pearance of disease; the dura mater and arachnoid covering the upper part of the left petrous bone were quite healthy. When the tentorium was removed, the left hemisphere of the cerebellum was

The Internal Surface of the Temporal Bone, showing the two orifices in the Lateral Sinus which were filled by the cerebellum, and also showing the carious Sulcus Lateralis.

observed to be much softer than natural, and the portion in contact with the posterior surface of the pars petrosa was dark in color and very soft. Upon gently drawing it backwards, it was found to be applied against two orifices in the posterior part of the lateral sinus, and to be separated from the cavity of the sinus by the thickened arachnoid and pia mater. A considerable vessel in the pia mater, opposite the orifice, was distended by a firm and dark coagulum, half an inch in length. The anterior membranous wall of the lateral sinus was absent; the bone forming the sulcus lateralis in the mastoid process was carious, and the sinus full of a dark-colored coagulum and purulent matter; pus was also found in the jugular veins.

The ear. The dermis lining the whole of the external meatus was soft, tumefied, and dark-colored, and its surface was devoid of epidermis; beneath it, posteriorly, was purulent matter, which separated it from the carious bones. The membrana tympani was absent; but there was no more appearance of disease in the tympanic cavity than might have been produced by the affection of the meatus. The

bone was carious anteriorly as far as the root of the zygomatic process and the fossa for the articulation of the lower jaw; superiorly and posteriorly, the caries extended for the distance of an inch and

a quarter, nearly to the margin of the parietal bone; but in some parts the external table only was affected, while in others it extended to the diploe and thence to the internal table. On holding the bone up to the light, small orifices were seen through it; so that its external surface, or that part which was covered by the membranous meatus, was directly continuous with the lateral sinus.

The progress of the disease in this case from without inwards, is very remarkable; for there is no evidence to prove that the disease originated elsewhere than in the meatus; and it is apparent, from the direct communication by bloodvessels between the membranous meatus and the bone forming the lateral sinus, that disease could easily be transferred from the inflamed meatus to the bone beneath. Careful consideration of the subject has, however, induced me to believe that the progress of disease from the meatus, inwards, to the internal sinus and cerebellum, is of rare occurrence; and to think that the majority of the cases of this kind recorded as having occurred to previous inquirers, were really instances of disease advancing from the tympanic cavity or mastoid cells outwards, to the meatus, in which process the cerebellum and lateral sinus were implicated.

Treatment. I have already stated it to be my opinion, founded

on a consideration of some of the cases already adduced, that when a disease of the brain originates in a chronic affection of the ear, the cause of its prolongation to the brain may be traced to the want of a free egress for the matter.

The modes in which this matter may be confined are various. In the case of the external meatus, the tumefied walls, together with its peculiar valvular disposition as seen in infants, create a sufficient barrier to the free egress of the secretion. In the tympanic cavity, the matter is usually retained by the membrana tympani, which either wholly or partially prevents its escape; sometimes, however, the hypertrophy of the mucous membrane is itself sufficient to shut up the secretion in parts internal to it; and occasionally even the thick accumulated matter itself may prove a bar to the egress of that which is beyond it. In the case of the mastoid cells, it appears that the matter may be retained by the peculiar position of their horizontal portion, the floor of which is often below that of the orifice into the tympanum; or it may occupy the vertical portion of the cells, which is quite below the part leading into the tympanum. The rules to be laid down in the treatment of chronic catarrh of the dermoid meatus, the mucous membrane of the tympanum, and the mastoid cells, are as follow:

1. By attention to the general health to attempt to diminish the catarrh.

2. To secure, if possible, a free exit for the secreted matter.

3. By keeping up an external discharge, to cause that within the ear to be absorbed; and thus to arrest further secretion, and allay the diseased action.

