THE TREATMENT OF ACUTE INFLAMMATION OF THE MIDDLE EAR AND MAS- TOID. BY EDWARD BRADFORD DENCH, M.D., Professor of Otology, Bellevue Hospital Medical College Aural Surgeon, New York Eye and Ear Infirmary, etc. REPRINT FROM American Medico=SurgicaI Bulletin, November 15, 1895. TO CONTRIBUTORS. Contributions of Original Thought and Experiences, on Medical and Surgical Topics, are desired by the AMERICAN MEDICO-SURGICAL BULLETIN on the following conditions: 1.-Authors of Scientific Papers or Clinical Reports accepted by us will receive-according to their own preference expressed with each communication either: a:-A number of Reprints of their article in neat pamphlet form (pocket size); or, b :-Instead of the above, an Equivalent value therefor in Cash. 2.-All contributions are received only on the express understanding: a:-That they have not been printed anywhere, nor communicated to any other journal. b:-That, if they have been read anywhere to an audience, this fact be stated in full detail by a note on the manuscript. Contributors will serve their own interest by heeding the following suggestions What we desire to print, and what professional men like to read, is information, not verbiage. An article will stand better chances of acceptance, and of being widely read and copied and discussed, the fewer its words are, in proportion to the facts or ideas it embodies. Of course, a thought too thinly clad must suffer. Use, therefore cheerfully, as many words as appear needed to convey your meaning,-but no more. Write Concisely and Clearly. Aim at Fact. it is not to be expected that every Medical or Surgical paper should be a mere array of statistical data, hospital records, tabulated figures, or graphic summaries; some room must be allowed to theory, or even conjecture, in its proper place; but the true aim of theory should never be left out of sight,-which is, to lead to fact; to a rule or result of practice.-And it should be likewise borne in mind that the Reader will attach little weight to mere generalizing statements (such as, that a certain rem- edy, procedure, or line of treatment has uniformly proved successful, etc.);-to be convinced, he wants to see positive evidences recorded in clinical detail of cases: con- ditions found, courses pursued, and results achieved. Do Not Fear, nowever, that a communication you may be inclined to make would be devoid or value because you have but little time to spend on writing it! If your thought be a good one to yourself and for your patients' benefit, it will be equally so to your colleagues and their practice, and will be worth communicating. It need not come in the garb of an elaborate Scientific treatise; a simple "Letter to the Editor " will often be just as acceptable. Some Rules of Order we should l!ke to have our esteemed Contributors comply with Do not write on both sides of the sheet. Write as legibly as you conveniently can (names especially so). Leave a liberal margin on the sheet, or space between the lines. ( dost writing is not conducive to correct typography; and what you save in writing material has to be expended a thousand-fold by us in eyesight labor, and expense for printer's corrections.) Address :-P 0. Box, 2535 New York citv Editor American Medico-Surgical Bulletin. THE TREATMENT OF ACUTE INFLAMMATION OF THE MIDDLE EAR AND MASTOID.* EDWARD BRADFORD DENCH, M.D., Professor of Otology, Bellevue Hospital Medical College ; Aural Surgeon, New York Eye and Ear Infirmary, etc. WHILE this paper, from its title, should deal only with the treat- ment of certain morbid condi- tions of the ear and of the adjoin- ing pneumatic spaces, the author begs the liberty of calling attention to a few facts re- garding the anatomy of the parts involved, as jvell as to the nature of the pathological processes which demand treatment. The reason for this digression from the subject assigned is that the measures to be insti- tuted for the relief of an inflammatory pro- cess in the middle ear or mastoid depend both upon the anatomical features of the parts affected and upon the nature of the morbid condition. By a horizontal line passing through the short process of the malleus, we may divide the middle ear into two parts: the upper segment, containing the body of the incus and malleus, the interossicular ligaments and numerous bands of connective tissue passing from the ossicles to the tympanic walls we may call the tympanic vault. The other portion below this horizontal line *Read before the Mississippi Valley Medical Association, at Detroit, September 5, 1895. 