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THE recent war has brought to the fore the urgent and essential need of adequate treatment for aural disabilities. Two immediate questions arise in the presentation of a program of aural rehabilitation: Is the field extensive enough to warrant concerted action of all interested groups at a considerable expense of time and energy? Is there a sufficient foundation of institutional experience with the treatment of large numbers of hard of hearing persons to enable interested groups to set up definitive procedures that are workable? The time has passed when the first of these questions needs much debate. No one knows precisely how many deafened persons there are in this country, but, with the recent addition of a tremendous number of service personnel who have suffered acoustic trauma, it is safe to put the figure in the hundreds of thousands, and there is no indication that this estimate will diminish. As

INJURIES of the larynx do not comprise the most frequent source of war casualties, but they do constitute one of the most serious forms of battle injury. This is true not only as to the immediate prognosis in regard to the loss of life but as to the future rehabilitation of the patient after the immediate crisis is past. The threatened advent of gas warfare would have sent the incidence of laryngeal injuries soaring, as the effect of poisonous gas on the larynx is well known and has been demonstrated not only from the experience of World War I but from accidents or improper handling of poisonous gases in World War II. As the battle casualties have mounted there has been a proportionate rise in laryngeal injuries, although the exact number will never be known as many of them have been recorded as injuries of the neck. Laryngeal and tracheal

The following case of carcinoma of the nasopharynx presents several features interesting not only to the otolaryngologist but also to the neurologist, the ophthalmologist, the roentgenologist and the pathologist. It is presented because of its value to both the clinician and the pathologist in that an attempt has been made to explain clinical symptoms from a complete study at autopsy. Of further interest was the intracranial extension of the tumor with marked destruction of bone, metastasis to the liver and an apparent implantation of tumor cells by contact from the growth in the nasopharynx to an ulcer on the nasal surface of the soft palate. This ulcer approximated and was irritated by the tumor in the nasopharynx on phonation and swallowing. That malignant tumors of the nasopharynx are not uncommon is evidenced by the abundance of literature on the subject, many authors reporting fairly large series of cases. It was

For general practitioners, in whose practice is included a major proportion of the medical management of infants and children, and for the specializing pediatrician as well, Postgraduate Medicine presents this special regular department devoted to brief discussions by recognized authorities on their preferred methods of the treatment and management of diseases and problems of infancy and childhood.

Remarkable strides have been made in the field of plastic and cosmetic surgery in the last fifteen or twenty years. The defects brought about by modern warfare provided a large experience in reconstructive surgery. Congenital defects, and those caused by syphilis, tuberculosis and carcinoma, necessitated the development of a technic for their correction. During and since the World War, reconstructive surgery has grown to become a well known specialty, and remarkable results have been shown in rather hopeless looking cases. Plastic repair of traumatic deformities about the face was originally employed in this special field, but of late years the tendency has been to drift to the more lucrative and less laborious cosmetic field. However, I wish to consider only those cases of the true reconstructive type, namely, those in which there is a total or subtotal loss of parts. Gillies, 1 one of the inventive geniuses in

The ancients were well aware of the presence of nasal polyps and of the problems which they presented, and they devised ingenious methods for their removal. The evaluation of the present knowledge of the etiology and treatment of nasal polyps must be viewed with a degree of skepticism engendered by a lack of unanimity of opinion. We do not now know the etiology of polyps. Polyps do not occur solely as the result of allergy; many allergic patients (with seasonal and perennial allergy) do not have them. Polyps represent a hyperplastic change of one portion or all of the nasal or sinal mucosa. Clinicians fail to distinguish between polyps that occur in one person and those that occur in another. This might explain why the same management or procedure is ineffective in one patient and effective in another. A patient with nasal polyps must be distinguished by an additional factor, possibly an inherited structural deficiency of connective tissue. Atopic patients with seasonal and perennial rhinitis associated with extensive nasal polyps may undergo surgery of the nose and/or sinuses. Nonatopic persons, however, are best approached with surgical reluctance, since bronchial asthma develops rapidly in this group. Dissatisfaction with present methods of management arises from failure to control the regrowth of polyps. This applies to those patients whose rate of recurrence of polyps has been prolific and rampant. Attention is directed to the fact that polyps may be a presenting part of underlying tumors, thereby clouding the true nature of the growth pattern. Furthermore, the proliferative nature of polyps may indicate a type of pathologic entity termed "inverting papilloma," erroneously considered to be "merely polyps." An integrated study by the allergist and the rhinologist should be encouraged if the problem is to be solved.

