Tlie Class of Cases in which we may expect Good Results front Excision of the Membrana ' y ' / . ' _ 1 . , Tyinpani and Ossicles. BY Lecturer on Otology and Chief of Aural Clinic in Jefferson Medical College of Philadelphia; Surgeon in Charge of the Ear, Throat, and Nose Department of the Germantown Hospital, Philadelphia, etc. S. MacCUEN SMITH, M.D., [Reprinted from the Therapeutic Gazette for July 15, 1893.] DETROIT, MICH.: GEORGE s' DAVIS, PUBLISHER. lS93- THE CLASS OF CASES IN WHICH WE MAY EXPECT GOOD RESULTS FROM EXCISION OF THE MEMBRANA TYMPANI AND OSSICLES. THE history of excision of the membrana tympani and ossicles has been brought to the notice of the profession so frequently that a repetition of these familiar facts would prove tiresome and uninteresting. We should, however, mention the fact that Kessel in 1875 and Schwartze in 1885 performed this opera- tion for the relief of deafness only ; while great credit is due to Sexton, who, in 1886, by his courage and skill, brought before the medical world the results of his numerous operations for the cure of chronic aural discharges, and later for the relief of deafness. It was Sexton, therefore, who first proposed this operation, and performed excision of the membrana tym- pani and ossicles for the cure of discharge from the ear. Burnett and others, however, soon followed, and by publishing their results did much to es- tablish this formerly-condemned operation and bring it to the almost universal recognition of that part of the profession especially interested in aural surgery. We are all familiar with the determined op- position this reasonable operation called forth from some quarters. It did, indeed, seem pecu- liar that advocates of rational medicine should have offered such strong and damaging protests against a surgical procedure which they could not but acknowledge was based on sound sur- gical principles; and especially did this opposi- tion appear unreasonable when we remember that these same opponents were acquainted with many unfortunate patients suffering from a chronic discharging ear with its many dangers, which had not only resisted their every effort, but had, moreover, baffled the skill of other specialists. The great danger to life arising from a sup- purative disease of the middle ear is now ad- mitted by all, and surely any procedure pro- posed for its relief is worthy of due and proper consideration, so long as the treat- ment thus suggested is not likely to produce bad results, and has for its support the same sound anatomical, pathological, and physio- logical backing that has characterized all the noted advances of modern surgery. Those who have not taken kindly to this rational treatment have declared the operation to be dangerous, and therefore involving too many risks to admit of its becoming popular; to all of which we would ask whether this or any other proper surgical procedure could be more of a daily menace to life than a chronic discharge from a cavity the walls of which are composed of plates of bone that are extremely thin and surrounded by such vital parts as the brain and important blood-vessels ? It is cer- tain that a continuation of the discharge favors necrosis of these delicate plates of bone, and thereby induces, through continuity of structure or by direct communication, abscess of the mas- toid, septic inflammation of the brain-substance and its coverings, or cerebral abscess, from which alone there are annually dying in the United States probably four thousand of her inhabi- tants. At present it is difficult to say precisely just what class of cases are most likely to yield good results from this mode of treatment. Some few cases, regardless of the duration of tinnitus and vertigo or the degree of deafness, will give very satisfactory results. As a general rule, however, it is not well to expect too much improvement of hearing from a chronic, non-suppurative otitis media; and yet, in this class of cases, where tinnitus, pain, and vertigo are urgent symp- toms, and have resisted other methods of treat-' ment, we should not hesitate to suggest the re- moval of the membrana tympani and one or more of the ossicles for their relief. It has not been our custom in the non-suppurative cases to excise the entire membrana tympani unless it is greatly thickened, opaque, and firmly ad- herent to the tympanic walls. In this class of cases it is interesting to note the large number of patients in which the tympanic membrane presents quite a healthy appearance. It is, however, in just such cases that we remove only sufficient membrane to enable us to excise the malleus, the incus, or both. This paper was read before the Section qn Laryngology and Otology of the American Medical Association, June, 1893. 