A CASE OF ORBITAL CELLULITIS AND PRIMARY 
MASTOIDITIS INTERNA COMPLICATING INFLU- 
ENZA ; OPENING OF MASTOID PROCESS ; RE- 
COVERY. 
BY 
CHARLES ZIMMERMANN, M.D. 
AURAL AND OPHTHALMIC SURGEON TO ST. MARv's AND EMERGENCY HOSPITALS, MILWAUKEE, WIS. 
[Reprinted from the Archives of Otology, Vol. xxi.. No. i, 1892] A CASE OF ORBITAL CELLULITIS AND PRIMARY 
MASTOIDITIS INTERNA COMPLICATING INFLU- 
ENZA ; OPENING OF MASTOID PROCESS; RE- 
COVERY. 
By CHARLES ZIMMERMANN, M.D., 
AURAL AND OPHTHALMIC SURGEON TO ST. MARY'S AND EMERGENCY HOSPITALS, MILWAUKEE, WIS. 
IN the following I beg leave to communicate an ocular 
and an aural complication of influenza, which, even if 
by too great a skepticism their connection with the latter 
should be doubted, are sufficiently interesting in themselves 
on account of their rather rare occurrence. 
History: The patient, a girl of ten years, moderately well 
nourished, had as an infant blennorrhcea neonatorum. In Decem- 
ber, 1888, I saw her first on account of adenoid vegetations in 
her naso-pharynx, which I removed with Gottstein's knife, and 
subsequent cauterizations with chromic acid, according to Her- 
ing's 1 method, with lasting good result. On March 28, 1891, I was 
called in consultation with Dr. L. Reinhard to see her at her resi- 
dence for an inflammation of her left eye. Her family physician 
stated that she fell sick two days previously with the symptoms 
of influenza, especially severe headache and general nervous 
prostration. 
Status PrcRsens: She is lying in bed. The left upper lid, in a 
state of ptosis, is hanging over the eye and cannot be raised to its 
normal position. It is slightly red and swollen. The palpebral 
conjunctiva shows only an inconsiderable increase of redness, 
no swelling, looks as if affected with a commencing catarrhal 
inflammation, and is partly covered with some threads of mucous 
discharge, which however is very scanty. The ocular conjunctiva 
is not chemotic, only somewhat hyperaemic. Cornea clear. 
Reprinted from the Archives of Otology, Vol. xxi., No. i, 1892. 77 
Orbital Cellulitis and Primary Mastoiditis Interna. 
Pupil reacting to light perfectly well and equally with that of 
the other eye. But there is a moderate exophthalmus with dis- 
placement of the left eye downwards and towards the temple. 
The movements of the eye are impaired, especially inwards and 
upwards. When looking upwards and inwards, crossed diplopia 
sets in. Tension the same as in the healthy eye. Pressure on 
the globe is painful, but the finger cannot feel any hardness 
between the walls of the orbit and the bulbus. Especially at the 
upper temporal region no circumscribed swelling, so that an 
affection of the lachrymal gland can be excluded. V and field 
of V normal. The ophthalmoscopic examination reveals a 
normal disc, but a marked tortuosity of the retinal veins, which 
might have been taken for a sign of retinal congestion, had not 
the other eye exhibited the same appearance, which, as it has not 
changed until now-at the same time causing not the least 
functional trouble,-seems to be an individual peculiarity of vas- 
cular arrangement. The tongue is thickly coated and has a 
strawberry-like aspect, as seen in scarlet fever. Both tonsils are 
very much swollen and painful, but are not covered with pseudo- 
membranes. The skin of the whole body shows an erythema of 
a scarlatinous redness. No oedema. No albuminuria. The fever, 
which at first has been very high, is now moderate. I made the 
diagnosis incipient orbital cellulitis, and ordered iced applications, 
to be applied day and night. The next morning I found about 
the same condition. Under this rigorous antiphlogosis, which 
was carried out most faithfully, the inflammation gradually sub- 
sided, so that, when I was called again on April 3d, the swelling 
of the upper lid was diminished and the child could partly open 
her eye. There was hardly any discharge. Exophthalmus and 
displacement downwards and towards the temple, divergent stra- 
bismus in looking to the right, and difficulty and limitation in 
movement upwards and inwards, and diplopia persisted. The 
swelling of tonsils had decreased also. But another ailment had 
set in, a violent pain in left mastoid process, which was increased 
by the touch with the finger. The external meatus plugged by 
epidermic scales, so that Mt could not be seen. Ord. ice-bag 
on mastoid process, instillation of natr. carbon, into the meatus, 
and calomel internally. 
