toid cortex, and then with chisel, hammer, gouge, curet, and rongeur, opening up the mastoid antrum and removing all diseased tissue, and let the wound heal by granulation. This operation did not directly open the middle ear, nor could one by this procedure remove diseased tissue from the middle ear. For this reason it was found that when the middle ear was involved and contained diseased tissues needing removal the Schwartze operation was inadequate and often left the patient uncured.

The Stacke operation was devised, and originally intended, to open up the middle ear cavities, attic and atrium, to surgical procedures. Its primary purpose did not include the opening of the antrum. It was, and is, especially applicable to the removal of diseased processes, such as caries, cholesteatomata, granulation tissue, etc., from the middle ear. It consists, in brief, in an incision over the mastoid, laying bare the bone, separating the membraneous meatus from the bony canal, removing the postero-superior wall of the osseous meatus down to the tympanic cavity, the removal of the external attic wall, and having thus gained a free entrance into the middle ear cavities all diseased tissues are to be removed. But it was found that in these chronic suppurative processes the antrum was often involved, so that the operation was gradually extended backward so as to open up and clean out the mastoid antrum and cells. By this operation the middle ear and mastoid antrum and cells are converted into one common cavity. Thus the Stacke operation was originally a middle ear operation, not a mastoid operation; but was gradually extended so as to include the mastoid. The plastic feature, dressing, etc., will be considered later.

The Radical operation, as gradually evolved, is intended to open up and clean out both the mastoid process and middle ear. It is indicated in the acute, but more especially in the chronic, suppurative processes characterized by the development of cholesteatomata, cario-necrotic changes, etc., both in the antrum and middle ear. It consists in an incision over the mastoid down to the bone, laying bare the cortex, separating the membraneous from the osseous meatus, removing the mastoid cortex with the external part of the posterior wall of the osseous meatus, opening and

cleaning out the antrum and surrounding cells, removing the external attic wall, throwing the tympanic and mastoid cavities together by the removal of the external wall of the aditus ad antrum and the removal of all diseased tissue of whatever kind. Thus by the Radical operation, as by the Stacke, the middle ear and mastoid antrum and cells are converted into one common cavity.

In what then does the difference between the Stacke and the Radical operations consist? Principally in two things:

I. In the manner they are performed. In the Stacke the middle ear is first opened and afterward the mastoid; while in the Radical the mastoid is first opened and afterward the middle ear.

2. In the size of the wound and the distance to which it extends posteriorly. In the Radical operation the wound is larger and extends further back, thus making the Radical more suitable for cases with cerebral complications, as the cranial cavity can be more easily reached and opened.

The Modern mastoid operation, as recently described in an elaborate monograph by Whiting, is essentially a Schwartze operation, differing from the latter only in some details of technic, and in being more thorough in execution. Like the Schwartze operation it does not open the middle ear.

The plastic part of the Radical and the Stacke operations, as I have most often seen it done in metropolitan clinics, is carried out after the method of Panze. The membraneous meatus is slit lengthwise, the end near the concha met by a transverse incision, and the flaps so formed, having been freed from cartilage, are placed, the one against the upper, the other against the lower wall of the bony cavity. Thus epidermization is facilitated, stricture of the meatus is prevented, and the common cavity made by the operation may be inspected and treated through the external auditory canal. The retro-auricular wound may be closed immediately or left open temporarily or permanently as conditions require. Many variations from the operations, as above outlined have been made as the result of individual ingenuity and initiative on the part of the operator, and the necessity to meet ever varying

pathologic conditions.

Of the details of technic, the dangers of the operation and the extension of the procedure to the cranial cavity and its contents time does not permit me to speak.

In conclusion, I beg leave to report a recent case of

MASTOID SUPPURATION WITH THROMBOSIS OF THE LATERAL SINUS; OPERATION; RECOVERY.

History. Millard Plelps, male, aet. 19, single, laborer, white. Previous health good until March 20, 1906, when he had an acute suppurative inflammation of the left middle ear, with purulent discharge, followed by what his physician diagnosed as typhomalarial fever. No charts or written records were kept of the fever, but he is said to have had chills with a variable temperature, marked prostration, loss of appetite, etc. This condition, along with the discharge from his ear, continued for about four weeks, the patient being sometimes in, and sometimes out, of bed.

