follow that either spontaneous recovery from this condition is often
possible, or that a spontaneous perforation with drainage occurs without
operation much oftener than is generally supjxised.

Voltolini many years ago called attention to the fact that in most of
these cases there was a great tendency to involve that portion of the
mastoid to wliich the stcrno-mastoid muscle is attached, or at least that
this particular sjwt was almost always extremely tender. This is often
due to temporary infection of the small posterior auricular lymph-node.
When this is tender, as it so often is, it is almost impossible to distin-
guish between pain caused l>y pressure upon it or upon the bone. This
would seem to explain the circumstance to which Voltolini called atten-
tion. As a matter of fact, tenderness along the posterior border of the
mastoid is much more indicative than along tiie insertion of the external
ear. When tiie middle portion of this border is very tender, it is almost
certain that the underlying bone is involved.

Another symptom or sign of the greatest significance is the augmen-
tation in volume of the mastoid process. Whether the disease be acute
or slow, in young or old, the dimensions of the mastoid are practically
always altered, so that on palpation there seems to be more between the
palpating tiugers ujion the diseased than upon the sound side. This
increase in size is often combined with tenderness upon deep pressure.
It must, however, be distinguished from mere swelling of the soft parts.

In the ordinary cases of su]>[Hirative otitis media it seldom happens
that the discharged jnis is foul-smelling. When, in spite of general irri-
gation and the use of antiseptics, it is noticed that the pus has a foul
odor, then it is almost certain that the process has gone behind the mid-
dle ear and has extended into the mastoid cells. Almost always when
pus has this characteristic odor it becomes darker in color, sometimes
mixed with blood, and the discharge becomes irregular in amount —
sometimes less, sometimes more.

Desirable as it is that one should apjireciate the true condition of the
bone, this can scarcely be done without incision through the periosteum,
and even then the appearance of the outer surface of the bone is more
likely to be misleading than instructive. In iiict, one should have prac-
tically decided to perforate or not before inspecting the bone, since by
itself it gives little or no clear indication. If the symptoms point to
deep mastoidal disease, the bone nuist be perforated, no matter how
healthy it may appear.

It has been suggested to practise percussion of the mastoid area on
either side, it having been claimed l)y Koerner and Wild that the ear of
the surgeon may detect significant diiierences in the percussion-note in
the presence of disease between the two sides.

Lange thinks that the persistence of a fair amount of hearing speaks
rather against extension of disease from the middle ear than for it, and
should figure in the favorable prognosis.'

' Allport's record shows that the longitudinal, superior petrosal, lateral, and transverse
Vol. II.— 45



706 DISEASES AM) IXJllUES OF THE HEAD.

(Otlior (>])('mtivc inetliods, witli iiiiicli v:ilu;il)lo inroiniatioii, will be
found ill Samuel E. Allen's Tin' Mastoid Ojunition, ( iiicinnati, 1X92.)

Treatment of Intracranial Suppurations. — The general rule which
applies to eolleetlons of" \n\>i in any other part of" the body is ecjually
a])])lieable to absceisses within the brain when they can be recognized.
For, first, the detection, and second, the evacuation, of purulent foci in
this region operations are now regarded as not merely justifiable, but as
indicated whenever the diagnosis is fairly |)r<>balile. The only discussion
now hinges upon the wisdom of exploration when absolutely no diag-
nosis can be made. When we remember the inevitably fatal tendency
of these suppurations, it will be felt that there is no part of the brain in
which pus may accumulate which may iKrt be attacked with j)ropriety,
providing only we have a reasonably good indication for attacking it.
Save in those instances where an opening already exists, the jjreliminary
to evacuation of such collections consists in trejihiniiig. While most
of the indications for this operation have already been mentioned in
detail, there is one which, though rarely met with, is always pathogno-
monic. This is tli(> spontaneous escape of pus, either through a pervious
granulatiii"' wound, a fissure, or anv of the natural outlets of the
cranium, whether it escape directly or give rise to suggestive disturb-
ances upon the inside of the brain. The indications laid down by Perci-
val Pott about a century ago are still as valid as ever, but are not gen-
erally enough read or appreciated. The loosening of the pericranium,
the signs of im])lication of the bone, the headache, chills and fever
which Pott so graphically descriljed, the evacuation of pus with the
rapid disapjiearance of symptoms, are no rarity now-a-days, but entitled
Pott to the greatest credit for being far ahead of his own time. A cir-
cumscribed collection of pus is of course an indication for deliberate
trephining, since in no other way could it be reached. In the presence
of evident necrosis of bone the surgeon must of course select his own
instrumental means and the proper locality for use of the same. When-
ever after opening the cranium the dura is found to be distended — in
which instances the usual l)rain-pnlsation will be lacking — its incision is
indicated, or at least a deep exploration with the aspirating needle.
Long ago Donders came to the conclusion that it was irritation of this
memljrane which masked the pulsations of the brain — a conclusion sub-
sequently corroborated by experimentation in animals and by the later
clinical studies of IJrauii and Roser.' According to these writers, the
most common circumstance which masks brain-pulsation is the presence
of pus beneath the dura. Other indications for opening it are also dis-
coloration, or possibly its even gangrenous aspect. A few writers claim