April Afth.-Some of the impacted epidermis removed by syrin- 
ging. Walls of the external meatus swollen, preventing a view at 
the Mt. The child could stand the ice-bag very well, which Charles Zimmermann. 
78 
relieved her greatly. The sensitiveness of the mastoid consider- 
ably diminished. She slept well. No headache. 
April $th.-The patient feels very much better. Mastoid pro- 
cess hardly painful any more upon pressure. Epidermic plates 
in meatus still, but no pus. Eye affection the same, though less 
in degree. Tonsils still swollen, the left side of the soft palate 
cannot be raised so well as the right side (Loewenstein " 
observed the same). Iced applications on eye and ice-bag on 
mastoid continued, and calomel. I did not visit the child any 
more until April 16th, since the pain had disappeared, and she 
felt so well that she could leave the bed. On April 16th I was 
sent for again, the pain in left mastoid process having begun 
anew the night before last. The day before she felt better, was 
out of bed, and played. But last night the pain became exceed- 
ingly severe, radiating over the neck, head, and left shoulder. 
Pressure on the mastoid is very painful. The walls of meatus 
swollen, but not red. Mt cannot be seen on account of the 
swelling and some remaining epidermic scales, which resisted all 
efforts of removing, the child being very nervous. But the audi- 
tory canal is perfectly dry, does not contain the least discharge. 
Exophthalmus gone, but still slight ptosis and crossed double 
images, when looking to the right and upwards. Pupils acting 
normally. Fundus, especially optic disc in both eyes normal, the 
retinal veins exhibiting the above-mentioned tortuosity. V not 
affected. Temperature slightly raised. Pulse rapid and small. 
Child is put to bed. Mastoid and neck brushed with tinct. iod., 
and ice-bag applied to mastoid. Internally calomel 0.30 dos. iii. 
Temperature at 5 p.m., 38.4° C. ; at 8 p.m., 38.4° C. ; April 17th, 
Temp, at 6 a m., 36.10° C. She slept pretty well, but could not 
stand any more the pressure of the ice-bag. I ordered warm- 
water dressings and tinct. iodi applied twice a day. The integ- 
uments of mastoid presented not the least swelling or redness, so 
that there was no sign of a commencing periostitis externa. But 
the severe localized pain, the fever, and the sickly appearance of 
the patient, who looked rather pale, led me to believe, that there 
was an acute mastoiditis interna going on, and that the inflamma- 
tion of the lining membrane of the mastoid cells might have 
turned into suppuration already, or at least was threatening to do 
so. Therefore I prepared the parents for an eventual opening of 
the mastoid process on the next day. Temp, at 8 p.m , 38.0 C. 
(in axilla). 79 
Orbital Cellulitis and Primary Mastoiditis Interna. 
April iSth.-The condition of the patient being the same as 
yesterday (temp. 38,° at 6 a.m.), I thought it unsafe to wait any 
longer with the operation, for which I had everything ready. In 
chloroform-narcosis and under strictest aseptic and antiseptic 
precautions I made a large incision down to the bone No liga- 
tures were required. The periosteum and the external surface 
of the bone were healthy. The bone was opened with chisel and 
mallet. Corticalis pretty thick. When the antrum was reached 
the bone was chiselled off in such an extension, that an opening 
of a little more than 1 cm in diameter was obtained. The mas- 
toid cells were found to be completely filled with red spongy 
fungoid granulation tissue, which was scraped off with Volk- 
mann's sharp spoon. After thorough scraping and irrigation 
with sublimate solution 1 : 2000 a tampon of iodoform gauze 
with plenty of iodoform powder was introduced into the cavity 
and tightly packed. The external wound was not stitched. The 
meatus was also filled with iodoform gauze, and then a thick 
layer of iodoform gauze and carbolated absorbent cotton was 
fastened by sterilized bandages, encircling the head only, leaving 
the lower jaw free. The operation was performed at 8 a.m. 
