another otologist was made of an extradural abscess and exploratory operation advised. On further examination, however, it showed that there was also considerable tenderness over the shoulder of this so-called monoplegia, and that the patient could raise the arm with considerable pain. This proved that the condition was a thrombosis of the suprascapular vein, with a joint infection, and not a monoplegia due to an extradural abscess. No operation was performed, and the patient recovered with some limited motion in that shoulder.

Of 16 extradural abscesses, 11 were found at the time of operating for mastoid, sinus thrombosis and frontal sinus disease. Twelve of these 16 cases recovered after operation. Of the 4 fatal. cases, 3 were operated on and became complicated by intradural abscess, meningitis and general sepsis. One case diagnosed refused operation, but a post-mortem performed revealed a large extradural abscess in the cerebellar region.

INTRADURAL BRAIN ABSCESS

Intradural brain abscess usually gives rise to grave symptoms, especially the more acute forms, before any localization or walling off has taken place. They are very frequently associated with a great degree of meningitis. I have been very unfortunate in not having saved many patients with intradural abscess, but believe that with the improved technic of operating in two stages, as suggested by Dench and McKernon, namely, to perform an early decompression and walling off with gauze, and later simply opening the abscess wide and draining it well, we will reduce the mortality considerably.

CASE 1. A man, aged 39 years, was brought to the hospital in a semi-comatose condition. The statement made by his family physician was that for the past five days he had been having very severe headaches, which were diffused all over the head; vomiting spells and a stiffness in his neck, the latter condition increasing within the last twenty-four hours, previously to which he was most of the time conscious. No history of any previous illness could be elicited.

Examination: A well nourished man in a stuporous condition, muttering at times; neck rigid; slight Koernig; no Babinsky. Pupils small and equal. Dilatation of the pupil by homatropine revealed slight papillitis. Examination of the left ear: Small perfora

tion high up. Spinal puncture demonstrated somewhat turbid fluid escaping under pressure. Microscopical examination of same revealed increase of the cellular elements and a few scattered diplococci. Reaction for sugar showed its absence. Wassermann reaction negative. Blood examination: Leucocytes, 12,000; increase in polymorphonuclear variety. Was

sermann negative. Radiogram: Mastoid and sinuses showed left-sided mastoid involvement. Diagnosis: Seropurulent meningitis secondary to a probable chronic suppurative mastoiditis.

Operation: Typical extensive simple mastoid operation with lateral sinus exposure. The mastoid disease appeared to be of the chronic character and no evidence of any necrotic area towards the meninges could be discerned. The sinus was normal. The typical Haynes operation for the drainage of the cisterna magna was performed, with only one difficulty, viz., in attempting to place the patient in a position face downward he would stop breathing, so that we had to operate on the side. In reattempting to place him on his face downward during the latter part of the operation, he again stopped breathing.. The complete operation of mastoid, as well as the Haynes operation, required an hour and twelve minutes. The patient never regained consciousness and died that night.

Post-mortem examination revealed a moderate amount of diffused meningitis. There was no evidence of the thick yellow exudate that was formerly found in the cases of meningitis previously cited. The entire left temporo-sphenoidal lobe, including the portion of the occipital, was involved in an abscess, with a moderately thin wall, containing about half a pint of pus, of a very fluid character. The tegmen of the left temporal area showed no evidence of any necrotic focus, or a path of infection to the brain.

The comments on this case are: 1. The fact of his stopping breathing when his face was turned down, which would suggest that this large abscess probably in that position pressed on the vital respiratory center. 2. The absence of a significant shadow in the radiogram outlining the abscess, notwithstanding that the latter was streoscopic. 3. The complete masking of the localized symptoms of the abscess by the meningeal symptoms. 4. The absence of any necrotic focus suggesting extension of the infectious process from the mastoid.

CASE 2. A boy, aged 7 years, for several years had had a discharging ear on the right side. For the past three weeks has been having headaches, which were particularly localized on the right side. He has had several vomiting spells, having also lost appetite and strength. Noted that he could not walk straight, usually falling to the right. After two weeks of these symptoms and treatment by a family physician, he presented himself, with the above history.

Examination: Poorly nourished child, having a blepharospasm, photophobia and spontaneous nystagmus, particularly to the right. Barany's pointing sign not well defined. Diado-aconesia positive. (The coordinate movements of the hands in pronation and supination rapidly performed is impossible.) Spinal puncture negative. Blood examination: Slight leucocytosis. Examination of the fundus oculi showed some dilatation of the veins; vision normal. All other cranial nerves negative. Reflexes negative.

