Notwithstanding the principles just enun. edema, redness, auricular displacement, disciated, however, it must not be imagined that charge, and general febrile manifestations, purulent deposits may not burst their osse. may cause even un experienced observer to ous fetters in other directions, for fistulae hesitate somewbat before a positive diagno. may as a matter of fact, appear in almost any sis is made. A careful examination of the portion of the mastoid process. Such ne. parts, however, under full illumination will crotic openings may occur over the antrum, disclose the meatus and not the mastoid to into the external auditory meatus, through be the storm center of trouble, not forgetting the digastric groove, or in short thrcugh al- the fact, however, that a virulent middle most any portion of the mastoid cortex, to ear disobarge accompanied perbaps with say nothing of raptures through the inner mastoid involvement, may produce a meatal table of the bone into the brain cavity. furuncle, and complexity of conditions not Fistulae through the digastric groove of the easy to unravel. The character of the dis. temporal hone underneath the mastoid tip charge stould always be examined from sup. and called by courtesy Bezold's mastoiditis, purating ears, as it often plays an important is both an interesting and perplexing form of part in advice given to patients relative to the disease, and is caused by gravitation of the necessity for an operation, for, when the pus to the large tip mastoid cells and the presence, especially of the streptococcus, in bursting of the thin bone through the digas. the discharge is established, the probability trio fossa. Under these circumstances pus of an operation is at once very mucb magni. escapes into the cervical tissues, infection in fied. this treacherous territory takes place and ab. The mastoid patient can frequently he di. scess after abscess occurs by easy infectious agnosed immediately he enters the surgeon's dissection from one portion of the neck to the consulting room by his pained and anxious other, sometimes even extending to below the countenance and the care with wbich he car. claviole, or back as far as the vertebrae. ries his head stiffy to one side to avoid pull. While distinct objective and subjective febrile ing and straining on the soft tissues of the and inflammatory manifestations are usually head and neok. The pain may be slight in present while pus is confined within osseous , extent or extremely severe, involving not only barriers, it sometimes happens that as soon the mastoid area, but other portions of the as cortex fistulae oocur and pus becomes head and neck as well, and requiring heavy thereby liberated into the soft tissues, and and frequent potions of anodynes to relieve. the pressure is removed there will ocour & The bowels are usually constipated but may temporary lull in dangerous manifestations, be the reverse, and the appetite is poor or which will, of course, be regarded with entirely absent. The occurrence of cbills muob suspicion by the experienced observer, may usually be expected in mastoid ab. but which is sonetimes deplorably misunder. soesses ranging all the way from distinct stood by the unwary until large pus accumu. chilly sensations to pronounced rigors. lations and pus absorption produce symptoms This sypmtom is tolerably frequent in pure that are unmistakable in their gravity. mastoid empyema, almost invariably present

Unless Bezold's mastoiditis exists, a con. in sinus phlebitis and thrombosis and usu. dition which as a rule is not difficult to ally occurs about once in brain abscess. The diagnose, pain and tenderness at the mas temperature, pulse and respiration reflect the toid tip need not generally be regarded as presence of retained pus in the usual septio very important (although it should never be morning and evening wave, and being un. disregarded) as this is a frequent symptom in usually elevated wben meningitis ocours, simple acute purulent otorrhea and other non- spasmodically irregular upon the intervention complicated inflammatory conditions of the of phlebitis or tbrombosis, aud very likely tympanum and antrum, but pain and tender subnormal when actual brain abscess takes ness over the antrum or at the inner upper place. All these oonditions may with some portion of the bony meatus should always be rarity occur, however, in a single oase which regarded with grave suspicion, and when will produce a oomplex clinical pioture rethese symptoms are accompanied with redness quiring skill and experience to clarify, and and swelling at these areas, suspicion should which, indeed, may not be fully understood give place to immediate operative advice. until the patient is upon the operating-table