1 constitutes a true cavity, lined with mu- cous membrane, and is termed the atrium. The upper division of the middle ear or the tympanic vault communicates posteriorly with a pneumatic space, varying somewhat in size, the mastoid antrum, and through this, indirectly, with numerous other air spaces, which vary in size and number in individual cases. The lower portion of the middle ear (the atrium) is continuous an- teriorly with the pharyngeal vault, through the eustachian tube. The tympanic vault differs, therefore, from the atrium, in that it contains certain bony and ligamentous structures, which, with bands and reduplications of the mucous lining, fill it more or less completely, while the atrium is a free cavity, its mucous lining being closely applied to the walls. These two portions of the middle ear usually com- municate with each other, but occasionally they are entirely separated. The atrium is separated from the meatus by the mem- brana vibrans, a septum of connective tis- sue of special structure, which is inserted along the periphery into a groove in the tympanic ring; while the outer wall of the vault is formed above by the superior wall of the bony meatus, and below by the cuta- neous covering of the superior wall passing downward, and becoming continuous with the membrana tympani. The portion of the drum membrane then, lying above the short process of the malleus, or the mem- brana flaccida, is really a portion of the tegumentary lining of the bony meatus, and differs essentially in structure from the glis- 2 tening, pearly-white septum which forms the outer wall of the atrium. It should also be borne in mind that the membrana flaccida is richly supplied with blood-vessels. Here the anastomosis be- tween the vessels of the tympanum and of the meatus is particularly free. These anas- tomotic vessels encircle the entire drum membrane, forming a vascular plexus along the entire periphery, but the branches are larger and more numerous in the region of the membrana flaccida. Turning our attention now to the structural changes which must follow an inflammatory process in these two portions of the middle ear, it will at once be evident that any inflammation within the atrium will be characterized by changes which are common to a similar condition in any cavity lined with mucous membrane. We should expect serous effusion, and an increase in the normal secretion of the glandular structures, but nothing more. The tenuity of the lining of the cavity al- lows the engorged vessels to relieve them- selves by serous transudation, and tissue ne- crosis is not a prominent feature of the pro- cess. If the cavity becomes overdistended a localized necrosis may take place in the fibrous outer wall, constituting a perfora- tion of the membrana vibrans, but such a perforation is of small size, and heals quickly as soon as the pressure within the tympa- num is relieved by the exit of the contained fluid. When, now, the upper portion of the cavity or the tympanic vault is the region involved, the vascular engorgement cannot 3 be relieved by the transudation of serum, on account of the anatomical structure of the parts. This portion of the middle ear is, even in a normal condition, nearly filled by the ossicles and by reduplications of the lining membrane. When the blood-vessels in this region become engorged, the tissues quickly became edematous from serous transudation into their substance, and fill the vault completely; very soon this swell- ing is sufficient to completely shut off the upper portion of the cavity from the lower, and relief by drainage in this direction is impossible. Under such circumstances ex- tensive tissue necrosis occurs quickly. The result of this necrosis is the formation of pus, as occurs whenever there is extensive tissue necrosis in arty other portion of the body. The purulent fluid displaces the outer wall of the tympanic vault outward- that is, it causes a bulging of the membra- na flaccida, and frequently burrows along the superior wall of the meatus separating the tegumentary lining from the bony wall, and reducing the vertical diameter of the fundus of the canal, as viewed through the speculum. If perforation occurs, the open- ing is usually through the membrana flac- cida. Occasionally the purulent fluid drains into the atrium along the long pro- cess of the incus, and then the opening lies in the membrana vibrans. It appears, therefore, that an inflamma- tion of the middle ear will be catarrhal or purulent, according as the lower or upper portion of the cavity is attacked. Why in one instance an inflammatory process should be limited to the lower portion of the middle 4 ear, and in another should attack the con- nective tissue located in the tympanic vault, may at first seem difficult to explain. It is probable