General Treatment.-As far as general measures go, the same observations will apply to the diseases of each of the different parts of the ear. As it seems probable that the usual predisposing cause of these diseases is a scrofulous diathesis, every means should be taken to invigorate the health. Abundant exercise in the open air, especially in the country or by the sea-side, simple, nutritious, but not stimulating diet, and mild tonic medicine, are to be specially recommended. Great care should be taken that the patient sleeps in a well-ventilated room, in a bed without curtains, the head being kept high and cool, and above the bed-clothes. Everything which is liable to excite must be sedulously avoided; and rough play, in which the head is apt to receive a blow, must not be allowed. From whatever source the discharge comes, it is desirable, when practi

cable, that the membrane whence it issues should be washed frequently with tepid water; hence the use of the syringe is of great importance. When there is congestion, the application of one or two leeches is desirable, and sometimes gentle counter-irritation should be resorted to. This may be effected by a liniment to be rubbed over or around the ears and down the spine. Gentle astringents may also be used. Whatever may be the source of the discharge, as a general rule, its continuance for some months after the exciting cause is symptomatic of a scrofulous or otherwise unhealthy diathesis; and, in spite of every effort, the hypertrophied membrane is but very slowly affected, and consequently the discharge is generally of long duration. It is important, however, that the medical man, knowing the exact nature of the disease, and its peculiarly chronic character, should inform the parents or friends of the patient that any attempt to stop the discharge by powerful astringents, or otherwise than by gentle means, may be attended with serious consequences, as the production of acute inflammation. Here, perhaps, I may be excused a few words on a subject so frequently adverted to as the danger of stopping a discharge from the ear. The supposed danger of an arrest of the discharge by local applications seems to have originated in the knowledge of the fact, that one of the most common symptoms in the early stages of acute inflammation of the ear, following upon a chronic disease, is the cessation of the discharge which previously, and often for many years, had been There can be no doubt that in these cases the cessation of the discharge is one of the effects, and not one of the causes of the inflammation; for other symptoms of inflammatory action may usually be observed before the discharge disappears. In cases where strong astringents have been employed in order to arrest a discharge from the ear, the symptoms that follow are not dependent upon the cessation of the discharge (for, indeed, the discharge does not always diminish), but upon the inflammation caused by the irri

constant.

tant.

To sum up what has been said respecting the general treatment,

Many of the syringes in common use are very inefficient, as they do not send the water into the ear with sufficient force to remove the discharge. The best and most simple for patients to use, is the four ounce vulcanized india rubber bottle, made by Bell & Co. The metal nozzle should be made so as to allow of being easily removed. When the syringe is to be filled, the nozzle should be taken cut, and the fluid to be injected should be poured into the bottle, or it may be allowed to fill itself, the air having been previously expelled by pressing the sides together.

where there is simple chronic catarrh from the dermoid meatus, membrana tympani, or the tympanic mucous membrane, with free egress for the matter when there are symptoms of congestion, apply one or two leeches near the part affected; syringe the ear frequently with an abundant supply of warm water; use mild astringent lotions, and endeavor to improve the health by every means possible to the patient. In face of all these measures, the medical man may expect to see the disease make very slow progress towards amelioration; but he must be content that its advance inwards towards the bone and the brain is averted.

In cases of catarrh of the dermoid meatus there is very frequently some source of irritation of the tympanic mucous membrane, of which the catarrh of the meatus is but a symptom. Thus it is not uncommon to find obstruction of the Eustachian tube, even at the faucial orifice, attended by catarrhal inflammation, and even by polypus in the meatus; both of which secondary affections wholly disappear when the primary disease is removed. Cases of simple catarrh of the dermoid meatus do, however, occasionally occur: and one which terminated fatally has already been cited. As a general rule they may be distinguished from the secondary cases by the absence of all appearance of disease in the tympanic cavity; by the power of hearing being but slightly affected, and by the healthy state of the membrana tympani, except an occasional increased vascularity of its dermoid layer. Primary catarrh from the dermoid layer usually occurs in children suffering from debility; when the dermis, instead of secreting its epidermis, pours forth a watery fluid composed of serum, in which float epidermoid cells in different stages of development. This discharge has often an extremely offensive odor, dependent generally, not upon the presence of dead bone, but upon a deranged action of the ceruminous glands. The discharge from the meatus, in cases of chronic catarrh, differs from that which attends the same affection in the tympanum in the way already pointed out; and it usually subsides under the use of a syringe and tepid water, tonic medicine, and the ordinary plans for strengthening the constitution of the patient. When the health is much deranged, it may take some months to effect a cure; but during the whole of this period daily syringing must be practised.

(d.) ULCERATION OF THE DERMOID MEATUS.

Cases of catarrh of the dermoid meatus, if neglected, may advance to ulceration; the bone may become diseased, and a small osseous