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3. Caries and necrosis.

is in intimate contact with the brain, while the 4. Cholesteatome formation.

superficial parts form a wall of dense ivory like Hypertrophy and hyperplasia of the mucous

bone which renders perforation and escape of membrane lining of the tympanum affects pus externally impossible. chiefly 'the membranous folds of the attic al- The formation of cholesteatome during the though the lining of the entire tympanum is course of a chronic mastoiditis is of frequent often involved. From the attic extension back- occurrence. It results from the extension backward into the antrum is merely a question of ward of a similar process in the tympanum after

a time. This hyperplastic tissue becomes infil- the chronicity of the suppurative otitis media trated with small cells, loses its epithelium has become firmly established, the cellular eleand becomes converted into chronic granulation ments of the cutaneous lining of the external tissue. These granulations vary greatly in size auditory canal take on an active proliferation from the more minute to those large enough with a resulting ingrowth of epidermis through to appear in the external ear as polyps. This the patent perforation in the tympanic memchange is communicated to the lining mem- brane. The same proliferation takes place, to brane of the mastoid cells with the result that a limited extent, in the mucous membrane of they become more or less completely filled with the tympanum. The epidermis thus formed chronic inflammatory fibrous tissue. This tissue invests firmly the walls of the tympanum and may persist without further change, or may grow into the most minute pneumatic cells and be transformed into bone with complete eburna

Harverscan canals. If the suppurative process tion of the mastoid process. This is the patho- is of low grade and if no caries is present, epilogical condition found in many cases, the dermatization may stop the discharge and line chronicity of which is determined by continued the tympanum with a dense steel gray memreinfection from the tympanic orifice of the brane. If, however, the discharge is profuse, Eustachian tube.

or if caries exists, proliferation and desquammaIf the hyperplasia of the antral mucous mem- tion are very rapid and the tympanum becomes brane is sufficient to prevent the escape of pus filled with a peculiarly foul smelling discharge into the middle ear, necrosis of the mucous known as cholesteatome. The mastoid becomes membrane follows, exurberant granulation tis- involved by the extension backward of this episue forms, the blood supply of the walls of the dermatizing process. The first change noted is antrum is cut off and caries results. By an ex- in the antrum,, the walls of which become lined tension of the process the mastoid becomes con- with the newly formed membrane. If no obverted into abscess cavity filled with pus, gran- struction to the free escape of the discharge ulation tissue and dead bone. Caries is not takes place, the condition may be present for limited to the walls of the mastoid cells. The years without further extension of the disease walls of the mastoid process itself are frequent- or occurrence of symptoms. If partial obstrucly destroyed. Extension takes place upward

tion occurs the discharge collects under pressure into the middle cerebral fossa, backward into sufficient to destroy the walls of the antrum the lateral sinus and posterior cerebral fossa, and neighboring cells. In this way the mastoid inward through the inner tympanic or antral is occasionally converted into one cell lined by wall into the labyrinth, or downward into the pearl gray membrane and filled with cholesteajugular bulb and the neck. It occasionally hap- tome. Under certain conditions this cholesteapens as caries progresses, that the blood supply tome, instead of appearing as cheesy lumps, is of large portions of the temporal bone is cut cast off uniformly in layers so as to form lameloff with the resulting sequestrum formation. lar tumors (cholesteatomata) having an appearIn this way the anterior mastoid wall, the ex- ance not unlike that of an onion and composed ternal attic wall, the mastoid tip, and even the

of layer upon layer of desquamating epidermis. entire labyrinth become loosened and converted

When associated with caries, the pressure of into foreign bodies. These two pathological

the cholesteatome is frequently sufficient to deprocesses are almost always associated, in which

stroy the walls of the mastoid' and to allow case it generally happens that caries is most

infection to reach the internal ear and middle marked in the tympanum and in the neighborhool of the antrum, while sclerosis is most

and posterior cerebral fossas. Cholesteatome is mailin in the more superficial areas. The re

occasionally found upward in the zygoma or sult is that the deeper parts are converted into backward in the occipital, separated from the an abscess cavity, the purulent contents of which primary focus by apparently healthy bone.

