Operations 2 | Operating Microscopes

Operations
By J. ORNE GREEN, A. M., M. D.,
OF BOSTON, MASS.
OPERATIONS ON THE AURICLE.

Auricular appendages are composed either of fat or cartilage covered with skin (Fig. 520). Their removal for cosmetic effect by an elliptical incision is usually simple. If they are cartilaginous, the cartilage often extends inward quite deeply, but the removal of the whole is unnecessary; it is sufficient to cut off the cartilage just below the level of the surrounding surface and suture the skin.

Coloboma of the lobule may be congenital or acquired, the latter usually caused by heavy ear rings, which have slowly cut their way out. The operation fir both' varieties is practically the same (Fig. 521). Cut a strip of skin from (a) to the lower edge of the lobule and turn it down; from the same point, a, freshen the edges as far as b by removing. a thin strip ;suture the lobule at c and d by transfixing sutures, then suture a to b by fine sutures, and the skin at any gaping spots also by fine sutures. The results n the acquired fissures are almost perfect; but in the congenital variety are not so good, as the edges of these fissures are apt to be somewhat atrophied. Hemorrhage during the operation can be wholly avoided by enclosing the lobule in a Snellen's clamp (Fig. 522).

Fissures of the auricle, either congenital or the result of traumatism, may be corrected in the same manner as those of the lobule.

Macrotia, or abnormally large auricle, has been improved by Schwartze in the following way: An elliptical piece of the cartilage was removed from the fossa of the helix, and then a triangular piece from the helix well into the 'concha; the edges were then united by deep sutures.

Projecting Auricle. To tie down an auricle which is protruding from the bead make two concave incisions 5 CID. long behind the ear, one on the mastoid 1 cm. backward, and one on the auricle 1 cm. forward, with the concavities facing each other, the cuts uniting above and below at acute angles. Dissect off this skin, loosen the remaining skin at the edges for 0.5 cm., unite the edge by sutures, press firmly into position by iodoform gauze, and bandage the auricle firmly against the skull.'

Grooving or excising a segment of the cartilage in the fossa of the helix is needful in some cases, as in the previous operation.

Defects of the auricle can rarely be benefited, because the defect is usually too great to be improved by plastic surgery, In exceptional cases, however, a fairly well formed auricle is simply adherent to the skull and can be dissected off ; a flap of skin can then be inserted behind and a considerable gain in appearance thus obtained.

Congenital fistula, a remnant of the fetal first branchial cleft, only requires surgical interference when the secretion is so abundant as to be a serious inconvenience, when there is retention and the formation of a large cyst, or when the fistula becomes infected and suppurates. In such cases the only effectual course is to dissect out the entire epithelial lining of the tract, which usually extends quite deeply, one half inch or more In two cases which I operated upon the removal of the deepest portion of the fistula 'exposed the capsular ligament of the temporo maxillary articulation.

Wounds of the auricle usually heal wonderfully well, even if deep in the cartilage. Wounds at the orifice of the meatus, if granulating, are liable to cause stenosis or atresia, which must be guarded against by packing, cauterization, removal of granulations, or by grafting of skin.

Fibroma of the lobule, ear ring tumor or keloid, requires complete removal by taking out a triangular piece of the lobule; any portion of the new growth left will cause a recurrence of the tumor. Pass a narrow bladed knife through the lobule in healthy tissue above the middle of the tumor and incise through the base of the lobule in healthy tissue; do the same on the opposite side and bring the parts together by deep sutures. The operation is practically the same a, that for coloboma, except in the care necessary to excise all of the growth; and if it is possible to get a narrow flap of healthy skin and insert it on the edge of the lobule, as described above for coloboma, the disfiguring notch in the contour of the lobule will be avoided.

Atheromatous, dermoid, and serous cysts require the removal of the entire cyst wall by dissection.

Angioma. The treatment must vary according to the size of the growth: if small it can be dissected off and the skin sutured over the wound, or it may be destroyed by the thermocautery or by electropuncture. Large growths involving the whole thickness of the auricle may require am¬putation of the portion of auricle involved. Occasionally the whole auricle is involved in a mass of large tortuous blood vessels which communicate freely with enlarged and irregular arteries arising from the carotid. In these amputations by slow dissection, ligating the vessels as they are cut, is our only resource; and ligation of the common carotid artery must precede the amputation. After removal of the auricle the deeper tortuous veins can be dissected out. Then, as in every wound involving the orifice of the meatus, an attempt should be made to turn a flap of skin into the meatus to prevent atresia from granulation tissue.

Epithelial Carcinoma. Our only resource is early extirpation by excision ; if small, excise the growth with the whole thickness of the cartilage; if large, amputation of the entire auricle is necessary, and, if the tissues within the orifice of the meatus are involved, the entire cartilaginous meatus should be removed with the auricle. Any infiltrated glands should be dissected out. If the orifice of the meatus is involved, a plastic operation should supply a surface of skin, at least on one side, to prevent atresia.

Some cases do well, and I have followed such for several years without there being any recurrence; in other cases there is a rapid return, either in the cicatrix or in the meatus, which is usually fatal in a few months from involvement of the deeper ear and brain or of the parotid region. A recurrent growth, small and isolated, justifies. a second operation ; but a rapid recurrence in the form of a diffuse infiltration, usually in front of the tragus, is, in, my opinion, beyond surgical relief.

OPERATIONS ON THE MEATUS.

Congenital atresia is usually associated with malformation of the auricle, and in most cases also with malformation of the middle and inner ears from imperfect development. This internal malformation renders surgical interference inadvisable except in the rare, simplest forms where the closure is merely by a thin layer of skin and where an exploratory puncture shows there is no fibrous or osseous closure further in. The skin can then be excised by a circular incision as near the periphery as possible, or quartered by two cross cuts and the triangular flaps excised with curved scissors. By either method great difficulty is experienced in maintaining the opening, which can only be done by keeping a tube, metallic or rubber, in the passage until the skin has united over the wound, or else by a plastic operation insertin skin from the concha or tragus. Secondary contraction may occur unless combated long after apparent healing.

Acquired atresia is the result of grantilation tissue within the meatus, which, uniting across the passage, has fused into a connected mass, undergone fibrous organization, and been covered with epidermis. A successful operation here depends very much on the same conditions spoken of under congenital atresia, except that there is no question of malformation of' the middle and inner ears. In many of these cases the occluding membrane is thin, 1/32 to 1/16 of an inch in thickness; but occasionally the entire meatus is converted into a dense fibrous tissue. If the membrane is thin, the same operation described for congenital atresia holds good; but where a considerable portion of the meatus is occluded by fibrous tissue, I do not believe any operation will succeed in making a permanent opening.

Carcinoma of the meatus is usually of the epithelial variety and an extension of the same disease from the auricle. If it involves only the cartilaginous meatus it can be removed together with the auricle (see Carcinoma of the auricle) ; if it involves the osseous meatus, however, an operation is, in my opinion, unjustifiable, as it cannot be successful and is liable to set up increased activity in the morbid growth. Varieties of carcinoma of the meatus other than epithelial are extensions of the disease from neighboring parts, usually from the parotid gland.

