14. Case of LEDERMANN (reported in ARCH. OF OTOL., xxxi., 77, Case 3, and in German Zeitsch. f. O., xxx., 78, Case 3). Chronic otorrhoea right. Radical operation; about four weeks later bleeding from mastoid through ear, nose, and throat. After a second bleeding from the rhino-pharyngeal cavity, posterior tamponade. In three days death from the loss of blood. Postmortem: Extensive necrosis of the petrous or mastoid parts, ulcerous decay of the wall of the lateral sinus. Softening of the left temporo-sphenoidal lobe.

15. Case of GRUNERT (Arch. f. O., xl., 222). Man of thirtyfive years. Cholesteatoma. Retro-auricular ichorous abscess the size of a fist. Radical operation. The middle-ear spaces and the external ear-canal converted into one large cavity, filled with a decaying cholesteatoma which extended to the dura mater and sent off shoots between the dura and the roof of the petrous pyramid into the cranial cavity. On palpation of the cavity backward a sinus bleeding in a black stream as thick as a finger suddenly occurred, but was controlled by prolonged digital compression so as not top revent the finishing of the operation. The cause of the bleeding proved to be a softening and invasion of the sinus wall with cholesteatomatous matter.

16. Case of BLOCH (Verhandl. d. deutsch. otol. Gesellschaft, 1896). Older man with chronic otorrhoea right, from caries and cholesteatoma. Radical operation. In curetting the anterior lower part of the drum a powerful stream of dark blood welled out of the wound. Tamponade. No renewed bleeding. More than a year after the operation, repeated hemorrhages occurred from the operated ear, also from the mouth and nose, only when he was lying down. One of these attacks was accompanied by suffocation and terminated fatally. The last bleeding originated in the carotis; the first not in the jugular bulb as was supposed, but in the carotic sinus; the anterior wall of the drum, the part between the middle ear and the carotic canal, was totally destroyed by caries, creating a wide gap between both cavities. Even if the first bleeding was traumatic, the case has to be mentioned here, as it was not sure whether the subsequent bleedings, with exception of the last, which came from the carotic, did not originate in the carotic canal.

17. Case of GRUNERT and ZERONI (Arch. f. O., xlix., p. 184). Chronic suppuration with cholesteatoma in the right middle ear. External gangrenous pachymeningitis. Extradural abscess.

Purulent sinus thrombosis. Total chisel-operation; sinus operated on with tying the jugular vein. Pyæmia cured. After the removal of a bridge of bone left between the sinus wall and a fistula found at the base of the skull, the softened wall of the lateral sinus suddenly burst. The moderate hemorrhage suggested a partial

thrombosis of the sinus.

Including my own case there are eighteen cases on record where hemorrhages from the brain sinuses, including the jugular bulb, occurred by arrosion of their walls caused by suppuration in the temporal bone. Twelve of these refer to the lateral sinus, I to the superior petrosal (Kuhn, 12), I to the inferior petrosal (Böke, 11), I to the sinus caroticus (Bloch, 16); to several sinuses at the same time, viz., superior and inferior petrosal, the jugular bulb, 1 (Huguier, 3); the jugular bulb, 2 (Böke, 10, and v. Beck, 13). Thirteen cases occurred in chronic suppurations, 4 in acute, I no statement.

As causal factors are mentioned: scarlet fever, phthisis, cholesteatoma; in most cases no etiology statement is made. The age of the patients varied between five and fifty

years.

The sex is mentioned in eleven cases: nine males, two females. This preponderance of the male sex agrees with the statements of Bürkner, Körner, Hessler, and others concerning the prevalence of the male sense in contracting purulent diseases of the ear and their intracranial complications.

A single attack of hemorrhage is noted in nine cases, in three of which it was continuous for several days; repeated hemorrhage was met with in the same number.

Death occurred in eight cases during or soon after it (up to a few days) in consequence of it, in five days not directly after it, including the case of Bloch, as the fatal hemorrhage originated in the carotis.

Recovery occurred in three cases-Grunert (15), Grunert and Zeroni (17), Eulenstein (18).