Monday, April 16, 1906, he was feeling much better and wished to go down town, but was restrained by his parents. Monday evening a severe pain developed in the left side of his head. This was followed, during the night, by profound coma and repeated convulsions. Early Tuesday morning Dr. Deering J. Roberts was called in consultation. Dr. Roberts found the patient in profound coma and witnessed some of the convulsions. He diagnosed mastoid disease with cerebral complications, and advised an immediate operation.

There was coma and the

I saw the case Tuesday at noon. general appearance of the patient was most grave. I was told of Dr. Roberts' diagnosis and proposed treatment. Externally the mastoid appeared absolutely healthy, tenderness on pressure could not be elicited because of the coma, and there was a slight discharge of pus from the ear. Under such conditions and with a moribund patient, I hesitated to operate. But Dr. Roberts insisted, and the patient was sent to the City Hospital, prepared, and operated on at 3 o'clock Tuesday afternoon.

The mastoid antrum and cells were opened and cleaned out. The bone was discolored, softened, and macerated. There was no general pus cavity, but the individual cells were filled with pus and necrotic tissue. The bone was removed down to the lateral

sinus, which felt hard and was found to be perforated. probe was easily passed through the perforation into the sinus, and its removal was followed by the escape, not of blood, but of pus. The incision was enlarged, and the bone over the lateral sinus was removed backward for more than an inch in the direction of the torcular. The sinus was now exposed for about two inches. It was gray in color and hard to the touch. With scissors the exposed sinus was now slit up for about two inches. The sinus contained a firm, rather white, thrombus and some pus. These were removed with the curet, and the instrument pushed on through the sinus toward the torcular for more than an inch and the vessel curetted. Pus and fragments of the thrombus were removed, but no blood. Next the sinus was curetted in the direction of the jugular vein as far as the curve in the vessel would permit the instrument to pass.

The patient was now moribund, and was, in fact, with the greatest difficulty kept barely alive by the use of all forms of artificial stimulation, including everything from adrenalin to hypodermoclysis. The angles of the incision were hastily stitched, the wound packed with iodoform gauze, dressed, and the patient put to bed. As the patient recovered from the shock neither coma. nor convulsion remained, nor have they since reappeared. The pulse and breathing rapidly became, and have since remained, about normal. Only once, on the ninth day, did the temperature reach 101°, and then only for a few hours; in general the temperature was normal. From the time of operation to the present, just six weeks to-day, there has been only one unpleasant symptom; and that was a mild attack of amnesic aphasia, which developed on the seventh day after operation, and which was much better three days later, and has since gradually and completely disappeared. The wound is now almost entirely healed, and the patient otherwise apparently perfectly well.

The following points in this case would seem to be of interest:

1. The supposed typho-malarial fever with which the patient suffered for four weeks before the operation was, in my opinion, really a septicemia, due to an infected thrombus in the lateral sinus.

2. That notwithstanding the thrombus and septicemia the patient was up and wanted to go down town the day before coma and convulsions developed.

3. The brilliant diagnosis made by Dr. Deering J. Roberts, when the patient was in profound coma, and with only an imperfect history, and with no external evidence of mastoid disease; and his wise decision to have the mastoid opened.

4. The successful recovery, so far, shows the error in Schwartze's original teaching not to operate after the development of cerebral symptoms.

THE SURGICAL TREATMENT OF DUODENAL ULCER; WITH A RESUME OF THREE OPERATED CASES.

BY WILLIAM D. HAGGARD, M. D., OF NASHVILLE, TENN.

IN the last seven months the writer has had under observation eight cases of duodenal ulcer (one post-operative which was diagnosed by him eighteen months ago); three cases were operated upon with recovery. Two cases were referred to Dr. W. J. Mayo for operation. One was treated medically with, at least, temporary cure; another, a physician, has deferred operation, and the last was a fatal hemorrhage in a young woman in which the diagnosis seemed to be fairly certain. Three were females, aged thirty-three, twenty-four, and seventeen; and five males, aged sixtytwo, forty-six, forty-three, forty-two, and thirty-three respectively.

The duodenum is unique in its functions. It acts as a vestibule for the small intestine and is a meeting ground for the acid stomach ingesta and the alkaline biliary and pancreatic secretions. The four inches above this point partakes of the character of the stomach and its ills, and is more frequently diseased than any other part of the intestine of equal length, save the rectum. denal ulcer is much more serious than gastric ulcer. The coats are much thinner and the danger of erosion of large blood vessels is much greater and the likelihood of sudden death from perforation makes it a very fearful malady.

Its symptoms are not so frank, and when present are either *Read at the Annual Meeting of Tennessee State Medical Association, at Memphis, April 1906.