products, the removal of actually necrosed tissue either bony or soft, and the establishment of free drainage from all the affected parts.

This does not mean the radical operation so frequently described in medical literature in the past few years, and so well known by every physician of the present day. In fact, in my own opinion, the employment of the radical operation in cases of acute mastoiditis is actually criminal and has been the cause of many deaths in the ten years just gone by. The operation that will, with the least destruction of tissue, and with the least opening up of new territory for infection, produce complete drainage to the affected parts and stop short the destructive pressure necrosis, which is always going on in these cases until relief is given, is the operation par excellence.

A brief description of the procedure followed by my partners and myself, for several years past, in our work at the St. Joseph's and General hospitals and which have resulted in no deaths in uncomplicated cases, may not be out of place at this point.

The patient having been prepared in the usual way for a mastoid operation, the hair having been removed for two inches or more around the mastoid and the parts made as clean and aseptic as possible, the patient is given a general anesthetic and is ready for the operation. If these preparations can be begun twenty-four hours before the operation and an antiseptic dressing worn in the meantime, so much the better. However many of the cases are not seen until so late that delays are dangerous and consequently are operated on as soon as proper preparations can be made.

Beginning at the tip of the mastoid a cut is made one quarter inch behind the auricle, through the skin, soft tissues and periosteum to the bone. This is extended upward in a slight curve to a point nearly even with the top of the auricle. The periosteum is then separated from the bone forward and backward, and retractors put in place so as to draw the soft tissues and periosteum completely out of the way, exposing the denuded surface of the mastoid and the outer part of the porterior wall of the external auditory canal. I prefer Dr. Alport's automatic retractors as they allow your assistant to do more important work and at the same time by their constant pressure they stop the oozing of blood which is often so annoying and causes so much interference with rapid work in these

cases.

Always examine the exposed bony surface with a probe for

an opening, a sinus or fistula, leading into the antrum and if found, this gives a sure guide to follow for entrance into the antrum. If no opening is present, being guided by the landmarks given in the text books, with chisel and mallet, an opening should be made through the outer table and the cancellous bone beneath, directly into the antrum.

The antrum once reached, the point of vantage has been attained from which further procedures can be decided upon. The outer table should now be removed, either with chisel or strong bone forceps so that the entire cavity of the antrum is completely exposed. This cavity should be cleaned of its contents, usually pus and granulation tissue and the walls carefully examined to determine the amount of damage already produced by the disease. If the walls are in fairly good condition the opening through the anterior wall into the middle ear should be sought out with a bent, blunt probe and any granulation tissue at the mouth of this opening curetted away.

Never however, should the curette be allowed to pass into the middle ear for a few strokes of this little instrument in the tympanum can do more damage than weeks of a purulent otitis media may have done before. Light packing of the antrum with strings of antiseptic gauze to insure good drainage and prevent too rapid healing of the soft parts, the examination of the drum membrane and usually the enlarging of the opening, the placing of gauze drainage in the external auditory canal and the case is ready for the outer antiseptic gauze dressing and bandage.

But in some cases, on examining the walls of the antrum, they are found already necrosed. When this condition exists, it is best to chisel off the outer table clear to the tip of the process, so that all of the cells can be examined and all dead bone removed.

The application of drainage and dressings as in the milder cases completes the operation. With the above simple procedures, the great majority of cases of acute mastoiditis will go on to rapid recovery and not only that but recovery with a fair amount of hearing preserved, which never can be where the radical method of operation has been employed. Out of a large number of cases that have come under our care in the last ten years, there have been no deaths except in one case which at the time of admission, was in a semi-comatose condition caused by a supurative meningitis. As a rule the recoveries were rapid, the patients being confined to the bed but a

few days and only in a very small per cent of cases were any further operative procedure found necessary.

Dr. F. S. Owen, Omaha.

DISCUSSION.

The radical operation in the mastiod is very seldom necessary, but I believe that what is called the complete operation is necessary in the majority of cases. The difference is that in the radical operation you undertake to clean out the middle ear along with the antrim. In the complete operation you remove all diseased bone and the whole mastoid. I do not think that the complete operation is more serious or more dangerous than the simple operation, that is, simply opening into the middle ear and depending upon drainage. I believe your whole duty is not done unless you follow up the area of softened bone. So frequently when you think you have perfectly healthy walls of your wound you will find a soft place and it will lead along then until you find a cavity containing pus. I believe the important thing in this operation is not to decide by the looks of the bone, but by the feeling of it, whether it is soft. All the soft bone should be removed. It prevents secondary operations.

I have been doing this for the last ten years and have not had to do a single secondary operation.

Dr. Bryant closing:

In acute cases of mastoiditis there are three things the surgeon should constantly bear in mind.

