DISEASES 
OP THE 
p a'it oi d 
THEIR 
DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
BY 
ALBERT H. BUCK, M.D. 
[Reprinted from Archives of Ophthalmology and Otology, "Vol. III., 1, 1873.] 
'A(\v loth: 
WILLIAM WOOD & COMPANY, 
27 Great Jones Street. With the Compliments of 
Albert H. Buck, M. D. 
No. 50 East 31st Street. 
DISEASES OF THE MASTOID PROCESS; 
THEIR DIAGNOSIS, PATHOLOGY, 
AND TREATMENT. 
ALBERT H. BUCK, M.D., 
OF NEW YORK, 
The bony prominence, lying behind the ear and 
known as the mastoid process of the temporal bone, 
may be the seat of various morbid processes. It is true 
that these are usually secondary to affections of the 
meatus or tympanic cavity, where the disease originates 
and from which it is propagated either to the fibrous 
covering of the bone or to the peculiar cells which fill 
its interior. This propagation is not the rule, however. 
In the far larger proportion of cases the inflammation is 
confined to the locality where it first made its appear- 
ance, and only in rarer cases the mastoid body is in- 
vaded. These are the cases in which we meet those 
groups of clinical phenomena which are usually known 
as mastoid diseases. As a rule we are not justified in 
giving a new name to morbid processes which are sim- 
ply extensions of the same vital changes to different 
portions of the same tissue. In this instance, however, 
the ultimate pathological results give rise to special 
trains of symptoms which call for peculiar treatment, 
and therefore warrant us in regarding the diseases them- 
selves as essentially separate. 
Two important facts will attract our attention in re- 2 
A. H. Buck : 
viewing the literature of this subject. It will be seen 
that in a large majority of instances the disease was not 
appreciated and that the mortality has been very large. 
Let us inquire into the causes of these two facts. The 
rarity of the affection cannot be urged by practitioners 
as a reason for their ignorance. I have good grounds 
for believing that such cases occur with tolerable fre- 
quency in ordinary practice: they certainly form a fair 
percentage of the cases which come under treatment at 
our infirmaries. Much of the fault must be laid to our 
ordinary text-books on surgery, even the most recent, 
for they either omit the subject entirely or dismiss it by 
a brief allusion to caries of the mastoid body as a dis- 
ease of rare occurrence. We find 
some attention given to the subject 
in our text-books on otology and in 
monographs, but much still remains 
buried in obscurity. 
The following article will aim to 
show the course of the diseases 
through their various stages. A 
sufficient number of cases will illus- 
trate the points brought forward, 
and certain features will be noticed 
that will enable the ordinary practi- 
tioner to recognize the gravity of the 
affection at an early stage. 
Fig. i. 
A vertical transverse sec- 
tion through mastoid por- 
tion of an infantile temporal 
bone. 
d dura mater. 
A antrum. 
m rudimentary mas- 
toid process. (Natural 
size.) 
At birth the mastoid process consists of a small, flat- 
tened tuberosity, containing but one cell of considerable 
size—the antrum. (See Fig. i.) At puberty there 
is a distinct prominence, coijical in shape, whose apex Diseases of Mastoid Process. 
3 
points downwards, and whose length, in some in- 
stances, may measure an inch and a quarter. (Figs. 3 
and 5.) The substance of this bony prominence is 
formed of a number of small cavities, or cells, varying 
very greatly in size and shape. These, cells commu- 
nicate with one another, and are lined with an ex- 
tension of the mucous membrane of the tympanum. 
Their mode of distribution and size vary so much 
in different individuals, that 
it is scarcely possible to 
give a description which 
will be true in even a ma- 
jority of instances. The 
accompanying figures illus- 
trate some of the most strik- 
ing forms. In thickness the 
outer lamella of bone varies 
very materially in different 
individuals; at times being 
almost as thin as ordinary 
Fig. 2. 
Mastoid process of a child (set. circa 
5). 
Same section and lettering as in Fig. 
1. (Natural size;) 
writing paper. At the posterior end of the tympanic 
cavity is the entrance to the mastoid vestibule, if I may 
so call it. This entrance, which is sometimes double, 
is rather narrow, and lies at a much higher level than 
the floor of the tympanum. 
In the adult the vestibule, or antrum (horizontal por- 
tion of the mastoid cells, Toynbee) is placed much 
nearer the dura mater and the lateral sinus than the 
outer surface of the bone. 
It is an irregularly-shaped cavity, oblong in its ante- 
ro-posterior diameter, and having honey-combed walls 4 
A. H. Buck : 
with numerous ridges and intervening depressions, 
which lead to the surrounding- cells. In adults the ves- 
tibule is just large enough to admit a small-sized pea, 
or sometimes a still larger body. 
Mastoid process at puberty. 
Same section and lettering as in Fig. i. (Natural sire.) 
As a rule the cells are not confined merely to the 
mastoid process, but extend forwards over the external 
auditory canal, and upwards towards the parietal bone, 
to a still higher level than the canal. (Fig. 4.) In fact 
we may regard the entire mastoid system as a collection 
of bony cells, each one of which is lined with mucous 
membrane, and communicates with its neighbor by a 
narrow passage. They all have their final outlet into 
the middle ear through the antrum. 
In no other part of the body do we find a mucous 
cavity so ill adapted to withstand the action of morbid 
processes. Diseases of Mastoid Process. 
5 
In this respect the ethmoid, sphenoid, maxillary and 
frontal cells, which are the only similar structures, are 
much more favored. The reasons of this are apparent. 
The nasal cavity, into which they all open, has very 
Fig. 4. 
Mastoid process. External portion chiseled away to show how far the cells extend. 
broad outlets and is rarely the seat of grave inflamma- 
tion. The ethmoid and frontal cells have a further ad- 
vantage: their outlets are at the most dependent por- 
tions of the cavities, so that gravity facilitates very 
materially the discharge of any accumulation. This is 
not true, however, of the antrum maxillare and sphenoid 
cavity, though in their case the danger of the extension 
of an inflammation to the brain is materially lessened 
by the circumstance that the point of least resistance is 
on the side toward the nostril, and not toward the brain. 
In the mastoid cells the reverse is true: their natural 6 
A. H. Buck: 
outlets are so small that under inflammatory action they 
may very readily become closed, and before the impris- 
oned pus can force its way through the outer table of 
the bone, the periosteum and thick integuments, there 
will be great danger of its involving one or both of the 
adjacent structures—the brain and lateral sinus. The 
danger is still further enhanced by the passage of one 
or more small veins through the upper portion of the 
process, which form a medium of communication be- 
tween the lateral sinus or its branch, the superior pe- 
trosal sinus, and the veins on the outside of the crani- 
um (Henle). 
Fig. 5 
Diagram showing the relations of the dura mater, lateral sinus, external meatus 
and tympanum to the mastoid cells. 
T = Eustachian tube. _ M = mastoid process. 
M. T membrana tympani. L. S. location of the lateral sinus, 
d = dura mater. A. = antrum. 
Disease of the mastoid process may usually be recog- 
nized under the following forms : 
i. Inflammation of the external periosteum. 
2. Simple congestion of the mucous membrane. 
3. Congestion and filling up of the cells with a 
reddish, pulpy material. Diseases of Mastoid Process. 
7 
4. Chronic subacute inflammation of the mucous 
membrane with sclerosis or hyperostosis. 
5. Caries, with accumulation of pus, within the 
mastoid process. 
The second, third, and fifth forms are simply the 
three different stages of an acute inflammation; yet for 
practical purposes it is better to regard them as separate 
varieties. 
/. Inflammation of the External Periosteum. 
This occurs as a concomitant symptom or phase of 
an acute inflammation of the external auditory canal. 
The periosteum of the mastoid process is a direct con- 
tinuation of that which lines the meatus externus ; hence 
it not infrequently happens that an inflammation of the 
latter extends to the mastoid body. As it is character- 
ized by tenderness, pain, and swelling of the parts, it 
may easily mislead one into the belief that the mastoid 
cells themselves are the seat of the trouble. 
The following case is a good illustration of this first 
form:— 
Case I. (New York Eye and Ear Infirmary).—Sarah Golden, get. 18, 
October 16, 1872. No ear trouble until about a week ago, when she 
began to suffer from a roaring in the left ear, followed shortly by pain, 
which gradually increased in severity, and extended to the mastoid re- 
gion. No discharge. Watch heard at a distance of two inches. 
Outer orifice of the meatus almost closed by the congested and swol- 
len condition of the parts. Beyond the constriction a hard mass of 
impacted cerumen was seen. The integuments covering the mastoid 
process were red, swollen, and tender to the touch. Patient evidently 
in great suffering. The impacted mass was broken down piecemeal, 
by a probe, and removed with a delicate pair of bent forceps. The 8 
A. H. Buck : 
deeper portion of the mass was found to rest against the membrana 
tympani. 
All the unpleasant symptoms rapidly disappeared after the removal 
of the mass. 
In these cases the treatment consists in allaying the 
inflammation of the meatus, after which the tenderness 
and pain behind the ear soon disappear of themselves. 
Sometimes the inflammation of the periosteum results 
in the formation of an abscess in the subcutaneous cel- 
lular tissue of the mastoid region without involving the 
subjacent bone to any appreciable extent. In such cases 
the indication is to afford a free outlet to the pus by a 
suitable incision. The following case illustrates this 
point;— 
Case 11. (New York Eye and Ear Infirmary).—March 27, 1872. 
Benjamin Curtin, set. 24, a robust, powerfully-built man, was taken 
with a severe earache and tinnitus nine days ago. No discharge until 
two days ago. Removal of pus from the meatus brought into view a 
small mass of granulations, springing from the lower wall, about at the 
junction of the cartilaginous with the osseous portion. By the aid of 
a curved probe it was ascertained that these granulations concealed 
the entrance to a sinus, which led downwards and backwards a dis- 
tance of three-quarters of an inch. No exposed bone could be felt. 
The integuments over the mastoid process were red, swollen, and ten- 
der to the touch. Membrana tympani red and swollen, but not per- 
forated. 
Valsalva’s experiment caused pus to escape from the opening in the 
lower wall of the meatus. Membrana tympani punctured, and pus 
driven out through the incision by means of Politzer’s inflation. 
