Chronic secondary mastoid disease is frequent and varied :-catarrhal and suppurative inflammation, formation of granulation tissue, collections of cheesy and pearly material, caries and necrosis. For brevity's sake I shall discuss this variety according as prominent symptoms furnish special indications for

treatment.

In many cases the inflammatory products are retained in the mastoid, and the irritation is extended to the brain, by granulations filling the drum-cavity after more or less extensive destruction of the membrana tympani. Thorough cleansing and inspection of the drum-cavity should be our first step in taking charge of any case of chronic perforative inflammation. The removal of polypoid excrescences is self-evident. But even when this has been done, the otorrhoea and severe cerebral symptoms may continue. I have seen cases where excruciating headache, nausea, occasional vomiting, and delirium at night existed for weeks, yet the mastoid region was neither swollen nor red, nor sensitive to the touch, but the inner and lateral walls of the drum-cavity were lined with a thickened mucous membrane, which showed no polypoid masses, nor a particular protrusion of the inner upper wall of the meatus. The probe, in such cases, detects the fleshy character of the proliferating mucous membrane. I have found it best in such cases to scrape all the fleshy masses out, according to Oscar Wolf, and have seen severe cases rapidly recover under this treatment. The spoon which I employ for that purpose and find very excellent, and which also Bezold uses, is Schuft-Waldau's cataract spoon. It not only removes all granulation tissue, but also carious portions from the walls of the drum.

Another symptom suggestive of retention of morbid material within the mastoid cells is a spherical protrusion of the upperinner end of the meatus, as first pointed out by Toynbee and Duplay. This swelling should always be incised with a slightly bent scalpel or a sharp hook-like instrument. The posterior wall of the meatus and drum-cavity, especially the upper part of the latter, should then be explored with a grooved flexible blunt hook, in order to ascertain the nature of the contents of the mastoid antrum, as well as the surface of the bone. In this way I have liberated pus, sealy masses, and cheesy material. The opening and exploration may be advantageously followed by directing a stream of warm water cautiously to the diseased

part. If the hook brings out particles of cheesy material, and syringing is of insufficient immediate effect, a warm half per cent. solution of bicarbonate of soda may be instilled several times daily, and the syringing repeated according to circumstances. I have seen that syringing in this way brought out incredible quantities of decomposed or dried-up substances which were retained in the antrum and cells of the mastoid, just as persistent and gentle syringing will bring out the accumulations. in the meatus and middle ear.

Sequestra of the meatus, the drum cavity, and the mastoid process, if projecting into the drum or meatus, are best removed by means of the grooved hollow flexible hook, which I have used and recommended for the extraction of foreign bodies from within the eyeball.'

The propagation of tympanic disease to the mastoid process is, so far as my experience goes, always accompanied by tenderness to the touch, redness and swelling of the mastoid region. When these symptoms were absent, and the mastoid process was opened for the relief of severe cerebral symptoms, I have always seen the operation fail to evacuate pus or any other morbid substance. As I have repeatedly witnessed such operatious, I have been on my guard and warned my pupils against the indiscriminate opening of the mastoid process. Though I have never considered this operation as formidable in any degree, yet I cannot shut my eyes to its possible dangerous consequences from erysipelas and thrombosis, consequences which I have observed sufficiently to be impressed with the importance of this operation to which I resort only when unmistakable. indications are present. I have spoken of these indications in acute cases. In chronic cases they are the symptoms above mentioned combined with cerebral symptoms-of which persistent pain over the corresponding half of the head is in itself sufficient or persistent, offensive otorrhoea which does not yield to treatment of the middle ear.

There is, in addition, one symptom which we very frequently find, fluctuating swelling behind the ear, the so-called post-aural abscess. It presents itself in two varieties, which are different in their aspect as well as in their origin, as Bezold has lately pointed out. The one is a diffuse swelling of the posterior face of the auricle and the adjacent skin of the mastoid process. The

Archives of Ophthalmology and Otology, pp. 311, vol. vii.

auriculo-mastoid sinus is filled up, and the auricle pushed forward as if a wedge had been driven in between it and the mastoid process. This variety is due to the periostitic and carious processes in the bony portion of the meatus, the posterior wall of the drum cavity, and the adjacent mastoid cells and antrum. The matter creeps up under the periosteum or through the tympano-petrosal fissure. The opening in these cases should be made close to the insertion of the auricle, the condition of the bone explored with a probe, carious parts cleansed, and necrosed parts removed with chisels.

