common being mania, melancholia, and various forms of depressive psychosis.

It is stated by most authors that these conditions are more frequently met in women than in men, and while I have no desire to contract this statement, yet my own personal observation and experience rather indicates the opposite view to be correct.

Many of these patients hesitate in the beginning to speak plainly of their difficulties and fear, and yet if the physician will exercise ordinary care, and put forth the usual spirit of kindness, he will experience but little or no difficulty in gaining the entire confidence of the patient and securing a clear history of his difficulties, and if the patient is a bright and intelligent individual, as very many of them are, frequently the statement that he has suffered greatly in fearful anticipation of a nervous breakdown, and a foreboding of a decidedly uncertain future. Many individuals in such a depressive state develop a marked suicidal tendency, this tendency being rather more noticeable in men and women who happen to be parents, than others, and just in this connection I am reminded of a case which came under my notice, that of a married woman, thirty-five years of age, with an excellent family history, and previously perfectly healthy, mother of two bright little girls, who with her husband and children occupied a comfortable and pleasant rural home, with little or nothing of a domestic or business kind to mar their happiness, quite unexpectedly, developed a mild depressive psychosis, with a decided degree of anxiety, which difficulty, by the way, was apparently perfectly curable. She possessed, during her depression, a suicidal tendency, and showed marked anxiety for the future welfare of her children, and while her friends were very strongly impressed with the importance of having her placed at once in some good hospital or sanitarium, and in the hands of a good competent neurologist, who had modern hospital facilities at his command, one well qualified to do the best possible for her, yet a delay of several days occurred while giving the family pyhsician, as friends expressed it, a chance to cure the case if possible. The family physician, an excellent gentleman and a very thorough physician, did not want this opportunity, however, and strongly advised against it. During this delay the patient wrote a neat, intelligent little note to her husband, advising that she thought it best to end all, so far as her own earthly career was concerned, and also stated she could not gain her own consent to leave behind her

children motherless and in the care of others; then carefully placed this note where it could be found later, and threw her two little ones into an open well and jumped in following, where the three bodies were found soon after, which discovery completed the story.

This case, in addition to giving further evidence of the great importance of a very early diagnosis and early care and treatment in these patients, verifies the statement which has often been correctly made that mental cases cannot, as a rule, be treated in their home, even under the most favorable conditions.

A very serious obstacle in the care of these incipient cases is, on the one hand, the fact that friends feel the patient not sufficiently ill to be passed upon by a county insane commission and committed to a state asylum, which action is necessary in most states before a patient can be admitted to a state hospital for the care of mental cases; furthermore, there is a natural prejudice against the necessity of having the fact that the patient is insane certified to by the necessary county authorities or individuals making up the usual county insane commission, and having the same become a matter of court record. This is usually thought to place a stain upon the patient and his family which will cling to them for all time, and even though this prejudice may be unwarranted and very unwise, yet it is very strong, and not infrequently sufficiently so to stimulate relatives and friends to permit of much unnecessary delay, and in that way valuable time is often lost, and incipient cases not infrequently converted into more confirmed or even incurable conditions.

On the other hand, the friends of such patients often feel themselves unable to meet the expense necessary in having the patient cared for in a modern private sanitarium or a hospital equipped for the treatment of such cases, hence permit of more or less delay in getting the patient properly cared for.

A few of the large general hospitals in this country are maintaining wards or departments for the care and treatment of mild and incipient mental cases, and admit also a large number of confirmed insanity cases, caring for them temporarily, and in the most modern way, and if within a reasonable time such patients do not show signs of satisfactory improvement, they are then passed upon by the usual commission and transferred to the department for insane, or to a hospital caring for mental cases only. In this way a large number of incipient, mild, and

curable mental cases, where friends are not willing to have them adjudged insane and sent to a state hospital in the beginning of their mental disturbance, or are unable to meet the cost of having them cared for in a modern private sanitarium, receive early and satisfactory care and treatment, and show a very large per cent of recoveries in patients, who, under other and ordinary conditions, would have been committeed direct to a state hospital in the beginning, thus creating an insanity record in the case, to which so many strenuously object, or else perhaps permitted to drift into a chronic or incurable condition, after which admission to a state hospital for insane is found necessary,and to remain there indefinitely, if indeed not to spend the balance of their lives in such an institution. Many state hospitals throughout the country are perhaps only fairly equipped for the proper care of incipient cases, due largely, I believe, to the fact that usually the state is more inclined to practice commercialism rather than scientific medicine, and yet state insane hospitals and asylums for the care and treatment of nervous and mental cases throughout this country today are, in the main, admirable institutions and compare very favorably with the best of the kind throughout the world. It may be safely said, however, and to their credit, that the vast majority of state hospitals in the middle west for the care of mental and nervous diseases are at this time modern and well equipped, and a very large amount of excellent work is being done and good results obtained.

