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ease-pain all over and surrounding the mastoid process, otorrhoea, deafness, large perforation of the membrana tympani; added to these the history I have above detailed. Having carefully considered the case, it was evident to me that the line of treatment calculated to relieve him was trephining. And confident of disease existing, and pus being present without sufficient exit, on Dec. 7 I made an incision such as I have described, and selected a trephine somewhat smaller than that used in the former case. I placed the lower part of the crown on a level with the external auditory meatus, and thus opened the mastoid cells and the tympanum, and exposed the envelope of the brain

which comprises all the rest of the membrane. This lax portion is the most frequent seat of perforation. The patient had pain round the mastoid process, and on tapping it considerable pain, especially at a point corresponding to the posterior root of the zygoma, but inferior to the latter. When the ear was syringed and cleansed further discharge would flow by getting the patient to forcibly blow his nose. The otorrhoea was of comparatively recent duration. He stated he was quite well four months previous to admission, when he had an attack of fever, which, he said, was typhus. On recovering from this the purulent discharge commenced. He had some pain at the back of his ear, but it was never much. Having the dura mater; the pus actually welled up. come to the determination that disease existed in the mastoid cells, I made up my mind to operate, and on March 3, the patient being under the influence of ether, I made an incision from the upper part of the mastoid process in the direction of the posterior root of the zygoma and a little above it, and continued this in a semicircle downwards, close to the pinna, and a little below the external auditory meatus, and dissected all back towards the mastoid process. I then placed the crown of a trephine on a level with the external auditory meatus, and removed the piece of bone shown in the accompanying Plate, Figs. A and D. The disease on its internal surface is evident. The upper portion, it will be perceived, is eaten away. By the removal of this piece of bone the mastoid cells were opened, the tympanum also, and the dura mater exposed. Pus did not flow from the wound for 23 hours, when the discharge from the ear lessened, and finally ceased. For two or three days after the operation he had some pain down the right side of his neck, which was relieved by opiate fomentations. In one month the wound was closed, and he left perfectly well. I saw him within the last week; he is in excellent health.

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Nothing could have been more satisfactory. The bone shown at Fig. B is a good specimen of carious disease. Two points of suture closed the wound above, the lower edges were kept separate by a small piece of lint, a hot flannel fomentation was placed over the wound, and the side of his head covered with oil-silk. The patient was then removed to bed. Pus continued to flow through the wound; the discharge from the ear lessened. The patient's temp. on night of operation 98.8°; pulse 88. Stated that he was not suffering pain, and he slept well subsequently to the operation. Left completely recovered, and is now well.

CASE 3. T. H., blacksmith, Oct. 17, 1883. Strong, well-built, about six feet high, and perhaps æt. 35. Was suffering from deafness and dizziness. There was considerable swelling over the right mastoid process, accompanied by pain and redness; also the part pitted upon the application of pressure. Could not give any history of an injury; had, however, suffered when a boy from scarlatina, which was followed by deafness. Trephined him Oct. 25, when, upon the removal of the piece of bone, matter welled out copiously, apparently from both the mastoid cells and the tympanum. The wound healed by granulation, and his highest temp. did not exceed 99°. Discharged cured Dec. 1, 1883. A month ago I was informed that he was in active employment and in perfect health. The internal and external surfaces of the bone removed are shown in Figs. C and F, in the former of which evident osseous disease is palpable.

CASE 2. M. F., 41, Nov. 27, 1882. He had always been healthy. Some 13 or 14 years ago he had a running from his right ear, which stopped suddenly. He thought no more about it. Last Nov. he got a severe cold, and had acute pain in the region of his mastoid process; the entire side of his head became painful; he could not bear to have it touched, and got no sleep for more than eight days. He was told Acute inflammation of the mastoid process, it was erysipelas; and after about a week, which the subject of the second case I have during which period he suffered intensely, a detailed evidently suffered from, is not common purulent discharge came from his ear. He in the adult, but is more usually seen in the then got some relief. Before his admission, I young. Of 67 cases collected by Mr. Buck, of am informed that during the acute symptoms New York-13 were 10 years old or younger; he was dull, and did not answer questions asked of him, until repeated two or three times-in fact, he lacked response. This patient exhibited all the signs of osseous dis

26 were 10 to 25; 9 were 25 to 40; 12 were 40 to 55; 7 were 55 to 60. The youngest was eight months old; the eldest 62 years.

