symptoms, ten months previously she had become suddenly deaf, first in one ear and then in the other. After being deaf for a month, there was a crack in each ear, and she regained her hearing, which had remained perfect until within a few days, when, during a severe cold, she again became deaf. Upon examination, I found the meatus of each ear full of dark cerumen; the hearing distance was only half an inch, and the patient required to be spoken to loudly within a yard. Upon removing the cerumen the hearing was perfectly restored.

Case II. Mass of cerumen extremely hard and very difficult to remove.-Lord D., aged between 50 and 60, consulted me, in April, 1851, on account of deafness in the right ear, accompanied by a sensation of fulness in that organ. A large mass of cerumen was detected in the meatus, which was not at all affected by syringing for half an hour. A solution of carbonate of soda in water (3j @ 3j) was ordered to be dropped into the ear for some days; but the mass was scarcely at all softened. The application of the solution was therefore continued, and it was only after several weeks that the cerumen was dissolved sufficiently to be removed with ease.

Case III. Accumulation of cerumen attended with pain and inflammation of the dermis.-Miss H., aged 30, consulted me in May, 1853, on account of a shooting pain in the right ear which she had experienced, with scarcely any intermission, during a fortnight. She was not aware that the hearing power was at all diminished. On examination, each meatus was found full of cerumen, the hearing distance of the right ear being half an inch; that of the left, ten inches. The cerumen was removed from each ear; and that in the right was exceedingly hard, requiring frequent syringing. The hearing distance of the right ear rose to six inches; that of the left became natural. The surface of the right meatus was red, and it was swollen. The pain ceased, and the symptoms of inflammation disappeared, after the cerumen was removed.

Case IV. A mass of cerumen producing inflammation of the dermoid layer of the membrana tympani.-J. R. M., aged 55, a surgeon, complained, in 1849, of pain in the right ear, with much deafness. The pain was paroxysmal; very acute; and was increased during the act of swallowing. The meatus was found distended with cerumen, the removal of which gave immediate relief to both pain and deafness. The upper half of the dermoid layer of the mem

brana tympani, against which the mass of cerumen had evidently pressed, was red and much swollen; the lower half was healthy.

Case V. An accumulation of cerumen causing neuralgic pains in the face.-G. W. H., Esq., applied to me, in May, 1853, on account of a dulness of hearing in the right ear, accompanied by slight pain in the ear, and a good deal of pain over the right side of the face. This facial pain came on at times very suddenly, was very acute, and then disappeared: it had lasted for eight or nine days. A large accumulation of cerumen was found to fill the right ear: and when removed by the syringe, the dulness of hearing, the pain in the ear and in the face, entirely disappeared.

Case VI. An accumulation of cerumen causing pulsation in the ear.-W. E., Esq., aged 53, consulted me, in October, 1851, on account of a pulsation in the right ear whenever he reclines, but which ceases directly he assumes an upright position. He also complained of occasional singing in both ears. For these symptoms he had for some time been under medical treatment, but it had not succeeded in diminishing them. A mass of cerumen was found filling each ear, the removal of which improved the hearing greatly, and entirely removed the pulsation.

Case VII. A collection of cerumen in the external meatus; giddiness and other symptoms of cerebral irritation cured at once by the use of the syringe.-L. S. M., Esq., aged 43, consulted me in November, 1845. He stated that, five or six years previously, he had an attack of deafness in the left ear, attended with a considerable amount of singing noise; since that time he has occasionally felt deaf in the morning, but has usually recovered his hearing during the day, and at times, after blowing his nose, he has been deaf for a short time. Eleven months ago, after going into the open air from a warm room, a singing suddenly came on in the right ear, and has remained ever since. Lately he has had a sensation of weight at the top of the head, and frequent attacks of giddiness, which have caused him great alarm. While walking in the street, he has observed himself now and then to make "a lurch." Upon inspecting the ears, each meatus was found to be nearly full of hardened cerumen; which was carefully removed by means of the syringe. The symptoms immediately disappeared, and he had no recurrence of them. Another patient, an artist, who suffered in the same way, was so giddy that he was obliged to lean on the railings, and rest, on his way to my house. He was also unable to discern the features

of his "sitter" for more than a minute at a time, and had the greatest difficulty in writing an ordinary note. He likewise was cured at once by the removal of cerumen from each ear. A third patient was by the same means cured of a constant pain and numbness in the head in a fourth, the pain had extended down the back. The following case is also interesting:

·Case VIII. Confusion in the head, inability to walk straight, caused by a collection of cerumen.—Mrs. R., aged 45, consulted me in April, 1845. She stated that, four months previously, she first began to experience noises in the ears, which were followed by a great amount of deafness. These symptoms lasted seven weeks, and then disappeared for three weeks, at the expiration of which time they came on again, accompanied by a sense of confusion in the head. This, at times, was so bad, that not unfrequently, for a few seconds, she could not tell where she was. She has at times been so giddy, that she has reeled and fallen in the streets; and, at other times, she has not been able to retain her hold of things, so that they have fallen from her hands. On examination, a large compact mass of cerumen was found in each ear; which, after some syringing, was got rid of; and the operation was followed by the entire disappearance of all the symptoms.

