 and 11 P.M. the mastoid was opened and found to contain pus. He was unable to say whether the infection had been latent. Since then he has had two other cases almost as rapid, in which within twenty-four hours the mastoid filled with pus. All of these cases recovered.

Dr. PHILLIPS spoke of his first experience in finding the diplococcus intercellularis meningitidis. He immediately questioned the patient for brain symptoms, but found that it was simply a mastoid case and operated. The patient made a good recovery. In his experience with this organism an operation has been required in every case. He was not, however, prepared to state its comparative virulence positively, although he felt that it was nearly if not quite as virulent as the streptococcus. With regard to the ice-coil in streptococcic cases, he thought that it not only was contra-indicated but might, as a result of delayed operation, lead to great harm.

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