upon the subject, entitled, "Indications for and Against Total Removal of the Human Stomach." This writer makes the following classification regarding this operation:

Ist.

The diagnosis and age of the patient.

2nd. The state of the blood.

3rd. The heart.

4th. Pre-existing conditions as environment, habits, food, previous diseases.

6th. The proper preparation of the patient.

The difficulty of a diagnosis is discussed under the first heading. Any case over forty years exhibiting marked emaciation, lassitude, anorexia with absence of normal leucocytosis, together with the presence of filiform bacillus of Boas, contraindicates operation.

As to the blood, it is stated leucocytosis is not present in uncomplicated cancer and when marked shows a metastatic condition exists.

The heart, nervous and muscular system must be intact. As in other conditions, drinking, syphilis, drug users, etc., contraindicate an operation.

Evidences of a metastatic condition are decidedly unfavorable to an operation.

Preparation of patient should include, among other things, rest for a week or two with care in diet and daily lavage of stomach.

DISCUSSION OF DR. WRIGHT'S PAPER.

DR. FREEMAN.-I think such an important contribution to surgery should not pass without something being said upon the question. It is a great pleasure to know that we have surgeons in the West who have been able to perform this operation upon the stomach. It has been done in the East, and it has been done. by Dr. Wright here.

The question of cancer has received great attention from time immemorial down to the present, and everything has failed; even the injection of medicines of various kinds into the tissue of the cancer itself has failed to produce those results we would like to see. Coley's antitoxine has but very little if any effect upon it, and hence the only thing we have to depend on is the knife, and however objectionable that may be, it is our duty

to carry its use as far as we can possibly carry it and preserve the life of the patient. It is the only chance the patient has and hence we are justified in doing extreme things. Whether we are justified in making the entire removal of the stomach with the hope of trying to cure the patient is still a very questionable consideration, but judging from the cases already reported we are not justified in this. Dr. Wright, however, found himself in a position where it was necessary to do a certain thing, and he had the nerve to do it, instead of closing up his patient and waiting for him to die, which he would have done without some attempt to save his life, and I think he is entitled to great credit for his action.

DR. PARKHILL.-Mr. President: I did not hear all of Dr. Wright's paper, but I am very glad to congratulate the doctor for his boldness under the circumstances. I have performed the operation myself once. My patient was a woman about forty years of age. She had a large cancerous growth of the stomach, involving almost the entire organ. I performed the operation, and the patient died the following day, and in my opinion, died of shock from the operation. I believe, however, that the patient would have recovered had it not been for the fact that she was simply starved to death when I saw her and operated on her. She had vomited almost continuously for about two weeks, and it was as a last resort that I operated. I believe if she had not been in the starved condition in which she was, she would have recovered. In such a case I would again remove the stomach.

SUPPURATION OF THE MIDDLE EAR.*
By L. W. SNOW, M.D.,

Salt Lake City, Utah.

Suppuration of the middle ear, or purulent otitis media, may be either acute or chronic in its course, and each form of the disease presents certain features and characteristics peculiar to itself. The former frequently merges into the latter, however, with no definite line of separation, and each has not a few symptoms in common.

Acute suppuration of the middle ear often results from a cold in the head and may be caused by an inflammation of

* Read before the Salt Lake County Medical Society, March 10, 1902.

any part of the upper respiratory tract. Cold winds striking the ear, bathing, getting wet, pouring or sniffing cold fluid into the nose, and the entrance of soap and water into the auditory meatus are frequently responsible for this affection. It not unusually follows the introduction of fluids into the middle ear through the eustachian tube. The presence of pus in any locality depends upon a necrotic process of adjacent tissues, and the organism producing this must possess a certain amount of virulence. One of the most common causes of suppuration of the middle ear is some acute, infectious disease, scarlatina and measles being the most frequent, although it often follows la grippe, pneumonia and other diseases. During the epidemic of la grippe of 1891, I observed a large number of cases of this affection. In these cases of suppuration, there is perhaps usually an invasion of the middle ear by micro-organisms through the eustachian tube; in some cases they may gain entrance through a perforation in the drum head. Bezold found the diplococcus pneumonia in suppuration of the middle ear in pneumonia. In acute suppuration streptococci or pneumococci are usually found followed by the staphylococci pyogenes.

