Aural Cholesteatoma," in which he advanced the theory that aural cholesteatoma is a primary condition, an altered state of the epithelium lining the middle ear, an epidermoid growth, and that the suppuration, so frpquently found associated with it, is secondary. This idea is contrary to textbook teaching. It required an iconoclast like Dr. McKenzie to disturb a preconceived notion and rouse us out of our lethargy. The idea is not entirely new, but has hardly received the attention it deserves. We owe a debt to Dr. McKenzie for his work on this subject.To-day I wish to bring further evidence in support of the hypothesis that cholesteatoma is a primary condition which greatly increases the gravity of cases of aural suppuration.In treating suppurative otitis media by zinc ionization, one is struck by the difference in the behaviour in ears with cholesteatoma and those without. In 1923 I published some results of treatment by ionization. None of the cases diagnosed as cholesteatoma were cured. But omitting these cases, the percentage cure was 80%. I will quote my remarks on these cases:-" Attic and Cholesteatoma Cases."These were of the well-known type with tiny attic perforation either in Shrapnell's membrane or burrowing under the anterior or posterior ligament of the malleus.The membrane itself was glued to the inner wall of the tympanum by cholesteatoma, and was by the pneumatic speculum shown to be either totally fixed or mobile only in small areas. These cases, which generally have only a scanty foul-smelling discharge, usually have symptoms of toxiemia, such as headaches, giddiness, and chronic ill-health.They are the most dangerous class, always on the brink of a calamity. In the hope of benefiting this type of case I tried various preliminary methods of treatment, such as drops of liquor pepticus, liquor pancreaticus, and aniline oil with spirit. After these had been used for a week, I washed out the tympanum with warm ether, followed by the zinc solution, and then ionized. My hope was that the cholesteatoma would be partially disintegrated and thus capable of being washed out. Not one of these cases was cured. I am firmly convinced that such cases are not curable by any form of antiseptic treatment nor by ionization. " Cholesteatoma is in a class by itself. Our knowledge of its causation is incomplete. At present the only efficient treatment is a radical mastoid or possibly ossiculectomy operation. Occasionally a case that seems to be cholesteatoma does dry up, leaving a wax-like fixed drum, but such cases are the exception." My ideas to-day are nearly the same, but with the flood-lighting cast on the subject by the theory that cholesteatoma is the primary condition with suppuration grafted on it, these statements seem more illuminating.The results of other surgeons who use ionization in the treatment of otorrhca show how resistant to treatment is the group known as "attic " cases. In some of the published results, the percentage cure is nil-in others very small. Now why should these " attic" cases differ ...