Hearing apparently normal in either ear. Caloric test appears to increase the spontaneous nystagmus. Romberg sign is present. Patient falls to the right in walking. Radiogram showed a shadow in the right cerebellar region. Right-sided mastoid involvement. Diagnosis: Cerebellar abscess on right side. Operation: Subtentorial flap exposing right cerebellum revealed no evidence of abscess, but just beyond this point, through a very firm capsule, a small abscess containing a thimbleful of pus, escaped under slight pressure. Cultures from this were made. A drainage wick introduced and wound closed. Patient rallied well and spontaneous nystagmus markedly diminished. However, the headache still continued; also temperature and pulse remained high. After four days, the patient continuing to run a septic condition notwithstanding free drainage and large doses of urotropin and antistreptococcic serum, we decided to open the mastoid, which was deferred at the time of the first operation, owing to the poor condition of the patient. There was very little evidence of active mastoid disease.

For the next ten days the boy gradually improved in so far as the symptoms of headache, nystagmus, temperature and pulse were concerned, but on the fifteenth day following the operation cardiac collapse cccurred, and the patient died.

Post-mortem was not permitted.

This case illustrates the virulency of and violent toxemin resulting from a streptococcic infection.

CASE 3. A man, aged twenty-seven years, admitted to the hospital with a history of lues sixteen years ago and now complaining of headache, some dizzines, nausea and seeing double.

Examination revealed a paralysis of his right abducens muscle. Right ear discharging pus, patient states for many years. Wasserman of the blood, negative. Placed upon anti-luetic treatment in large doses without any result.

Referred to the neurological clinic where patient showed slight disturbances in his gait and spontaneous nystagmus, particularly to the left, all other reflexes normal, and the neurologist now made a diagnosis of a cerebellar abscess on the right side, secondaty to his chronic suppurative ear.

He was now referred to the otological clinic for further examination and treatment. The attending otologist, making a hasty examination, believed it to be a case of cerebral syphilis; he having made a hearing test by means of tuning forks and constituting the following findings: That the patient heard in the diseased ear; a prolonged negative Rinne; Weber laterating to affected ear.

I was then called in the case and found the following condition:

A poorly nourished man, somewhat dull in expression, but apparently in great pain, which he directed towards the back of the head. The eyelids were drooping (no evidence of any ocular muscle paralysis nor nystagmus), pupils were reacting normally, the fundus examination negative; right ear foul smelling

discharge, the remains of the drum membrane thick and swollen, the upper canal wall appeared to be sagging and a small perforation situated in the extreme anterior and superior quadrant; left ear negative. Placing a vibrating tuning fork of low pitch into the left auditory canal, patient could not hear the lowest sound. (Norval Pierce test.) Reversing the test, fork in right ear, the patient heard almost normally. Irrigating right ear with cold water produced no nystagmus, whereas cold water in the left ear produced a marked compound nystagmus. These tests demonstrated definitely that the right labyrinth was destroyed.

Blood examination: Leucocytosis polymorphonuclear 85 per cent. Wasserman again negative. Spinal puncture, fluid was under normal pressure, clear; Nonne negative. Noguchi globuline test positive; no increase in the cellular elements. Barany's pointing test negative. Diado-aconesia absent.

Consulting now with the neurologist, we decided that it was not a cerebellar abscess, but a suppurative labyrinthitis, secondary to a chronic suppuration of the middle ear and mastoid, decided upon an operation, which I performed, namely: Radical mastoid, including Neumann labyrinth operation.

The usual picture of a chronic suppurative mastoiditis encountered. The horizontal semi-circular canal was intact, as were also the tegmen towards the cerebrum and the sinus wall. Exploration of the middle ear revealed a necrotic promontory of the cochlea, the probable source of infection of the internal ear. The usual technique of the Neumann labyrinth operation was carried out without any difficulty. The electric bur proving great aid in the technique. The anterior vertical semi-circular canal when opened showed distinctly containing pus.

Subsequent course: Patient rallied, pains general, toxic condition, drooping of the eyelids disappeared on the third day. However, patient still complained of being dizzy. On the fourth day the abducens paralysis recurred, as also was apparent a slight facial paresis, both, however, disappearing within the next three or four days. From now on the patient made an uneventful recovery, dizziness completely disappearing at the end of the third week.

