seldom intermissions; although at times, by the mere fact of its long continuance, the patient may become so accustomed to the milder stages of the pain as to be apparently unconscious of its presence.

The pain is accompanied at times by sudden exacerbations of an acute throbbing or boring character, deeply seated in the ear and mastoid process. In some instances it may radiate up to the side of the head and down into the neck and again back to the occiput, but, as a rule, it is not associated with pain in or anterior to the meatus.

Deafness may be complained of according to the amount of involvement of the conductive or perceptive apparatus. Usually there is an absence of tinnitus and vertigo.

A slight rise of temperature may be noted in the early stage of the disease when the new bone tissue is forming, but later, during the hardening period, it is never present.

Age does not seem to bear any causative relationship to the disease.

The employment of auscultation, percussion, or transillumination has as yet proven of no convincing value to me in the diagnosis.

One final word now as to the possibility of error in determining between a purely neurotic disorder and one of osteosclerosis, and that is, in the proper individual, who is susceptible and impressionable, the persistent, nagging, torturing, and often agonizing pains incident to a case of osteosclerosis, may soon bring forth the latent qualities of a full-fledged hysteria, just as it brings forth the demand for powerful sedatives and analgesics to relieve him of his suffering, until finally he finds himself a helpless, miserable, and pitiful subject of the drug habit.

Treatment. In considering the treatment of this condi tion, we may divide the subject into the medical and the surgical.

Under the medical treatment we will refer to all such measures employed other than that of operative.

Remedies of this class, to be of any particular value, should be used in the early stage of the disease—that is, where there is great vascularity as a result of the new bone

forming process. At such a time the various rubefacients or epispastics may be tried, such as mustard, capsicum, cantharides, ammonia, camphor, and turpentine. The methods of "firing" and acupuncture are little used nowadays, but in their stead we may find the employment of the X-rays and mechanical vibrations. The leech, dry cups, and gal. vanism are remedies familiar to all.

The surgical treatment is the important part of the therapeutics of the disease. Notwithstanding the advice and practice of such authorities as Politzer (23), Hartmann, and Knapp, one is amazed at the apparent apathy, part ignorance and also prejudice, existing relative to the employment of operative measures in this particular condition.

As far back as 1875, Professor Gosselin (17) read a paper before the Paris Academy of Sciences, entitled "Osteo-Neuralgia of the Long Bones," in which he advises trephining in order to relieve the pain. That this same view is held to be applicable in cases of osteo-neuralgia of the mastoid is seen by reading the opinions of men like Politzer, Green, Buck, Hartmann, Schwartze, Knapp, and others.

Buck says: "We should not hesitate to perforate the bone," in order to bring about relief in these conditions.

Schwartze (19), the pioneer in mastoid surgery, the man to whose personal efforts through research and indomitable courage aural surgery owes a great deal of what is good and beneficial to-day, advocated and practised operating on the mastoid in cases of intense and uncontrollable pain of the mastoid process.

Hartmann (5) says: "Practice proves that the symptoms of violent pains, in connection with idiopathic sclerosis, can be relieved by opening the mastoid process."

Sattler (20) cites numerous cases illustrating the condition under discussion, which upon operation gave permanent relief.

Herman Knapp (21) has repeatedly operated for osteosclerosis of the mastoid process, with success as to the relief of pain in all cases.

Trephining the skull is practised by many surgeons for the solitary symptom of headache. Siegel (22) cites such a

case and reports finding eleven similar interventions on record. All cases are reported cured by the operation.

As I have already stated in a previous paper on this subject, after having made your diagnosis and exhausted the simpler means of relief, an operation of opening into the process is the only rational, positive, and successful means of putting an end to the patient's suffering.

Where we decide to operate in a case associated with hysterical stigmata, it is important not to burden the patient's mind with any doubtful prognosis, but, on the contrary, carry conviction with our words by predicting a most hopeful outcome.

In operating, our object is to relieve bone tension, and with this in mind we should remove as large a core of bone as possible, making the superficial circumference of the opening of large diameter, and the edges and surface of the cavity clean and smooth.

In the uncomplicated variety of this disease, it may not be necessary to penetrate into the antrum. In fact, the rule is not to.

