palpable below the ribs. He noticed also a slight rise in the evening temperature at times. The urine contained no abnormal ingredients, averaged thirty ounces in twenty-four hours and a specific gravity of 1.030. Curettement of the uterus was performed in 1893 for excessive menstrual flow, which gave relief to the trouble but did not materially alter the lumbar pain. In the fall of 1894 the patient came under my charge.

The general appearance was that of health. The thoracic organs appeared healthy; there was no complaint of indigestion, but the bowels were obstinately constipated; menstruation was regular, and the pelvic organs appeared normal. There was a tumor on each side of the abdomen, occupying the place of the kidney; the one on the left side was the larger and extended downward and forward to the

level of the umbilicus. Both tumors appeared smooth and somewhat lobulated, giving the feel of a non-fluctuating and yet not a solid growth; both were painless and freely movable. From the lower extremity of the left tumor there projected a growth about the size of a lemon, which appeared to be attached to the larger tumor by a small neck or peduncle. The urine was carefully examined; the amount for twenty-four hours was 18 ounces; specific gravity, 1.025; acid, amber, clear; urea 2.2 per cent., 169 grains in twenty-four hours; no albumen, peptone, bile, or sugar; a few hyaline casts; no pus or blood, and no renal epithelia.

Dr. Christian Fenger was called in consultation, and the diagnosis of double hydronephrosis or of cystic degeneration of the kidneys was made. Daily examinations of the urine were made from October 15 to October 29, 1894. The amount of urine for twenty-four hours

varied between 18 and 48 ounces; the specific gravity was relatively low; the urine clear, acid in reaction; no albumen, blood or pus was found. The urea was diminished for twenty-four hours. Granular casts were found in one specimen only, and that after a rather thorough physical examination of the tumors on the preceding day. Hyaline casts were found in most specimens.

It was decided in consultation to make an exploratory lumbar incision. Accordingly, on November 30, 1894, Dr. Fenger operated, assisted by Dr. W. E. Morgan and the internes of Mercy Hospital. The exposed left kidney showed the characteristic cystic degeneration. The enlarged organ was fixed to the deeper surfaces of the wound by sutures passed through the capsule of the kidney, and the external wound was closed in the usual antiseptic manner.

The patient was placed on a diet suited to a deficient kidney, and Basham's mixture of iron and strychnia. Her present condition is about the same as when first examined. However, since the operation the urine has at times contained blood and albumen, and now contains some pus.

BIBLIOGRAPHY.-Dickinson, "On Renal and Urinary Affections," vol. iii, p. 841 et seq. Orth, "Pathological Anatomy," p. 313 et seq. Porter, "Renal Diseases" (1887), p. 160. Osler, "Principles and Practice of Medicine" (1892), P. 772. DeCosta, "Medical Diagnosis," sixth edition, p. 734. Flint, "Practice of Medicine" (1886), p. 910. Delafield and Prudden, "Pathological Anatomy and History," fourth edition, p. 559.

REPORT OF CASES OF BRAIN LESIONS-ABSCESSES, MENINGITIS, AND SINUS THROMBOSIS-RESULTING FROM DISEASE OF THE MIDDLE EAR.

BY J. T. ESKRIDGE, M.D., Denver, COL.,

Professor of Nervous and Mental Diseases in the Medical Department of the University of Colorado; Neurologist to the Arapahoe County and St. Luke's Hospitals.

The following notes of cases throw some light on the clinical history and diagnosis of brain lesions resulting from disease of the middle ear, and are therefore worthy of publication at this time, when cerebral suppuration is attracting so much attention both from the physician and surgeon-principally on account of the brilliant results achieved by Macewen in the relief of this trouble.

The histories and examinations of some of the cases are incomplete, and the autopsies of others are wanting; but sufficient may be gleaned from the study of each case to impress upon one the danger of neglecting a chronic otorrhoea-the importance of recognizing the early symptoms of brain complications and adopting radical measures for their relief when it becomes evident that ordinary therapeutic measures are impotent and that delay simply lessens the chances of surgical success.

The following is a good example of the danger likely to result from neglected otorrhoea in childhood:

Case 1.-Disintegrating Sinus Thrombosis; Leptomeningitis; Abscess. -A boy of 13, with negative family history, had suffered more or less with disease of the left ear since the time, ten years previous, when an attack of measles had left him with an acute otitis media. Periods of intermittence, sometimes extending over several months, had occurred, the discharge temporarily ceasing. In the summer of 1889 he contracted a cold which was followed by acute pain in the left ear and mastoid region; a week or two later the ear discharged quite freely, relieving the severe pain for a time, but the mastoid region remained sensitive to pressure. In September of the same year the discharge became very slight and somewhat offensive, and he began to experience pain radiating from the mastoid region to the superior triangle of the neck and over the left temporal region. The ear had been neglected for several weeks, and, the quantity of the discharge being greatly lessened, the parents thought the trouble was subsiding; but pain in the head became a prominent symptom, and Dr. McLauthlin was summoned. He found the temperature ranging from 100° to 101°; pulse from 90 to 110; the boy irritable and restless and slightly

