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35 cases =
cells. After this the operation was forgotten for several decades, till revived by Forget (1849) in cases of caries, and by Von Troeltsch and Follin (1859). Numerous cases of its adoption, mostly for the relief of caries of the mastoid with threatening fatal symptoms, followed till 1861, when Von Troeltsch proposed the operation for the relief of some obstinate otorrhoeas.
To establish its value in the different varieties of disease of the mastoid, and the best method of doing it, was the task Schwartze set before himself by accurately recording in chronological order any and every case of the operation which he himself performed, together with any peculiarities in each case. Save the first, the articles contain the histories of the cases in all important particulars, together with the results a long time after treatment.
The last article includes the conclusions drawn from the whole series of fifty cases.
Of these were,
70 per cent.
Died The of causes death were: meningitis two, meningitis tuberculosa one, pyæmia two, abscess of cerebellum one, anæmia one, epithelioma of bone one, tuberculosis pulmonum two. Of these ten cases, the fatal disease certainly was wholly independent of the operation in six; in three the connection of the operation with the death seems very uncertain ; and in one it was undoubtedly the direct cause of death, the dura mater being perforated by a splinter of bone during the operation, causing traumatic meningitis. The cases show, as Schwartze says, that it is in this way possible to cure the severest forms of caries, even of the petrous bone. The cases are also interesting as showing the effect of curing the chronic ear disease upon the general health. In one case chronic and very alarming debility was completely relieved; in two the favorable effect upon tuberculosis pulmonum was very marked; in one epilepsy was permanently relieved; in two facial paralysis was cured.
The effect upon the hearing of course depended upon the amount of destruction which had taken place before the operation : in eight it became perfectly normal ; in twenty-three was very much improved ; in four absolute deafness remained, the result of previous destruction of the labyrinth by caries.
The ages of the patients were : one year to ten years twelve, eleven to twenty years sixteen, twenty-one to thirty years thirteen, thirty-one to forty years one, forty-one to fifty years three, over fifty years five. The oldest was seventy-two years of age, the youngest two.
As indications for the operation are given, first, acute inflammations of the mastoid cells with retention of pus, where Wilde's incision or treatment with ice does not relieve the oedema, pain, and fever. Second, cases in which there is intermittent swelling over the mastoid and fistulous openings in the skin, or where, in other words, nature is evidently endeavoring to effect an opening through the bone; in these cases the operation should be performed before symptoms threatening to life set in. Third, cases in which there is fluctuation beneath the cutis of the upper posterior wall of the meatus, corresponding to the floor of the antrum, or where a fistulous opening has already formed at this spot the operation should be performed without hesitation if brain symptoms are noticed. Fourth, distinct caries of the mastoid, of the mastoid and tympanum, and of the osseous labyrinth all indicate the operation, which should not be neglected even in the worst cases, as experience shows that even the whole labyrinth may be removed by necrosis, and yet the cavity fill up with healthy granulations which gradually ossify, and the otorrhea is cured.
In cases where sequestra exist in a mastoid without external symptoms Schwartze considers the operation useful, but the difficulty is in making the diagnosis of this condition. Pain, fever, and a decidedly offensive odor to the otorrhoeal secretion, in spite of the most careful cleansing and disinfection of the tympanum and Eustachian tube, point to the existence of retained pus in the cells.
The operation as a prophylactic measure merely, to relieve chronic suppuration of the tympanum, and to avoid the possible dangers of pyæmia, meningitis, and tuberculosis as suggested by Von Troeltsch and Jacoby, is considered by Schwartze of doubtful justification, on account of the risks of the operation and the possibility of anomalies in the formation of the parts involved. The operation is, however, an indicatio vitalis in these cases whenever symptoms of irritation of the brain are noticed.
Dividing the operations according to the conditions found, we have,
I. Acute inflammation of the mastoid process without external abscess, cured eight, uncured one, died two, = eleven cases.
. II. Inflammation of mastoid with external abscess or fistulæ, cured eighteen, uncured two, died five, = twenty-five cases.
