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January 22d.-Much better; slept well; pain abated.
January 24th.-Pain returned as violently as ever.

January 27th.-Delirious during the whole of the day.

January 29th.-Delirium continues: complains of intense pain in both sides of the head; discharge from the ear abundant; head drawn backwards.

January 30th.-The delirium has left him, but he is exceedingly drowsy, and is roused with great difficulty. The movements of the limbs and their sensation unaffected. The pupils acted properly.

February 1st. The drowsiness has vanished; has had no delirium; and has passed a good night; but still complains of considerable pain in the ear and over the eyes. He remained in this state until the 5th, when he gradually sank, without coma or cerebral symptoms of any marked character. The retraction of the head continued to the last. He was quite sensible before he died.

Autopsy, thirty-six hours after death.-On removing the dura mater, the surface of the arachnoid was observed to be remarkably dry; the vessels of the pia mater were more than usually injected on the convex surface of the hemispheres; there were two or three small yellow patches beneath the arachnoid. Each lateral ventricle contained at least three ounces of clear fluid; in the posterior corner of the right, and in the inferior of the left, were two patches of bright yellow lymph, as large as half-a-crown, which were covered by a thick creamy purulent fluid. The third ventricle contained a dark clot of blood, of the size of a small walnut, which could be traced into the fourth ventricle, where there was also a small coagulum. The commissura mollis was broken down. Surrounding the lower part of the commissure of the optic nerves, and covering the pons Varolii, crura cerebri, medulla oblongata, and upper part of of the medulla spinalis, was a layer of pure yellow pus and lymph, nearly half an inch thick; it embraced the nerves at the base of the brain to their passage through their several foramina. The parts in direct contact with this layer were very soft. Under the pia mater, where the right anterior lobe rests on the orbital plate of the frontal bone, there was a patch of effused blood, the size of a shilling. The dura mater covering each petrous bone was healthy, and the exterior of the bone did not present any appearance of disOn examining the cavity of the ear, the membrana tympani

ease.

was found to have been destroyed by ulceration, and all the ossicles. had disappeared. The tympanic cavity was full of the most offensive secretion, and its lining membrane was ulcerated. The fenestra ovalis was open, and, in the cavity of the vestibule, similar matter was found to that in the tympanum. The whole of the natural membranous labyrinth had been destroyed. The auditory nerve was tumefied, and of a dull livid color, the disease having evidently advanced to it through the cribriform floor of the internal auditory meatus, and thence to the base of the brain.

It is to be remarked, that in this case there appeared to be no obstacle to the free egress of the matter, except the accumulation of thick masses of it in the cavity of the tympanum. It is far from improbable that, in cases of ulceration of the mucous membrane of the tympanum and loss of the stapes, the thick secretion in the tympanum may be quite sufficient to cause the disease to advance inwards. The case is also another illustration of the necessity there exists for frequently washing out the tympanic cavity with warm water. It is, however, no doubt possible, ere the stapes is removed, for the disease to advance to the vestibule without the agency of the pent-up matter in the tympanum.

Besides the two cases just described, I have met with two others; and as these four cases are the only instances I have found on record of this peculiar form of the disease, brief particulars of the two latter are subjoined.

The first of these cases occurred in the practice of Mr. Streeter, and was laid by him before the Westminster Medical Society on the 13th January, 1844.

Disease extending from the tympanic cavity to the labyrinth, and thence to the medulla oblongata and the base of the brain.-The patient was a lady, aged 42, who had been deaf in the right ear since the age of seven, but from what cause was not known. Two or three months previous to her death, she became affected with a severe headache, for which a blister was applied at the back of the neck. Nothing serious, however, was thought of the matter until the 17th December, when the severity of the pain so increased as to become of a maddening character, and almost to produce delirium. The right portio dura nerve was paralyzed, and there was severe pain down the spine, which was attributed to a fall received when getting out of bed. The pulse did not warrant active depletion, but two or three leeches were applied behind the affected ear; a large

poultice was applied over the face; the ear was gently syringed with warm water, and saline medicines were ordered. On the 18th she had some sleep in the night, but complained of an almost intolerable pain in the back. The catamenia now appeared, and the cause of the pain remained obscure. She was quite sensible, the pupils acted, but the cornea on the affected side had begun to ulcerate. There was a slight discharge from the right ear, and the left had become somewhat deaf. It was thought that a hole could be observed in the membrana tympani : calomel and opium were administered.