that the degree of virulence of the infection causing the inflammation is the chief factor in determining the particular portion of the tympanum which will be in- volved. Clinical evidence seems to bear out this view, from the fact that in the acute infectious diseases a complicating inflam- mation of the middle ear is usually catarrhal or purulent, according as the systemic toxe- mia is mild or severe. Another factor of importance which is not to be overlooked is the condition of the naso-pharynx and nasal cavities. If the pharyngeal vault is filled with adenoid vegetations, or if nasal stenosis has existed for a long time, the circulation within the middle ear can hardly be normal, and a cause which, with normal anatomical conditions, would have been either insufficient to cause more than a slight congestion of the middle ear, or, at the most, a mild catarrhal otitis, may result in a severe purulent inflammation. So much for the conditions of the middle ear which we are to treat. In the inception of middle-ear inflammation, the indica- tions are to relieve pain and to abort the inflammatory process; in the later stages the pain is not prominent, and we devote our efforts both to the prevention of local and general infection and to the repair of the damage already wrought by the disease. If seen, then, during the first few hours of the attack, the patient should be put to bed. We should attempt to deplete the vessels within the tympanum by ab- 5 stracting blood from the immediate vi- cinity of the external ear. The region immediately in front of the tragus is usually chosen as the site of the operation. From i to 2 oz. of blood should be with- drawn, either by the wet cup or by natu- ral leeches-preferably the former. The abstraction of blood usually affords at least temporary relief from the pain, but at the same time is particularly indi- cated as a means of aborting the in- flammatory process. Still further re- lief to the pain may be obtained by the application of dry heat over the ear. This may be done by means of the ordinary hot-water bag, which should be covered with several thicknesses of flannel and made to serve as a pillow, upon which the patient rests the affected ear while lying down. Under no circumstances should any oleaginous material be introduced into the meatus. Even irrigation with warm water is contra-indicated in the early stages. The objection to irrigation is that moist heat tends to soften the tissues! and promotes their dis- integration; in other words, it hastens the progress of the condition which the treat- ment is intended to abort. Dry heat is not open to this objection, and is. fully as serv- iceable in relieving' the pain as is moist heat. At this early stage a full dose of morphine or of one of the preparations of opium should be administered. This not only re- lieves the pain, but, by insuring perfect rest for a few hours, renders the measures insti- tuted to abort the inflammation much more efficacious. 6 It is to be understood that these meas- ures are to be employed in the very early stages only, and are not to be repeated in case the pain returns. A return or per- sistence of the pain is an indication that the inflammatory process is still progressing, and under no consideration should it be re- lieved by the internal administration of drugs. The administration of a single dose of morphine very early in the attack is of value as insuring more complete rest, and thus contributing to the success of the measures taken to cut short the inflamma- tion. Aside from this single dose, how- ever, the use of opium in any form is to be condemned. These measures, instituted early, will prevent the further progress of many of the milder cases of acute catarrhal otitis- that is, of those cases confined to the lower portion of the tympanic cavity, and al- though much less certain to be successful in the more severe form which involves the tympanic vault, should nevertheless be used before resorting to more radical meas- ures. I am inclined to emphasize this advice for the reason that an eminent otologist has recently declared that local blood-letting is entirely useless, as the inflammatory pro- cess is due to the presence of pathogenic bac- teria within the tympanum, and that these are not removed by leeching or any kindred measure. It would be difficult to find a more absurd statement. It is hardly necessary to add that the value of depletion depends upon the fact that by correcting the venous stasis the tissues are enabled to 7 resist the action of infectious germs more completely. Unfortunately, many cases are not seen sufficiently early to enable the attack to be aborted by treatment. If