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such an irrigation, in which the wound, the ear, nose and pharynx were simultaneously cleansed, is self-evident. It was noticed after the second dressing that the motor paralysis of the right eye had partially subsided, and that the patient was now able to close the eye within one-quarter inch of complete closure. The dressings were reapplied daily for three months with but slight change in the general appearance of the wound or patient. Throughout the entire course of treatment, since the operation, there has been absolutely no pain, tinnitus aurium, vertigo, nausea and vomiting, or febrile reaction.

About the first week in November a change was noted in the general condition of the patient. He became restless, peevish, and complained of a general feeling of lassitude with a constant drowsiness.

The clinical memoranda appended will show the most interesting factors in the development of the case.

Nov. 5th. On redressing the wound, noticed for the first time a necrotic mass of bone, black in color, rough in surface appearance and touch, projecting from the anterio-lateral wall of the posterior auricular sinus. Discharge profuse and intensely fetid.

Nov. 6th. On irrigation, numeraus soft, long discolored shreds were washed away. Discharge in 24 hours amounting to half an ounce of viscid, greenish, foul-smelling pus.

Nov. 7th. The black necrotic mass appeared nearer the surface of the sinus orifice. When touched with the tip of the irrigating syrine, it was found to yield slightly. With a strong shanked, milled-pointed dissecting forceps the mass was firmly grasped, the head of the patient steadied, and by gentle, steady traction, the entire sequestrum was painlessly removed, through the fistulous opening. Not the slightest hemorrhage ensued, even 00zing being scarcely perceptible. The entire proceeding was borne by the patient without the least expression of pain or a single unfavorable symptom. The wound was lightly packed with iodoform gauze and the auditory canal cleansed and dried. Sound tests were then instituted, as hereinafter described.

Nov. 8th. The discharge diminished to one-third the quantity, issuing only from the auditory canal. The posterior wound, through which sequestrum had been removed, was clean, the gauze strip being removed almost dry and without stain. Inspection reveals the walls smoothly lined with numerous soft granulations. The foetor has disappeared. Drainage is free and clear. Antiseptic irrigation used throughout the treatment, of hydrarg. bichlor. 1-2000 and 2 per cent acid carbolic, in luke warm aqueous solution. Walking and standing tests for equilibrium were made. Results detailed later.

Nov. 9th. The discharge remains odorless; quantity unchanged; general condition much improved.

Nov. 11th. Patient has again assumed his former lively disposition; eats heartily; sleeps soundly; rarely offers a complaint, even of slightest discomfort. Perceptible decrease in the quantity of discharge.

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Nov. 12th. On daily inspection by special illumination, after thorough irrigation, detected a flat oblong sequestrum at distal end of long sinus, and gently removed same with small angular forceps. Removal painless and without the slightest sequence. In the depth of this wound canal a pulsating or oscillating fluid, seemingly clear and shining, was discernable, and supposed to be the mucous of the exposed Eustachian tube.

Nov. 13th. Only traces of pus in the external auditory meatus; small, soft necrosed masses detached from the depth of the canal and removed with forceps and syringe.

Nov. 14.

Mirror illumination in wound canal reveals the presence of a necrotic bone mass, attached to the posterior wall of the sinus. Examined with probe, it was found loose, and with forceps this, the third sequestrum was easily removed.

Nov. 15th. Discharge very slight. Another small sequestrum was removed from the upper wall of the sinus. Numerous healthy looking granulations were observed in the depth of the sinus. Patient is beginning to cough; a hoarse, short cough with frequent expectorations.

Nov. 16th. Discharge practically nil; a slight serous exudation noticed; similar to that found on granulating surfaces. Profuse granulations filling sinus.

Nov. 20th. Again some slight discharge. Located a small focus near the distal end of the bony portion of the internal auditory canal, with accumulations of epithelial shreds and pus.

Nov. 25th. Discharge of an even, yellowish green color, of thick consistency and increasing quantity. Cough has become more aggravated, loose, and expectoration profuse and of a muco-purulent character. Microscopical examination of the sputum revealed the presence of the tubercle bacillus in large numbers.

Dec. 10th. A bone sequestrum presents near the wound orifice. In restlessness of patient during attempted extraction, the mass was pushed out of place. Free communication between the sinus and the external auditory canal exists, as indicated by the probe in manipulation.

Dec. 11th. The sequestrum again presents, this time in the external auditory canal; presents with long diameter of sequestrum transversely to the axis of the external auditory canal. After some manipulation, succeeded in turning and removing the rounded necrotic bone mass from the posterior sinus.

Dec. 15th. No discharge; wound looking comparatively dry. Thorough irrigation followed by dusting canal and wound with iodoform; very small gauze strips inserted.

Dec. 19th. Both wound canal and external auditory canal dry; dressing of four days standing removed dry and unstained; drainage perfectly

clear.

Jan. 5th. Above condition of wound unchanged. The patient is in lively spirits, talkative, and feels no discomfort from his recent siege of treatment. He is considerably emaciated, cough is still very harassing; expectoration very profuse. Physical examination, by courtesy of Dr. Hersman, reveals the following: In the apex of the left lung there is

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cavernous percussion sound, and cavernous respiration, and many gurgling rales. Over the entire area of the right lung there are medium sized mucous rales, with slight percussion dullness; harsh inspiration over the right apex; prolonged expiration of raised pitch; numerous subcrepitant rales. History of the case points to the probability of a rapidly developing phthisis pulmonalis. The mesenteric glands are enlarged and easily localized by palpation. The cervical and other lymph glands of the head present almost a "rosary" outline, so general, regular and continuous is their enlargement. The sputum analysis reveals the presence of numerous tubercle bacilli. Emaciation of the patient has been marked and rapid the past few weeks, A phthisical febrile reaction has also been noted; regular rise of temperature, accompanied by night sweats and continued coughing.

