After-Care of the Radical Mastoid

Operation.

Philip Hammond, Boston (Journal A. M. A., November 17, 1906), describes his technique in the after-care of the radical mastoid operation. After a thorough bone operation, all bone being carefully smoothed down, Eustachian tube cleared out and Korner flap turned into the mastoid, the whole cavity is packed with short pieces of iodoform tape. The posterior wound is sutured tightly. This dressing is not touched for one week. The patient is then etherized, the entire packing removed from the wound, all bleeding stopped and any clotted blood removed. A graft is now cut from the thigh. After being separated the skin is spread out and a piece of peau de soie placed on it. This is used to keep the skin from curling up and to serve as a protective medium between the graft and the gauze plug on which it is inserted into the ear. The graft must be very thin, of sufficient area to completely cover the surface of the exenterated cavity and carefully inserted into position, the apex reaching the middle ear. The sutures in the posterior wound are removed at this time. On the third day all dressings are removed and from that time on no packings of any kind are employed. As little as possible is done to this cavity for several days. Thereafter dry mopping is resorted to to keep the surface clean. The part which gave most trouble with other systems of grafting, the antrum, is always epidermatized from the start.

Effect of Long-Continued Pressure Upon

the Interior of the Mastoid

John D. Richards, New York (N. Y. Med. Journal, September 22, 1906), reports a case illustrating the effect of longcontinued pressure upon the interior of the mastoid by a fluid of low infectivity. For a number of years the patient, a woman aged twenty-five, had had at frequent intervals attacks of neuralgic pain in the right ear, accompanied by deafness and a feeling of stuffiness, but with no

discharge. A year and a half ago she had violent pain in the mastoid region, and a slight swelling behind the ear, moderately tender to touch. The pain of this attack abated, but tenderness and swelling continued for five months. Throughout the entire period of her illness she had neither chill, fever nor sweat. Immediately above the superior attachment of the auricle there is a soft, resilient swelling, the size of a hen's egg. The skin over this area is not reddened and there is no edema surrounding the tumor. No tenderness and absence of doughy induration. The tumor appears to be non-inflammatory in origin, and gives the impression of a cyst. It is impossible to obtain a view of the fundus of the canal, owing to the closure of its cartilaginous portion by the sagging of its superior wall, which meets the floor. No discharge is found in the meatus. The examination of the eyes is negative, respiration and pulse are normal. Cerebration is clear.

Operation.-On making the post-auricular curvilinear incision there was evacuated a small quantity of pus, together with an ounce or more of pale, strawcolored, ropy material, resembling in appearance and consistence the white of an egg. As the wound refilled a marked pulsation, transmitted to the fluid from the brain beneath, was to be seen. On introducing the finger into the incision it entered directly into the mastoid cavity, and upon complete exposure the entire structure of the mastoid, including the cortex, was found absent. The bottom of this cavity was formed by the dura covering the antero-lateral surface of the cerebellum, that of the sinus, and that of the inferior aspect of the temporo-sphenoidal lobe. Attached to the dura, and separating it from the fluid contents in the mastoid cavity, was a thin, delicate, cyst-like pellicle, which detached with readiness from the meninges, leaving this latter structure of a finely granular, but healthy, red appearance. The posterior canal wall, with the exception of its extreme inner end, had disappeared. The effect of pressure-absorption was beauti

fully illustrated at the posterior roof of the zygoma. There the pneumatic structure had disappeared, and the posterior root was represented as a cup-shaped depression absolutely smooth; it appeared to have been excavated with a burr. The tegmen tympani was absent, the membrana tympani intact, the tympanum filled with large, pale, flabby granulations. The inner end of the anterior wall of the auditory canal was eroded, and the joint of the inferior maxilla exposed. The Eustachian tube was of enormous size and packed with granulations similar to those occupying the tympanum. From the collection of superiosteal fluid immediately above the pinna a sinus lead forward over the zygomatic arch into the temporal fossa; from this, material similar to that occupying the cavity of the mastoid was drained. The response of the dura, in the production of the cyst-like pellicle to long-continued pressure by a fluid of low infectivity, was interesting.