Granulations, inflammatory growths of granulation tissue, are usually an expression of some other trouble deep seated inflammation and often caries; but their removal is demanded to give exit to pus or to get at the deeper disease. If pedmiculated they can be cut off with a No. 30 or 33 copper wire in a Wilde's snare, or removed by evulsion with forceps or curetted away. Cocain in 10 per cent. solution is useful both for local anesthesia and to diminish the bleeding. After the removal the underlying disease requires its appropriate treatment; and until this is cured the possibility of recurrence is not excluded.

Exostoses. Their removal is demanded only when they close the meatus, thus producing serious impairment of hearing, or when there is suppuration of the deeper structures and the growth prevents the evacuation of pus.

If distinctly pedunculated, it may be possible to separate them by placing small osteotome against the pedicle and fracturing this by a sharp blow from a mallet, then removing the growth with forceps. If not pedunculated, the growth can be best reached by deflecting the auricle and cartilaginous meatus forward. This is done by beginning at the extreme upper anterior edge of the auricle and carrying an incision 1/2 cm. from the auricle behind, around, and down to the lower wall of the meatus through the skin; then dissecting off the auricle without the periosteum until the meatus is reached, when the periosteum is incised close to the meatus above and behind and separated together with the cartilaginous meatus from the bone until the exegesis is reached. This can then be thoroughly exposed by drawing the separated auricle and meatus forward with a long flat hook. The growth can now be removed by chisels and mallet or by burrs on a surgical engine. Strict asepsis is, of course, necessary. After removal the periosteum should be carefully replaced together with the cartilaginous meatus, the auricle stitched into position, a light packing of dry iodoform gauze placed in the meatus to retain the periostemn firmly against the bone, and an aseptic dressing applied over the whole ear and mastoid. The frequency of dressings must depend upon the condition of the ear: with suppuration, daily dressings are necessary.

Hyperostosis, a general hyperplasia of the bone, is particularly liable to occur with chronic suppurations of the tympanum; and if the hyperostosis closes the meatus an operation may be a vital indication to prevent retention of pus.

In such cases two methods are applicable. One is to drill through the growth in the meatus with a surgical engine and enlarge the opening by burrs. This has been done with success: but the opening thus obtained is a small one which, becoming covered with granulations is kept open with difficulty; and, as the hyperplastic process in the bone will probably continue, a renewed closure is likely to occur even when the seat of operation has healed well.

The other method is to do a full tympano mastoid exenteration (see page 796), removing all the hyperostosis on the posterior wall. This has the advantage of making a large meatus, of enabling one to treat the underlying tympanic disease, if there is one, as is usually the case, and is much more likely to put a stop to further hyperplasia of the bone.

Exostosis Cartilaginee. Still a third form of osseous growth is occasionally found in the meatus, apparently congenital and probably developed from a remnant of fetal cartilage. To the American Otological Society in July, 1893 and 1894, 1 reported four cases of osseous growth, three on the mastoid wall of the meatus and one apparently arising from the tympanum ; they differed from ordinary exostoses in being covered with cartilage and in lying free or but slightly attached to the cavities of the surrounding bone. They were removed by exposing them by displacement of the auricle forward and then extracting them with forceps, without any cutting of the bone. A full description and discussion of them can be found in the Transactions, 1893 and 1894.

Foreign bodies can, in most cases, be removed by syringing, and this should be tried in all cases ; instrumental interference is unjustifiable except when syringing fails, either from the body being firmly impacted or becoming impacted by swelling from moisture. In these exceptional cases the ingenuity of the surgeon is sometimes taxed to the utmost to adapt his instrument to the peculiarities of the foreign body and its position in the meatus. In children and nervous adults a general anesthetic is often required, especially if the meatus is irritated from previous injurious manipulations.

Angular toothed forceps are adapted to bits of wood, grass, or similar objects. The wire loop of a snare can sometimes be passed around a pebble, an(] it can thus be gradually rolled out. A small sharp hook is very useful for peas and beaus; a blunt hook for beads.

These are perhaps the most common instruments; but in a difficult case the surgeon's armamentarium can scarcely be too large. Occasionally a foreign body is so firmly impacted in the deeper meatus or tympanum that it cannot be displaced by any instrument through the meatus, either through lack of space to exert sufficient force, or through the body's having been forced beyond the narrowest part of the meatus and then having swollen, or through its having been impacted within the tympanum. In such cases the auricle and cartilaginous meatus should be displaced, as already described under exegeses ; free access is thus gained to both osseous meatus and tympanum, and instruments adapted to the body can now be used with success. By this method I have successfully removed impacted glass, a tooth, and several flattened bullets from the tympanum, and swollen vegetable substances from the deeper canal, which it was physically impossible to have got out through the cartilaginous meatus.

OPERATIONS ON THE TYMPANUM.

Paracentesis. Good illumination by means of a reflector and speculum is necessary. Asepsis in regard to meatus, auricle, hands, and instruments should be practised. The pain of the operation is very variable; if the drum membrane is bulging extremely from the pressure of secretion, its sensitiveness is often so reduced that but little pain is felt ; if, on the contrary, it is very much thickened by infiltration, the pain is often severe. The natural sensitiveness varies also in different parts, being least in the lower half of the membrane and greatest in the posterior superior quadrant just behind the short process. The operation is so rapidly performed that narcosis is often unnecessary; but with children, with the timid, or where the drum membrane is much infiltrated, primary etherization is desirable.

The object to be attained is a cut through the drum membrane, in length from one quarter to one half of it , diameter and made in such a direction that both the radial and circular fibers of the membrana propria shall be incised, thereby insuring a slightly gaping wound from the contraction of both sets of fibers, facilitating drainage. The chief difficulties of the operation are (1) the judging of the distance, as only monocular vision can be used, and (2) getting the incision long enough, allowance Dot being made for the inclination of the membrane. The first can be overcome by keeping the point of the knife in slight motion as it is passed down the meatus, when, as the point touches the membrane, its motion is arrested and the puncture is immediately made by a slight thrust. The second is obviated by continuing to pass the knife slightly inward as the cut is made downward. Before withdrawing the knife the edges of the wound should be pressed apart to prevent their adhering with the slight bleeding which ensues.

Although various instruments with and without guards have been proposed, nothing in my opinion is so simple and good as the original paracentesis needle of Schwartze, a small lance shaped knife, the shank of which is 5 cm. long, bent at an angle of 50 degrees and inserted in a handle 10 cm., long. For enlarging an existing perforation or an insufficient puncture the blunt pointed, slightly curved dilatation knife of Schwartze cannot be improved.