Temperature at 6 p.m. normal. No pain. The child feels easy, 
sitting up in bed. The pain never returned after the operation, 
and the highest temperature was 37.5 0 C. The first change of 
dressing was made April 27th, on the 9th day after the operation. 
There was very little secretion in the iodoform gauze. No pain 
at all in the wound. Walls of the external meatus still swollen 
but not painful, and no discharge in its gauze. The swelling 
was gone at the next change of dressing, a week later. The 
dressing was renewed once a week until July 6th, when the very 
small tampon was left off. July 17th the wound was perfectly 
healed, exhibiting a depressed funnel-shaped scar. Hearing 
normal. Aft of normal appearance. Since the operation the 
child's general condition had improved wonderfully. 
When I first saw the patient I had the impression that 
her disease was scarlet fever. The scarlatinous exanthema, 
the severe angina tonsillaris, the strawberry tongue, and 
the fever formed the well-known aspect of this disease. 
But the sudden attack of the previously healthy child, the 
rapid development of these symptoms with nervous pros- 
tration, and the subsidence of the exanthema after two Charles Zimmermann. 
80 
days, without desquamation later on, corroborated in my 
mind the diagnosis of the well-experienced family physician 
who had seen the sickness from the first day. Exanthemata 
in influenza, especially scarlatinous erythema, are de- 
scribed by a number of observers. Fraentzel2 relates two 
cases of influenza in two children, which he at first took for 
scarlet fever, on account of the erythema, but found this 
diagnosis erroneous from the short duration of the redness 
and the absence of subsequent desquamation. Leyden,' 
Ewald,4 P. Guttmann,6 Renvers,6 Riess,7 Schwimmer,' 
Duflocq,9 report similar cases, and Antonin 10 distinguishes 
a special form of influenza, which commences with an ex- 
anthema. Pharyngitis and angina tonsillaris are considered 
also as very often associated with influenza by Leyden, 
Renvers, Fraenkel,11 Glower.12 Loewenstein 13 observed it 
in all his 78 cases of influenza from the very commence- 
ment. Since, from these considerations, there could be no 
doubt any more that we had a case of influenza, the next 
question arose, whether the affection of the left eye was in 
connection with the general disease. There being no local 
cause for the orbital cellulitis, I thought it to be of metas- 
tatic nature, induced by the general infection. It seemed 
to be analogous to orbital cellulitis or orbital phlegmon 
observed in other infectious diseases, as in glanders, 
anthrax, typhoid fever, variola, and scarlatina (Berlin,14 
Schweigger 16). In the last two years several observations of 
similar eye affections due to influenza have been published, 
wavering, however, between the diagnosis orbital cellulitis 
and tenonitis, so that it seems to me worth while to give this 
question some attention. Tenonitis was first described by 
O'Ferrall16 under the name " inflammatio tunicae vaginalis 
oculi," not based, however, on anatomical researches. He 
laid the chief stress on one symptom, the limitation of the 
inflammatory oedema to the tarsal portion of the upper lid. 
Berlin 17 contends the pathognomonic value of this symp- 
tom, and is of opinion that the affection of Tenon's cap- 
sule is only a complication in some forms of phlegmon of 
the retrobulbar tissue, being only a portion of the latter. 