Although many observations have been carried out on the results of section of the trigeminal nerve in man for tic douloureux, little attention has heretofore been paid to its effect on the nose and the nasal mucosa. This is rather astonishing, as the present day conception of nasal pathology attributes many of its factors to reactions which can only be explained basically as a result of a disturbance of the nerve equilibrium, maintained in the nasal mucosa by its sensory and autonomic innervation. Especially, the wide range of so-called allergic reactions encountered daily with pathologic conditions of the nose should make advisable a morphologic study of noses which have been deprived of their first line of defense, their reaction to pain and irritation. Much of this pathologic change is attributable to mechanical irritation, and it is to be expected that the presence of such irritation, unnoticed by the patient, would

The development of tumors as a result of reaction to metabolic disturbances, chronic septic states or local changes in the tissues often presents a perplexing clinical and pathologic problem. Lederer, Fabricant and Milles 1 recently described an unusual cellular response to chronic infection. Another unusual type of cellular reaction, lipoid cell granuloma, prompts this report. Attention has been directed by a number of authors to the aural manifestations of this disease, but the American otologic literature is devoid of any reference to this entity. It is, therefore, not unreasonable to suppose that many cases have been overlooked. CLASSIFICATION The recent articles of Rowland 2 have done much to clarify the conception of the various clinical manifestations of disturbed lipoid metabolism. While the major interest has been in the Schuller-Christian syndrome, a number of less generalized forms of xanthomatosis have been described, which differ somewhat in

"E.N.T. ESSENTIALLY Negative," or the commonest variation on the same theme, "E.N.T. Not Remarkable," is perhaps the grossest misunderstatement recorded on the average patients' chart. Actually, these expressions are written confessions of inadequate examination and improper interpretation. Such an inadequacy may characterize the uninformed and the unskilled, but when the same inadequacy extends to the specialistic group who have been under the spell of the whisper campaign that "otolaryngology is a dying specialty" then a dangerous state of affairs exists. The same physicians who are annoyed and bored by the constant and repetitious present complaint of postnasal dripping, tinnitus, nasal blockage or headache had better get a rubber stamp, or perhaps this maneuver constitutes too great a physical effort. We otolaryngologists are in the stage of revivals of remedial agents used by our predecessors who did not have the advantages of proper preparation for the specialty, nor did they have

F EW speciahties can have Iess reason than the otoIaryngoIogica1 to be satisfied with their methods of anesthesia. In rg251 I reviewed the methods of IocaI and genera1 anesthesia, emphasized their shortcomings and made a pIea for recta1 anesthesia in major surgica1 procedures about the head and neck as a means of placing anesthetic methods on a more accurate, rationa and convenient basis. The justification for the empIoyment of rectal methods of administration of anesthetic agents in our speciaIity is based upon the fact that we wouId minimize the manipuIations of too many hands in an aIready smaI1 operative fieId and thereby not transgress the rigidly aseptic technic which many of our procedures demand. Since anesthesia is never IikeIy to become an exact science, there is a great need for a form of rectal anesthesia on an agreed basis that wiI1 yieId uniformly good results which will be comparabIe wherever obtained. of puImonary compIications but we aIso know that such compIications can be secondary to genera1 anesthesia when given for abdominal procedures or even foIIowing operations done under Iocal anesthesia. It is generally conceded that infection may trave1 either by the lymphatic or the cardiovascular system or by direct extension into the tracheobronchial tree. Just at this time there are mainly two groups, one hoIding that the infection is emboIic and ‘the other that aspiration is the only possible way. Both schooIs of thought offer facts to substantiate their particuIar side of the question. It is not the object of this paper to discuss the pros and cons of either side, the point being relative to the uncertainty of the so-caIIed perfected methods of local and genera1 anesthesia.

The osseous structures of the head are capable of undergoing pathologic changes which are of interest to the otolaryngologist. The bony labyrinth of the ear, for example, may be affected by such diseases as fragilitas ossium, osteitis deformans, osteoarthritis, osteogenesis imperfecta, osteomalacia, osteopsathyrosis, rickets, Paget's disease, senile osteoporosis, chondrodystrophy and athyreopituitary dwarfism. Many of these may affect any and all parts of the skull. There is a group of idiopathic hyperostoses of the skull, which have long been considered rare, viz., osteitis deformans, or Paget's disease, and craniosclerosis, or leontiasis ossea. Recently Coppo,1in connection with a description of a patient with the latter condition, reviewed the literature extensively and found the cases recorded not numerous. Virchow2proposed the term "leontiasis ossea" for a particular form of hyperostosis of the skull. The name was suggested by the appearance which the face of the patient came to assume, due to enlargement