The point of election for the operation will depend upon the object sought to be accomplished. The most common object is evacuation of secretion, and for this, if the drum membrane is greatly bulging, the cut should be made through the most prominent projection; if, however, there is no very conspicuous bulging it should be through the posterior lower quadrant, beginning a little above the umbo, midway between that and the periphery, and continued slightly obliquely downward to the lower periphery; this secures the most thorough evacuation and drainage. In paracentesis of the upper posterior quadrant, which is never advisable except with a bulging at that point, the risk of injuring the ossicles, especially the articulation of the incus and stapes, requires that the operation be done with great caution against too deep a thrust into the tympanum. A paracentesis of the anterior half of the membrane is never advisable except where there is a distinct bladder like protrusion of the membrane at that situation, which is extremely rare; an opening at this point evacuates very insufficiently the secretion collecting posterior to the opening. When the drum membrane is much infiltrated it may be advisable in exceptional cases to make a cross cut, thus giving a triangular flap, which, being pressed back, will keep the opening patent for a longer time.

The tympanum having been thus opened, if the secretion is thin and under any degree of pressure, it will evacuate itself freely; and if the Eustachian tube be open, slight inflation by Valsalva's method will complete the evacuation, and the air will pass out without rales, with the characteristic perforation whistle. If the secretion is thick and adhesive or if the Eustachian tube is closed, it may be necessary to use the catheter, through which injections of warm sodium chlorid solution (3/4 of 1 per cent.), boric acid solution (5 per cent.), or some other mild and warm antiseptic solution may be used. My own practice varies with the case. In otitis media acuta with a thin bloody serum I content myself with following the paracentesis by simple drainage by means of a wick of corrosive sublimate cotton, without inflation of any kind; with a simple acute effusion without congestion and with marked retraction of the drum membrane due to closure of the Eustachian tube (hydrops. ex vacuo), I use moderate inflation most commonly by the catheter, because the force of the inflation with this is so completely under the control of the surgeon although with children or timid persons Politzer's inflation may be necessary. In chronic catarrhal cases where the secretion is thick, often jelly like and adhesive, injections by the catheter are frequently necessary to soften and wash out the masses, and aspiration from the meatus by means of Siegle's speculum will sometimes assist the evacuation; but care should be used to avoid any extreme congestion from the suction. In acute suppurations I avoid inflations at first; and if the secretion is too abundant and thick to be absorbed by a short wick, use hot syringing, especially if there is much pain.

Although paracentesis is most frequently used for evacuation of serum, mucus, and pus from the tympanum (and in all of these conditions is indispensable, and in the case of the last often life saving), it is also occasionally useful for enabling us to get into the tympanum for the purpose of (1) divided ing synechie (2) removing intratympanic polypi, (3) relieving anomalies in tension of the drum membrane.

To get at synechie a short incision should be made as near their attachment as possible and the adhesions divided by passing a curved or rightangled knife through the opening. For intratympanic polypi a large opening, often with an extended cross cut, is necessary its situation dependent on the seat of the polypus. Anomalies in tension may be either increased or diminished tension. For the former, incision of the posterior fold as proposed by Lucae requires that the fold should be pierced close to the periphery directly behind the short process and the cut continued downward through the whole fold; although injury of the chorda tympani may result, it is of absolutely no importance. For diminished tension numerous small incisions in the most relaxed portion of the membrane have been advised with the object of increasing the tension by the resulting cicatrices. Neither of these operations for tension have, however, received general approval, as they but imperfectly relieve a single one of several pathological conditions which produce the deafness.,

Tenotomy of the tensor tympani muscle for the relief of deafness and subjective noises produced by sclerosis or adhesive processes in the tympanum is of slight, if any, value. In my own hands it proved so worthless that I gave it up years ago. It can only relieve the retracted condition of the drum membrane; while we now know that the important pathological changes are on the inner wall, especially about the base of the stapes, and that these cannot be influenced by the operation. Almost the same thing can be said of tenotomy of the stapedius muscle; in a few exceptional cases I have seen a certain degree of relief to subjective noises and vertigo by this operation, where the stapedius was greatly thickened by cicatricial tissue resulting from previous suppurations and where. the condition could be diagnosticated by direct inspection through a large perforation of the drum membrane.

Tenotomy of the tensor is performed best in the posterior superior quadrant by incising the membrane parallel with the manubrium, just behind and a little below the short process; the tenotome is then inserted through the opening toward the tympanic roof and with its edge forward until the head of the malleus is felt; it is then rotated forward until it engages the tendon of the muscle, which can be severed with a slight sawing motion. As the tendon is cut through it is felt to yield, and the manubrium with the drum membrane will be felt and seen to move outward more freely than before. By far the best tenotome is Schwartze's.

Tenotomy of the stapedius can be done with any small straight knife or with a paracentesis needle when the stapes lies low and is exposed through a large perforation.

Excision of Parts or the Whole of the Conducting Mechanism These operations should be carefully divided into

(1) Excisions for the relief of deafness otherwise incurable.

(2) Excisions for existing tympanic suppuration

Under the first head the operations are undertaken with the object of removing parts of the conducting apparatus which have become so immovable by disease that they prevent vibrations from reaching the auditory nerve. The diseases producing this immobility are (a) adhesive inflammations (thickenings, calcifications, adhesions), the result of previous tympanic suppurations and catarrhs ; (b) the obscure pathological process known as sclerosis, the important characteristics of' which are changes on the inner (labyrinthine) wall of the tympanum and about the niche and foot plate of the stapes.

It is impossible here to give the full history of' the various operations which have been proposed; they can be briefly summarized as follows: excision of the tympanic membrane and malleus; of the incus; of the long process of the incus ; of the tympanic membrane, malleus, and incus ; of the stapes ; of the tympanic membrane, malleus, incus, and stapes.

The methods of' operating will be considered later, as they are the same whether done for deafness or for suppurations, except that in the former, with a healthy drum membrane, the strictest asepticism is absolutely necessary.

In regard to the operations for deafness, I think it can be said that in neither the adhesive nor the sclerotic diseases have the results equalled the expectations of their originator s or received general recognition by otologists.

In adhesive inflammations occasionally fair and even good results are obtained (see page 738) ; but only, in a small proportion of cases as yet, and the indications for or against the operation are not established. In sclerosis any degree of success is so rare and the failures so many that for my own part I have given up all varieties of the operation for this disease.

With our present pathological knowledge only two of the operations for deafness are worthy of consideration

(1) Excision of the tympanic membrane, malleus, and incus, leaving the stapes in position.

(2) Excision of the tympanic membrane, malleus, incus, and stapes. Which to adopt must depend upon the condition of the individual case. If the rigidity exists in the malleus and incus and, after their removal, the stapes is found by the probe to be freely movable, it should be left in position; if, however, it is immovably fixed and not to be released by the separation of adhesions of the crura to the niche, the only hope of success is in removal of this bone also.

