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successful; concerning the technics of this special operation and its plan we have treated before. We should still have to mention attempts which have been undertaken in the upper arm to replace the triceps and the deltoid, attempts which from the first could not count on a full success.

We now leave the domain of flaccid paralyses and turn to the group of spastic paralyses. We here have to deal with a mixture of paralysis and spasm. This mixture shows a very varied combination indeed, so that sometimes we have a spastic condition only; in another case, on the contrary, a decided and widespread paralysis combined with spastic contractures. We have before designated the aim and the attainable result of transplantation in such cases to be the return of active motion by the removal of the spastic condition, as well as the correction of the deformity.

If we wish to keep true to our division originally selected, viz., into peripheral, spinal, and cerebral paralyses, we must first of all speak of the spinal spastic paralyses. However, it is difficult or even impossible for the neurologist to give an exact diagnosis of the seat, spinal or cerebral, in this group of diseases. Very frequently we have to do with an affection of both organs. It therefore seems to us advisable not to attempt this separation. Probably it might be practicable to distinguish cases of spastic paralysis with unimpaired intellect from those with different high degrees of idiocy. With it we should get at the same time an important sign for prognosis, because naturally the result of our operation must be the less favorable the less we can be helped by our patient, who cannot grasp the object and purpose of our treatment, or we may distinguish from clearly external signs onesided or doublesided spastic paralyses.

We begin with the first group, and with so called cerebral infantile paralyses. At the lower extremity the equinus so very frequent with this affection, which is mostly combined with a more or less pronounced position of clubfoot, gives us cause for transplantation. With an equinus of high degree it is advisable to lengthen plastically the tendo Achillis and afterward to execute a transplantation combined with a shortening into the extensor digitorum. I have seen very good results as to position and mobility of the foot by means of such operations. Transplantations into the extensor have been done with success in separate cases of a spastic contracture of the knee joint; and lastly it has been tried to do away with the well known flexor contraction of the wrist and fingers by means of transplantation and shorten

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ing. We possess reports of good success; we can, however, here produce a passing impairment of the condition by the transplantation, in so far that the extensors of the fingers are shortened too much and now interfere with the closing of the fist. The attempts to correct the pronation of the forearm, which is frequently combined with the flexor contraction, are interesting. Tubby has aimed to obtain this by an operative transposition of the tendon end of the pronator teres, in carrying it round the radius, so that its tension must produce a supination. Hoffa has tried to achieve the same by the transposition of the origin of the same muscle, with the same idea of transforming it into a supinator.

Of the onesided spastic paralyses, we should have to mention the apoplectic hemiplegia. Of late, as is known. increased attention has been given to the physical mechanical treatment of the sequels of apoplexies, and it has been found that usually sufficient muscle material has been spared from paralysis to restore with its aid a certain usefulness of the paralyzed entremity. It is this circumstance which has led to the thought of a tendon transplantation and of the restoration of the most important functions, and the obviating of contractures by the proper distribution of the preserved muscles. Naturally, such an operation can only be performed if the danger of a renewed apoplectic attack is remote. I myself have under such circumstances operated on the lower extremity in half a dozen cases with good success.

The experience of tendon transplantations is still greater in diplegic paralysis, especially in Little's disease, which has given me occasion to operate in more than thirty cases. The combination of manifold tenotomies, for the removal of contractures in the hip and the knee joints, with the transplantation in the leg, the fixation in the correcting bandage carried out sufficiently long. and the energetic after-treatment in most cases, render the little patient completely able to walk, and afford a pleasing result, supposing that the upper extremities are useful and that we do not have a substantial interference with the intellect. (To be concluded.)

Bequests to Charitable Institutions.-By the will of Amos West, who died recently in the Norristown Asylum for the Insane, the Methodist Hospital receives $5,000 on the death of his legatees to endow what shall be known as the West Bed.

By the will of John J. Holmes, on the death of his widow, the residue of his estate, after some private bequests, reverts to St. Joseph's Home for Industrious Boys.

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functional disturbances to which the term traumatic neurosis has been applied. Here the prime responsibility of the surgeon appears to me to be the prevention, by judicious treatment, of the development of the nervous derangement. Many of the nervous wrecks seen in the courts, demanding, and often receiving from juries, large sums of money for accidents, are the creation of injudicious, thoughtless, or dishonest doctors.

In all these classes of injury there may be developed an hysterical or neurasthenic element; but it is in the last two classes that such neuroses are most likely to occur.

In this paper the open attitude of suspicion frequently exhibited by corporation agents towards injured persons and their medical attendants is not under discussion; but the unjust verdicts sometimes obtained explain that attitude. Crafty lawyers and dishonest doctors are obtainable in all large communities to aid in a miscarriage of justice and to bring discredit on their respective professions.

