CASKS OF FATAL OTORRHCEA. FIVE CASES OF FATAL OTOBRIICEA, WTTII RE- 
MARKS ON THE COURSE BY WHICH 
SUCH CASES LEAD TO DEATH. 
By J. Orne Green, M. D., of Boston. 
The accompanying cases are submitted to the Society as 
contributions to the pathology of the ear. 
For the opportunity of witnessing the following autopsy 
and dissecting the specimen I am indebted to the kind- 
ness of Dr. Francis Minot. The history is taken from the 
hospital records. 
I. B., aged 28, pedler ; entered the Massachusetts General 
Hospital, on May 12, 18(19. Both parents were phthisical, 
lie himself had always been well till two years ago, when he 
had an abscess under the right jaw, referred by him to a 
carious tooth, but more probably due to an inflammation of 
the tympanum. At the same time a discharge began from 
the right ear, which has continued ever since, but given him 
no special inconvenience. In October, 1868, after exposure, 
had pleurisy, and ever since has had a cough, with occasional 
bloody expectoration. 
On May 2d, after a long walk in the rain, the muscles of 
the right side of face became paralyzed, and this was soon 
followed by general pain on the right side of head. Ten 
days after, he entered the hospital, complaining of constant 
vertigo and pain on the right side of head, but was able to 
be about. All functions natural. Pulse 96. 
May 11th.— Pain in head continued severe, keeping him 
awake at night. Towards morning, without marked chill, a 
heavy cold sweat with nausea, and followed by considerable 
prostration. 
From this time to the 22d, vomiting was very frequent, 
but then ceased ; the pain in the head continued severe, and 
could not be relieved by any opiates. 
23d.— A careful examination showed that all parts sup- 2 
plied by Ihc right facial nerve were] completely paralyzed. 
The hypoglossal was also affected, for the whole body of the 
tongue when protruded, was pushed to the right side, but 
the tip could be moved freely from side to side. Sensation 
was good. The right arch of the palate was higher and 
rounder than the left; the uvula was slightly inclined to the 
left. 
24tli.— The pain in the head was for the first time relieved 
by a subcutaneous injection of sulphate of morphine, gr. 
There was some delirium. 
25tli.— The delirium had increased, and there was great 
restlessness at night; which was relieved, however, by mor- 
phine, gr. £, subcutaneously. 
2tith.—Became gradually comatose, the respiration 
shorter, and without any new symptoms, he died. 
The autopsy, six and one-half hours after death, by Dr. 
John Homans, revealed as follows : — 
"The right external auditory meatus filled with pus. 
"Head: convolutions of brain universally flattened ; arach- 
noid rather dry, fluid opaque. Both ventricles contained an 
unusual amount of fluid which was opaque, and, at depending 
portions, purulent. Membranes of the right half of Pons 
Varolii, covered with a grumous deposit, and the substance 
of the lower part of Pons, and of the corresponding olivary 
body was broken down nearly to the wall of the fourth ventri- 
cle. Substance of the right half of cerebellum destroyed to 
the depth of three-fourths of an inch. Tissues in the neigh- 
borhood of the ventricles much softened. The base of the 
brain covered with a purulent deposit which extended for- 
wards to the optic commissure, and over to the left side of 
Pons. 
" Thorax:—Many old pleuritic adhesions. 
" Lungs :— Tubercular masses in both. 
"Abdomen:—Tubercular masses in peritoneum. Many 
tubercular ulcerations of the large intestine.” 
Dissection of the petrous bone. The meatus interims 
filled with pus, and the dura mater on its edges for the dis- 3 
t:inco of half an inch dissected up, leaving the hone hare hut 
not carious. On washing away the pus, the facial and audi- 
tory nerves at their exit from the meatus were distinct and 
apparently not affected. At the orifice of the aqueductus 
vestihuli, on the posterior aspect of the petrous portion of 
the hone, the dura mater was bulging for a space half an 
inch in circumference, and pus was exuding through a small 
opening. 
Lateral and petrosal sinuses were not affected. No caries 
of the hone at any point. 
Hoof of tympanic cavity unusually thick : this was removed 
and the cavity found filled with muco-purulent matter; the 
mucous membrane lining it was much swollen and of a livid 
color. Malleus whole and distinct, hut no signs of the incus. 
The cavity was then opened by sawing through the whole 
hone. The membrana tympani was much thickened by 
hypertemia and swelling of its mucous lining, and was perfo- 
rated both anterior and posterior to the manubrium, the 
anterior perforation being the larger. The malleus was 
normal and in normal position, hut completely buried in 
the swollen mucous membrane. The mucous membrane 
of the promontory was so swollen as to nearly fill the 
depressions of the fenestra}, ovalis and rotunda. No traces 
of the stapes could be found. Thick, adhesive, puru- 
lent matter exuded from both fenestra}, and the vestibule 
was completely filled with it. The cochlea was opened, 
was free from pus, and appeared to the eye normal. 