Of the above pathological changes, caries and This is due to ignorance of the location and sclerosis are almost always associated, while character of the pathological changes within cholesteatome occurs with great frequence. The the mastoid and also those measures by which amount of caries or sclerosis depends upon the a cure can be effected. Physicians have become virulence of the infection, upon the duration weary of irrigating and treating the middle ear of the dis ase, and the character of the mastoid. through the canal without result and have been

, Thus the amount of caries is greater in cases dismayed at seeing recurrence of the disease of marked virulence, or of protracted course after thorough curettage of the mastoid. When occurring in large thin walled pneumatic celled one considers, however, that the attic of the mastoid, while marked sclerosis is to be met middle ear is invariably involved and that this with in most cases of protracted course occur- region is not reached by the ordinary mastoid ring in small celled or deploetic mastoids. The operation and also that caries and cholestearelative proportions of these changes varies tome formation invade the most minute Haverwithin the widest limits. At the time of opera- sian system of the temporal bone, he sees two tion one case shows the mastoid to have been good reasons for his failures. Study of the sponconverted into thin walled abscess cavity filled taneous cures sometimes affected by nature in with pus and dead bone or cholesteatome. An- even the most extensive cases has made clear other shows the entire mastoid sclerosed and as the operative procedure by which success may hard as ivory with the antrum abnormally small.' be attained. We not infrequently see patients In the majority of cases, there is a moderate who, in previous years, have suffered from a amount of superficial sclerosis, while the deeper chronic suppurative otitis, and whose ears have parts contain pus and cholesteatome. In one ceased to discharge. In a fair percent of these series of cases published by the writer : cases the reason for the cessation of discharge

1. Marked Sclerosis was present in 52% is plain. Caries has destroyed the external wall 2. Cholesteatome was present in

79% of the attic and the inner end of the posterior 3. Meningitis was present in.... .71.2%

wall of the auditory canal. This has thrown 4. Adenoids were or had been present in.. 75% 5. Disease of childhood had been present in 75%

the external auditory canal, the tympanum and 6. Facial paralysis present before operation 11%

the mastoid into one irregular cavity, the walls 7. Jaw had been entered in ...

4% of which have become lined with epidermis by 8. Labyrinth had been entered in

15% extension inwards of the skin of the external 9. Dura had been uncovered in


canal. This is natures radical operation and is 10. Perforation through some wall


the condition which the operator brings about In estimating the clinical significance of

by the radical mastoid operation; that is, a sinchronic mastoiditis one must take into consider

gle cavity with smooth walls secured by throwation the surgical relationship of the mastoid

ing the tympanum, antrum, mastoid and canal to the structures; i. e., the brain and the vas

together by removing the external attic wall, cular channels of the dura, and must realize

the posterior and superior canal walls and the that 75 per cent. of all brain abscesses and the

entire mastoid process. By this method the majority of all cases of suppurative meningitis

entire diseased bone is removed and a satisfacare of otitic origin. Inasmuch as the extent

tory approach to the brain, sinuses and labyrinth of the pathological change can not be determin

afforded should the necessity for attacking them ed before operation and as the brain, dura and

arise. Although this method renders possible sinuses can be involved without the causation

the exposure of all diseased areas, it can not of symptoms, the presence of a chronically dis

be expected that it or any other procedure will charging ear can not be regarded with compo

permit the operator to eradicate the microscopisure by even the most optimistic of observers.

cal bits of carious bones and cholesteatome that The presence of this focus of suppuration is re

have invaded the minute pneumatic spaces and sponsible for many a case of lowered vitality Haversian canals that are met with in the deepand may therefore be indirectly the cause of

est parts of the temporal bone. It is the cholesmany diseases with which it apparently has no

teatome that is the most difficult to eradicate. connection.