In conclusion, I desire to emphasize the vast importance of the early recognition of nervous and mental diseases, and their early and judicious treatment, and while it is by no means absolutely essential that each and every patient be placed in an expensive private institution or sanitarium for the care of nervous and mental cases only, yet the great importance of desirable and modern hospital facilities and care, with the most pleasant and cheerful surroundings, cannot be overestimated.

Mastoid Abnormalities (Structural)

*By WILLIAM F. CALLFAS. C. M., M. D., Omaha.

EXTERNAL SURFACE.

The external surface is usually convex, but may be flat or

concave.

*Read before the Nebraska State Medical Association, Lincoln, May 7-9, 1912.

A few weeks ago I saw a mastoid of a child, three years old. The external surface was concave, still there was a considerable space between the internal and external plates.

THE CORTEX.

The cortex is usually thin, especially in children, and gives way to suppurative inflammation.

The cortex may be thick and dense and not give way to a suppurative inflammation. This class does not show the external signs easily, viz: Mastoid tenderness, superficial redness, oedema and later subperiosteal puss.

THE MASTOID CELLS.

These vary greatly, both as to size and position. They may be very large or very small or altogether absent. I saw a case a year ago last winter in which the cells were very large. The subject was a man about sixty years old. The mastoid, as to the external appearance, was about the average size. On removing the cortex, the cavity was very large and composed of only a few cells, separated by frail partitions. The cells may be very small, or may be altogether absent. Kopetsky reports a case in which the external surface and landmarks were perfectly normal, but there were no cells at all. The cerebellum being covered only by the external plate in the mastoid region, an operation was performed, the external plate removed, which exposed the cerebellum.

The mastoid cells present great variety as to their location. They may extend far into the zygomatic root, under the lateral sinus, far behind the lateral sinus, or far into the petrous portion of the temporal bone.

Mosher reports a case on which he did a mastoid operation on one side though both sides had been suppurating, and upon irrigating the operated ear the fluid ran out of the opposite ear, showing a communication between the two temporal bones through the petrous portion.

Mastoid cells communicating with the sphenoidal sinus. Wells, Chicago, has a specimen, in this case, where the mastoid or ear was irrigated, the fluid ran out through the nose.

Mastoid cells communicating with the jugular process of the occipital bone.

In 1907, while doing some work on the mastoid, I found a chain of cells connecting the mastoid with the jugular process of the occipital bone; these cells were quite large (considering the location) and easily broken down. The jugular process was

completely honey-combed, made up of cells and covered only by a thin layer of cortex.

I called the attention of some of the leading ear specialists in Omaha and St. Louis to this specimen. It was the first of the kind that they had seen.

In such a case suppuration could easily extend into the jugular process of the occipital bone and infect the lateral sinus and bulb.

Since exploring this case, I examined some forty others and found that in about 30 per cent a chain of cells connected the mastoid with the jugular process of the occipital. I took into consideration only those cases in which it might be said that a suppuration, occurring in the mastoid, could extend into the jugular process through the connecting cells. I think this a very important and interesting class on account of the close relation of these cells to the lateral sinus and bulb. I have failed to find any literature on this class.

LATERAL SINUS.

Otto J. Stein, Chicago, and Beyers, each report a case in which the sinus was double.

I saw one case of double sinus, but did not get a chance to follow it up, as the patient lived.

Lateral sinus completely filling the mastoid, except the tip. I operated on a boy 7 years of age and on removing a thin cortex pus was found covering what appeared to be a large cell. On removing more bone, it was found that this mass filled the mastoid except the extreme tip. This mass proved to be the lateral sinus. It was more than twice the usual width.

The lateral sinus may be very superficial and lie close to the plate separating the mastoid from the external auditory meatus.

I have a specimen which I removed from a subject a year ago last winter. In this the sinus passes forward to the auditory plate, then curves down at right angles. The sinus at this point was covered only by a thin layer of cortex.

In such a case it would be impossible to get into the autrum, without exposing the sinus.

THE PETROSAL SINUS.

C. M. Robertson, Chicago, has a specimen showing the superior petrosal sinus passing into the mastoid cells, with no bony covering, passing through the cells and re-entering the cranium just before entering the lateral sinus.