Notwithstanding the principles just enunciated, however, it must not be imagined that purulent deposits may not burst their osseous fetters in other directions, for fistulae may as a matter of fact, appear in almost any portion of the mastoid process. Such necrotic openings may occur over the antrum, into the external auditory meatus, through the digastric groove, or in short through almost any portion of the mastoid cortex, to say nothing of ruptures through the inner table of the bone into the brain cavity. Fistulae through the digastric groove of the temporal bone underneath the mastoid tip and called by courtesy Bezold's mastoiditis, is both an interesting and perplexing form of the disease, and is caused by gravitation of pus to the large tip mastoid cells and the bursting of the thin bone through the digastric fossa. Under these circumstances pus escapes into the cervical tissues, infection in this treacherous territory takes place and ab. scess after abscess occurs by easy infectious dissection from one portion of the neck to the other, sometimes even extending to below the clavicle, or back as far as the vertebrae. While distinct objective and subjective febrile and inflammatory manifestations are usually present while pus is confined within osseous, barriers, it sometimes happens that as soon as cortex fistulae occur and pus becomes thereby liberated into the soft tissues, and the pressure is removed there will occur a temporary lull in dangerous manifestations, which will, of course, be regarded with much suspicion by the experienced observer, but which is sometimes deplorably misunderstood by the unwary until large pus accumulations and pus absorption produce symptoms that are unmistakable in their gravity.

Unless Bezold's mastoiditis exists, a condition which as a rule is not difficult to diagnose, pain and tenderness at the mastoid tip need not generally be regarded as very important (although it should never be disregarded) as this is a frequent symptom in simple acute purulent otorrhea and other noncomplicated inflammatory conditions of the tympanum and antrum, but pain and tenderness over the antrum or at the inner upper portion of the bony meatus should always be regarded with grave suspicion, and when these symptoms are accompanied with redness and swelling at these areas, suspicion should give place to immediate operative advice.

Although the warning may seem superfluous, those who observe many mastoid patients know that it is not impossible to mistake a mastoid abscess for a severe boil of the meatus, which if located on the posterior or upper meatal wall and presenting such symptoms as pain, swelling, sensitiveness,

edema, redness, auricular displacement, discharge, and general febrile manifestations, may cause even an experienced observer to hesitate somewhat before a positive diagnosis is made. A careful examination of the parts, however, under full illumination will disclose the meatus and not the mastoid to be the storm center of trouble, not forgetting the fact, however, that a virulent middle ear discharge accompanied perhaps with mastoid involvement, may produce a meatal furuncle, and complexity of conditions not easy to unravel.

The character of the discharge should always be examined from suppurating ears, as it often plays an important part in advice given to patients relative to the necessity for an operation, for, when the presence, especially of the streptococcus, in the discharge is established, the probability of an operation is at once very much magnified.

The mastoid patient can frequently be diagnosed immediately he enters the surgeon's consulting room by his pained and anxious countenance and the care with which he carries his head stiffly to one side to avoid pulling and straining on the soft tissues of the head and neck. The pain may be slight in extent or extremely severe, involving not only the mastoid area, but other portions of the head and neck as well, and requiring heavy and frequent potions of anodynes to relieve. The bowels are usually constipated but may be the reverse, and the appetite is poor or entirely absent. The occurrence of chills may usually be expected in mastoid abscesses ranging all the way from distinct chilly sensations to pronounced rigors. This sypmtom is tolerably frequent in pure mastoid empyema, almost invariably present in sinus phlebitis and thrombosis and usually occurs about once in brain abscess. The temperature, pulse and respiration reflect the presence of retained pus in the usual septic morning and evening wave, and being unusually elevated when meningitis ocours, spasmodically irregular upon the intervention of phlebitis or thrombosis, and very likely subnormal when actual brain abscess takes place. All these conditions may with some rarity occur, however, in a single case which will produce a complex clinical picture requiring skill and experience to clarify, and which, indeed, may not be fully understood until the patient is upon the operating-table and the various pathological lesions are disclosed by the thorough opening of the mastoid process, a procedure which fortunately is practically always primarily necessary in cases of mastoid abscess sequelea.

