The operative procedure in opening the mastoid and antrum cavities in chronic intramastoiditis, by means of hammer and chisel, resembles that de scribed for trepanation of the mastoid in acute mastoiditis. It must be borne in mind, however, that in a case of acute intramastoiditis in an ear previously free t , t shall lind a much L 1, • torttx than would be found in . the -tat of chronie purulency.
t. t l'rst instance it is preferable to ti• tlie point of trepanation at the s• raii,tatal triam:de and aim at once fi r t t antrum. We make no effort t. txt o-t the attic and middle ear and d -tur the o=sieles, lest we destroy the thouLdi we arrest the purulency.
throinc purulent intramastoiditis, a result of chronic purulency of tl t drum-cavity, the surgeon in chiseling ..ptn such a mastoid should follow any ,:..ntoneous opening. in the cortex al rtady irtsent, or open at a discolored or -4.,fttnt d spot in the cortex, and then aim ft r the antrum and middle ear, thor • explore the middle-ear cavities, and rtni..ve all diseased tissues, including tlie =liens and incus or their remnants, ,'.ut never the stapes in any ease. This knclet is very resistant to suppuration, and hence prevents the entrance of pus from the middle ear to the internal ear rind thence to the cranial cavity. To re im.ve it in chronic suppuration of the iniOdle ear would be to invite the en trance (.f pus to the internal ear and e.rayiequent grave disaster. Every mas toid cavity, and hence every case of ntrania:qoiditis, varies from all others. The surgeon must, therefore, prepare to ,lowly, picking his way until he has xf cr,ed enough of the outer wall of the tra,toid to see his way to the antrum or t, the mastoid cavity before reaching the ..n:r.ira, as is often the case in chronic .+ntramastoiditis. It should go without ;lying that no one should attempt a radical operation on the mastoid unless he has had ample practice on the ca daver. And he should also he able to penetrate the cranial cavity, by follow ing a septic pathway from the middle ear and mastoid cavities if one exist and relieve the nidus in the brain-cavity.
llallance's grafting modifieation of the radical mastoid operation. This consists of two operations: The first, to remove the disease, varies in some respects from the Stacke-Schwarze. The external in cision begins above and half an inch in front of the meatus, in the line of the hair, \\Ilia it follows backward and downward; then forward from the line of the hair to the posterior part of the mastoid apex. The skin is raised for a third of an inch toward the pinna, and then another curved incision is made down to the bone, the soft structures being raised as far as the edge of the bony meatus, as usual. The posterior wall of the bony meatus is removed, and the antrum, attic, and bony meatus are very thoroughly exposed and cleared out. 13allanee lays great stress upon the thor ough removal of the outer wall of the attic and the efficient curetting of the attic and antro-tympanie passage. The lining of the inferior wall of the canal is divided with a long and narrow knife, well into the concha, when the incision is carried in a curved direetion upward and backward to the level of the com mencement of the helix. The conehi meatal flap, formed by the posterior wall of the meatus, is then raised upward and backward and sutured to the mastoid llap by silk-worm-gut threads, raw sur face to raw surface. After the packing
of the cavities with iodoform gauze the external wound behind the auricle is closed by sutures, the ultimate scar be ing at the line of the hair.
The second. or grafting, operation may be done in children at the end of a week, but the interval in adults may extend to two or three weeks. In children, unless the wound is foul, the packing need not be removed before the seeond operation, although the outer dressing of gauze may be change.d. The day before the operation the gauze is removed from the meatus and other cavities. which are irrigated several times with 1 to 40 car bolic lotion. On the morning of the op eration the cavities are washed out three or fonr times with warm, sterile saline r:olution. The patient being again under a general ancesthetie, the external in cision is opened with the handle of the knife, the cavities are exposed, and any exuberant granulation-tissue, or other morbid product, removed from the gran ulating surface. All oozing of blood should be carefully and thoroughly ar rested by pressure with pieces of gauze. The graft is taken from the inner sur face of the thigh or arm with a large razor, the surface being first washed and then kept bathed in a normal saline so lution. The thinner the epithelial layer removed, the better, even thin to trans parency, and one large graft is better than several smaller ones. The surfaces upon which it is specially important to lay the graft are the roofs of the tym panum and antrum and the inner sur faces of the antrum, attic, and lower tympanum. The graft is carried on a microscopic-section lifter and, beginning at the outer edge of the anterior wall of the cavity in the bone, the thin, al most transparent, graft is then inssinu ated inward from the section-lifter by a probe. A steel probe with pear-shaped head presses the graft into the recesses of the bone-cavities; if possible, no space should be left between the bone and the graft, and, when successful, the definition of the surfaces should be quite clear. Drops of blood or bubbules of air may prevent the due approximation of the graft, and should be removed by suction with a glass pipette. As a protective to the graft Mr. Ballanee employs fine. pure gold leaf, which is introduced and ap plied to the epithelial surface in the same manner as the graft. A narrow strip of iodoform gauze is packed into the cavi ties, one end of the gauze being brought out through the meatus. The wound behind is again sutured and outside dressings applied. For a week the gauze plug remains; when removed, the gold leaf is seen through tbe enlarged meatus outlining the attic, antrum, and tym panum. The gold leaf is removed three or four days afterward with forceps, when the white surface of the grafted cavity is seen. A gauze packing is again used, and is changed every two or three days, till the healing process is complete, the cavity being then quite dry and light pink in color. "This grafting method has proved remarkably successful. The after-treatment is, by it, reduced from many months, or even a year, to five or six weeks, resulting in a more complete and permanent cure." Thomas Barr ("Manual of Diseases of the Ear," third edition, 1901; Jour. of Ophtbal., Otol., and Lar,yu., Sept., 1901).