I saw the patient at my office March 20th, two months afterwards. She claimed not to have been entirely free from pain in her ear ever since my first seeing her. I now gave the case a thorough examination; carefully analyzing the subjective symptoms and the objective findings in the light of her previous history. In order to be brief I shall only give a summary of my examination.

Personal history.-A subject of digestive disturbances for years. Has eructation of gas to such an extent as to attract embarrassing attention of all who may be about; constipated, as the average woman is; has what one may call a neurotic temperament. Her teeth, although in very fair condition, exhibited a deposit of tartar that for quantity was indeed something astonishing to behold in a lady of her quality. She sleeps very poorly; has had rheumatism.

Subjective Symptoms.-Suffers from severe pain, amounting to that of neuralgia, within the ear and mastoid process. The severe pains subside at times to a dull ache that seems to be continuous, having been so now for over two months; slight involvement of hearing caused by a sense of fulness in the ear; no tinnitus.

Objective findings.-Tenderness on firm pressure over the mastoid area. Learned nothing from auscultation of the mastoid. Skin and tissues over mastoid region normal in appearance. The drum membrane was not even congested, but in its posterior inferior qualrant was to be seen a large calcarious deposit. Another smaller one was toward the center. The position of the drum was slightly exaggerated in the concave. The shadow of the tip of the incus could be seen. The Eustachian tube was patent to inflation. The temperature registered 99.5 F. The pulse was regular, but feeble, and counted 88. The urine showed alkalinity on the first examination but later was neutral.

Functional examination.-Rinne, positive; Weber, negative; Gelle, positive. The capital C tuning fork was heard 10/25 (Rinne positive). The capital C fork was heard 0/8. The c1 fork was heard 0/3. Galton whistle heard through its entire scale. Inflation has no influence on the hearing.

To relieve the pain and get some sleep the patient has been an habituate to the use of "Bromo-Caffein," so that dozens upon dozens of empty bottles of the drug have been removed from her room at short intervals. Aside from this, kindred other "quieting powders" were constantly used. Most of these were proprietary preparations which taken in the quantities used by her could not but prove injurious. She told me that she could not live without the use of something or other to relieve her head pains and quiet her sufficiently so as to get some sleep at night.

The patient was under observation for several weeks, during which time her teeth were first ordered to be attended to. i stomachic tonic containing dilute hydrochloric acid, nux vomica, black pepper and gentian was employed. Besides bromides, largely diluted with great quantities of water, were given for the pain. In

addition the diet was regulated so as to eliminate as much as possible the nitrogenous elements, and a five grain lithia tablet was ordered taken with each meal. Electric massage, with the addition of physical exercise was given her.

Eight weeks of this treatment proved of some little benefit, but still the pain was in that side of the head. At the very outset the patient was made aware of her condition by my explaining the pathology present. I told her I believed the process was one of osteosclerosis, and as is so frequently the case during the hardening process, the patient suffers severely from neuralgic pains. I told her that as a last resort we might trephine the bone and relieve the tension within and thereby the existing pain. This was at last done. The entire mastoid process operated upon was found as dense and hard as ebony. Almost immediately after the operation the severe pains disappeared entirely and have not recurred.

I have a similar case under observation now, only she has not been operated as yet.

The second case I wish to report was one occurring in a young lady of about 24 years of age. Her trouble originated as an acute otitis media on the left side, which terminated in a suppuration with perforation of the drum membrane. The suppurative symptoms soon subsided and the drum head healed. Shortly following this she complained of neuralgic pains in the left mastoid process, radiating over the entire side of the head, back of neck and even into the eyes. In spite of all attempts to relieve her suffering the condition continued for a couple of months, when I finally decided to perform a mastoid operation. In this case, as in the one just reported, the mastoid process was very hard and devoid of any cells. The pain in this case disappeared shortly after the operation.

Owing to an absence of a sequence of symptoms that point definitely to decided pathologic changes within the temporal bone, it has been presumed that a positive statement as to the presence of an osteosclerosis of the mastoid process is difficult. It is true that in establishing a diagnosis in such cases we are confronted at the very first with a lack of an array of symptoms characteristic of the condition. But this very lack of definite ear symptoms is really an aid to the establishment of a positive opinion.

When pain is present, it is the all important symptom, and it must be studied very carefully in order to exclude other possible causes. As for instance the imaginary pain of hysteria, the pain of lithemia, gout and rheumatism, chronic abscess of the bone, cholesteatoma of the mastoid process and the reflex neuralgias.

Observers and writers on ear diseases, years ago, recognized the cause of pain in connection with the hardening process of the mastoid.

Brühl says "while the process of osteosclerosis is going on the patient may complain of neuralgia." All the older writers reported the prominence of pain as a symptom in connection with hardening of the mastoid process.

Possibly the malingerer and the hysterical subject are the two possible sources of mistake. in neither of which would it require more than the suggestion of an operation as the remedy to be employed, to cause them to declare a sudden and marked improvement in their condition.