Although the warning may seem superflu. and the various pathological lesions are dis. ous, those who observe many mastoid pa. closed by the thorough opening of the mas. tients know that it is not impossible to mis- toid process, a procedure which fortunately take a mastoid abscess for a severe boil of is practically always primarily necessary in the meatus, which if located on the poster. cases of mastoid abscess sequelea. ior or upper meatal wall and presenting such It is a matter of common observation that symptoms as pain, swelling, sensitiveness, middle ear absoesses followed by mastoid abscesses ocour with frequency after such whether complications of a most serious na. diseases as influenza, measles, soarlet fever, ture are present, which may well call into typhoid fever, dipbtberia, pharyngitis, ton play the knowledge and experience of the exsillitis, eto., which should certainly teach the pert otologist. It seems reasonable to sug. family physician the necessity for the regu. gest, therefore, in a general way that no cne lar and frequent antiseptic cleansing of the should undertake what appears to be a simple nose and throat during the life of such dis. mastoid operation who is not fully prepared eases, as well as the strict admonition against by special study and clinical observation to the violent blowing of the nose during such proceed with the case, no matter what develmaladies, which unquestionably forces infec. ops after the operative field is fully exposed ; tion not only into the middle ear spaces but for, while the mere opening of the mastoid into the other accessory sinuses of the nose process can be easily accomplished, brain, as well. It should also teach them the ne. sinus, and other complications may develop in cessity for the prompt and thorough open the most unsuspected cases, necessitating the ing of middle ear abscesses in a proper man- exercise of a high order of surgical judgment ner in order that tympanio infeotions may be and skill to properly overcome. limited to this space, and not extend beyond The ocmplete sbaving of the skull and the into the mastoid antrum and cells. A long close-cropping of the beard and mustache, is and careful observation of mastoid diseases of course, one of the ideal preparatory prowill teach the lesson, that in spite of the usual cedures, but many modifications from this symptomatology present in such cases, ex. strenuous requirement will have to be obtensive necrosis and brain destruction may served, especially in female patients. The ocour with almost no symptoms whatever. bair should at all events be shaved for an Cases will sometimes present themselves com. area of from two to three inches backwards plaining merely of mastoid pain, or mastoid and upwards from the meatus, and the unout tenderness, or slight mastoid swelling, or un. hair thoroughly and antiseptically shampooed controllable aural discharge, unaccompanied and held out of the operative field as com. in each instance by other symptoms, where a pletely as possible. The long, infeoted, un. rather apologetio operation has revealed an manageable hair of a woman is a distinct extent of disease truly remarkable in its char menace, not only to proper operative proced. acter. These instances, however, are not of ures, but also to the sometimes protracted the usual type, and while not to be forgotten, period of dressings following the operative should never disbearten the surgeon in the act. The process of preparing the cutaneous vigilant search for mastoid abscesses. Neither operative field for surgical intervention is so should he be too quick to advise operative well understood that no space need be wasted procedures, for all surgeons oan remember in its description, but it should not be formore or less frequent instances wbere al gotten that the meatus should be thoroughly though unmistakable mastoid symptoms, cleansed by perhaps peroxide of hydrogen, such as middle ear absoess, mastoid pain, red. alcohol and warm bichloride irrigations, ness and swelling were present, the prompt and plugged with gauze before the primary and faithful use of suob remedies as rest in incision is made. bed, cathartics, diuretics, a thorough drum. The writer does not depend upon daylight head inoision, hot bichloride irrigations, for illumination, but invariably uses an elecetc., have been followed by a subsidence of trio headlight which furnishes the best and mastoid symptoms, and a cessation of the most intense light with which he is familiar. aural discharge. It may be said in this in. The operator should stand behind the pa. stance, that most experienced surgeons bave tient, at least until the chiselling is well discarded the use of the ice-coil over the under way, at wbich time many surgeons premastoid process in the belief that while it fer to stand or sit at the patient's side. He frequently mitigates urgent symptoms it, at should commence the incision at a point the same time unfortunately masks the true about one-quarter of an inoh below the masintra-mastoid condition.

toid tip, and extend it upwards about oneThe ordinary uncomplicated operation for quarter of an inch posterior to tbe lobe of the mastoid abscess is not a diffioult procedure, ear, making a slightly curved incision to con. nor one that need tax the skill of any good form with the general outline of the lobe, general or special surgeon. It must, how. care being taken not to cut off the cartilagin. ever, be remembered that not until tbe oper- ous meatus, which is not by any means an ation is well under way, and the interior of accident one can afford to forget. The inci. the mastoid process fully exposed for inspec. sion should be extended upwards and fortion can the operator determine whether the wards until it reaches a point directly over patbological lesions are simple in their na. the anterior extremity of the auricular ap. ture, and ourable by simple methods, or pendage. This incision is ample for all or.