By far the most interesting and important factor which presents itself for consideration in this case, is the existence of the faculty of hearing on the affected side, after removal of the cochlea and deep structures of the petrosa.

I have been thoroughly cognizant of the difficulties and responsibilities attending an effort to substantiate so radical a statement, and have necessarily adopted the most careful methods and delicate tests to convince myself of the accuracy of my conclusions. The most serious obstacle to contend with was the exclusion of the healthy ear from the sound tests which were instituted. In the majority of the tests made, I adopted the method suggested by Dennert and Lucae, with modifications. In determining what degree of sound perception still exists in an affected ear in a case of one-sided deafness, the healthy ear of the patient is stopped, turned towards the source of sound and the tests then made, the affected ear being alternately opened and closed. Whatever difference in the hearing then elicited, is attributed to the affected ear.

A more delicate modification of this method has been successfully used by Burnett. The patient is so placed that the affected ear is toward the operator. The healthy ear (not the ear to be tested) is plugged. With the affected ear open, hearing tests are then instituted. Having thus reached the apparent limit of the hearing power of the affected ear, that ear is then closed, and the tests continued. If the closure of the deaf ear causes no difference in the hearing distance already obtained, it is fair to conclude. that whatever amount of hearing exists is not due to passage of sound through the external auditory canal of the affected ear turned towards the test. In such a case the conclusion must, therefore, be that sound has reached the brain through the agency of the healthy ear. If, however, the stoppage of the affected ear is accompanied by an absolute inability to hear sound tests, it is again rational to conclude that this difference in the hearing power must be attributed to the affected ear. Thus, the final conclusion: "Whatever is heard just as well with the deafer ear stopped as when open, the

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better ear remaining stopped throughout the testing, mnst still be heard by the better ear through the head; but whatever is heard only with the worse ear open, the good ear being stopped, must be attributed to the worse ear."

The question might be asked, why cannot sound be conveyed to the deaf ear through the head; if it is conveyed to the better ear which is stopped and turned away from the sound source? The reply would be that an ear which, either when stopped or open, perceives no difference in sound conveyed by the meatus, is not sensitive enough to hear sound conveyed to it through the head.

In the consideration of the case at hand, bone conduction tests by aid of tuning forks were excluded, as they were deemed less delicate for a differentiation than aerial sound consuction. Furthermore, as our dealings. were directly with an exfoliated labyrinth, the tuning fork, relative to bone conduction, was practically of no value.

The following tabulated relations will indicate clearly the conclusions reached in hearing tests of the affected ear:

In the execution of the enumerated tests the patient was blindfolded; the plugging of the meatus was done by a competent assistant, the forefinger being used as a tight plug. Taking into account the age of the patient and all tendencies to a possible misrepresentation of the hearing capacity, the tests were repeated at frequent intervals with many variations, yet the tests proved doubly valuable, owing to the demonstrable accuracy of the patient's statement.

Next in the order or importance of the clinical phenomena observed, was the preservation of the equilibrium and balance of the patient. As previously stated, one hour after the operation, patient was up and walking home with absolutely no trace of altered equilibrium. Walking and standing tests have been repeated frequently, varying the same in every conceivable

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way by blindfolding the patient, testing with eyes closed, permitting the patient to walk under the influence of loud noises, etc. The results are always positive; his gait firm and steady; the power of equilibrium preserved to a nicety.

A factor of great interest is the prominent role played by the bacillus tuberculosis in the development of this case. Early in the history of the case a microscopical examination was made of the discharge from the ear, and the presence of the tubercle bacillus demonstrated. A physical examination at that time gave no indication of a phthisical onset. The free communication of the suppurative aural focus with the pharynx; the tendency to frequent swallowing of this purulent material infected by the tubercle bacillus; the gastro-intestinal disturbances; incessant coughing; profuse expectoration; febrile reactions; enlargement of the lymphatics of the entire system; rapid emaciation; great prostration; and finally, the involvement of the lungs, as determined by recent examination; the demonstration of the presence of the bacillus tuberculosis in the sputum,—this well-marked series of symptoms point to a development of a rapid phthisical process. It seems rational and reasonable to conclude that this acute phthisis is, perhaps, a secondary development of the original tuberculous process in the ear.

In maintaining my position in the case at issue, with my conclusions drawn from the careful tests made and clinical phenomena observed, I realize that I am treading on delicate ground, and that the presentation of these results opens for consideration a new phase of development in the theory of sound, and in the complicated functions of the labyrinthian

structures.

It is not my purpose to discuss the pros and cons of the theories which the results attained in the present case may suggest, but to indicate in the presentation of this series of simple firm facts, the existence of some inaccuracies in the now accepted theory of sound, and in the functioning of the semicircular canals in relation to balance and equilibrium.

DISCUSSION:

DR. ROBERT BARCLAY-"Extensive destruction, involving the main structure of the petrous portion of the temporal bone, is rare; the most frequent condition being that of exfoliation of the cochlea, where, after the problem of saving has been satisfactorily solved, the question next arises as to the possibility of hearing without this portion of the labyrinth. It is fortunate that the essayist has introduced here tonight the subject of hearing after exfoliation of the cochlea-a question of exceeding

importance to us, and one particularly deserving of our close consideration, inasmuch as no less than three of our local professors of Otology have given public expression to their views on the subject, in a manner and to an effect, which, at best, appear intemperate, if not, indeed, not positively misleading.

At a meeting of the Medico-Chirurgical society of this city, on February 21, 1887, in the essay of the evening by Prof. M. D. Jones, this statement was made (and I quote from the essay as published