2 Good Results from Excision of the Membrana Tympani and Ossicles. In this modified operation it is very unusual to have any reaction, and we likewise avoid the pain and suppuration that has at times been re- ported. By this partial myringectomy, regen- eration of the membrane is so slow that at present we can recall at least seven cases in which the original opening has remained for more than two years. Moreover, in our expe- rience of over two hundred patients operated on, we are convinced that it is seldom neces- sary to remove the membrana tympani after re- generation has occurred, unless, of course, the operation had been performed in one of the suppurative cases, and where regeneration of the membrane had confined a dangerous necro- sis of the tympanic cavity, or concealed a threatened mastoid involvement. In order to obtain good results in the sup- purative cases, we believe it to be positively es- sential to remove every fragment of the mem- brane, as this is the only way in which we can hope to obtain free drainage and procure an opening through which to properly treat the diseased cavity. If the attic is involved it will be found neces- sary to excise both the malleus and incus, for these bones are very susceptible to carious de- generation, and where either is left behind, the suppuration is almost sure to continue; and even if the discharge should cease, it is likely to reappear at any time in the future. In regard to the operation for excision of the stapes, which has met with such good results in the hands of Dr. Jack, of Boston, I can say but little, as my experience with this operation is limited to two cases; both of these, however, were somewhat successful in the relief of symp- toms that have otherwise resisted treatment; but as each of these cases suffered from pro- longed staggering vertigo as sequela of the op- eration (possibly due to my lack of skill), and as out-patients have generally recovered with- out this procedure, we have found no indi- cation for advising or performing this more formidable operation. In order to show the benefit that is some- times obtained from apparently the most hope- less condition, we will review the detailed his- tory of several unique cases, characterized by marked deafness, severe pain, and vertigo, all of which were relieved by operation. Case I.—J. K., thirty-nine years, began to lose his hearing, accompanied by an itching of the external auditory canal, ten years ago. This loss of hearing was in both ears, and continued to grow worse until eighteen months ago, when he was suddenly taken with severe pain in each ear, radiating over the entire head. This pain continued without interruption for nine months; then, without apparent cause, the pain increased in such violence as to necessitate his going to bed and summoning a physician. Before re- lief could be obtained he became totally deaf in the left ear. At the end of two weeks pain was so much better as to enable him to leave his bed. Some pain, however, has con- tinued, and now seems to be confined to the right ear. On January io, 1893, he consulted the writer (bringing a note from the family physician, to whom I am indebted for his pre- vious history). It is well to state that this patient has never had any discharge from the ear, nor does he remember having had at any time an injury to his head. Except for the inflammation extend- ing along the manubrium, nothing of any im- portance could be seen to account for his suf- fering. The mastoid region presented a healthy appearance ; the drum, however, was much re- tracted find firmly adherent to the promontory. His hearing-power was nil through aerial con- duction of sound. Bone conduction was about three-fourths normal. With the hope of relieving the pain alone, we suggested the removal of the drum and os- sicles. On January 16, 1893, under ether, in the hands of Dr. Pontius, we removed the drum by the circular incision and extracted the mal- leus and incus in a piecemeal way, their vital- ity having been so completely destroyed by the process of necrosis that they crushed to powder under the slight pressure of a delicate pair of forceps. These bones had undergone the several changes which are more forcibly than elegantly expressed by the term “dry rot.” I believe this was the first and only case in the writer’s experience where complete excision of the drum was accomplished without any hemor- rhage, After operation the tympanum and canal were lightly packed with iodoform cot- ton and the patient kept quietly in bed. For three days the pain was in no way relieved, al- though the hearing was materially improved. From the third day, however, the pain and tin- nitus grew less, while the hearing-power con- tinued to increase. On January 24, or eight days following the operation, the pain and tinnitus were so slight as to be barely noticeable. Could hear loud conversation at three feet; tuning-fork and watch were negative in result. March 12, or about two months after the op- eration, reports that he has been free from pain and almost free from tinnitus for two weeks. Hearing-power slightly improved. May 16, has not had pain since six weeks Good Results Jrom Excision oj the Membrana Tympani and Ossicles. 3 following the operation, and the tinnitus is now so slight as not to annoy him. Thinks it is growing less each day. Can hear ordinary conversation at six and a half feet, fork and watch each at four and a half inches. It is difficult to say why this man should have suffered so severely, for surely the condi- tion as above narrated does not seem to be a sufficient explanation. As regards tinnitus and loss of hearing, we consider this to be fully ex- plained in expressing the belief that a thick drum bound down by adhesions, with anchylo- sis or other disease of the ossicles, acts as a foreign body, and as such produces tinnitus and deafness, the degree of which is in direct ratio to the extent of the disease present, and consequent interference with their normal func- tion. We would, therefore, consider the re- moval of such disturbing foreign elements as not only sufficient reason for the partial or complete restoration of hearing, but it can also be hoped for and reasonably expected that we may secure relief from distressing tinnitus and ofttimes dangerous vertigo. Case II.