The first stage of the process consists of a hyperaemia of the membrame of the middle ear, which may be seen through the translucent drum head. This period of congestion is followed rapidly by a transudation of the fluid elements of the blood, and this is followed by necrosis, the tissues breaking down with the formation of pus. The drum head bulges from the presence of the accumulated fluids, becomes softened and finally ruptures. The whole tympanic cavity becomes involved, and the purulent fluid may find its way into the mastoid antrum and cells. Sometimes, owing to the swelling of the soft parts, there is little or no communication between the upper part of the middle ear and the rest of the cavity. This may occasion a very marked bulging of the upper part of the membrane-the membrana flaccida. Dench mentions a case in which this bulging was so extensive that the membrane protruded from the meatus and might easily have been mistaken for a polypus. Occasionally the pus will burrow the entire length of the meatus, passing between the cartilage and bone, dissecting up the soft parts and appearing in the post-auricular region as a soft fluctuating swelling. This is more frequently seen in children, where the soft tissues are less firmly attached to the parts beneath. Involvement of the mastoid cells nearly always occurs in these cases,

Infection of the intracranial structures may take place through necrosis of the squamous portion of the bone.

Symptomatology.-Usually, in an acute purulent otitis, a severe, deep seated pain comes on suddenly and increases in intensity until it is almost unbearable. Attending this is a decided elevation of temperature, ranging from 101 to 103 degrees; headache, constipation, and in children delirium and convulsions frequently occur. In adults the pain is usually not so severe. The pain is more or less intermittent and is generally more severe during the evening and night and is increased by coughing and swallowing. The affection is often accompanied by subjective sensations of hearing, such as ringing, roaring or hammering sounds. Hearing is more or less affected in the early stage to a slight degree, which becomes more marked as the exudation appears.

Course and Issue.-The course of acute suppuration of the middle ear depends principally on its cause, on the intensity of the process, on the constitution of the patient, and on the external circumstances. Perforation of the membrane often occurs on the third or fourth day, although it may take place in a few hours, or in protracted inflammations sometimes only after two or three weeks. When the pressure has been relieved by an incision or a perforation and the pain is much less severe, a decrease of the inflammation may be inferred. The suppuration often lasts from ten to twenty days, although in some cases the discharge may cease in two or three days and in others may continue for a number of weeks. After the perforation is closed, its site is usually indicated by a slight depressed cicatrix, although sometimes this cannot be distinguished and no trace of a past inflammatory process is observable on the membrane. In some cases cicatrices, calcareous deposits, opacities and partial atrophies result, which may or may not occasion a disturbance of hearing. An irregular protracted course often occurs from scarlatina, la grippe and in cachectic persons. These cases are often associated with involvement of the mastoid, where the perforation has closed before the suppuration ceased.

The results of acute purulent inflammation of the middle

ear are:

1.—Cure, with the hearing completely restored.

2.-Transition of the purulent inflammation into serousmucous catarrh.

3. Fermanent disturbance of hearing, due to connective tissue adhesion in the tympanic cavity or in consequence of extensive losses of the drum head, with or without destructive changes in the ossicles.

4.-Inflammation of the mastoid cells. This is frequent in children, and the perforation of the abscess often takes place externally with exfoliation of a necrotic portion of the bone.

5.-Death may occur from pyaemia, meningitis or cerebral

abscess.

6. Acute purulent inflammation may result in chronic purulent inflammation of the middle ear.

Diagnosis. It is not always possible to make the differential diagnosis between acute purulent inflammation of the middle ear and an acute inflammation of the middle ear that has not resulted in the formation of pus. After perforation has taken place the discharge may be seen in the meatus; or if very scanty, by inspection of the drum head. The perforation may usually be seen after merely cleansing the meatus and drum head, and after inflating the middle ear. In children an examination of the membrane is more difficult. The perforation is rarely visible on account of the great swelling and narrowing of the external meatus and the discharge of the secretion. A diagnosis between a purulent inflammation of the middle ear and a purulent inflammation of the meatus can generally be made by inflation of the middle ear by Politzer's bag. In the former case pus will be forced into the meatus. If the secretion is scant the auscultation tube may be used when the sound of a perforation is very apparent. A localized swelling of the canal, indicative of mastoid involvement, is situated upon the posterosuperior wall of the meatus close to the drum membrane. Tenderness, upon deep pressure, over the mastoid is an indication. that the bone is involved, while tenderness on pressure about the ear around the fibrocartilaginous portion of the meatus, points to a circumscribed external otitis of a simple character.

Prognosis. After the formation of pus and its evacuation, the perforation may heal and the parts restored to a normal condition. This termination is rare, however, as a destruction of the membrane over a greater or less area may be expected. Large cicatrices of the drum head may exist; cicatricial tissue causing more or less adhesion of the ossicles is not uncommon. When the membrane is mostly destroyed a dry, glazed condition of the internal wall of the middle ear may be observed.