The pain in osteosclerosis of the mastoid process is very deep seated. My patients express it as "away down deep in the car." A dull ache, similar to a slight toothache is constantly present. At intervals the pain increases to the extent of being neuralgic in character. It is centered mainly back of the ear, in the mastoid region, and thence radiates up towards the side of the head and down into the neck. At times there is an associated occipital headache. I have never heard them complain of pain in front of the ear.

This condition continues to persist day after day, week after week and month after month, often bringing the patient to a state of mental as well as physical exhaustion. To relieve this persistent, intense and often intolerable suffering they most naturally take recourse to remedies that tend to relieve their agony, and from a simple sedative they are gradually lead to use the stronger ones, until even the more powerful and dangerous hypnotics and analgesics relieve their suffering but temporary. Is it any wonder that such patients fall an easy prey to the use of injurious drugs?

In addition to the pain just described, one will always find a spot over the mastoid process which when pressed upon will elicit a sharp sensation of pain. This spot is usually found on a line with the meatus. Although the tenderness may not be limited to this region, but at times may extend over quite a large area. The auricle, the integument lining the auditory canal, the region in front of the tragus and just beneath the lobe of the ear are not at all sensitive to the touch. In this we have a difference between the hyperasthesia of these parts noticed in hysteria and the malingerer. In reflex neuralgia the pain can usually be traced along some particular nerve to the origin of the trouble.

My cases have all shown a slight rise in temperature, 99° to 100° F., at times during my observations.

Very frequently the history of previous ear disease, either a

catharrhal or a suppurative variety, is given, and at times evidences of such may be found in the form of perforation of the drum membrane with pus, adhesions of the drum membrane, cicatrices, atrophic spots or calcarious deposits.

In some cases transillumination and auscultation of the mastoid process might be an aid in the diagnosis, although I myself do not place much reliance upon them.

In addition to the pain as a symptom of this condition, the importance of the operative measure in rendering relief is what I want to lay particular emphasis upon.

Dr. Knapp, in a paper read before the Twentieth Annual Meeting of the American Otological Society, in 1884, on the Indications for Opening the Mastoid Process, says, "In subacute or chronic sclerosing nonsuppurating mastoiditis with an intact drum membrane, the mastoid may be opened when cerebral symptoms are present, or especially intense and obstinate pain, radiating from the mastoid over the whole side of the head, incapacitating the patient from work."

The opening of the mastoid for the relief of this condition has been done on several occasions, but it is not a common procedure. Dr. Knapp first performed it in 1881 (Archives of Otology, Vol. 10, page 365) on a girl of 16 years, with no symptom of ear inflammation at any time, excepting an excruciating pain centered in the left mastoid process, and which was relieved immediately and entirely by opening the mastoid.

Cases are known where the process has been opened by mistake, that is a mistake in the diagnosis, where the operator thought he had to do with an abscess condition, but on opening the parts they found nothing but hard and dense bone. But to their astonishment their patients got entirely well.

Dr. M. H. Cryer in his recent book entitled Studies of the Internal Anatomy of the Face, says, a propos of facial neuralgia, that secondary bone deposit of inflammatory origin in the cortical or cancellated tissues of the face is an important factor in producing facial neuralgia.

The particular operation performed in this class of cases is a simple one and scarcely ever need require more than the removal of a large core of bone just posterior to the meatus. It may not even require the exposure of the mastoid antrum. The operation is best done with an instrument that will leave a clean and smooth surface, and in my hands I have found nothing better for this pur

pose than an instrument known as the Russian Perforator. With this instrument you remove a core of bone about the size required; you have perfect control of the instrument and of the parts you are working in, so that there is no danger of injuring any of the important neighboring structures; you have a surface that is free from irregularities and spiculae of bone, thus favoring a rapid healing by first intention.

100 STATE STREET.

A CURIOUS CASE OF EMPHYSEMA.

BY DR. G. G. TAYLOR, M. D., GRAND HAVEN, MICH.

A youth of fifteen years of age, while running, fell, striking the frozen ground just above his right eye. There was no visible external injury, and there were no symptoms or signs of constitutional shock. A few minutes later, upon vigorously blowing his nose, the right upper eye lid immediately bulged out, completely closing the right eye.

On examination, shortly after the occurrence, the right eye was found completely closed. The entire upper lid was the seat of a tense, symmetrical swelling, which crepitated upon pressure. There was no sign of ecchymosis or fluid effusion. The eyeball itself appeared normal; there was no conjunctival or ciliary injection; the pupillary reflex was present and unimpaired; vision was not disturbed save by the bulging lid. At the point of traumatic impact, slightly below the middle of the right superciliary ridge, there was pain on pressure, but no distinct sign of fracture. There was also a sensation of fullness throughout the frontal sinus. The skin was unbroken. Examination of the nose and ears was negative, but inspection of the nasopharynx revealed traces of blood upon its posterior wall. This blood probably came from the posterior nares.

The diagnosis appeared to present no great difficulty, although the case is unusual. There was in all probability a slight, fissured fracture of the antero-inferior osseous wall of the frontal sinus, without external wound. The increased intranasal tension attendant upon the vigorous blowing of the nose forced additional air up through the infundibulum and into the frontal sinus, whence