—A. M., aged sixteen, applied for treatment August 10, 1890. When seven years old had scarlet fever. This was followed by discharge from both ears, which was continuous until the above date. Meanwhile, was progres- sively and rapidly losing her hearing. Suffered continuous pain, sometimes very severe; was totally deaf in left ear. After making many and various unsuccessful efforts to arrest the discharge and relieve pain, we suggested the removal of the fragment of drum and malleus. This we performed on December 9, 1890, after which the ear was packed with iodoform cotton, and replaced by fresh cotton every one or two days. December 20.—No discharge since opera- tion ; hears fork at five inches, watch at three inches, ordinary conversation at three feet. January 26, 1891.—Tympanum entirely dry; hears fork at five inches, watch at six inches, ordinary conversation at five feet. April, 1891.—No discharge since operation ; hears watch at six inches, fork at seven inches, ordinary conversation at twelve feet. Dece?nber, 1891.—Slight improvement over the above. July, 1892.—Hears watch at JJj, fork at twelve inches, ordinary conversation at four- teen feet. May 24, 1893, or two and a half years after operation, hears watch at fork at seventeen inches, ordinary conversation at twenty-seven feet; no discharge since date of operation ; health much improved; performs the duties of life quite as well as if she had never been deaf or suffered from pain in that ear. Case III.—H. D., sixty-two years old, ap- plied March io, 1893. Six years ago resided in England, at which time was taken with a severe pain in the right ear, which she thinks came from cold. Never had any ear-trouble before, and has always enjoyed good health. Was treated by physicians in England for three years, but received no benefit. Has been in this country for three years, and undergone treatment at the hands of many physicians and as a private patient at several hospitals, without beneficial results. On March 10 last, or three months ago, she consulted the writer at the Jefferson Hospital, suffering extreme pain and greatly annoying tinnitus in the head. Never had a discharge from the ear, but has suffered from severe head- ache since early adult life. The drum and external auditory canal, on examination, revealed nothing abnormal, ex- cept some inflammation covering the manu- brium. The Eustachian tube was somewhat swollen, but inflation of the tympanum by Politzer’s method was easily accomplished. This interference, however, gave her some in- crease of pain. By aerial conduction of sound she could hear only very loud conversation; watch and tuning-fork could not be heard; bone conduction, however, was quite normal. Aside from operative interference it was diffi- cult to suggest or carry out a line of treatment with any reasonable prospect of securing re- lief, and inasmuch as she had undergone much treatment of the usual routine kind without in any way being benefited, we felt justified in suggesting excision of the drum and malleus, which was performed on March 30, 1893. For one week following operation she con- tinued to suffer some pain, but it was markedly less severe. On the tenth day a slight dis- charge of pus was noticed, at which time the pain entirely ceased. The discharge became quite copious three days later. Sixteen days after operation the discharge was quite scanty and the pain returned. A free discharge, how- ever, was re-established, and the pain again ceased, not to return again. April jo, i8gj.—Pain relieved ; discharge entirely gone; heard the fork at one inch, watch at ; ordinary conversation at six feet. May 10, i8gj.—Tympanum entirely dry; no pain; hears watch at fork at nine inches ; ordinary conversation can be heard at the normal distance. Patient expresses herself as feeling entirely well; hears everything at church or opera. 4 Good Results from Excision of the Membrana Tympani and Ossicles. Case IV.—E. M., thirty-nine years old ; first seen January 15, 1893. When four years old had a severe illness, which was followed by a discharge in both ears. This continued until eighteen years old, when the discharge ceased in each ear. Two years later she suffered from severe pain in the left ear for one week, when the drum ruptured, followed by the free escape of pus and relief from pain. The running con- tinued for some weeks, then ceased, since which time she has been free from discharge or incon- venience of any kind until two years ago, when her hearing began to fail, accompanied by some “neuralgic pain” in head and distressing tin- nitus. Is now totally deaf to aerial conduction of sound, the osseous conduction being quite normal. After making unsuccessful efforts for her re- lief, I advised the removal of the ossicles and drum of the left ear, which we did on March 20, 1893. The operation was followed by con- siderable discharge for several days, but the hearing began to improve almost immediately and the tinnitus to grow less. The pain has been entirely relieved. May 18, 1893.—Pain and tinnitus entirely relieved; hears tuning-fork at ten inches, watch at ordinary conversation at two feet; general health, which had been very poor be- fore operation, is greatly improved ; discharge has entirely ceased; tinnitus and pain effect- ually relieved. Case V.