Patient

Case three-Mrs. B., age 53, mother of four children. was sent to me May 30th, 1904, after three months' irrigations, hot and cold applications, ice caps and a curettage of the attic through the external auditory canal under an anesthetic.

The trouble began with Grippe. The mastoid at that time took on acute conditions, the swelling subsided, but at no time was she free from a profuse discharge, temperature and pain. When I was consulted the pain was so great the patient feared for her reason, she had lost flesh and looked the part of a sick woman begging relief from her sufferings.

It was my opinion that nothing short of the radical operation would give the desired relief, and I did not care to take the case unless I could operate within the next few hours. She entered the hospital June 1st and was operated on the next morning at 7:30.

The mastoid was a mass of granulation tissue, the probe passing directly through to the sinus-a peri-sinus abscess, the tip was full of pus, the induration and swelling extending down the neck, the antrum and the attic were full of free pus, altogether a bad state of affairs existing.

I did not open the sinus in this case but had more cause to than in any of the other cases. I know now that it would have been surgical to have done so and would have caused me fewer anxious hours; however, the case has gone on to a satisfactory conclusion excepting a slight discharge from the eustachian tube. After the operation patient said she was freer from pain and hearing better than for the past three months.

There continues a little discharge from the tube which I occasionally have to wipe out, but I am still in hopes of closing in the aurifice. This woman has regained her usual weight and health and in spite of the discharge referred to, I seem to have no patient more grateful than she.

The next case I have to report is a Mr. M., a double mastoid, making in this series my fourth and fifth. Mr. M. is 38 years old, married, and a traveling salesman. At nine years of age he had a very severe attack of scarlet fever, caught cold, and had a relapse, both ears becoming infected, the right more than the left. Since that time when exposed to cold, both ears would suppurate and discharge, at first a thin watery fluid, later a thick pus, with much pain and swelling until the discharge started.

Sept. 16th, 1901, had an attack of facial paralysis, which passed off after several months of treatment. He also had difficulty in phonating. Two years ago he caught a severe cold and the old trouble

started in with renewed energy, the right side became paralyzed, accompanied by noises in the ear. When patient consulted me late last August the tinnitus was most distressing, there were also shooting pains from the mastoid to the temporal and parietal regions. While there was no tumefaction, there was great tenderness over the mastoid and in the external auditory canal. At that time the left ear was quiescent, but by the time he was ready to submit to operation on the right ear he was having tinnitis and pain sufficient to convince him that both sides should be given the benefit of the radical. October 3rd, 1904, the right side was operated on. There were extensive necrosis of the mastoid and middle ear and cholesteatomatous-like masses filled the antrum and attic.

The external semi-circular canal seeming to be in a fairly good condition, I took the chance of a sequestrum, the dura was exposed and the sinus opened but no thrombus found. After packing the sinus, the wound behind the ear was closed excepting at the lower angle which was left open for sinus drainage, the balance of the packing done through the enlarged meatus. Ten days later the patient was again anæsthetised, the first ear dressed and the left operated upon. The only points of interest differing from the first side were, that while the sinus was exposed it was not opened, and that I got lost. locating the antrum, but, resorting to Stacke's method, found it. The wound was entirely closed and all dressings done through the canal. At the end of a week both sides were dressed, and both incisions had healed by primary union, dressings were dry, sweet and clean. Patient left the hospital at the end of the third week to return every third day to be dressed. Bandage was removed at the end of the sixth week, there never having been a rise of temperature or pulse. The wound has remained dry up to the present time. Just now, however, there is a little discharge of mucus from the eustachian tubes, for which a tubal catarrh is responsible. Under electricity the paralysis has greatly improved and the tinnitus is much better. The hearing in the right ear has increased from almost nothing to being able to use the 'phone and to understand the slightly raised voice. The left ear was the better of the two and the hearing power has not been decreased. He expects to resume his occupation the first of the year.

James, age 5 years. Family history good, one aunt died of tuberculosis. At three years of age had measles and six months later right ear began to run. He has had discharge off and on ever since. When the child was brought to me the discharge was a thin, stinking pus. He was a delicate and poorly nourished lad. 'I tried the usual treatment for discharging ears without results, not even on the odor. Oc

tober 12th, 1904, he was given the radical and the usual destruction and filth being found, the diseased tissue was removed and the post auricular wound sutured in its entirety.

The boy began to improve from the first, his temperature and pulse being each a hundred for the first few hours, but not again above normal. At the first dressing there was noticed some of the old odor and the ear was irrigated with one to two thousand formalin solution three times during the next week, when the odor disappeared. There was no pus or discharge. The child was put upon a nourishing diet and given tissue remedies by Dr. Weir, our house physician. The bandage came off the fifth week and the patient sent home a different specimen of boyhood than when he entered the hospital.