It is a matter of common observation that middle ear abscesses followed by mastoid

abscesses occur with frequency after such diseases as influenza, measles, scarlet fever, typhoid fever, diphtheria, pharyngitis, tonsillitis, etc., which should certainly teach the family physician the necessity for the regular and frequent antiseptic cleansing of the nose and throat during the life of such diseases, as well as the strict admonition against the violent blowing of the nose during such maladies, which unquestionably forces infection not only into the middle ear spaces but into the other accessory sinuses of the nose as well. It should also teach them the necessity for the prompt and thorough opening of middle ear abscesses in a proper manner in order that tympanic infections may be limited to this space, and not extend beyond into the mastoid antrum and cells. A long and careful observation of mastoid diseases will teach the lesson, that in spite of the usual symptomatology present in such cases, extensive necrosis and brain destruction may occur with almost no symptoms whatever. Cases will sometimes present themselves complaining merely of mastoid pain, or mastoid tenderness, or slight mastoid swelling, or uncontrollable aural discharge, unaccompanied in each instance by other symptoms, where a rather apologetic operation has revealed an extent of disease truly remarkable in its character. These instances, however, are not of the usual type, and while not to be forgotten, should never dishearten the surgeon in the vigilant search for mastoid abscesses. Neither should he be too quick to advise operative procedures, for all surgeons can remember more or less frequent instances where although unmistakable mastoid symptoms, such as middle ear abscess, mastoid pain, redness and swelling were present, the prompt and faithful use of such remedies as rest in bed, cathartics, diuretics, a thorough drumhead incision, hot bichloride irrigations, etc., have been followed by a subsidence of mastoid symptoms, and a cessation of the aural discharge. It may be said in this instance, that most experienced surgeons have discarded the use of the ice-coil over the mastoid process in the belief that while it frequently mitigates urgent symptoms it, at the same time unfortunately masks the true intra-mastoid condition.

The ordinary uncomplicated operation for mastoid abscess is not a difficult procedure, nor one that need tax the skill of any good general or special surgeon. It must, however, be remembered that not until the operation is well under way, and the interior of the mastoid process fully exposed for inspection can the operator determine whether the pathological lesions are simple in their nature, and ourable by simple methods, or

whether complications of a most serious nature are present, which may well call into play the knowledge and experience of the expert otologist. It seems reasonable to suggest, therefore, in a general way that no cne should undertake what appears to be a simple mastoid operation who is not fully prepared by special study and clinical observation to proceed with the case, no matter what develops after the operative field is fully exposed; for, while the mere opening of the mastoid process can be easily accomplished, brain, sinus, and other complications may develop in the most unsuspected cases, necessitating the exercise of a high order of surgical judgment and skill to properly overcome.

The complete shaving of the skull and the close-cropping of the beard and mustache, is of course, one of the ideal preparatory procedures, but many modifications from this strenuous requirement will have to be observed, especially in female patients. The hair should at all events be shaved for an area of from two to three inches backwards and upwards from the meatus, and the uncut hair thoroughly and antiseptically shampooed and held out of the operative field as completely as possible. The long, infected, unmanageable hair of a woman is a distinct menace, not only to proper operative procedures, but also to the sometimes protracted period of dressings following the operative act. The process of preparing the cutaneous operative field for surgical intervention is so well understood that no space need be wasted in its description, but it should not be forgotten that the meatus should be thoroughly cleansed by perhaps peroxide of hydrogen, alcohol and warm bichloride irrigations, and plugged with gauze before the primary incision is made.

The writer does not depend upon daylight for illumination, but invariably uses an electric headlight which furnishes the best and most intense light with which he is familiar.