In conclusion, allow me to urge upon you the recognition of a broader field for surgical intervention in affections of the temporal bone. The modern surgery of the mastoid process has given to us the ways and means whereby serious symptoms and fatal results may be thwarted, and the revelations made to-day by such procedure explain the lethal cases of former years. Although the condition of sclerosis is not, as a rule, associated with the possibilities of a fatal issue, it very often makes itself manifest by such uncontrollable pain that it leads the patient a life of intolerable suffering, which evokes within him such a strong desire for relief that the drug habit is soon acquired. In the face of such a condition or such prospects, can we as otologists of to-day remain unmindful of the mental and physical deterioration that results from such state of affairs, and with a remedy so potent and powerful in our hands refuse to be moved by the sense of what is our proper and legitimate duty?

LITERATURE.

The Laryngoscope, vol. xii., No. 12.

Handbuch der pathologischen Anatomie. KLEBS, Gehör

ARCHIVES OF OTOLOGY, 1873, vol. iii., No. 4.

Report Congress Internat. Otol. Soc., 1876; Trans. Am.

Otol. Soc., 1875-1881, vol. ii.

5. HARTMANN, A. Zeitschr. für Ohrenheilk., 1879, vol. viii., 18-21; ARCHIVES OF OTOLOGY, 1879, vol. viii.

6.

BUCK, A. H. Medical Recorder, 1883, vol. xxiii.

7. LIPPINCOTT, J. A. Trans. Am. Otol. Soc., 1884, vol. iii., pt. 3.

8.

9.

10.

II.

12.

STEIN, O. J. Chicago Medical Record, January, 1903.
GRADENIGO. Encyclo. für Ohrenheilk, 1900.

BRÜHL. Atlas and Epitome of Otology, 1902.

Voss. Zeitschr. für. Ohrenheilk., Bd. 40, 1902.

LANNOIS and CHAVANNE. Annales des maladies de l'oreille, du

larynx, du nez et du pharynx, July, 1901.

13. JENDRESSIK. Deutsche med. Wochenschr., vol. xxviii.

14. LEDERMAN, M. D. N. Y. Academy of Medicine, February 13, 1902. KÖRNER. ARCHIVES OF OTOLOGY, vol. xxvi., 1897.

15.

16. KUHN Münch. med. Wochenschr., 1902, vol. xi.

17.

GOSSELIN. British Medical Jour., 1875.

18. AGNEW, C. R. Report of the Am. Otol. Soc., 1870. SCHWARTZE. Arch. für Ohrenheilk., vol. xiii.

19.

20.

xxviii.

21.

SATTLER, ROBT. ARCHIVES OF OTOLOGY, 1898, vol. xxvii.; 1899, vol.

KNAPP, H. Trans. Am. Otol. Soc., 1884; ARCHIVES OF OTOLOGY, vol. x., p. 365.

22. SIEGEL. Am. Medical Journal, 1903.

23. POLITZER, ADAM. Text-Book of Otology; Diseases of the Ear and Adjacent Organs, 1902.

THREE CASES OF ENCEPHALITIS IN CONNEC

TION WITH OTITIS MEDIA.

BY DR. VOSS, RIGA, RUSSIA.

Abridged Translation by Dr. JULIUS WOLFF, New York.

TRÜMPELL'S effort to trace the cause of cerebral in

ST

fantile paralysis to an encephalitis has led to the publication of many articles upon this subject. Although these matters are of no direct interest to otologists, still it is evident that the picture of the so-called acute, hemorrhagic, non-suppurative encephalitis may also at some time be encountered in a patient suffering from an otitis media. In 1897 Oppenheim, treating the subject of encephalitis in Nothnagel's Spec. Pathologie u. Therapie (vol. IX., ii., 3d edition, p. 17), made the statement that while reviewing the literature he had been impressed by the fact that relatively often patients with encephalitis were also afflicted with an old or a recent purulent otitis. While demonstrating a patient before the Berlin Society for mental and nervous diseases on December 11, 1899, Oppenheim described the disease as follows: "In all five cases there developed, acutely and with the symptoms of an infectious disease, a cerebral affection which from the very outset presented, in addition to the general cerebral symptoms, focal symptoms, such as motor aphasia, usually in conjunction with right faciobrachial monoplegia (twice beginning with cortical epilepsy). Whereas the general symptoms usually quickly subsided, the focal symptoms alone persisted for some time."

The history of Oppenheim's case was as follows:

A student, seventeen years of age, had suffered since his first