Of 19 cases, 2 recovered. Both of these were in the temporo-sphenoidal area, and the operation was by way of the mastoid tegmen route. In neither case could there be any microorganism recovered from the pus of the abscess, either in smear or culture. In one case the abscess followed a rapidly destructive mastoiditis in an influenza infection, and the second in the seventh week of a scarlet fever otitis media, in a child aged three years. Of the 17 remaining cases, 10 came to operation. Six were in the cerebellar region; 2 fronto-parietal, and 2 temporo-sphenoidal. The seven cases either refused operation

off the entire ethmoid region. No evidence of any ear affection; the hearing was normal. Local application to the nose and Eustachian tube (inflation from the opposite side) did not relieve him; on the contrary, he grew worse. The headaches became more constant and more intense, and frequently woke him from his sleep. While at work he would sometimes be seized by the attack of head-pain, causing temporary weakness and dizziness. Since there was no benefit from the local treatment, it was assumed that he had worked too strenuously for the entire year, and therefore he was advised to rest. A general examination as well as the laboratory findings, including the Wassermann, were absolutely negative. The eye, as to vision, fundus, visual field (not perimetric for color, only roughly), as well as the reflexes, were negative. There was no evidence of any disturbance of the cerebrospinal nervous system. I then recommended the resection of the nasal septum, on the ground that he had a neuralgia from pressure on the naso-ethmoidal nerves, or perhaps some blocked cells. I referred him to two of my confreres, oto-laryngologists, and one agreed with me, the other believing that most of his symptoms were neurotic (hysterical or neurasthenic). He then consulted an eminent neurologist, who concurred in my diagnosis and recommended the septum operation. A few days later I performed a regular submucous septum operation under cocaine anesthesia, and I encountered something that I had observed only two or three times in my experience, namely, that he appeared as though in a cataleptic state. It was impossible to get a word out of him, although he was absolutely conscious. He would hold the head or hands in any position that I placed them. As soon as the operation was completed he became very talkative, and he spoke incessantly until late that night. It was first thought that this was due to cocaine intoxication, although he had none of the other symptoms characteristic of such a complication. After the night's rest and the removal of the nasal packing he felt much better. The septum healed perfectly. For the next three or four days the headaches seemed to be less intense, and he felt generally better. There was, however, one particular symptom noticeable to those about him, and that was of misnaming persons; however, immediately correcting himself. This was the first mental deviation from the normal. The next observation was his growing dissatisfaction with the members of his family, of whom he formerly was very fond, and his complaints were unfounded. By this time his attacks of headaches returned, as severe as ever, principally over the same area-fronto-temporal-but at times localizing on the right side. At this time he called me to his room, where he had an attack of severe head-pains, and a sudden vomiting spell. His tongue was markedly coated-he had not had a bowel movement for two days, in spite of cathartics. I expressed my opinion that these symptoms were very

suspicious of brain tumor. He then consulted the internist who had treated him three years ago, who, on account of the similarity of his former attack, diagnosed this to be a gastro-intestinal disturbance associated with a neurasthenia, but the same treatment which acted favorably three years ago gave no relief this time. He then went to live with his brother, Dr. Carl Beck, in order to be observed. The latter made the observation that the headaches were worse at night, and must have been very agonizing. Following the attacks he would fall into a very deep sleep, from which he could scarcely be roused. After a few days' stay at his brother's, he again became very dissatisfied, and became suspicious and unnaturally reproachful to several members of his family. In order to satisfy him, he was taken to his other brother, Dr. Emil's home. Dr. Emil made the same observations, namely, that following these attacks of headache he went into a deep sleep, lasting ten to fourteen hours. While thus sleeping Dr. Emil would call, make all kinds of noises, but could not rouse him unless he shook his body.

He was now put upon a starvation diet, and for forty-eight hours he ate absolutely nothing, but this had no influence upon the headaches.

On January 31, 1913, he was taken to a prominent neurologist who, after a very careful examination, would not make a definite diagnosis, but believed it to be a severe neurasthenia and desired to observe him.

On February 1, 1913, he suffered intense headache the entire night, and gradually fell into a comatose condition. Once he got out of bed, stood in the middle of the room and urinated on the floor. Dr. Emil observed that the patient, when returning to bed, was somewhat unsteady in his gait. He fell into the usual deep sleep, and now could not be roused even when shaking his body. The condition took on an alarming appearance. He would mutter incoherent words when urged to speak, refused food and drink, and recognized no one. There was a ptosis of both eyelids and constant lateral rolling of the eyes. The neurologist who had examined him the day before was hurriedly called, and after examination expressed the opinion that in the absence of a definite diagnosis it was perhaps brain syphilis, and advised the immediate intravenous injection dose of neosalvarsan. An expert in this work as well as a surgeon of note in brain surgery, and the internist who had previously treated him, held a consultation and agreed that while there was no positive symptom of lues, he should be given the benefit of the doubt and given the salvarsan. Although the patient was entirely unconscious, he resisted and showed great strength during the injection. After the injection he remained in the comatose condition. He retained fluids very poorly and had urinated and vomited once involuntarily. The temperature rose to 101 degrees, and pulse to 120. During the next night he suddenly appeared to