He

The operator should stand behind the patient, at least until the chiselling is well under way, at which time many surgeons prefer to stand or sit at the patient's side. should commence the incision at a point about one-quarter of an inch below the mastoid tip, and extend it upwards about onequarter of an inch posterior to the lobe of the ear, making a slightly curved incision to conform with the general outline of the lobe, care being taken not to cut off the cartilaginous meatus, which is not by any means an accident one can afford to forget. The inci

sion should be extended upwards and forwards until it reaches a point directly over the anterior extremity of the auricular appendage. This incision is ample for all or

dinary emergencies, and by curving the incision forward over the lobe into the squamous region, a wide expansion of the flaps becomes subsequently possible. The straighter incision of Whiting and others, with the secondary incision backwards for one inch towards the occipital protuberance, is excellent and affords a wide field for operation, but the writer fails to see that it possesses any advantage over the simplier method just described. The writer makes the incision on the start as extensive as he expects it ever to be, realizing that it is sometimes larger than necessary. This, however, signifies nothing, as a few sutures will easily set matters to right, and it is most embarrassing during the subsequent steps of the operation to be delayed by extending the incision, and annoyed by fresh outbursts of hemorrhage. After the incision is completed to the bone, the periosteotome is used to force back the soft tissues, care being taken to preserve the periosteum as much as possible, as it is of infinite value in the subsequent healing of the case, and should by no means be ruthlessly torn and destroyed. It is always important that the soft tissues of the anterior flap should be reflected forward to such an extent as to enable the operator to always keep in view the posterior and superior margins of the bony meatus, as their outlines afford to the surgeon a sense of location that is invaluable. The forcing back of the periosteum will be comparatively easy except in reoperative cases and over the roughened and uneven surface of the mastoid process proper, especially as the tip is approached, upon which the mus. cular tendons, etc., are attached. Over this area the periosteotome devised by the writer is of no value, and the instrument of Buck and Langenbeck should be used. Even these, however, may not be entirely successful, as then tendinous tissue is so firmly attached as to usually necessitate its removal by ourved scissors. The use of the curved scissors or other instruments for this purpose should be tempered with caution, for it is not impossible to cut around the mastoid tip so vigorously as to injure the facial nerve which presents in this vicinity. Conservatism at this point should also be observed and the cervical tissues not exposed unnecessarily, because of the possibility of infection migrating from the mastoid focus downwards into the cervical tissues. Thus, while the entire mastoid cortex should be freed from soft tissue, and made ready for subsequent removal by the chisel, rongeur and curette; nevertheless, care should be taken that needless and injurious procedures should not be performed. In this connection it should be remembered that the rough and careless manipulation of a sharp

periosteotome may tear or cut the cartilaginous meatus, and produce an embarrassing complication, not only during the operation, but also in the subsequent healing of the case. After the periosteum has been thoroughly removed from the field of prospective operative interference, the flaps of the wound should be firmly and widely expanded by retractors to afford the surgeon ample opportunity for observation and operation. The writer again desires to recommend the selfretaining retractors devised years ago by himself as possessing useful qualities rendering them extremely desirable for retracting purposes. By being self-retaining, they dispense with extra hands around the operative area, and maintain a steady pressure on the separated flaps. By expanding them to their utmost limit, and placing one pair in the upper angle of the wound and another pair in the lower angle (except infants where one pair is sufficient), they open a large and ample operative field, and at same time control all hemorrhage except that proceeding from the bone; indeed, the writer almost never uses an artery forceps in this operation, knowing that the moment the retractors are placed in position all flap hemorrhage will cease.

After the retractors are in position and the parts wiped clean and dry, search should always be made for softened bone areas or fistulae, which will be frequently found in cases of acute mastoid abscess, especially in children where the cortex is thin and soft. Such perforations will most frequently be found over the antrum, which it must be remembered in very young children is located above and somewhat behind the roof of the osseous canal, gradually attaining its ordinary position as time advances. Fistulae of the cortex may be frequently (especially in children) used as the initial point of entrance into the antrum or cells, which may be often thoroughly exposed by the rongeur and curette, without the use of the chisel. In young children this is doubtless the best method of procedure, as in infants the mere opening of the soft parts covering the mastoid, and the gentle scraping away of the necrosed bone over the antrum is frequently all that is necessary or prudent to accomplish, although Pollak reports a case in a healthy child where. a neglected ear resulted in the exfoliation of the entire temporal bone, with a recovery of the patient. In adults, however, the mere persence of a fistula should not deter the operator from the object of his surgery, which is to thoroughly expose the entire interior of the mastoid bone, and to remove all pathological products. Thus, while it is possible that the presence of a softened and necrosed

cortex may render the use of the chisels needless and undesirable, yet in a vast majority of cases it will be necessary to carefully remove much of the mastoid cortex by the chisel and mallet.