Leeches also applied to mastoid region. April 3. Swelling behind 
the ear is more prominent, and extends much lower downwards. A 
free incision gave escape to about two ounces of healthy pus. A 
careful exploration revealed the fact that the bone was still covered at 
all points by periosteum. From this time the recovery was rapid. Diseases of Mastoid Process. 
9 
:As a point of interest in differential diagnosis it will 
be well to mention here that a small gland is sometimes 
found lying directly upon the mastoid process. In cer- 
tain affections of the middle ear and external auditory 
canal, this gland becomes painful, swollen, and tender 
to the touch, and may lead the surgeon to suspect mas- 
toid disease. A few applications of the tincture of 
iodine usually suffice to dispel the pain and swelling. 
11. Simple Congestion of the Mucous Membrane. 
The second form may be observed, in a very slight 
degree, in many cases of acute inflammation of the 
middle ear. In these cases the patients direct the sur- 
geon’s attention to the deeper parts of the ear, and rarely 
to the mastoid region. In a few cases, however, the 
trouble is referred chiefly to the mastoid process. 
These are the cases which may be classified under the 
head of simple congestion of the mastoid mucous mem- 
brane. The following examples will illustrate the 
prominent clinical features of this form of disease :—■ 
Case 111.—Mrs set. circa 30, of excellent health, after 
exposure during house-cleaning on the Ist of May, 1872, began to 
suffer from sore throat, slight deafness, and pain in the right ear. The 
pain soon extended to the parts behind the ear, and gradually increased 
in severity, robbing her of her sleep. On the 6th of May I saw her 
for the first time, and found the ear in the following condition :—The 
external auditory canal normal; the membrana tyrapani red and swol- 
len, though entire; the Eustachian tube closed to Politzer; very 
marked tenderness on pressure, and some redness of the skin over the 
mastoid process. Upper portion of pharynx moderately congested. 
Watch heard when pressed against the ear. Four leeches applied over 
the mastoid process gave great relief. May 9th. Pain and tenderness A. H, Buck : 
entirely gone. A solution of nitrate of silver (3j—|j aquae) ap- 
plied to the still swollen membrana tympani. May 13. No return of 
the pain. Swelling of the membrana tympani diminishing. Watch 
heard at a distance of half an inch. She subsequently had no return 
of the pain in that ear, and the improvement in hearing was steady 
and marked. 
On the Bth of the following November I was consulted again for a very 
similar attack in the left ear. The history given was that about the xst of 
November she was attacked with a severe pain behind the ear, accom- 
panied by tenderness on pressure, and a little swelling. The applica- 
tion of six leeches to the affected part relieved these symptoms en- 
tirely, but on the previous night the pain returned with considerable 
severity. On examination I found the left membrana tympani sunken, 
but not congested. Watch heard at a distance of three feet. There 
was tenderness over the mastoid process, and some oedematous swell- 
ing of the integuments. Six leeches applied behind the left ear af- 
forded entire relief. Since this time there has been no recurrence of 
the trouble. 
Case IV.—(N. Y. Eye and Ear Infirmary.)— Mary A. Hanley, set. 
32, in robust health, was attacked with an influenza on the 9th of No- 
vember, 1872. She had more or less fever, and a constant catarrh of 
the eyes and nose. On the 12th, the right ear became involved, the 
symptoms being moderate deafness, roaring and some pain. Watch 
heard at a distance of 6 inches. External auditory canal healthy. 
Membrana tympani dull, opaque and rather flatter than normal. The 
air during inflation entered the middle ear with a dry sound. Four 
leeches applied in front of the ear. Nov. 14. The leeches afforded 
only partial relief. Membrana tympani oedematous in appearance and 
somewhat convex outwardly. Nov. 15. Passed a bad night. The pain 
is again severe, and is referred by the patient to the entire side of the 
head. Tenderness on pressure over the mastoid process. The poste- 
rior wall of the external auditory canal has also become tender upon 
pressure. A free vertical incision through the posterior half of the 
membrane was followed by an oozing of bloody serum from the wound. 
By inflation of the middle ear through the Eustachian catheter the 
serum was made to escape in such quantity that it ran down over her Diseases of Mastoid Process. 
11 
cheek. Nov. 16. Comparatively free from pain last night. The 
watery discharge continued through the night, as shown by the stains 
on the pillow. The tenderness has disappeared, and patient feels quite 
well again. No subsequent return of the pain. 
If the pain should not yield to moderately active local 
blood-letting (leeching), an incision may be made over 
the mastoid process, down to and through the perios- 
teum, If both of these means fail to relieve the patient’s 
suffering, and especially if after the temporary relief, 
which leeches or an incision are pretty sure to afford, 
the pain returns with even renewed severity and extends 
backwards toward the occiput and upwards toward the 
vertex, we may then draw the inference that the disease 
has already passed into the third, or even the fifth form. 
As a rule, however, the measures here recommended 
prove sufficient to check the further progress of the in- 
flammation. 
IV. Chronic subacute inflammation of the mucous 
membrane with sclerosis, or hyperostosis. 
While this form constitutes a distinct pathological 
condition, we are not yet in possession of sufficient 
clinical facts to guide us to a positive diagnosis. 
Sclerosis or hyperostosis of the mastoid process, is 
associated with either chronic catarrhal, or chronic 
purulent inflammation of the middle ear. Its progress 
is so insidious and so rarely accompanied by any 
marked symptoms that it is only at the post-mortem 
examination, or when called upon to trephine the bone, 
that we discover the existence of this condition. As the 
very delicate membrane, which lines the mastoid cells, 12 
A. H. Btick: 
serves the double function of mucous membrane, and 
periosteum to' the intercellular bony septa, it will be 
readily understood how a chronic congestion of the 
membrane may result on the one hand in thickening of 
its substance, and on the other in hypertrophy of the 
bone which it nourishes. In place then of air-containing 
cavities, separated by thin septa of bone, we find a 
tolerably dense bony mass, whose substance is studded 
throughout with small collections of slightly vascular 
connective tissue. (Fig 6.) Where this condition of 
things is the result of a chronic purulent inflammation 
of the middle ear we shall often find that the antrum is 
the receptacle for a mass of cheesy material, produced 
by a retrograde metamorphosis of pus, epithelial cells 
and mucus. Such masses have sometimes been found 
in the cavity of the tympanum, where the perforation 
in the membrane was small, or in one of the upper seg- 
ments. This material probably owes its existence to 
the fact that the fluid elements of the discharge find an 
escape through the small outlet, while the solid portions 
remain behind and gradually accumulate until they form 
a solid mass, which entirely fills the antrum. From the 
frequency with which such masses are found in fatal 
cases of caries of the mastoid process, I think we are 
justified in believing that their presence in the antrum 
is not unattended with danger to life. The carious pro- 
cess in these cases appears to originate in the antrum, 
and its further progress to be confined chiefly to the 
region lying between that cavity and the fossa sigmoidea. 
This may be explained by supposing that the pus, pre- 
vented by the cheesy mass from escaping through its Diseases of Mastoid Process. 
13 
natural outlet, sought an escape through the bone in the 
direction of least resistance, viz., toward the lateral sinus, 
or the dura mater. 
I know of no series of symptoms which will enable us 
to recognise this form of disease with certainty, though 
sometimes certain symptoms, like those narrated in 
case No. 5, should lead us to suspect its existence. 
Dr. Hermann Knapp of this city gave me an instance 
of a case of this kind which came under his observation. 
Suspecting cheesy matter in the antrum, he introduced 
a curved probe (as first proposed by Toynbee, Med. 
Times and Gazette, March 16, 1861) and succeeded in 
dislodging and removing quite a large accumulation 
from that cavity. I proposed to make a similar attempt 
in the following case, in which sclerosis of the mastoid 
cells with cheesy accumulation in the antrum was sus- 
pected. The patient however did not consent. 
Case V.—Mr. C., set. 24, somewhat anaemic, but otherwise in good 
health, consulted me in March, 1872, for an otorrhoea of fifteen years 
standing. It had established itself as a sequela of scarlet fever and 
was accompanied by tinnitus and a dull steady pain, referred to the 
deeper parts of the ear. Various methods of treatment had been pur- 
sued, but the discharge had never materially diminished. An inspec- 
tion of the ear showed the membrana tympani to have been entirely 
destroyed, the handle of the hammer resting against the promontory, 
the mucous membrane pale and very fibrous in appearance, and the 
posterior upper portion of the tympanic cavity filled with a small mass 
of granulations which seemed to grow from the entrance to the 
antrum. There was no tenderness over the mastoid process. The 
watch could be heard at a distance of 7 inches. A few applications 
of chromic acid were made, and the granulations shrank entirely out 
of sight behind the projecting angle of bone. 
The subsequent treatment consisted in introducing a probe armed A. H. Buck : 
with cotton, thoroughly cleansing and drying all the parts within reach, 
and then applying nitrate of silver in solution (the strength being gra- 
dually increased from twenty grains to a drachm to the ounce of water). 
At the expiration of two weeks the discharge was just as abundant as 
at the first. On the 29th of March, X substituted powdered alum for 
the silver solution, blowing it in with a suitable tube. The quantity used 
was just sufficient to form a thin layer over the exposed mucous mem- 
brane. On the 30th the patient reported that there had been almost 
no discharge since the last application. The alum was accordingly ap- 
plied a second time, after all the remains of the first charge had been 
removed. This second application was followed in the course of an 
hour by dizziness, nausea and vomiting, and a throbbing sensation in 
the ear, without tinnitus. Objects appeared blurred before his eyes. 
Two hours afterwards he had a second similar attack, which compelled 
him to take to his bed. The dizziness and nausea continued then for 
nearly 48 hours, when the discharge reappeared, and he was again able 
to walk about. 
In view of the long continuance of the discharge, 
of the constant, dull, deep-seated pain, of the presence 
of granulations which seemed to spring from the en- 
trance to the antrum, and from the throbbing sen- 
sation which ensued, when that entrance became 
closed—as it doubtless did when the alum was applied 
—it appeared to me probable that the case was one of 
chronic purulent inflammation of the antrum, associated 
perhaps with a cheesy accumulation and sclerosis of the 
mastoid cells ; and in this opinion I was confirmed by 
Dr. Hermann Knapp, who afterward saw the patient 
with me in consultation. Case No. 16 shows us that 
we may meet this form of disease in persons as young' 
as Mr. C. .* 
* Dr. J. L. Vandervoort of this city has given me the following details of a case 
which perhaps belongs more properly to this than to the first form :—A lady, set. Diseases of Mastoid Process. 