The idea of perforation of the mastoid cells

and galvano-cautery over the mastoid process;
such procedure, as it appears to me, would be
likely to set up irritation and inflammation.
Unless, indeed, the suppuration is compara-
tively superficial, or discharging through a
fistulous opening, I would not select to operate
over the mastoid process; there one cannot
remove the entire portion of the bone, on ac-
count of the proximity of the lateral sinus, and
so cannot expose the dura mater, to do which
I hold is very essential.

The site I would always select for operation,
with the exceptions as above named, would be
such as to place the lower border of the tre-
phine on a level with the external auditory
meatus, and anterior to a line dividing verti-
cally the mastoid process. By adopting this
course there will be no danger of wounding the
lateral sinus, the tympanum and mastoid cells
will be opened, giving full exit for discharge,
the dura mater will be exposed, and should
pus exist between it and the cranium, there
will be ample freedom for its escape.-Dub.
Jour. Med. Science, Oct.

PATHOLOGY OF SUPPURATIVE IN-
FLAMMATIONS OF THE KIDNEY.

BY JOHN LINDSAY STEVEN, M.D.
(Continued from p. 389.)

dates from Vesalius, who was amongst the
first to demonstrate the external structures of
the mastoid process and the communication of
its cells with the tympanic cavity. But it was
not explicitly recommended till 80 years later,
when Riolan advised its adoption for the evacu-
ation of intra-mastoid collections of pus. The
first operation of trephining appears to have
been done by T. L. Petit, in the case of caries
of the mastoid bone. Jasser next perforated
the mastoid process, in 1776, for the cure of
deafness. 98 cases of perforation have been
collected by Poinsot, in 35 of which the trephine
or trepan was used; in the remainder other
instruments, gouge, drill, trocar, &c., were
employed. Of the total number of cases, 15
terminated fatally; in 2 the result is not stated;
in 5 there was no recorded result; 5 others
were under treatment at the time at which their
cases were reported; the rest were successful.
Of the 35 cases in which the trephine or
trepan was used, 4 terminated fatally, while
the result in the other cases has not been re-
ported; in the total number of cases, the re-
sult of which are differently specified, 17% were
fatal, and 21% successful. Buck has collected
37 cases of suppurative inflammation in which
the cases were left to nature (expectant treat-
ment); 34 were fatal. It will be readily seen
from the foregoing that the operation of tre-
phining for mastoid disease is a fairly suc-
cessful one, and, on the other hand, that, from
the expectant treatment in suppurative inflam-
mation, there is little to look forward to but a
fatal result. That the operation should be
practised early is a self-evident fact; it is
useless when pyæmia, meningitis, or phlebitis
of the sinuses has appeared, although the first
cerebral manifestations should not intimidate
the surgeon from operating, and I doubt not
but that good service will be done towards the
patient by his attendant who advises operation
even where no bone disease existed, but when
the discharge from the tympanum has lasted
for a lengthened period, and has not yielded to
other treatment, such as syringing and enlarg-patches, moreover, scarcely ever extend into
ing the opening of the membrana tympani if
necessary. Setons and issues I believe to be
of little use, for although only the mucous
membrane may be engaged, yet we know that
a blow on the mastoid process, a severe cold,
a depressing illness, may cause disease to
advance to the bone, pyæmia may ensue, or
death by general cerebral irritation, without
the formation of abscess. A well-accomplished
operation will always give free vent to pus
when existing, and prevent it passing to the
brain through some of the numerous channels
I have recorded, and will thus save the patient.
I must deprecate the operation recommended
by Dr. Bagroff-namely, the use of the gouge

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In an article on Consecutive Nephritis, in Reynold's System of Medicine, Mr. Marcus Beck makes the following remarks with regard to the shape of the purulent points: The abscesses, and the pale streaks between them, naturally assume a wedgelike form, in consequence of the anatomical arrangement of the structures amongst which they are situated; but this is very different from the form of an embolic abscess. In embolic patches the width of the base is seldom less than half its length, but, in these abscesses of interstitial nephritis, the base showing on the surface may be only the width of a pin's head, while the length of the wedge may be one inch or more. Embolic

the pyramids." With regard to the present
class of cases (namely, where the virus enters
by the lymphatics—but not where it enters by
the uriniferous tubules), my own observations
confirm these remarks, but, in addition, they
also convince me of something more. Thus,
in Case 2, the abscesses were frequently found
situated between the capsule and the renal sub-
stance, and involving the former quite as much
as, sometimes even more than, the latter.
When this was so, the abscess was oval or
rounded. See fig. 6. When, however, the
inflammatory process had spread in upon the
kidney tissue, then the wedge-shape described
by Mr. Beck was observed. This elongated