For tympanic suppurations, removal of parts of the conducting mechanism is merely fulfilling the well recognized surgical laws of removing obstructions to the thorough evacuation of pus so as to get surgical cleanliness and remove diseased bone (microbic foci) which keeps up the infection. It is especially indicated where the suppuration is in the epitympanum. or attic ; for the head of the malleus, the incus and stapes, the tensor tympani and stapedius muscles, the ossicular ligaments and many folds of mucous membrane are crowded into or below this narrow space; and a suppuration .of the mucous membrane, which covers all of these structures, with its resulting swelling, often so interferes with free drainage that recovery is absolutely impossible without an evisceration of the cavity. In addition to this, the retention of pus is very apt to produce caries of the ossicles or of the petrous bone, which keeps up the suppuration. For both pus retention and ossicular caries the operation is indicated and successful in a large proportion of cases. In performing it the whole of the existing drum membrane, together with the malleus and incus, should be removed ; for any of these being removed the others become useless and merely act as obstructions to cleanliness; while in caries of the ossicles, pathological statistics show that both ossicles are usually diseased, but the incus more extensively than the malleus.

The different steps of the operation are as follows:

(1) Separation of the drumhead by incision around its periphery as near the tympanic ring as possible.

(2) Tenotomy of the tensor tympani muscle by passing a Schwartze's tenotome over the tendon and dividing it, as already described on page 788. After severing the tendon the knife should be passed downward along the inner edge of the manubrium in order to separate any adhesions which are., tying that bone down.

(3) Disarticulation of the incudo stapedial joint by incising it by short cuts with a small sharp pointed knife set at nearly a right angle with its shankthe incisions being made in the plane of the joint, perpendicular to the axis of the stapes. If the stapes is situated low in the tympanum, the joint can be seen; if high, the disarticulation must be done by feeling. A. free movement of the long process of the incus proves the success of the disarticulation.

(4) Removal of the hammer by seizing it in strong forceps at or near the short process, carrying it slightly inward to bring the neck out from its insertion in the Rivinian notch, and then bringing the bone downward into the meatus and withdrawing it together with the drum membrane. Occasionally the incus comes away with the hammer, but usually it remains; if its long process is visible, it can be seized with forceps and withdrawn ; if it is not seen, it must be brought down into view by all incus hook, as described below (Fig. 523) in regard to carious ossicles, and then withdrawn.

(5) Separation of adhesions about the crura of the stapes, if any, can be accomplished by any small sharp pointed knife or by a paracentesis needle.

(6) Removal of the stapes, if' that be desirable, is accomplished by inserting a small, blunt steel hook between file crura and drawing the bone out gently. Unless the foot plate is ankylosed this can be done readily; but with ankylosis the crura fracture and removal of the foot plate is then impossible.

The whole operation can be done under cocain with scarcely any pain if the patient is steady ; but each successive portion of tissue requires to be cocainized by a pledget of cotton on an applicator. In an intact drum membrane the first puncture must necessarily cause pain, but from that puncture the saturated cotton point inserted. in the opening will thoroughly anesthetize about one eighth of an inch of tissue ; file cut can then be continued that distance and then another application of cocain made. Solutions of 5 per cent. are sufficiently strong. Absolute immobility of the head is required, and in a nervous patient general anesthesia is necessary.

In the operation for suppuration certain modifications may be necessary. In these suppurative cases there is often much granulation tissue which bleeds freely, masses of inspissated pus and cholesteatornatous material, and the ossicles are often reduced to mere fragments, with calcifications fixing them so that considerable force is required for their removal. The most common spot for caries in the ossicles is the long process of the incus, which in 60 cases of my own bad produced a natural articulation in 75 per cent., thus doing away with the operative disarticulation. With mere fragments of ossicles adherent by calcification, the Ludwig's incus books are often necessary; and in removal of the incus, which is often reduced to a portion of' the body only, these instruments I consider indispensable and prefer them to anytiling I have yet seen (Fig. 523). The malleus and tympanic membrane having been removed, the incus hook should be passed into the anterior superior portion of the epitympanum, with its concave surface backward; it should then be swept backward so as to engage the body of the incus and bring it down into the meatus, whence it can be withdrawn by forceps. With a broad and deep attic several sweeps of the hook may be necessary in different portions of the cavity before the incus is dislodged, and in sweeping along the media] (labyrinthine) wall the position of the Fallopian canal should be borne in mind and but slight force used at this point; any twitching, of the facial nerve is a signal of danger. Occasionally the incus is not brought into view by the backward sweep, but can be found by reversing the process and sweeping from behind forward. After removing the incus, the cavity should be thoroughly cleansed of cholesteatomatous masses, inspisated pus, and granulations by the Ludwig hooks, by snare and forceps. Bleeding can be greatly reduced b the use of cocain, and before beginning the operation I always inject the cavity with a, 5 per cent., solution. In the operation for suppuration I have generally found etherization necessary, as the tissues are inflamed. The after treatment consists Of cleansing with tile tympanic syringe and the use of antiseptics applied directly to the tympanum: a saturated solution of boric acid in absolute alcohol for granulations, simple boric acid powder for a slight serous discharge, and a solution of carbolic acid in glycerin (I : 25) for simple suppuration.

Polypi and granulations should be carefully distinguished from sarcomata or epitheliomata. Their removal is required because they keep up the inflammation of the parts to which they arc attached, and because, if large, they cause retention of pus. Whatever their attachment, whether on meatus, tympanic membrane, ossicles, or tympanum, they must be got rid of before the inflammation can subside. They are almost without exception inflammatory granulation tissue, soft or firm according to the amount of fibrous tissue which they contain; occasionally they contain cysts and exceptionally assume a teleangiectatic character from excessive development of blood vessels. They usually are pedunculated, but occasionally are broad based; and they vary in size from a pin's head to one inch or more long. They are the result of inflammation of the underlying tissue, often of a simple suppuration, often of caries of the bone.

The choice of methods for removing them must depend upon their size, shape, character, and attachment. Small soft granulations can be destroyed by caustics, preferably argentic nitrate fused on a probe, or shrivelled by alcohol; but in most cases immediate removal is the quickest, surest,, and least painful method, This can be accomplished with snares, forceps, or curettes

Small pedunculated granulations can be seized and removed by evulsion with appropriate forceps if their situation admits of it; small broad based ones, if' soft, can be crushed by the same means; if firm and their attachment admits of it, they can be removed with a small curette. In either variety where evulsion is undesirable, as in attachment to the ossicles or drum membrane, a delicate snare will cut them off. Pedunculated granulations in the epiitympanum or aditus can often be swept down and removed with the Ludwig incus hook.

Large polypi attached to the walls of the meatus can also be removed with forceps by evulsion, but only exceptionally can their attachment be made out with such certainty as to this method; in almost all of these cases the snare is the only appropriate instrument.