15 
111. Congestion and filling up the of cells with a 
reddish, pulpy material. 
V, Caries with accumulation of pits within the 
mastoid process. 
In very many cases the clinical features of these two 
forms coincide so closely that it is exceedingly difficult, 
if not impossible, to distinguish between them. It is 
only in certain well-marked cases, that we can say: in 
this case the disease has gone on to the formation of 
pus in the mastoid cells. The important point, how- 
ever, is to diagnosticate whether the disease has 
reached either of these two stages, for if left to itself 
the third form will soon pass into the fifth and endanger 
the patient’s life. 
The following cases will illustrate these two forms of 
disease. 
Case VI. (reported by Dr, Flaiz, in the Archiv fur Ohrenheilkunde, 
vol. 2). The patient, a man 46 years of age, and previously in 
good health, was exposed to severe weather during the summer of 1864. 
Pain in both ears with deafness ensued. His physician sent him to the 
warm baths at Aargau, but at the end of three weeks he returned, 
having grown worse rather than better. On the 17th of September, 
1864, Dr. Flaiz was called to see him. On examination he found the 
mastoid process of the left side very tender on pressure. The calibre 
of the external auditory canal was diminished, and filled with pus. 
The membrana tympani was invisible. Inflation of the middle ear 
revealed the existence of a perforation in the membrane. Ordered a 
cathartic and leeches to the left ear. 
54, has an exostosis projecting from the central portion of the mastoid process. It 
is about the size of a nutmeg, hemispherical in shape, smooth and painless, and has 
existed for over 30 years. When 14 years old she had scarlet fever which left her 
with an otorrhoea that ceased only twelve months ago. The growth of the tumor 
was quite slow. It has remained at its present size for many years. 16 
A. H. Buck : 
September 20ih. No relief yet. Leeches to be repeated. 21st. 
A free incision over the mastoid process. This relieved the pain, and 
the wound was allowed topical. 
October 15th. Pain has returned. Fluctuating swelling over mastoid 
process. Incision and evacuation of half an ounce of pus. No rough- 
ness of bone detected. Pain relieved. Wound again allowed to heal. 
By degrees the pain returned with its former severity, and was referred 
chiefly to the left occipital and parietal region. October 26th. Pa- 
tient delirious. Mastoid process perforated with a drill, no pus found. 
October 27th. Free discharge from the wound. From this time there 
was a steady amelioration in all the symptoms, and at the end of four 
weeks the patient was able to resume his work. 
In this case we are not informed what the condition of 
the mastoid cells actually was. It should be remembered, 
however, that when an operation of this kind is per- 
formed, the facilities for making a minute examination 
into the condition of the bone are not usually at hand; 
the most we can do is to distinguish the red of the con- 
gested mucous membrane, the yellow of the pus, or the 
whitish hue of the sclerosed bone. 
Case VII. (N. Y. Eye and Ear Infirmary.)—Pichard Murphy, ast. 
11, phthisical in appearance, contracted about the 4th of September, 
1872, a pain in the left ear, in consequence of exposure to cold. Two 
days later a discharge appeared, and from that time to this (September 
nth) he has suffered from severe pain in the affected ear. To-day the 
discharge ceased. Patient appears to be in great suffering. Pulse 108 
and feeble. Tenderness and oedema over the left mastoid process. 
The external meatus closed by the swelling of its walls. Valsalva’s 
experiment caused dizziness, and retching. The patient being under 
the influence of ether, an incision was made through the integuments 
of the mastoid process. The surface of the bone was found to be 
normal in appearance and consistency. The outer shell of bone was 
then perforated with a conical drill, which exposed to view the mastoid Diseases of Mastoid Process. 
17 
cells at a depth of less than two lines. These were found to be highly- 
congested, and the thin bony septa readily broke down under the pres- 
sure of the steel director. No pus was found. A small tent was intro- 
duced into the wound, and a poultice applied to the parts. Milk and 
beef-tea diet. Decubitus. September 12th. Pain is gone, but he is 
unable to keep anything on his stomach. The discharge from the 
meatus has returned. Some erysipelatous swelling about the wound. 
Ordered lime water p. r. n. 
Sept. 13.—Food retained. General condition decidedly better. 
Free discharge from the meatus. Wound granulating. No return of 
pain. Ord. simple dressing to wound, tent to be left out and poultices 
omitted ; also to take quin, sulph. gr. i. t. i. d. and solid food. Sept. 
14. Erysipelatous blush is fading away. Sept. 16. Continued im- 
provement. Is now able to leave the house. Sept. 18. A free dis- 
charge both from the meatus and from the wound. Ord. iron and 
cinchona to be substituted for the quinine. Sept. 21. Entire freedom 
from pain since the operation. His general condition, however, is not 
so good as when he last visited me three days since. Night-sweats 
have set in. 
Since the last note I have not heard from the boy, 
and am inclined to think, judging- from his low con- 
dition, that he did not survive many weeks. The 
operation certainly gave great relief, but the subsequent 
copious discharge of purulent matter was too great a 
strain for a system burdened with phthisis, and he 
probably succumbed under both. 
Case VIII.—Dr. A. P. W., of Chester, S. C., set. 56, of a strong 
constitution, consulted me, Oct. 12, 1872, for a painful affection of the 
mastoid process. He gave the following history;—ln 1835 he con- 
tracted an acute inflammation of the left middle ear from the bursting 
of a gun barrel. The severe symptoms soon passed off, but the puru- 
lent discharge continued for some time after. Since that time, how- 
ever, the ear has not troubled him in any way, except that there has A. H. Buck: 
been a moderate degree of deafness and some tinnitus. The perfora- 
tion in the membrane has always persisted. About the middle of last 
July he noticed a slight serous discharge from the left ear, and felt a 
little pain in it. The pain became gradually more severe and was 
associated with headache and fever. The doctor bled himself to the 
extent of about sixteen ounces ; six hours later he took from the arm 
an additional quantity of about eight ounces. A profuse suppuration 
from the ear soon took place and the pain then became tolerable. 
For a month no marked change occurred in the condition of the ear. 
The discharge continued, but at times it would almost stop. On the 
23d of August he had a rigor, which was followed by a return of all 
the acute symptoms. The pain was referred to the base of the brain, 
the mastoid process and the articulation of .the jaw. That night the 
pain, according to his own words, was frightful. Bleeding to the 
amount of twelve or fifteen ounces afforded some relief, and the dis- 
charge again became abundant. For a week the pain remained bear- 
able. On the 31st of August he had another rigor, followed by intense 
pain, referred to the mastoid process, and thence backward toward the 
occiput and occipito-vertebral articulation; in fact the whole side of 
the head was painful. There was tenderness over the mastoid process 
and the auricle was pushed somewhat out from the head. On the 2d 
of September, Dr. Darby, Professor of Surgery in the University of 
Columbia, S. C., and Dr. Robinson, of Winsboro’, were telegraphed 
for, but by the time they arrived the discharge was re-established, and 
the pain had moderated. The mastoid region, however, was still 
swollen and quite tender on pressure. On the 18th of September, no 
improvement having taken place in his condition, the doctor started 
for New York in the hope of obtaining relief there. The sea voyage 
from Charleston benefited him very decidedly. The severe symptoms 
abated, and for some time after reaching this city he enjoyed, at least 
during the day, comparative comfort; toward night, however, the old 
trouble returned with greater or less severity. During the few days 
preceding his visit to me he suffered acutely from pain in the ear. 
On examination the meatus was found to be normal, the membrana 
tympani perforated anteriorly, the Eustachian tube freely open, and 
only a trace of pus in the middle ear. Mastoid region oedematous 
and tender on pressure. The tenderness also extends back toward Diseases of Mastoid Process. 
19 
the occiput. General condition fair. Pulse a little over 90. No 
heat of skin. At a consultation with Professor James R. Wood and 
Dr. Hermann Knapp, it was deemed best to perforate the mastoid 
process. At the patient’s own request the operation was performed 
without ether. The appearance of the bone, after the periosteum had 
been lifted aside, was entirely normal. The drill was applied on a 
level with the upper wall of the meatus, and made to penetrate to a 
depth of three-fifths of an inch without encountering mastoid cells. At 
this depth, however, a tolerably firm pad of connective tissue was felt. 
The supposition at the time was, that this mass filled the antrum, but 
on subsequent inspection I became persuaded that, owing to the thick- 
ness of the swollen integuments, and the recumbent position of the 
patient, I had erred somewhat in the direction which I gave to the 
drill, pointing it too far backwards. The pad of connective tissue was 
undoubtedly the outer wall of the lateral sinus. 
October 13th.—Passed a pretty comfortable night. Pain much easier 
than before the operation. Ord. quinine gr. ij. t. i. d. 
October \\th.—Pain again severe. Consultation with Drs. Robert 
F. Weir (Professor Wood out of town) and Hermann Knapp. A 
second perforation was made, this time nearer to the meatus and on a 
lower level than the first. Mastoid cells congested, but no pus present. 
Tent inserted; poultices. Oct. 15. Slight improvement. Appetite 
rather poor. Ord. tinct. ferri chlor. gtt. X with each dose of quinine. 
Oct. 16. Appetite better. Temperature 970. Pain diminishing. 
Ord. carbolic acid dressings to wound, from which there is a free dis- 
charge. 
October 17th.—Marked improvement in every respect. Poultices 
to be stopped. 
November 14th.—Feels quite well again. There is no discharge 
from the meatus, and the wound behind the ear has healed except at 
two points, corresponding to the two sinuses which lead to the perfora- 
tions in the bone. To return to South Carolina. 
October 23d-—Tenderness over mastoid process almost gone. 
A few weeks later I heard from the doctor that there had been no 
return of the pain, and that his general health was quite good again. 
Case IX. (New York Eye and Ear Infirmary.)—Wm. B. Hillison, 
aet. 45, janitor, previously in good health. In August, 1872, he over- 20 
A. H, Buck : 
heated himself, and then sat in a draught of cool air. A few hours 
later, he experienced severe shooting pains in the right ear, and a 
throbbing sensation in the mastoid region. The pain continued, with 
varying severity, for ten days. At the end of this time a discharge 
appeared, and was soon followed by relief from pain. Early in 
November the discharge ceased, and the pain again became severe. 