awaken from the coma and desired to get up and urinate, which he did. He also began to speak somewhat coherently. Next morning he began to recognize those about him, and now rapidly improved. The sudden change following the injection of neosalvarsan naturally strengthened our belief that lues was the cause of his trouble. We began at once to administer large doses of KI, 120 grains daily, until on the third day he received 380 grains, and two injections of cypridol. The patient began to eat and was the greater portion of the day free from headache, but the following night it returned with marked severity. After a few days he desired to go to a neighboring sanitarium. The first day he was well satisfied there; he would take his walks, although he constantly complained of headaches. On the third day of his stay at the sanitarium I was hurriedly called and found him in a severe attack of head-pains and fear of persecution. This night he was very restless, and on the following morning early he insisted on leaving this place, for fear of being unjustly dealt with. He now went back to Dr. Carl Beck's home, where he was again perfectly satisfied. Medication (KI) was discontinued, owing to gastric irritation. The next week he appeared to be improving, and planned a trip to Europe.

The attending neurologist was now leaving for Europe, and since he required the services of another, we consulted such an authority. The diagnosis made by him was general paresis. This contradiction in diagnosis, his constant complaint of severe headaches, and his desire to leave the city, induced us to go to Philadelphia to consult some other eminent neurologists there. He made the trip East without any great difficulty and arrived in good condition. That night, however, he had very severe head-pains. The only remedy that he found any relief from except morphine was a hot water bag to the head, the degree of heat of which would be scarcely borne by anyone else. On the following morning we consulted a prominent neurologist who, after a very careful examination, made a diagnosis by exclusion of cerebral syphilis. The following day we consulted another neurologist of international reputation, and his diagnosis was paresis with very grave prognosis; however, he asked to have a spinal puncture as the corroborating test. A sanitarium treatment was recommended, and since we knew of a place that was near the place of my brothers' former home in Europe, I decided to take him there, especially since I was yet uncertain of the correctness of the diagnosis and wished to consult some European authorities, who might, after all, make a diagnosis of tumor with a chance for operation. On March 1 we left by way of a slow steamer from Philadelphia to Hamburg, and while the separation from his brother, Dr. Emil, caused him to be greatly excited, he was nevertheless in very fair condition. The first afternoon of our voyage began with the patient suffering very great head-pains, radiating over the whole head, but appearing to localize on the

left side and to the back of the head. This pain continued all through the night, requiring morphin to control it. Food and drink were refused and he slept for several hours the next morning. I, thinking it might have been from morphin, examined the eyes and found, however, that the pupils were dilated. I now decided that he could not stand the trip and, since the steamer stopped at New York, I transported him to a private hospital in New York City and called in an eminent neurologist. He unqualifyingly made a diagnosis of brain tumor and located it in the thalamic region in the anterior portion of the brain on the left side. He wished, however, to, exclude syphilis and paresis by a spinal puncture examination. There was no possibility of obtaining a history from the patient at this time; also very unsatisfactory examination could be made. He was

now absolutely unconscious. On the following day he cleared up somewhat, so that a consultation with an eminent brain surgeon and the neurologist was more satisfactory. Both agreed on the diagnosis of brain tumor. A spinal puncture was made, and the fluid was, under slightly increased pressure, of greenish tinge, but clear. The analysis of the fluid showed Noguchi globulin negative, cell count eight to the field, Wassermann negative, culture negative. Following the spinal puncture, the patient improved considerably. It was now decided to observe him further, for which purpose he was taken back to Chicago. He made this trip with considerable difficulty, was considerably weakened, and his gait became very unsteady. After arriving in Chicago he grew very much worse as to his head-pains. Another neurologist was now consulted, as well as a surgeon, with the hope that an operation might be performed. Both decided that an operation was useless, believing it to He now rebe a tumor, but of syphilitic nature. ceived another injection of neosalvarsan, which this time he permitted without any resistance. There was not the slightest improvement of his symptoms following this injection. On March 13 he grew violent and had to be restrained and given morphin. The following day he was very quiet and breathed quite superficially. He would not eat at all and appeared to be losing rapidly in strength. At seven o'clock p. m. he breathed shallow and fast, with a very deep inspiration about every fifteenth breath. At eight o'clock he suddenly had an attack as though he were suffocating, and attempts at artificial respiration proved of no avail. Death occurred at 8:20 p. m.

Post-mortem examination was made by a competent pathologist, and his report is here appended!

REPORT OF POST-MORTEM FINDINGS OF DR. RUDOLPH BECK'S CASE, MARCH 15, 1913, THREE

HOURS AFTER DEATH.

After the calvaria had been removed, a normal dura was presented, and after its removal the pia arachnoid was found moderately congested, otherwise normal.

After the tentorium cerebelli had been severed on both sides an attempt was made to remove the brain.