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LECTURE 1. AN ANALYSIS OF FIFTY-SEVEN FATAL CASES OF EAR DISEASE, AND OF TH:E COMPLICATIONS WHICH LED TO DEATHI. OTORRHEA is but too frequently looked upon as a troublesome complaint that must be endured, and when patients have had a discharge which has persisted for many years in spite of all treatment, they, at any rate, if not their medical attendant as well, are apt to con3ider that they have done with it, that it is hopeless for them to trouble any more about it, and that it will never alter. Yet there can be no greater mistake, for occasionally, under some exciting condition, the inflammation spreads to the cranial cavity, the patient rapidly becomes mortally ill, and in many instances dies after an illness of a few days', or it may be some weeks', duration. The unexpected onset of grave symptoms, the agonising headache which too often forms one of them, the state of mental torpor or coma into which so many of the patients pass, and the utter uselessness of medical treatment in the more severe cases, must on various occasions have impressed themselves deeply on everyone here. Of late years improved methods of surgery, and especially the more effective means that are adopted to sterilise foul and septic centres of infection, have led, in a few instances, to more successful results. Now that attention is being directed to the matter, we may look for a much greater measure of success; and here, as has so frequently been the case, the pathologist is able to indicate to the surgeon the lines on which the treatment should be laid down. For my purpose I have examined the post-mortem records at Guy's Hospital for the years 1869 to 1888, a period of twenty years, and have found 57 inspections in which ear trouble has set up disease in the cranial cavity, which ultimately proved fatal. 1 desire to express my appreciation of the kindness of my colleagues in placing their cases at my disposal, and thus providing me with a large number of valuable records, the majority of which have not been previously published. I am more particularly indebted to Dr. Goodhart, who made a large number of the post-mortem examinations. During this period there were nearly 9,000 inspections. Death was, therefore, traceable to ear disease in 0.66 per cent. of the cases. Further examination shows that 27 of the cases had occurred during the last four years, which would raise the ratio for that period to 2 per cent. I am quite unable to offer any explanation of this very greatly increased frequency. An examination of the reports fails to throw any light on the matter, and there is no reason to suppose that it was due to any great difference in the treatment. No case of simple otitis media, with or without disease of the mastoid cells, was fatal during the whole of this period; and only twice was the complication that led to the fatal result outside the cranial cavity, and even then it was in contiguity with it. In one there was a retropharyngeal abscess, and in the other the patient bled to death from rupture of the internal carotid artery. Death from ulceration of the carotid is a very rare event, only fourteen cases having been recorded, according to Politzer. It is worth remembering that when pyremia occurred in ear disease, the onset was preceded in all cases by thrombosis of the lateral sinus. The difficultiesof diagnosis in ear disease are much increased by the fact that, not only may a patient die without any otorrbcea having been noticed (this occurred in nine, that is, in one-sixth of the cases), but in two instances the membrana tympani was found intact at the inspection. These patients died with meningitis and lateral sinus thrombosis respectively. The possibility of the otorrhoea being secondary to the meningitis may be the explanation of these cases. Of the 57 cases, 34 were males and 23 females. The right ear was the source of the mischief rather less frequently than the left. Seventeen of the patients were under 10, the same number between that age and 20; 14 in the next decennial period, and only 9 over 30. The only patients over 50 were the man aged 65, who died from hemorrhage from ulceration of the carotid, and a woman aged 66, who died with meningitis. Three of the 4 babies who died under 3 years of age succumbed from meningitis. The acute symptoms in ear disease appear sometimes to come

The Goulstonian Lectures on Some Cerebral Lesions