an inflammation of the acute catarrhal variety proceeds unchecked, the middle ear is gradually filled with sero-mucus, which forces the drum membrane outward and threatens the integrity of this septum unless the tension is relieved. The indication, then, is to relieve the tension due to the effu- sion before the pressure is sufficient to cause rupture of the drum membrane. I do not mean that the presence of a small amount of fluid in the tympanum is an indication for surgical interference. If the inflammatory process has ceased, as evidenced by the ab- sence of pain, and the tension is not exces- sive-in other words, if the membrana vi- brans is not bulging-we may hope to cause an absorption of the effusion by the use of the catheter, or, in children, by inflation with the Politzer bag, and thus effect a cure with- out surgical interference. If, however, the atrium is full of fluid, as evidenced by bulging of the posterior seg- ment of the drum membrane, it is never wise to await spontaneous rupture, nor should we attempt to hasten the spon- taneous evacuation of the fluid by em- ploying measures which will favor such an occurrence. Such an opening in the drum membrane is the result of local necro- sis, and implies a complete destruction of this structure over the area involved. Such a perforation may heal, and this is the usual course, but the repair is not complete, the fibrous layers not being re-formed at all or 8 but to a slight extent. This thin cicatrix constitutes a tension anomaly, and as it gradually becomes relaxed, owing to its tenuity, may be the cause of noticeable im- pairment of hearing in later years. On the other hand, if the fluid within the tympanum is evacuated by a free and ex- tensive incision through the membrane, there is no local necrosis, the fluid is com- pletely evacuated, vascular tension is re- lieved, and the inflammatory process ceases at once. The margins of the incision are in perfect apposition, healing follows in a short time (i to 3 days), without the forma- tion of cicatricial tissue, and the tension of the drum membrane is not disturbed. Certain precautions are necessary in in- stituting surgical procedures of this char- acter, but if due attention is paid to the technique of the operation the result can- not fail to be gratifying to the patient and to the surgeon. Having decided, therefore, in a given case of acute catarrhal otitis, that surgical inter- ference is indicated by the persistence of pain, the bulging of the posterior portion of the membrana vibrans, and the bright red color of the entire drum membrane, we should first thoroughly sterilize the field of operation by irrigating the canal with a 1 : 5000 aqueous solution of bichloride of mercury. After this the meatus should be dried with the cotton-tipped probe, the parts being illuminated during the manipulation by means of the head mirror. All instruments to be introduced into the meatus should be sterilized by boiling in a weak sodium-carbonate solution, cutting in- 9 struments being immersed for a moment only, as prolonged boiling will dull them. After the meatus has been dried, the walls of the canal and the surface of the mem- birana tympani are brushed dightly but thoroughly with a dilute alcoholic solution of bichloride of mercury to insure complete asepsis. The parts having been thus prepared, a sharp, delicate knife is introduced into the meatus and carried through the drum mem- brane in the posterior quadrant, close to the periphery. The edge of the knife may be directed upward or downward, according to the choice of the operator, and the con- ditions presenting. As the outward dis- placement is usually greatest above, I per- haps more frequently enter the knife in the postero-inferior quadrant, and cut upward as far as the posterior fold, although in many instances the incision is made in the oppo- site direction, the preliminary puncture being made close to the periphery of the membrane and just below the posterior fold. It is of little importance as to whether preliminary puncture is made in the upper or lower posterior quadrant, so long as it lies close to the periphery. The point of the knife is carried inward until it is felt to impinge upon the bony internal tympanic wall, and is then made to divide the drum membrane in a line parallel to its posterior attachment and just within this, from the posterior fold to the middle of the postero- inferior quadrant, the knife being entered below and carried upward to the posterior fold, or introduced just under this and car- ried downward close to the periphery, 10 well into the posterior inferior quad- rant. It is well to keep the point of the knife