—F. B., aged twenty-five, consulted me September 21, 1889. In 1887 I had treated the sister of this patient for impairment of hear- ing, due to'impacted wax; and, as she was im- pressed with the idea that something unusually skilful had been done for her, she informed me of a sister living in Breslau, Germany, who had bean deaf from early childhood, and suggested that possibly we might be able to give her re- lief. She was advised to send for her sister, who presented herself about two years later, giving the following history: Has suffered pain ever since she was old enough to remem- ber. At times it was so severe as to necessitate her going to bed, and could only be relieved by the hypodermic injection of morphine. This pain was not confined to the ears, but seemed to be general over the entire head. Does not remember ever having had discharge from the ears. Noises in the head, of almost every character, were very severe and caused her great annoyance. She expressed herself as being entirely satisfied if she could be re- lieved of the pain and tinnitus, as she had given up all hope of ever hearing again. She claims to have been treated without success in Berlin, Vienna, Dublin, and London, and to have had a “nerve cut” three different times with the hope of securing relief from the severe pain. On examination we found the external audi- tory canal in each ear somewhat obstructed by an accumulation of inflammatory products, and very painful to the touch. The drum of each ear was congested, markedly thickened, and so much retracted as to be immovably adherent to the promontory. We found the Eustachian tube obstructed, which, however, promptly yielded to treatment, but without improving the hearing to any appreciable extent. On careful examination of the hearing-power, she proved to be totally deaf to all sounds, regard- less of their pitch or character. The osseous conduction of sound, however, was perfect. Of course, the history and unfavorable results of the examination, except for the good bone conduction, compelled us to regard any hopes of improvement in hearing as improbable. However, feeling it our duty to at least make an effort to relieve the pain and tinnitus, we concluded to remove the drum and one or more ossicles, as might be necessary. Accord- ingly, on October 3, 1889, we excised the drum and ossicles of the left ear. The patient positively refused to take an anaesthetic of any kind, because a relative had died under its use. This was the first case of this character that I have ever done under cocaine. The pain was quite severe during the operation, but being a woman of determination and pluck, she stood her suffering very well. The malleus and incus both showed evidences of necrosis, particularly the malleus, which was only about half its natural size, and through necrosis resembled in appearance and structure a piece of dried dead wood, that one could with but little force crush between the fingers. The meatus was packed with iodoform cotton and the patient kept quietly in bed for three days. On re- moving the cotton she said she could hear our conversation and the noises in the street. The tympanum was dry ; pain almost relieved ; tin- nitus much less, and patient feeling happy. October 12, 1889.—There has not been a drop of pus; tympanum entirely dry; pain gone, and only a little pulsating tinnitus. Hears the fork at nine inches and watch at ordinary conversation at fourteen feet. November, 1889.—All the above good re- sults continue. The patient feels so well satis- fied with the results of the operation on left ear that she now makes a request to have the other ear operated on, as the pain still continues in it. This, however, we refused to do at present. Good Results from Excision of the Membrana Tympani and Ossicles. 5 February 6, 1890.—Again the patient re- turned to have the right ear operated on. She was advised to wait a few months longer, so as to ascertain definitely whether the results of the operation on the left ear are positively perma- nent. May 9, 1891, or about eighteen months from the date of first operation, the right ear was op- erated on and a similar condition of the drum and ossicles found. The results of operation were quite as satisfactory. January, 1892.—Patient has been entirely relieved of pain since second operation; hears perfectly well; tinnitus entirely gone ; general health excellent, and likes America so well that she has concluded to make it her future home. May 9, 189J.—Has been entirely relieved of pain from date of second operation ; tin- nitus has not returned ; hearing is entirely nor- mal, and all of these favorable results from the 'operations have been permanent for over two years. Case VI.—B. S., aged eighty-one. In April, 1888, this patient consulted me for deafness, tin- nitus, and vertigo. He gave the following his- tory : Forty years ago, while exposed to the sun’s rays, was suddenly attacked with slight pain in each ear. He became dizzy, fell to the ground, striking his head with much force, and was car- ried home in a semi-conscious state. For three years prior to this attack had occasionally com- plained of a “ fulness and queer feeling in the head.” For seventeen weeks he suffered so much from vertigo as to prevent him from leaving his bed. From the time of this acci- dent, which was in 1848, to the year 1889, cov- ering a period of 'forty-one years, he has suf- fered more or less from vertigo, increasing tinnitus, and deafness. For the past ten years the vertigo would appear without warning, and with