88. Mounier. Erroneous purulent otitis caused by cervical glands opening into the auditory canal. Arch. internat. de laryng., etc., vol. xv., No. 3. 89. Bandelier. Spastic mydriasis from foreign body in the ear. med. Wochenschr., No. 21, 1901.

Münch.

87. Neuralgia of the auricle, simultaneous hyperesthesia of the skin of the head of a patient aged sixty years, after influenza. BRUEHL.

88. A broken bunch of glands below the mastoid process perforated into the external auditory canal through the opening of Santorini, simulating Bezold's mastoiditis. Recovery after operation. SCHWENDT.

89. The mydriasis disappeared on removal of a glass bead from the auditory canal by syringing. It is worth while in cases of foreign body in the ear to look for this symptom. SCHEIBE.

MIDDLE EAR.

a.-ACUTE MIDDLE-EAR DISEASE.

90. Sune y Molist. Treatment of acute purulent otitis with extension to the mastoid. Archivos latinos de Rhinol. Laryng. d' Otolgia., Ann. xiii., No. 115.

91. Coussieu. On the bacteriology of acute middle-ear disease. Ann. des mal, de l'or., du lar., 1902, 5.

92. Burnett. Scarlatinous empyema in the anterior and superior cells of the mastoid. Am. Jour. Med. Sci., March, 1902.

93. Randall, B. A. Modern operations on the mastoid process, with remarks on one hundred new cases. Am. Jour. of the Med. Sci., April, 1902. 94. Harris, T. J. Temperature after mastoid operations. Annals of Otology, May, 1902.

90. The author describes his method of treatment in an extensive paper with the contribution of fifty-two case-histories. An unusually favorable action is obtained from the administration of the salicylate of soda in doses of one gram every hour until symptoms of salicylism set in-tinnitus in both ears, deafness in the healthy ear. At this point the aural and the retro-auricular pain disappeared. HARTMANN.

91. COUSSIEU has examined twelve cases and found that the presence of only one micro-organism speaks for a rapid course, while the presence of a number probably means a chronic course. The infection frequently follows secondarily, and can be restricted by asepsis of the naso-pharynx and auditory canal.

ZIMMERMANN.

92. A patient, eighteen years old, with acute otitis, after scarletfever, suffered from enormous swelling of the cheek and oedema extending to the eye. At operation an opening was found in the bone above and behind the bony external auditory canal. Recovery. CLEMENS.

93. Among 100 operations performed by RANDALL during the last two years, the antrum was exposed in 49, 39 radical operations and 2 Stacke operations were performed. In acute otitis the application of heat was the best method of treatment. More than 1000 mastoid inflammations disappeared after the application of heat, which procedure failed in only 12 cases. CLEMENS.

94. In 90% of the cases the temperature did not rise above 102.4° F. In 67% it remained under 101°. The author concludes as follows: Moderately high temperatures are usual after mastoid operations. The cause for elevation of temperature is not to be determined. Unless accompanied by other symptoms mere rise of temperature is of no significance.

b. CHRONIC SUPPURATIVE OTITIS.

CLEMENS.

95. Grunert. On the occurrence of glycosuria following otitis. Arch. f. Ohrenheilk., Bd. lv., p. 156.

95. GRUNERT gives the history of this subject, which has not received very much attention, and adds two personal observations from the ear clinic in Halle.

I. A patient with chronic purulent otitis showed no sugar in his urine on the day of admission on a mixed diet. Cerebral symptoms were present, increasing subsequently. They were associated with polyuria, the glycosuria was not influenced by the withdrawal of carbo-hydrates. The glycosuria disappeared entirely after a very large quantity of serous fluid had been evacuated from the cranial cavity.

II. A man, aged forty-seven, suffered from an otitic extradural abscess. On the day of his admission to the hospital he was on mixed diet, and his urine was free from sugar. Two days later, the diet not having been changed, the urine showed sugar. An intracranial collection of pus was then let out, and the sugar disappeared. In the first case it is undecided whether the increase in the ventricular fluid associated with external hydrocephalus and consequent increase of pressure in the ventricles, especially

the fourth, can be regarded as the cause. Probably such increased intracranial pressure cannot be regarded as the only cause. In the second case, owing to the smallness of the extradural abscess, no increased pressure within the cranial cavity could have taken place. It is therefore assumed that the toxic influence starting from the abscess is responsible for the transitory glycosuria similar to the transitory glycosuria occurring in phlegmonous and septic processes, and to the repeated presence of sugar in the urine occurring at the height of acute otitides, which is also supposed to be toxic. The author considers that the origin must have been started reflexly from the ear.

HAENEL.

C. CEREBRAL COMPLICATIONS.

96. Braunstein. On extradural otitic abscesses. Arch. f. Ohrenheilk., vol. lv., p. 168.

97. Barker, A. E. Cerebellar abscess with sudden paralysis of the respiratory centre. Brit. Med. Jour., 19th April, 1902.

98. Alt. A healed case of otitic thrombosis of the sigmoid sinus and jugular vein, with metastatic pulmonary abscess. Wien. med. Presse, No. 24, 1902. 99. Dench, E. B. Treatment of sinus thrombosis after aural suppuration. Am. Jour. of Med. Sciences, May, 1902.

100. Lermoyez. A case of pyæmia due to thrombophlebitis. mal, de l'or., du lar., 1902, I.

Ann, des

ΙΟΙ. Furet. A case of thrombophlebitis of the right lateral sigmoid sinus. Operation. Death. Ann. des mal. de l'or., du lar., 1902, 1.

