In

Dr Wm. J. Gillette, Toledo, closing discussion: reply to the first question-I would say that a minor has a right to begin suit after he reaches age.

About six years ago none of the defense unions were in existence. A man who has a good deal of surgical work to do is likely to be sued frequently, but these companies are by no means to be depended upon to see him through any suit because both the New York Company and the Fort Wayne Company reserve the right to drop a man at any time. The laws of the State should be strong enough to defend us. We do not ask anything, or any protection for wrong doing, we do not want laws of such a character that they will protect us in wrong doing, but there should be laws enacted as to how, and the time when these suits can be brought. As the matter stands today there are no laws as to the matter at all.

CHAPTER V-EYE, EAR, NOSE and THROAT

The Effect of Mastoid Operation in Recent Middle-Ear Suppuration

BY JOHN E. BROWN, A. M., M. D., COLUMBUS

Tympanomastoid exenteration, more popularly known as the radical operation, has demonstrated its efficiency as a curative procedure in chronic suppurative otitis media. In looking to this finality for the chronic process, we must not overlook that other equally well-demonstrated fact that the much simpler operation-antrectomy-or Schwartze's perforation of the mastoid antrum, is of itself efficient in the cure of cases of recent middle-ear suppuration, which may have resisted other more conservative forms of treatment.

Granted that from the beginning of the disease the most intelligent treatment has been given there will be a small percentage of the cases of acute suppuration in which the discharge from the ear persists, or which develop more or less grave complications. Of the latter the most frequent is mastoid infection, with resultant empyema. When mastoid symptoms are pronounced the diagnosis is not difficult and the indications for operation are plain. It is when these symptoms are not so clearly manifested that the surgeon may feel taxed in making his decision. In acute otitis media, bulging of the posterosuperior portion of the membrana tympani, sagging of the adjacent meatal wall, pain and tenderness on pressure over the mastoid antrum or tip, are given as the classical symptoms of mastoid infection. There are surgeons before me who were taught as students that edema over the process was the symptom in mastoid disease indicating the necessity for operation. Then came tenderness on gentle pressure, and now we give equal consideration to that elicited on firm pressure.

It is generally believed that in every case of otitic suppuration there is some involvement of the mastoid antrum and perhaps of the adjacent pneumatic spaces. This, then, occurs when we have no focal symptoms to point to mastoid involvement. It seems, therefore, that our present diagnostic symptoms do not mean merely the presence of infection in the mastoid, but rather a certain predominancy of this infection over that in the tympanic cavity, or unusual activity in its attack on the tissues in and about the mastoid.

Experience has demonstrated that all the classical symptoms may be lacking and yet extensive disease be present in the mastoid. If after syringing, inflation and drying of the parts, pus almost immediately reappears, there must be a reservoir not simply in the tympanum itself, but in the cavity of the mastoid antrum or mastoid cells. With such an infection, even if it does not result in empyema, is it reasonable to suppose that any line of treatment will be uniformly successful in curing the disease unless the infected area is opened up and drained?

If a rational treatment, in which early incision or paracentesis of the membrana tympani is so important a part, (note the records of Bezold and Körner of 405 consecutive cases of mastoiditis which came to operation, which show that in only 43 of these had an early paracentesis been performed) does not result in a cure we are in duty bound to consider surgery, which at this time will be much more effective than after the disease has become chronic. We do not need the so-called classical symptoms to warrant an operation. The persistence of the discharge is a sufficient indication. The ills which result from a continuance of the disease are amply testified to in the developments of the special surgery to combat them.

The statistics of reported antrectomies show the efficacy of this procedure as a cure for the associated suppuration, when not of too long standing. Gradle, Meierhof and others call attention to the importance of this indication for the

operation but the most extended and exhaustive essay on this point is that of Milligan (Manchester).

Hammerschlag, voicing the teachings of Politzer's clinic, says that it is not always necessary to open the antrum in mastoid cases, and that perforation of the cortex and curetting of diseased cells often suffices, but the preponderance of opinion is with the Schwartze school, that the equally 'safe antrectomy is surer of good results and diminishes the probability of later operation.

Investigations in the bacteriology of acute middle-ear suppuration have led to practical results, so much so that it should be a rule of practice in these cases to have a bacteriologic examination made to determine the nature of the infection. The three forms most frequently found are streptococcus, staphylococcus and pneumococcus, the order of frequency for these three differing according to the findings of the different observers. It is found as a rule that the infection is seldom monomicrobic. It is an aid to us to know that the pneumococcus is usually associated with a form of infection more benign than that of the two other more frequently found forms; that the streptococcus infection is grave, that in it bone-tissue more quickly disintegrates and that its presence is by some always considered an indi cation for opening the mastoid. The findings of the bacteriologic examination may lead to the use of a proper antitoxic serum which may aid greatly in the treatment of the case. Percussion of the mastoid, while of value, cannot influence our decision as to operation in this class of cases.

How long shall we wait in a case of middle-ear suppuration before resorting to antrectomy? I believe that Gradle has given the rule that best conserves the interests of patient and surgeon, namely, if under proper treatment the symptoms are stationary for a period of two weeks, showing no improvement, this period of two weeks not being reckoned from the beginning of the disease, but from the time when under observation the symptoms ceased to show improvement, then no cure can be expected until the mastoid has

been opened. That cases of mastoiditis can be cured without operation does not influence the question we are discussing.

How does mastoid operation cure recent middle-ear suppuration? It does so by opening up and removing foci of infection in the antrum and pneumatic spaces; by clearing the aditus and attic of infectious material when there present; by relieving the mucous membrane of the tympanic cavity of the irritation of discharge from the antrum and mastoid cells; by giving opportunity for a thorough cleansing of the meatus, tympanic cavity, mastoid antrum and cells and then protecting them under aseptic surgical dressings, maintained until the infection is under control or the middleear discharge ceased; by instituting for the patient a hospital or postoperative regime in which bodily resistance has better opportunity to help overcome the infection.

Milligan's valuable resumé shows that in 10 acute cases in which the mastoid was opened, the ear discharge promptly stopped in all. In 10 subacute (recent) cases, nine were entirely cured by the operation, while one was lost sight of. Bacon says that the discharge in these cases usually diminishes in quantity or ceases altogether. My own experience in recent years has been to the effect that operation in recent cases of suppuration is almost invariably followed by entire cessation of discharge, cicatrization of the membrana tympani, and save, when unusually destructive lesions have been present in the ear, a return of good hearing. Reviewing the records of the last 25 cases of this class I find but two in which it was noted that a discharge continued. One of these was that of a negro child suffering from tuberculosis, which had already suffered the amputation of a leg, and where the local disease was tubercular in nature. The other was that of a child in which scarlatinal otitis had resulted in mastoid abscess, cervical (Bezold) abscess, destruction of the membrana tympani and exfoliation of the ossicles. The discharge remaining in this case was not sufficient to