On laying open the meatus interims, the facial nerve con- 
tained in it appeared normal, but the auditory nerve was dis- 
colored, and surrounded by and infiltrated with pus. The 
Fallopian canal in its passage through the tympanic cavity 
seemed to be only a groove, no bony wall separating it from 
the cavity, and the facial nerve was here only covered by 
the swollen mucous membrane. The inflammation had appar- 
ently not extended into the Fallopian canal. A microscopic 
examination of the facial nerve taken from the tympanic 
cavity showed no disorganization. 4 
The semi-circular canals contained no pus, and appeared 
normal. The mastoid cells were few in number, but all 
contained purulent matter. 
The extensive breaking down of the substance of the base 
of the brain on the right side, and the purulent deposit there, 
showed that this was the oldest spot and centre of the brain 
disease. The presence of pus in considerable quantity 
beneath the dura mater at the orifices of the meatus interims 
and aqueductus, and these collections only communicating 
with the interior of that membrane by small openings, indi- 
cated that the matter had collected there from the side next 
the bone, and had not penetrated from that next the brain. 
The bone not being carious at these points, it was necessary 
to look further; and following the pus into both these pas- 
sages it is traced directly into the vestibule, which, from the 
destruction of the stapes, communicated directly with the 
tympanum. Further, the part of the brain disorganized was 
just along the course of the auditory nerve of the affected 
ear, and this nerve was found throughout its course discol- 
ored. 
From these facts the source of the brain disease can be 
distinctly traced. From ulceration of the membrane around 
the stapes, the purulent matter of a chronic inflammation of 
the tympanum had penetrated the vestibule, and from here 
running along the only two passages communicating with 
the interior of the skull, had emerged at the aqueductus 
v'estibuli and meatus interims, and thus set up a fatal menin- 
gitis. A portion of the infecting matter had also probably 
run along the auditory nerve. 
The first symptoms in the case, aside from the otorrhoea 
of two years’ standing, were paralysis of the facial nerve on 
the affected side, followed by constant dizziness, nausea, 
vomiting, and severe pain referred to the whole side of the 
head. After several days the vomiting ceased; the severe 
pain in the head could not be relieved by any remedies. The 
right hypoglossal nerve became paralyzed. The last two 
days of life lie was delirious, and died on the twenty-fourth 
day from the beginning of the head symptoms. 5 
IT. G. II. W., aged twenty-two, a stont, healthy negro, 
entered the City Hospital, April 13, 18G9, with a number of 
small superficial scalds on scalp and face. Three days after- 
wards, without known cause, he was seized with severe pain in 
right car, soon followed by discharge. On examination at this 
time, I found an acute purulent inflammation of the right 
tympanum, with a small perforation on the anterior segment 
of the membrana tympani and a free discharge of pus. The 
inflammation was treated with leeches, syringing, and astrin- 
gent instillations, and ran a very short and favorable course. 
The perforation, which had enlarged to one and a half lines 
in diameter, began to heal, and on May 12th lie was dis- 
charged, to report as an out-patient; the perforation had 
contracted to the size of a pin-hole, the discharge had entirely 
ceased, and the hearing had been rapidly improving for sev- 
eral days. 
On May 15th he returned, with severe pain in the ear and 
discharge, and reported that on the day of his discharge from 
the hospital, he laid on the damp grass and took cold. Ex- 
amination showed the tympanum again intensely inflamed, and 
the perforation enlarged. He was immediately taken into hos- 
pital, and treated as before ; but two days afterwards an 
otitis externa set in with so much swelling that the deeper 
parts could not be seen ; in about ten days this had subsided 
and inspection then showed a perforation about two lines in 
diameter, through which a small polypoid growth, the size of 
a pea, protruded. This was removed close to the membrana 
tympani by means of the wire snare, and the base cauterized 
with pernitrate of mercury. Two days after, the whole 
base of the polypus, with the slough from the caustic on one 
side was washed out by syringing. 
The discharge gradually ceased under treatment, the 
mucous membrane of the tympanum could be seen smooth 
and free from inflammation, the membrana tympani began to 
heal rapidly, and on June 2d he was discharged and ordered 
to report in two days, as an out-patient. ]S’o more was seen 
of him, however, till .November 23d, when he gave the fol- 6 
lowing account. Soon after leaving the hospital he went 
into the country, and was kept there for four months to work 
off an old debt, being obliged all the time to sleep in a barn. 
During this time he had a slight discharge from the ear, for 
which nothing was done. Two weeks ago he had severe pain 
in the ear, and a swelling formed in front of tragus : this 
pain has continued severe, and the swelling has increased. 