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dinary emergenoies, and by ourving the inci. periosteotome may tear or cut the cartilagin. sion forward over the lobe into the squamous ous meatus, and produce an embarrassing region, a wide expansion of the flaps becomes complication, not only during the operation, subsequently possible. The straighter inci. but also in the subsequent healing of the sion of Whiting and others, with the second. case. After the periosteum has been thor. ary incision backwards for one inoh towards ougbly removed from the field of prospective the occipital protuberance, is excellent and operative interference, the flaps of the wound affords a wide field for operation, but the should be firmly and widely expanded by writer fails to see that it possesses any advan. retractors to afford the surgeon ample oppor. tage over the simplier method just described. tunity for observation and operation. The The writer makes the incision on the start as writer again desires to recommend the selfextensive as he expects it ever to be, realiz retaining retractors devised years ago by ing that it is sometimes larger than necessary. bimself as possessing useful qualities ren. This, however, signifies nothing, as a few dering them extremely desirable for retract. sutures will easily set matters to right, and it ing purposes. By being self-retaining, they is most embarrassing during the subsequent dispense with extra bands around the operasteps of the operation to be delayed by ex- tive area, and maintain a steady pressure on tending the incision, and annoyed by fresh the separated flaps. By expanding them to outbursts of hemorrbage. After the incision their utmost limit, and placing one pair in is completed to the bone, the periosteotome the upper angle of the wound and another is used to force back the soft tissues, care pair in the lower angle (except infants where being taken to preserve the periosteum as one pair is sufficient), they open a large and much as possible, as it is of infinite value ample operative field, and at same time con. in the subsequent bealing of the case, and trol all hemorrhage except that proceeding should by no means be ruthlessly torn and from the bone; indeed, the writer almost destroyed. It is always important that the never uses an artery forceps in this opera. soft tissues of the anterior flap should be tion, knowing that the moment the retractors reflected forward to such an extent as to en. are placed in position all flap bemorrbage able the operator to always keep in view the will cease. posterior and superior margins of the bony After the retractors are in position and the meatus, as their outlines afford to the sur parts wiped clean and dry, search should alyeon a sense of location that is invaluable. ways be made for softened bone areas or fisThe forcing back of the periosteum will be tulae, which will be frequently found in comparatively easy except in reoperative cases cases of acute mastoid abscess, especially in and over the roughened and uneven surface children where the cortex is tbin and soft. of the mastoid process proper, especially as Such perforations will most frequently be tbe tip is approached, upon which the mus. found over the antrum, which it must be recarlar tendons, eto., are attached. Over this membered in very young children is located area the periosteotome devised by the writer above and somewhat behind the roof of the is of no value, and the instrument of Buck osseous canal, gradually attaining its ordinary and Langenbeck should be used. Even these, position as time advances. Fistulae of the however, may not be entirely successful, as cortex may be frequently (especially in obild. then tendinous tissue is so firmly attached as ren) used as the initial point of entrance into to usually necessitate its removal by ourved the antrum or cells, which may be often thor. scissors. The use of the curved scissors or oughly exposed by the rongeur and ourette, other instruments for this purpose should be without the use of the chisel. In young tempered with caution, for it is not impossi. children this is doubtless the best method of ble to cut around the mastoid tip so vigor- procedure, as in infants the mere opening of ously as to injure the facial nerve which pre. the soft parts covering the mastoid, and the sents in this vicinity. Conservatism at this gentle scraping away of the necrosed bone point should also be observed and the cervi. over the antrum is frequently all that is nec. cal tissues not exposed unnecessarily, because essary or prudent to accomplish, although of the possibility of infection migrating from Pollak reports a case in a healthy child where the mastoid focus downwards into the cervi. A neglected ear resulted in the exfoliation of cal tissues. Thus, while the entire mastoid the entire temporal bone, with a recovery of cortex should be freed from soft tissue, and the patient. In adults, however, the mere made ready for subsequent removal by the persence of a fistula should not deter the oper. chisel, rongeur and curette; nevertheless, care ator from the object of bis surgery, wbioh is should be taken that needless and injurious to thoroughly expose the entire interior of procedures should not be performed. In this the mastoid bone, and to remove all patholo. connection it should be remembered that the gical products. Thus, while it is possible rough and careless manipulation of a sharp that the presence of a softened and necrosed

cortex may render the use of the chisels need. lected either between the bone and the soft less and undesirable, yet in a vast majority parts (subperiosteal abscess) or within the of cases it will be necessary to carefully re. mastoid shell (mastoid abscess) been drained move much of the mastoid cortex by the and mopped away and the entire field of oper. chisel and mallet.