in contact with the bony internal wall of the middle ear in making the incision, and to divide the mucous mem- brane in this region as well; by this means the engorgement of the vessels on the in- ternal wall is relieved and the course of the inflammation shortened. When we have to deal with an acute in- flammation of the tympanic vault, surgical interference is demanded much moreprompt- ly. In this variety of otitis media the drum membrane below the level of the short process of the malleus may be normal in color and in luster, since the portion of the tympanic cavity which it covers may be completely • shut off from the region in- volved. This form of middle-ear inflamma- tion is essentially a cellulitis, since the in- fection is in the reduplications of mu- cous membrane with which the vault is lined. Otoscopic examination in such a case reveals intense redness of the mcm- brana flaccida, and after the process has continued for a short time considerable tumefaction of this region, frequently so ex- tensive as to overhang the shortprocess ofthe malleus and to present an appearance very similar to that of granulation tissue. This tumefaction does not necessarily indicate the presence of fluid, but is often due to the swelling of the connective tissue in the vault. Owing to the intimate connection between the tympanic vault and the mastoid an- trum, and to the virulence of the infection, as evidenced by its location in this region, it is never wise to postpone incision until free 11 flufid is present. Blood-letting, dry heat, etc., may be used early in these cases, but unless prompt relief is afforded the inflamed membrane should be incised, al- though the operator is certain that the cavity contains no fluid. The object of such an in- cision is to relieve the tension in the en- gorged tissues and to prevent local necrosis, which must follow unless the tension is re- lieved. The location and extent of this incision are matters of considerable importance, and are worthy of consideration in detail. The procedure was first suggested by Blake,1 and, with slight modifications, I have em- ployed it constantly with the most gratify- ing results. The canal having been thor- oughly sterilized in the manner already di- rected, a sharp-pointed knife is carried into the canal, with the cutting edge directed backward, the "flat" of the blade lying in the horizontal plane. If the short process can be seen the point of the knife is entered just behind this, but if this landmark cannot be made outtheknifeis introduced into the most prominent point of the swollen mass and pushed inward, upward and backward into the tympanic vault and through the dense mass of connective tissue which it contains, until it has traversed the entire width of the cavity. All these tissues are then in- cised by carrying the knife horizontally backward until the edge impinges upon the tympanic ring posteriorly. The edge of the knife is then turned upward, and, being still kept firmly in contact with the bone, is ^'Archives of Otology," XIX, p. 212, 12 drawn outward, incising the tegumentary covering of the superior wall of the meatus completely, for from 1-4 to 1-2 in. In this way the rich vascular plexus in the mem- brana flaccida is opened, and the tympanic vault and adjacent cells of the mastoid de' pleted. The advantage of continuing the incision on the superior wall of the canal lies in the fact that by this procedure a triangular flap is formed, which, as it retracts, favors the rapid discharge of serum from the swollen tissues. If this incision is not made until the inflam- matory process has existed for from 24 to 48 hours, the operation will evacuate pus, but we should never wait until the signs are pathognomonic of fluid. The incision is de- manded quite as urgently for the relief of tension in the earlier stages as for the evacu- •ation of retained pus in the later. After incision for the evacuation of ef- fused fluid in an acute catarrhal inflamma- tion, or for the relief of tension in the early stages of an acute purulent inflam- mation, simple cleansing is all that is re- quired to bring about a complete cure. It is of the utmost importance to remember that all danger is not over when the middle ear has been freed from effusion by incision, or when tension has been relieved in a similar manner. If the serous or sero-mucous dis- charge is allowed to lie in the canal, it be- comes readily infected through the air, and, in a comparatively short time, this infection spreads to the tympanum. This statement may be applied as well to cases in which the membrane has ruptured spontaneously from an acute catarrhal inflammation. Here 13 nature is ready