the disease appears to yield to the ordinary remedies. What amount of subsequent deafness ensues or remains after all recognised syphilitic action has ceased, and so passes undetected as a result of that disease, I cannot offer an opinion. But I do not think that syphilis is among the frequent causes of obstinate obstruction of the Eustachian tube, because the classes among whom I have found this most frequent have certainly not been those most exposed to that cause. Of course, the cases of extensive ulceration obliterating the faucial orifices of the tubes by scars are not here referred to. (5) Albuminuria has been detected as a cause of tympanic disease in the form of hæmorrhage, but both this affection and diabetes remain as yet almost unexplored in this direction. (6) The convulsive affections of children also stand in a most important relation to diseases of the tympanum and of the labyrinth: sometimes a sudden affection of the labyrinth seems to be the starting-point of the symptoms; but more often a tympanic inflammation unsuspected is the source of fever and convulsions, which go on unrelieved for days until a sudden discharge from the ear reveals at once the source of the evil, and too often the irreparable nature of its results. (7) Especially the frequent dependence of inflammatory affections of the ear upon diseases of the teeth, and mostly of those of the lower jaw, should not be overlooked; and no obscure case of ear-affection can be considered sufficiently explored until the teeth have been thoroughly examined. (8) The relation also to disease of the ear of abnormalities of the cerebral circulation, of the poison of ague, of the climate of India and the effects of quinine, of exhausting attendance on the sick, of parturition and suckling, of overwork at school, of depressing emotions, of relationship of parents-these and many more are questions which the student of diseases of the ear has to do his best to solve; and not less important-but, indeed, in their practical relations more important-the effects, in their turn, of even lightly regarded affections of the meatus or tympanum upon the general health challenge his watchfulness. For nervous symptoms of the utmost apparent gravity may arise from mere abnormal pressure in the external meatus; and intense depression, amounting even to mania, has been known to cease with the removal from it of foreign bodies or cerumen. CHAPTER III. DISEASES OF THE AURICLE AND EXTERNAL MEATUS. IN respect to affections of the auricle I have very little to add to that which is well known. The effusionof blood known as Hæmatoma auris, occurring chiefly in the insane, has received a considerable amount of attention. Drs. Yeats and Needham* have reported cases to show that even when co-existing with pronounced insanity it is not so unfavourable a symptom as had been supposed; and the evidence that violence is generally concerned in producing the affection is becoming more considerable. Dr. Farquharson of Rugby also has observed a very similar condition in boys after football. On the other hand, Dr. Roosa quotes Dr. Hun as holding that the existence of such a tumour, not caused by violence, is sufficient ground for an expectation that insanity may develop itself even in a person perfectly sane; and Dr. Brown Séquardt has found that sections of the restiform bodies in the guinea-pig will produce hæmorrhage beneath the skin of the auricle, generally of the same side, in from eight to twenty-four hours; the * "Brit. Med. Jour.," July and August, 1873. hæmorrhage is soon followed by gangrene: sections of the sciatic nerve, by reflex action on the medulla, give rise to the same result, and Dr. Séquard has produced in his own person flushing of the auricle by pinching the sciatic nerve. He believes that disease of the base of the brain, which is however not always attended by insanity, is the cause of hæmatoma auris. And in this view it is noticeable that a temporary improvement of hearing has been reported as coinciding with its occurrence in a deaf patient. In respect to treatment, the balance of opinion seems to be in favour of evacuating the clot and using compresses.* The occasional occurrence of malignant disease will not be overlooked; nor the presence of small whitish deposits, rarely painful, of urate of soda, in obscure cases of gout. The external meatus is liable to occlusion, partial or complete, and to inflammation. Occlusion may occur from 1. Foreign bodies, or the larvæ of insects. 2. Cerumen. 3. Masses of hard epidermis. 4. Sebaceous tumours. 5. Vegetable fungi. 6. Falling together or thickening of the walls. * Dr. Yeats, loc. cit., June 21, 1873. Inflammation of the meatus is either diffuse, or local, or furunculous; to which may be added eczema and syphilis. 1. Foreign bodies are almost exclusively met with in children, the chief exception being that pins used to pick the ear by adults will sometimes slip in. This has happened two or three times to my experience, and the point of the pin being generally directed outwards is apt to penetrate the floor. I have not found difficulty in removing them when the meatus and membrane have been well illuminated. A firmly-holding forceps will grasp them, and the point to remember is to keep them well from the membrane. When other bodies enter the ears of children, it should always be borne in mind that there is one, and but one, great danger; the danger lest the surgeon should suffer himself to be drawn on into hurtful efforts at extraction. No one who remembers how great is the difficulty of abandoning a seemingly simple task in which he finds unexpected difficulties, probably under the eyes of anxious friends before whom an apparent failure will be intolerable, will suffer himself to take up any instrument for the removal of a foreign body from the ear, until after the most patient efforts to avoid it, and the most serious consideration of its absolute necessity. I must be pardoned for speaking earnestly on this point. Even to this day it remains the fact that ears are thus destroyed without shadow of |