He now has sharp, lancinating pains in ear, over the whole 
right side of face and head, difficulty in swallowing, and 
headache. There is a moderate discharge of thick pus from 
the meatus, and the whole of this passage is filled by a firm 
polypus with a red granular surface. He is much emaciated, 
feverish, with hot skin and rapid pulse. Jn front of the tragus 
is a swelling extending on to the cheek and down the neck, 
without fluctuation ; only slight tenderness over mastoid pro- 
cess, and no swelling or redness. Appetite poor. 
Leeches and blisters were applied about the ear, and nar- 
cotics r. n. 
On Nov. 28th, dry rales were reported over both backs 
and there was a bloody viscid expectoration. Other symp- 
toms same as on entrance. 
Dec. 7th. — Pain in ear and head continued : complained of 
great vertigo, and vomited all food. 
Dec. 8th.—I saw him for the first time since his re-entrance, 
at the request of Dr. Cheever ; etherized him, and attempted 
to remove the polypus. The wire snare surrounding the 
growth was passed in as deeply as possible, and the mass 
cut off, apparently about one-fourth of an inch from the posi- 
tion of the membrana tympani. The walls of the meatus were 
covered by exuberant granulations. This operation was fol- 
lowed by such a rapid and profuse oozing of blood from the 
granulations and from the polypus, that it was impossible to 
remove more of the growth. With the probe, bare bone 
could be felt through the granulations. An incision was 
made into the swelling in front of the tragus, but no pus 
found. 
Dec. 1 Oth. — The pain in ear was less ; purulent discharge 7 
continued. Complained of sore throat and dysphagia. Li- 
quid diet. 
Different astringent instillations and caustics were tried 
to prevent the growth of the polypus and granulations, but 
without avail; the profuse bleeding prevented any further 
attempt to remove the polypus. The vertigo, vomiting, and 
pain, which were much relieved for a few days after the ope- 
ration, returned with increased violence. 
On January 3d, however, the vomiting had ceased, but the 
dysphagia had much increased, and on protruding the tongue 
it was drawn to the right side from paralysis of right hypo- 
glossal nerve. Pain and discharge in ear as before. Under 
ether the swelling in front was freely incised by Dr. Cheever, 
but no pus found, and a seton was inserted over mastoid pro- 
cess. For the next week there was a slight improvement in 
the general symptoms, but there was occasional severe pain 
in ear, and the paralysis of hypoglossal remained as before. 
On the 26th he began to fail rapidly. There was occa- 
sional cpistaxis and obscured vision, but no difference in 
pupils. No new paralysis. 
On the 28th, scmi-conscious. Tongue dry; could not be 
protruded. No pain. 
On the 30th he became profoundly comatose, without ster- 
torous breathing; and, without convulsions, chills, or any 
new paralysis, died. 
The autopsy by Dr. Webber showed in brief a general 
inflammation of the meninges of the brain, most severe at the 
base, with a large formation of lymph there. From the 
arachnoid covering the under surface of middle lobe on the 
right side, was a morbid growth resembling granulations : 
from the arachnoid of the right lobe of cerebellum was a sim- 
ilar growth through which the 9th, 10th, and lltli nerves 
passed ; the 12th nerve was not implicated. A similar and 
larger mass covered the whole surface of the dura mater over 
© 
the petrous portion of the right temporal bone, filling nearly 
the whole of middle fossa of skull and passing through the 
foramen ovale, carotid foramen and foramen rotundum to out- 8 
side of skull. The lateral sinus was implicated in a similar 
growth and apparently obliterated. The tissues of the neck 
and around the ear were infiltrated with a purulent, grumous 
matter. The inner table of skull on right side was roughened 
as in the first stages of caries. A small portion of 12th 
nerve, external to the skull, was examined microscopically 
and found entirely degenerated, no normal fibres being seen; 
this being probably due to the pressure of the inflammatory 
products where the nerve had its exit from the skull. 
The right temporal bone was removed and dissected. On 
removing the roof of the tympanic cavity, a polypus was 
seen attached to the promontory, and projecting into and 
filling the osseous meatus. The tympanic cavity contained 
much thick pus. No traces of any of the ossicula could bo 
discovered. The internal ear was opened by sawing through 
the petrous portion of the temporal bone; the vestibule, 
cochlea and semi-circular canals were filled with a red, solid 
flesh-like mass, the membranous structures having been thus 
changed. The mastoid cells were filled with thick pus, and 
carious. 
The mass described above on the dura mater projected 
slightly into the meatus interims, and also into the aque- 
ductus vestibuli. The polypus grew from the whole surface 
of the promontory, and was attached to no other part of the 
tympanum. The granulations of the meatus, seen a few days 
before death, had entirely disappeared, and the whole in- 
ternal surface of that passage was denuded of periosteum, 
and carious, and almost the whole anterior wall had disap- 
peared. The walls of the carotid artery and jugular vein 
were thickened, but these vessels were pervious and con- 
tained no thrombi. The lateral sinus was not affected. 