such severity as to necessitate his having an attendant with him constantly. During this period of ten years the tinnitus has correspond- ingly increased, and the hearing-power in like manner become progressively defective. He was entirely deaf to aerial conduction of both watch and fork ; loud conversation could be heard at one foot. In his efforts for relief he consulted many physicians, making three trips to Europe for this purpose. In September, 1889, we suggested the removal of the drum and ossicles. This proposition was accepted with great reluctance on account of his age, and more especially because he had been ad- vised not to submit to any surgical operation. We operated on the left ear September 12, 1889, and found the drum in this case thick- ened and adherent to the tympanum ; likewise the ossicles had undergone the above peculiar changes due to necrosis. Six days after opera- tion his hearing and tinnitus had somewhat im- proved ; no pain nor disturbance of any kind followed the operation. September 27, or fifteen days after opera- tion, he states that nearly all pain and tin- nitus has been relieved; has had but little vertigo. October 18.—Pain entirely relieved ; tin- nitus much improved ; slight vertigo remaining. November 1, 1889.—Tinnitus and pain en- tirely relieved ; hears ordinary conversation at seven feet; has had but two attacks of vertigo in three weeks. April 6, 1890.—Operated on right ear with similar good result. July 6, 1890.—Has just returned from At- lantic City, and reports himself as entirely free from pain, vertigo, and tinnitus; hears ordi- nary conversation at sixteen feet, watch at one inch, and fork at four inches. September 12, 1892, or about three years since first operation and two and a half years since the second ; has continued in good health, except a slight attack of dizziness, which, how- ever, lasted but a few days. April 14, 189j.—Has just returned from a trip to the Pacific coast, where he spent the winter and enjoyed good health, being entirely free from tinnitus and vertigo. He hears very much better than men usually do at his time of life. In the foregoing list of one hundred and fifty-four operations it will be found that from Cases 15 to 84, inclusive, we record sixty-nine patients presenting the non-suppurative variety of middle-ear disease. Many of these patients suffered from distressing tinnitus, severe pain, staggering, vertigo, and marked impairment of hearing, while others complained of one or more of these same symptoms in a much less degree. Their ages range from twenty-one to eighty-one years. The time in which the pa- tients suffered from one or more of these symp- toms varies from two to forty years, while the time elapsing since the date of operation is from three months to four years. The im- provement in tinnitus and vertigo has been in many cases most striking and satisfactory, not- withstanding the little hope that could be offered for their relief, in some of the cases, before op- eration. The probable improvement of hearing in this class of cases is, of course, not marked by so many favorable possibilities as in the suppurative variety, and yet a perusal of the carefully-recorded results will, we think, be convincing that the operation in selected cases 6 Good Results from Excision of the Membrana Tympani and Ossicles. Discharge. Hearing-power. Results of operation. Hearing-power. hv. o Age. X 0 in Continuous. Recurrent. Duration. Tinnitus. Pain. [ Vertigo. w Voice. Tuning-fork. Watch. Bone con- struction. Discharge. Pain. Tinnitus. Vertigo. Voice. | Tuning-fork. Watch. I Time since operation. Cause of dis- ease. Operation. I l6 M. Yes. No. 12 yrs. No. No. No. L. Loud 2 ft. Nega- No. Normal. No. No. No. No. 0. C. 19 ft. II in. 3§ 3 yrs- Scarlet Mai. and tive. fever. inc. 2 24 F. No. Yes. 9 “ Yes. Yes. Yes. ii No. No. ii “ ii “ a a “ 4 “ 3 “ 10 mos. Not known. a 3 36 “ Yes. No. 19 mos. Severe No. No. a “ ii ii X “ ii “ a “ “ 21 “ 16 “ J? 4 yrs. La grippe. a 4 9 “ No. Yes. 7 yrs. No. ii a R. 0. C. i “ a ii % “ a ii a “ “ 10 “ 5 “ tjIt 7 mos. Measles. a 5 81 M. “ No. No. Severe Severe Yes. Both No. a a X “ a i 6 a a “ 11 “ 7 “ U 314 yrs. Not known. a 6 7 F. Yes. ii 2 yrs. No. No. No. “ 0. C. 2 “ a a “ a a a “ 6 “ 9 “ A 1 yr. Scarlet a . fever. 7 18 C( No. Yes. 13 “ Yes. Yes. a “ “ 3 in. a “ X “ a a Slight. a “ 15 “ 12 “ 1* 16 mos. « . “ 8 14 a Yes. No. 2J4 “ No. No. a R. “ 1 ft. 2 in. “ ii ii a “ No. a “ 10 “ 5 “ 2 yrs. La grippe. Incus. 9 7 M. No. Yes. 4/4 “ ii Yes. “ “ 1 “ 1 “ a a “ « “ “ “ 16 “ 8 “ 3 “ Scarlet ii fever. IO 52 F. a No. Severe No. Severe Both L. C. 1 “ No. No. Slight. a a Slight a “ 2 “ No. No. “ Not known. Mai. and improve- inc. ment. ii 12 ii Yes. “ 2 yrs. No. “ No. R. 0. C. 2 “ 1 in. 33 Normal. a a No. a “ 12 “ 4 in. 7 33 4 La grippe. “ 12 12 M. “ a 3 “ “ a “ “ X“ ~5<5 U “ a ii a “ 18 « 9 “ 16 33 “ a Malleus. !3 54 ii “ “ 3 “ Yes. “ Yes. ii a t a 1 No. No. ii a “ ii a “ 26 “ 16 “ s? ii ii a Incus. 14 45 a No. Yes. 7 “ Severe Severe Severe L. “ 3 “ ii ii “ a a ii a “ 5 “ 9 “ 11 33 4 “ a ii 15 80 a ... 30 yrs. No. 20 yrs. Both Very L. 1 it ii K “ a “ ii “ “ 4 “ 2 “ A 3K “ Not known. Inc. and severe. severe. ft. mah, drum intact. 16 53 F. IO yrs. ii 3 yrs. “ 0. C. 3 ft. a “ “ “ a a Slight. a “ 2 “ 1 “ 33 a a ii ii severe. severe. 17 62 ii 2 yrs. ii 2 yrs. ii “ % “ “ “ X “ a a No. “ ii ry ii 4 “ 30 2 X “ a ii severe. 