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Suppuration in the petrosal pyramid is found to occur in two forms. In one, an osteomyelitic lesion develops in the bone, and in the other, coalescent osteitis is present. The symptoms which present themselves differ essentially in the two types of lesion; and in order to make a diagnosis it is necessary to differentiate these forms clinically. It is therefore necessary to touch on the pathologic entities of these infections so as to comprehend their varying clinical courses and differing clinical pictures. Both these lesions are found to accompany or follow an infection of the tympanic cavity.According to Ramadier, one deals with two forms of osteomyelitic lesions in the petrosal pyramid. One form is termed hematogenic, and the second form, otogenic. The former is most frequently present in the very young patient. The clinical picture is one of general infection. There is marked prostration; there are gastro-enteritic disturbances, and often the signs of pulmonary involvement cloak the advance, step by step, of the infection as it infiltrates the diploic bone, with its contained bone marrow, in the petrosal pyramid. Otitic phenomena are present, but the signs and symptoms from the middle ear do not dominate the clinical picture. Eventually, and almost inevitably, the lesion reaches the endocranial structures, and the final picture is that of meningitis. One significant characteristic has been established: The lesion is usually bilateral.Otogenic osteomyelitis, on the other hand, more clearly takes a course which shows it to be a sequela of otitic infection. This form of osteomyelitis is not confined to infancy or childhood. It occurs usually in the course of suppuration of the middle ear. Its onset most often takes place after the initial acute phase of the suppurative otitis assumes a subacute status. Nevertheless, its onset is marked by acute signs. Suddenly, in the course of an attack of otitis which has seemingly subsided into a prolonged course of otorrhea, there are violent auricular, periauricular and hemicranial pains on the side of the head Read before the Section of Laryngology, Otology and Rhinology at the