lining. He recommends trephining the mastoid process for their removal if they produce symptoms of irritation and cannot be otherwise removed. Whether the membrane is perforated or not, cases of this kind treated with continued gentle syringing and withdrawal of the successively protruding masses, aided by the use of Politzer's bag, will recover to all appearance perfectly, though the hearing may remain impaired. Some of the worst and most obstinate cases of perforation are caused by these masses ulcerating through the membrane; the destruction then commences generally at the upper part, and the symptoms, not so much of acute pain as of continued distress and brain irritation, are severe. In one well-marked case in which a healthy condition was regained after the repeated evacuation of large solid masses, the earlier stages of the affection seemed to be connected with a diseased tooth of the same side, from which a sudden pain shot into the ear, and the extraction of the tooth was followed by great temporary relief. Incision of the membrane seems indicated, but in the few cases in which I have tried it, the results have been negative. The diagnosis is difficult in the early stage, and the mass seems to tend to collect so much quite at the upper part of the cavity that its removal through an incision cannot be ensured.

5. Vegetable fungi are found within the meatus. The most frequent is the aspergillus (flavus, glaucus or nigricans); but besides this, penicillium glaucum, graphium penicilloides, and tricothecium roseum have been de

scribed; and a peculiar encysted form was met with by Meyer in 1844. Schwartze * was the first to make generally known the presence of aspergillus, and Dr. Wreden at St. Petersburg seems to have found it very common. It is the same as the mould that occurs on damp walls. Dr. Roosa is of opinion, not only that the

FUNGUS FROM THE MEATUS (after Blake).

fungus is always secondary to some disease that loosens the epidermis, but also that the disease is usually eczema. I think the occurrence of fungi in the meatus must be more common both on the Continent and in America than in England. Dr. Bezold of Munich brings ten cases to prove that the affection is due to the habit of dropping oil into the ears; and probably this practice is less common here than in some other countries. This view of the cause (which would represent the parasite as not necessarily depending on prior disease) is supported by the following case given by Dr. J. Green of St. Louis. A gentleman, æt. thirty-eight, remembered that two years ago an insect entered the right meatus. It was destroyed by "Arch. f. Ohr.," 1867, p. 7.

+ Ib., 1868, p. 1.

pouring oil into the ear. Eight months ago he was seized with pain in the ear and became deaf. The meatus was plugged with epidermic masses, including a small cockroach. The walls of the meatus were red and covered with flakes of adherent epidermis. Six months after the symptoms returned; the meatus was full of a white substance of exactly the appearance of cotton, mingled with a little pus. Dark specks appeared upon the flakes; and examination showed the mass to be identical with the blue mould formed upon a crust of bread.* Dr. Orne Green † reports his own case. He had several times suffered from furuncles, the last time nearly two years ago. During June and July, 1865, he was treating a case of aspergillus glaucus, and was at the time perfect in health and ears. In August he felt some ill-defined irritation in the ears attended by a slight serous discharge, just enough to be felt by the fingers, but soon ceasing. In November it returned with pricking, itching, and occasional slight pain and feeling of fulness in the

ears.

The meatus on each side showed patches of deep congestion and small white masses apparently of epidermis. Recovery took place in six weeks. Dr. Green tried solutions of carbolic acid, of soda, and of hypochlorate of lime. The latter he found very soothing. Wreden, from experiments, pronounces it the most powerful parasiticide; he recommends gr. ij to the 3j,

*"Tr. Am. Ot. Soc.," 1870.
+Ibid. 1869, p. 23.

freshly mixed on account of the chlorine and oxygen set free. Regular cleansing by warm water alone however seems to suffice for the cure. Dr. Roosa pencils the meatus with a strong solution of nitrate of silver to remove the inflammation. My friend, Dr. McCall Anderson, of Glasgow, also finds fungus in the meatus very rare; he recommends as a lotion Hydr. perchlor. gr. j—3j. In a case reported by Zaufal,* the fungus was found after the occurrence of a blue discharge, attended with bacteria.

6. Thickening of the walls, or their falling together from lack of natural elasticity, occurs in the old. The remedy is a small silver tube, about 2 inch long, and made to fit the meatus, with a small flat portion externally to lie in the concha. An abnormal formation of the cartilaginous portion of the meatus sometimes occurs also in the young, which is best remedied in this way; the tube appearing as it were slightly too long, and curved downwards. When the thickening due to chronic eczema is not removable, a similar tube is indicated. It is in such cases alone that the small advertised tubes are of

use.

7. Polypi occur more frequently with ruptured membrane, and will be spoken of hereafter; but a careful watch should be maintained for granular swellings of the superior or posterior wall of the meatus, which indicate affections of the bone. I have seen a case, unique

* "Arch. f. Ohr.," B. vi.

See Atlas, Plate xxv., No. 6.

in my experience, in which a polypoid mass appeared growing from the upper wall of a much enlarged meatus, and on its removal, which required, besides the snare, a continued application of caustics, there appeared a circular orifice in the bone, a third of an inch in diameter, the basis of which became, as the granulations disappeared, of a dull greyish hue and of an even surfaceevidently the interior of the horizontal portion of the mastoid cells; the probe could be passed in for half an inch without meeting firm resistance. The edges of the orifice were smooth, and no dead bone could be anywhere detected. The patient was a healthy girl of 12. The origin of the disease was ascribed to a blow on the head by a door during play. The membrane had lost its transparency and was of a dense bluish yellow colour, irregularly convex, the malleus seemed short and thick as if imperfectly developed. The other ear was natural. The hearing remained much impaired, but all active disease disappeared. The nature of the case appears to me obscure, but my thoughts tend to connect it with the idea of a sebaceous tumour, that had probably expanded the meatus and destroyed part of the wall, and had come away. At other times large fleshy growths are connected with caries of the posterior or lower wall of the meatus, and it becomes urgently necessary to prevent them from interfering with the free escape of pus.

Inflammatory affections of the meatus seem sometimes to result in complete closure of the canal. Dr.