1. Cases in which there is obvious physical lesion of a serious character, such as fracture, dislocation, or wounds. Here the surgeon's medicolegal responsibility centres to a great extent in the prognosis. for the diagnosis and treatment are sufficiently clear.

vania.

2. Cases in which a physical lesion is obvious, but evidently of little importance. Here the professional responsibility is largely concerned with diagnosis, and the doctor must be on the alert to detect, by careful and repeated examinations, symptoms of obscure danger to the nervous system or other deep structures.

3. Cases of mental shock without obvious physical lesion, in which there is a possibility of the development at a later time of the so called

Read before the Medical Society of the State of Pennsyl

Immediate and careful examination, with accurate record of the patient's statements and of the symptoms at the time of injury, the avoidance of injurious suggestions, the prompt institution of scientific treatment, and an early settlement of damages will diminish litigation and hasten the recovery of the patient.

The doctor should make several examinations, because errors and oversights are thus avoided. He should remember that disease may have existed before injury, that disease may follow injury and yet not be due to it, that the patient may be mistaken and not dishonest, and that hysteria and neurasthenia are common conditions, which may exist with organic lesions without being directly connected therewith.

Corporations liable to be sued would save money by always employing experienced practitioners to examine the injured early, in company with the medical attendant, and by insisting upon at least two such examinations. This procedure would usually get at the truth, often restrain the patient from malingering, sometimes prevent the development of traumatic hysteria or neurasthenia, perhaps scare away scheming lawyers and doctors, and generally restore the patient's health more promptly.

Delay in settlement, too many examinations by various doctors, unwise suggestions of symptoms made by thoughtless examiners, and numerous conferences with lawyers are productive, in many instances, of traumatic neurosis and have unjustly drawn many thousands of dollars from corporation treasuries.

ALLPORT: CHRONIC PURULENT OTORRHEA.

632

In conclusion, I desire to emphasize two points: First, that an ignorant, careless, or injudicious doctor may be the real cause of many cases of traumatic hysteria and neurasthenia ; and, secondly, that prompt settlement of damage suits is an inestimable aid in the cure of accidental injuries associated with litigation.

313 SOUTH SEVENTEENTH STREET.

SOME OF THE DIFFICULTIES TO BE OVERCOME IN THE RADICAL MASTOID OPERATION FOR THE CURE

OF CHRONIC PURULENT

OTORRHEA.*

BY FRANK ALLPORT, M. D.,

CHICAGO,

CLINICAL PROFESSOR OF OPHTHALMOLOGY AND OTOLOGY IN THE NORTHWESTERN UNIVERSITY MEDICAL SCHOOL, ETC.

In a ten minute paper it is, of course, impossible thoroughly to treat the subject under consideration, and the writer will merely attempt a rambling and disjointed discussion on the objections to the radical mastoid operation for the permanent relief of chronic purulent otorrhoea, which may be broadly defined, as expressed by Berens and others, to be a suppurative process that has persisted more or less actively for six months or more. The indications for the ordinary operation for a mastoid abscess will be utterly ignored through lack of time, and from the fact that its urgencies and necessities are well understood and generally recognized. The writer believes that the asking of a single question should place the necessity for the radical mastoid operation, for the relief of chronic purulent otorrhoea, in its proper light. Why should the ordinary. rules of surgical expediency, which point to the removal of necrotic and dangerous tissue in other portions of the body, be more or less ignored in cases of intractable chronic purulent otorrhoea? This question is emphasized by the fact that in almost all such cases the morbid changes are not confined to the middle ear space, but are continued back through the aditus ad antrum to the antrum, and usually into the mastoid cells. It may be stated with reasonable certainty that instances of pure middle ear suppuration, even if accompanied by necrosis, can usually be cured by the conservative treatment with which the average surgeon is quite familiar; bearing in mind that occasionally removal of the malleus and incus, together with middle ear curettement, may be necessary to effect a complete healing. But where such measures fail to cure, is there any good reason for not advising

* Read before the Chicago Medical Society.

PHILA. MED. JOURNAL.

the radical operation, which throws the meatus, middle ear, aditus ad antrum, antrum, and probably the mastoid cells into one large accessible cavity, thus rendering it possible to eradicate every vestige of diseased tissue, and to obtain a healthy healing of the parts, such as is continually accomplished in all other parts of the body by general and special surgeons? In answering this question, a number of replies must receive consideration. In the first place, many ultraconservative physicians have been for many years preaching the gospel of non-interference in cases of aural discharges, until many of the lay community, and some medical men, who should know better, believe that an aural discharge is a fortunate vent for the drainage of unhealthy material, the cessation of which would cause brain disease and death. Again, the same misled doctors and their lay followers observe that many people carry discharging ears for years, and, inasmuch as no calamity has befallen them, listen with incredulity and scepticism to the wiser and more advanced surgeon, who enlarges upon the danger of discharging ears, and advises operations for their cure. These objections, however, are met to a greater or less extent in all fields of surgery, many of the ultraconservative medical men and their lay followers championing a general prejudice against all operations, and really never setting aside their preconceived beliefs until death has nearly stamped a victim for its own.