sinuses and internal jugular are affected by phlebitis and thrombosis with about equal
frequency, and these much more often than any other. Thus it does not appear that the
lateral is most frequently involved. That the internal juijijlar is so frequently involved
is accounted for by transmission of disease from the middle and internal ear by three
channels; (1) By the roof of the tympanum; (2) by the small veins passing from the
middle ear into the middle meningeal vein ; and (3) by connection from the internal ear
into the superior petrosal sinus.

Post-mortems have shown frequent cases of brain-thrombi not suspected during life.
Their explanation is probably the vicarious action of the rich collateral circulation.
Barr reports one case where autopsy showed complete occlusion of the lateral sinus by
fibrous bands.

' CentralUatt f. Chir., 1875, No. 11.



RELATIONS OF THE MASTOID TO MIDDLE-EAR DISEASE. 707

to have been able to detect fluctuation through the trephine opening, but
this will be at least seldom possible. The most feasible metliod at hand
for tlie discovery of pus lying within the brain is the aspirating needle.
Its use was first suggested by Renz, and it has come into such general
use here, as in various other parts of the body, that it has become a mat-
ter of routine with modern surgeons to use the hollow needle for this
purpose.

To be more particular, abscess of the brain, as coming under the
surgeon's notice, may be rougidy divided into those cases due to middle-
ear disease and those not of such origin. Of tlie latter, we have mostly
to deal with abscesses of the hemispheres, usually of traumatic origin,
although the history of the case may show that the injury was received
a considerable length of time before the development of symptoms of
infection. These, for the most part, are to be localized by scars or by
the well-known phenomena of cerebral localization, by which or liy both
together the surgeon must decide at what point to open and wliat further
course to pursue. Each of these cases is a law unto itself, and minute
directions cannot be formulated.

With regard to abscesses following middle-car disease we are in posi-
tion to give more exact directi<>ns, in the main as follows : In either case
rigid aseptic precautions must be observed, the head having been shaved,
preferably at least ftjrty-eiglit hours ]n"eviously, the scalp thoroughly
cleansed, and the head then enveloped in an antiseptic comj)ress or poul-
tice.' This prej^aration is re})eated just before operating and after the
patient is ansesthetized. An elastic tourniquet can l)e ap})lied about the
skull if the operator prefers it. There are cases of abscess in which
time is not aiiorded f.r such careful preparation ; the same is true also
of many recent traumatic lesions. In such event the scalp must be
cleansed as best it can. It is well that all possible sources of supjiura-
tion or infection from the orbit, nose, and oro])harynx, as well as from
the bony sinuses, should be eliminated. If there be discharges from any
of these cavities, they should be made antiseptic if ])ossible. Furuncles
about the face may call for careful attention before anything is done to
the cranium proper. Tlie middle car itself sliould also be carefully
cleansed, since it may become a focus for subsequent infection at a most
undesirable time.

Next will come up the question whether to open the mastoid antrum,
the mastoid cells, or the brain-cavity proper. Indications for opening
the mastoid antrum are —

1. History of repeated inflammation with swelling over the mastoid
process and fistulous opening, if present.

2. Acute inflammations with signs of retention of pus.

3. Beginning symptoms of intracranial mischief with purulent otor-
rhcea. These call for complete exposure of the interior of the mastoid
region and complete cleaning out of the middle ear.