The further history of the case was that of an uneventful healing without rise of temperature.

Mastoid Disease.

Plummer and Germain, Boston (Fournal A. M. A., November 24, 1906), reported to the Section on Laryngology and Otology of the American Medical Association ten cases of mastoid disease operated upon by their method in which the time of healing is remarkably shortened. After an exenteration of the mastoid process the posterior wall and part of the roof and floor of the bony canal are removed. Rougem forceps are used as deeply as the facial ridge, after which the electrometer burr is employed to smooth the facial spur. The posterior membrano-cartilag. inous canal is then packed firmly backward into the osseous cavity, where it is securely held in position by a tampon of iodoform gauze inserted into the auditory canal and by a pad over the concha held in place by a pressure bandage. A gauze wick drains the cavity. The external incision is closed by sutures except for the point of emergence of the drain. The middle ear is drained by a free incision beginning in the attic and sweeping through the posterior fold of the membrana tympani, terminating on a level with the floor of the annulus tympanicus.

In these ten cases complete healing of the primary mastoid wound occurred in seven, eight, nine, ten, twelve, sixteen and seventeen days.

Brain Abscess Following Acute Otitis
Media.

T. H. Halsted, Syracuse (American Medicine, October, 1906), reported to the American Laryngological, Rhinological and Otological Society a case of brain abscess following acute otitis media. The patient was a boy, aged eleven years. In the beginning there was comparatively slight earache for the first nine days of the otitis media, there was unusual bulging of the drumhead, complete relief from earache followed incision, and the discharge ceased at the end of four days, with a healing of the drumhead at the end of the ninth day, possibly earlier. From this time there was almost no complaint regarding the ear or head, but a marked anorexia, listlessness, change in disposition, and an absence of definite symptoms pointing to a brain complication, until vomiting, dizziness and slow pulse occurred ten days from the time of incision of drumhead. Headache was continuously absent, excepting once. There were no mastoid symptoms at any time. The blood count six days before the operation showed a marked leucocytosis, and on the day of the operation this was very decided.

Following the first operation for twentyfour hours there seemed to be a marked relief of all symptoms, attributed by the parent to the vomiting of a long, round worm, but by Halsted to the relief of pressure afforded by exposing the dura and allowing the escape of an appreciable quantity of serum. Thirty-six hours from the time of this operation, however, a sudden convulsion, marked lowering of pulse, pupil changes, vomiting and beginning stupor, showed the diseased area had not been reached, and that a rupture into one of the ventricles had occurred. latter supposition was apparently verified by the escape of first, clear cerebro-spinal fluid, followed immediately by thick pus from the abscess cavity when this letter was reached. The success of the operation was greatly handicapped by the venous hemorrhage, first from the diploë and then from the sigmoid sinus, so that the patient almost died from hemorrhage on the table

This

Book Reviews.

The Prophylaxis and Treatment of Internal Diseases. Designed for the Use of Practitioners and of Advanced Students of Medicine. By F. FORCHHEIMER, M.D., Professor of Theory and Practice of Medicine and Clinical Medicine, Medical College of Ohio, Department of Medicine of the University of Cincinnati; Physician to the Good Samaritan Hospital. New York and London: D. Appleton & Company, 1906.

In these days of therapeutic nihilism it is a pleasure and a profit to encounter a book in which the author evidently believes in the efficacy of drugs under proper indications and in appropriate doses. Indeed, whether the physician believes very much in drugs or not, he is com. pelled to admiuister them, and he would naturally prefer to use those that have been of service in skilled hands. But not drugs alone are considered as therapeutic resources in the book under discussion; hydrotherapy, gymnastics, exercise, diet, are all allotted their proper place and always with a view to their adaptation in private practice. In addition, remarks are made upon prophylaxis, both general and individual, before treatment is touched upon, a plan of attack of very material advantage to the praticing physician.