delirious during the evening; the tongue coated, bowels constipated, appetite poor, but no vomiting. Fearing the brain had become infected, he asked me to see the child. I did so and concluded that if the brain had not already become affected it was in imminent danger unless we could prevent further infection. On thoroughly cleaning the ear and keeping it as aseptic as possible by means of repeated douches of warm water and the use of peroxide of hydrogen, the symptoms soon began to abate, and within a week the boy was free from pain. The ear was treated for some time by an aurist, who succeeded in curing the otorrhoea; but subsequently, when the boy took the slightest cold, he would complain of a dull, heavy sensation in the mastoid region.

Early in March, 1890, on contracting a severe cold, the mastoid region became the seat of constant pain, and scant but offensive discharge from the ear took place. A homoeopathic physician treated the patient four weeks for typhoid fever. During these weeks the temperature varied from 99° to 101°; the pulse ranged from 70 to 100; respiration was normal; there was pain in the head; the eyes were sensitive to light; the boy was restless; tongue coated; stomach irritable; bowels constipated; and vomiting frequently occurred. On the 9th of April I again saw the boy in consultation with Dr. McLauthlin. We found him considerably emaciated, feverish, temperature 101°; exceedingly restless, irritable, and complaining of constant pain in the left ear and left side of the head, the pain extending from near the forehead to the back of the neck. He lay with the head slightly retracted, but it could be brought forward without giving rise to much. pain, although the posterior cervical muscles of the left side were slightly sensitive to pressure and exhibited some rigidity. The gastric irritability still continued, and there seemed to be almost complete anorexia. The optic nerves showed slight neuro-retinitis without swelling; vision was impaired; pupils were small and not readily responsive to light. No paresis, paralysis, or twitching of any muscles. The deep reflexes were increased, and the superficial were absent. The boy was greatly prostrated and impatient of the slightest disturbance. There was no oedema over the mastoid, but a slightly offensive discharge from the left ear, the odor of which disappeared on cleansing the ear with peroxide of hydrogen. Meningitis, with possible cerebral abscess in the cerebellum, was diagnosticated. The symptoms grew rapidly worse, the head more retracted; the patient became listless, holding his hand to the left side of the head and giving evidence of great suffering. The temperature was constantly above normal, varying from 99° to 101°, sometimes registering in the axilla 102°. Occasionally shock-like contractions occurred in the muscles of the

arms, and at the same time the head would be considerably retracted. A semi-conscious condition ensued; deglutition was at times almost impossible; the pupils were dilated and did not respond to light; and the optic neuritis increased. On one or two occasions there were tonic convulsive movements, with a condition of opisthotonos. The boy, though apparently nearly unconscious, was restless and tossed. from one side of the bed to the other, and now and then gave evidence of great suffering. The pulse varied from 120 to 140; but the respiration was rather slow, sometimes irregular, and at times intermittent. On the night preceding his death, which occurred early in the morning. of April 14th, there was a decided convulsion, soon after which CheyneStokes respiration developed, and he passed into a condition of deep coma and a few hours later died.

Autopsy (four hours after death): On removing the skull-cap the membranes and cortex on the convex surface of the brain presented nearly a normal appearance, save a slight venous engorgement. The blood in the longitudinal sinus was fluid. On carefully removing the brain from the basilar cranial cavity, several pathological lesions were exposed. The dura over the left sigmoid sinus was nearly black, and over the left lateral it was dark, the color lessening toward the cerebellum. On opening the sinuses a disintegrating thrombosis was found, extending from the sigmoid into the lateral sinus, but not into the jugular vein. A small blackened necrotic opening through the left tegmen tympani had established a pathway for free communication from the cavity of the tympanum to that of the brain. The mastoid cells and antrum contained a few drops of pus and inspissated, dark-colored material which had a very offensive odor. The petrous portion of this temporal bone, dark on its upper surface, was softened and had stained the superior petrosal sinus and adjacent part of the dura. No coagula were found in the petrosal sinus. The pia on the left side in the posterior fossa was inflamed and covered with recent exudate and considerable pus. Around the pons and beneath the cerebellum the pial inflammation had extended beyond the median line, but the bones, sinuses and membranes on the right side showed no further evidence of disease. The left temporo-sphenoidal lobe in its lower and posterior portion was the seat of a non-encapsulated abscess containing about an ounce of offensive greenish pus and broken-down brain substance. A second abscess, in character like the first, was found in the left side of the cerebellum. On the left side, in the lower portion of the floor of the fourth ventricle, an ulcerated area containing a few drops of yellowish pus was found.

The case just reported suggests several points worthy of elaboration. One which cannot be too strongly emphasized is the danger