This time it was referred chiefly to the region behind the ear, and was 
accompanied by some tenderness and swelling of the parts. The 
swelling gradually increased, and on December 14th he reluctantly 
decided to seek medical advice. His physician, Dr. Chas. E. Laight, 
found the meatus swollen, and the mastoid region the seat of a pretty 
large swelling, A free incision liberated about an ounce of healthy 
pus. No denuded bone detected. Dec. 15. Pain relieved. A pro- 
fuse sweat to-day. Dec. 16. Mastoid region again moderately painful. 
Wound healing by adhesion. Occasional pain in the right chest, 
Dec. 18. To-day I saw the patient for the first time, in consultation 
with Dr. Laight. The pain again severe. The countenance pale. 
Pulse 108, and feeble. Holds his head as if suffering from a stiff 
neck. The skin and subjacent tissues over lower portion of mastoid 
process, and extending at least two inches below it, are soldered by 
inflammation into a single, flattened, hard mass, red on the surface. 
Tenderness on pressure, extending up toward squamous portion of 
temporal bone. Meatus very much swollen, and filled with fetid pus. 
A small mass of granulations on posterior superior wall of meatus, 
just beyond the junction of the cartilaginous with the osseous por- 
tion. From this point a sinus leads to bare bone, as ascertained by 
probe. Deeper parts not recognizable. Perforation of the bone 
advised, and patient recommended to enter the New York Eye and 
Ear Infirmary. The operation was performed the same afternoon by 
Dr. Laight. The perforation was made with a drill, which was applied 
at a point half an inch behind the meatus, a little below the level of 
the upper wall, and was directed inwards, decidedly forwards, and a 
little upwards. The instrument first encountered cell-structure at a 
depth of three-fifths of an inch. No pus. Ordered decubitus, poul- 
tices, generous diet, iron and quinine, and sherry wine, 3 vj. daily. 
Dec. Ig. Almost entire relief from pain. Pulse 90, and stronger 
than yesterday. Meatus still swollen. Takes food well. C. T. Diseases of Mastoid Process. 
Dec. 20. Free discharge from the wound and from the meatus. 
Steady improvement. The wound and the meatus both to be syringed 
frequently with a weak solution of carbolic acid. 
21 
Jan. 18. The wound has entirely healed except at one point, where 
a small sinus leads to the perforation in the bone. The sinus in the 
meatus has also closed. Since the Bth of January there has been no 
discharge from the meatus. A small perforation still present in the 
membrana tympani. General condition greatly improved. No return 
of pain since the operation. Jan. 29. Patient is to-day discharged 
cured. 
Case X. (N. Y. Eye and Ear Infirmary.)— Mrs. Kate Ryan, set. 
36, with syphilitic destruction of the bones of the nose, but otherwise 
in good health, consulted me January 15th, 1873, for a painful affec- 
tion of the right ear. She stated that a week previously she was at- 
tacked during the night with a severe pain and roaring in the ear. She 
had always been hard of hearing in that ear, but could not recollect 
ever to have had a discharge from it. In the course of twenty-four 
hours she obtained some relief by the sudden giving way of something 
in the ear and the appearance of a discharge at the outer orifice. 
Soon, however, the pain returned and gradually became almost intol- 
erable. It extended over the entire side of the head and was accom- 
panied by soreness in front of and behind the ear. No head symptoms. 
On examination I found the external auditory canal closed by an 
oedematous swelling of its walls. Membrana tympani perforated but 
invisible. Tenderness on pressure over mastoid region; moderate 
oedema. Tongue coated. Appetite poor. Pulse 90 and of fair 
strength. No appreciable heat of skin. Incision of the mastoid in- 
teguments. 
January 16. No relief from the incision. Pulse 104 and feeble. 
She is evidently in much suffering. Consultation with Dr. Robert F. 
Weir. Perforation of the mastoid process advised. As the patient pre- 
ferred to bear the pain, the operation was performed without anaesthesia. 
The bone was perforated with the larger of the two drills (Fig. 7) to a 
depth of half an inch, without encountering pus. The cells were few 
in number, and separated by strong septa. The outer surface of the 
bone appeared to be perfectly normal. Treatment:—introduction of 
a tent into the opening in the bone, poultices every four hours, iron and A. H. Buck: 
22 
quinine, and moderate stimulation. January 17. Decidedly better in 
every respect. Pain moderate. Pulse 88. Takes nourishment well. 
The meatus and the wound to be syringed every four hours with a 
warm, weak solution of carbolic acid. 
January 22. Continued improvement. Wound granulating. Occa- 
sional shooting pains. C. T. 
January 29. Entire freedom from pain in the right ear. Wound 
rapidly filling up with healthy granulations. Almost no discharge from 
the meatus. Three days ago, without any apparent cause, the left ear 
became acutely inflamed. Incision of membrana tyrnpani afforded an 
outlet to the pus. Relief from the pain, February 8. Steady im- 
provement. Left ear free from pain. 
February 13. No discharge from the right ear since the 10th. A 
thin cicatricial depression indicates the location of the former perfora- 
tion in the membrana tyrnpani. Outer wound entirely healed except 
at one small spot which is still covered by a scab. 
Case XI. (Reported by Von Troeltsch in Virchow’s Archives. 
Vol. XXI., p. 296.)—A girl, set. 16, while in good health, was attacked 
with scarlet fever. On the second day after the appearance of the 
eruption she began to suffer pain in both ears. The pain increased 
until the fifth day, when a discharge appeared. Subsequent decrease 
of pain, but at no time entire freedom from it. Constant discharge. 
When first seen (March 24, 1858) the patient complained of pain in 
and behind both ears. There was no fever. Tenderness on pressure 
over both mastoid processes. On the right side, redness and a diffuse 
swelling behind the ear. Meatus swollen. Membrana tyrnpani per- 
forated. Watch heard only when pressed against the ear. Ordered 
injections of warm water into both ears four times daily. 
March 30. Swelling behind the right ear increased in size. Pain 
severe. A free incision over mastoid process gave temporary relief. 
April 1. Pain again severe. 
April 3. A small opening found in the bone. This was enlarged 
by using moderate force with a buttoned probe. No appearance of 
pus until a few hours later. 
April 4. Pain entirely gone. General condition much improved. 
By syringing a communication was found to exist between the external 
fistulous opening and the cavity of the meatus. About the middle of Diseases of Mastoid Process. 
23 
June the discharge ceased on the right side. External wound nearly 
closed. 
A year and a half later she died of phthisis pulmonalis. At the post- 
mortem examination the cells of the right mastoid process were found 
to be very small and in part filled with a semi-gelatinous material. 
Case Xll.—April 8, 1871, I was called to see Mrs. Peter Green 
(colored), set. 47, and of strong constitution. The story was that on 
the preceding Christmas she had been attacked with severe pain in the 
right ear, followed soon after by a purulent discharge. Eight days 
previously, the discharge having almost ceased, she had again suffered 
from a severe earache, sleeplessness, occasional vomiting and at times 
incoherence of speech. At the time of my visit she appeared to be 
in great suffering. Pulse 104 and rather feeble. No heat of skin. 
Pus escapes through the Eustachian tube into the pharynx. Marked 
tenderness over the mastoid process. The external auditory canal 
closed by the swelling of its walls. A free incision over the mastoid 
process and warm fomentations. April 9.—Last night, soon after the 
operation, the discharge re-appeared. 
April 18, Comparative freedom from pain since the last note. To- 
day I discovered a mass of granulations springing from the upper and 
posterior wall of the meatus, a little beyond the junction of the carti- 
laginous with the osseous portion. May 25. Occasional attacks of 
pain. June sth. Another severe attack of pain last night. Motion of 
the jaws painful. Mastoid process tender on pressure. Ordered two 
leeches to the part. June 6. Some relief from the leeches. June 
15. Since the last note the pain has been steadily growing worse. 
Leeches have been applied from time to time, but with only temporary 
relief. To-day there has been some nausea after meals. June 16. A 
sinus discovered leading from the mass of granulations mentioned 
above to the mastoid cells. Consultation with Dr. Robert F. Weir. 
Perforation of the mastoid process advised. The patient being under 
the influence of ether, an incision was made exposing to view the sur- 
face of the right mastoid process. The lower part of the process ap- 
peared to be softer than natural. The bone was perforated with a 
small drill, and the opening afterwards enlarged by means of a small 
gouge. No pus found. Mastoid cells congested. Two probes intro- A. H. Buck : 
24 
duced into the mastoid process, the one through the sinus, the other 
through the newly made opening, were found to meet. 
From this time there was a rapid improvement in all the symptoms. 
Her general health, which had suffered materially by the prolonged 
sickness, soon regained its usual standard. On the 27th of July I was 
unable to find any trace of the fistulous opening in the meatus, and the 
discharge had entirely ceased. No return of the pain at any time. 
Nos. 6, 7, 8, 9 and 10 afford good illustrations of the 
third form of mastoid disease. Nos. 11 and 12, how- 
ever, represent intermediate forms between the third 
and fifth. Von Troeltsch’s (No. 11) appears to be the 
only case on record in which an opportunity was offered 
of making a post-mortem examination of the mastoid 
cells after recovery had taken place. Case No. 12 con- 
firms strongly the view that the third form, when left to 
itself, passes directly into the fifth. The limited caries 
in that portion of the mastoid cells, which lies nearest 
to the external auditory canal, afforded too small and 
too remote an outlet for the gorged cells of the remain- 
ing portion ; hence the relief was unappreciable. In the 
following case, however, death seems to have occurred 
directly from an extension of the inflammation to the 
lateral sinus, before any appreciable amount of pus had 
formed in the mastoid cells. As a rule the mastoid cells 
will be found to be filled with pus in the cases that 
terminate fatally. 
Case Nlll.—(Reported by Dr. Stokes in the British Medical Jour- 
nal, Feb. 12, 1870.)—A fisherman, aet. 49, of powerful build and 
temperate habits, was admitted to the Meath Hospital, Jan. 12th, 
1870. His history was that on the first day of the year he caught cold 
and began to suffer from headache. This finally became so severe that Diseases of Mastoid Process. 
25 
he was obliged to stop work, and seek for relief at the hospital. By 
questioning him it was ascertained that whenever he caught cold he 
was subject to a fetid discharge from the right ear. 
At the end of 24 hours the head symptoms became more pronounced. 