After maceration, the extent of the caries could be better 
seen. The entire wall of the meatus was carious, and a large 
part of the anterior wall had disappeared. The temporal 
bone, for the extent of one-half an inch around the meatus 
and the roots of zygoma were carious, being honeycombed by 
minute openings. The glenoid cavity was slightly carious, 9 
ns was also the superior surface of the petrous hone, and the 
wall of the lateral sinus. At the entrance of the aqucductus 
vestibuli, was a considerable loss of hone from caries. The 
walls of the carotid canal were carious. The entire floor of 
the tympanic cavity had been destroyed by caries, and no 
traces of the jugular fossa existed. 
A miscroscopic examination of the masses attached to the 
dura mater, by Dr. J. C. Warren and myself gave a regular 
and imperfectly defined net-work of connective tissue, con- 
sisting of fibres mixed with numbers of small round cells, 
such as arc seen in ordinary inflamed tissue ; in the meshes 
of this stroma were larger cells, whose shape and appearance 
could not be made out, as the preparation had been hardened. 
An examination of the polypus showed only a sarcoma- 
tous growth, such as is generally found in polypi from this 
position. The growths from the dura mater and the laby- 
rinth were considered the result of inflammation, but tlieir 
high organization is worthy of observation. 
III. T. M., clerk, aged 22 ; was first seen by me on May 
27th, 1870. At that time he was suffering from a purulent 
inflammation of the right tympanic cavity, with a small per- 
foration of the membrane : the mastoid cells were likewise 
inflamed, and over them was a small abscess which had opened 
spontaneously a few days before. With a probe no caries 
could be felt. 
lie was prescribed for, and ordered to report in two 
days. lie was not seen again till June 22d, when he reported 
that lie had been confined to the house with severe pain in 
ear and head, and had been unable to work for four weeks, 
lie was much emaciated, and was complaining of very severe 
pain in right ear and side of head. There was a free dis- 
charge of pus from the meatus ; after cleansing, the mem- 
brana tympani was seen to be somewhat inflamed, and with 
a small perforation through which air could be blown by 
Valsalva’s method. Over the right mastoid was a red, fluc- 
tuating, and painful swelling, size of a lien’s egg. lie was 10 
immediately taken into the hospital; and, under ether, Dr. 
Thaxter made an incision two inches Ion" in the abscess, 
evacuating a quantity of laudable pus ; the incision was pro- 
longed through the periosteum, but no bare carious bone 
was discovered. From this time I saw him occasionally, 
with Dr. Thaxter. 
On the 23d, the next day, the pain in ear was inconsider- 
able. Syringing, and the instillation of sulphate of zinz, gr. 
ij. ad §i. ordered for the tympanum. 
27th. — The discharge from meatus was diminishing, but 
there was some pain and tenderness over the mastoid. R. 
Tr. Ferri Muriatici gtt. x. t. d. 
July l,s£.— The inflammatory induration from mastoid was 
extending down neck, but was not tender. Appetite improv- 
ing ; wound healing. 
§th. — He Avas first reported to complain of periodical pain 
and tenderness over occiput, coming on at fi r. m. Wound 
over mastoid closing. Pulse 94. Was ordered Quinine, gr. 
viij. in gr. ij. doses, in the afternoon. 
8th.— Less pain and tenderness over occiput. The indu- 
ration of neck had extended further towards opposite side, 
was red, sensitive, but without fluctuation. P. 84. Some 
swelling of eyelids. Urine normal. Appetite good. On 
account of constipation an enema was ordered. 
14th. — The swelling of neck had increased in size, was 
painful, fluctuating, and gave him difficulty in swallowing. 
P. 100. 
[Under ether, an incision IJ in. long was made below 
right mastoid, and a considerable quantity of pus evacuated. 
Another incision 1 in. long was made on the anterior edge 
of mastoid and pus again found ; through the two wounds a 
seton was then passed. The pus was found to have burrowed 
quite extensively in the neck. 
1 bth.—Pain in neck entirely relieved since operation. 
The occipital pain however continues, requiring subcutaneous 
injections of sulphate of morphine, gr. The sputa for 
several days have been noticed to contain pus, probably due 11 
to the discharge ot matter from the car through tii Eusta- 
o o 
chian tul)e, as examination of the lungs by Dr. Knight re- 
veals no disease there. 
For the next week the pains in the occiput were very severe 
at times, usually much worse about 4 r. m. Relieved hy 
morphine subcutaneously. The general condition became 
worse. The pulse varied from 84-94. 
On the 27th, he began to improve again ; and on 29th pain 
in head was much less ; he could sleep without opiates, and 
was able to walk about the ward. The seton was removed. 
Aihj. 2d.—The pain in occiput again returned, of the 
same character as before ; on the 6th it had extended, and 
was referred to the whole surface on both sides, from occiput 
to forehead. 1%. Syr. Ferri, Quinioe et. Strychniae, 3j. t. d. 