The snare can he used either as an evulsor or as an ecraseur, according to whether the wire is drawn against a cross bar at the end of the instrument or completely into the tube in the absence of a cross bar. The canula of the snare should be small and delicate for small granulations attached to delicate parts; much larger and heavier for large, especially for fibrous polypi. The size and quality of the wire should be adapted to the work also; for small growths on the tympanic membrane or ossicles I prefer a soft, malleable copper wire, even as small as No. 36; for large growths copper wire, No. 28 or 30 ; occasionally for large fibrous growths steel piano wire, No. 2, is necessary. The malleable copper wire seems to adapt itself to the base of the growth better than a stiffer material, and I prefer it in almost all cases. The loop of wire, being made a little larger than the growth, is passed around it, bearing in mind the anatomical peculiarities at its attachment; the loop is then tightened or drawn into the tube and the tumor removed. Evulsion is to be preferred as more thorough where it is not liable to tear away important parts , where it is liable to do this the ecraseur action is to be used. With large polypi it is often difficult to pass the loop completely down to the base. As much as possible is removed at the first, insertion and the remainder by subsequent insertions. Except with very nervous person’s general anesthesia is unnecessary, thorough cocainizing with a 10 per cent., solution being sufficient.

The subsequent treatment consists in destroying all remnants of the growth and getting the seat of it healed If caries exists, the only course is to get rid of the process, for without this the growth is certain to recur, and the object of removing the polypus is to enable us to get at the caries. Without caries the remnants should be disposed of by cauterization or by shrivelling ; for the former I confine myself' almost entirely to argentic nitrate fused on a probe, applied superficially in case of a small remnant of a soft growth, or bored directly into the growth if the remnant is large and firm. For shrivelling, alcohol (95 per cent.) and glycerite of carbolic acid (1 .25) are very useful, applied either by instillation, by injection through a tympanic syringe, or by painting.

Mastoid operations are required for two pathological conditions : (1) pus in the pneumatic cavities of the mastoid, the retained products of suppuration of the mucous membrane lining the cells (emplvema); (2) different varieties of ostitis, including suppuration of the diploe, inflammation of the cortical substance, caries, and necrosis. They are of two kinds: (a) opening of the mastoid antrum (Schwartze's operation) ; (6) cleaning out the whole interior of both mastoid and tympanum, a tympano mastoid exenteration (SehwartzeStacke or Schwartze Zatifal operation).

The antrum operation consists in opening the antruin through the external mastoid cortex, and in so doing exposing the whole interior of the mastoid so as to remove all diseased tissue, whether osseous or soft. The antrum is the objective point to be reached, for it is the only constant cavity within the mastoid; the rest of the bone may be, instead of pneumatic, as usually described, diploeic or selerosed. There is no' method of determining beforehand the condition of the interior of the bone; a large prominent mastoid is more likely to be pneumatic than a small, depressed, ill developed one; the bone in a dolichocephalic skull is more likely to be well developed and pneumatic than in a brachycepballe skull. It is equally impossible to foretell whether we shall find empyema, ostitis, or osteomyelitis

the opening of the bone finally settles the question. Osteoselerosis can be excluded in acute mastoiditis resulting from acute tympanic suppurations, unless the mastoid has been inflamed front some, previous disease; it is unlikely in a mastoiditis which has shown symptoms of extension outward as subperiosteal abscess or extension downward into the. neck; it can be strongly suspected in chronic, long continued tympanic suppurations.

Certain irregularities of formation may be found in any mastoid, apparently regardless of its perfect or imperfect development.

(1) The roof of the antrum, which forms the floor of the middle fossa of the skull, may vary as much as 2 cm. up or down; the linea temporalis marks the line of this roof fairly well externally, and measurements on large numbers of skulls show that the floor of the middle fossa is never I am below the linea temporalis. A safe, rule, then, to avoid opening the middle fossa is to keel) I cm. below the linea temporalis, but as this linea, is sometimes imperfectly developed, another rule is to make the upper edge of our opening 3 mm. below an imaginary line drawn horizontally backward from the tipper edge of the meatus, which is well marked by the spina supra meatunt.

(2) The outward curving of the sigmoid groove which carries the lateral sinus varies very much ; it may project even to the external cortex, and such a possibility must always be borne in mind, and possible wounding of the lateral sinus guarded against by the use of chisel and mallet worked slowly and carefully, and by the omission of all boring instruments, like trephine or drill.

(3) The extent of cancellated structure varies; it sometimes extends far backward and far inward ; and as in osteomyelitis especially, the removal of nearly all cancellated structure is desirable, the possibility of this peculiarity should not be forgotten.

The floor of the antrum, roughly stated, is on a level with the upper wall of the meatus, and the cavity itself is from to inch back of the superior posterior edge of the tympanic ring.

Method of Opening the Antrum. Expose the mastoid by an incision through the periosteum I cm. behind the attachment of the auricle, beginning 1 cm. above the linea temporalis and extending the cut down nearly to the tip of the process. Separate the periosteum forward so as to expose the suprameatal spine, and backward so as to expose the surface of the mastoid. From the spine draw an imaginary horizontal line backward (Fig. 524), and begin the tipper edge of the opening 3 mm. below this line and about 1 cm. back from the posterior edge of the meatus, removing the cortex by thin chips with a gouge and mallet. The seat of election is usually marked by a flat and slightly depressed surface. The cortex of the bone varies in thickness from a tbi; shell to I cm.; remove it by thin chips overa surface 7 to 10 mm. in diameter, taking care to work parallel with the meatus, or, if anything a little more forward and upward. As soon as the cortex is cut through, examine with a probe ; there may be large pneumatic cavities, in which case feel for landmarks, upward for the roof of the mastoid to define the floor of the middle fossa, backward and inward to define the posterior fossa. Now break down all the partition walls between the cells with a curette till the antrum is reached at a depth of not over 15 mm. 10/16 1 61 inch) from the outer anterior edge of the surface opening; clear out the involved interior of the mastoid with curettes, removing the walls of the cells, granulations, pus, and detritus, douche gently with corrosive sublimate (1:5000), pack with iodoform gauze, and bandage.

In other cases on opening the cortex the interior is found to be partly or wholly dilplotic; more careful work is then necessary, and the diploe, should be removed straight inward, parallel with the meatus, to the depth of 6 to 9 mm. 1/4 to 3/8 inch), and then it is necessary to work slightly forward, inward, and upward to reach the antrum ; but never go beyond 15 mm. 10/16 inch) from the external surface at the seat of election for fear of wounding the facial nerve or posterior semicircular canal. Having opened the antrum, the whole diploe of' the mastoid should be removed with curettes, then cleanse, pack, and dress.

In still other cases no pneumatic or diplotic structure is found; the deeper the opening is carried the harder the bone becomes osteoseterosis. These are by far the most difficult operations; one gets no guide from the probe as in the other varieties of bone, and the greatest care is necessary to keep the proper direction of the opening. The bone should be removed in small chips, the opening carried straight in, parallel to the meatus, to the depth of 5 to 8 mm. (1/5 to 3/8 inch), and then continued upward and slightly forward not deeper than 15 mm. (!, 0,¬inch) from the external surface. Often after going through selerosed bone for 7 to 14 rum. (I/4 to I/2 inch) diploe is met; this should be removed by curettes as thoroughly as possible ; then cleanse and pack.