No matter how great pains have been taken The chief reason, I believe, why practitioners nor how extensive the operation, the surgeon have regarded chronic suppurative otitis media must recognize the possibility of infection in with indifference is that the majority of cases the depths of the wound during healing by the with which they have come in contact have minute bits of cholesteatome forced out of the resisted treatment either operative or otherwise. Haversian canals. To overcome this re-infec

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tion, it has been necessary to maintain the operative field open to observation and free of granulation tissue until epidermization of the mastoid cavity has become complete. By means of a plastic operation upon the soft tissues of the posterior wall of the external auditory canal, the mastoid cavity can be kept under perfect observation until healthy skin can grow in from the edges of the canal, replace the cholesteatome and cover the cavity with steel gray epidermis. When this has taken place, the patient may be considered well. The final result then is a cavity hidden from view, composed of external auditory canal, tympanum and mastoid, covered with firm epidermis.

If, as a result of the operation, we can look forward, safe guarding the patient's life and causing cessation of the discharge, and that without destroying that degree of hearing which the disease has left him, certainly these cases

, of chronic suppurative otitis are worthy of operative interference.

and that is the use of vaccines. I started to use vaccines on mysell. I had had a tonsilitis, and incidentally an infection of the kidney with a pronounced case of nephritis, and was in bed a good many weeks. I made a perfect recovery, but I do not think my recovery was perfect until I began to use these vaccines. I had used them before, at first very moderately. Two or three times I stopped because I would get results I could not understand. I would use vaccines in some of the ear cases--some would get well and some would not, and suddenly some would give very bad reactions, It led me to the conclusion that the vaccine treatment of a good many

or these cases is a very important thing. I do not believe we know very much about the use of vaccines, but I think in twenty-five years from now we will know a lot about them, and in twenty-five years from now I think we will find that in a great many cases instead of giving people so much treatment internally we will give them vaccines. We will know more about what we are doing. It seems to me that

the most encouraging thing in the treatment of these cases or chronic discharge from the middle ear has been the use of vaccines. I have bad cases where I had treated them in the regular way and practically had no results, and finally decided I would do an operation; but before doing that I tried a little vaccine, and have been very much surprised with the way some of these cases were arrested in response to the vaccine treatment. It is a form of treatment that you have to study to find out how you are going to use the vaccine-find out what the patient's resistance will be. All these things I think eventually will be cleared up. I think there will be a laboratory way of finding out just what we can do with vaccines. 1 think we are in the beginning of it, and probably a great many of you will do as I have done. I have finally come back to the use of vaccines, and the more I use them the more I am inclined to use them.



DR. EMIL AMBERG, Detroit: We have all enjoyed the classical presentation of Dr. Canfield's paper. He spoke of the thickening of the drum membrane of the middle ear. It has been shown by Bezold that this thickening is enormous, and it has also been shown that the early incision of the drum membrane does away to some extent with this thickening.

The doctor touched upon a very interesting point concerning the spreading of the disease beyond apparently healthy bone. This is a great trouble we have to contend with in mastoid infertion. If the disease would spread by continuation only it would be a very easy matter to cure mastoid infections. have some help in detecting these detached places of infection by the aid of the X-ray.

As far as the complete mastoid operation is concerned, one should be a little critical. of course the main factor is, as Schwartze once told me, to remove all diseased bone. I once visited the old gentleman in Halle. He was very abrupt, and young as I was I did not take kindly to his manner. He asked me. "Did you come to Halle to see the clinic or to see me?'' I answered that I came to Halle to see him and to see the clinic. He was very nice after that, and invited me to come the next Monday to see Doctor R do a mastoid operation in which he would remove all the diseased bone—that that was the crux of the situation, to remove all of the diseased bone. It remains for us to find out where the diseased bone is. I, for instance, we have an abscessed cavity, an empyema the origin of which we can explain very well, taking into consideration also the clinical symptoms before the operation and perhaps the X-ray picture that is one class of case. And then we have as a rule simply to drain that empyema and the pa tient is cured.

One point should be emphasized, and that is the character of the odor of the discharge. Of course we know that some. times there may be an offensive discharge that clears up after cleaving the cars patients are perhaps negligent and allow an accumulation of pus to remain in the ear. But if we have a chronic mastoiditis we will have an offensive odor, which if it does not improve after one or two treatments, should warn us that there is something behind it. I had a case the other day -the boy's mother said his ear had been running since he was a little child. lle is now ten years old. He had an osteocholesteatoma of the middle bone, and at operation we found the lateral sinus exposed at least one-sixth inch. We did not expose the lateral sinus-the suppuration had done that. This boy perhaps in the course of six months or a year might have had either an extra dural abscess in the posterior fossa, or might have suffered from a sinus thrombosis.