In some cases, the hard mass of cerumen has pressed against the outer surface of the membrana tympani, with sufficient force to cause inflammation of its substance, and of the mucous membrane of the tympanum. When this has been the case, the application of leeches has been required before the head-symptoms entirely disappeared: in other instances, they have only gradually subsided, though, as a general rule, they disappear with the removal of the cerumen.

CHAPTER V.

THE EXTERNAL MEATUS (continued).

THE DERMIS AND ITS DISEASES.

1. ACUTE INFLAMMATION-a, ACUTE INFLAMMATION CONFINED TO THE DERMIS-TREATMENT-CASES, b, ACUTE INFLAMMATION EXTENDING то THE BRAIN AND ITS

MEMBRANES-TREATMENT-CASES.

2. CHRONIC INFLAMMATION, CHRONIC INFLAMMATION, WITH HYPERTROPHY AND EPIDERMIS-TREATMENT CASES. b, CHRONIC CATARRHAL

ACCUMULATION OF

INFLAMMATION-TREATMENT-CASES.

e, CHRONIC CATARRHAL INFLAMMATION EX

TENDING TO THE BONE AND TO THE BRAIN-TREATMENT-CASES. d, ULCERATION.

THE diseases to which the dermis of the external meatus is subject are:

I. Acute Inflammation, ending in resolution, discharge of serum, mucus or pus, or in ulceration.

II. Chronic Inflammation, with or without discharge, polypoid growths, or caries of the bone.

I. ACUTE INFLAMMATION OF THE DERMIS.

This is one of the diseases hitherto comprised under the term otitis. The external meatus is very sensitive, especially towards the middle. This sensibility is due to the dermis, which is abundantly supplied with nerves and blood vessels, and is covered by a delicate layer of epidermis. This membrane is liable to inflammation from many causes, such as the introduction of foreign bodies or acrid drops into the meatus; an accumulation of cerumen; the application of cold or of heat, especially when arising from sudden changes of temperature in the weather; or any debilitating illness.

The symptoms of this affection, at its commencement, are a feeling of fulness, stiffness, and uneasiness in the meatus, which is in

creased when the ear is pressed upon, or when the outer ear is moved by its muscles. This sensation is followed by pain, often very acute, although not so distressing as in severe inflammation of the mucous membrane of the tympanum: throbbing and singing often accompany the pain, and there is sometimes a diminution of the power of hearing. The latter symptoms are probably due to congestion of the middle and internal ears. With these symptoms there is generally a quick pulse, feverishness, and restlessness; and the pain sometimes extends over the side of the head. On examination in the early stages, the dermoid meatus is seen to be red, its bloodvessels being apparent through the epidermis. This redness sometimes extends to the dermoid layer of the membrana tympani, the vessels in the circumference of which become enlarged. Should the affection advance, the dermis becomes tumefied, so as to diminish the calibre of the meatus one-third or one-half, and the pain increases. In some cases, these symptoms subside without the formation of matter; in others, a copious secretion suddenly takes place, and is followed by such immediate relief that the patient thinks an abscess has burst. Examination, however, reveals the real condition of the meatus. The discharge filling the meatus having been carefully removed by the syringe, the surface of the tumefied meatus is seen to be of a deep red color, wholly denuded of epidermis, and in its place secreting a mucous fluid. In the severe forms of this inflammatory action, this secretion consists of mucus, which comes away from the ear as a large mass of viscid white matter, somewhat analogous to that secreted by the mucous membrane of the tympanum in cases of catarrh; the difference being, that in the case of mucous from the tympanum, the circumference of the mass is more filamentous, the color not so white, and the substance less consistent. After this discharge has continued for some days, it loses its viscidity, and becomes milky, remaining so as long as the affection continues to be chronic. When the inflammation is not very severe, the character of the secretion is always milky, not mucous. There are cases in which the secretion is thin, and nearly as transparent as serum; at times it is tinged with blood. The quantity of this serous secretion astonishes both patient and medical man. I have never had the opportunity of collecting the secretion, so as to be able to form a correct estimate of the quantity effused in twenty-four hours; but, judging from the saturation of handkerchiefs, linen, and pillows, it must amount to several ounces. The source of this large quantity