It is the exception to find the pathological condition as clearly defined as is here given; caries is very apt to complicate; and if during the operation carious bone is found, it should be thoroughly removed, care being taken to avoid wounding the dura mater, the facial nerve, and the labyrinth. Not infrequently the roof of the mastoid next the cerebrum is carious, also the inner posterior wall next the lateral sinus and cerebellum; these carious spots should be removed by a curette, the dura being pushed back from the bone. Narrow gauze strips can be carried into any crevice to stay the bleeding, and cleanse for thorough inspection. At any stage of any operation the removal of a small chip of bone may expose a gray shining membrane, which is a signal of danger; it may be cholesteatoma, pyogenic membrane, or dura, and must be examined carefully before proceeding. Extensive caries may require enlargement of the whole original opening.

The only cases which are exceptions to the above general rules of operating are those in which there has been extension of the internal suppuration through a carious fistula of the cortex outward through the external cortex, forward through the anterior cortex, or downward into the neck through the mastoid floor. With extension outward, incise the periosteum as in the regular operation, expose the fistula and follow this in, clearing away all softened bone, and within the mastoid be guided by the existing conditions as described above. With extension forward, after the first incision expose the posterior wall of the osseous meatus by pushing the periosteum forward, and the fistula can be seen and followed. With extension downward, fistulas are to be looked for in the base of the mastoid; this can be done by Meeting the periosteum from the posterior aspect of the mastoid tip and then passing a bent probe or director beneath the periosteum along the digesters fossa which constitutes the base of the mastoid. Having thus found the fistula, remove the outer surface of the tip, exposing the interior of the bone together with the fistula, and cleanse as in the other varieties.

These fistula are always to be suspected and carefully looked for when the external tissues are edematous and swollen; they are almost certain to exist whenever any pus is found between the periosteum and the bone; with extension outward the edema begins on the external surface ; with extension forward, on the posterior wall of the meatus; with extension downward, beneath the mastoid in the neck, early assuming the characteristics of a cellulitis, which may form an abscess anywhere in the neck beneath the deep fascia and burrow extensively, even into the pleura. Next to the extensions to the brain these inflammations in the neck are the most serious complications of mastoiditis, sometimes requiring deep dissections of the neck, even to the vertebra, in order to evacuate the pus.

With extensions toward the brain upward, inward, and backward, the tympano mastoid exenteration is usually necessary.

The tympano mastoid exenteration is well described by the name; it is an evisceration of the interior of the bone by making the mastoid, antrum, tympanum, epitympanum, and meatus one large cavity with perfectly smooth and healthy walls, by removing the external cortex of the mastoid, its entire cancellated structure, the posterior osseous meatus wall, the tympanic membrane, the malleus and incus, and the outer wall of the epitympanum. It is indicated for simple caries of the bone which cannot be read hed by the ordi¬nary antrum operation i. e. caries of the tympanum, epitympanum, aditus and extensive caries of the mastoid, and also for cholesteatoma of the mas¬toid and tympanum. The variations in formation of the bone, the low lying roof, the outward curvature of the lateral sinus, the extensive cancellated structure, are of as much importance to the surgeon in this as in the antrum operation. The same may be said of the measurements given in speaking of the antrum operation. In addition, in this operation the danger of wounding the facial nerve is much increased; and the course of the Fallopian canal and its relations to the floor of the aditus and to the posterior osseous meatus should be continually in mind, as well as the relations of the external semi¬ circular canal.

There are two methods of getting at the antrum and aditus: one advocated by Schwartze, Zaufal, and their followers, who open from behind forward; the other advocated by Stocks, who opens from in front backward. The former extirpate the posterior superior membranous lining of the osseous meatus; the latter saves it to make a flap for covering the exposed bone.

The former operation is divided into seven steps:

(1) Exposure of the operative field;

(2) Extirpation of the posterior and superior lining of the osseous meatus;

(3) Exposure of the antrum by chiselling away the mastoid and posterior osseous meatus;

(4) Removal of the pars epitympanica;

(5) Exentelation of the tympanum and mastoid;

(6) Stitching and bandaging;

(7) After treatment.

For the first step incise over the middle of the mastoid from 2 cm. above the linea temporalis to 2 cm. below the tip, and from the upper end of this cut make a horizontal incision forward for 3 to 4 cm. and backward also for 3 to 4 cm. From these cuts expose the entire mastoid by making a skin periosteal flap forward to the meatus and the same backward.. Secondly, separate the carfilaginous from the osseous meatus on its posterior and superior circumference , then incise the skin of the tipper anterior wall of the osseous meatus from the tympanic ring outward; parallel with and opposite this make a similar incision along the posterior lower wall of the meatus; separate from the bone all of the skin included between these incisions on the upper ,%,all from without inward and remove it with scissors, thus thoroughly exposing the tipper and posterior walls of the meatus, Thirdly, enter the antrum as already described in the antruin operation, and then remove the wedge between this opening and the tympanum by chisels, or else chisel away the bone at once from the antrum surface (place of election for the antrum opening) forward into the osseous meatus , without first entering the antrum, going deeper and deeper until mastoid, antrum, aditus, tympanum, and meatus are united by a deep groove in the bone (Fig. 525). Check all bleeding, and the tympanic membrane or its remnants are now visible. Fourthly, separate any portions of the drum membrane which exist at the tympanic ring and remove them together with the malleus by forceps disarticulate the incus from the stapes and remove it by forceps (see Operation for Carious Ossicles, page 791), it is usually buried in swollen mucous membrane and granulations. Now push the mucous membrane of the epitympanum inward and remove the whole floor of that cavity by gouge and mallet and curette till the roof of the epitympanum passes without any ridge into the tipper wall of the meatus (Fig. 526). Fifthly, clean out all the cavities, removing all cancellated structure, all prominences and ridges, making every part smooth, beginning with the mastoid, then respectively antrum, epitympanum, roof of tympanum and its walls. Examine every portion of the remaining walls for caries with a right angled probe, especially the lower inner corner next the lateral found remove it even if it exposes the dura. Wipe dry with pledgets of gauze, taking care to remove all bits of bone.

Finally, split the cartilag¬inous meatus from near the concha throughout its length along its pos¬terior wall, thus making two triangu¬lar flaps (Fig. 526). Sixthly, stitch the horizontal wounds and 2 to 3 cm., of the upper part of the perpendicular wound, laying the skin periosteal flap carefully against the bone; stitch the corners of the meatus flaps above and below into the skin so as to stretch them up and down, and then pack the tympanum and antrum with iodoform gauze from the meatus, and similarly fill the mastoid from the wound; add an aseptic dressing and bandage. Sevently, the after treatment requires the most careful personal attention of the surgeon. The healing must take place, not by the cavities filling with granulations, but by granulation of the entire surface merely, which must then become covered by a firm, dry epidermis. The two chief points are to keep the wound aseptic and to keel) down redundant granulation tissue, which can only be done by keeping the whole cavity packed firmly with iodoform or sterile gauze, every little crevice receiving attention. If granulations become prominent, they must be removed by the snare, by argentic nitrate, or by the galvano cautery.