Low delirium. Fetid discharge from the ear. Profuse perspirations 
on this and the following days. On the 17th a sudden and extreme 
oedema of both eyelids. 20th. Constant delirium. Involuntary evacu- 
ation of urine. 22nd. Slight puffiness over the right mastoid process. 
Integuments incised, but no pus found. Death occurred on the 25 th. 
Up to the last, but very little febrile disturbance. 
At the post-mortem examination purulent basilar meningitis found ; 
also superficial softening of antero-inferior portion of the right side of 
the cerebellum. Lungs free from purulent deposits. Membrana 
tympani destroyed. Mucous membrane of middle ear pulpy, vascular 
and bathed in pus. Mucous membrane of mastoid cells in the same 
condition. Lateral sinus completely obstructed by softening coagula. 
Purulent matter lay between the outer wall of the sinus and the bone. 
Same condition in superior and inferior petrosal sinuses. 
“ From the absence of any fetor, discoloration or softening of the 
bone, it appeared that the lesion which caused death was essentially 
not a caries, but a suppurative phlebitis of the sinuses of the skull, 
propagated through the cells of the mastoid bone, from the inflamed 
mucous membrane of the middle ear.” 
The change from the third to the fifth form probably 
takes place in the following manner :—The inter-cellular 
passages being closed, and the cells themselves filled 
with the swollen and congested mucous membrane, 
stasis follows in the local circulation, the bone becomes 
deprived of its nourishment, and the soft parts filling the 
cells break down into pus. The bony septa then either 
become dissolved, forming granular detritus, or separate 
as a connected whole from the surrounding healthy 
bone. The following cases afford good illustrations of 
the clinical features of this fifth form. 26 
A. H. Buck: 
Case XIV.—(N. Y. Eye and Ear Infirmary.)—-William McCiusky, 
a resident of Orange, N. J., aet. 21, of a healthy constitution, consulted 
me Sept. 4th, 1872, for a painful affection of the mastoid process. 
He stated that in June he was seized with a severe pain in the ear after 
bathing. The pain continued for three or four days, and then stopped, 
leaving him quite deaf in the affected ear. At the expiration of two 
weeks a discharge appeared, and this had continued since until the 4th 
or sth day previous to his visit to me. Shortly before the discharge 
stopped, he noticed some tenderness behind the affected ear. The 
pain, which for four days had been growing steadily worse, was referred 
to the mastoid region, whence it extended upwards and backwards to 
the parietal and occipital regions. Tinnitus. Appetite pool*. Coun- 
tenance pale. Watch heard at a distance of 4 inches on the affected 
side. The skin covering the mastoid process red and swollen. Ex- 
ternal auditory canal diminished in calibre by the falling forward of the 
posterior cutaneous wall. Membrana tympani invisible. Incision of 
the integuments covering mastoid process. Free escape of pus and 
blood. The periosteum was dissected up a short distance on either 
side and the underlying bone seemed healthy. The following day, 
Sept. sth, while pressing pretty firmly against the bone with a steel 
director, it seemed to me that the point of the instrument met with less 
than the usual resistance. I then attempted to perforate the outer 
shell with a small steel drill, and in doing so suddenly exposed a large 
abscess which nearly filled the entire mastoid cavity. The opening was 
further enlarged with a conical drill until the little finger could be ad- 
mitted, and the contents were then entirely evacuated. Tent inserted 
and patient allowed to return to his home where he said he could get 
further medical treatment. The incision of the integuments on the 
previous day had already greatly alleviated his sufferings. 
On the 14th of November following he wrote :—“ The pain never 
returned since you performed the operation, and the wound healed 
inside of ten days. I went to a doctor to have it dressed, but he re- 
fused to have anything to do with it, and said that it was a very dan- 
gerous operation, and might have killed me; so I went to a friend of 
mine and had it dressed. In ten days the outside was all healed, and 
I could hear a great deal better. Now I can hear my watch tick 
about twenty-four inches from my ear.” Diseases of Mastoid Process. 
27 
Case XV. (New York Eye and Ear Infirmary).—Mrs. Sarah Curry, 
aet. 62, of a rather feeble constitution, consulted me July 10, 1872, for 
a painful affection of the left ear. Her story was that for many years 
she had been somewhat hard of hearing, especially in the left ear, but 
had never had any discharge from either ear. Two years previously 
she had an attack of facial paralysis, affecting the left side. After a 
certain length of time this passed off entirely. About nine weeks 
previously she began to suffer from pain in and behind the left ear 
and extending over the entire left side of the head. There was also 
tenderness behind the ear. For two days and nights the pain was 
severe. After that there remained a steady, dull aching, together 
with a moderate degree of tenderness behind the ear. Two weeks pre- 
viously the acute pain again returned, and since then she had suffered 
pretty constantly up to the time of her visit to the Infirmary. 
On examination the meatus was found nearly closed by a falling for- 
ward of the posterior cutaneous wall. Membrana tympani invisible. 
No appreciable tenderness in the meatus. No discharge. Tenderness 
over the mastoid process, and also over the lower part of the parietal 
bone. Watch heard when pressed against the ear. The patient’s coun- 
tenance was indicative of great suffering. Incision of the integuments 
and periosteum covering the mastoid process. No pus found. 
July 13.—Little or no relief afforded by the incision. To-day the 
auricle is pushed forward by a swelling behind the ear. Incision en- 
tirely healed. A second incision gave exit to about half an ounce of 
pus. No roughened bone or sinus discovered. 
July 18.—Comparative relief from pain until last night, when the 
pain again became severe. She refers it to the mastoid process, the 
top and back of the head. The meatus is less swollen and the mem- 
brana tympani can now be seen. It is entire, but of a very tough, 
opaque, tendinous appearance. Eustachian tube open. The en- 
trance of air is accompanied by rales. No brain symptoms. Con- 
sultation with Dr. Robert F. Weir. Mastoid process perforated with 
a conical drill. The outer surface of the bone found to be in every 
respect perfectly sound. At a depth of about one-fifth of an inch pus 
was found filling a cavity about the size of a filbert. Pus removed 
with pledgets of cotton, and outer orifice of the cavity enlarged suffi- 
ciently to admit the end of my little finger. 28 
A. H. Buck: 
July 19. Patient much relieved by the operation, but she still com- 
plains of soreness over the back and side of the head. Pressure over 
the left occipital and parietal regions produces pain. 
July 20.—Severe pain in the head, behind the mastoid process. 
Appetite only moderately good. Is losing strength. Stimulus or- 
dered. Wound discharging freely. 
July 22.—Still severe pain behind the mastoid process. Consulta- 
tion with my father, Dr. Gurdon Buck. Skull trephined about three- 
quarters of an inch behind the mastoid process, at the point of greatest 
tenderness. The outer surface of the bone appeared to be perfectly 
healthy; but on withdrawing the trephine, after sawing through the 
outer table, the circular track was found to be filled with healthy pus, 
which had welled up from the intervening cancellous diploe. No ap- 
preciable softening of the bone. The removal of the inner button of 
bone exposed to view a tense, deep-red dura mater, but no pus. The 
subsequent oozing of venous blood from the ruptured branchlets was 
readily checked by laying a pledget of cotton-batting in the circular 
opening. 
July 23, 11 a.m.—Patient slept a part of the night. This morning 
she has considerable heat of skin. Pulse 100 and feeble. Less pain 
in the head. Eight p.m. pulse 106 and feeble. Intellect perfectly 
clear. The discharge from the mastoid process appears to have nearly 
ceased. Vomited once this evening. 
July 24, Noon.—Patient is evidently sinking. Pulse no and very 
feeble. Respirations 44. No rales over anterior and lateral por- 
tions of the chest. Intellect still clear, but she has not sufficient 
strength to speak in an audible tone when answering my questions. 
She died on the 26th, apparently from exhaustion. 
Post-mortem examination refused by the friends. 
The disease, if unchecked by operative procedure, 
may terminate in various ways:— 
(a) In death, through basilar meningitis (Nos. 16 
and 17) ; abscess of the brain (No. 18); embolus and 
pysemia (No. 21) ; or exhaustion (No. 20). 
(3) In recovery, after the extrusion of the carious Diseases of Mastoid Process. 
29 
bone en masse or in fragments through an opening in 
the outer table of the bone, either behind the ear (No. 
23), or in the external auditory canal (No. 22). If the 
caries has resulted in the formation of an abscess, the 
pus may find an escape through a similar opening. 
The carious process may also be followed by the growth 
of polypoid masses in the mastoid process (No. 24). 
Case XVI. (New York Eye and Ear Infirmary.)— Michael Casey, 
ajt. 23, a sufferer from pulmonary phthisis, applied to me March 20th, 
1872, for relief from a painful affection of his left ear. He stated that 
two months previously he first noticed a discharge from the left ear ; 
that at first there was no pain connected with it, but that when the 
discharge became copious, as it did about two weeks before, he began 
to suffer from earache. On examination, the left meatus was found to 
to be completely closed by a collapse of the upper cutaneous wall. 
After the speculum had been forced in for a certain distance, it en- 
countered a mass of granulations, which obstructed a view of the 
deeper parts. Three leeches applied near the orifice of the meatus. 
March 23. Better. The motion of the lower jaw produces pain in 
the left ear. Granulations removed with Blake’s snare. Probe en- 
countered denuded and roughened bone surface in the meatus. 
March 30. Paralysis of the left side of face noticed to-day for the 
first time. 
April 6. (Edema of the skin above and behind the ear. Incision 
over mastoid process gave escape to a large quantity of pus, a part of 
it lying between the periosteum and the bone, the surface of which 
was somewhat roughened. Occasional nausea to-day. 
Aprils. Is steadily losing strength. Pulse 112, and feeble. Suffers 
great pain throughout left side of head, but does not refer it to the 
mastoid region. On my advice the patient entered St. Luke’s Hos- 
pital, where he could obtain proper food and nursing. 
On the 9th of April, Dr. George A. Peters made a free incision 
through the upper wall of the meatus, exposing to view the denuded 
and roughened bone, and giving a free outlet to the pus that had accu- 
mulated above the auricle, and to that which was constantly forming 30 
A. H. Buck: 
in the deeper parts of the ear, but had hitherto found an escape chiefly 
through the Eustachian tube. 
The operation afforded the patient great relief; but in the course of 
a few days the temperature rose to io6°, the head symptoms became 
alarming, and the patient died comatose. 
