I shall not attempt to give a detailed statement of the symptoms and treatment; suffice it to say that the case was closely watched, all symptoms noted, and indications promptly fulfilled. She was ordered a generous diet, with as much fresh air as she could avail herself of; and no unfavorable accident supervened to prevent her rapid progress toward health, and I discontinued my daily visits on the 12th of the following month :

I again quote from my notes:

I

Dec. 21. The family have been attending to the dressing since my last visit. Some discharge continues from the external ear, as well as from the upper and lower sinuses of the wound. left the case, with instructions to call at my office if anything appeared to be wrong.

In five days, my patient called and was entirely well, with the exception of deafness in the left ear, and continued so until about two weeks since. Complaining of pain in the ear and tenderness over the track of the old cicatrix, syringing with warm water relieved her.

I recently mentioned the particulars of the case to my friend, Dr. D. Webster, who kindly requested me to send the patient to his office for examination. She accordingly went, and returned with the following note:

"No. 19 EAST 39TH STREET, "NEW YORK, November 11th, 1876.

"My Dear Doctor :-Julia Higgins is, so far as I am able to judge, entirely deaf in her left ear. She does not even hear the tuning fork with it when placed against the forehead. She has a large perforation of the membrana tympani, leaving only a rim on all sides, except the lower portion, where not a vestige is left. The auditory canal, is normal, except that it is somewhat excoriated from being constantly bathed with offensive pus from the middle ear. That there has been loss of substance of this mastoid is evident enough.

Hoping to meet you Wednesday night, I remain

"P. S.-Cleansing and astringents are indicated. D. W."

This, Mr. President, completes what I have to say at present on the subject; and as it is the custom of the Society to allow its members to express their views on all subjects brought before it, I hope to be followed by remarks or the narration of cases by others, which will no doubt add material interest to this meeting.

DISCUSSION.

Prof. J. L. Little, M.D., said: I have listened with a great deal of pleasure to Dr. Harwood's interesting paper on mastoid disease. The operation of trephining or opening the mastoid process, in cases of suppuration or caries of the mastoid cells, has become of late years a recognized procedure. In two cases which have occured in my practice, after an incision was made through the soft parts and the bone exposed, a fistulous opening was found, leading into the mastoid cells. In a large proportion of cases, this condition will be found when the external incision is made, and all that is necessary for the surgeon to do is to enlarge this opening so as to permit a free escape of the pus. This can be very easily done, I think, by an instrument used by dentists called the "burr drill." These drills can be obtained of different sizes, so that the opening may be enlarged to any extent. (The doctor exibited these drills to the Society, Fig. 2.)

Mastoid disease is rarely, if ever, a primary affection. In all the cases which have come under my notice, a discharge from the ear had existed for some time previous. Inflammation of the middle ear, with perforation of the membrana tympani, is the primary difficulty. Patients with so-called "otorrhoea," or, more properly speaking, suppuration of the middle ear, are always exposed to two formidable complications: First, Mastoid disease, and second, cerebral abscess by the extention of the inflammation through the roof of the tympanum. This last condition occurs more frequently than the first, and is always fatal.

In all cases where complaint is made of severe pain in the head accompanying a discharge from the ear, a careful exam

ination of the mastoid process should be made, and if tenderness exists, or if the scalp is swollen and oedematous, at this point a free incision down to the bone should be made at once. In some cases, sim

ple periostitis exists, and the incision gives immediate relief. If relief is not afforded, perforation or trephining of the mastoid should be resorted to.

A case of this disease came under my observation while lecturing at Burlington, Vt., last June. I was called in consultation with Dr. A. P. Grinnell to see an old lady about sixty-five years of age, who had suffered from a discharge of pus from the right ear for some months. About two weeks before I saw her, she had severe pain in the right side of the head, and especially in the vicinity of the mastoid. Swelling over the mastoid took place, and Dr. Grinnell very properly made an incision, and a quantity of pus made its escape. On examination, I found the external meatus filled with pus, and so swollen that a speculum examination could not be made. The incision over the mastoid was enlarged, and a probe could be passed through the bone into the mastoid cells, and as the pus seemed to have a free outlet, nothing more was advised to be done. Prof. D. B. St. John Roosa, M. D., of this city, was present and concurred in the advice. In a few days after, however, brain symptoms manifested themselves, and the patient sank into a comatose condition and died.