4. Persistent otorrlura, resisting treatment, considered incurable by
aurists, even without inflanunatory indications about the mastoid. This
is particularly true when the discharge is otJ'ensive. Macewen insists

' The preparation which the writer prefers is to have the scalp, after careful shaving
and cleansing, thickly smeared with a preparation of sapo viride to which has been
added from o to 10 per cent, of some such antiseptic as lysol, creolin, or hydronaphthol.



708



DISEASES A XI) I SJ CRIES OE THE HEAD.



tliat the most serious intracrauial mischief is often present without
marived mastoid swelling.

The mastoid antrum is the key to regional anatomy in all operations
where we wish to expose the mastoid cells. In locating himself projjerly
the surgeon will have the external ear held forward, and will place the
fore finger upon the |)osterior zygomatic; root and liis tluinih on the tip of
the mastoid ])roeess, or rice rrrxil, and make a straight incision one-fourth
of an inch behind tiie posterior border of the external osseous meatus,
from the tip of the mastoid to the posterior root of the zygoma. This
incision should extend at once to the bone, the periosteum being elevated
with the soft tissues to an extent permitting full exposure of the pos-
terior surface of the external auditory meatus.

AVithin tile triangle, which iVIacewen has aptly termed " the supra-
meatal triangle," formed by the posterior zygomatic root, Uie upper and
the posterior segments of the external osseous meatus, the opening into



Fig. 425.




1, tip of mastoid : 2, roof of osseous meatus ; 3, asterion ; 4, parieto-squamo-mastoid junction : 5,
inion; 6, Imnlida : 7, parietal eminence ; 8, bregma; 9, stephanion ; 10, glabella ; 11, pterion;
12, external angular process: 13, suprameatal triangle.

The short vertical heavy line indicates the base of the suprameatal triangle: the longer vertical
line from 1 to 4 overlies in its upper two-thirds the sigmoid sinus ; the otilique line from 2 to
3 overlies the sigmoid sinus from its commencement to" its knee (Macewen).

the mastoid antrum can be made with safety. When the osseous meatus
is very oblique the antrum is situated more anteriorly than otherwise.
The distance of the membrana tympaui from the surfiice should be
gently measured with a probe, since if the middle ear lie deep, the antrum



RELATIONS OF THE MASTOID TO MIDDLE-EAR DISEASE. 709

may also bo more deeply situated. The opening is to be made at the
base of the triangle, and within it the ]ierf'oration directed inward and
forward so as to expose the antrum. So long as the excavation be con-
tinued in this direction within the triangle, the sigmoid groove will not
be injured.

The safest instrument fV>r the purpose of opening tlie antrum is the
burr of some .surgical or dental engine, or its ecpiivalent rotated by hand,
foot, or electric power, the size of the burr depending upon the dimen-
sions of the triangle. In the absence of this a chisel must be used with
gi'eat caution. Sometimes the outer wall of the antrum is much thick-
ened by the disease, so tliat tiie cavity itself may appear to lie deep.

IMaceweu directs that after opening the antrum the surgeon determine,
first, tlie position of tiie passage between it and tlie middle ear, and
second, the position of tlie facial canal, which generally traverses the
inner half of its floor obliquely from without inward, it being often
marked by a ridge. If, however, the antrum be deeply seated and its
walls sclerosed, it may be impossil)le to make out this canal. In these
cases the antrum ougiit to l)e approached along the U])per part of the ex-
ternal wall, so as to avoid the nerve. The occurrence of facial twitchings
may announce proximity tf) it of the surgeon's instruments. If the
antrum be filled with granulations, these .should be touched with the
probe, in order that if they enclose the nerve the surgeon may be aware
of the fact. By taking these precautions the facial nerve is rarely
injured. If granulations project from the roof of the antrum, they
should be closely examined to detect whether tiiey be protrusions from
the dura. If so found, we have evidence of an external pachymenin-
gitis. If the mastoid cells back of and below the antrum are involved,
they must be exposed and their contents removed. It is safest to do this
by working from the antrum downward and backward. Now, the loca-
tion of the sigmoid groove must be borne in mind, since granulations
springing from tiie dura of the cerebellar fossa and covering the sigmoid
sinus may jirojcct into one of these cells.