The places of perforation, as far as they are specified, are to be found in the report of the cases.

The time of the operation was in six cases before the oper

ation, the method was the radical operation in five cases (Ledermann, v. Beck, Bloch, Grunert, Grunert and Zeroni); in one the simple anthrectomy with opening of the middle and posterior cranial fossæ [and temporary opening and digital compression of the tranverse portion of the lateral sinus during the operation] (Eulenstein).

The time of the occurrence of the bleeding in the operated cases was four weeks (Ledermann), seven days (Beck), one year (Bloch). In the cases of Grunert (15), and Grunert and Zeroni (17), the non-traumatic hemorrhages took place during the operation; in Eulenstein's case (18), ten days after it.

The bleeding was internal in sixteen cases, external in one, and simultaneously internal and external in one.

The distinction between arterial and venous hemorrhage is easy according as the blood is bright red and jerks out periodically with the pulse, or is dark red (in some cases almost black) and escapes in an even stream.

Hessler' draws attention to the fact that arterial hemorrhage in ear disease is stopped by compression of the carotis at the neck; as with the carotis also the jugular vein is compressed, the venous blood will be dammed up and escape in greater force through a leak in the sinus.

For

Concerning treatment, we have to divide the cases into two groups: the unoperated and the operated ones. the former the following means have been tried: injection of cold water into the external ear canal, instillation of perchloride of iron, plugging of the ear, nose, and throat, liga. tions of the carotid, based on an erroneous diagnosis once. The effect of these modes of treatment are of little, if any, good effect.

In regard to the non-operated cases I would resort to the method I described in the epicritical remarks to my case, namely, the exposure of the bleeding spot after previous compression of the peripheric end of the sinus, eventually after ligation of the jugular vein, so as to be able not only to still the bleeding efficiently, but also to treat the primary affection thoroughly. It is recommendable in general to

1 "Carotisblutungen," Arch. f. Ohrenheilk., xviii., 42.

operate, as the bleeding mostly starts from the lateral sinus, and, in case another sinus is affected, it will be likely to afford an approach to a more direct and efficient tamponade.

For the second group, the operated cases, there has been used: tamponade and digital compression of the bleeding spot, the tamponade of the rhino-pharyngeal cavity, and the tamponade after exposure of the sinus in its peripheral part. In spite of the plugging, hemorrhage repeated itself and did not preclude the fatal issue in the cases of Beck and Ledermann, whereas it had a good result in the cases of Grunert and Grunert and Zeroni. In conclusion I beg leave to recommend again the method by which the case under consideration, desperate as it looked, was brought to a satisfactory termination.

GENERAL SEPSIS IN CHRONIC SUPPURATION OF THE MIDDLE EAR, WITH A CENTRAL PERFORATION OF THE DRUM.

IN

BY PROFESSOR BEZOLD, MUNICH.

Translated by Dr. ADOLPH O. PFINGST, Louisville, Ky.

N a former publication,' in which I reported twenty deaths occurring as a result of complications of acute and chronic middle-ear suppuration, I called especial attention to two of the cases where an acute exacerbation had taken place during a chronic otorrhoea, with a central perforation of the drum. In all of the other cases death resulted after cholesteatoma, with or without caries, or caries alone had developed. In the two cited cases none of these conditions was present, so that I feel justified in putting them in a category of their own. I have since then observed another similar case. The three cases were characterized by the development of acute general sepsis when the clinical and anatomical conditions had in no way suggested such a

course.

CASE 1. The first case occurred in a girl fifteen years old who had been treated at our clinic two years previously for chronic otorrhoea. At that time the left ear had a perforation in the anterior portion of the drum. The right one could not be seen as the canal was closed by furuncles. When she returned, Jan. 20th, she had been suffering for four days with pain in the left. ear. Soon after her admission to the hospital the ear began spontaneously to discharge a tenacious mucus. She had some elevation of temperature at the time and there was considerable mental hebetude. Two days later, an exudate appeared upon the

tonsils.

1 These ARCHIVES, vol. xxvii., p. 309.