The details of Stacke's operation are as follows: Make a curved incision at the insertion of the auricle or close to it from the temporal region to I cm. below the tip of the mastoid through the skin and subcutaneous tissue only. Dissect off the soft parts above the linea temporalis outside of the temporal fascia and draw them downward. From the linea temporalis downward extend the first cut through the periosteum and along the linea, make a crosscut forward through the periosteum, thus making a triangular flap of periosteum, which is then raised by a raspatory as far as the edge of the osseous meatus; then with a narrow elevator raise the membranous meatus from the bone deeply into the osseous meatus till the whole posterior and upper osseous meatus is visible by drawing the parts forward. The whole mastoid should then be exposed by pushing its periosteum backward, if necessary making a cross cut. If a fistula or discolored cortex exists, follow this into the antrum; then remove the posterior wall of the meatus and epitympanum.

If no fistula exists, with a small curved scalpel cut the posterior and upper membranous meatus as near the tympanic ring as possible, and draw this, together with the loosened auricle, forward by a blunt hook. After checking bleeding, the membrana tympani is visible; and the whole membranous meatus is retained to cover the bone.

The next stage is the exenteration of the tympanum by removing the drum membrane or its remnants, together with the malleus. Then place a gouge, bent slightly backward (Fig. 527), some millimeters above the free edge of the epitympanum. and separate the bone by short light blows with a mallet, measuring the depth of the epitympanum with a bent probe, and continue removing the bone till the roof of the epitympanum is smooth and continuous with the upper wall of the meatus. The incus is now seen and removed.

Next pass a probe along the tegmen tympani into the aditus and with a small gouge, bent backward, remove the posterior superior meatus wall into the aditus until the probe freely enters the antrum and a good orientation of every part is obtained. Instead of the probe, Stacke uses a protector, as be calls The external cortex and lateral portion of the posterior meatus wall is Dow removed in large pieces by the chisel, the position and size of the antrum being known, and the antrum changed from a fistulous cavity into a narrow trough, which passes smoothly into the upper and lower meatus walls without corners or sinuses. Medialwards the so called spur between the antrum and tympanum must be smoothed, the now visible facial prominence forming the lower limit, which it is impossible to touch without endangering the facial nerve. From the height of this prominence the spur must be sloped off till it entirely disappears laterally in the lower meatus wall. Here a minute artery of the bone is often encountered; and bleeding from it can be best checked by rubbing its orifice with a blunt instrument. All pathological products can now be removed under inspection, working carefully in the tympanum to avoid the stapes. The hypotympanum, as it is called by Kretschmann, only remains, and, except with caries of the tympanic floor, it is unnecessary to remove it; the danger to the facial nerve is very great here. With cholesteatoma, after removing everything macroscopically pathological, Stocks grinds down the bone with burrs on an electrometer engine to remove any pathological masses in the Haversian canals. Lastly, if the cells of the mastoid toward the tip are involved, they should be cleaned out.

Finally, the last stage of the operation is to make a flap from the membranous meatus to cover the bone as far as possible. This is done by making a horizontal cut parallel with the axis of the meatus and along the middle of its upper wall from close to the concha to its inner end; perpendicular to this, close to the concha, make a second cut downward and backward so as to make a rectangular flap (Fig. 528). Now tampon tympanum, epitympatitim, and aditus with small pieces of gauze, and then through the meatus tampon this rectangular flap to cover the bone between the meatus wall and the floor of the antrum. The tipper part of the wound is sutured into position and an aseptic dressing applied.

The final result by either method of operating is the same the mastoid, antrum aditus, tympanum, epitympanum, and meatus are turned into one large, continuous cavity with smooth walls which must become covered with a dry, firm epidermis. This epidermis can only grow from other epidermis which must extend inward from the external edges or be transplanted into the cavity. This transplantation can be by Thiersch grafts after the bone has become covered with small, firm granulations, and also by turning into the cavity a flap of skin taken from the outside; the latter implies a permanent opening behind the auricle. There is necessarily a large surface of exposed bone from the operation, and the more this can be covered at the time the quicker the healing and the less the risk of caries; and the more epidermis there is in the cavity the more rapidly will epidermization of the whole take place. Various methods of covering the bone and obtaining epidermis have been proposed. One is in the first exposure of the mastoid to cut down to the tip in front, then around the tip and upward at the posterior edge of the mastoid, then dissect tip the skin alone and turn it upward for one flap; next dissect up the entire periosteum of the mastoid from above and turn it down for a second flap, so that after completion of the operation these flaps can be tamponed over the bone. Another is to turn in a flap of skin taken from the neck; while still another is to dissect up the skin behind the mastoid, to take from this place as large a flap of periosteum as is desirable to turn in, and then replace the skin against the bone, where it soon adheres. I have practised the first two methods with satisfaction. The last I have never used; it has the disadvantage of not supplying any of the desired epidermis.

Although the operation for ebolesteatoma is the same as for caries, the surface affected by the growth requires special treatment; not only the whole investing membrane, if any, should be thoroughly curetted away, but the surface of the underlying bone should be as thoroughly curetted as its position admits to remove any growth in the Haversian canals. Zaufal advocates cauterizing it with a Paquelin cautery; Stocks uses an electrometer engine instead of the sureties

The after treatment of the cavity is tedious, lasting from three to six month,, the tamponing must be kept tip till epidermization has covered the greater part of the cavity; it cannot be omitted till at least one of any two opposing surfaces are skin covered. When, however, epidermization is well advanced, the omission of the tampons and exposure to the air will hasten the cure. Aristol and dermatol in powder are important aids to epidermization and to protect the young epidermis from maceration.

The tympano mastoid exenteration, whatever method of performing it experience may finally determine to be best, seems to me destined to take an important position not only in the surgery of chronic otorrheas, but also in the surgery of the otitic brain diseases.

The otitic brain diseases are:

(1) Pachymeningitis externa purulenta, with extradural abscess;
(2) Leptomeningitis purulenta, or arachnitis;
(3) Phlebitis and thrombosis of the sinuses and of the jugular;
(4) Abscess of the brain, or encephalitis.

The brain disease is due to infection of the brain from the infected ear, the infectious material reaching the brain through disease of the bone next the dura, through the natural communications which lead from the ear to the inside of the cranium, or through some of the tissue connections, blood vessels, or connective tissue fibrils, which pass into and through the bone from both tympanum and dura. If the extension takes place through the roof of the temporal, the brain disease is in the cerebrum; if through the inner wall, the brain disease is in the cerebellum.

