in apposition to one another, and this fact is frequently the cause of imperfect drainage of discharges from the middle ear in young subjects; while swelling of the walls of the canal from sub-periosteal or furuncular inflammations may render the canal practically impervious as a drainway for ear discharges.

Etiology. The causation of many cases of mastoiditis must be attributed to certain unknown idiosyncracies and dyscrysiæ. It is evident, however, that influences affecting the hygiene of the Eustachian tube and middle ear predispose to mastoid involvement indirectly. Thus adenoid growths of the naso-pharynx and other

Fig. 1.-Horizontal section, life size, of infantile temporal bone cut above the level of upper border of the external auditory meatus. The body and long process of the incus (1) are cut through at same level and appear in situ. (a) Floor of antrum. (b) First turn of cochlea. (c) Aditus. (d) External auditory meatus.

abnormal states of the nose and throat in childhood may be properly regarded as predisposing causes of mastoiditis. Exposure and other conditions generally regarded as productive of acute inflammatory conditions are exciting causes; while the acute contagious diseases of childhood, first, by depressing the vital forces of the patient, and secondly, by directly affecting the mucous

membrane of the throat and ear, render the latter susceptible to the attacks of micro-organisms of other species.

In tubercular mastoiditis, conditions of low vitality in the infant combined with unsanitary surroundings furnish the predisposing factors necessary to the successful propagation of the tubercle bacillus in any organ; the exciting cause of its attacking the ear and mastoid is only an object for speculation.

Symptomatology.-In young infants many early symptoms may be overlooked. Thus the first sign of mastoiditis in very young children who are not able to indicate their ailments by speech may be a suddenly appearing swelling just above and behind the ear. This is especially the case when no discharge from the ear has previously existed or has been noticed. In most cases the history is one of a severe type of earinflammation with earache and. other symptoms, which, instead of subsiding on the occurrence of a discharge, persist and recur, with earache, headache and variable temperature. The discharge from the ear is apt to be profuse, but may be slight or absent.

In the presence of ear symptoms, with or without a discharge, close attention to the temperature chart is of assistance in arriving at a thorough understanding of the individual case. Thus a high temperature (104° or 105° F.) changing rapidly to nearly normal or below and continuing variable is very suggestive of infection of the lateral sinus or jugular bulb.

The following symptoms have been observed in certain obscure cases in which the cause of the infant's illness was uncertain until the diagnosis of mastoiditis was arrived at: Attacks of loud crying, throwing backward the head, fumbling at or pulling at the ear. It may be observed in passing, that children of three or four years may complain of stomach ache when the trouble is really earache. It may be noted that children suffering with earache have a greater tendency to throw the head backward and to burrow into the pillow or against the nurse for the sake of warmth than have children with actual abdominal distress. The latter draw up the knees and squirm with pain. The early symptoms of mastoiditis in infants are largely those of acute middle-ear inflammation and only to be distinguished from the latter by the persistency, recurrence and severity of the symptoms. Symptoms of cerebral irritation occur in the later stages. The eyes may show abnormal reflexes while retraction of the head may indicate an already established meningeal

complication. Vomiting or convulsions are likewise an indication that complications secondary to the mastoid inflammation may be present.

Acute inflammation of the mastoid antrum as a complication of middle-ear abscess, if unrelieved, usually proceeds to the formation of:Acute sub-periosteal abscess of the mastoid. When not controlled during its earlier stages, mastoiditis proceeds more or less rapidly-sometimes in a few days, sometimes after several weeks to the formation of acute sub-periosteal abscess. Infection may take place by pus burrowing beneath the periosteum of the external auditory canal wall, from the antrum and middle ear to the external surface of the mastoid, but is doubtless usually affected by progressive inflammation of the bone spaces between the inner and outer tables, extending until it reaches the mastoid cortex. Although on section of a normal infantile mastoid, one finds that pneumatic spaces, properly speaking, are lacking, yet between the inner and outer tables there exist spongy spaces -the future pneumatic cells, through which infection seems to be readily conveyed from the antrum to other portions of the bone, and by which, likewise, infection may be conveyed to the cranial contents or to the lateral sinus as well as to the outer mastoid surface.