The condition of the ear had, apparently, somewhat im- 
proved ; the inflammation and discharge were less ; there 
was no pain in the,ear; the wound over the mastoid had 
healed without any caries having been discovered; the per- 
foration of the membrana tympaui remained as at flrst. 
On account of my absence from the city I did not see him 
after this, and the remaining history is from the hospital 
records. 
The pain in the head increased, and hy the 14th he required 
subcutaneously, morphine gr. and atropine gr. J)0 . Pulse 
varied from 68-90. Strength continued fair. lie then besran 
to complain of a tender spot over occipital protuberance, and 
after each meal vomited. Was ordered brandy and egg-nogg. 
By the 23d | gr. morphine were required to relieve pain. 
A small tumor, size of a pea, which had formed above occipital 
protuberance was incised, and a minute quantity of pus 
evacuated. The wound over mastoid had healed. 
R. Ext. Aloes, Alcoholic. 
" Belladonnas, aa gr. daily. 
27tli.— Pain in head and vomiting continued. Pulse 80, 
regular. Only liquid diet could he retained. 
ft. Iodofoi •m. 
Ferri Carbonatis, aa gr. ij. t. d. 12 
Sejpt. ls£. — Pain in occipnt much increased. The 
wound in the neck which had closed to a mere sinus, but had 
continued to discharge freely, then became dry ; a probe could 
be inserted for two inches, but no caries could be felt. P. 90. 
4th.— The pain in head had much increased during last 
three days. At two r. m., was found in a semi-comatose 
condition, but moving continually. Pupils sluggish and con- 
tracted. Pulse 80. Respiration 10. 
Evening.—Moaning and vomiting often. Comatose. No 
pulse at wrist. General tonic convulsions, lasting ten min- 
utes, and then died. No autopsy. 
On being received into the hospital, he was apparently 
suffering from a very severe inflammation of the middle ear 
only, with abscess over the mastoid ; the brain symptoms 
were not present. On opening the abscess the bone was not 
softened or carious, nor did it become so later. The inflam- 
mation in the ear seemed to be doing well, the pain was very 
much less, and the discharge from the tympanum was dimin- 
ishing till fifteen days after entrance when, without any ap- 
preciable change in the ear, he began to complain of pain in 
the occiput, which seemed to yield to quinine, and was 
thought at the time to be neuralgic. Inflammation in the 
neck followed. The occipital pains returned for ten days, 
then ceased so that he was about the ward. The pains then 
returned all over the head, accompanied by vomiting; both 
these symptoms continued, the pain increased rapidly in 
intensity during the last few days of life, and he died in 
general tonic convulsions, eleven weeks after entrance. Ilis 
strength continued fair till one week before death, when it 
failed rapidly. 
The diagnosis would seem to be either meningitis or ah- 
scess of the brain, the purulent matter probably penetrating 
in some of the ways to be described. 
IV. T. A. F., aged 21, had always been considered healthy, 
with the exception of occasional trouble in right ear, to which 
lie had paid little attention. The early history of the ear 13 
disease is imperfect. For fourteen years lie had had occa- 
sional pain and discharge ; two years ago, at the same time 
that there was a discharge from the meatus, an abscess 
formed behind the ear, was opened and healed. For four 
weeks before entering the City Hospital he had been confined 
to the bed from very severe pain in head and ear, attended 
by great prostration; there had also been a purulent dis- 
charge from the meatus. A few days before entrance, a 
large polypus had been removed from the meatus. 
On April 7th, 1870, lie entered a private ward of the hos- 
pital under the care of Dr. J. G. Blake. lie was then very 
weak and much emaciated; in bed, complaining of severe 
darting pains over right side of head, with constant headache 
on right side. There was a purulent discharge from the 
meatus and some swelling below and around auricle. His 
intellect was clear. Pulse 70, regular. Tongue coated. No 
appetite. Bowels constipated. 
Ordered ice bag to head. Ear to be kept clean by syring- 
ing. Bromide of potass, gr. xx every three hours. Liquid 
diet. 
8th. — Pain same. The bromide was omitted and chloral 
hydrate, gr. xx every three hours, ordered. The polypus had 
grown so rapidly as to be seen externally, and the swelling 
around the ear was increasing. 
9tli.—I saw him in consultation with Dr. Blake. The 
whole meatus was then completely filled with a firm polypoid 
growth, and it was immediately proposed under ether to 
remove this as thoroughly as possible. The patient’s mother 
refused her consent, however, and would only allow the 
removal of the external portion without any amesthctic. This 
was done and the growth cut off with the wire snare at about 
the middle of the meatus, and the remainder touched with 
nitrate of silver. An instillation of sulphate of zinc gr. v. 
ad 5j., and three leeches on the swelling below the ear were 
ordered. 
