Crawford W. Long, the great discoverer of anesthesia.
Then may we exclaim with the poet :

"Patriots have toiled and in their country's cause
Died nobly. And their deeds, as they deserve
Receive proud recompense. We give in charge
Their name to the sweet lyre. The historic muse,
Proud of the treasure, marches with it down
To latest times; and sculpture in her turn
Gives bond in stone and ever-during brass
To guard them and immortalize her trust."

THE INDICATIONS FOR THE MASTOID

OPERATION.

BY F. PHINIZY CALHOUN, M.D., ATLANTA.

The relation that the mastoid bears to intracranial structures is so important that I have chosen the above subject as one of interest to present before this body; and, while I may not interest you in discussing it from an otological point of view, I hope it will be worth your while from the view of a general practitioner and sur

geon.

More cases of mastoiditis (both acute and chronic) are seen now than formerly. Not because mastoiditis is more common; not because there are more abscesses of the middle ear; not because we are liable to more colds, but more to our ability to recognize the early symptoms of this important disease. Cases of mastoiditis left to themselves, receiving no treatment except perhaps some hot poultices of flaxseed, soon reach the point where vital structures are placed in danger; and while an operation in the great majority of cases may result in a cure, so far as the suppuration is concerned, one of our most delicate senses is made to suffer, and the organ of hearing is greatly impaired, and the patient remains deaf the balance of his life. It is my purpose, therefore, in this paper, to call your attention to the early operative symptoms of mastoiditis, with a view of maintaining a normal organ.

The indications for a mastoid operation are so evi

dent in the vast majority of cases, that with the application of a few tests, no great skill is required to make the diagnosis certain.

It is the general rule, with some exceptions, that mastoiditis occurs secondarily to an acute purulent otitis media. The drum membrane has usually ruptured, and the canal is filled with a muco-purulent or purulent secre-tion. In the majority of cases of acute purulent otitis media, there is some mastoid involvement, and pain on palpation can be elicited if sought for. This pain may be due to nothing more than an engorgement of the mucus membrane, lining some of the superficial cells of a highly cellular or pneumatic mastoid, or the antrum, or the large cell at the base of the mastoid might be solely infected, giving symptoms of mastoid infection. These symptoms should subside in a day or so with the subsidence of the acute ear; but if persistent, they then assume the dignity of symptoms of real mastoiditis, and demand more attention.

In determining the diagnosis, first an inquiry into the history of the case should be made, and, where possible, accurate data kept.

In cases of long duration, for instance, two or three weeks, we would more than likely have a greater bone destruction than in a case of three or four days' existence. The fact that an attack is a second one would also call our attention to pathological changes that could have taken place in the mastoid, and we would likely find scierosed bone, indicating that pus forming in this particular case under pressure would be more apt to travel inward toward the brain than outwardly.

Inspection would be our first means of examining the case, and at a glance one could determine whether there was a swelling or redness over the mastoid. But the

mere presence of edema or redness over the mastoid should not be taken as conclusive evidence that there is mastoid involvement without a careful examination into the case and an inspection of the canal and drum. An acute otitis externa or furuncle of the canal gives frequently the same picture as that of a sub-periosteal abscess in mastoiditis, and where there is an association of mastoiditis and furuncolosis, the diagnosis is most confusing. Usually, though, traction of the auricle. pressure in the canal with the finger tip or probe, and pressure in front of the tragus is very painful in furunculosis, and in the absence of an acute otitis media there is likely an absence of a discharge.

An adenitis might cause post-auricular swelling, resembling swelling of mastoiditis; but it is usually superficial and rarely acutely painful.

The swelling of mastoiditis having progressed to the stage of pus formation or not, usually begins in the postauricular fold. It may be of two kinds, viz.: a periostitis, with a subsequent infection of the surrounding tissues; or no tissue infection at all, but the spontaneous rupture of the cortex of the mastoid and the escape of the fluid contents subperiosteally. This is usually the case. This type of mastoiditis with marked swelling, the auricle greatly pushed forward, marked fluctuation, and some pain, alarms the general practitioner; often frightens the aurist, and he is impressed with the idea that the patient is in great danger. As a matter of fact, such a case is in less danger than if the cortex had not ruptured, where the pent of pus under pressure between the two tables of bone is only waiting for the point of least resistance to give way and an intracranial complication results.

I had occasion, a few years ago, in a large New York

hospital, to assist in or operate upon 271 cases of mastoiditis. Swelling as a symptom in that series did not occur in but 133 cases or about fifty per cent. Of this number of 133 having swelling, eighty-eight, or sixtysix per cent., had reached pus formation.

Swelling usually occurs as an early symptom in children and infants, as does also the formation of a subperiosteal abscess, and it occurs as a late manifestation in adults. The statistics in this series that I have collected corroborates this statement. Where a sub-periosteal abscess had formed in an adult it was evidence of a long-standing disease.

Frequently in cases of long standing, we find in the neck beneath the tip attachment of the sterno-mastoid muscle, swelling without fluctuation. It is hard, brawny, and it is only by a deep incision that pus is evacuated. This is called Bezold's mastoiditis, and it is due to the rupture of the inner plate of the mastoid tip in the digastric groove, and it usually occurs in cases of several weeks' duration.

Swelling, then, is not the commonest symptom of mastoiditis, by which one not an aurist can make a diagnosis. Some other symptom more frequently found must be sought, and palpation is that chief sign. The patient's side face or profile should face the operator, and while one hand steadies the head to keep him from drawing away, the thumb of the other hand is used to make pressure.

In many acute attacks of otitis media, there is during the first day or so, some pain in the mastoid, usually elicited on deep pressure over the antrum. This character of pain might be compared to the intense neuralgic pains present in the ethmoid cells or the frontal sinus, during an attack of acute coryza. In the acute ear in