to repair the damage, and does so more or less perfectly unless the discharge becomes infected by being al- lowed to remain in the external meatus. All must have seen cases of simple acute catarrhal otitis which seemed to be pro- gressing favorably, when, suddenly, the symptoms have iDecome aggravated, the discharge has changed from sero-mucus to pus, and the tympanic vault and even the mastoid have become involved. Not only may the tympanic inflammation be changed from the catarrhal to the purulent variety through infection of the discharge while in the meatus, but the canal walls may suffer in a similar manner. The superficial epithe- lium of the integument lining the meatus becomes macerated and exfoliated, owing to the combined action of heat and moisture, and the resulting denuded areas are easily infected. The frequency of cir- cumscribed or diffuse inflammation of the meatus complicating suppurative otitis media among those whose surroundings or habits are uncleanly, finds an explanation in this way. For these reasons, therefore, the external auditory meatus must be kept free from fluid, and especially from fluids which either are toxic themselves or may become so through aerial infection. While good results have been claimed for the method of packing the canal with antiseptic gauze in these cases, I prefer the simpler and, in my hands, the successful plan of maintaining an aseptic condition of the meatus by frequent irrigation with a mild antiseptic solution. Besides the asep- sis, we have the additional advantage of 14 the mechanical cleansing of the meatus by the fluid injected. After incision, therefore, or when the membrana tympani has rup- tured spontaneously, I order that the mea- tus be irrigated every two to four hours with half a pint of a warm solution of bichloride of mercury of the strength of I : 5000, the fluid to be injected with an ordinary hard-rubber ear syringe. If the discharge is very profuse I advise that a small pledget of cotton be worn in the incisura intertragica; in this way excoriation of the lobule may be avoided. Under no condition is the pledget of cotton to be inserted into the meatus, as the discharge is confined by such a procedure, and is almost certain to infect the meatus, causing either a furun- cle just at the entrance of the meatus, or a diffuse inflammation of the entire canal, from absorption of the discharge, which has not only been a source of infection in the canal, but, by its prolonged contact with the walls of the meatus, has caused an ex- foliation of the superficial epithelium, and has left a denuded surface through which infection can easily take place. As the discharge diminishes in quantity, the frequency of irrigation is reduced, and, when the edges of the incision in the case of an artificial opening have become adherent, it is my custom, if all evidences of inflam- mation have disappeared, to dust a little powdered boric acid over the surface of the drum membrane and over the canal walls to preserve asepsis, in case a vigorous ef- fort at blowing the nose, or some other un- foreseen occurrence, should separate the edges of the incision, and cause a little serum 15 to exude into the canal. The acid is merely dusted lightly over the walls of the canal and the surface of the membrane, and un- der no circumstances is the canal to be filled or packed with the powder. Even when employed in small quantities the case should be seen daily, to guard against any obstruction to drainage in the event of a sudden congestion of the middle ear, and a consequent rapid effusion of serum. While there is any appreciable amount of dis- charge, no powders should be used, and even after this they should be employed only with the greatest caution. Regarding the use of astringent solutions to be instilled into the canal after cleansing, I can only say that instillations of any kind have never, in my experience, been neces- sary in cases seen before spontaneous rup- ture of the membrana tympani has taken place, and seldom in cases of acute catarrhal otitis in which the drum membrane had ruptured spontaneous- ly, and which were seen before the vault of the tympanum had become involved second- arily. In regard to "ear-drops," to be used by the patient at home, the author's expe- rience has been that they are of little value, except as a means of securing an aseptic condition. For this reason I have, for the last five years, used nothing of the sort, with the exception of alcoholic solutions of boric acid, io grn. to i oz., or of bichloride of mer- cury i, alcohol 2000, water 1000. These solutions, instilled into the canal after syr- inging, establish a condition of surgical