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shape of the suppurative areas was specially microscopic examination, the inflammations in well seen in Case 6, in which the inflammatory the kidney substance presented, with one or process extended in a long and somewhat two exceptions, pretty similar appearances to straggling manner from the capsule right those already described in connection with the through the cortex to the pyramid. In the other varieties. In their elongated and pyrastained specimens this appearance could be midal shape and cortical situation, they differed

FIG. 6.

detected quite well by the naked eye, owing to | from the suppurations occurring as the result the inflammatory corpuscles taking up the of the entrance of the virus into the uriniferous

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micro-organisms were discovered in large numbers. In Case 2 they were present as small colonies in the neighborhood, or interior, of the abscesses. In Case 4 the colonies were of very large size, and the individual organisms, though very minute, were distinctly rod-shaped, thus differing from the ordinary rounded shape of the micrococci (fig. 7). It may be remarked in passing, that the inflammatory changes in this kidney seemed to be much more extensive and severe than in the others. In Case 6 the micrococci were scattered amongst the leucocytes, and were not grouped into distinct colonies.

In Case 2 the capsule, which had been only partially removed at the post-mortem, presented microscopic appearances of very considerable importance as bearing upon the mode of infection. It showed well defined areas of leucocytes in its substance, which were strikingly similar to those which have already been described as existing in the external layers of the bladder and ureter. It also contained numerous capillary blood-vessels, outside many of which leucocytes were seen grouped in large numbers. In its substance, too, numerous colonies of micrococci were observed, and these were frequently seen lying in the lymphatic spaces surrounding the small capsular blood-vessels. As has been already noted, the small abscesses were often observed to involve the capsular as much as the renal tissue, the whole appearances being strongly indicative of the fact that they had primarily originated in the tissue of the capsule itself, and afterwards passed inwards to the substance of the kidney, as is well shown in fig. 6.

As

second, and, in order that the state of matters
involved under the second heading may be
understood, it is necessary to say a word or
two concerning the lymphatics of the kidney.
The lymphatic vessels of the kidney and
ureter were described as early as the year 1787
by Mascagni in his work entitled 'asorum
Lymphaticorum Corporis Humani. He showed
that they were arranged in a superficial set,
disposed in the capsule, and a deep set passing
outwards from the hilus of the organ. He also
describes a group of lymphatic vessels passing
upwards along the course of the ureter.
the result of their researches on the histology
of the kidneys, this description of the lym-
phatic vessels has been adopted by Ludwig
and Zawarykin, although Sappey in his work
on Anatomy, published in Paris in 1879, does
not believe that there is a superficial set as
described by these observers. Ludwig's con-
clusions, however, are accepted by the majority
of histologists, and the results of the present
investigation lead me very strongly to the
opinion that they are right. Not only do I
believe in the superficial and deep set of lym-
phatic vessels of Ludwig, but I also hold the
view that the superficial or capsular lymphatics
of the kidney are in communication with those
ramifying in the wall of the ureter. Patho-
logical evidence confirmatory of any point in
normal anatomy or physiology is regarded by
all as very valuable, and for this reason the
testimony which this research bears to the cor-
rectness of Ludwig's views is all the more
important. But the following observations are
also of very great significance in the present
connection: At the recent Discussion on
Albuminuria held by the Glasgow Pathological
and Clinical Society, Dr. Newman's assistant,
Mr. H. Lyon Smith, showed sections obtained
from a kidney which had by accident been in-
jected from the ureter instead of from the renal
artery. Upon cutting up the organ, the injec-
tion mass (carmine and gelatine) was found to
be distributed mainly in the cortex-it had, in
fact, obtained access to the lymphatic channels
of the ureter, had passed along the spaces of
the connective tissue of the capsule of the
kidney, had then penetrated its substance, and
was seen, under the microscope, lying in spaces
between the uriniferous tubules. Dr. Newman
informs me that, some years ago, while work-
ing with the late Dr. Foulis, he noted similar

