When these measures fail to deodorize, success can sometimes be obtained by filling the ears with a fluid of less surface tension than water. A mixture of alcohol and ether may penetrate into crevices inaccessible to the syringe. It is especially when this alcoholic instillation is followed by an ear bath with carbolated glycerin that an occasional success is obtained in deodorizing the discharge. As soon as the odor has been removed, the case may then be regarded as one of the simple type, without retention, and will, as a rule, heal under the previously described treatment. The healing, however, is apt to require more time.

When all these attempts have failed to remove the fetor, the author can recommend one other measure previous to surgical intervention. This is the drainage of the secretion by capillary absorption through a gauze drain. The meatus is packed with a sterile strip of gauze placed in contact with the drumhead, or even the tympanic lining, and replaced by another before it has become completely soaked by the discharge. This method introduced in the treatment of chronic purulent otitis by N. Pierce proves successful in the end in a number of instances which would otherwise be incurable except by a radical operation. The action of the gauze drain is peculiar. The discharge is often increased. slightly at first. It then diminishes gradually without losing its offensive odor until the gauze remains dry. This may take from two to four weeks, or longer if the treatment has not been carried out properly. If a relapse occurs after the odor has once disappeared, the pus is odorless. The various measures may all be combined in the interest of the patient. There is no objection to beginning with gauze drainage at the first treatment. Every effort possible, however, should be made to dislodge pent-up pus from the beginning. For as soon as deodorization of the discharge shows success, precious time has been gained, while if this has failed, the gauze drain has in the meantime begun its influence. Even

after the stagnation of pus has been obviated these cases may prove very slow in healing. But, on the other hand, it is no great hardship to a patient to come once in four or six days for a fresh packing, even though some months be required. When the gauze is left in the meatus for many days it should be kept aseptic by powdering it freely with a mixture of boric and salicylic acids. The longer the time required for the cure of the suppuration, the greater the probability of a relapse at some future time. But even by means of a radical operation we cannot give these patients absolute exemption from relapses, and in the meantime we can at least assure them that they are free from danger as long as the ear stays dry, and practically so if they submit to treatment at once in case of relapse.

381. When it proves impossible to remove the odor, or even when the odorless discharge does not yield, which is very exceptional, we must decide whether—(a) to desist and wait, (b) remove the ossicles, (c) open the antrum, or (d) perform a radical operation. To desist from further treatment means to keep the patient in constant jeopardy as long as the fetor shows stagnation of pus. If, however, efficient drainage is proven by the absence of odor, the danger of waiting indefinitely while packing the ear aseptically is probably no greater than that of any operation. With aseptic packing such cases will generally heal in the end.

The removal of the ossicles (see ¶ 346) cures those instances in which pus stagnates in the pockets and recesses of the attic, and especially those in which the ossicles themselves are carious (385). A small perforation in Shrapnell's membrane is strongly suggestive, though not proof positive, of caries of the anvil or hammer or both. A larger destruction of the flaccid membrane, especially if it extends to the periphery, points to caries of the walls of the attic. We cannot foretell, however, in any such case whether the mastoid antrum is involved or not, and hence ossiculectomy,

while usually beneficial, is not always curative. When the pus is abundant we can almost surely expect disease of the antrum. The operation of ossiculectomy is free from serious danger in the hands of the expert. If the stapes is accidentally dislocated, distressing dizziness may follow for many days. Ossiculectomy rarely injures the remaining hearing power, but often improves it to a moderate extent. The operation is usually too painful without general narcosis in purulent cases. In the case of a narrow meatus it cannot be done without temporary resection of the cartilaginous portion. This makes a larger operation, and in such cases it is better to do the radical operation at once.

382. Opening the mastoid (¶ 370) cures the majority of cases of otherwise incurable suppuration of the attic and antrum. In these chronic instances, however, the after-treatment is sometimes very tedious and protracted through months. It should be the preferred operation in those instances in which the persistence of good hearing makes it desirable to save the ossicles. It may also be done when the ossicles have been entirely destroyed previously by disease. Simply opening the mastoid is, however, not so sure of success as the radical operation, but, on the other hand, easier and perhaps a trifle safer. After establishing a large opening into the antrum, both this artificial canal and the meatus should be kept packed until all discharge has ceased. This may take from one to four months. In old chronic purulent otitis the mastoid is often found sclerotic, probably as the consequence of long-continued suppuration. It is hence usually more difficult to chisel into the antrum than in the case of fresh disease.

383. The radical operation is intended to convert the tympanic cavity, the attic, and the mastoid antrum into one large continuous cavity with unobstructed outlet. It should be done in all cases of inaccessible cholesteatoma or of chronic fetid suppuration otherwise incurable, especially, however, when urgent danger symptoms are pres

ent.

Of the various modifications of the radical operation, I will describe the one suggested by Zaufal as the easiest (compare mastoid operation, ¶370).

General narcosis. Detachment of the auricle and of the cartilaginous part of the meatus by a long, slightly

FIG. 143. The radical operation completed. Antrum and attic fully ex

posed and the two ossicles removed. Of the internal portion of the posterior wall of the meatus a slanting ridge is left intact in order to protect the canal of the facial nerve.

curved incision down to the bone from above the upper rim of the auricle to a point below the tip of the lobule, I cm. behind the insertion of the auricle. Elevation of the periosteum backward and forward from the incision

up to the cartilaginous meatus. Detachment of the latter from the rear, and transverse (vertical) incision with a tenotome through the posterior upper cutaneous wall of the bony meatus as far inward as possible. The partially detached cartilaginous meatus is pulled forward by the steady action of a small retractor placed in the meatus. The mastoid surface is now attacked by the chisel in the usual place-viz., immediately behind the meatus and a trifle above its center. But instead of merely making a funnel-shaped hole in the mastoid process, the chisel is directed against the meatus so that its upper posterior wall is gradually removed. The wound in the bone assumes thus the shape of a broad crater, the inferior and anterior boundaries of which are the normal inferior and anterior walls of the meatus. soon as the antrum is reached any bleeding granulations are curetted.

As

While at the external orifice of the wound in the bone the posterior wall of the meatus should be entirely removed, the lower part of the posterior wall must be scrupulously avoided as the surgeon approaches the tympanic cavity (Fig. 143), for otherwise the facial nerve and possibly the external semicircular canal would be wounded. The internal portion of the posterior wall of the meatus hence forms a slanting ridge along the floor of the cavity thus created. After the antrum is reached, small chisels are carefully used to cut away the external wall of the tympanic attic (upper wall of the meatus), so as to gain access to the entire tympanic space, until a curved probe meets with no obstacle in gliding outward from the roof of the attic along the upper (partly resected) wall of the meatus. During this part of the operation Stacke's guard (Fig. 144) may be used to protect the internal wall of the drum cavity (labyrinth and facial nerve) against accidental slipping of the chisel. The guard is held by an assistant after introduction into the drum cavity. The patient's face should be watched continuously by the assistant, in order to call attention