Schweigger18 thinks it to be very unlikely that an inflam- 81 
Orbital Cellulitis and Primary Mastoiditis Interna. 
matory process of well-marked symptoms should be con- 
fined exclusively to Tenon's capsule, without involving the 
orbital tissue. Linhart19 considers tenonitis only as a " sup- 
posed possibility." In opposition to that Mooren 90 charac- 
terizes tenonitis by the following symptoms: impaired 
mobility of the globe with slight protrusion of the eye and 
transparent chemosis. Hock21 describes a case of genuine 
tenonitis, based upon redness and chemosis of the ocular 
conjunctiva, lack of mobility in all directions, tearing pain, 
especially in movements, but the eye not protruded. He 
considers the latter symptom as the most important in re- 
trobulbar cellulitis. The clinical features of orbital cellulitis 
are : dull pain in forehead or orbit, inflammatory swelling of 
lids, especially the upper lid, swelling of the ocular conjunc- 
tiva, deficiency of mobility, either general or partial, 
exophthalmus, and diplopia. The lack of mobility and 
exophthalmus are caused either mechanically by the in- 
flammatory effusion acting as a displacing foreign body, or 
by paralyzing the nerves and muscles through pressure. 
By some authors inflammatory and degenerative changes in 
the ocular muscles were observed (Schmidt-Rimpler,22 Ley- 
den,23 myopathia propagata, Friedberg24). The superior 
rectus and the levator palpebrae superioris seem to show a 
predilection for the affection (according to Pagenstecher26), 
causing ptosis and preventing rotation upwards. In the 
milder forms of orbital cellulitis authors concur in the 
absence of chemosis. If we consider now the recent observa- 
tions of tenonitis and orbital cellulitis in consequence of 
influenza, so far as I have perused the incident literature, 
they come under the following headings : Purulent Tenoni- 
tis : one case of Fuchs2'and one of Schapringer." Serous 
Tenonitis: three cases of Fuchs and one of Greef.28 Orbital 
Cellulitis: two cases of Pfliiger,29 one of Stoewer,30 one of 
Valude,31 with orbital abscess: one case of Borthen,32 and one 
of Socor.33 Fuchs as well as Greef, in their cases of serous 
tenonitis suspected at first incipient phlegmon of the orbital 
tissue, but corrected this assumption into the diagnosis 
tenonitis on account of the three following points: 1. 
The intense oedema of the conjunctiva (chemosis); 2. 
6 Charles Zimmermann. 
82 
The unusual limitation of mobility of the globe ; 3. The 
moderate exophthalmus. Pfliiger, however, thinks that 
the three cases of Fuchs, as well as his own two, are 
to be taken for cases of inflammatory oedema of the orbital 
structures, since in all the globe was displaced only in one 
direction, namely, forward and downward. He apparently 
thinks, and Stoewer and Borthen are of the same opinion, 
that in tenonitis the displacement is only forward, and the 
lack of mobility is general, not partial. He further says that 
the inflammatory oedema of the lids is a sign of orbital 
cellulitis, whereas Stoewer claims the absence of this phe- 
nomenon as confirming his diagnosis of retrobulbar effusion 
behind Tenon's capsule, excluding tenonitis. If we remem- 
ber the anatomical relations of Tenon's capsule to the eye- 
ball, nothing seems to be more natural but that one of the 
first symptoms of tenonitis, i. e., an effusion between its 
parietal and visceral portions, must be chemosis of the 
ocular conjunctiva. The resistance there is much less- 
being only the loose, pliable, and easily movable con- 
junctiva-than at the posterior segment of the globe, where 
the whole eyeball would have to be pushed forward. The 
equal restraint of mobility in all directions, and the pain 
experienced in movement, are easily understood from the 
fact that all the ocular muscles are ensheathed by Tenon's 
capsule, and must naturally suffer from accumulations of 
inflammatory products in the capsule. In those cases 
described as tenonitis, in which the exophthalmus was more 
conspicuous, it seems to me more natural to assume a 
simultaneous inflammation of the retrobulbar tissue, which 
cannot expand except by protruding the eyeball, and 
therefore explaining, if circumscribed, the displacement 
not in the direction of the orbital axis, but forward and 
downward. In our case, however, as well as in those of 
Pfliiger and Stoewer, the orbital cellulitis was not uni- 
versal, but only confined to the upper portion of the orbit, 
affecting the upper branch of the oculomotor nerve by 
compression, and thus creating paresis of the levator and 
superior rectus, and the branch supplying the internal 
rectus. It was very mild, not implicating Tenon's capsule, 83 
Orbital Cellulitis and Primary Mastoiditis Interna. 
and therefore not producing chemosis, so that Tenon's 
capsule acted, as it were, as a barrier, preventing the 
effusion in the orbital tissue from finding its way into the 
capsule itself, and then beneath the ocular conjunctiva. 