cleanliness, and prevent or inhibit the growth, not only of the bacteria of suppu- 16 ration, but also of the various forms of as- pergillus, which are a not infrequent predis- posing cause of infection of a more serious character. If astringent or stimulating solutions are to be used for the purpose of restoring the mucous membrane of the tympanum to a normal condition, they will be efficient only in the hands of the physician himself, since he alone is able to apply them with the nec- essary precision. As we are dealing, in this paper, with acute inflammation only, the discussion of these therapeutic measures need not be extensive. We have spoken of the secondary infec- tion of the tympanic vault, due to failure to observe surgical cleanliness in a case of or- dinary acute catarrhal otitis. In such a sec- ondary infection, the incision of the mem- brana flaccida and the underlying struc- tures, in the manner before described, should be at once undertaken, as the dan- gers of rapid extension are great, and mild- er measures, such as wet cupping, are! sel- dom of the slightest use. In cases where the inflammatory process threatens the mastoid, the aim of our treatment in the early stages is to arrest the extension of the inflammation in this direc- tion. Perhaps in no region of the body can there be more extensive disease, with fewer signs and symptoms, than in the mas- toid process. The author has come to re- gard the temperature as of but little value in diagnosis, but he finals that tenderness on pressure over the mastoid is, as has been emphasized repeatedly by Dr. Gruening, of New York, an almost constant sign of mas- 17 toid involvement. Care must be taken, in eliciting this tenderness, to press upon the mastoid only, and not to impart any mo- tion to the fibrous canal; if this is done, a diffuse external otitis may cause an error in diagnosis. Another sign of great importance is the sinking of the upper and posterior walls of the meatus, close to the membrana tympani, narrowing the deep canal and obscuring the upper and posterior part of the drum membrane. As the walls of the bony meatus form the floor of the tympanic vault, and the floor and anterior wall of the antrum, the significance of tumefaction in this region is evident at once. When treatment is instituted early in an acute otitis, the mastoid usually escapes; but when the tympanic vault has been im- perfectly drained, or when spontaneous rup- ture of the drum membrane is awaited in acute purulent otitis, the pneumatic spaces of the mastoid may participate in the in- flammation. The first indication, if the mastoid is in- volved, is to secure the best possible drain- age of the tympanic vault, through the external meatus, by an incision through the membrana flaccida, from the short pro- cess of the malleus backward to the tympanic ring, and from this point outward through the soft tissues covering the superior wall of the canal for a distance of 1-4 to 1-2 an inch'. This not only evacuates any fluid in the tympanic vault, but, by depleting the tissues, is of value in cutting* short the in- flammatory process. /Hi!e deep incision along the superior wall of the meatus, re- lieves the tension due to the incipient mas- 18 toid inflammation, since this portion of the canal forms the floor of the tympanic vault, and of the mastoid antrum. The patient should be kept perfectly quiet in bed, and the diet should be restricted to fluids. It is scarcely necessary to add that the bowels should be kept free, although this is an im- portant point, and is sometimes forgotten. The canal should be irrigated with the i : 5000 bichloride solution every 2 to 4 hours, as in cases not complicated with mastoid inflammation. After the drainage has been made as free as possible through the canal, the local application of cold to the mastoid is of undoubted lvalue as a means of preventing an extension of the inflammatory process. This is most con- veniently done by the small aural ice-bag devised by Dr. Sprague, of Portland, or by the application of the Leiter coil. The length of time during which cold applica- tions should be continued in the hope of aborting the inflammation should not, in my experience, exceed 48 hours, and usu- ally thirty-six hours are sufficient. If at the end of this time local tenderness has not completely, or nearly, disappeared, no, fur- ther benefit will be derived from them. If the tenderness has disappeared, the patient should be allowed to get up and move about, and the diet should be in- creased gradually. If the local tenderness returns, or if it has failed to disappear after the employment of cold applications, in the manner above described, the