At the post-mortem examination, the dura mater covering the con- 
vexity of the left hemisphere was found to be intensely red; on the 
right side it was nearly normal. Pus at the base of the brain on the 
left side. Dura mater covering the left tegmen tympani thickened, 
Fig. 6. 
Region of carious bone. 
d—dura mater ; very much thickened over antrum. 
A—antrum. 
L.S.—lateral sinus. 
P—pus collected between dura mater and bone. 
m—mastoid process. 
(Antero-posterior vertical section. Natural size.) 
(Case No. 16.) 
and of a maroon color. The thickened portion, whose limits were 
very abrupt, could easily have been mistaken for a swollen Peyer’s 
patch, as seen in typhoid fever, so close was the resemblance between 
the two. Between the swollen dura mater and the greenish, softened Diseases of Mastoid Process. 
tegmen tympani lay quite a collection of cheesy, disorganized pus. 
The lateral sinus was not involved. The antrum mastoideum was 
nearly filled with a cheesy mass enveloped in a coating of foul greenish 
pus. The mastoid cells were sclerosed. A small sinus led from the 
outer surface of the upper portion of the process directly inwards to 
the antrum. {lt was not detected during life.) The tympanum was 
filled with the same greenish, foul pus, which had also accumulated in 
the vestibule and scala tympani, owing to the destruction of the stirrup 
and membrane of the round window. The lining mucous membrane 
of the tympanum was not recognizable; the pus seemed to be lying 
in direct contact with the bone. Membrana tympani totally destroyed. 
The cavity of the temporo-maxillary articulation filled with pus. 
Eustachian tube ulcerated and very much enlarged. The pus had 
also burrowed down in the direction of the basilar process of the 
occipital bone. 
Case XVII.—On the 21st of September, 1872, I was asked by Dr. 
Hermann Knapp to see with him, in consultation, a Mr. F., set. 57, 
and of a strong constitution. The history of the case was briefly this ; 
During the previous ten or twelve years Mr. F. had had five distinct 
attacks of acute purulent inflammation of the left middle ear, from all 
of which he made a good recovery. The present attack began about 
seven weeks previously, and was characterized by headache and dul- 
ness of hearing, unaccompanied by discharge. On examination of the 
ear Dr. Knapp found the external auditory canal swollen, especially 
on the posterior side ; the membrana tympani injected, and the mas- 
toid process tender on pressure. In the progress of the disease, the 
membrana tympani becoming more congested and convex outwardly, 
the doctor incised it. No pus escaped, but the patient experienced 
relief from his suffering for about a week. The pain then returned, 
and the integuments covering the mastoid process became swollen. 
The patient also noticed a gurgling sensation in the ear, whenever he 
shook his head. An incision down to and through the mastoid perios- 
teum afforded only temporary relief. The pain again became severe. 
At the consultation (Sept, 21) it was decided that perforation of the 
mastoid process was the only course that offered any hope of recovery. 
The patient however refused. 
Sept, 22. Up to this time there had been no brain symptoms, but 32 
A. H. Buck: 
to-day, being called in haste to see the patient during the absence of 
Dr. Knapp from the city, I found him unconscious, pupils non-respon- 
sive, face flushed, and head very hot; pulse about 120, and full; 
breathing stertorous. The friends were then willing enough to have 
the operation performed, but it was clearly too late. The patient died 
the same night. 
At the post-mortem examination, purulent basilar meningitis was 
found, together with a free communication between the mastoid an- 
trum and the cavity of the lateral sinus. The two formed together an 
irregularly-shaped cavity filled with pus. The pus did not extend 
down into the jugular vein, nor back toward the torcular Herophili. 
Both these portions of the vein contained venous blood. Sclerosis of 
the mastoid cells. Membrana tympani entire. 
Case XVIII. (Reported by Von Troeltsch in the “ Archiv fur Ohren- 
heilkunde,” Vol. IV.)—A girl, set. 20, of habitual good health, but 
affected for more than ten years with a discharge from the left ear, 
began to complain in November, 1866, of frequent headaches. Her 
family also noticed that she was depressed in spirits. On the 6th of 
January, 1867, the headache returned with great severity. On the Bth 
of January the family physician was sent for. He found her somewhat 
feverish, pulse 96, occasional vomiting; she complained of great pain, 
of a boring, lancinating character, in and around the left ear. Fetid 
otorrhoea. Ordered six leeches to the ear, cold applications to the 
head, and calomel internally. 
January 9. Pain still severe. Vomiting. Pulse no. Ordered six 
leeches to ear. 
January 10. Pain less severe. 
January n. Delirious during the night. Pulse 120. Ordered 
leeches for the fourth time. 
January 13. Some stupor. Pulse 140. She died on the 14th, 
At the post-mortem examination an abscess was found in the left 
cerebellum, and one also in the left lower lobe of the cerebrum. Dis- 
coloration and thickening of the dura mater over the tegmen tympani. 
Discoloration of the bone near the mastoid antrum, which was filled 
partly with a greenish pus, and partly with cheesy material. Mucous 
membrane of the tympanum green, swollen and ulcerated. The mem- 
brana tympani very much thickened and defective in the upper and Diseases of Mastoid Process. 
33 
posterior portion. {This, however, may have been artificially produced 
by the saw). The vestibule of the labyrinth filled with a brownish 
semi-fluid substance. 
Case XIX. (Reported by Ludwig Mayer in the “ Archivfiir Ohren- 
heilkunde ” Vol. I.)—A boy, set. 15, of good health, was attacked 
July 10th, 1864, with a severe pain in the region of the left ear, chiefly 
behind it. For fifteen months previously he had been troubled with 
a discharge from that ear. An examination of the parts revealed 
swelling and tenderness over the left mastoid process. 
July 13. Patient had a chill to-day. Steady increase in the severity 
of the pain. Dizziness, fever and. loss of appetite. Pulse 130. Dis- 
charge fetid. Motion of jaws painful. Meatus filled with pus, but 
not tender on pressure. Membrana tympani entire and of a milky 
hue. Polypoid granulations on the upper wall of the meatus near the 
membrana tympani (Dr. Mayer states that probably a sinus led from 
this portion of the meatus into the cells which often lie above it.) In- 
cision over mastoid process. Surface of bone rough. Perforation 
performed with a trocar. Very little pus found. Ordered poultices. 
July 14. Much better. Pulse 72. 
July 16. Chill followed by sweating. Pain in head. Ordered fif- 
teen leeches to the left mastoid region. Discharge from the meatus has 
ceased. 
July 17. Double vision. Several passages from the bowels. ChilL 
July 18. Delirium. 
July 20. Comatose. Patient died on the 22d July. 
Post-mortem examination not allowed. 
Case XX—Mr. I. H. N., set. 40, a sufferer from pulmonary tuber- 
culosis, was sent to me in consultation by Dr. William Hyde, of 
Stonington, Conn. He stated that he became somewhat deaf in the 
left ear eight years previously. In the autumn of 1871 he was attacked 
with pain, roaring and throbbing in the left ear, followed in the course 
of a week by a discharge. Since then the discharge had never ceased, 
and there had always been more or less pain. On one occasion he found 
a small fragment of bone in the discharge. Pain pretty severe recent- 
ly, but not referred specially to the mastoid process. 
The condition of the patient at the time I saw him was that of a per- 
son advanced in phthisis. An examination of the ear revealed a 34 
A. H. Buck : 
marked degree of deafness, tenderness over the mastoid process, and 
pus escaping from the meatus, which was quite blocked up by the pre- 
sence of a mass of granulations, springing from the upper and posterior 
cutaneous wall. During the exploration I extracted four loose frag- 
ments of bone, which were evidently bony septa from the mastoid cells. 
By aid of a curved probe I ascertained that a sinus led from the meatus 
(quite near the outer end of the osseous portion) backwards into the 
very centre of the mastoid process. In its course the probe encount- 
tered two or three sharp projecting spiculae of bone. The patient was 
so feeble that I was obliged to desist from further exploration. 
On the 28th of September following the patient died, with no other 
symptoms than those of exhaustion. Two days before death, there was 
a considerable haemorrhage from the ear. 
No post-mortem examination made. 
Case XXI. (Reported by Von Troeltsch, in the “ Archiv fur 
Ohrenheilkunde,” vol. iv.)—Patient entered the hospital March 30th, 
1866. She was 21 years of age, and in the sixth month of pregnancy. 
She complained of daily chills followed by fever and sweating. During 
these attacks she suffered from severe frontal headache. The diagnosis 
of febris intermittens was made, and quinine prescribed in moderate 
doses. On the sth day a purulent discharge from the right ear was 
discovered. The patient said it had existed for three years. On ex- 
amination oedema and redness of the skin were found in the neighbor- 
hood of the ear, and extending back toward the occiput. Meatus 
swollen and filled with thick pus. Treatment : frequent syringing of 
the ear with warm solutions of acetate of lead ; blister to the mastoid 
process; poultices. On the seventh day some delirium. Right pupil 
more dilated than the left. The chills continued in spite of large doses 
of quinine. On the 13th of April the child was bom. It lived but a 
few hours. On the 15th diarrhoea; patient comatose; increase of 
swelling around the ear. April 17. Profound coma and death. 
At the post-mortem examination the following pathological condi- 
tions were found : phlebitis of the right lateral sinus. Metastases in the 
lungs. Tissues around the right ear infiltrated with pus. Pia mater of 
the right hemisphere much congested. Dura mater along the right 
lateral sinus very vascular, and of a greenish hue. Within the sinus Diseases of Mastoid Process. 
35 
transversus a purulent, yellowish-red material. Along the upper surface 
of the petrous bone, beneath the dura mater, two distinct collections ot 
a creamy, yellowish-green pus. Beneath one of these collections, the 
bone was found to be rough and discolored. Pus between periosteum 
and right mastoid bone, whose outer surface was discolored. Upper 
and posterior wall of the meatus decidedly swollen. Membrana tym- 
pani intact but very much thickened, and of a bluish red color. Bony 
roof of antrum perforated by caries. Antrum itself entirely filled with 
cheesy pus. The cells of the mastoid process converted into a large 
cavity containing discolored pus and fragments of bone. The adjacent 
bone green. The ceils immediately above the meatus filled with thick- 
ened, discolored pus ; lining membrane everywhere much thickened 
and congested. Tympanum filled with dried pus. 