10//<. —The swelling and tenderness below the ear were 
much diminished. Headache continued severe, but the 14 
patient was less dull and stupid and the appetite was very 
much improved. 
12th. — The pain in head continued as severe as ever, aaid 
morphine subcutaneously was ordered (gr. 1 jp. r. n.) 
13th. — Some relief to headache from the morphine. Some 
redness and swelling of lobe of ear and over mastoid. Poly- 
pus grows as fast as it can be destroyed by the caustic, and 
there is a free, very offensive purulent discharge from the 
meatus. Poultice over mastoid. 
15th.—Has become much more dull, aroused with diffi- 
culty, but intelligence fair. Appetite again good. Pulse 
80, of fair strength. Tongue coated, but moist. 
18£/i. — Little brighter, but more restless. Less headache. 
Takes nourishment well. Some cough with slight expecto- 
ration. 
20th.—Distinct fluctuation behind ear, and by incision 
§ss. pus evacuated; a probe passed in to the depth of two 
inches and the bone was felt to be extensively bare. 
22cl.—Very little pain in head or ear. Eats well. 
Dowels regular. Pulse 80, dicrotic. Only semi-conscious , 
gets out of bed, and walks about staggering. Discharge from 
wound entirely ceased : that from meatus diminished. With 
the probe the walls of the meatus were entirely denuded and 
probably carious. As a last resort in consultation with Drs. 
J. G. and C. J. Blake, it was proposed to establish an open- 
ing through the mastoid cells with the tympanic cavity, 
remove the whole of the polypus and so get a free communi- 
cation through which water could be syringed and the pus 
washed out. This was refused by the mother, and the patient 
removed from the hospital the same day. 
As I learned from the attending physician, the brain symp- 
toms became more marked; he lost consciousness, became 
weaker, and without any chills, nausea, vomiting, convul- 
sions, or paralysis, died on the fourth day after leaving the 
hospital. No autopsy was allowed. 
For the specimen of the next case I am indebted to Dr. 15 
Goo. E. Francis, of Worcester, who made the autopsy. The 
history is imperfect; the following are all the facts that 
could be obtained : — 
V. A man, aged 25, subject to catarrh, and called by the 
family scrofulous. For two years he had been subject to what 
was called " abscess of the ear,” resulting in the discharge 
of pus, which would last some weeks, and which was attended 
by deafness of both ears. Two months before death he con- 
sulted Dr. II. Clarke, of Worcester, for deafness so extreme 
that communication by writing was required. Shortly after, 
lie showed cerebral symptoms, dizziness, headache, double 
vision, and partial paralysis ; but of what regions is unknown. 
He was confined to his bed, and the hearing power is reported 
to have improved somewhat. lie died comatose, and at the 
autopsy a collection of pus was found in the brain, just over 
a carious spot communicating with the tympanum. The pus 
lay directly upon the bone. 
On laying open the bone a sinus was found through the 
upper osseous wall of the meatus, just above and external 
to the small process of the hammer. This opening was 
large enough to admit the point of an ordinary probe, and 
communicated with the meatus externally, and with the small 
cavity in front of the head of the hammer internally. From 
this cavity it passed backwards and inwards towards the mas- 
toid process, into a circular cavity about £ in. in diameter 
in the cancellated structure of the bone, and the roof of bone 
over this cavity had entirely disappeared, so there was a 
direct communication with the brain. All the walls of this 
cavity were irregular and carious. The membrana tympani 
was entire and apparently healthy, of normal transparency 
and thickness in every part below the small process of the 
hammer. From the manner in which the bone had been 
opened the insertion of the upper edge of the membrane had 
been removed, so that it was impossible to speak of the 
condition in which the so-called membrana Shrapneli was‘ 
whether whole or perforated. The head of the hammer and 
the whole incus were wanting, but whether lost from disease, 
or during the dissection, cannot be said. 16 
The point of interest in the case is the peculiar caries of 
the bone, associated with, an imperforated and apparently 
healthy membrana tympani, the caries in the cancellated struc- 
ture of the bone having destroyed the wall of the meatus on 
oi\e side, and the roof which separated it from the brain on 
the other, and yet not having communicated with the tym- 
panic cavity, or injured the membrana tympani. 
The possibility of such accidents as occurred in this case 
can be easily explained by looking at sections of a normal 
bone, where it will be seen that but a thin lamina of firm 
bone separates the cancellated structure from the cavity 
of the skull on the one side, and from the meatus on the 
other. The small cavity, a part of the tympanum, above 
and external to the head of the hammer, it will be seen 
is separated from the meatus by an extremely thin lamina of 
bone ; and within two years Troltsch has directed especial 
attention to this cavity by a specimen which he dissected, and 
in which he found this plate of bone perforated, and through 
the perforation a polypoid growth from the mucous mem- 
brane projected into the meatus. 