First Opening up the pus cavity wherever that may be so as to procure free drainage. Usually pus is found in the antrum, probably in 90 per cent of the cases. After the antrum is once opened the operator is master of the situation, as from this point of vantage he can explore in all directions and open up any other territory that may have become involved in the suppurating process.

Second-It should always be remembered that the greater part of the necrosis in these cases is caused by the pressure from the pent up pus and removing this pressure early allows some of the partly necrosed tissue to come back.

Third-Every effort should be put forth to prevent extension of the infection to healthy tissue, so great care should be exercised not to open up parts of the mastoid that have not already become involved, as this simply invites farther extension of the disease.

Acute Head Injuries. with Special Reference to Nervous Symptoms.

*By F. E. COULTER, M. D., Omaha.

In this day of rapid transportation, when man must travel with the greatest possible speed through the air, or over land or sea, acute head injuries are not uncommon. Every practitioner of medicine, we care not what his particular branch, is liable to come face to face with such a condition at any moment.

The subject has not been discussed before this society for

*Read before the Nebraska State Medical Association, Omaha, May 2, 3 and 4, 1911.

some time; therefore, it may not be out of place to review some of the more recent observations in this connection; but to treat it exhaustively would be out of the question, in the time at our disposal.

We need not spend time to review the fact that the brain is one of the best protected organs in the body, or to tell you that under certain circumstances, it is apparently the most vulnerable.

The mechanism within the skull is the most delicately adjusted of all organs; hence, the most easily thrown out of bal

ance.

In this connection, you recall, no doubt, the quarryman, who had an iron bar, used as a hand-spike, driven entirely through his skull, yet survived with but little or no change in his capacity as a laborer; and you will also recall the old farmer who entered his chicken house after dark, and, as he was passing along near a perch upon which a rooster was resting, the bird gave him a peck on the head, which resulted in his death. Both are authentic, and serve to remind us of the extremes at least, that may be encountered in head injuries.

All acute head injuries may be classified under one of three divisions. First: Those apparently of no importance, trivial in extent, and not accompanied by complications, or followed by sequelæ. Second: Those followed by symptoms attributed to the injury, after varying periods of time, from a few minutes to a few weeks or months, perhaps. Third: Those, that from the beginning, are obviously surgical, and are accompanied by surgical complications of a pronounced and definite character, and are readily recognized as such.

The second and third class give the physician and surgeon the most concern, both from a medical, and often from a legal standpoint.

The first class is not devoid of many interesting possibilities, and is often taken advantage of by unscrupulous persons in both law and medicine. It is in this particular class that one must be on his guard if he would be just, both to the patient and to those responsible for the injury. Many an honest physician, and we might add, attorney, has been taken advantage of by this class of cases, through premeditated efforts of the parties interested.

The physician, surgeon or neurologist, when brought face to face with an acute head injury, should recall, at least to some extent, the anatomy and physiology of the parts with which

he has to deal, for certainly under no circumstances is such a review more important.

Too many of these injuries are diagnosed and treated as if the scalp and bone, especially the latter, was all there was to be considered, forgetting entirely that the brain tissue, blood vessels and nerve tissue beneath, are of paramount importance, and these should always be reckoned with. One must be in possession of at least a reasonably good general working knowledge of all the parts mentioned, if he is to be of intelligent assistance in such cases; also, the nature of the injury, its location and character, and the general surroundings are not to be forgotten.

For example: a head injury may be encountered where the bone is seriously fractured even at the base, yet the soft tissues may escape almost completely; or, on the other hand, the soft tissues may be seriously injured, but the bone and scalp escape, and then hemorrhage and oedema should always be thought of as a possible complication, recent or remote.

ETIOLOGY.

Etiologically, head injuries are the result:

First Of violence applied directly to the head, as in the case of a blow or a fall, the patient landing on his head.

Second: Of violence applied to some other part of the body, such as a fall, when one alights on his limbs or buttox, or some other prominent portion.

Third: It may be the result of a penetrating wound, such as that received from a bullet, a sword, or some other sharp instrument.

SYMPTOMS.

When we come to study the symptomatology of head trauma, we are almost overwhelmed; we find so many compli-· cations and combinations, as a rule; yet in rare cases, only a few symptoms may be present; in fact, only one may be apparent in a most serious trauma of this character.

As the brain is the seat of intelligence, we would expect, naturally, and rightly, too, that this function should be altered to some degree, which is the case generally. This is evidenced usually by the impairment of consciousness, yet fatal brain injuries may occur without the loss of consciousness, but such

are rare.

This multitudinous symptomatology may be divided for sake of convenience into four groups: mental, surgical, cerebral, (including focal) and general.