Case XXll.—(Reported by Dr. Chas. Laight in the Transactions o. 
the American Otological Society, July, 1871.)—William Quinn, aet. 13, 
of good health, was admitted to the N. Y. Eye and Ear Infirmary July 
sth, 1871. He stated that six years previously he had been sick with 
a painful affection of the left ear followed by a discharge which had 
continued ever since. Present condition :—Pain in the ear. General 
condition good. An examination of the ear revealed the presence of a 
loose mass of bone in the meatus ; it was attached only by a small 
fleshy peduncle to the upper cutaneous wall. Discharge very fetid. 
Bony mass removed. On examination it proved to be a portion of the 
mastoid process, about the size and shape of a small bean, which had 
come away as a single sequestrum. Further examination revealed the 
existence of a correspondingly large sinus, leading from the external 
meatus back into the adjacent mastoid cells. 
The pain passed off at once, after the removal of this large seques- 
trum, and the otorrhoea soon after ceased entirely under appropriate 
treatment. 
Case XXIII.—A. 8., ast. 15, of robust health, consulted me on the 
28th of September, 1871, for a deafness of the left ear. The history of 
the case, so far as I could ascertain it, was as follows ;—When a small 
child he had measles, followed by inflammation of the left ear. For 
several years subsequently there was a discharge from the outer orifice 36 
A. H. Buck : 
and some difficulty behind the ear, but exactly what was the nature of 
that trouble he could not recollect. For the past three or four years, 
however, he had been entirely free from otorrhoea. 
On examination I found evidences of a former purulent inflamma- 
tion of the left middle ear. Behind the ear there was a deep depres- 
sion in the skin, corresponding to a similar depression in the mastoid 
process, a large portion of which had come away, either en masse or 
in fragments, through an opening on the outer side of the bone. This 
depression was large enough to admit the end of my little finger. 
Case XXIV.—(N. Y. Eye and Ear Infirmary).—Catherine Berge- 
man, set. 42, of healthy appearance, consulted me February 7th, 1872, 
with reference to a polypus in the right ear. Her history was simply 
this :—From childhood she had always been troubled with a discharge 
from the affected ear, and had first noticed the existence of the polypoid 
growth about six years previously. On inspection I found a rather tough, 
fleshy mass, presenting at the outer orifice, and extending out a little dis- 
tance from it. With Blake’s snare I succeeded in extracting the mass 
entire. The subsequent hemorrhage was moderate and soon ceased of 
itself. An examination of the parts then showed that this large poly- 
pus (length if in., greatest diameter •§• in.) sprang from the farther end 
of a broad sinus, which led from the external osseous meatus far back 
into the mastoid process. No exposed bone could be felt with the 
probe. No trace of membrana tympani or ossicles. 
Four days later I again saw the patient and ascertained that there 
had been no discharge since the removal of the polypus. Subsequently 
she did not make her appearance. 
These cases will serve to illustrate the chief charac- 
teristics of mastoid diseases, with the course they pur- 
sue either towards a favorable or a fatal issue. In con- 
cluding this portion of the subject, I shall briefly 
recapitulate the symptoms that will lead us to diagnosti- 
cate between these different varieties, and then take up 
the question of treatment. 
In simple periostitis we have tenderness on pressure, Diseases of Mastoid Process. 
37 
pain and swelling- of different degrees. If we find the 
external auditory canal inflamed, without any appreciable 
trouble in the middle ear, we may feel pretty sure that 
the inflammation is limited to the outer fibrous textures. 
The pain too is not so deeply seated, nor has it the same 
intensity as when the cells themselves are affected. Pus 
occasionally results from this inflammation. 
In simple congestion of the mucous membrane we 
may expect to find tenderness on pressure, pain and 
swelling of the integuments. If we remember that this 
is simply an extension of the diseased process from the 
middle ear, the difficulties in diagnosis will be materially 
lessened. As a rule, we shall find the pain more in- 
tense and deeper seated than in simple periostitis, and 
the external auditory canal will be unaffected. The re- 
lief which follows local depletion or an incision will dis- 
tinguish it from other mastoid diseases. 
Chronic subacute inflammation is not characterized by 
any definite train of symptoms. Its existence can only 
be shown by direct physical examination. 
In the two remaining forms, it is scarcely possible to 
make a differential diagnosis, except perhaps in certain 
welbmarked examples. This, however, is unnecessary, 
for the treatment in both cases is the same. The symp- 
toms of pain and tenderness on pressure are almost in- 
variably present. Dr. Roosa’s case (No. 25 of the 
statistical note) is the only exception I know of. These 
two symptoms will not be permanently relieved by local 
depletion, or incision of the integuments or membrane. 
In some cases there is an entire absence of swelling. 
There are certain other phenomena observed in these 38 
A. H. Buck: 
two forms which vary more or less in constancy. They 
are so valuable as aids to diagnosis that I shall mention 
them somewhat in detail. 
(a.) Prolapse of the posterior or superior wall of the 
external auditory canal has been noticed in a few cases. 
In all of them it seemed to be associated with caries of 
the meatus. Swelling and tenderness of the posterior 
wall are frequently present in both forms. 
(3.) Brain symptoms do not always indicate uniform 
pathological conditions. They may occur in inflamma- 
tion with or without pus. They may also be absent 
when there is extensive caries of the part with local 
meningitis. 
(c.) Facial paralysis is an occasional intercurrent 
symptom, and usually indicates that the bony walls of 
die tympanum, in which the nerve is embedded, have 
become involved. 
(d.') Cessation or marked diminution of the purulent 
discharge is the usual precursor of acute mastoid inflam- 
mation. 
(e.) In rare cases the membrana tympani remains 
entire. 
(/.) The discharge of pus through the Eustachian 
tube indicates that some obstruction exists preventing 
its escape by way of the meatus. 
(g.) The presence of granulations, springing from 
either the upper or posterior wall, should lead us to 
suspect that there is an opening leading to the mastoid 
cells. This fact can easily be ascertained by explora- 
tion with a bent probe. Diseases of Mastoid Process. 
39 
Treatment.—The preceding cases illustrate so fully 
the methods of treatment to be adopted, that we have 
nothing new to add. We shall, therefore, simply give 
a brief recapitulation. 
In the earlier stages of disease, when there is merely 
pain, tenderness on pressure, and perhaps swelling in 
the mastoid region, the most prompt relief can be 
afforded by local depletion. Apply from four to ten 
leeches, and follow them with warm fomentations. The 
external auditory canal and middle ear should then be 
carefully examined and treated according to indications. 
No reliable exploration can be made without the spec- 
ulum and reflector. 
If these measures do not give relief, and the unfavor- 
able symptoms persist, a free incision through the 
integuments and periosteum of the mastoid process 
should be made. 
The knife should enter at the level of the upper wall 
of the meatus, about £ inch posteriorly to the insertion 
of the auricle, and should extend downwards nearly to 
the tip of the process. 
Should this latter procedure also fail, the bone should 
be trephined or perforated in such a way as to expose 
the mastoid cells. 
This latter operation has now been repeated so many 
times that its great value and comparative freedom from 
danger have been securely established. It may be 
easily performed and will enable us to save life in a 
large majority of cases where a fatal termination is im 
minent. 
Out of thirty-one cases (see statistical note), in which 40 
A. H. Buck : 
the operation has been performed, the progress of the 
disease was arrested in twenty-three ; in the remaining 
eight fatal cases, death could not be attributed to the 
operation, directly or indirectly, in more than one case 
(No. VII). In the remaining seven cases the operation 
was performed too late ; pyaemia had already developed 
itself, or there was already inflammation of the brain or 
its membranes; or pus in the lateral sinus. 
Some surgeons discountenance the operation in 
young persons, and claim that the disease in such cases 
will almost always terminate in recovery by a spon- 
taneous perforation of the outer bony wall. 
The incorrectness of this view will be shown further 
on in the statistical note. We are unable to judge of the 
comparative fatality of such cases from the insufficiency 
of our data. It will be seen, however, that a sufficient 
number of fatal cases are on record to make it unsafe 
for us to trust to natural processes only. 
The steps of the operation are briefly as follows : 
A free vertical incision should be first made through 
the integuments and periosteum of the mastoid bone. 
The condition of the bone should then be noted. If it 
be soft or roughened, an attempt should be made to 
break through the outer lamella by firmly pressing 
upon it with the end of a steel director. If pus be 
found between the periosteum and the bone, search 
should be made with a bent probe for a sinus through 
which the pus may have found an escape from the 
mastoid cells. If such a one can be found, apply the 
drill or trephine at this point, and simply enlarge the 
existing opening. If no opening be found, dissect up Diseases of Mastoid Process. 
41 
Fig. 7. 
Drills for perforating the mastoid process. 
Retractors. 42 
A. H. Buck : 
the periosteum from that portion of the mastoid process 
which is situated immediately behind the external 
auditory canal, and apply the trephine or drill * at a 
point a quarter of an inch distant from the canal and a 
little below the level of its upper wall. The drill should 
be rotated in a direction inwards, forwards, and a little 
upwards; that is, nearly parallel with the canal. The 
depth to which the instrument should be carried will 
vary in different cases. The aim should be to reach 
the peculiar cell-structure of the mastoid process. If 
the patient be an adult, and the case be one where 
sclerosis of the mastoid cells existed before the develop- 
ment of the acute symptoms, it may be necessary to 
penetrate to a depth of three-fifths of an inch to reach 
the mastoid antrum, the usual center of disease in such 
cases. Ordinarily, however, the fragile cell-structure 
will be found at a depth of a fifth of an inch. The drill 
can then be withdrawn and the steel director used to 
break down the bony septa. In infants the antrum is 
situated so near the outer surface of the bone that very 
little effort will be required to establish the desired 
opening. The only danger connected with this opera- 
tion is that of wounding the lateral sinus.t 
The after-treatment consists in ;—a, inserting a tent 
of lint to prevent union by adhesion: this tent should 
* The drill appears to me to be preferable to the trephine. Fig. 7 gives the 
actual size of the three different drills best adapted to this purpose. 
f In Dr. Weir’s case (No. 27 of table of operations) the outer wall of the sinus 
was exposed over a circular space a third of an inch in diameter. At the post- 
mortem examination, twelve days later, this part was examined very carefully, and 
yet no trace could be detected of any inflammatory action, either in the fibrous wall 
or in the neighboring bone. Diseases of Mastoid Process: 
43 
be replaced by fresh ones at least once in twenty-four 
hours, until suppuration is freely established; b, poultices, 
until the pain moderates and free suppuration becomes 
established; c, carbolic acid dressings and lotions fre- 
quently repeated.* 
STATISTICAL NOTE. 