Concerning the meninges, there are a great many cases of

DR. ILIROLD WILSON, Detroit: I did not hear the first paper, but I am quite of the opinion expressed by Dr. Amberg, that we are too satisfied with our own attainments, and too apt to consider them our own accomplishments. Something like one thousand years ago the prognosis in middle ear infections was about as it is today. and 1.300 years ago the treatment of chronie defects was not essentially different. Although we have progressed in our knowledge of oto-stimulation, yet we definitely associate the pathology with the treatment.

To my inind the pathology is very much like many other things, unless it bas wliat is called a pragmatic value, it is a matter of orilinary importance. I believe our prognosis has been a mat. ter of small advances- almost infinitesimal accretions from generation to generation and from individual to individual. It gives us some comfort, perhaps, in one sense, that we have reached the age, professionally speaking, when we can look bark upon our careers and and think we have added anything worth while to the practice of medicine: but I think if we Were more familiar with the history of medicine we would think less of our own accomplishments.

DR. ALBERT E. BERNSTEIN. Detroit: I was especially delighted with Doctor Amberg's paper. Andre Perez was one of the first to do a real mastoid operation. He had seen sev. eral operations done in Italy, and when Louis, the son of Catharine de Medici, who was married to Marie Sturat, came down with an acute mastoid, Perez wanted to operate, but was prevented by the Catholic Church and by political machina. tions I believe afterwards Perez did several operations of this kind.

With reference to one feature of Dr. Canfield's paper-he spoke of these isolated areas of cholesteomata. I am certain a great deal of our failure or success in the radical operation may be traced to that. I have in mind an instance right now

a man on whom I did a radical mastoid in August. He got along fairly well, but shortly afterwards 'he complained of a pain over the ear, and the X-ray showed a small area of choles. teomata which we evacuated, and he got well, He still complained and we operated the third time and found another area. He got a long all right, and then later went up to Ann Arbor and was operated there, and a few weeks ago he turned up at my office again, still suffering. These things show how careful one should be about condemning another operation, that may have been done very carefully, and still something left behind.

DR. R. S. GOTX, Detroit: There is one factor in the care of these cases that I think should be mentioned at this tirpe,

meningitis which do not come from the ear-not all cases can be traced to middle ear suppuration. We have tubercular men. ingitis, we have pneumococcic meningitis, and it has been shown in the literature that the ear may become involved secondarily--that we may have the meningitis first and the ear trouble secondarily. This of course should not throw us off our guard in considering meningitis as a complication of middle ear disease.

So far as the healing of the radical mastoid operation is concerned, sometimes we have to be satisfied if we have healing by epidermization of the lower tympanic cavity. This is nice, but it we have mucous healing we should be satisfied, too.

I would like to take issue to some extent with my friend, Dr. Goux, concerning vaccines. Perhaps I was a little frightened. I had a patient in which the subjective symptoms were improved by vaccines, but the objective did not tally with the subjective. This is a point that is to be taken into consideration, and until the time comes when this question can be illuminated I will not be as optimistic as Doctor Goux.

DR. B. N. COLVER, Battle Creek: I am interested in Dr. Cantield's point in regard to the removal of all the diseased bone, and also in Doctor Amberg's remarks. I would be very glad to have Doctor Cantield go further with this anatomical operation in closing.

He mentioned particularly the deep cells that might be left in the roof of the zygoma.

There are two other areas I have seen left where the cholesteomata originated. One is the group of cells between the

and the lateral sinus posterior to the floor of the fossa; the other is the portion of the sigmoid sinus between the trigastriç fossa and the sigmoid, where the cells continue posteriorly some little distance deeper than the superfici group of pneumatic cells.

DR. C. H. BAKER, Bay City: I think Doctor Amberg has taken a very pessimistic view of the situation as regards the progress of medicine in our specialty, the ear.

When you stop to think of conditions in the days of Hippocrates and of Perez, and how few Hippocrates and Perez there were, and how few ever found the lesions there were, then look over the field now and see the great development there has been and what a wide field is being covered-I think the prospects for the next century are certainly very favorable for an advance. ment which will put in the shade everything done before.

