The initial incision in the membrana may be made with a sharp-pointed knife (Fig. 4, B), but further cutting should be made with a blunt-pointed one (Fig. 4, A). The incus is best detached from the stapes by means of the incus hook-knife (Fig. 4, D), and if adherent to the attic should be turned forward, into the front and lower part of the drum-cavity, by means of an incus hook knife with a longer and blunter blade than. that for detachment of the incus from the stapes. When the incus is en tirely freed from its attachments it may be drawn from the drum-cavity by the blunt incus hook-knife, or by means of the foreign-body forceps of Sexton's pat tern.
ht no case should the drum-cavity be curetted, as such a procedure is very likely to wound the facial nerve and in duce facial palsy. It is, furthermore, un necessary, as g,ranulations will disappear and denuded bone-surfaces be covered in with new membrane, under proper antisepsis.
After removal of the diseased rem nants of the membrana and ossicles the ear should be mopped with an antiseptic I like alcohol or a solution of bichloride (1 to 5000) or formalin (1 to 1000), the meatus stopped with a light tampon of sterilized gauze, and the ear let alone for twenty-four hours. If the gauze in the ear becomes moist with blood or bloody serum, it should be removed and a dry dressing put in the meatus—not far in the canal. In all cases the discharge diminishes at once, and ceases entirely , in the majority of cases within a period ranging from a month to eighteen months. The after-treatment should consist in mopping the discharg.e from the ear and the instillation of a formalin solution (1 to 1000) from once a day to once a week, according to quantity and frequency of the discharge.
The hearing improves to varying ex tents, the general health of the patient is rendered better, and he is freed from the danger of extension of the suppura tion to the mastoid and cranial cavities.
Chronic Mastoiditis. — Chronic mas toiditis the result of chronic suppuration may, like the latter, continue a long time without caries and necrosis of either the medial or the lateral plate of the mastoid cavity. In many instances the latter cavity becomes the seat of a cho lesteatoma as the result of the long-con tinued suppuration in the middle ear and mastoid antrum.
It may be safely assumed that in every case of chronic suppuration in the drum cavity there is a concomitant suppura tion in the mastoid antrum, and some times, also, in the mastoid cells. If the
chronic tympanic suppuration can be controlled or cured the lesions in the mastoid antrum are also cured at the same time. As has been said, ossicu lectomy is the best way of curing chronic suppurative otitis and warding off or curing mastoid disease. However, many cases of chronic suppuration are either not treated at all or improperly treated, and the mastoid cavity becomes more in flamed; i.e., its mucous membrane more infiltrated and its drainage defective.
Symptoms.—The disease may now take one of two courses, rarely both: Pain in the mastoid, with headache and fever, without any external mastoid symptoms, may indicate an irruption of pus either into the lateral sinus and posterior cranial fossa or forward into the middle cranial fossa. Or pain in the mastoid and fever may be followed by tenderness and swelling of the outer mastoid sur face and spontaneous opening of the cor tex, with escape of pus beneath the dense tissues of the cutaneous mastoid region.
To diagnose mastoid disease a small stethoscope is placed over tbe tips of the mastoid, and the handle of a vibrating tuning-fork over the antrum. If the cells are obliterated or filled with pus or gran ulations the sounds are much more per ceptible than ou the opposite or healthy side. Andrews (Jour. Amer. Med. Assoc., Jan. 26, 1901).
Treatment. — An incision should be made and the pus evacuated. The osse ous surface should then be fully exposed and the opening in the bone discovered. This should be followed, the bone well chiseled away, and the mastoid cavity thoroughly explored, all diseased tissue, both soft and hard, being removed. If the inner wall is intact, the cavity may be allowed to fill with blood (Blake), the wound drained and stitched, and healing by first intention sought. If, at the same time, all diseased tissues in the mid dle ear can be removed, entire recovery from the chronic purulency niay be ex pected. If, after exposure of the mas toid and middle-ear cavities, a sinus is found leading to the cranial cavity, the mastoid operation represents but the pre liminary to an operation upon the cranial cavity. No operation upon the enceph alon for an otitic lesion can be consid ered complete until the mastoid and mid dle ear have been opened and the path way of disease from the ear to the brain sought and followed, and the septic nidus in the drum-cavity and the mastoid per manently removed.