Should the condition of the middle ear make it desirable to open the
tympanum, it may be done by means of a burr applied to the junction
of its roof with the outer wall of the antrum. The floor of the passage
must not be encroached upon, nor its inner wall, lest the facial nerve be
injured. If the malleus and incus be diseased, they sliould be removed.
They can easily be taken out through the antrum l)y means of minute
hooks or scoops. To leave them is to invite further extension of disease.
The stapes should be left if possible, since, when it remains, hearing on
that side is usually sufficient for ordinary conversational purposes.
When the malleus and incus are to be removed, it is almost impossible
to avoid destruction of the chorda tymjiani. This causes loss of taste in
the anterior two-thirds of the tongue, but is s.'ldom comjilained of.
Macewen advises caution in injecting fluid through tiie antrum into the
middle ear, since it may possibly run down through the Eustachian tube
into the pharynx and cause laryngeal symptoms or convey infective
matter into the lungs.

In the subsequent care of the case, if the ossicles have been removed,
a strip of gauze may be jiassed tiirough tiie meatus into the middle ear,
and then into the ma.stoid antrum, it being taken for granted, of course,



710 DISEASES A^D EY JURIES OF THE HEAD.

that the parts have been absolutely cleansed of all infectious materials
by peroxide of hydroiren or whatever the surgeon may prefer to use.

The Treatment of Temporo-sphenoidal Abscess. — If ])as be
found t(j issue throiij;;li the dura above tlie ti'i^iiieu tyiii|)aui, tlie abscess
may periiaps be evacuated by enlarging- tlie approach, extending it out-
ward tlu'ough the s(piamous portion of the temp()ral. Such an opening
may suffice for temporary purposes, thougii it is hardly .safe to trust to it
alone ; and it will be better to trephine above the ear, and through the
opening thus made to remove all slougiis of brain-tissue and possible
infcctii )us materials.

M'lien sucii al)scesscs arc attacked from the outside of the skull, the
opening should be made as near tlie seat of disease as possible. If the
mastoid has been already attacked, the incision may be extended upward
for a couple of inches, and the centre pin of the trephine placed three-
fourths of an inch al)ove the posterior root of the zygoma. Here we
come to tlic thin portion of the s(piamons bone, and tiie trephine must
be used with caution. After exposing the dura it nuist be cleansed, if
need be, and its color and ap])earance noted. If it be normal, the
course of the larger pial vessels may be discerned through it. The
pressure of a large abscess, however, is often enough to empty the su-
perficial vessels, which, therefore, do not appear through the dura.
Before opening it, it is well to rub into the exjiosed l)oue-cdges iodo-
form powder, in order to protect them from cuntamination by infectious
pus as it escapes. It is well to open tlie dura first at the centre of the
opening, since the vessels can be more easily secured if cut. The in-
cision in the dura ought to be in line with these vessels. Small deep
abscesses may exist without affecting the cerebral pulsations. If there
has been lejitomcningitis, tlie membranes will probably be all fused
together.

For the purpose of exploring for ])us there may be used a small
trocar and cannula, a hollow needle, a pair of sinus forceps, or an in-
strument devised by Horsley for this ])urpose, which from the opening
above descril)ed should be first inserted in an inward, downwai'd, and
slightly forward direction — in the dii'cction, in fact, of the roof of the
tympanum. If j)us be found, the rate of its outfiow will, after a little,
be influenced by respiration, increasing during cxjiiration. Debris and
minute sloughs usually come away with it, the latter being sometimes so
large as to require a larger opening for their removal. It is best in this
case to retain the cannula as a guide, and then, Ijy introducing a pair of
dressing force])s and opening tiiem in xitu, debris can be removed, the
cavity irrigated, or, if necessary, the sharp spoon l)e used. It is of im-
portance to remove everything thoroughly. The cavity may lie freely
washed out with the boric or weak carbolic solution, provision being
made for easy outflow of the fluid used. The surgeon should be abso-
lutely sure that the fluid is going into the abscess-cavity, and the head
of the patient should be finally turned so as to permit escape of the last
drops of the same. If the cavity connect with the middle ear already,
the opening in the ear shoidd be enlarged so as to make ample access
from below.

If an abscess-cavity has been thoroughly cleansed, drainage is of
little value, drainage-tubes being of use only in ease of doubt. They



OPERATION'S UPON THE SINUSES. 711

always cause more or less irritation, and are to be avoided if possible.
Macewen prefers decalcified-bone tubes for this purpose.

Cerebellar Abscess.