Sub-periosteal abscess of the mastoid makes its appearance usually after several days of pain, restlessness and rise of temperature. Rarely vomiting may have occurred, or even convulsions. A flow of pus from the ear may or may not have occurred.

Swelling appears above, behind, and sometimes in front, of the ear. The ear is pushed downward and outward rather conspicuously, so that the head presents a peculiarly lop-sided appearance. The whole outer ear seems displaced outward and downward. The pain is apt to subside or occurs in shorter paroxysms, with the appearance of the external swelling. The temperature, however, remains elevated or runs an irregular course. The abscess thus formed may dissect the periosteum from the bone in a backward, upward, or forward, direction. Edema may be present in the cheek, over the scalp of the entire side of the head, or even extend beyond the median line; and later, pus may replace the edema. The cellular structures outside the periosteum become edematous, and later, the site of pus collections.

Physical Examination of the Ear.-In examing the ears of infants greater difficulty is met with than in adults. At birth, the

upper and lower walls of the external auditory canal are practically in contact with each other and the drum membrane is placed on a nearly horizontal plane. The upper walls of the canal and the drum are thus on a nearly continuous plane, the angle formed by their meeting being very obtuse.

In examining the ears of infants one should pull the lobe of the ear strongly downward with the fingers of the hand which is holding and directing the speculum. This procedure draws the lower wall away from the upper and affords sufficient space to allow a clear view of the drum, though it is seen even then at a considerable angle and cannot be be looked at vertically; though by tilting the head of the patient away from the observer a more nearly vertical view is obtained.

Diagnosis of Mastoiditis of Infants.-It is proper to assume that some degree of inflammation of the antrum exists with all severe infections of the attic. On examining the ear the posterior superior quadrant of the drum membrane is found red and bulging; or if it has spontaneously ruptured, it presents the typical teatlike swelling indicative of inflammation and edema of the mucous membrane of the attic. At this stage, before any external swelling is present, it is often difficult to determine the proper course of procedure, since mastoid inflammation with intracranial symptoms often develop no external swelling. At this time the appearance of the tympanic membrane and the severity of the ear symptoms must be the chief guides.

Recourse to bacteriological examination of the discharge is frequently of value in determining the indication for or against an operation. In the routine examination of cases in the New York Eye and Ear Infirmary it has been demonstrated that the virulence of the infection varied with the organism. In spite of preventive treatment, almost all cases of mastoid inflammation due to the streptococcus came to operation; those in which the pneumococcus was found required operation in one-half the cases; in those due to the staphylococcus the mastoid operation was rarely required.

Tenderness about the ear, especially over the antrum, is significant, if present, but the presence of a point of tenderness is often difficult to elicit in infancy.

A rapidly changing temperature, reaching at times a high point, rarely in childhood beginning with a chill or a convulsion, is significant of involvement of the lateral sinus or jugular bulb. On the other hand, phlebitis of the jugular

has been observed to be quickly followed by pneumonia, which complicates the situation and masks the typical course of the original disease.

Necrosis of the mastoid bone in the direction of the sinus may lead to an invasion of this structure with the gradual formation of an infective clot. The dura covering the sinus resists these inroads for a time with apparent success, for it is quite a common experience to find at this point the surface of the sinus the site of an abscess, while the vessel beneath is uninjured. In infants an infection of the sinus is marked by restlessness and a marked rise of temperature. In adults the invasion is ushered in by a chill.

Abscesses of the cerebellum are not a rare result of inflammation extending from an infected clot in the lateral sinus.

Complications.-The two points through which infection is most likely to extend from mastoid antrum abscesses to the cranial contents are the tegmen tympani and the wall of the lateral sinus. The thickness of the bone is least in these directions, and consequently least resistance to inflammatory action is here met with.

In infants perhaps the most common intracranial complication is meningitis; either leptomeningitis or tubercular meningitis. Autopsies occasionally disclose the track of both these forms of meningitis to have occurred by way of the middle-ear, and the writer cannot too strongly emphasize the need of strict attention to the ears of infants affected with acute otitis, especially during the course of acute contagious dis

ease.