III. Inflammation of mastoid, external wall healthy, the operation being an indicatio vitalis, cured two, uncured one, died none, = three
In regard to the operation, after exposing the bone thoroughly and checking the bleeding, one of two conditions will be found : either the bone is softened by caries or contains fistulæ, or else the bone is healthy or sclerosed. If carious nature has already pointed out the direction for the operation, all softened bone should be removed with a gouge; fistulous openings should be enlarged with the hammer and gouge, till, if possible, the little finger can be inserted into the cells. If sequestra exist they must be removed, and all fungous granulations should be scraped away with a sharp spoon. The wound should then be cleansed thoroughly, disinfected with a two per cent. solution of carbolic acid, and a drainage tube inserted, which may be carried out through the meatus if a fistula connects with that passage.
Where the bone is healthy or sclerosed, Schwartze prefers the use of the gouge or chisel and hammer to either trephine or borer, and the opening should be funnel-shaped, large externally, and gradually sinaller, as thus better drainage is secured, and the risk of septic infection from the wounded surface is diminished. The opening should be made at the height of the meatus, and, to avoid the lateral sinus, should run inwards, forwards, and downwards, parallel with the meatus. The chief caution to be observed is to avoid the lateral sinus.
The after-treatment is extremely tedious, and requires considerable manual dexterity: the cavity should be washed with a warm solution, three fourths per cent. salt and one per cent. carbolic acid, and in some cases it is days before the inspissated pus is thoroughly washed out; the meatus must be kept free, inflation by the catheter used, and granulations either in the meatus or wound destroyed as occasion requires. The drainage tube must be renewed daily at first, but can afterwards be replaced by leaden plugs to keep the wound open. These should not be removed permanently till the suppuration in the depth of the ear is reduced to a minimum, and till the meatus is free from granulations and swelling.
Little febrile reaction was noticed in Schwartze's cases after the operation, but he recommends restricted diet, the use of the ice-bag for a time, and that the patient keep in bed till all fever is gone.
Past experience shows that the dangers from the operation itself are pyæmia, exposure of the middle fossa of the skull or of the lateral sinus ; experience also shows that these two accidents last named may occur without injurious effect if the dura mater and sinus are uninjured, and they may unexpectedly happen to the most careful surgeon from a malformation of the bone, which is, however, extremely rare.
PROCEEDINGS OF THE ESSEX NORTH DISTRICT MEDICAL
SOCIETY. The annual meeting of the Essex North District Medical Society was held in Haverhill, May 7th, Dr. W. H. Kimball, president, being in the chair. After the usual routine of business was completed, the society listened to a paper on Animal Heat and Fever, by Dr. E. P. Hurd, of Newburyport, corresponding secretary. The following is a synopsis.
The essayist, after a brief consideration of the nature, conditions, and theories of animal heat, said that to-day the chemical theory of Lavoisier demands our chief attention, for around it harmoniously gather all the facts of physiology and chemistry. The latest and most exact science testifies to the general
truth of the theory, although it has undergone important modifications since Lavoisier's time.
Lavoisier, in 1777, demonstrated the striking relations which exist between respiration and combustion, comparing the human body to a lamp whose wick (or point of combustion) was the lungs. Calorification was due to the combination of vital air (oxygen) with the base of fixed air (carbon) and inflammable air (hydrogen) furnished by the blood. This view of Lavoisier, that the precise seat of organic combustions is the lungs, was combated by Lagrange, who showed that the lungs were not essentially hotter than other organs; by Spallanzani, who demonstrated that respiration goes on to some extent by the skin; by Williams Edwards, who showed that when frogs were confined in hydrogen gas they still generated CO, as proved by analysis of the excretions; and by Magnus, who analyzed the blood and obtained its gases, showing that oxygen and CO, exist in the blood, and the latter in greater proportion in venous blood.? (This seemed to show that the carbonic acid which is removed by the lungs is formed in the system at large.) It became then generally admitted that the lungs constitute only the place of exchange of gases; the foyer of organic combustions was in the tissues. The rapid emaciation attending fevers was remarked, and striking instances were recorded where for some hours after death bodily heat goes on augmenting. 8
It is singular that the first experiments made to determine the source of animal heat should have given confirmation to the theory of Lavoisier that the lungs were the seat of organic combustions. Crawford in 1788, Scudamore in 1824, Krimer in 1823, Davy in 1815, Becquerel and Breschet in 1837,
- these and other able experimenters found the temperature of arterial blood to be greater than that of venous by from half a degree to a degree or more. These experiments were made on animals recently killed, and were erroneous and unreliable, as shown by G. Liebig in a masterly treatise on animal heat published in 1854. He showed that it was necessary to operate on living animals. In opening the thorax you cool the contents of that cavity; and even if the thorax be not opened, if the animal have ceased to live, a stagnation of blood occurs, which changes the distribution of caloric. The older experimenters made much of thermometric observations of the blood in the cavities of the heart, in the veins and arteries, of animals on which they experimented after death. Liebig pointed out the fallacy of this mode of observation. He records many experiments of his own on living animals, which prove that venous blood is considerably hotter than arterial. Fick, in 1855, undertook like
experiments with like results. Hering has published observations of a similar • nature. In 1857 appeared a memoir by the late Claude Bernard, recording a long series of experiments confirmatory of the conclusions of Hering, Liebig, and Fick, and establishing the theory of capillary combustions on a solid basis. Bernard operated, as Breschet had done, mostly with thermo-electric needles.