It is not even necessary to assume an effusion ; it might 
have been simply a hyperaemic condition of the retrobulbar 
tissues, as observed in other organs, being one of the 
characteristic effects of influenza. 
The ear is the organ which has shown particularly well 
the tendency of influenza to lead to hyperaemia. Michael ** 
has formulated the character of ear diseases in influenza in 
the following resume: " The ear symptoms in influenza are 
objectively and subjectively the expression of an intense 
hyperaemia of the mucous membrane of the hearing organ." 
" Middle ear and mastoid process are enormously painful, 
because the swollen mucous membrane suffers from pres- 
sure. The products of inflammation, however, are absent, 
and with these the usual doughy swelling." " The hyperaemia 
is the indirect cause of the observed complications, lead- 
ing to ruptures of blood-vessels, whose walls may be altered, 
and consequently to hemorrhages, and rendering the 
mucous membranes more susceptible for the invasion of 
infectious matter." Mostly all observers described as the 
most common ear complication in influenza, otitis media 
of great intensity and great pain, with tendency to hemor- 
rhages. According to Schwabach.31 the external ear partici- 
pated more frequently than usual with intense inflam- 
matory infiltration of the walls of meatus and extensive 
scaling of epidermis. Szenes34 observed several times 
eczema of external meatus. In regard to affections of the 
mastoid, the observers are divided. Stimmel37 never had 
to open the mastoid in his 100 cases of otitis media. 
Dreyfuss " found seldom the tendency to mastoiditis. 
Hoffmann " never observed it in 35 cases; Eitelberg 49 1 ; 
Schwabach 41 2 in 100 cases of otitis media, of which only 
one was opened. On the other hand, Politzer,41 Gruber,41 
Meniere,44 Szenes,41 Chatelier,4* noticed frequently the impli- 
cation of the mastoid. Ludewig47 saw repeatedly acute 
caries. Of Jansen's41 100 cases, the mastoid was affected in Charles Zimmermann. 
84 
57, in 25 chiselling, in 12 subdural abscess, with 2 deaths. 
Moeser49 describes a case of primary periostitis of the 
mastoid due to influenza. In all these cases the mastoiditis 
was secondary to otitis media. Our case, however, is a case 
of acute primary mastoiditis interna. The accumulation of 
epidermic scales had nothing to do with the inflammation, 
and the swelling of the walls of the meatus was only a second- 
ary affection to the inflammation of the mastoid. There was 
never any discharge from the ear, and from the very begin- 
ning the pain was confined to the mastoid spontaneously, 
and on pressure, without redness or swelling of the integ- 
uments. Primary mastoiditis interna, 1. e., the primary 
inflammation of the lining membrane of the mastoid cells, 
without manifestations on the external surface of the bone 
or the periosteum, and without preceding otitis media, is a 
very rare disease (Schwartze,50 Politzer,61 b ulton,63). Accord- 
ing to Politzer, it is due to the effects of colds, injury or 
syphilis. The chief symptom, on which the diagnosis 
rests, is the constant and persistent pain in the mastoid, 
radiating over the head, face, neck and shoulder, as very 
precisely described by Knapp.6J If left to itself, there will 
be a very late appearance of inflammatory symptoms, as 
swelling and redness in the external parts. In our case the 
pain was very characteristic with absence of external symp- 
toms, the fever and the influence on the general condition of 
the patient supporting the diagnosis very effectively. The 
intermission of pain of about ten days may be explained by 
the abatement of the hyperaemia (under the very rigorous 
antiphlogosis), which, from the violent symptoms from the 
very beginning, must have set in very rapidly and very 
intensely. It returned when the inflammatory products, 
the fungoid vegetations of the degenerated mucous mem- 
brane had developed to such a degree that they filled the 
mastoid cells, obstructing the access to the tympanic cavity, 
and thus preventing a secondary inflammation of the latter. 