ation thoroughly cleaned and irrigated, the To do this properly and safely, the sur softened bone and possible granulation tissue geon should always remember to keep the should be carefully removed with the ourette, cutting edge of the chisel well under obser- being cautious not to injure an exposed sinus. vation, bearing in mind the possibility of in- Whiting and others have called attention to jury to anseen structures, and especially to the information derivable from the conduot the sigmoid bend of the lateral sinus, par. of primary escaping pus from a matsoid cavtioularly if a malposition of that elusive ity. For instance, if it oozes out slowly it vein happens to be present. In chiseling indicates limited pathological changes; away the mastoid cortex, tbe chisel should should large quantities without pulsation esbe first placed with its outting edge on the cape, it indicates extensive pathological bone, just back of the posterior margin, and changes, but inact internal mastcid walls; below the superior margin of the meatus, should large quantities escape with pulsation, at about the position of the meatal spine. extensive pathological changes, with destrucThe chisel should not be held upright or tion of the inner table of tbe skull and at even nearly upright, but at an angle of about least epidural abscess is indicated. These 30 or 45 degrees from the head, so that a observations are certainly in accordance with mere shaving of bone is peeled off at each the views of any surgeon with extensive blow of the hammer. Thin strips of cortex mastoid experience. should thus be gradually chipped away with. After the softened bone and granulation out allowing the ohisel to plunge into the tissue have been cautiously removed, the mastoid interior, until the bony casing is re- field of operation should again be irrigated, moved and the cells thoroughly exposed, re. and dried, when the intericr of the mastoid membering that is best to proceed slowly shell is ready for careful inspection. Perhaps when the bone is found compact in character, the first thing to be done now is to find and as in such cases there is apt to be a forward cleanse the antrum, which sbould not be diffidisplacement of the sinus. The opening cult of accomplishment after the cortex, sof. thus accomplished should extend from the tened bony partitions, pus and granulation upper portion of the mastoid, on a line with tissue have been removed, although Politzer the superior margin of the bony meats, to does not favor opening the antrum in acute the mastoid apex, and from the posterior mastoid abscess unless distinct indications margin of the meats to the osseous covering for such a procedure exist. Under the list of of the sigmoid sinus, and should be at this, such indications he classes necrosis of the its widest, portion about one inch, or perhap. bony wall separating the antrum from the abthree-quarters of an inch, in breadtb.

scess, or evident antrum granulations, or In the opinion of the writer, the mastoid signs of meningeal irritation. In such views, antrum sbould not be searched for until the however, he stands nearly alone, as some oper. cortex of the bone has been thus removed, ators feel that the trouble began in the midwhen it can usually be found with much dle ear, and proceeded to the antrum and greater ease and safety than if burrowed for cells, and that this space sbould be cleaned as the initial step of the bone operation, and drained. The position of the antrum After an anple opening in the cortex hae will usually be clearly seen, but if not, a been effected with the chisel, the writer be. search should be instituted in the extreme lieves that the remainder of this portion of upper and anterior angle of the bony openthe operation can frequently be best accom. ing, just back of the superior and posterior plished with the careful use of the ronguer; angle of the osseous meatus. If the chisel indeed, he is convinced that the ronguer is, and curette be carefully used at this point, where it can be used, a much safer and more proceeding inward, forward and a little upefficient instrument than the obisel, and ward, and keeping olose to the superior posshould be used wherever possible, care be terior wall of the meatus, to a depth of about ing taken when removing the shell at the five-eighths of an inob, the antrum will be mastoid tip not to forcibly and ruthlessly pull almost invariably found, bearing in mind and tear from their beds the attached fibers that in children this cell is very near the of the tendons and fasciae of the neck, thus mastoid cortex, and that, indeed, in infants, inviting cervical inflammation. Such tissue a single blow of the chisel and mallet will enshould be carefully cut.