Tubercular Meningitis.-Cases of tubercular otitis subsequently involving the mastoid antrum and terminating in meningitis are not rare. The writer has seen several typical cases. The course to a fatal termination is favored by the less dense structure of the bone in infancy. The inroads made by the disease in the children living in poor and unsanitary quarters, before the parents regard them as really ill, are almost incredible. The disease may, however, progress without apparently very pronounced symptoms. Discharges from the ear, which, it seems, often drive the parents of the poor to the hospitals and clinics because of the foul odor, in tubercular otitis are often almost odorless. Apparently in this class of patients the discharge is often entirely overlooked since it is a common experience to find that they are ignorant of it when the child is presented at the clinic.

Facial Paralysis is one of the uncommon complications of mastoiditis in young children in the

experience of the writer. A case occurring in a child of six months of age with tubercular mastoiditis is pictured below. In this case at the first examination of the patient the incus of the affected side was found unattached in the external auditory canal. The removal of this obstruction furnished free vent to the inflammatory discharges; but the other side shortly developed in rapid sequence suppurative otitis media, subperiosteal mastoid abscess and meningitis. I am indebted to Dr. A. C. Brush for his courtesy in making the photograph.

The lepto-meningitis of otitic origin differs in no respect from that due to traumatism or other sources except in such symptoms as are occasioned by the previously existing disease.

In localized ulceration of the brain, in epidural and subdural abscesses, more or less localized or general meningitis is present; so that the differentiating symptoms may be difficult to recognize. The predominance of lepto-meningitis occasions high fever, photophobia, cephalalgia, rapid pulse and respiration, retraction of the head from contraction of the muscles of the spine, delirium and stupor. When the collection of pus is localized (brain-abscess) and sufficient to occasion pressure of the intracranial contents, a slower pulse, more variable temperature, profuse sweating and a septic apearance are the rule.

Treatment.-Preventive treatment of mastoiditis in children consists in free and frequent syringing of the ear when a discharge exists in an acutely inflamed ear; and in freely incising the drum, behind which, on examination, pus is observed to be exerting pressure in those cases in which no discharge exists. Pouting perforations of the upper and posterior portion of the drum, which may be regarded as often on the border

line of mastoid inflammation, may likewise be incised with benefit when it is found that the perforation is insufficient to carry off the inflammatory products.

Active treatment consisting of operative interference should not be delayed too long, especially when restlessness and pain continue. A discharge, however insignificant, is a symptom not to be disregarded in infants when recurring attacks of pain point unmistakably to the presence of active inflammation in a region where the escape of inflammatory products is fraught with so many unpleasant possibilities.

Operation. In operating for simple mastoiditis of infants it is proper to make the object point, first of all, the mastoid antrum. Some cases, it is true, recover with simple incision of a sub-periosteal abscess. But the percentage of thorough recoveries must be few, relapses many, and the establishment of chronically discharging bony sinuses are common results of this unscientific treatment. In most cases a suppurative process is present in the antrum from which a continuing rarefying osteitis may extend in any direction with a possibility of the cranial contents becoming ultimately involved. The mastoid antrum should be entered in every case in which an operation is performed. Having once entered the mastoid antrum, free drainage may be established, necrotic material may be thoroughly removed, and one has the satisfaction of thoroughly understanding the state of his patient. Chronic suppuration of the middle ear is otherwise about the least harmful condition which is likely to result from a mastoiditis which is not thoroughly operated upon.

petent to discuss. One of the incidental remarks caused some question in my mind: the statement was made that gall stones introduced into the gall bladder of healthy dogs were dissolved after a short period. I would like to know whether these gall stones were first obtained from the gall bladders of dogs or from the gall bladders of human beings. From what we know of the special actions of glandular secretions, unless these gall stones were obtained from dogs, we could draw no conclusions as to the fact of their being dissolved, because the gall of the dog might dissolve the stone of the human being, whereas the bile from the human being would not dissolve the gall stone from the human being.