The dangers of the radical mastoid operation are such that, while they should not deter the competent and progressive surgeon from undertaking the work after the conviction for its necessity has been reached, the operation should not be performed without much study, experience, and observation, and not until its urgency is unmistakably manifested. The question as to what should finally cause the surgeon to advise the radical mastoid operation is one of great importance. Cases of aural suppuration accompanied with symptoms of grave intracranial and constitutional complications will not be considered, as time forbids, and the necessity for operative procedures in such cases is so plain as to be unmistakable. The time for advising operation in quiescent cases of chronic intractable tympanic suppuration is, however, another matter, and opens up a wide field of discussion, in which this paper may not participate on account of its required length and because it would require an answer to several questions; as, for instance: How long must a discharge continue before it can be called chronic? and What can be properly called an intractable tympanic discharge? While many interpretations of such classifications are possible, and while no hard and fast rule for chronicity and intractability can or should

be established, the writer believes that in a general way an aural discharge may be considered both chronic and intractable when it continues to exist after about six months of faithful and intelligent care and treatment.

the breaking of the walls of the tympanic Falloppian canal by probing, chiseling, or curetting, an accident which may occur to the most painstaking operator, especially where openings of the canal either of a necrotic or congenital nature are present. Indeed, facial paralysis is said to occur from the mere jarring of the nerve during chiseling proceedings, an opinion which argues in favor of gentle manipulations, a soft head cushion, and more familiarity with a reliable dental engine, instead of the chisel, for the bone work.

The chief objection to the radical mastoid operation is the production of facial paralysis (an accident which should seldom if ever occur after the operation for acute mastoid abscess), and this is a menace of no mean calibre, and one from which the average operator may well shrink. It is a most distressing sight for a surgeon to see a face pulled to one side after anesthesia unconsciousness has passed away, and to realize that this is the work of his own hands. If this disheartening appearance is shocking in an obscure hospital patient with few or no friends and little or no influence, what must it be to witness such an occurrence amid wealthy and influential surroundings, where the bad tidings will spread like wild fire to the undoubted detriment of the operator's reputation? While these circumstances, under any social conditions are bad enough, the possibilities for a suit for malpractice must never be forgotten, nor the effect of this drawn and one. sided countenance upon the community at large, and the trial judge and jury in particular. It may be said, however, for the encouragement of operators who are doing this character of work, that these patients almost invariably recover in a few weeks or months, and those who do not recover may usually be successfully operated upon by the attachment of the facial nerve to the hypoglossal or spinal accessory nerve, as recommended and successfully practised by Ballance and others. The facial nerve may be injured in any portion of its course, from its entrance into the middle ear at the upper middle portion of the tympanic wall, to its exit from the skull at the stylomastoid foramen. Contrary to popular belief, the facial nerve always remains within the confines of the petrous portion of the temporal bone, and does not enter the mastoid protuberance at all. On chiseling away the mastoid cells, the hard petrous covering of the nerve may be clearly seen at the anterior portion of the cell structure, just back of the bony meatus and below the floor of the antrum, and should be carefully avoided, although considerable protection is afforded by its sclerotic casing. The shell of bone protecting the nerve as it passes through the tympanum is, on the contrary, very thin and sometimes entirely absent in spaces, thus accounting for the occurrence of facial paralysis during middle ear suppurations. Most cases of facial paralysis following mastoid operations are due, not to injury of the nerve after it leaves the tympanum on its way to the stylomastoid foramen, where it is protected by its petrous covering, but to

Another danger to be avoided during the radical mastoid operation is the infliction of an injury to the horizontal semicircular canal. At the extreme upper and posterior portion of the inner wall of the tympanum, between the facial nerve and foramen ovale anteriorly, and the mastoid antrum posteriorly, can be seen the hard bony convexity covering the horizontal semicircular canal, usually easily recognized as a yellowish prominence in the middle of the inner tympanic wall. Being situated just at the floor of the angle where the antrum merges into the aditus ad antrum, injury to this portion of the internal ear may be easily inflicted by a blow of the chisel, especially after the superior posterior wall of the bony meatus has been cut away in the performance of the radical operation. Nevertheless, it would seem that this accident rarely occurs, as not many instances of disturbances of equilibrium and dizziness are recorded after such surgical procedures, symptoms which assuredly would be expected after injury to these centres of equilibrium, and symptoms which, fortunately, as a rule, pass away in a few days. A partial explanation of the infrequency of injury to the facial nerve on its downward course, and of a similar infrequency of injury to the horizontal semicircular canal during the radical operation, resides not only in their hard and compact coverings (which protect them from accidents, and, to the eye of the operator, distinguish them from their bony surroundings), but also in the fact that they lie below the plane of proper chiseling procedures, as in cutting away the posterior meatal wall, while the initial opening should be wide, the receding space should gradually diminish in size as the inner wall of the tympanum is approached. Thus, the space produced should be triangular in shape, with the apex at the inner wall of the tympanum and the base at the opening of the bony meatus. By thus carefully chiseling, both the descending portion of the facial nerve and the convexity of the horizontal semicircular canal will lie outside the lines of incision and escape injury. Both these vulnerable anatomical points may also usually be avoided by the use of the Stacke protector as the last few pieces of bone

