that the inflation draws the stapes from the vestibule, which in the normal condition it does not. In one case I found inflating the tympanum produce a marked improvement for the voice, but at the same time a decided diminution of the hearing for the watch. It was a case of chronic catarrh with polypus growing from the meatus. As it recovered, inflation by the bag improved the hearing both for voice and watch.

CHAPTER XI.

DISEASE OF THE EAR IN CHILDREN.

In some respects, this is the most important part of the whole subject of diseases of the ear. Not only are aural affections most frequent during early life, but in even the majority, probably, of cases of confirmed deafness at a later period, the foundation is laid then. The affections of the ear in infancy and youth also are often full of peril; and finally remedial measures are more efficient then than at any other period. It is a reasonable belief that if fair care were given to ear disease in childhood, half, at least, of the disease which affects that. organ in manhood would never exist. For it continually happens that adults come before us, dating back their deafness a few months or years at most, to whom we say at once, because the condition of the ear betrays it: "You had disease of the ear in childhood;" and find that there existed then a long-continued discharge, for instance, or repeated attack of earache with deafness following.

It is the constant practice of medical men to say to the parents of children who have discharge from the ear, or otherwise suffer in it, that they will grow out of the

affection. In the great majority of cases this may be true; in some it certainly is so; but also in others the discharge does not cease, nor the hearing return, but the latter becomes progressively more impaired, and the former continues for thirty or even sixty years. What we want is some basis on which a judgment can be formed, which of the affections of the ear in childhood will advance to a spontaneous recovery, and which will not. It is impossible that such a basis ever should be gained except by a careful examination of the ear in every case-a task which must devolve upon the general medical practitioner. The most probable supposition is that those cases recover well in which there is free escape for all morbid secretion; and that those in which such escape is impeded continue diseased.

The Exanthemata, as is well known, are the great enemies to the ear in childhood. Their chief result is partial destruction of the membrane, and more or less chronic inflammation of the whole mucous tract behind it. But in their severer forms they do much more than this: scarlatina, especially, often totally abolishing the hearing not only with, but even without, visible injury to the tympanum. Next, or perhaps equal in frequency to scarlatina in this respect, stands mumps, which has an effect on the nervous apparatus of the ear which has yet received no explanation, and affords no clue to the use of remedies; every part of the ear being normal, so far as examination can extend, but the function almost abolished.

But some cases of damage to the ear from mumps present an intermediate character, showing clear signs of a tympanic disorder mixed with the nervous symptoms. The similarity of the nerve affection that follows mumps to that which ensues upon parturition, is very striking; and the resemblance is increased by the fact that quite frequently the latter affection also is accompanied with symptoms of a catarrhal character.

I have had a few opportunities of studying the mild attacks in children which are called earache, and are followed by a slight discharge; and in the cases I have seen. the affection has been a subacute catarrh of the tympanum, with a small perforation of the membrane, soon healing.

May, 1863, I saw a girl, æt. 10, of good constitution, but subject to intermittent albuminuria that had continued since scarlatina two years previously. During a cold she had had an attack of pain, lasting a few hours, in the left ear, which was seen to have at first a flat and slightly dull aspect; afterwards red vessels were visible on its surface, both radiating and around the circumference, and it presented also a peculiar appearance chiefly at its upper part, being marked by faint oval outlines, which appeared to arise from bubbles in contact with its inner surface. The hearing was much dulled. In another week the membrane had become less vascular, but it was decidedly concave, the stapes being plainly visible and apparently in contact with its inner surface. The tympanum was gently inflated twice. The membrane lost its vascularity, and the hearing in a few days became good, but not perfect. (Two feet for a watch heard on the right side at six feet.) Just twelve months after, on May 17th, she woke again in the night with pain in the left ear, followed the next day by a watery discharge. There was a little fever, and the hearing was reduced to ten inches on the right side, and four on the left. The left membrane was white and thick. A saline powder

was ordered, and a lotion of three grains of borax. Four days after, the ears being quite easy, there was syringed from the left meatus a small mass of soft flaky discharge, and a circular orifice about the size of a large pin's head was seen at the lower part of the dull white membrane. The next day the orifice was smaller and of an oval form: four days after, it was scarcely to be detected as an orifice, but appeared as a small dark point with somewhat thickened white edges, but air passed through it with a slight dry sound. In three days more no trace of it was visible, and air inblown entered the tympanum with a hollow puff, not escaping. The right ear in this instance was involved as well as the left, being indeed the more deaf of the two, and the membrane becoming for a time uneven, and of a dull, dark grey hue, with a slight tinge of pink.

This is an example of a large number of cases which pass almost or entirely unobserved. There was nothing in the symptoms indicative of anything more than an ordinary slight discharge from the ear. The recovery seemed perfect, though the hearing continued for a long time slightly impaired.

It is interesting to note the presence of an excess of fluid in the tympanum twelve months before the occurrence of the perforation.

Thus, it is probable that perforation of the membrane takes place in slight infantile affections much more often than would be supposed. In one case which followed an attack of bronchitis three months previously, in a boy of four, a bulging of the membrane, of a deep red colour, took place at the upper part. There had been pain, not very severe, for four nights, and the upper and posterior part of the membrane, including the greater portion of its extent, was seen of a bright pink colour, and very promi