December 19th.-She has slept better and remained somewhat improved until five or six in the evening of the 21st, when she was suddenly seized with coma, and continued in that state until the following morning, when she died.

Autopsy. On examining the brain, slight sub-arachnoid effusion and vascularity of its surface were found, as also some increase of vascularity in the interior; but there was no effusion in the ventricles. An abscess was discovered in the tympanum and labyrinth, and there was a counter-abscess, about the size of a large pea, in the condensed arachnoid and pia mater, occupying the fossa where the facial and auditory nerves proceed, from the junction of the medulla oblongata with the pons Varolii and cerebellum. Pus was effused beneath the arachnoid and pia mater, investing the right side of the upper portion of the medulla oblongata, and the adjoining part of the right lobe of the cerebellum, to about the extent of a square inch; but there was neither softening nor apparent lesion of the proper cerebral tissue beneath.

The exact condition of the tympanic cavity and labyrinth is not detailed in the above notes by Mr. Streeter; but there can be no doubt that the disease (most probably ulceration of the mucous membrane) had extended from the tympanum to the vestibule, either through the fenestra rotunda or ovalis, or by means of an orifice in the osseous wall of the labyrinth. The state of the portio dura and portio mollis nerves is not stated; but judging from the records of other cases of a similar character to the present, these nerves must have undergone some morbid change and communicated the disease to the base of the brain.

The remaining case is taken from M. Itard's work,' and is as

'Traite des Maladies de l'Oreille, 1821. Tome i, p. 254, Obs. 22.

follows: A man, aged 22, five weeks before his death, complained of toothache: this was followed by febrile symptoms. On the twelfth day after the attack, discharge took place from the left ear, but symptoms of cerebral irritation increased until his death.

Autopsy. Over the convex surface of the brain, and in its substance, were a number of small purulent deposits. The cerebellum was similarly affected, but in a less degree. The auditory and facial nerves were in a state of suppuration, and almost wholly destroyed: pus was also found in the internal auditory meatus, the vestibule, cochlea, and semicircular canals, and the tympanic cavity.

The treatment to be pursued in these cases is similar to that recommended in cases of disease of the tympanum and the mastoid cells.

CHAPTER XVII.

MALIGNANT DISEASE OF THE EAR.

ORIGIN IN THE MUCOUS MEMBRANE OF THE TYMPANUM-DESTRUCTION OF THE PETROUS BONE-SOMETIMES MISTAKEN FOR POLYPUS-OPERATIONS TO BE AVOIDED-BRAIN

AND DURA MATER INVOLVED-TREATMENT.

CASES of malignant disease, advancing from the ear towards the brain, appear to be of rare occurrence. So far as my own experience and the aid of published cases permit me to judge, it appears most probable that the part of the ear in which malignant disease usually originates, is the mucous membrane lining the cavity of the tympanum. After the diseased growth has destroyed the membrana tympani, it advances through the external meatus to the outer orifice, where it shows itself in the shape of a small tumor, which has sometimes been mistaken for a polypus, and the removal of which has caused hemorrhage and an aggravation of the symptoms. At the same time that the disease advances outwards, it also encroaches upon the whole of the parts surrounding the organ of hearing. The osseous walls of the meatus externus and of the tympanic cavity are wholly destroyed; the outer part, and even the whole of the petrous bone, are converted into a mass of disease; the lower part of the squamous bone also disappears, and the tumor advances into the cavity of the skull, where it destroys life, either by its pressure upon the brain or its blood vessels, or by involving the brain itself in the disease.

This malignant disease is sometimes of the nature of fungus hæmatodes; at other times it has the characters of encephaloid disease. This affection occurs at various periods of life: the ages of the three patients to whose cases reference is about to be made, were respectively 3, 18, and 35; the progress is very rapid generally, and forms a marked contrast with those cases of chronic

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