are removed to make the triangular space, or opening, necessary for the careful inspection and treatment of the middle ear, antrum, etc. The protector should also be used in chipping away the ledge of bone separating the attic from the meatus, without which procedure a perfect cure is highly improbable. It should not be forgotten, however, that the introduction and retention of the footplate of the protector may in itself injure the facial nerve and semicircular canal unless carefully introduced and used, and that the same thing may occur from undue force in malleting through the chisel on to the footplate of the protector through an undue sense of security.

The wounding of the sigmoid portion of the lateral sinus is undoubtedly one of the dangers of the radical mastoid operation, although the writer believes that this danger has been very much overestimated, both as to its probability and also as to the damage accomplished by such an accident. The knee of the sinus usually lies about one inch back of the posterior wall of the meatus, except in children and people of small heads, when its proximity is closer. It may lie farther backward or farther forward, even to the extent of impinging close upon the meatal wall, and absolutely preventing the performance of the classical mastoid operation. Vascular connections exist between the sinus and the cells, thus affording at least one explanation as to the frequency of sinus infections. The outer osseous covering of the sinus is easily broken, and care should be exercised to prevent this accident during operative procedures. Still, no especial anxiety need be felt if this occurs, although the subsequent operative steps are always thereby considerably embarrassed, through constant vigilance lest the dural covering be also ruptured. Even, however, should this occur, the prompt use of tampons will almost always control the hæmorrhage, and the danger of infection is not great. The writer believes that the danger is not so much in damaging the sigmoid sinus as in the improper handling of a case where phlebitis and thrombosis are discovered; and, as these conditions are generally to be found (if found at all) in cases of acute or subacute mastoiditis, or in acute exacerbations of chronic mastoiditis and otorrhoea, where the operation is clearly indicated as a life saving measure, it need not be considered in the present paper.

Another danger in the radical mastoid operation is the possibility of exposing the dural covering of the temporosphenoidal lobe or the cerebellar lobe of the brain; and here it may also be said that, in the opinion of the writer, this danger has been much overestimated, and that but little anxiety need be entertained, even if such accidents occur.

There is, of course, some danger in opening up an avenue of infection through the foramen ovale; in case of the accidental removal of the stapes during the extraction of the malleus and incus; or in middle ear curettement; or in entering the carotid artery in front and beneath the middle ear; or the jugular fossa directly underneath the tympanum, by too vigorous operative measures. But these accidents, especially the two latter, are of extremely improbable occurrence, and should not enter into our calculations in estimating the advisability of an operation.

While, therefore, meningitis and other intracranial complications and accidents to the facial nerve, horizontal semicircular canal, sigmoid sinus, etc., may result from the performance of the radical mastoid operation, the only occurrence that seems to the writer to sustain much weight is the embarrassing and unfortunate occurrence of facial paralysis. This is surely a valid objection, and one that demands consideration; but the only suggestion that can be offered by the writer is not to neglect or abandon this truly admirable operation, but to perfect our skill, knowledge, precautions, and surgical technics so that this and other accidents and misfortunes will not occur. So far as danger to life is concerned, in a properly executed radical operation for the cure of chronic purulent otorrhoea, when no dangerous symptoms are present, the writer believes that such an occurrence, while of course possible, is extremely improbable, and he has never seen it in his own practice.

Another objection to the operation is the fact that the ultimate result is not always successful as to the cessation of the discharge. Such a result, after passing through the dangers of the operation, the protracted healing, and the considerable expense, is not reassuring, and naturally discourages both the operator and the patient. Unsatisfactory issues of this nature are, however, in the opinion of the writer, practically always unnecessary and due to improper and insufficient operative procedures, such as lack of care in the extermination of every particle of necrosed bone, or insufficient curettement of the Eustachian tube opening, which should be thoroughly scraped, cleansed, and, if possible, sealed as its office after this operation is lost, and its orificial patency only serves to perpetuate a discharge.

The failure to remove the upper ledge of bone between the meatus and tympanic attic is also frequently the cause of imperfect healing, as when operative measures cease, the upper meatal wall should be perfectly continuous with the upper attic wall, or the tegmen tympani, so that a bent probe touching the tegmen tympani can

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