1. Longet, Traité de Physiologie, Paris, 1869. Tome ii., page 493. 2 Claude Bernard, La Chaleur Animale, Paris, 1876. Leçon 2.
3 In one instance (observed by myself) the bodily heat, which was 1070 at death, did not perceptibly decline from that point (as tested by the thermometer in the axilla) for three hours after life was extinct.
4 Claude Bernard, loc. cit., page 43. The left side of the heart, being thicker than the right, is better protected against refrigeration, and arteries are, as a rule, thicker and better protected than veins.
5 Cited by Bernard.
If the blood in the veins is hotter than the blood in the arteries, and the blood in the right side of the heart botter than the blood in the left (as shown by the careful experiments with thermometric instruments of Bernard and others above mentioned), the presumption is that the chemical processes, of which heat is the expression, take place in the systemic capillaries, or in the cells of the tissues.
Bernard proved that thermogenesis is a phenomenon essentially extra sanguine by plunging his thermometric needles into solid tissues; the temperature of these parts was indicated, and this was compared with that of the entering artery and emergent vein, the result always being that the blood was cooler by some fractions of a degree than the organs which it traverses. Indirect proof, a deductive kind, is found in the fact that animals, as zoophytes, which have no blood, have a heat of their own which is higher than that of the surrounding medium; and even plants generate heat, as proved by experiments of Hubert, Vrolick, and Vriese. From these experiments (some of which were quoted) the writer drew the important biological lesson that life and nutrition and the evolution of heat are inseparably associated. The essential characteristic of all living beings is nutrition, and this is composed of two factors exactly balanced, assimilation or organization, and disassimilation or disorganization. There is an outward movement of waste, and an inward movement of repair. Oxygen and pabulum are necessary adjuvants to these processes, which in health are exactly balanced, oxygen being the complement of the factor disassimilation, food being the complement of the other factor. The conclusion at which the essayist arrived, after further speculations as to the nature of calorifying processes in the animal system, was that the essential phenomena of life occur in plants and in animals that have no blood, but in the higher animals, a healthy circulation, bringing constant supplies of oxygen and pabulum, and conveying away the débris of the tissues, was necessary; is in the cells that oxidation and calorification take place, and the condition of evolution of heat is the contact and exchange between the elementary tissues and the blood at the moment when the chemical acts of nutrition take place.
In answer to the question, What is the material constantly consumed in thermogenesis? it was considered problematical, as no one has ever explained the transformation of pabulum into bioplasm, or the steps attending disintegration of bioplasm or formed tissue. There is no doubt as to results. Tissue is consumed, and we trace its products in the excreta, and the animal body is. kept for days at a nearly constant temperature, though not an ounce of food is taken during this time. (Allusion was made to the experiments on starvation performed by Chossat and Martins; these are recorded in the chapter on Animal Heat in Physiology of Common Life, by G. H. Lewes.) Liebig's classif
1 Longet, loc. cit.
2 Longet, loc. cit., p. 497. Vrolick and Vriese have shown that concurrently with the ele vation of temperature, which is manifested in the spadix of certain plants at the flowering season, oxygen disappears from the surrounding air, and is replaced by CO? The temper. ature of the spadices of Arum Cordifolium was found by Hubert to be twenty degrees above that of the circumambient atmosphere.