18 49 M. Severe ii 7 mos. ii “ 7 in. « ii a a a ii “ “ 12 “ 7 “ 33 1 “ a ii *9 57 F. Yes. “ 3 “ ii ii j ii a ii a “ a Slight. a “ 12 “ 0 “ 33 0 1/ << 3/2 a a 20 71 M. Severe ii 14 yrs. ii “ 2 ft. a ii X “ a a “ “ 16 “ 3 cc J5 ii a “ “ 21 39 ii Yes. ii 5 “ a “ 4 “ 2 in. “ a (6 a a a “ 9 “ 11 “ 33 'X “ La grippe. 22 29 ii 2 yrs. Slight. 3 “ “ 6 “ 3 “ ii a a “ a a « 6 “ 7 “ 33 1 “ a a severe. 23 47 “ a No. 6 “ “ “ 13 “ No. ii a a “ No. “ “ 16 “ 5 “ 33 “ Not known. a 24 55 a Yes. a 12 “ a “ 3 “ in. ii a a a a a “ 24 “ 4 “ 33 2 “ a 25 57 a ii a 4 “ a “ 3 “ No. a a a a “ a “ 21 “ 17 “ T?3 -> <t 0 “ 26 48 a 12 yrs. “ 2 “ L. No. a a “ “ a But lit- Little im- « No. No. No. 6 mos. “ severe. tie im- prove- proved. ment. 27 37 F. Yes. a 1 “ Both 0. C. 6 “ a 3 in- a a “ Slight. No. “ 12 ft. 4 in. 363 7 “ 28 35 M. • “ -* a J L. “ 3 “ 2 in. No. a “ a << “ 19 “ 7 “ No. 9 “ a Good Results from Excision of the Membrana Tympani and Ossicles. 7 29 53 M. Yes. 4 “ “ “ 3 « 66 3 66 a 66 66 No. « “ 5 “ 7Yz “ 0§ 13 “ 66 66 30 46 F. “ 3 Both “ 7 “ 4 “ « <( “ Slight. “ 66 12 “ 6 00 5 “ 66 “ 3i 42 U 66 2 “ “ “ 9 66 7 “ 7 in. “ Slight. “ “ “ 66 25 “ 9 << 5o 8 66 66 66 32 3i M. “ 9 “ “ 66 9 66 6 “ 2 “ “ No. 66 66 “ 66 31 “ 11 U H 16 “ 66 66 33 36 66 “ 1 “ L. 66 9 “ 2 “ No. 66 66 66 Slight. Slight. 66 12 “ 9 “ 0? 9 “ 66 “ *24 u Yes. 66 66 8 66 1 “ 66 66 66 66 66 12 66 66 a 66 a 35 62 F. 66 R. 66 7 66 * 4 “ 4 “ 66 66 66 66 « 66 13 “ 11 “ 8 00 6}4 66 .« a 36 48 M. “ 66 “ “ 12 V 3 “ No. “ 66 “ 66 “ “ 27 « 7 “ 5s 7 66 66 F. 66 66 66 u 6 66 2 “ 66 “ 66 66 66 66 66 8 << 3% 66 66 66 O / 38 57 66 66 2 yrs. 66 « 4 66 3 “ “ “ “ “ No. 66 3 “ 1 a 00 3 « 66 « 39 56 66 No. L. 66 4 66 Y in. 66 “ “ 66 “ 66 “ 9 “ 2 a No. 2lA U 66 u 40 47 M. 66 “ “ 66 3 “ I in. 66 “ “ “ “ “ 66 7 “ 4 “ 7 00 18 “ 66 66 41 64 “ “ No. “ 66 “ 5 66 in. “ a 66 66 “ 66 “ 12 “ 1 a 12 00 20 a 66 66 42 48 66 “ 1 yr. R. 66 6 66 3 in. “ 66 “ “ “ 66 66 11 “ 2 00 19 u 66 66 43 47 66 66 2 yrs. L. 66 7 66 1 “ 66 “ “ “ “ “ * 26 “ 13 “ 4 00 19 a 66 66 44 53 66 66 1 << 3 66 “ 3 66 4 “ A 66 “ 66 “ “ 66 3 u 3 “ 00 19 “ “ 66 45 32 F. 66 66 No. 66 “ 11 66 3 “ 3% “ “ “ 66 61 66 11 “ 7 “ 30 3 yrs. 66 66 46 34 M. “ 66 66 66 66 10 66 1 “ 30 66 “ “ “ 66 66 20 “ 9 “ 00 2/^ “ “ 66 47 39 66 66 “ Both “ 7 66 4 “ 6 00 66 “ “ 66 “ 66 21 “ 5 “ 00 4 “ “ 48 35 F. 66 “ 66 L. 66 5 66 2 “ 4 00 66 “ “ 66 66 66 9 “ 17 “ 00 a “ 49 47 M. 66 “ 3 yrs. R. 66 13 “ 7 “ 00 66 66 “ 61 “ “ 19 “ 13 “ 12 30 3 “ 66 a 5o 64 F. “ 66 I “ 66 66 4 66 1 “ No. “ Slight. 66 Slight. 66 66 27 «* 5 66 4 00 9 mos. 66 << 5i 47 66 66 4 “ “ 66 3 66 2 “ Oo “ No. No. No. 66 U 3 “ 2 “ 00 9 66 66 “ 52 54 M. “ 66 12, “ L. “ 1 a No. No. “ “ U “ 66 “ 4 “ 3 66 00 13 66 66 53 45 66 “ I9 “ Both 66 1 6i 66 “ 66 “ 66 66 66 “ 4 “ 3 6' No. 7 “ 66 “ 54 57 66 “ 7 “ “ “ 2 66 “ X “ “ “ 66 “ 66 5 “ 2 “ “ 4 “ 66 66 55 62 20 yrs. “ 15 yrs. “ L. C. 1 66 66 U “ “ 66 66 Slight. “ 7 “ 4 “ U 4 << 66 66 severe. severe. • 56 53 66 Yes. 66 Yes. L. 0. C. 3 66 3 in- 66 66 66 66 “ 66 2 “ 3 “ o4o 11 “ 66 66 57 43 66 “ 66 “ R. 66 3 “ 4 “ 4 00 66 6 6 66 66 No. “ 9" 9 66 o6o 12 66 66 61 58 39 F. 66 “ 66 66 66 4 “ 5 “ 00 “ 66 “ 66 Slight. 66 12 “ 8 66 00 9 66 “ 66 59 40 “ 66 “ 66 66 “ 12 66 8 “ 00 66 66 “ Yes. “ 66 16 “ 9 “ 00 7 “ 66 66 60 46 66 “ 66 “ L. 66 9 66 4 “ 35 66 66 “ “ No. “ 20 “ 12 “ 00 16 “ 66 66 61 54 66 66 66 66 66 66 11 “ 9 “ No. 66 “ “ No. “ 66 9 “ 9 66 00 3 66 66 66 62 38 M. 66 66 Slight. 66 66 7 66 1 “ 66 % “ 66 66 Slight. Slight. 66 6 “ 1 “ 66 2 yrs. “ 66 63 63 F. 66 “ Yes. Both “ 7 “ 3 “ 66 U U 66 66 66 U 8 “ 2 66 No. 1 “ 66 66 64 42 M. 66 66 R. 66 5 66 2}4 hr. 66 X “ “ “ 66 “ “ 5 “ 1 66 “ 3 66 66 66 65 47 66 66 66 Slight. “ 66 12 66 I in. “ 66 66 66 Not much 66 11 “ 2 66 u 7 mos. 66 “ improved. 66 5i 66 66 66 “ L. 66 1 66 3 “ 66 66 66 No. 66 66 No. 2 66 “ 12 “ “ 67 5° 66 66 66 “ R. 66 1 66 1 “ 66 X “ 66 66 Slight. 66 66 No. No. a 3 66 “ 66 68 57 66 66 66 66 66 66 2 “ 2 “ u a “ “ No. No. 66 2 ft. 2 in. 00 3 “ 66 66 69 48 F. “ “ 66 66 “ 3 66 2 “ 00 “ “ 66 66 “ 66 4 “ 4 66 o2o 4 66 “ 66 70 49 M. “ “ No. L. “ 4 “ 1 “ 00 66 66 66 66 66 66 “ 3 “ 3 66 00 8 66 66 66 7i 39 F. 66 “ 66 66 66 4 66 4 “ 00 66 66 “ 66 66 66 66 6 « 4 “ 030 10 66 66 66 72 33 66 66 66 66 R. “ 2 66 -> 66 3 00 66 66 66 “ Slight. “ 66 4 “ 4 “ 00 14 66 66 66 73 4i u 66 66 66 66 “ 2 66 5 “ 1 66 66 66 a 66 66 “ 8 “ 7 66 00 iS 66 “ “ 74 44 M. 66 66 66 66 66 4 66 2 “ u4o 66 66 66 66 “ “ “ 7 “ 2 “ 00 9 66 66 66 75 38 F. 66 66 Yes. 66 4 1 “ No. 66 No. 66 4 “ 2 66 30 3 yrs- 66 66 8 Good Results from Excision of the Membrana Tympani and Ossicles. O OOO O O O O O'O'O'O'O'O'O'O'O 'O'OOOOOOOOOOO 00 00 00 00 00--4 ~-4 VJ 1 No 00 »-4 0\0i Oj N) M OnOi to m O 00 CJnOi 04 to m OH3 On 1 04 10 H h to -P“ w M to M « to H to M O' ~-I C\ 04 Cn Ol O to 04*- to ~-4 VO VO -P* to 00 O'-J to 00*0 MOJ OO'O '-J 40- 4- cn -|i. \o vo 00 w Age. S 1! 5,*!) 5 Sg 5 I 5 - 5 £ S S5" hr) - g Sex. ~ s p n> •• ££££££rt>*a>:a> • ~ n> • p ~ cd • • • ... .. I in in ’ m in in in ••..... . Continuous. U o IX £? o3 n> ... Kj K| . . K^..1^... 0) ... £ft*******n>*(D* (D • • fT> • • • • • • ... .. . in ... in * in ' in * in * * ... .. Recurrent. 'JOtOvOIOO'OtOO'HMtJlO - tO 04 M • • • ■ • j '■ '. I „ 3 „ 3 „ - ‘i g „ : ::::::: : c/3 ' O c/jO in ** O w . • . ... . • . • in • m • in • • ....... . Duration. ■ *P ..2! „«P *P izjtjvo Kj 3 - “ ? “3 ? £ ? 2 ? 2 ? s • • * •—«*—{ *—« *—t ►-« »-t O) in fD (fl O' (fl Tinnitus. Kj y a - - o : rD ~ 0 rV ~ ~ ~ ~ o' y1 • -n w m • in • in .in . • CT Pain. *P 5P “P !^<T>04n>4>*<T'0KP 1? l<| s “ " P “ 3 " R 5 - SS!!!8 3 5 8 s s P £ S * S !