The plan of the book comprises twelve sections and an appendix. In the section on infectious disease, naturally, the greatest attention has been given to typhoid fever and pneumonia. In the latter disease the author advocates his open-air treatment, admitting, however, that the method has not been largely used on account of passive resistance on the part of the nurses and decided opposition on the part of friends.

Under constitutional diseases considerable space has been given to the discussion of diabetes mellitus, particularly to the dietetic treatment and the principles upon which the dietetic treatment of all nutritive diseases is based. The chemistry of this disease has been thoroughly entered upon and the reasons for the appearance of certain abnormal ingredients in the urine clearly elucidated. Forchheimer's routine treatment is to first give a test diet; then, after the urine is sugar-free, the patient's tolerance of carbohydrates is established, and from this the permanent diet is computed. One cannot but doubt the wisdom of adopting as routine the plan of establishing a sugar-free urine by dietetic treatment, even under the restrictions the author has given.

Under the section of digestive diseases the chapters on the diseases of the mouth have already in former works stood the test of time and taken an acknowledged place in the literature. One is indebted to the author that he has given us rational therapy on these muchly-discussed diseases of the stomach and intestines. It is not probable that the most of his readers will agree that the results of the non-operative treatment of enteroptosis are excellent, nor that a bandage is of much value in holding in place a dislocated kidney. Under mucous colitis the use of high enemata of olive oil, a method which has met with success from a variety of sources, is not mentioned.

The author has reached his best in the section on diseases of the circulatory system, and the reviewer has never before read so satisfactory an article on the treatment of chronic myocardial insufficiency.

In the very complete appendix are given tables upon the edible portions of food materials and on liquors containing alcohol. A chapter is given npon the general principles involved in the treatment of poisoning, and finally there are lists of drugs and prescriptions.

In a word, Forchheimer's work is a conspicuous success, not alone as a scientific but as a practical treatise as well. The reviewer has in the last few months consulted its pages many times, and has never been disappointed. Its material success is also evidenced by the fact that a second edition will be issued shortly.

Text-Book of Psychiatry: A Psychological Study of Insanity for Practitioners and Students. By DR. E. MENDEL, A.O Professor in the University of Berlin. Authorized Translation, edited and enlarged by WILLIAM C. KRAUSS, M.D., Buffalo, N. Y. Philadelphia: F. A. Davis Co., 1907.

The many Americans who have profited by the valuable clinical instruction of its distinguished author will welcome this translation of his text-book by one of the foremost American neuro-psychiatrists. Though entitled a "Psychological Study of Insanity," which it undoubtedly is, it is more than this-an exceedingly practical and systematic treatment of the subject from a clinical viewpoint. The book is compact, concise and comprehensive.

Within the limits of 300 small octavo pages is given a résumé of general psychiatry (Part I), 160 pages; special psychiatry (Part II), 151 pages; a synopsis by the American editor of the New York laws relative to commitment of the insane; and a copious index. Clinical histories are omitted. As the author well remarks, histories cannot convey a correct picture of disease in psychiatry; clinical instruction only can do this. The preface informs us that (since May, 1901) attendance of medical students upon the psychiative clinic is obligatory in Germany, and that physicians are required to pass an examination on the subject in order to qualify for practice. These conditions may be expected to obtain in the United States generally in the early future.

A notable feature of the book-and a most commendable one-is the emphasis with which the sensory beginnings of psychic processes are presented. Disturbances of thought, memory, feelings, emotions, consciousness and action follow in logical order. A special chapter is devoted to speech, writing, and other forms of expression of ideas.

Pathological processes in the body generally are treated from the viewpoint of psychiatry. Chapters in general causation, clinical course, pathological anatomy, diagnosis, prognosis and treatment are given; following which (in Part II) the special forms of mental disease are systematically treated.

Altogether, the book is a most lucid and practical addition to the literature of modern psychiatry. F. W. L.