To do this properly and safely, the surgeon should always remember to keep the cutting edge of the chisel well under observation, bearing in mind the possibility of injury to unseen structures, and especially to the sigmoid bend of the lateral sinus, particularly if a malposition of that elusive vein happens to be present. In chiseling away the mastoid cortex, the chisel should be first placed with its cutting edge on the bone, just back of the posterior margin, and below the superior margin of the meatus, at about the position of the meatal spine. The chisel should not be held upright or even nearly upright, but at an angle of about 30 or 45 degrees from the head, so that a mere shaving of bone is peeled off at each blow of the hammer. Thin strips of cortex should thus be gradually chipped away without allowing the chisel to plunge into the mastoid interior, until the bony casing is removed and the cells thoroughly exposed, remembering that is best to proceed slowly when the bone is found compact in character, as in such cases there is apt to be a forward displacement of the sinus. The opening thus accomplished should extend from the upper portion of the mastoid, on a line with the superior margin of the bony meats, to the mastoid apex, and from the posterior margin of the meats to the osseous covering of the sigmoid sinus, and should be at this, its widest, portion about one inch, or perhap three-quarters of an inch, in breadth.

In the opinion of the writer, the mastoid antrum should not be searched for until the cortex of the bone has been thus removed, when it can usually be found with much greater ease and safety than if burrowed for as the initial step of the bone operation. After an ample opening in the cortex has been effected with the chisel, the writer believes that the remainder of this portion of the operation can frequently be best accomplished with the careful use of the ronguer; indeed, he is convinced that the ronguer is, where it can be used, a much safer and more efficient instrument than the chisel, and should be used wherever possible, care be ing taken when removing the shell at the mastoid tip not to forcibly and ruthlessly pull and tear from their beds the attached fibers of the tendons and fasciae of the neck, thus inviting cervical inflammation. Such tissue should be carefully cut.

After the mastoid cortex has been thus removed, and any pus which may have col

lected either between the bone and the soft parts (subperiosteal abscess) or within the mast oid shell (mastoid abscess) been drained and mopped away and the entire field of operation thoroughly cleaned and irrigated, the softened bone and possible granulation tissue should be carefully removed with the curette, being cautious not to injure an exposed sinus. Whiting and others have called attention to the information derivable from the conduct of primary escaping pus from a matsoid cavity. For instance, if it oozes out slowly it indicates limited pathological changes; should large quantities without pulsation escape, it indicates extensive pathological changes, but inact internal mastcid walls; should large quantities escape with pulsation, extensive pathological changes, with destruction of the inner table of the skull and at least epidural abscess is indicated. These observations are certainly in accordance with the views of any surgeon with extensive mastoid experience.

After the softened bone and granulation tissue have been cautiously removed, the field of operation should again be irrigated, and dried, when the intericr of the mastoid shell is ready for careful inspection. Perhaps the first thing to be done now is to find and cleanse the antrum, which should not be difficult of accomplishment after the cortex, softened bony partitions, pus and granulation tissue have been removed, although Politzer does not favor opening the antrum in acute mastoid abscess unless distinct indications for such a procedure exist. Under the list of such indications he classes necrosis of the bony wall separating the antrum from the abscess, or evident antrum granulations, or signs of meningeal irritation. In such views, however, he stands nearly alone, as some operators feel that the trouble began in the middle ear, and proceeded to the antrum and cells, and that this space should be cleaned and drained. The position of the antrum will usually be clearly seen, but if not, a search should be instituted in the extreme upper and anterior angle of the bony opening, just back of the superior and posterior angle of the osseous meatus. If the chisel and curette be carefully used at this point, proceeding inward, forward and a little upward, and keeping close to the superior posterior wall of the meatus, to a depth of about five-eighths of an inch, the antrum will be almost invariably found, bearing in mind that in children this cell is very near the mastoid cortex, and that, indeed, in infants, a single blow of the chisel and mallet will enable the surgeon to view its interior. The antrum should be cautiuosly but thoroughly cleansed and curetted, and its mastoid open