FIG. 2.

In conclusion, Mr. President, I would call the attention of the members of the Society to the importance of a careful examination and the early treatment of all cases of aural disease accompanied by a discharge of pus from the ear.

Dr. C. S. Wood said: I have, during a period of twenty-five years, been so fortunate or unfortunate as to have seen quite a number of cases of mastoid disease; some of them terminated fatally, while others have recovered by the supervention of suppuration from the ear. We all are well aware that the

cause of the disease is suppurative otitis and is usually the result of scarlet fever. As a rule suppuration has existed for a considerable period of time, the child enjoying good health in the meantime, when, from exposure to cold, the discharge suddenly ceases, or nearly so, at which time cerebral symptoms at once become manifest. There is fever, anorexia, vomiting and restlessness, often preceded by convulsions, soon followed by coma and local or general paralysis. On examination of the post-auricular region, usually there is found more or less redness and tumefaction, pressure upon which causes the patient to cry with pain. In such cases there is no question about the propriety of making a free incision down to the bone, which, with the application of warmth and moisture over the ear, will, by the reëstablishment of the discharge relieve all the threatening symptoms. In the majority of the cases, such will be the result; but, if the suppuration is not reproduced, the severe symptoms will not yield, when it may become necessary to make an opening through the outer table of the skull. Even after this operation many, perhaps, according to my experience, most of them die, as we do not always get pus as expected, it having formed, by a sort of metastasis, in some other portions of the brain.

I have recently lost a case, a girl aged six years, where the suppuration had existed for more than two years, caused by scarlet fever, which ceased suddenly after exposure, when cerebral symptoms immediately supervened, without any special evidence of mastoid disease, sufficient to justify an operation. Still she had strabismus, vomiting, coma, etc., and died within a week from the time of attack as I predicted she would unless the discharge from the ear could be reëstablished, which, uufortunately, was not the case.

I have lost several patients under similar conditions, and some of them after operating and expecting to find pus enclosed in the mastoid cells, and am of the opinion that where we can reëstablish the original discharge (which in the majority of cases we can do), they will recover; but if not, whether with or without an operation, the prognosis is very grave.

Dr. A. R. Robinson said: Inflammation of the mastoid cells can follow either an otitis interna or a periostitis partis mas

toideæ ossis temporis. This latter inflammation can be either primary, i. e. arise independently from mechanical injuries or chemical irritants to the part; or, as is generally the case, it is secondary to some inflammation in the neighborhood. The most frequent cause, however, of an inflammation of those cells is an otitis interna purulenta. This form of inflammation can arise ex contiguo from inflammation in cavo pharyngo-nasali, and is a frequent sequence of scarlatina and variola, especially in scrofulous children. Inflammation of the mastoid cells appears to be a common accompaniment of a purulent inflammation of the middle ear; but it is rare for the inflammation to pass further inward. When this latter occurs, it does so by passing along the vessels and connective tissue bundles in the sinus sigmoidus producing a phlebitis in the sinus; or a thrombus is formed with or without a breaking down of the latter, and from here the inflammation passes inward and produces a meningitis, or encephalitis, or both. I can confirm Gubler in the statement that inflammation of the brain is not a frequent consequence of an otitis interna in young children, for though I have seen a great many cases of otitis interna purulenta in children—and consequently of inflammation of the mastoid cells, I have not yet seen a case in which the inflammation has passed to the brain or its membranes. When the inflammation is seriously threatening to extend inward from the mastoid cells in spite of the operation of myringotomy, or spontaneous perforation of the tympanum by the pent-up pus, the operation of trephining down to the cells should, according to all authorities, be performed without delay. These cases, when operated upon, however, are usually not so fortunate in their termination as was Dr. Harwood's. Therefore on account of this very danger of the inflammation spreading from the mastoid cells inward and proving fatal, I think cases of inflammation of the middle ear especially, should not be neglected in the manner they usually are, either because the patients are unaware of the possible ulterior result, or that the physician in charge is not competent to treat such cases and allows them to proceed unchecked. Such cases, I believe, should always be placed in competent hands, and I never fail to direct such patients where they will receive the proper treatment. But few medical men possess the requisite knowledge to treat