Or it may be interpreted by a re-invasion of the pathogenic 
poison of influenza, as some observers commented upon the 
relapses during the course of influenza. In otitis media due 
to influenza, the following micro-organisms have been found : 85 
Orbital Cellulitis and Primary Mastoiditis Interna. 
diplococcus pneumoniae (Frankel-Weichselbaum), strepto- 
coccus pyogenes, staphylococcus pyogenes albus and strepto. 
pyog. alb. (Zaufal,64 Finkler,55 Scheibe,66 Gradenigo "). Fuchs 
found the diplococcus pneumoniae in purulent tenonitis, 
Socor diplo-, strepto-, staphylo-cocci in phlegmon of the 
retrobulbar tissue. This leads us to the question, whether 
the ear complications in influenza are a propagation of the 
inflammation of the pharynx and tonsils, or whether they 
are a localization of the influenza itself in the ear. In our 
case the latter seems to be the most probable, inasmuch as 
a transportation of the phlogogenic matter from the pharynx 
would have followed the anatomical paths and first affected 
the tympanic cavity instead of leaving it intact, invading 
only the mastoid cells. Besides that, the character of the 
hyperaemic condition, as found at the operation, would be 
in favor of a direct localization. 
In regard to the treatment leeches (Michael, Z. r.) 
are most recommended as best adapted to relieve such 
hyperaemic affections. The general condition of our patient, 
however, did not admit of such weakening measures, 
especially as in case of failure opening of the mastoid 
would have been resorted to. The affliction being an acute 
one, the pain alone would not have been a sufficient 
indication, as, according to Knapp (Z. r., p. 368), " the vast 
majority of cases of acute mastoiditis get well without an 
operation, when rest in bed and rigorous hygienic deport- 
ment are enforced." "Yet when the symptoms are alarm- 
ing, and when in spite of strict treatment the headache does 
not abate, I think the opening of the mastoid indicated." 
Schwartze (Z. r.) proposes the operation, if after eight days 
the antiphologosis has not produced a decided improvement. 
In our case, the revival of the symptoms after an inter- 
mission of ten days, especially the fever and the impover- 
ished condition of the child were sufficient proof that a 
further delay of the operation would have been deleterious 
to the patient. The possibility was that, our waiting for the 
development of empyema of the mastoid with more striking 
symptoms, might have exposed the patient to the dangers 
of pyaemia or meningitis, or to a secondary purulent otitis Charles Zimmermann. 
86 
media with perforation of Mt, and lingering course or, what in 
our case was not very likely, that by passing into a chronic 
mastoiditis interna it might have led to sclerosis of mastoid 
(as observed by Knapp, I. cl), causing great suffering to the 
patient, and necessitating, perhaps, a later operation under 
much more unfavorable circumstances. The condition of 
the mastoid cells found at the operation and the result 
proved, that in this case the operation was the only right 
proceeding. Our case, therefore, is a new addition to the 
series of those aurists who, under similar conditions, advo- 
cate an early operation. In regard to the technique of the 
operation and the treatment in this as in other cases, the 
strictest aseptic and antiseptic measures, with iodoform- 
gauze tamponade as drainage (no tubes, no plug of lead), 
have given excellent results. 
To sum up, we have a case of influenza-its diagnosis 
based upon the sudden onset of symptoms with nervous 
prostration, exanthema, angina tonsillaris, pharyngitis-with 
orbital cellulitis and acute primary mastoiditis interna as a 
result of the tendency of influenza to cause hyperaemic, 
and further on inflammatory, conditions in different organs. 
Literature. 