The following statistics are based upon the record of 
sixty-seven cases, a small portion of them taken from 
my own case-book, the majority from the various medi- 
* Lallemand (Recherches anatomico-pathologiques sur I’encephale. Vol. 11., 
p. 87. Paris, 1825), relates the following narrative as an illustration of how these 
cases may become the subject of medico-legal inquiry:— 
J. Conrard, set. 20, pale, thin, and of a feeble constitution, was struck several 
times while quarreling with another boy, and in consequence fell sick. He had all 
the symptoms of an ataxic fever and died on the 20th day. 
The magistrate, believing that death might have been produced by the blows the 
boy had received, ordered the body to be opened and examined. The physicians 
reported “ that they had found :—r, the brain rather more congested than natural; 
2, a thin layer of pus between the under surface of the brain and the dura mater; 
3, a collection of pus in the anterior portion of the right lobe of the cerebellum; 
4, the arachnoid in contact with the right petrous bone, adherent to the dura mater 
and of a deeper red than normal.” 
A superficial observer would have felt justified, in the presence of such ample evi- 
dence, in attributing the boy’s death to the blows he had received twenty days pre- 
viously. Happily, the physicians, whose duty it was to enlighten the consciences of 
the jury, were not hasty in arriving at a conclusion. As there was no trace of any 
serious contusion on the surface of the cranium, and as the abscess was contained in 
a well organized cyst, they questioned the boy’s parents about his antecedent history, 
and ascertained—thanks to their truthfulness—that their son had been troubled with 
his head for a long time previously, and had been subject to attacks of pain in the right 
ear. The physicians then returned to the body and made a further examination of 
the temporal bone, which resulted in their finding the mastoid cells filled with pus, 
and the middle ear similarly affected. They then reported “ that the disorganization 
which they had found must have existed already before the occurrence of the fight 
and had no connection with it: that it was simply possible that the blows may have 
hastened the course of the disease.” 44 
A. H. Buck : 
cal periodicals and works on otology which were within 
my reach. Only those cases were taken in which the 
post-mortem examination or the clinical history afforded 
unmistakable evidence that the mastoid cells were dis- 
eased (third or fifth form). 
Out of sixty-seven cases I found that thirteen oc 
curred in children 10 years of age and under, 
26 in persons between the ages of 10 and 25, 
9 “ “ “ 25 “ 40, 
12 “ “ “ 40 “ 55, and 
7 “ “ “ 55 “ 62. 
The youngest patient was 8 months old, the oldest 
62 years. More than hall of the patients were under 
25 years of age. Six of the cases belonged properly 
to the third form, two were doubtful (third or fifth), and 
the remainder belonged to the fifth. Of the entire 
number three terminated in a spontaneous recovery, 
twenty-two were operated upon and recovered, eight 
were operated upon and died, and the remainder, thirty- 
six in all, terminated fatally. All the cases of sponta- 
neous recovery occurred in persons under 16 years of 
age. Diseases of Mastoid Process. 
45 
TABLE OF OPERATIONS ON THE MASTOID PROCESS. 
Where reported 
External ap- 
and name of ope- 
Age. 
Form of 
Otorrhoea. 
pearances of 
Instrument 
Result. 
£ 
rator. 
disease. 
the bone. 
used. 
X 
Jasser, 1776 
(Arneman’s Be- 
Adult. 
Simple 
deafness. 
None. 
Normal. 
Trocar. 
Recovery 
from ope- 
merkungen 
ration. 
liber die Durch- 
bohrung des 
Processus mas- 
toideus. Gat- 
tingen, 1792.) 
Iiclitz 
iNot cle’r- 
Present. 
Not stated. 
Some kind 
Recovery 
(Ibid.) 
Adult- 
ly stated. 
of borer. 
Fielitz 
An old 
Simple 
None. 
Normal. 
Same. 
Recovery 
(Ibid.) 
woman 
deafness. 
from ope- 
Loffler 
ration. 
Adult. 
Simple 
None. 
Normal. 
Same. 
Recovery 
4 
(Ibid.) 
deafness. 
from ope- 
Hagstroem.... 
(Ibid.) 
ration. 
5 
Adult. 
Simple 
deafness. 
Not stated. 
Normal. 
Gouge. 
Recovery 
from ope- 
J. L. Petit 
ration. 
6 
Not 
Not 
None. 
Not stated. 
Gouge. 
Recovery 
(Von iroeltsch’s 
stated. 
stated. 
work on Otol- 
°gy-) 
7 
Weber 
44 
5th. 
Present. 
Not stated. 
Not stated. 
Recovery 
(Mentioned by 
Von Troeltsch 
in Virchow’s 
Archives, vol. 
xxi.) 
8 
Forget 
14 
5th- 
Present. 
Not stated. 
Not stated. 
Recovery 
(L’ Union Medi- 
cal e, i860, No. 
52-) 
Follin 
5th. 
Present. 
Not stated. 
Trephine. 
Recovery 
y 
(Gazette des H6- 
pitaux, 1864.) 
IO 
Ludwig Mayer.. 
15 
5th. 
Present. 
Roughened 
Trocar. 
Death 
(Archiv fur Oh- 
from 
r e n heilkunde, 
vol, i.) 
pyaemia. 
II 
Flaiz ... 
46 
3d- 
Present. 
Normal. 
Drill. 
Recovery 
(Arch, flir Oh- 
renh., vol. ii. 
12 
Jacoby 
48 
5th. 
Present. 
Pus on the 
outer side of 
bone,but no 
roughn’ss or 
softening. 
Drill. 
Recovery 
(Archiv. fiir Ohr., 
vol. iv.) 46 
A. H. Buck: 
TABLE—CONTINUED. 
3 
o 
Where reported] 
and name of ope-l 
rator. 
Age. | 
Form of 
disease. 
Otorrhoea. 
External ap- 
pearance of 
the bone. 
Instrument 
used. 
Result. 
13 
Jacoby 
(Archiv fiir Ohr., 
vol. VI.) 
10 
Sth. 
Present. 
Not stated. 
Drill. 
Recovery 
14 
1acoby 
(Ibid.) 
37 
Sth. 
Present. 
Not stated. 
First with 
drill, later 
with t r e - 
phme. 
Death. 
15 
Jacoby 
(Archiv, vol. v.) 
20 
3d- 
Present. 
Normal. 
Drill. 
Recovery 
16 
Kessel 
(Archiv. fiir Oh- 
renh., vol. iv., 
p s»o 
24 
5 th. 
Present. 
Not stated. 
T rocar. 
Recovery 
17 
Pagenstecher ... 
(Mentioned by 
Jacoby, in the 
Archiv. fiir Oh- 
renheil., vol. 
iv., p. 222.) 
Pagenstecher . .. 
(Ibid.) 
60 
5th. 
Present. 
Not stated. 
C a r t i lage 
knife. 
Recovery 
r8 
Not 
stated. 
Not 
stated. 
Present. 
Not stated. 
Drill. 
Recovery 
19 
Hinton 
(Med. Times & 
Gazette, Sept., 
1868.) 
58 
5th. 
Present. 
Not stated. 
Trocar. 
Recovery 
20 
Colles 
(Dublin Quarter- 
ly, Aug., 1870) 
Middle 
Age. 
Sth. 
Present. 
JNot stated. 
Drill. 
Recovery 
21 
Buszard 
(British Med. 
Jour., Jan., 
1871.) 
40 
5th. 
Present. 
Small sinus 
in upper 
portion of 
mastoid 
process. 
Trephine 
and chisel. 
Recovery 
22 
Barwell 
(Lancet, April, 
1871.) 
6 
Sth. 
Present. 
Softened at 
one point. 
Pointed 
gouge. 
Recovery 
23 
Barwell 
(Ibid.) 
47 
5th. 
Present. 
Not stated. 
Same. 
Recovery 
24 
Stokes 
(Dublin Med, 
Jour., Aug., 
1870.) 
49 
3d- 
Present. 
Normal. 
Semi-circu- 
lar saw. 
Death. 
25 
Agnew 
(Trans. Amer. 
Otol. Society, 
1870.) 
Middle 
life. 
Sth. 
Present. 
Small sinus. 
Trephine. 
Recovery 
26 
Roosa 
(Ibid.) 
38 
5th. 
None. 
Small sinus. 
Not stated. 
Death. 
27 
Weir, N.Y. City 
(Reported ver- 
bally. I was 
also present at 
the operation.) 
12 
3d- 
Present. 
Normal. 
Drill. 
Death. Diseases of Mastoid Process. 
47 
TABLE—CONTINUED. 
2 
p 
Where reported 
and name of ope- 
rator. 
Age. 
Form of 
disease. 
Otorrhoea. 
External ap- 
pearance of 
the bone. 
Instrument 
used. 
Result. 
28 
Laight,N.Y.City 
(Reported ver- 
bally. I was 
also present at 
the operation.) 
45 
Sth. 
Present. 
Normal. 
Drill. 
Recovery 
29 
North 
Waterbury, Ct. 
(Reported ver- 
bally.) 
19 
3d- 
Present. 
Normal. 
Trephine. 
Death. 
3° 
Buck 
62 
5 th. 
None. 
Normal. 
Drill. 
Death. 
31 
Do 
11 
3d- 
Present. 
Normal. 
Drill. 
Death. 
32 
Do 
21 
5th. 
Present. 
Softened. 
Drill. 
Recovery 
33 
Do 
56 
3d- 
Present. 
Normal. 
Drill. 
Recovery 
34 
Do 
47 
5 th. 
Present. 
Normal. 
Drill. 
Recovery 
35 
Do 
36 
3d- 
Present. 
Normal. 
Drill. 
Recovery 
The cases of Jasser, Von Troeltsch, and Turnbull 
are omitted from the list simply because I can find no 
evidence in the printed reports of these cases that any 
operation was performed upon the bone, beyond the 
mere introduction of a buttoned probe into a small fis- 
tulous opening. Other cases have been omitted through 
inability on my part to gain access to the printed re- 
ports. The names of these surgeons are Pagenstecher, 
Schwartze, and Von Bruns.