In regard to the cases of the type of which Doctor Bernstein spoke, where he found cholesteomata developing again and again in new areas and where he was obliged to operate repeatedly. I have in one or two instances succeeded by a very simple procedure in keeping them under control and curing them. One was the application of a very dilute solution of iodine in alcohol. I gave it to the patient for his own use and let him apply it with a pledget of cotton on a probe. That has controlled the cholesteomata in a number of my cases or prevented its development.

In regard to Doctor Goux's experience with vaccines, mine is the same--sometimes you get brilliant results and you think you have the right thing, and the next case, which looks exartly identical, you do not get any result whatever, or an adverse result. I think one difficulty is that most of us have not the time or the facilities for the cultural investigation which is necessary. In other words, we do not make blood tests and see what the resistance is, or the fixation tests, or the wbite corpuscles, or what is still more important in a good many cases, to see whether the blood is the carrier of the germs of infection. If we could make these examinations, In all of our cases I do not think it would take very long to clear up the vaccine question.

DR. MYRON METZENBAUM, Cleveland, Ohio: I have certainly enjoyed this classical presentation of Doctor Canfield. I hoped, on the subject of the pathology of mastoiditis, he would have referred to his own inflexible rule to operate a mastoid early so as to prevent this gross pathology which the paper deals with. About twenty-five years ago, when appendectomies was first made known to the general surgeon, and for ten years thereafter, the great debate was-when to operate. It varied from the minute you make the diagnosis to the interim of attack and later when an abscess forms, until today I believe the consensus of surgical opinion is to operate an appendicitis as early as the diagnosis can be established. I think at Camp Greenleaf, under the direction of Colonel Seale Harris, the rule was that every soldier should have his mastoid opened if the ear did not show marked improvement from a bacterio logical standpoint as well as clinically, in six to ten days. I think the results as to later complications were very good.

The prevention of the pathology is probably far more important than the cure of it. I do not believe the otologists, at least in this country, have come to as decisive opinions in rela. tion to when to operate a mastoid case as the general surgeon in regard to the operation for appendicitis. Nowadays, with the aid of the stereoscopic X-ray pictures of both sides of the mastoid, which enables you to compare their relative density, you get an insight into the condition of the mastoid that you could not have otherwise, and in a picture wbich shows the one side cloudy, even if it is apparent on the third to sixth day, it seems needless to wait to see if the ear will get well. It might get well from a clinical standpoint for the time being, but there is more likely to be some functional disturbance of the auricles of the ear if the case is not operated. At least in our city there seems to be a rule that if the patient shows no improvement from the first to the tenth day, he is considered a subject for operation. If he does not improve very materially within three weeks, he surely should be operated, and no patient should go longer than six weeks if you know what the condition of the discharge is. I think the experience of most men is that if the operation is performed relatively early there is generally better hearing than if the operation is postponed, The danger of other complications arising from the ear that continues to discharge would be minimized by early operation, but I would like to throw a lot of shrapnel into the meeting when this is finished by discussing the question of when to operate a mastoid.

DR. FERRIS N. SMITH, Grand Rapids: I have nothing to say about Doctor Canfield's paper, except to commend it as a very finished presentation of the subject of pathology.

In regard to Doctor Amberg's paper, I think we can sum up the whole thing by saying that the large number of procedures which are used in common practice for the care of a suppurating otitis is evidence sufficient of the scant appreciation we have of the condition going on in the ear and the proper treatment for it. If there is any condition in medicine for which there is advocated a large number of treatments or preventive procedures, it is generally a condition about which we know little or have a poor conception concerning. It does seem to me if ear abscesses were regarded as abscesses in other parts of the body, it would be more simple. The general surgeon when he opens an abscess does not syringe it with every pos. sible concoction he can lay his hands on; he opens the abscese freely enough to drain properly, drains it and expects it to heal in the course of time. I think the average middle ear which is opened at the proper time and treated as abscesses in the soft parts of the body, will heal all right. Of course an abscess in the middle ear is not quite analogous, because it is in a box-like.cavity. I do not want to open up the subject of the proper management of the ear at the stage when you get a serous discharge or the stage when you get a purulent discharge, because that has been thrashed out and you would not care to hear it. So far as abscesses in a bony cavity are concerned, the surgical practice is different. Your general surgeon in dealing with abscesses of the long bone opens them up, cleans them out, and expects them to heal. That is what happens in a case of simple mastoid, and if the cavity is thoroughly cleaned out and the wound left so that the soft parts can come in contact with the bony surface, you may expect healing. I do not think there is anything very weird about it. I think it is foolish to use any kind of irritating antiseptics in the middle ear, and that many of the cases which go to magtoid operation are forced there by the specialist who puts these antiseptics in the middle ear.