Francis L. Lederer, MD, Chicago, Chairman: Before we got into this question and answer period, Professor Hamberger would like to make a statement. Carl-Axel Hamberger, MD, Stockholm: When I heard the very interesting round table discussion about selection of closed vs open technique for cholesteatoma, I remembered a discussion in Stockholm in 1934 or 1935 about exactly the same thing. It was by Robert Barany, Nobel Prize winner in 1914. He was at that time professor of otology in Upsala, Sweden. He had used this closed technique during the 1920's and beginning 1930's. He said during this discussion together with Holmgren that he had very few recurrences of cholesteatoma. I might say that we have operated upon all of these cases afterwards; therefore, we could see recurrences in nearly 100%, but you see, we operated upon them, I would say, 10, 14, 15 years afterwards, so you have to wait

PROGRESS heralds hazards as well as rewards. The opening and enlarging of new frontiers bring new problems into focus. Otolaryngologists in particular and physicians in general are faced by many natural and physical challenges. As man strives to overcome conditions engendered by his environment, the air he breaths, his mode of living, his methods of transportation, by what he eats, drinks, or what he smokes, new situations are brought about, and additional emotional and physical states are created. Newer pharmaceutical agents, diagnostic and therapeutic concepts and instrumentarium, as well as the response of the physician to the rapid change in the modern socioeconomic order, all have a profound effect upon the practice of medicine. F. M. Anderson recently presented a modern version of Hippocrates' admonition, "The aim of the physician should be to do good to his patient, or at least, to do no harm," by stating that "We are

The larynx of old persons has frequently been examined. However, a perusal of the literature reveals that no two physicians agree in their findings as far as the muscles of this organ are concerned. Kofler 1 mentioned slight atrophy of the muscles, without giving further details, and Imhofer 2 found that the lipoid pigment usually situated around the nuclei of the sarcolemma increased in amount in old persons. Segre 3 found simple atrophy of the adductor and the abductor muscles, characterized by an increase of the nuclei of the sarcolemma and an increase in both the collagenous and the elastic fibers. This atrophy was least marked in the interarytenoid and the vocal muscles. In contrast, Imhofer 4 did not observe an increase in elastic fibers. The cricothyroid muscles showed hypertrophy in the cases of Segre, 3 which was considered compensatory, because of the atrophy of the adductor muscles. Carnevale Ricci 5 described essentially the same conditions

Esophageal foreign bodies, particularly when they are pointed and embedded against the plane of removal, present almost unsurmountable difficulties to the operator. Even the greatest skill in these cases results in some degree of esophageal laceration, which is usually a superimposed extension of the preexistent perforation. It is not our purpose to report a great number of cases over a period of years with tabulations of percentages, although we do not deny that statistics serve their purpose. It must be remembered that often these may be applicable for the reporter, but with another geographic site and certain changes in personalities, not only of the surgeons but also of the patients, statistical compilation unrecognizably alters the moral. The following brief reports typify this natural consequence: In China,1foreign bodies are more frequently found in the esophagus than in the respiratory tract. An article from Los Angeles2records as a

The histologic examination of tumor-like formations in the external auditory canal, frequently observed in association with chronic suppurative otitis media, may yield information of diagnostic, prognostic and corroborative clinical importance. It is well recognized that neoplastic formations such as carcinoma, specific granulomas associated with tuberculosis and syphilis, and manifestations of metabolic disorders may be combined with chronic suppuration of the middle ear. These groups will be discussed briefly with emphasis on certain points of clinicopathologic interest. The main purpose of this communication is to encourage a renewal of interest in the benign neoplastic formations and perhaps a new interpretation of their clinical significance. CARCINOMA Malignant neoplasms affecting the middle ear are relatively frequent. The literature shows a paucity of material on the subject, and even any reference there to "primary" carcinoma of the middle ear requires explanation. Proof of the occurrence of such a neoplasm is most difficult. Notably do

AS a general rule, radiograms are taken mainly with the idea in mind of making a diagnosis for surgical or non-surgical interference, but the study of X-ray films after operation has been neglected or treated lightly and only in gross errors or medico-legal cases have they been called into play. Then, too, the number of monographs in the literature which deal with diagnosis of diseases of the head and neck by the radiogram is relatively small. This is especially true if one takes into consideration only the publications of those authors who have broad experience of the clinical and pathologic entities in this field. There can be no doubt that radiography of the head, when properly undertaken, is distinctly a science—a branch of medicine of the utmost importance—but it can rightfully be said that knowledge of the pathologic conditions and of their clinical values is by no means the common property of all physicians. What is meant by the pre-and post-operative study of radiograms? Since we are discussing wh...

