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MASTOID OPERATIONS.To the Editor of THE LANCET.

SIR,—The recent publication in THE LANCET

(Feb. llth) of a paper by Mr. Heath on certainmastoid operations prompts me to make a fewremarks.

It is generally agreed " that, in striving honestlyourselves, we should heartily acknowledge thestriving of our neighbour." Also that we should neverforget what is due to those who have gone before." In the light of history the present and the futuremay be interpreted and guessed at." This is no newopinion, for Celsus wrote :

" Though we should notrefuse to give modern authors due credit for theirdiscoveries and happy imitations, it is none the lessjust to restore to the ancients what properly belongsto them." To

Damn with faint praise....And without sneering teach the rest to sneer,"

is hardly cricket. But, after all, in some

circumstances-" To be dispraised, is no small praise."

Long years ago I met Schwartze and Stacke andI was very familiar with the pioneer labours of vonTroltsch, Jacoby, Kuster, Korner, Zaufal, and Eysall.In the gradual evolution of truth, and at the end ofeach stage of the world’s history, it would seem thata great man appears, who is the messenger of a newknowledge, the herald of the dawn of a wider insightinto life and truth. Such a man was Schwartze.It is to the scientific insight and work of Schwartzethat we are indebted for the discovery of the operationfor acute infection of the mastoid process. This wasa momentous scientific and surgical triumph. This ’,operation not only saves the life of the patient, but ’,saves intact the hearing. ’

When Mr. Heath disparages thq operation, describesit as altogether too primitive, and speaks of facial Iipalsy, dislocation of the incus, deafness, unsightlyscars, painful dressings, inaccessibility of the mastoidantrum, prolonged suppuration, wounds that neverheal, and fatal results, he must be thinking of and Iconsidering some operation which Schwartze, if alive,would not recognise as the one which bears his name.The object of the Schwartze operation for acute disease

is twofold, as is also the object of the Schwartze- IZaufal, or Schwartze-Stacke operation for persistent Ichronic suppuration : (1) The removal of the disease, Iand (2) the conservation and improvement of thehearing. These have been the aims of all surgeonsof my acquaintance ever since these beautiful opera-tions have been devised and practised. They areconservative operations. The surgical principlesunderlying their performance cannot be varied withoutrilr OT fftilnr’e——T nm MiT* vm11’>: faitTifnnv I

CHARLES BALLANCE.

CARBON DIOXIDE IN ANÆSTHESIA.

To the Editor of THE LANCET.

SIR,—With regard to your leading article lastweek on the medical uses of carbon dioxide, may Ioffer a few remarks on its employment in theadministration of anaesthetics ? My clinical experiencehas not led me to consider it to be of sufficientimportance to be included in the anaesthetist’s equip-ment ; it may even prove a cause of anxiety if theapparatus is not in perfect order and an overdosebe inadvertently given.

It has been stated that the presence of CO2 in smallquantities is likely to obviate holding the breath andthus bring about a quicker induction. In adultsholding the breath and struggling by the patientduring induction I find to be of very rare occurrenceindeed if the induction is commenced by carefuland tactful measures. There is no object in makingthe induction so short that the patient is discomforted.The mask in the open method can be held 3 or 4 inchesfrom the face with very little anaesthetic on it, theamount gradually increased, and the distance from

the face gradually decreased, and by the time it isactually on the face most patients are sufficientlyasleep without struggling for the anaesthetic to bemore quickly pushed and the vomiting centrecontrolled. Neither have I experienced simplearrested respiration which has not very soon beenrestored either by waiting a minute or two or bycutting off oxygen if it was in use at the time. Ofcourse, one would not wait a moment if the pulsestopped before taking measures to restore the dormantheart.

Lastly, the advantage claimed for increased respira-tory action and amplitude from inhaling CO2 afteran operation, in order to wash the anaesthetic morequickly out of the system, may be open to objectionon the grounds that the patient is called upon touse his respiratory muscles in excess while in a stateof fatigue instead of waiting till he has graduallygained strength.

Dr. R. M. Waters’s observations on the danger ofCO2 in cases of acidosis are very important, more soof course in respect to children than adults.

I am, Sir, yours faithfully,JOSEPH BIRT.

GASTRO-DUODENAL ULCERATION.

To the Editor of THE LANCET.

SIR,-For the past two years I have been prac-tising this method of treatment on lines very similarto those described by Prof. H. MacLean and hiscolleagues. I can substantiate the full claims madeby them that this is the only real effective methodof dealing with the ulcer. In one series of 25 cases(the early ones) 24 became quite well and have keptwell, the twenty-fifth was one of marked pyloricstenosis and was put on the alkali as a temporarymeasure till the operation advised was performed.The use by the writers of the word " cure " seems

have raised a difficulty, but the 24 patients of whomI write are quite definite about it, and as no evidenceof ulcer, radiological or otherwise, is found in theircase, may one not reasonably assert they are" cured " ? The method used was a modification ofSippy’s. He was quite clear (Jour. A.M.A., 1915)on the question of cure and even included all casesof pyloric stenosis except those of extreme narrowingdue to definite cicatricial contraction following ahealed ulcer. That the method does control the hyper-acidity can be proved by the Einhorn tube, and it iswell to acknowledge, as claimed by MacLean, that it isthe continuous secretion of HCI which requires con-trolling before healing takes place. In my casesI never met with an alkalosis.

It may be suggested that the quoted cases are oftoo recent a date to warrant the assertion of cure,but they may be of interest following the much longerexperience of those others. I have the temerity topublish them since I have seen nothing from anyother source in this country. of this particular method.

. T am ir_ VOUl’f’I f::l.itl1fnllvA. J. D. CAMERON, M.B., Ch.B.

THE DISPOSAL OF THE DEAD.To the Editor of THE LANCET.

SiR,-In a leading article under this heading,appearing in your issue of Feb. llth, reference ismade to the fact that 166 out of some 200 municipalitieshad given categorical responses to request for infor-mation about cemetery undertakings, a responsewhich you rightly regard as "an unusual event."May I, in fairness to the various authorities and inacknowledgment of the courtesy shown in respondingto the questionaire, be allowed to point out that asa matter of fact every authority applied to responded.One hundred and sixty-six sent as complete anddetailed information as they were able (and in the bulkof cases replied to each question on the form). Thirty-one other authorities also replied, but as they did