Tlie skull over the mastoid is very thick, but over the inferior occip-
ital fossa it is very thin. Cerebellar abscesses are usually secondarv to
suppuration in the vicinity of the sigmoid sinus, and are often accom-
panied l)y tlu-umbosis of that vessel. Macewen recommends to expose
the siiiinoid s>roove first, with the view of ascertaining the condition of
its sinus, which will generally be found covered by granulation tissue,
and whicii should be reuiovctl along with extradural pus. The general
description above given will ap])ly to cerebellar abscesses. During ope-
rations upon these it occasionally haj)])cns that respiratory difficulties
are exjierieiu'cd. These should hurry tlie operation, and it may be well
to alter the j)osition of the jiatient's head, by wiiich sometimes improve-
ment in breatliing is effected. Macewen records two cases during which
artificial respiration was maintained — in one case for twenty-four hours,
in the other for six.

Frontal Abscesses.

These may l^e ojiened either from the front or from the temporal
region. Those situated in the posterior part of the frontal lobes are
nearest to the surface of the temporal bone. The frontal sinus should
be avoided unless it he involved in the lesion. Infection proceeding
through the etiuuoid may cause abscess near the middle line of tlie
frontal, and trephining through the frontal sinus might better serve
for its discovery.'

Operations upon the Sinuses.

For exposure of the sigmoid sinus the incision should extend from
the tip of the mastoid process over its prominence to the posterior
root of the zygoma. The soft tissues and the periosteum should be
reflected in one piece. At the upper extremity of this incision the
parieto-scpiamo-mastoid junction is to be exposed (this being the an-
terior extremity of the jiarieto-mastoid suture, and not the asterion).
From this junction a line drawn to the tip of the mastoid gives
the course of the sinus. This usually will lie over its centre, but
may mark its posterior l)order, or possibly, on the left side, its an-
terior border. The opening now should be made on the level of the
bony meatus with its posterior margin touching this line. The sinus
may be a quarter of an inch, but possibly only one-twelfth of an inch,
from the bone-surflice, being much more su]ierficial than the antrum.
The asterion corresponds to the union of the lateral and sigmoid sinuses,
while the junction above mentioned corresponds to the union of the
Mgmoid and the superior petrosal ; and slightly below this point is the
vein of the sigmoid sinus with its convexity forward. In the adult a

' The frontnl sinuses are rudimentary in infants, small in cliiMren, and begin to in-
crease about pubiTty. They are usually divided Ijy a septum, which is often imperfect.



712 lUSHA.'^h'S AM) IXII'lilKS 0? TIIK HEAD.

vortical line Jialf an inoli hcliind the jKistcrior osseous wall of the meatus
will usually iiidieate the uiidclle of the anterior convexity of the sif;nioid
sinus. This is best opened into with the burr of a surgical engine, al-
tliougii other instruments may he used in ease of necessity.

In the course of operations ne(;essitated by ear disease the sinus \s
usually exposed after the antrum has been opened, in which case the
plate of bone between the antrum and the sinus, which so frecjuently
contains channels of infection, is to be removed by the same means.
The posterior wall of the anti'um being exposed, the bone is o])ened
behind it for half an inch horizontally. If in opening the sigmoid
groove granulation tissue I'rom the dura ct)ver the sinus antl there l^e
oozing of pus, considerable caution must be observed lest the sinus may
be oj)eued too early, before the surgeon is ready for it. If, now, he con-
siders it advisable to open this channel, fully a vertical inch of it ought
to be exposed, in order to facilitate the o])eration and the necessary after-
treatment. Diseased boue should, of course, be removed wherever it be
met with during these procedures. The space between the groove and
the sinus should likewise be thoroughly disinfected, and granulation
tissue should be first investigated with a probe, since it may surround a
sinus communicating with the cerebellum and an abscess therein. If
there be no sinus, the tissue should be removed at all events.

The sinus being incised and its contents cleaned out, it should be filled
with some antiseptic powder and lightly packed, its walls being fiilded in
so as to obliterate its lumen. Should hemorrhage occur after o])ening it,
it will not be difficult to arrest the same by a closer packing after detach-
ing a portion of its external wall and crowding it in to help obliterate
its cavity.

Air-embolism during these manipulations is not, for the most part, to
be feared, although it may possibly occur, and care should of course be
exercised to prevent it. To this end it is better to remove debris with a
small spoon than by means of the irrigating stream. Packing is a much