able the surgeon to view its interior. The After the mastoid cortex bas been thus re. antrum should be cautiuosly but thoroughly moved, and any pus whioh may have col. cleansed and ouretted, and its mastoid open

ing enlarged to admit of good drainage, but and the perisinus abscess, etc., just described. it is not usually wise to carry our investiga- It is, of course, possible that the removal of tions into the tympanio cavity or tbe aditus granulations may disclose a perforation of ad antrum. In curetting, or obiselling in the dural covering of the sinus, and more or the antrum aditus or upper portion of the less profuse hemorrhage be produced, in mastoid shell, it should never be forgotten which case cleansing of the sinus may be inthat the roof is thin and that the brain inay dicated, or a phlebitis or thrombosis may be be easily exposed, and the same warning present which will require a still more radi . should be remembered in working in the cal sinus operation. In case it become nec. neighborhood of the facial nerve, semi-circu. essary from any cause to remove the osseous lar canals and sigmoid sinus. The mistake

The mistake covering of the sinus, the latter will then be is frequently made of forcibly probing the laid bare for close and careful examination. ipiddle ear and the forcing of "through and The sinus in its natural condition is bluisbthrough” irrigation between the mastoid cav. white in color, easily compressible with the ity and meatus, both of which procedures finger or probe, sometimes pulseless, and are not only unnecessary but often barmful. sometimes pulsating from contact with con. The writer does not beileve that even investi. tiguous brain tissue. The different appear. gation of the tegmen tympani should be per ances of the sinus in health and disease and mitted by probing in acute mastoid abscess, the operations for the relief of its patbulogi. unless brain symptoms are evident, as dislo cal conditions are so varying and extensive cation of the ossicles, and interference with that they may not appropriately be dwelt the function of audition, etc., may easily be upon in a communication of this character, produced by even a careful surgeon.

and will, therefore, be allowed to pass withThe antrum having now been exposed and out further remarks. It occasionally hapcuretted, the entire inner mastoid plate should pens that the soft sinus wall will be acci. be minutely examined by a probe for the de. dentally perforated in the course of an operatection of necrotic softenings and perfora- tion by an instrument, or tions. Suoh pathological conditions are This acoident will be evidenced by a sudden most likely to be found over the sigmoid gush of venous bloud, #bich sometimes prebend or knee of the lateral sinus, through sents a truly appalling appearance. But little the tegmen tympani or tegmen antri, through anxiety need be felt, bowever, unless infecthe apex cell into the diagastric fussa, and tion bas been carried into the sinus interior, sometimes through the posterior wall of the as the hemorrhage can be easily stopped by external meatus of the ear. Should such firm pressure with an iodoform gauze pad, conditions be found in the osseous covering care being taken first, however, to remove of the sinus, the bony shell and granulation from the site of injury any bone splinter that tissue should be gently removed by curette, may have produced the trauma. At the operelevator or small ronguer, being careful to ation and in the first and subsequent dress. remove all unhealthy bone, and to obtain a ings of the case the sinus wound sbould be comprehensive view of the dural covering of kept as much separated from the other porthe soft sinus, which may, of course, be tions of the wound as possible by separate found in a normal or abnormal position, packings, to avoid infection, and this precauPus may be found between the dural and tion should also be observed where other osseous coverings of the sinus, constituting portions of the dura or brain tissue bave been what is called a perisinus abscess. This exposed. should be thoroughly evacuated and the bone Softened and carious areas of bone may removed as far as the pus extends, in order be found in either the roof or tegmen of the to obtain absolutely free drainage. In a case tympanum or antrum, and should be carefully recently operated by the writer the soft sinus removed in the same manner as suggested as separated from the bony sulcus almost as for similar conditions over the sinus, the far back as the torcular herophili, the space mistake never being made of merely securing being profusely occupied by granulations and an opening or vent through the bone; all of pus, which were thoroughly removed by the the carious bone should be removed and even curette. There was no intra-sinus disease, some of the healthy bone, if this proves nec. and the sinus was not opened. This was

esasry to thoroughly inspect and explore the case of streptococcus infection following in condition of the underlying dural or brain Auenza. The discharge was unceasingly tissue. Of course, this should be acoomabundant and bad existed for seven weeks. plished with much circumspection and under There was pain over the antrum, digastric intense illumination, gradually picking off fossa and inastoid rein, and no other symp- piece by piece, principally with a small ron. toms. The operation revealed most destruc geur, until a satisfactory view of the parts tive osseous changes, Bezold's mastoiditis, is obtained.

is obtained. An epidural abscess will some


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