DR. R. W. WESTBROOK: I cannot answer that question just as the Doctor has put it. All I know about these experiments is, that they were made by a physiologist of note, and I presume with all precautions and with just these points in mind that he has mentioned. The result of these experiments have been published in the Journal of Physiology within the past year, but I have not had access to the original article. That is a point that also occurred to me and a point which I wished to look up, but as they were made by a physiologist of note, I presume the facts and views adduced are of value. I think it very possible as the chemical composition is similar, that the gall of the dog might dissolve human gall stones, but I am not at all sure of that. It is a very pertinent question.

Arthur J. Capron, L. I. State Hospital, Albany Med Col., 1894. Proposed by Robert M. Elliott; seconded by Wm. Browning.

Thurston G. Dexter, 411 Hancock Street, L. I. C. H., 1901. Proposed by John C. Cardwell; seconded by J. H. Raymond.

Charles S. Cochrane, 400 Vanderbilt Avenue, L. I. C. H. Proposed by W. A. Northridge; seconded by E. H. Bartley.

W. B. Brader, 1195 Bushwick Avenue, Univ. Penn., 1885. Proposed by Alfred Bell; seconded by Tracy Clark.

J. A. Longmore, 26, Schermerhorn Street, L. I. C. H., 1901. Proposed by J. A. McCorkle; seconded by Membership Committee.

ELECTION OF MEMBERS.

The following having been duly proposed and accepted by the Council were declared, by the President, elected to active membership:

R. M. Rome, L. I. C. H., 1901.
E. C. Sullivan, Harvard, 1903.
W. T. Raub, L. I. C. H., 1897.
R. Byington, P. & S., 1900.
P. V. Costello, Yale, 1901.

HONORARY MEMBERS.

Dr. C. K. Mills of Philadelphia and Dr. Thomas Darlington of Manhattan were elected honorary members.

RESOLUTIONS.

The following resolutions adopted by the Council were read by the Secretary:

Whereas, The Medical Society of the County of Kings is and has been for many years firmly convinced that there should be a systematic enforcement in the said County of Kings of the provisions of the Public Health Law relating to the practice of medicine, as well as the provisions of other laws, affecting the public health generally; and

Whereas, The said Society has from time to time endeavored systematically to enforce this law, but each time has been compelled to cease. its efforts for the protection of the public health by reason of a lack of funds; and

Whereas, The said Society has not the means to carry on a systematic enforcement of the laws affecting the public health; and

Whereas, Such work is of a public character and properly chargeable to the public authorities; and

Whereas, Precedent exists for the appropriation of public moneys to private societies engaged

be it

Resolved, That the Medical Society of the County of Kings, through its committees named below, petition the constituted authorities to enact a law or laws appropriating public moneys whereby the said Society can carry on the work of enforcing the laws designed to protect the public health. Be it further

Resolved, That the committee consist of Drs. H. B. Delatour, David Myerle and H. A. Arrowsmith, togther with Dr. John E. Sheppard, President of the Society, and the Counsel of the Society. Be it further

Resolved, That the said committee be empowered to prepare the necessary act or acts, petitions, memorials and necessary printed matter of every kind, to bring about the end proposed, and to employ such other and further means as to the committee may seem expedient. Be it further

Resolved, That the committee is instructed to work in conjunction with a similar committee appointed by the Medical Society of the County of New York for a like purpose, on Monday evening, May 23, 1904.

On motion, duly seconded and carried, the resolution was adopted.

The following resolution was also received from the Council.

Resolved, That the Medical Society of the County of Kings retain Champe S. Andrews, Esq., to assist the committee appointed pursuant to a resolution adopted on the 21st day of June, 1904, by this Society, for the purpose of securing the appropriation of public moneys for the enforcement of the laws affecting the public health. On motion, duly seconded and carried, the resolution was adopted.

Dr. C. C. Henry presented a resolution, regarding a recent Supreme Court decision relative to drug substitution by pharmacists.

Dr. F. E. West moved that the matter be referred to the Council for consideration. Seconded and carried.

A vote of thanks was unanimously tendered to Dr. H. L. Elsner for his courtesy in coming to this city to read a paper at this meeting.

SCIENTIFIC PROGRAM.

1. Paper: A Method of Distinguishing Progressive Cerebral Hemorrhage. By Dr. William Browning.

Discussed by Dr. Barber.

2. Paper: Pain, Anomalous in Location and Character, in the Diagnosis of Some of the Dis