DR. R. S. GOUX: I want to correct the impression that I advocate the use of vaccines in all cases. If you have a case of necrosis, I do not think vaccines will cure these cases.

DR. R. B. CANFIELD, Ann Arbor: I want to agree with the conclusions that Doctor Amberg has reached in his essay. It seems to me we have learned very little since the time of Esculapius, We have learned many details and a good deal about the pathology, but we have not been able to get this across to our students or to the profession. We have not taught the general practitioner much, if anything, of the treatment of suppurative diseases of the ear. I am amazed and chagrined to see my own students send me back cases in bad condition which they could easily have taken care of themselves in the early phase and which they should have recognized. They have passed their examinations and gone out into the practice of medicine without knowing much about it, or at least they do not show it. I think it we should disseminate through the profession the knowledge of ear disease that Hippocrates had, we would do a great deal.

There is one point, and that is that in reading the mastoid plates you have to read your own plates. You should always work with the same Roentgenologist. I do not rely very much on the judgment of the Roentgenologist as far as the X-ray plate is concerned, because in my subconscious mind I always have the clinical symptoms to correlate with the X-ray picture. But I think Doctor Canfield's remarks should be listened to very carefully, and I want to emphasize them for one reason --that you should not send a patient to the Roentgenologist and then rely on the reading of this specialist, because he has not the knowledge of the case that you have. We have to take the whole picture of the mastoid into consideration, and the X-ray is only one part of it.

Doctor Baker raised the question of whose work shall endure -what mountain tops, so to speak, shall shine in the future. I think we will have to wait some fifteen hundred years, when somebody will be reading a paper similar to these, and I am sure Doctor Baker's name will be mentioned.

DR. HAROLD WILSON: I am indebted to you for this honor, for which I am deeply grateful. It was thrust upra me in my absence, and that is the only excuse I can make.

If an address from the incoming Chairman is in order, I would like to raise the question of the X-ray and say that I have formulated my opinion, too. In chronic mastoid I agr de with Doctor Amberg that it is of very little if any importance. In acute mastoid I would make two divisionschildren and adults; then young children with chronic mastoids, which is in the same category as adults-it is not necessary. So under these tbree heads I think we can say we have included all of the subject of the X-ray.

I think I can explain the value of vaccines. Yon know in certain Church ceremonies there is a laying on of hands, and the virtue is in who does it. If I were to baptize your chil. dren they would not go to Heaven; but if I were ordained and sprinkled water on their heads that water would have a peculiar quality which otherwise it would not have. In other words, those who are ordained to administer vaccines get results. Unfortunately, I have never been ordained.



Tlie doctor made a very good point when he spoke of the necessity of rest. If we had taught the general practitioner to put the case of earache to bed, we would have taught him a great deal. If we had but one method of treatment to use in acute ear trouble, I would say rest in bed should be that one. Of course drainage goes without saying, but rest in bed I really believe in acute inflammatory conditions of the middle ear, before perforation, is more useful than any other one thing. If all these people were put to bed and kept quiet, fewer would go to mastoid operation than now, when after their ears are opened they are allowed to move around.