1. Hering, Berl. klin. W., 1885, p. 167. 
2. FrAntzel, Deutsch, med. W., 1890, p. 17. 
3. Leyden, ibid., Nos. 3 and 4. 
4. Ewald, Bert. klin. W., 1890, p. 65. 
5. P. Guttmann, ibid. 
6. Renvers, ibid., p. 17. 
7. Riess, " Eulenburg's Real. Encycl.," xxi., p. 630, 2 Aufl. 
8. Schwimmer, Wien. med. W., 1890, No. 37. 
9. Duflocq, Revue de m<!d., 1890, Feb. 10. 
10. Antonin, Bull, de la soc. de mid. de Jassy, 1890. 
11. Fraenkel, D. med. W., 1890, p. 607. 
12. Glower, Annal. des mal. de I'oreille, 1890, Fev. 
13. Loewenstein, Berl. klin. W., 1890, p. 17. 
14. Berlin, Graefe-Saemisch, vi., p. 521. 
15. Schweigger, " Handbuch. d. Augenh.," 1880, p. 195. 
16. O'Ferrall, Dubl. Jour, of Med. Science, xix., p. 343, 1841. 
17. Berlin, I. c., p. 535. 
18. Schweigger, I. c., p. 198. 
19. Linhart, Verh. d. phys. med. Ges. Wuerzburg, ix., p. 245. 87 
Orbital Cellulitis and Primary Mastoiditis Interna. 
20. Mooren, Ophthalmolog. Mitth., 1874, p. 13. 
21. Hock, " Eulenburg's Real. Encycl.," ii. Aufl., xv., p. 46. 
22. Schmidt-Rimpler, quoted by Berlin, I. c., p. 526. 
23. Leyden, Virchow's Arch., xxix., p. 199. 
24. Friedberg, Virchow's Arch., xxx., p 585. 
25. Pagenstecher, Klin. Monatsbl., viii., p. 207. 
26. Fuchs, Wien. klin. W., No. 11, 1890. 
27. Schapringer, Med. Record, 1890, June 14, p. 679. 
28. Greef, Berl. klin. W., 1890, p. 605. 
29. PflOger, ibid, p. 665. 
30. Stoewer, Klin. Mon. f. A., 1890, p. 419. 
31. Valude, mentioned by Vignes, Soc. d'opht. de Paris, July 1, 1890. 
32. Borthen, Klin. Mon. f. A., 1891, p. 85. 
33. Socor, Bull, de la soc. de mdd. de Jassy, 1890. 
34. Michael, Deutsch, med. W., 1890, p. 107. 
35. Schwabach, Berl. kl. W., 1890, p. 43. 
36. Szenes, Monatsch. f. Ohrenh., 1890, No. II. 
37. Stimmel, Berl. klin. W., 1890, p. 1,000. 
38. Dreyfuss, ibid., p, 52. 
39. Hoffmann, Deutsch, med. W., 1890. 
40. Eitilberg, Arch, internation, de laryng., otol., et rinolog., 1890. 
41. Schwabach, Berl. klin. W., 1890, p. 1,000. 
42. Politzer, Wien. med. Blaetter, 1890, No. 9 and 10. 
43. Gruber, Algem. Wien. med. Ztg., 1890, No. 10. 
44. MfiNiiiRE, Soc. frani;, otol. et laryng., May 10, 1890. 
45. Szenes, I. c. 
46. Chatelier, Annal. des mal. de I'oreille, 1890, Mars. 
47. Ludewig, Berl. kl. W., 1890, p, 1,000. 
48. Jansen, ibid. 
49. Moeser, ibid., p. 341. 
50. Schwartze, " D. chirurg. Krankh. d. Ohres," p. 312. 
51. Politzer, " Lehrbuch d. Ohrenh.," 2 Aufl., p. 385. 
52. Fulton, quoted by Ayres in Arch, of Otol., xix., p. 96. 
53. Knapp, Arch, of Otol., x., p. 365. 
54. Zaufal, Prager med. Woch., 1890, No. 8. 
55. Finkler, rep. Arch, of Otol., xx., p. 175. 
56. Scheibe, Centralblatt fur Bacteriologie u. Parasiten-Kunde, 1890, No. 8. 
57. Gradenigo, Arch, internal, de laryng., otol., et rin., 1890. Cbe Knickerbocker flMess 
mew l>orh