mastoid should at once be thoroughly opened. Nothing is gained by using leeches or the wet-cup behind the ear, or by the applica- 19 tion of blisters to the mastoid, or by mak- ing the so-called "Wilde's" incision. Such measures may temporarily check the pro- cess, or rather may mask the symptoms, while the destruction of the osseous tissue still goes on. The mastoid operation, if properly conducted, is not attended with any risk to the patient, and, if Wilde's inci- sion seems indicated, the operator should certainly go a step further and open the bony cells. Whenever such an operation is under- taken, the strictest antisepsis should be ob- served. The head should be shaved for a distance of three inches from the meatus in every direction, the skin thoroughly scrubbed with soap and water, washed with ether, and then with a i : 1000 bichloride so- lution. The meatus should be syringed with a similar solution and tamponed with a strip of iodoform gauze. The ear and the field of operation should then be covered with a moist bichloridle dressing, which should not be removed until anesthesia is complete. All instruments should be ster- ilized by boiling, and the field of operation should be surrounded with moist bichlo- ride towels. Such precautions may seem unnecessary, but in no case can the surgeon be certain beforehand that it may not be necessary to extend the operation to the cranial cavity, in order to thoroughly eradicate the disease; or that this cavity may not be accidentally opened, owing to some anatomical anomaly. If these precautions are observed, the operator will not hesitate to proceed to evacuate a cerebral abscess, or to open and 20 cleanse a thrombosed lateral sinus, in case he finds that the disease is not confined to the mastoid. As I have already trespassed too much upon your time, I will not enter into detail regarding the technique of the operation. In all cases it should be thorough. The entire cortex of the mastoid should be re- moved from the tip to the linea temporalis, and all softened bone should be curetted away. The antrum should be opened invaria- bly, even in cases where the disease seems limited to the superficial cells, or in that form in which the pneumatic spaces at the tip ap- pear to be most involved. The operator should assure himself that the probe intro- duced into the opening into the mastoid passes freely into the middle ear, and should also carefully curette this canal, to remove all softened bone and granulation tissue, and to secure perfect drainage. New York; 17 West 46th street. 21 EIGHTH YEAR. A . $3.00 per year. American Medico=Surgical Bulletin A SEMI-MONTHLY JOURNAL OF PRACTICE AND SCIENCE. Issued on the ist and 15th of each month. THE BULLETIN PUBLISHING COMPANY, 73 William Street, N.Y. The BULLETIN is the only journal that publishes regularly complete report s oi all the meetings of the New York Academy of Medicine and its ten Special Sections. 1 he BULLETIN is also the Official Organ of the Sections on Orthopedic Surgery and on Laryngology and Rhinology. Editorial Staff. WILLIAM HENRY PORTER, M.D., FREDERICK PETERSON, M.D., Chief Editor. Associate Editor. WILLIAM C. GUTH, M.D., T. S. SOUTHWORTH, M.D., Pathology and General M edicine. Obstetrics, Gynecology, Pediatrics. SAMUEL LLOYD, M.D., WILLIAM FANKHAUSER, M.D., Surgery. Materia Medica and Therapeutics. ADOLPH ZEH, M.D., LEWIS A. CONNER, M.D., Pathology and General Medicine. Neurology. GEORGE G. VAN SCHAICK, M.D., ALBERT WARREN FERRIS, M.D. Pathology and Clinical Medicine. Neurology. WILLIAM OLIVER MOORE, M.D., PEARCE BAILEY, M.D., Ophthalmology and Otology. Neurology. ADOLPH BARON, M.D., MORTON R. PECK, M.D., Diseases of Children. Neurology. WILLIAM VISSMAN, M.D., LOUIS HEITZMANN, M.D., Pathology and Bacteriology. General Medicine and Pathology. T. HALSTED MYERS, M.D., DANIEL B. HARDENBERGH, M.D., Orthopedic Surgery. Obstetrics and Gynecology. GEORGE THOMAS JACKSON, M.D., OTTO H. SCHULTZE, M.D., Dermatology, Obstetrics and Gynecology. WILLIAM B. COLEY, M.D., JOHN HOCH, M.D., General Surgery. General Medicine. JAMES E. NEWCOMB, M.D., HOWELL T. PERSHING, M.D., Laryngology. Neurology. GEORGE K.SWINBURNE, M.D., THOMAS PECK PROUT, M.D., Genito-Urinary Surgery. Psychiatry, HENRY T. BROOKS, M.D., B. FARQUHAR CURTIS, M.D., Bacteriology. Surgery. JOHN WINTERS BRANNAN, M.D. ALBERT H. ELY, M.D., Neurology and Psychiatry. Gynecology. IRA VAN GIESON, M.D., GEORGE G. WARD, M.D., Pathology of Nervous System. Obstetrics. WILLIAM Y. FINCH, M.D., WALTER A. DUNCKEL, M.D., General Medicine. Diseases of Children. L. PIERCE CLARK, M.D., E. M. FOOTE, M.D., Psychiatry. General Surgery. GEORGE R. WHITE, M.D., Obstetrics and Gynecology.