From a consideration of the literature it appears that there is much confusion as to the significance of a cellular response predominantly of plasma cells such as one occasionally encounters in generalized septicemia. The difficulty is in separating or identifying the response of the lymph glands observed in cases of this type, as well as the granulomatous lesions encountered in the other tissues, from malignant conditions on the one hand and malignant lymphomas, particularly Hodgkin's disease, on the other. The response of the lymph nodes of the body to any stimulus depends on the degree of severity of the stimulus, on the length of time the stimulus continues to act and on the susceptibility to stimulation of the various elements composing the lymph nodes, i. e., the reaction threshold of the components. The degree of severity of the stimulus is dependent on the concentration in which the stimulating agent reaches

Crowe (1) called attention to the fact that lymphoid tissue in the nasopharynx, especially the lateral parts, could, as the result of hypertrophy and hyperplasia, cause intermittent or constant blockage of the nasopharyngeal orifices of the eustachian tubes. He noted that such blockage interfered with the normal ventilation of the middle ear cavity and was reflected, most often in children, in decreased hearing. The examination of the ear drums revealed retraction of the tympanic membrane and a reddish blush from the edematous mucosa of the medial wall of the tympanic cavity. Examination with an electric nasopharyngoscope showed actual encroachment of the lymphoid elements on the mouth of the eustachian tube. It was evident that surgical extirpation of the oral and nasopharyngeal lymphoid structures, no matter how complete, could not reach the laterally placed portions in the fossae of Rosenmuller and about the lips of the tubal orifice without causing serious damage to the mucosa and nearby anatomic part...

To appreciate the protean manifestations of neurologic, and the frequently related emotional, disorders affecting the head and neck areas, is to realize the morphological complexity of the human mechanism and its susceptibility to a wide range of disturbing experiences. Since these anatomical areas house all of the special senses, emotional and physical factors may interact in a number of interesting but puzzling ways. Few persons are ever entirely spared the sensation of pain or the malfunction of one or some of the cranial nerves, the cervical nerves, the brain, or the sympathetic nervous system. This discussion will concern itself with the symptomatologic approach. The symptoms which develop from neurologic disease, from trauma, or from complications of conditions encountered in the course of diseases of the ear, nose, or throat may be the earliest indicators of serious disorders. The majority of these may be listed under their broad, all-inclusive, generic

A discussion of the problem of hearing loss from the womb to the tomb involves covering not one, but 3 distinct areas of study: (1) hearing defects of the very young; (2) hearing defects of the young and middle-aged adult; (3) hearing defects of the very old. This system of classification describes the realm of the practicing physician and suggests a subtitle for this paper:The Natural History of Hearing Loss. Although we may encounter hearing-impaired people everyday, we seldom are aware of the impact a hearing loss has on an individual or on his family. Other, more dramatic, or disastrous, defects have received more publicity than hearing problems. Yet, depending on the age of onset, the hearing defect may alter every aspect of a person's life. Although some types of hearing loss are reversible, many hearing disabilities tend to remain static or reflect a progressively worsening quality. Social, economic

Several otorhinolaryngologic aspects of rheumatoid diseases are pointed out. With regard to rheumatic fever and rheumatoid arthritis, the removal of tonsils or other foci of infection will not alter the course of the disease or prevent recurrence. Arthritis of the cricoarytenoid joint may progress to the point of acute respiratory distress and even death. Such antirheumatic drugs as salicylates, phenylbutazone and gold salts have certain otologic and oral toxic effects. Salicylate-induced hearing loss is usually reversible. Salicylate hypersensitivity should be kept in mind. Other diseases that produce symptoms referable to the head and neck are discussed.

IN THE report of the Commission on Graduate Medical Education, 1 published in 1940, the phases of training which followed the customary four year medical course were divided into three categories: The first is the internship, which rounds out and gives added practical application to the medical school course and also accustoms the individual, while under supervision, to the assumption of responsibility. Hence, it should be considered a part of the basic preparation for practice. The second part is the residency, which prepares a physician for the practice of a specialty and, therefore, is properly termed graduate medical education. Finally, there are courses of varying lengths and other educational opportunities that aim to keep practitioners abreast of their present fields of practice and they can be correctly classed as postgraduate education. While we approve this classification, and hope that eventually it will be accepted by all institutions of medical education, we

The Moderator: Each one of you is expected to direct pointed questions and discussions. I hope that this will be the culmination of the problem as a result of the studies that have come about through the military services. I believe that this first showing before a public medical audience of a film produced by the Army will serve as a fair introduction and focus your interest on the problem. FILMS ON REHABILITATION Dr. Norton Canfield, Veterans Bureau: The film is the end result of a request of the Surgeon General to provide a pictorial history of the rehabilitative program as carried out in the Army during the War. This film was started about a year and a half ago, before the Army units were rearranged and before the unit which is now in operation at the Army was established at Walter Reed Hospital. The film depicts the course through