* !! * Vertigo. tti td^Ol- ss t-1 O ■ • O •• • S S 5 5 "O’-' 3“ S' S' Ear. p r p ~ S 5 5 S5SSS2SS55SSS - S 8 5 C 5 O 5 5 O S * 5 ~ ~ f> hi M ►" OJ to H C\ 10 Is) OJ M M H M 00 00 M to m OvPO 4* Voice. a P u (jq "d O 3 a> p OlM-f* 2<-ri OoMtOM4iOJH».GJ4. H to 4i VO to 4. to 10 Oo H l—i ■—• tO Tuning-fork. 3~ 3- S a- 8 S 8 8 8 S S S S S f Sh 3“ 3- Watch. x x $ Bone con- struction. . z; r£ , jz| £ * 2 - ~ ~ ~ Ocfq--'O ~ STS O 5" 5* Discharge. V n o o p o* p a CD P 5* erq ►d o * n> s . s s s s s s s s s s a s ... .. |J Pain. No. u a a << Slight. No. Yes. a No. Slight. iC No. Slight. No. << Slight. U No. << <( U a Slight. No. Tinnitus. No. Slight. No. Slight. a a u No. Slight. <{ No. CC Slight. (C Not much improved. << (( No. U a u C6 (6 Slight. No. Slight. “ Vertigo. O M hi tO tO »H HM hi hi 00 00 Hi to OO-Ph -P w HUt O a to VO hi oo 00 H to Cv 4^ Voice. kK. M m to MIO UVO 00 >0 UK 04 4>. to Ol 4> to Tuning-fork. S 5 o sh . 3» E P 3“ 3> 3“ 3=" 3“ 3- 3“ 3- = s s s p s 3- 3* % 3“ 3- s 3- s p Watch. MtO WWl-f H W n MtO 04 N 14 m 04 H\»w® O 00 t4 04 w to 04 O'"4 >0 1004 t0t4i-iO4i-i „ „ „ 3 „ 3 o; 3 = S 5 s -- - *i • c/j & in ’ in Time since operation. o s o r osoooooorosso - - - o o o o - - - - - - - ?r 3 O * 3 Cause of dis- ease. Mai. and inc., drum intact. U Mai. and inc. Inc., drum intact. U Mai. and inc., drum intact. <C U u u 66 66 66 66 66 66 66 66 66 66 66 66 “ Mai. and inc. 66 Inc., drum intact. 66 Operation. Good Results fro?n Excisio?i of the Membrana Tympani and Ossicles. 9 109 19 F. I “ No. No. No. a « 9 « 5 m. U4(J a a « « No. “ 1 a 1 a u 3 « u a no 7 M. Yes. Yes. 2 “ (< ii a “ a 12 a 8 “ u a “ Slight. “ L. C. 3 a l/z a a 3 U ii a in 28 F. ft ii 16 “ Yes. « a L. a 4 a 2 “ 3% Slight. a No. O. C. 7 a 4 a 343 12 mos. Scarlet fever. Drum, mal. and inc. 112 22 M. a 9 “ No. “ a ii it 6 “ 3 “ 36(T <( No. “ “ “ “ 7 a 3 a 33 4 ii ii a 113 3i it Yes. 12 “ Yes. a a ii “ 3 a 1 “ A << Slight. “ “ ii “ 12 a 3 (r 5 8 ii “ a 114 26 a ii 12 “ ii a “ R. a 8 66 7 “ 3% a No. ft ii “ 27 “ 11 a 33 2 yrs. it a 115 18 F. Yes. 4 “ No. a a ii a 6 a 9 “ a ii a “ it “ 12 « 5 « H 4 U ii a Il6 24 M. ii 9 “ ii a a L. a 3 a 2 “ 33 a “ “ ii a “ 12 a 12 a 3% 4 ii “ a 117 19 F. a 2 “ ii a a Both a 6 a 1 “ No. a a a “ a “ 18 a 4 “ A 3 “ Measles. a Il8 12 “ a 1 “ ii a “ L. it 11 a 1 “ a a ii tl “ 12 a 9 a 33 2 ii Scarlet fev. a II9 14 ii a 3 “ ii a a “ a 7 a 3 “ A a “ a a “ 9 a 7 a U 1 ii a 120 11 a “ 6 “ ii a a Both a 7 “ 1 « No. a a « a a “ 7 a 9 a ii 18 mos. ii a 121 7 M. tt 5 “ “ a a ii ii 3 “ 1 “ “ a “ a a a “ 6 “ 4 a 33 13 a “ a 122 5 F. a 2 “ a “ ii a 2 “ 2 “ a a a a a “ 4 u 2 ii 10 a ii a 12 3 6 ii ii “ ii a a ii a 8 a 2 u “ a a a a a “ 18 a 5 a 33 II a “ a I24 8 M. a 2 “ ii a a 1 1 “ it a a a a a “ 2 4 a 8 a Diphtheria. Drum and malleus. 125 11 “ a 2 “ “ “ a R. a 3 a 3 “ A a a “ a a “ 3 a 8 a A 18 “ Scarlet fev. ii 126 16 F. a 18 mos. Yes. a “ “ it 3 a 4 “ A a a a a a “ 10 a 4 “ 33 13 a ii ii 127 10 66 a 11 “ No. “ “ ii a 4 a 2 « A a a a “ a “ 8 a 3 “ 33 3 yrs. a ii 128 8 it a 16 “ U a a L. a 2 a 1 “ 3% a a a a a “ 3 a 6 a 33 2 “ a a 129 6 M. tt 22 “ “ “ a R. “ 1 a 6 “ 33 a a a a ii “ 2 a 12 a U 9 mos. a a 130 10 F. “ 23 “ Yes. a “ L. “ 1 a 4 “ No. a “ a a a “ 3 a 6 “ 6 “ “ a 131 13 M. a 3 yrs- No. a a a a 4 “ 1 “ a a a tl a “ 5 a 4 a 6 33 13 it a a 132 5 ii a 8 mos. ii a “ a a 8 a 1 “ U a a “ a a “ 9 a 2 a 343 1 ii a a 133 26 “ Yes. 19 yrs. Severe 8 yrs. Yes. Yes. Both a 1 a 3 “ a a Slight. Slight. a a “ 13 a 12 a A 3 tc a 134 16 a 4 “ No. No. No. R. a 6 a 2 “ A a No. No. a “ “ 5 “ 2 ti 33 20 ii a a 135 31 F. Yes. 21 “ Severe 12 yrs. Yes. Severe 9 yrs. Both a 4 a 4 “ u a Slight. Slight. Slight. Slight. “ 11 a 3 a 33 7 it “ a 136 21 M. ii 8 “ Severe 8 yrs. ii Yes. R. a 3 2 “ 33 a No. No. No. No. “ 7 a 1 a A 7 ii a a 137 8 “ Yes. 2 “ No. ii No. L. a 1 “ 1 “ No. a a ii ii ii “ 3 a 2 a No. 9 ii “ a 138 11 F. “ 4 “ “ ii ii “ a 8 “ 1 “ << a a ii ii it “ 18 a 4 a r 4 ii a a 139 9 ii “ 6 “ ii ii a a “ 2 “ 1 “ a a a 66 a 66 “ 6 a 3 a a 5 ii Measles. a 140 6 M. if 1 “ “ a a a a 3 “ 3 “ 33 a a ii a ii “ 6 a 3 a “ 7 a “ a 141 8 F. ii 3 “ ii a a R. a 8 a 1 “ A a a ii a ii “ 6 a 3 “ a 6 a “ a 142 12 M. “ 8 mos. ii a a “ a 2 a No. No. a a ii a ii “ 9 a 2 a 3 a Diphtheria. a J43 9 a 3 yrs. “ a a a “ 1 a << a a ii a ii “ 2 “ 1 a 33 2 a “ a 144 7 a “ 2 “ ii a a L. a 1 a a 33 a a ii a it “ 4 “ 3 a a 1 a a a 145 7 “ 1 “ ii a a Both “ 1 a a No. a a ii a a “ 12 a 8 a 1 “ “ a 146 8 F. ii 4 “ “ a a a a 3 a a a a a ii a 66 “ 4 a 5 “ A 1 a “ a 147 6 ii it 3 “ “ a a “ a 2 a u a a a a ii “ 3 “ 3 a 33 1 a Mumps. a 148 4 M. “ 2 “ a a a a a 2 a a a a a a a a “ 2 a 2 a 33 1 a a 149 3 F. it 1 “ a a u a 2 a a a a a a a a u 6 a 6 a No. 4 a “ a ISO 3 “ ii 2 “ a a a “ a 1 a 1 in. A a a a a a “ 10 a 3 u 33 4 a a a 151 5 it “ 3 “ a a a a a 1 a 2 “ 33 a a a a a “ 2 a 8 u 33 9 a “ a 152 8 ii “ 4 “ a a a “ a No. 2 “ No. a a a a a “ 3 a 7 “ 33 1 yr. a a 153 7 “ (( 5 “ a a a “ a ii 3 “ U a a a a a “ 3 a 9 a ii 11 mos. “ a 154 6 a << 2 « a a a a it 2 “ a a a a a a “ 4 a 3 a A 9 a 66 0. c. = Ordinary conversation. L. C = Loud conversation. Good Results frojn Excision of the Membrana Tympani and Ossicles. 