The seventh and last case is a Mrs. W., aged 50, family history negative. Personal history,-measles, whooping cough and mumps when a child, and at the present time passing through the climacteric. Last winter began having nasal catarrh, for which she used Silers' tablets as a douche. She continued along these self-prescribed lines until the latter part of October, when, after using the nasal douche, she began to have pain in the left ear, soon followed by rupture of the drum membrane. In spite of the most painstaking care and conscientious effort of a thoroughly capable physician the throbbing pain and pulsating discharge increased. She was sent to the hospital where a nurse stood over her night and day, using all of the therapeutics at the command of the otologist to no purpose. The pus was examined microscopically and reported bland, nevertheless the patient grew worse until when I saw her the temperature was 103 3/5, pulse 88, respiration 20. The breath had that sweetish odor of sepsis, the discharge had lessened and the patient gave many of the symptoms of toxæmia. Feeling that serious, even fatal complications would speedily develop I urged radical measures. At 7:30 A. M., Nov. 10th, 1904, she was sent to the operating room. The case held some surprises for us. I, at least. expected to find the process broken down and the attic and antrum full of pus, but there was no necrosis nor pus in either antrum or attic. There was no granulation tissue in the process but each cell appeared to be a small abscess. The bridge of bone separating the attic from the antrum oozed pus when my forceps bit into it. This condition existed all through the mastoid region down to the sinus which was accidentally opened in following up a focus of infection. The disease seemed to be spending its fury upon the mastoid, the sinus and the facial nerve being in the greatest danger. Patient was returned to her room with a temperature of 99 axilla, pulse 88, respiration 24, temperature resuming the normal within 24 hours.

Case was dressed on the eighth day and the wound not found in a healthy condition. There was a good deal of pus and the tissues were lacking in vitality, however the sinus showed no signs of infection and the stitches held.

Using formaline irrigations the pus was soon under control, the post wound has united and the case is progressing nicely at this time. Her low mental condition and reactive power no doubt is somewhat responsible for the sluggish condition of the wound, yet there is a reasonable doubt as to my having located and removed every point of infection. The menopause may have had something to do with it.

The time required for operation for these cases was from fifty minutes to over two hours. There was no attempt made at skin grafting, as I did not feel that it was justifiable. I am fully aware that the foregoing histories leave much to be desired. It would be a source of satisfaction to have the comparative tests for hearing, but with the exception of the child, all of these cases were sent to me in a critical stage. It was not a question of hearing but of relieving suffering and saving life that created a demand for my services. Again these cases had been of long standing (one over 30 years), and they had been treated more or less during that time, doubtless having had as many physicians as attacks, so that any tests other than the original would be comparatively worthless. In summing up, it will be seen that the dura matter was exposed in five of the cases, the sinus in four, two of which were opened without serious consequences. There was pus following operation in one case, a fistula in another, two closed eustachian tubes, five still open, for which a tubal catarrh is largely responsible. That it is safe to close the post auricular wound and dress through the enlarged external auditory meatus, thereby shortening the convalescence as well as producing less deformity, was demonstrated. The hearing power was improved rather than diminished, the subjective noises decreased, and the physical as well as the mental well-being of the afflicted changed for the better. The cases herein outlined had entered their last stage, threatening life in spite of irrigations, douchings, "bubbling drops," etc. How much more satisfactory results: might have been obtained had the cases been operated upon earlier, how much suffering and annoyance might have been prevented. I am sure that I hear some one say, "Would you advocate operation for every cose of suppurating ears?” No, only those cases that have resisted skillful treatment for a reasonable time. Again I hear it said, "We cure many cases without surgical interference." But do you? Doubtless the discharge is stopped and the case dismissed as cured, but are they cured, will not the condition return a little more deeply

seated, with the next exposure or passing excitant? Are my cases different than the general run? I doubt it. From 371⁄2 to 57% of all brain abscesses are otitic in origin, so different authorities say. Why should the aural surgeon tamper with pus any more than the general surgeon? "Pusing" ears are a menace to life, to say nothing of the disgusting discharge and the danger of facial paralysis. In conclusion. I will say that I believe that, after a year's trial of treatment, chronic otitis media suppurativa becomes a surgical disease and that the radical operation offers more than any other procedure, up to date.

ECZEMA: ITS PATHOLOGY AND NEWER METHODS OF TREATMENT. By Rollin H. Stevens, M. D., Detroit, Mich.

In this short paper it is the intention to describe briefly the pathological changes and the modern treatment of some of the more common manifestations of that ill-defined, multiform disease known as eczema, first mentioned by Aetius thirteen centuries ago, but not clearly described till the early part of the last century when Willan undertook a more exact description of its nature. Since then there has been and still is much confusion as to its nature and origin, there being those who would limit the term eczema to papulo-vesicular forms of the disease, and others who recognize in the various dry and seborrhoeic forms of dermatitis stages or types of the eczematous process. The question of its origin, too, whether microbic or amicrobic, still remains in obscurity, though the presence of cocci which unfavorably influence the disease in at least some cases, has been amply demonstrated in the laboratory and in clinical experience.

It is quite evident, however, that there must be other conditions present favorable to the development of the germ. These conditions may be constitutional or local but at present our knowledge of them is very limited, for eczema occurs in a very large number of cases where apparently there is absolutely nothing abnormal in the condition of the patient except the local condition. These cases get well under exclusively local treatment and suffer no other complaint either constitutional or local as a result of the local healing.

In order to appreciate the indicated local treatment it is necessary to be fairly familiar with the local pathology as well as the etiology. Of the former we now have a clear picture, thanks to the labors of Unna and his assistants. The latter is still a much disputed question. The slides under the microscope represent the four elementary changes which take place in eczema. They are also represented in the large drawings. [Slides and drawings shown.]