That a purulent inflammation of the tympanum could be 
fatal, without perforating the membrana tympani, was proved 
in a case of Troltsch’s, in which the roof of the tympanum 
was opened, and a fatal meningitis set up, and yet the mem- 
brana tympani remained entire. This case which I have 
described is, however, as far as I know, the only one recorded 
where a caries communicating with both the meatus and the 
brain had proved fatal without injuring the membrana tym- 
pani, and is of importance when we consider how little would 
have been seen during life by examination, and how neces- 
sary it is to bear in mind the possibility of such perforations 
of the wall of the meatus in searching for the source of a 
purulent discharge in the meatus. 
REMARKS. 
That a purulent discharge from the ear might in some rare 
cases cause necrosis of the bone in which that organ is im- 17 
bedded, and that ibis necrosis might cause fatal trouble in 
the brain, has been recognized for a very long time by 
pathologists. That such a purulent otitis might become the 
direct cause of death without the bone becoming diseased, 
has been known only of late years. The dissection of 
pathological specimens has, however, shown that necrosis 
is not the only thing to be feared in these cases, but that 
even if the petrous bone is unaffected, the disease of the 
ear may be the direct cause of death. 
The anatomical relations of the ear, as shown by the most 
recent investigations, prove that the ear is in more intimate 
connection with the brain and other important parts than had 
been supposed. By means of the microscope and tine injec- 
tions it has been shown that the numerous small foramina 
with which the petrous portion of the temporal bone is per- 
forated, furnish passages through which an inflammation may 
extend ex contiguo to other parts. 
The whole upper and inner surfaces of the bone lie in direct 
contact with the meninges of the brain, being covered with 
the dura mater which here serves as a periosteum and nour- 
ishes the bone. Part of the upper surface forms the roof of 
the tympanum, is variable in thickness, but frequently so 
thin as to be nearly transparent. 
The lateral sinus, a fold of the dura mater, and like it 
serving as a periosteum, is only separated from the mastoid 
cells by a thin lamella of bone through which many minute 
foramina pass directly into the cells. These mastoid cells 
form part of the tympanum. The facial nerve, in its Fallo- 
pian canal passes directly through the tympanum; is never 
separated from that cavity by more than a very delicate 
bony plate, and frequently from a deficiency in this, proba- 
bly due to an arrest of development, lies in direct contact, 
with the mucous membrane lining the tympanum. 
The floor of the tympanum is formed by the jugular 
fossa, in which lies the internal jugular vein ; in this floor is 
a foramen, through which a branch of the vagus passes into 
the tympanum. Occasionally here, also, from an arrest of 18 
development, the coverings of the jugular vein lie m direct 
contact with the mucous membrane of the tympanum. The 
anterior wall of the tympanum is formed by the carotid 
canal, is so thin that light passes readily through it, and is 
moreover perforated by foramina, through which the tym- 
panic branches of the sympathetic pass from the carotid 
plexus to the tympanum. 
The meatus internus gives a large canal from the cavity of 
the skull to. the labyrinth of the ear, and this latter is only 
separated from the tympanum by the thin membranes cover- 
ing the fenestra, ovalis and rotunda. This large passage is 
lined by a prolongation of the dura mater, which serves as 
its periosteum. The aqueductus vestibuli also connects the 
interior of the skull with the cavity of the labyrinth, and 
serves for the passage of a small vein. 
The petrosal-mastoid canal leads from the mastoid cells to 
the interior of the skull, thus furnishing still another commu- 
nication from a different part of the tympanum to the brain. 
It serves for the passage of a vein which has been followed 
into the superior petrosal sinus so that we have here the cir- 
culation of the tympanum in direct communication with that 
of the meninges of the brain. 
Without speaking of the different forms requiring various 
modifications of treatment, all of the serious otorrheeas con- 
sist essentially of a purulent inflammation of the mucous 
membrane lining the tympanum with a marked tendency to 
ulceration. This ulceration may, and usually does destroy 
the membrana tympani, making the meatus and tympanum 
one cavity, and it may destroy either or both the membranes 
of the fenestra leading to the labyrinth thus exposing that 
cavity. From these two cavities, tympanum and labyrinth, 
we have seen that there are various avenues leading to the 
brain and other important parts. The ulceration is liable 
to attack the bone, causing absorption; and we have seen 
that but a very thin osseous plate separates the tympanum 
from the carotid canal, the jugular vein, the transverse sinus, 
and the facial nerve, and these bony plates, even in their 
normal condition, are perforated by foramina. 19 
An examination of the recorded cases shows that all of 
the relations of the car which I have mentioned are attended 
with danger. By far the most frequent accident seems to be 
a perforation of the thin roof of the tympanum and the exten- 
sion of the inflammation ex contiguo onto the dura mater, 
causing a meningitis or suppuration of the substance of the 
brain directly above the perforation. The penetration of 
the purulent matter into the labyrinth by ulceration through 
the fenestne and thence along the meatus interims or aque- 
ductus vestibuli, is also a not infrequent cause of meningitis 
or abscess of the brain. Troltsch moreover records a case 
where a fistula had been produced by ulceration directly 
through the bone from the tympanum into the labyrinth, with- 
out destruction of the membranes of the fenestra}, and thence 
the inflammation had extended to the brain, the patient dying 
of meningitis of the base. 
