to any twitching of the facial muscles indicative of irritation of the facial nerve. Whenever feasible, delicate bone nippers may be used from the antrum forward to remove the bone in fragments. Finally the entire tympanic space, including its attic, becomes accessible, and on account of the previous removal of the cartilaginous meatus it can be well inspected with good illumination without head mirror. The two ossicles are now removed with forceps after severing their adhesions with small knives. Wherever granulations are found they are curetted off under the guidance of the eye from within. outward. Curetting blindly is too dangerous. The stapes should not be touched unless found denuded.

SHARP SMITH

FIG. 144.-Stacke's guard for the protection of the facial canal and labyrinthine wall in the radical operation.

After the removal of all diseased tissue the posterior membranous wall of the meatus is slit longitudinally from without inward, so that the two flaps can apply themselves to the posterior upper bony surface of the surgical channel.

In case of cholesteatoma, or when it has been found impossible to remove all diseased tissue with certainty, or in case of dangerous symptoms, the retro-auricular opening is left open and drained. Otherwise it may be closed by sutures and the after-treatment carried out through the meatus. Very careful packing with gauze is essential. The directions for changing the gauze are the same as in the case of the ordinary mastoid operation. During subsequent dressings any

adhesion of the gauze strips in the depth of the wound can be overcome in the gentlest manner by instilling peroxid of hydrogen solution. The cicatrization of the extensive cavity may be materially hastened by placing Thiersch grafts upon the exposed bone, either at the end of the operation or as soon as satisfactory cicatrization is in progress. Still it never takes less than three to four weeks, and not rarely as many months, before cicatrization is complete and all discharge has ceased. Considerable care is required during the aftertreatment. Excessive granulations must be curetted or touched with nitrate of silver. Careful packing is indispensable up to the end. After the discharge has ceased the patient should stay under observation for many weeks with periodic inflations of boric acid.

A properly done radical operation is absolutely curative, but it is not always possible to remove all diseased bone at once. The loss of the odor indicates whether the operation has been thorough or not. Even when some odor persists it will now yield gradually to packing. No radical operation, however, can give an absolute guarantee against a future relapse of suppuration. But with all obstacles to drainage removed, and nothing left but a clear space, such relapses are not likely to prove serious or rebellious to very simple treatment. The radical operation does not often injure what hearing there is left, and, indeed, may improve it moderately. Injury to the facial nerve, a deplorable accident, has happened occasionally in operations done by expert surgeons.

The form of radical operation described above is the one suggested by Zaufal, which I personally consider the easiest and safest for the less experienced operator. Nearly at the same time Kuester, Zaufal, and Stacke (1889 to 1890) advocated a more radical operation than the mere opening of the mastoid in chronic cases, by removing at the same time the posterior wall of the meatus and the external wall of the attic. Stacke's operation is primarily intended for the removal of the ossicles.. The auricle and cartilaginous meatus are detached, and the superior wall of the meatus is chiseled off until no barrier is left in front of the

attic. After cleaning the attic the mastoid cavity is explored through its aditus, and if found diseased is opened by chiseling away the posterior wall of the meatus. Most surgeons, especially in this country, prefer to remove the ossicles through the intact meatus when the anatomic conditions are favorable. Hence Stacke's operation, as mostly done, is really a radical operation with slightly modified technic.

A number of modifications have been devised in the plastic part of the operation, in order to cover the exposed bony surface. Among the most serviceable plans is that of Siebenmann. He does not keep the retro-auricular opening patent as such, but combines its orifice with the meatus by using the skin of the concha as a lining. The detached meatus is slit longitudinally in the center of its posterior wall, and from the external end of this slit a cut is made downward and another upward through the concha, so that the entire incision has the shape of a horizontal Y. The cartilage is thereupon resected from the posterior surface of these flaps, so that they can be completely adapted to the exposed bony surface of the wound, being held in place by tamponing.

As far as the bony surface is surely healthy it may be covered with Thiersch grafts at the time of the operation, which are kept in place by the tampon. In the deeper parts of the wound grafts should be used only after longer observation has shown normal healing without the presence of any bone disease or focus of suppuration.

CHAPTER XLIII.

LOCAL COMPLICATIONS OF CHRONIC PURULENT

OTITIS.

POLYPI.-CARIES AND NECROSIS OF THE BONE.-CHOLESTEATOMA.-PARALYSIS OF THE FACIAL NERVE.—

TUBERCULAR OTITIS.

384. Polypi are a frequent occurrence in chronic otitic suppuration. Granulation tissue in the form of red, elevated, easily bleeding patches is often seen in the tympanic cavity through perforations. When this occurs in the form of a tumor with a constricted pedicle, it forms a polypus. Polypi are made up of granulation tissue originally, but many in the course of time assume a firmer consistency by fibrillary transformation. They are lined. with epithelium and are quite vascular. They may resemble minute beads, being sometimes multiple, or may grow until a large reddish mass fills the whole meatus

FIG. 145.-A lobulated polypus springing from the upper part of the tympanic cavity and protruding through a large perforation in the upper posterior quadrant of the drumhead. The membrana tympani is thickened so that the manubrium is not visible.

(Fig. 145). They originate mostly from the attic; rarely from a carious spot in the wall of the meatus. They are often, but perhaps not always, indicative of caries underneath. When cut off incompletely, they are apt to grow again. Their removal should hence be thorough. Cocain and suprarenal solution make general anesthesia

superfluous. The most satisfactory instrument is a delicate snare (Fig. 146), the loop of which grasps the growth next to its base. The best wire is the thin flexible iron wire used by florists. The base should then be curetted. Cauterization is generally superfluous, except when the base is inaccessible to the curet in the attic. A suitably bent probe upon which a bead of chromic acid has been melted can then follow the path of the polypus to its base. The excess of the acid is removed by a solu

FIG. 146.-Blake's polypus snare.

tion of bicarbonate of sodium. It is worth remembering that small polypi may disappear without operation under boric acid insufflation, provided there is no stagnation of pus.

385. Bone disease is a frequent complication and often the cause of the persistence of chronic otitis, especially in poorly nourished subjects. Relatively rare in the simple form, it is very common when there is stagnation of pus. The more usual form of the disease is caries, while the necrotic separation of a sequestrum is much less common. The most frequent seat of caries is in the ossicles, especially the long process of the anvil; less frequently the head of the anvil or the head of the hammer. The destruction of bone is not a passive corrosion by pus, but a true ostitic ulceration. Caries of the head of the hammer is indicated usually by a fistula in Shrapnell's membrane. Destruction of the anvil may be suspected when the greater part of the membrana tympani is destroyed, or in case of perforation at its upper rear border. Less commonly than in the ossicles caries is found in some area of the tympanic wall; sometimes even in the