In the other variety the swelling is more pronounced half an inch behind the auricle, but may extend considerably above and even in front of the ear. The auricle is not, or only slightly pushed forward, and the wedge-shaped filling of the auriculomastoid sinus is either absent or little pronounced. This variety results from the perforation of a true intra-mastoid abscess, and as far as my experience goes, the perforation mostly takes place in the shallow depression of the bone situated about half an inch behind and at the level of the upper wall of the external auditory meatus, or very slightly higher. It is also in this place that this variety of post-aural abscess should be opened by a deep, yet cautious incision. The surface of the bone should be explored with a probe, and I do not remember one case in which I failed to detect the communication with the mastoid cavity. If this communication be insufficient, it can readily be enlarged with a strong probe or a gouge, and the cavity of the mastoid explored. Probing of the mastoid cavity should be done in every chronic case of mastoid abscess, in order to remove morbid necrotic portions of the bony wall of the process or its cells, granulation tissue, cheesy and scaly masses (cholesteatoma), and the like. When, after the surgical or spontaneous opening of the abscess, fistulous passages remain for a long time, they are commonly due to caries and necrosis in some part of the process. The fistulous opening should be enlarged, the sequestra removed, and the disease treated according to the strict rules of surgical cleanliness, or, to use the modern expression, according to the strict rules of antiseptic surgery.

With regard to the instruments used in opening the mastoid process, I have commonly employed strong scalpels, chisel and mallet, or a hand-gouge and chisel, instruments always at hand and easy and comparatively safe of application; but Dr. Buck's

drill, surrounded with a safety canula, has likewise rendered me good service without ever having caused unpleasant accidents. I could, therefore, not so decidedly disapprove of its use as Schwartze does.

Gentlemen, I have gone over an extensive piece of ground, here and there in a hurried and dogmatic manner, for which I beg your pardon, but my remarks were limited by your time, if not by your patience. One thing, however, I may state: I have not made one assertion that was not borne out by personal experience. My inferences may have been erroneous, but your, and perhaps my own, further experience will correct the errors. Had time permitted, I would have preferred to treat of this subject statistically, furnishing the histories of cases as evidence of my statements.

OPERATIONS FOR CATARACT AND FOR MASTOID

DISEASE.

By A. BLITZ, M.D.,

NASHVILLE, TENN.

CATARACT.

CASE of Mrs. E. M. T-, aged 71 years. Cataract in both eyes. Had been blind in right eye eighteen years, in left eye four years. Patient insisted upon having the right eye operated on, although of course I preferred to operate on the left, in which the cataract was more recent, and afforded a better chance of success. As she would not consent to this, I performed the operation on the right eye, at her residence, on September 23, 1877.

The patient was placed in the recumbent position, and, declining the anesthetic, I at once secured the lids with the spring speculum, and standing behind the patient, I applied the fixation forceps, and made the corneal section (as usual for linear extraction), with a Graefe's knife, completing the section very nicely, and without touching the iris.

I then took up the iris-forceps and scissors, to make the iridectomy, but before I could touch the eye, the patient unfortunately strained slightly, and I saw the lens (in its capsule) escape through the wound, which was immediately followed by a small quantity of the vitreous humor.

As quickly as possible, I removed the fixation forceps and speculum and closed the lids, to prevent a further escape of vitreous. Without opening the lids again, I applied the bandage.

Two days after this I commenced the use of atropine drops, twice a day, reapplying the bandage after each instillation, which was kept up until the ninth day, when I removed the bandage entirely, but finding the ocular conjunctiva irritated, I used hot water dressings, besides the atropine drops. The conjunctival irritation soon subsided. The wound had healed very nicely.

The appearance of the pupil was peculiar. It was enlarged