10 is now justifiably demanded. From the results obtained in the class of cases that would prop- erly come under the title of this paper, we beg to offer the following conclusions. First, however, I should like to remark that this is an age when the public wish to exact from the profession a promise as to the definite outcome of any prospective operation. It is of course proper and desirable that the probable result of an operation under consideration should be fully and carefully explained to the patient and his friends. It is well, however, that this should be done in the presence of your assistants or other auditors. A disregard of this simple precaution has caused some hon- orable physicians, who had worked hard for the best interests of their patients, to be summoned into court by designing and evil-minded per- sons, who enter suit for damages because a sup- posed promise had not been fully realized. We would, therefore, begin our conclusions with,— 1. Never promise positive results from an op- eration on the ear for the relief of tinnitus, pain, suppuration, and vertigo. This promise will often be exacted, but the present status of such surgical procedures is not sufficiently de- fined to warrant us in promising the results which we may hope to attain. 2. Probably no operation in the entire range of surgery (if carefully performed) is attended with so little disturbance, either local or con- stitutional, as excision of the membrana tym- pani, malleus, and incus, when not compli- cated with necrosis of the tympanum; in fact, there are very few diseased conditions of the human economy that are so prone to be pro- ductive of good results as is excision of the membrana tympani and ossicles in certain ear- diseases. 3. Tinnitus, vertigo, impairment of hearing, and pain are almost certain to be relieved by the removal of the drum and ossicles, if not de- pendent upon some structural changes in the internal ear. 4. The longer the middle-ear disease has ex- isted (as characterized by tinnitus, progressive loss of hearing, pain usually not well defined, and possibly vertigo) the greater is the danger of some serious structural lesion of the internal ear, and therefore the less hope of materially improving the hearing-power; and yet, even in extreme cases, 'the tinnitus, vertigo, and pain are more or less benefited, sometimes mark- edly so. 5. If, after due and proper efforts to relieve progressive aural diseases, you do not produce a speedy and marked improvement, no time should be lost in performing the radical opera- tion ; for by delay an internal ear complication may have become established, and this always makes probable benefit more doubtful. 6. It is not well to express too much hope that the operation will materially improve hear- ing in long-standing, non-suppurative cases; and yet, when the chances are so much in favor of its producing entire freedom from tin- nitus and vertigo, and especially since there are such great probabilities of a rapidly-pro- gressing disease becoming arrested from the date of operation, it would indeed seem unfor- tunate if such patients were not offered the benefit of this doubt, if such it can be termed. 7. In all cases where the membrana tym- pani is thickened, markedly retracted, and made firmly adherent by old inflammatory products to the tympanic walls, and where in this same connection you find the ossicles com- pletely anchylosed, the function of these parts under such circumstances is of course entirely suspended; therefore, in consequence of this condition, this part of the conducting appara- tus can be regarded only as a foreign body, and, as such, the only rational hope for relief is through removal, which will in the majority of cases relieve tinnitus and vertigo, while at the same time improvement in hearing can reasonably be expected on account of the opening thus formed admitting the sound-wave which impinges directly on the stapes and fenestra rotunda. 8. As a preventive of necrosis of the tem- poral bone, mastoid abscess, aural polypi, and serious brain-complications (when the result of chronic aural discharge), the suppurating ear should not be allowed to continue and thus be- come chronic. If, therefore, under the usual methods of treatment the discharge does not permanently yield, it is certainly good, and I might say imperative, surgery to promptly ex- tract all fragments of the membrana tympani and necrotic ossicles, for in so doing you have taken the only rational step to produce a cure of this always dangerous discharge by first re- moving all foreign matter and thereby estab- lishing a free drainage, and, furthermore, giving an opportunity of properly treating a diseased cavity that otherwise would be inac- cessible ; and inasmuch as the writer has not met with any failures in this class of cases (when unaccompanied by extensive necrosis of the tympanic cavity), he is forced to express the belief that timely surgical interference can- not be too strongly urged, for by so doing you eradicate the primary disease, and thus prevent these always serious and ofttimes fatal compli- cations. JANUARY 16, 1893. „ . ; 1 WHOLE SERIES. VOL. XVII. No. I. THIRD SERIES. VOL. IX. J ; TH E Therapeutic Gazette A MONTHLY JOURNAL General, Special, and Physiological Therapeutics. ! GENERAL THERAPEUTICS, H. A. HARE, M.D., ProftMor of Therapeutic. In the JelTenon Medical College OPHTHALMIC AND AURAL THERAPEUTICS. SURGICAL axe GENITO-'J AIN ARY THERAPEUTICS, I Q. E. DE SCHWEINITZ, M.D., EDWARD MARTIN. M.D., || Clinical Medic»'|hCollege.* 'h* Clinlral Profe.wr of Di.ean., Unlrenlty of !i EDITORIAL OFFICE, 222 South Fifteenth St., Philadelphia, U.S.A, GEORGE H. DAVIS, DETROIT. MICH., I'.S.A., 714 Filbert Street. Philadelphia, Pa. Published on the FiftQ|nth Day of Every Month. SUBSCRIPTION PRICE, TWO DOLLARS A YEAR. Agent for Great Britain: Mr. H K. LEvhs, Medical Publliher and BookteOer. ij6 Gower Street, Lonoon, W. C I