The following table of otitic diseases from Korner has a most important bearing on the surgery of these diseases:

The tympano mastoid exenteration, with modification for circumstances, in many cases is the best operation for these intracranial diseases; for as the ear is the original pus focus, still active and still infecting, it should be the first point to attack. This is the only operation which exposes at once the entire roof of the antrum, aditus, and tympanum, and also the inner wall of the mastoid, thus allowing a thorough exploration of most of the spots whence transmission of infection to the brain occurs. It also allows the most perfect drainage by evacuating the pus at its most dependent position. lit many cases, moreover, while we may feel confident of the existence of intracranial. disease, we are unable to define its nature exactly ; in other cases, while reasonably certain of our diagnosis of the brain trouble, we cannot be sure of its exact location; again, in a very considerable proportion of cases the surgeon first sees the patient when the brain disease is so active that time is more important than an accurate diagnosis. In all of these classes of cases a thorough exposure of the interior of the bone is the primary step for diagnosis, localization, and treatment; in this sense the operation on the bone is often exploratory. If any justification of this course is necessary, it is seen in the fact, shown in the table above, that in 79 per cent. of all otitic brain diseases the bone is diseased directly upon the dura, and the operation on the bone means following the disease inward. I would emphasize this necessity of operating early in intracranial disease without waiting for an accurate diagnosis; for in a large number of cases the full complex of symptoms necessary for a perfect localized diagnosis only appears a few hours before death.

Having performed the tympano mastoid exenteration in a case showing brain symptoms, disease of the bone next the brain should be sought by a careful examination of the whole superior and interior walls of the cavity. The diseased bone may be only a point not larger than the end of a probe; if found, it should be removed with curettes, and the opening enlarged by curettes or rongeurs.

With pachymeningitis externa (extradural abscess), pus is immediately evacuated and the dura cleansed. If the disease is in the middle fossa the only complications are arachnitis and brain abscess; a fistula through the dura renders one or the other probable, and such a fistula should then be sought; if not found, the opening in the bone should be enlarged so far as the anatomical situation will allow, thorough drainage established by wicks of sterile gauze, and the wound dressed often enough to keep it free from collections of pus, usually daily. The dumb becomes covered with granulations which adhere to the edges of the bone, and finally is covered by epidermization of the cavity.

Sinus thrombosis. If, however, the pachymeningitis is in the cerebellar fossa, besides the possibility of arachnitis and brain abscess, phlebitis of the lateral sinus should be looked for, as it is a very common complication. It can usually be recognized by feeling the cord of a thrombus; but in case of doubt the sinus can be explored by aspiration, when we get purulent serum if the thrombus is broken down at the point of puncture, no fluid of any kind if the thrombus is firm, and venous blood if there is no thrombus. If thrombosis exists, the sinus should be exposed from its upper to its lower curve by removing the bone with curettes, rongeurs, or an engine, laid open freely, and the thrombus withdrawn both from behind and from below so far as it is broken down, and the vein cleansed. Hemorrhage from removal of the thrombus has never been reported, I believe; should it occur, it can be checked by a tampon of iodoform gauze. Before opening the sinus, however, the internal jugular had better be ligated to prevent displacement of thrombi and general infection; but the dangers of a prolonged operation or infiltration of the neck from a gravitation abscess through the base of the mastoid, or from periphlebitis, may render this ligation inadvisable or impossible.

The following table from Korner is certainly in favor of the ligation:

If a fistula through the dura is found, arachnitis or brain abscess is prob Me;is'in ish which present is often impossible. If the former, the case is hopeless the latter, there is a possibility of cure. If the fistula is toward the cerebrum, the dura should be exposed over an extended surface, if possible, large as toward 3cm. in diameter, by cutting away, if necessary, the linea temporalis; if toward the cerebellum, by cutting away the posterior portion of the mastoid. The dura should then be opened by a crucial incision, and if the a abscess has reached the surface, as is often the case, pus is immediately evacuate and the abscess can be freely opened. If only a small fistula is seen in the brain tissue, or if no fistula is seen, the brain must be explored with a director. How deep this exploration can be carried without injuring specially important parts is of great consequence. These special parts are the anterior, inferior, and posterior horns, the lenticular nucleus, and the inner capsule; these can be avoided by confining the exploration to 2 ½ cm. (I inch)' perpendicularly inward from the surface of the dura and 4 cm. (1 1/2 inches) at an angle of 45 degrees with the surface; from the base of the brain upward the exploration can be carried to any distance, provided it is kept outside of 2 1/2 cm. from the lateral surface.'

Exploration having proved the presence of an abscess, the exploratory puncture should be enlarged by tearing, the abscess thoroughly evacuated, drained by gauze wicks, and subsequent drainage provided for in the dressing.

In case of doubtful diagnosis or localization, this plan of following the disease inward by a tympano mastoid exenteration or some modification of it is often best in my opinion; but it has its distinct limitations due (1) to the condition of the bone, (2) to the abscess lying beyond reach from the car. Under the first we may have such a bony sclerosis or such a low roof and projecting Fallopian prominence or such an outward and forward curvature of the sigmoid groove as to forbid an opening sufficiently large for the brainoperation. Under the second are the very exceptional abscesses in the frontal or occipital lobes, abscesses in the upper convolution of the temporal lobe, and some abscesses of the cerebellum.

If the condition of the bone forbids the opening through the car, bearing in mind the statistics which show that the chances are 80 in 100 the brain disease is directly connected with the bone, any exploration should be close to the bone. To get at the mastoid and tympanic roof the skull may be opened at a point 1/2 cm. horizontally backward from a point 2 cm. above the upper edge of the osseous meatus, the dura opened and explorations made as already described. To get at, the inner surface of the mastoid the posterior portion of that bone can be removed till the dura is fully exposed for at least 2 cm. behind the lateral sinus; explorations can then be made in the cerebellum in any direction to the depth of 3.5 cm. inside the lateral sinus. Another method of exposing the cerebellum, where the mastoid is so heavy or sclerosed as to make the above operation inadvisable, is to strike a basal line from the inferior osseous edge of the orbit to the occipital protuberance, and to open the skull on this line 5 to 7 cm. back from the edge of the osseous meatus, just below the superior curved line of the occipital bone.

Abscesses beyond reach from the ear can only be diagnosticated by a comp late complex of localizing symptoms; where such a diagnosis can be made, the skull must be opened over the seat of this abscess. To reach the upper or first temporal convolution, enter the skull 2 cm. back from a point 3 to 3.5 cm. above the upper edge of the osseous meatus; to get at frontal or occipital abscesses, open over their seat as determined by previous localizing symptoms; for them no rules can be given.

I would here utter a caution about the dangers of the trephine, at least on the squamous portion of the bone, which varies very much in thickness in different parts, and the trephine may easily enter the brain at one part of its circumference some time before. it has penetrated the bone in another part. In my opinion the only proper instruments are chisel and mallet, round burrs for thinning the inner cortex, and rongeurs to enlarge the first opening made.

Hesitation should always be felt in regard to opening the dura; it is justified only by the existence of a fistula in it or by urgent symptoms pointing to the encephalon, exclusive of arachnitis. Explorations can be carried to the dura with very little risk; it is a fibrous membrane Dot easily infected; but its incision exposes the arachnoid and pia, which are extremely sensitive to infection, and prolapse of the brain is very apt to follow withdrawal of the support afforded by the dura.

Where the ear cavities are not opened primarily, they must receive attention after the brain operation, or at a subsequent operation it should never be forgotten that they are the original cause of the brain disease.

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