The next question is-How has the infective virus obtained access to the kidney in this class of cases? It is obvious, from what has just been said, that the route is different from that described in the previous subsection-that in fact we have two distinct modes of infection -viz. (1), by way of the tubules, already discussed; and (2), (the mode at present under review) by the lymphatics. I do not find this distinction clearly insisted upon by any of the writers I have yet been able to consult. Thus, Klebs distinctly recognises the entrance of organisms by the tubules, and states that they may make their way into the interstitial tissue from them. Dickinson also holds that the virus enters by the uriniferous tubules, then passes into the veins, and is thus sown broad-appearances after injection of the kidney from cast through the organ. And Marcus Beck, the ureter. These observations are very while he recognises that the lymphatics are in- strongly confirmatory of the opinion to which, volved in suppurative nephritis, also holds that as the result of purely pathological researches, the septic material first passes into the urinif- I had long ago come, that the lymphatics of erous tubules. Each of the opinions just stated the ureter, and those of the cortex of the kidney, might be applied to the first mode of infection communicate directly with one another. I re-viz., by the tubules—but none of them to the|peated these experiments, and injected three

human kidneys from the ureter. Instead of carmine and gelatine, I used the cold Prussianblue injecting fluid, as I thought it would more easily run through the very small vessels. The injection was made by means of a continuous injection apparatus, the pressure employed varying from 4 to 8 cms. of mercury. The first effect was that the pelvis became greatly distended, then the blue fluid was seen to be making its way through the substance of the wall of the pelvis and the spaces of the renal capsule, and gradually filling up small starshaped or tortuous vessels on the surface of the kidney. In one of the experiments a vessel in

FIG. 8.

the pelvic wall of considerable size was seen to get slowly filled and stretch away over the surface of the kidney. On a little air getting by accident into the apparatus, minute air bubbles were seen to chase one another through this vessel, which was about the diameter of a fine sewing needle. The time employed for injection varied from 15 minutes to 2 hours, then a ligature was put on the ureter, and the organ was placed in weak spirit and water for 24 hours. Upon examination at the end of

that period, the surface of the kidney presented a number of delicate star-shaped or tortuous vessels, which were filled with the blue fluid, and which were very distinct from contrast with the general red coloration of the surface. A fair idea of the appearance is obtained from fig. 8. Upon section the cortex was seen to be traversed by minute blue streaks, leading down from the injected vessels on the surface. Sometimes these streaks were long enough to reach the pyramid, but as a general rule they were not so long. In a few cases the lower half of the pyramidal uriniferous tubules had been injected, but the injection never went nearly so far up as the cortex, see figs. 9 and IO. Upon microscopic examination similar appearances to those observed by Mr. Smith were seen-the blue coloration was found to be situated in the spaces between the uriniferous tubules, and to get gradually less the farther from the capsule it was. See fig. 11. These facts, then, taken along with the observations of Dr. Newman, render it almost certain that the lymphatics in the cortex of the kidney, and those in the wall of the ureter are intercommunicable, and, bearing them in mind, my theory as to the infection of the kidney by means of the lymphatics is readily understood.

One of the primary factors in the process of infection is the greatly inflamed mucous membrane of the bladder, in which, as has been shown, septic organisms proliferate in great numbers. From this breeding ground the infective material passes outwards by means of the lymphatic spaces through the bladder wall, and the micro-organisms are then found abundantly in the external layers, often having excited inflammatory changes in their progress. The organisms then obtain access to the lymphatic channels in the wall of the ureter, and gradually spread upwards; here also, as has been seen, often exciting localised patches of inflammation as they go. The mucous membrane of the ureter may perhaps be somewhat inflamed, but, in order that the kidney should become infected, it is not at all necessary that the mucous surface should be involved. That this is so is abundantly borne out by Cases 6 and 8 of the appendix, in which the mucous membrane was only very slightly or not at all affected. At length the.organisms reach the pelvis of the kidney, and then pass into the lymphatic spaces of the capsule, in various parts of which, as the result of their virulent action, small abscesses form. These abscesses also involve the superficial parts of the renal cortex, and the morbid products are gradually disseminated through its substance, exciting the inflammatory formations in the way already seen. The fact of the abscesses being so frequently met with situated between the capsule

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