So many topics aside from those mentioned in these two papers have been discussed that I take advantage of this op. portunity in closing the discussion. I would like to take issue with Doctor Amberg on the matter of the X-ray. I do not know whether I can get my stand on the X-ray across to you or not. I am just as enthusiastic a supporter of the X-ray as anyone, but I depreciate the fact that patients are sent to the X-ray laboratory without having been carefully examined by the clinician, and the diagnosis left to the radiographer and his statemeni teken as being the last word on the path. ological condition of the patient. I believe that the welltrained otologist ought not to find it necessary to have recourse to the X-ray in making a diagnosis of mastoid disease either as to whether it is present, as to its extent, or the indica. tions for treatment. We have so repeatedly seen the stere. oscopic picture of the mastoid lead men astray, that personally I do not care about the X-ray report. I am not egotistical about it, but I do feel that no radiographer can tell me very much about the pathological condition of the mastoid in sup. purative disease. We have been led astray by it; we have been told that it was healthy when it was filled with pus; we have been told the ear was normal when it was discharging, and anyhow, the X-ray plate is simply a record of the density of the bone, as to whether it transmits light readily or not. It is convenient often to tell us what pathological changes are taking place, but not honestly and accurately what is there. So I am not strong for the X-ray examination in mastoid disease. Of course, the difficulties of the radiographer are perfectly plain to all of us, and the different densities in the same process are clear to us. But let us go the ancients one better by teaching our students what everybody ought to know about suppurative otitis media, by making careful clinical examinations and learning ourselves what is going on in the bone and not let somebody else tell us about it, and finally, by using good common sense in the care of these people.

I do not know just what Doctor Colver meant by asking me to discuss the anatomical operation, but I believe it is almost always quite possible to eradicate the diseased bone in a mas. toid if we destroy and remove all the pneumatic structure which is accessible. If at the time the mastoid is excavated and this is done thoroughly-and extension to the neighboring structures has not taken place, then I think it will not take place. I make an effort in all mastoid surgery to remove all the pneumatic structure, and I am especially careful if the bone happens to be luetic in character. If it is it transmits infection more easily and in such mastoids one Ands many small vascular channels connecting the cranial sinuses. So it is worth while to be very meticulous in the toilet of your operation.

DR. EMIL AMBERG, Detroit: In regard to the matter of rest-do not think the general surgeon with a diagnosis of appendicitis lets the patient walk around-he puts him to bed, and we know that the peritoneum is very much more resistant to the infections than the meninges are. I am glad that Doctor Canfield mentioned the X-ray examination of the mastoid. Several years ago I read a paper in which I drew nine conclusions about the X-ray, and I am glad to say they have held. The points are these:

In a chronic middle ear suppuration or mastoid the X-ray plate is of little value because we have a dense bone and we cannot see in the X-ray plate what is going on around or behind the dense bone. In acute middle ear suppuration, without mastoid complications, the value is sometimes doubtful, too. Of course the X-ray man distinguishes first, second and third degrees, but the rule should be to consider first the clin. ical symptoms and then the X-ray plate. If the clinical symp. toms speak for an operation and the X-ray does not speak for it, I operate. If the clinical symptoms do not speak for an operation and the X-ray plate—in a case of acute magtoiditis or confirmed discharging ear--fails to show dis. tinct changes of a certain type, then I go in. Doctor Densch of New York, who has had a great deal of experience, cites a number of cases in which the X-ray was of material benefit to him in locating the diseased area which he would otherwise have overlooked. I think these were cases in the Yew York Eye and Ear Infirmary.



Cancer of the lip and tongue are among the most serious of malignant diseases. The mortality of cancer of the tongue is more than 50 per cent., if treatment is not instituted early and thoroughly, of the lip, between 50 and 60 per cent., unless operation is done before the glands are palpable.

In cancer of the oesophagus and stomach, where the means of making the diagnosis is more or less indirect, depending upon the clinical history, X-ray examination and special examination, etc.,

are able to make the diagnosis early and advise the proper treatment for such a condition, yet it is a common thing for a Surgeon to see a patient, with a carcinoma of the stomach, who has had symptoms, referable to it for a much shorter time than the usual case, who presents himself with cancer of the tongue or lip. These (ancers can constantly be seen by the patient and his friends and yet it is not an uncommon thing, in fact, unusual that the surgeon sees such cases until they have reached the ulcerative stage and when such is the case, the growth usually is very extensive, with metastatic infection present and infrequently, we also have super

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