102. Laurens. Extradural abscesses with pachymeningitis of otitic origin. Ann. des mal. de l'or., du lar., 1902, 2.

103. Zeroni. On otitic meningitis. Aerztliche Mittheilungen aus u. f. Baden, Nos. 10, 11, 1902.

104. Broca and Laurens. Meningitis following chronic otitis simulating cerebral abscess. Ann, des mal. de l'or., du lar., 1902, I.

105. Caboche. Cerebral hernia following intracranial operations in middle-ear suppurations. Ann, des mal. de l'or., du lar., 1902, 4.

106. Hinsberg. On operative exposure of the jugular bulb. Allg. med. Central-Zeitung, 1902, No. 15.

107. Daae. Acute suppurative otitis media, osteomyelitis of the mastoid, epidural abscess, sinus phlebitis. Operation. Recovery. Norsk Magazin for Lägevidenskaben, Bd. lxii., No. 8.

96. BRAUNSTEIN reports 88 cases of uncomplicated extradural abscess which have been operated in the Halle Ear Clinic since the date of Grunert's paper. Extradural abscesses were found in the ten years, 1891-1901, in 8.2% of all mastoid operations. Of these, 4.2 % were in acute and 4% in chronic cases.

Of all the acute middle-ear suppurations with involvement of the mastoid process, extradural abscesses were found in 1.8 %, in 1% of all chronic middle-ear suppurations, and of acute and chronic suppurations 1.3 %; 76 % were observed in males, and 24% in females. The second decade seemed to be the most affected in chronic cases and all cases taken together. In the acute cases the fifth decade seemed to be preferred. The right and left sides were affected equally. The chronic abscess was situated in 70% of the cases in the posterior, and in 28 % in the middle cranial fossa. The abscess in the acute cases occurred in 73% of the cases in the posterior, and in 22% in the middle cranial fossa. The extradural abscess is always the result of disease of the bone adjoining the dura, and is the result of purulent inflammation of the external surface of the dura. In the chronic cases otoscopic examination revealed a severe ear trouble. There was always a deep-seated disease of the temporal bone and generally a passage leading to the abscess. This was wanting in a few cases of caries, where it is possible to assume that the diseased bone had already recovered and that the progress took place along a microscopic channel. Of the chronic cases, three were associated with deep-seated abscess. In the acute cases the otoscopic picture did not reveal the severity of the intracranial complication. In one-third of the cases there was no suppuration from the ear, but the surroundings of the ear were usually affected. At operation the temporal bone was partly carious and the cells in the cavities contained pus and granulations. A fistula to the extradural abscess was present in eleven acute cases. The fistula in the acute, as well as in the chronic, led to the abscess in the sigmoid sinus in only one-half of the cases. Among the acute cases there is one which Grunert has described, namely, deepseated abscess in the region of the lacerated foramen, extension from the tympanum along the carotid canal. The abscess in the chronic cases was, in general, larger than in the acute cases. They were generally shut off by granulations on the dura. In one case there was a gravitation abscess starting from the extradural abscess (retropharyngeal abscess in deep-seated extradural abscess). The dura in all cases was changed, usually to a marked degree, covered with necrotic granulations, or softened or covered with fibrinous exudate. The granulations in the acute cases usually appeared more or less recent. In the acute cases the diplococcus pneumonia of Fraenkel was usually present. This

germ can probably be regarded as the cause of these abscesses. In the chronic cases the diplococcus was never found. Staphylococci and streptococci and, in one case, tubercle bacilli were found. The streptococcus can be regarded as the most frequent cause of chronic abscess. The important and comprehensive chapters on the diagnosis must be read in the original.

The local changes in the ear and its surroundings show no diagnostic symptom characteristic of extradural abscess. Suspicion of extradural abscess, however, is in order if œdema or abscess occur upon the mastoid process in the region of the mastoid emissary or the occipito-mastoidal suture, or near the suprameatal spine, the linea temporalis, or in the bony auditory canal. An unusually profuse otorrhoea may come from intracranial suppuration. Headache was absent in more than one-half of the cases. The exact localization of these headaches-whose intensity does not stand in any relation to the insignificance of the objective symptoms-may serve as an aid to diagnosis." "In patients who are not apt to exaggerate and show no morbid process which can explain the severe headache, the ear must be very carefully examined, and with the slightest foundation for suspicion in this region the presence possibly of an extra-dural abscess must be reckoned with."

66

Facial paralysis and pathological changes in the eye grounds are of no aid in diagnosis of extradural abscess. Variations in the pupil, retardation of the pulse, stiffness and rigidity of the neck point to increased intracranial pressure. Attacks of vertigo, gastric symptoms, and fever do not, according to the experience of the Halle Clinic, stand in any causal relation to the intracranial abscess. An exact diagnosis of an uncomplicated otitic extradural abscess is impossible. A diagnosis of probability can only be made. Positive diagnosis is only made on operation.

Operation performed at the proper time gives a good prognosis. Recovery took place in 76% of the chronic and 89% of the acute cases. Death never resulted from the evacuation of the abscess. The treatment of the lesion by operation is fully discussed. The granulations should not be removed from the dura and should be meddled with as little as possible. The paper concludes with a review of the 88 case histories. HAENEL.

97. The patient was a girl, aged fourteen years, who, while being lifted on to the table for operation, suddenly ceased breathing, and death occurred in spite of pus being evacuated from the