The petrosal-mastoid canal would undoubtedly on examina- 
tion be found a more frequent source of communication than 
is supposed. Voltolini has described a case, fatal from puru- 
lent meningitis, in which this canal was much enlarged from 
inflammatory softening and the dura mater around it intensely 
inflamed. He was not at that time aware that this passage 
conveyed a vein to the petrosal sinus, and no mention is 
made of the condition of the sinus. Troltsch has also given 
a case where the inflammation extending along this passage 
had caused phlebitis of the superior petrosal sinus, and this 
had given rise to a pachymeningitis and two abscesses in the 
brain. 
Occasionally the transverse sinus becomes inflamed from 
the mastoid cells, and Troltsch found this sinus filled with 
a thrombus which had led to metastasis in the lungs. Ilicm- 
orrhage from this sinus, either external into the tympanum 
and meatus or internal into the cavity of the skull, lias occa- 
sionally occurred from an extension of an inflammation from 
the mastoid cells, and Wrcden has described a case fatal 
from two perforations of this sinus, through one of which the 
hemorrhage was external and through the other internal; he 20 
lias likewise given a synopsis of eighteen such perforations 
from various authors. 
An inflammation of the jugular vein may occur in the same 
manner as in the transverse sinus, the inflammation extend- 
ing from the tympanum through its floor to the jugular fossa. 
In Virchow’s lecture-room some years ago, I remember see- 
ing a very marked case of this kind, where the floor of the 
tympanum was largely perforated and the internal jugular 
vein intensely inflamed and filled with a large thrombus 
which had led to metastatic deposits in different internal 
organs. The inflammation here may also take an ulcerative 
form, and the vein thus be perforated, causing a venous 
liajmorrhage through the external meatus or Eustachian tube. 
The carotid artery is liable to the same injuries as the ju- 
gular vein and transverse sinus. It has been found inflamed 
and obliterated by a firm clot, and quite a number of cases 
are reported where it has been perforated, and the patients 
have died from arterial haemorrhage. In a few cases where 
such a haemorrhage occurred and the lesion was diagnosti- 
cated, ligature of the common carotid was performed with 
success. 
Affections of the facial nerve from inflammation of the 
tympanum are by no means rare ; the absence or perforation 
of the thin plate separating the Fallopian canal from that 
cavity, allowing the inflammation to extend along the sheath 
of the nerve, or else allowing the swollen mucous membrane 
to press directly on the nerve, causing a paralysis of all the 
parts supplied by it. So far as I know, however, no cases 
are reported of an extension of the inflammation along this 
passage to the brain. 
In addition to these different forms of disease in which the 
connection with the ear can be distinctly traced, it is now 
generally accepted that any suppuration may be the exciting 
cause of pyaemia, and that an inflammation of the substance 
of a bone is especially liable to lead to this. One or more 
abscesses in the brain, remote from the ear and surrounded 
by healthy tissue are sometimes found, for which no other 21 
cause than a suppuration of the ear can bo discovered, and 
Troltsch. with other writers have considered that the circu- 
lation was the channel which carried the exciting cause 
of the abscess, be it a minute embolus or putrid matter, 
from the ear. On this subject Troltsch remarks : — 
" Not only the true diploe, but the bone of the os temporis in 
general is in direct connection, by means of its blood-vessels, 
with the dura mater on the one hand, and with the soft parts of 
the ear on the other. The temporal bone in general receives its 
vessels from within and from without, and also sends them in 
both directions, not only to the dura mater, but also to the 
membranes lining the outer and middle ear. Diseases of the 
latter produce abnormal conditions in the bone and its vessels, 
which either through the contents, or along the tissue of the 
walls of the blood-vessels pass onto the dura mater, and there 
call up secondary pathological processes. These announce 
themselves in the one case as purulent inflammations of the 
brain membranes or of the walls of the sinuses, in another by 
clot-formation and closure of the caliber of the vessels, or by 
the entrance of putrid matter into the circulation. That all 
these processes developing themselves within or on the ves- 
sels, can be produced by the purulent inflammation of the soft 
parts of the ear without the existence of a ' caries of the 
petrous bone ’ cannot often enough be impressed upon the 
practitioner, since many are inclined to fear only a 'caries of 
the petrous 1k>uc,’ not, however, a simple otorrhcea or puru- 
lent inflammation of the soft parts of the ear.”