selves as to the progress of the medicine. Another early symptom is, a slight discoloration of the mucous membrane upon the inside of the cheeks: it loses its fresh, red colour, and becomes whitish, particularly opposite the crowns of the lower teeth, the indentures of which soon manifest themselves upon it, and in a short time, if the medicine be not lessened, ulceration will ensue in that locality. One of the first places, however, where any breach of surface occurs upon the mucous membrane is immediately below the red border of the under lip, opposite the junction of the gum with the lower incisors. About the same time the tongue becomes slightly swollen, and its edge deeply indented with the lower front teeth; it is of a greyish-white colour, and covered with slimy saliva. All the glandular apparatus within the mouth is then excited to excessive action; the papilla of the sublingual ducts become swollen and erect, and the ulcerations upon the inside of the lower lip and opposite the buccal glands upon the cheeks present the appearance of aphthous sores, greyish in the centre, with a slight straw-coloured margin; and saliva, mixed with mucus, pours from every possible outlet. As, however, these observations are not intended as a dissertation on the pharmaceutical preparations or therapeutic effects of mercury, but are here put forward in order to explain its applicability to certain diseases of the ear, it would be out of place to enter into an exposition of the means best calculated to correct its illegiti mate action either upon the mouth or gastro-intestinal membrane.

In the more chronic or subacute forms of aural disease—often where the mucous membrane is extensively engaged, or when congestion, more than inflammation, is present-mercury is a valuable remedy, either as an alterative or to keep up sustained but gentle action on the mouth; and in such cases the milder preparations, such as the hydrargyrum cum creta, in combination with cicuta, will be found advantageous.

The third, and perhaps the most efficacious form, in which mercury may be used, is that of the bichloride, still commonly known in this country as the oxymuriate, one of the most valuable medicines of the entire Pharmacopoeia. A treatise might be written on the virtues of this remedy, and the vast field of dis

Combined with

ease over which it exercises a sanative influence. Peruvian bark-which the chemists say is incompatible, but the product of the decomposition said to be produced by which, may be the very substance which acts most beneficially—it is almost a panacea for most of the strumous inflammations in children and young people; and its power in controlling scrofulous ophthalmia, corneitis, and iritis, &c., extends equally to the cure of kindred affections in the ear. It is the best remedy I know of for inducing absorption of lymphy deposits in the membrana tympani, and general thickening and opacity of that structure, as well as very old cases of chronic inflammation of the membrane of the cavitas tympani. It is, moreover, when properly administered, one of the safest as well as the surest preparations of mercury: it may be taken for a great length of time; it seldom interferes with the ordinary occupations or amusements of the individual; it leaves no ill effects; it rarely induces ptyalism; and patients improve in health, and absolutely grow fat while using it.* It may be given alone, either in pill or dissolved in nitrous ether, proof spirits, or some of the tinctures, such as cascarilla, but it is much more soluble in distilled water than is generally known; it may be combined with the muriated tincture of iron with good effect, or with some of the preparations of sarsaparilla; but bark-either the tincture, syrup, or decoction-is of all others the medicine best suited for its administration. Our Dublin preparation of the syrup is, particularly for children, a good vehicle for it, provided the mineral is first dissolved in a little distilled water. Oxymuriate of mercury and bark sometimes disagree, producing, shortly after being taken, pain in the stomach, tenesmus, griping, and even diarrhea; in such cases it will generally be found that it was taken before breakfast or on an empty stomach; it should therefore be administered an hour or two after meals. But when it disagrees, even with such precautions, a separation of the constituents will obviate the unpleasant effects: thus the mercury may be taken an hour or two before or after the bark. From the sixteenth to the eighteenth, or even a quarter of a grain, may be taken three times

* I understand that the bichloride of mercury, in large doses, is used to fatten and improve the condition of horses in the West Indies.

a day, according to the circumstances of the case, for weeks and even months together, with, however, short intervals occasionally.

Deafness has been attributed to the over-use and abuse of mercury, and I was myself once under the impression that such might happen, from having seen some cases of almost complete loss of hearing in persons who, it was stated, had taken large quantities of mercury for a long time. I have recently made particular inquiry after these cases, and I have carefully examined the membrana tympani in each, and in every case I found it thickened, opaque, and manifesting all the appearances consequent upon deposits between its layers, the result, no doubt, of specific inflammation. Each of these cases were originally syphilitic, and exhibited evident traces of a scrofulous taint, and they all acknowledged that they had taken the mercury most irregularly, and had been for years affected with secondary symptoms. I think it yet remains to be proved that mercury produces inflammation of either the eyes or ears. Practitioners of the present day have received, as by a sort of hereditary tradition, and still entertain the idea that mercury will produce iritis; and the homœopaths flourish the assertion whenever and wherever an opportunity offers, as a proof of the grand principle of their doctrine. Is it a fact that mercury taken for the cure of other diseases than those which will of themselves induce inflammation of the iris, the sclerotic, or choroid,-such as syphilis, rheumatism, gout, or scrofula, has ever caused the train of symptoms of internal inflammation of the eye generally known as iritis?

The preparations of iodine and potassium may be employed in aural affections, and will be found efficacious just as they act on the general health or the diseases of other organs; so likewise with cod-liver oil. The only medicine I know of which appears to exercise an influence upon tinnitus aurium is leopard's bane, the arnica montana, formerly much in use for rheumatic affections, and as an external application in sprains and bruises. The value of this and other remedies in diseases of the ear, as well as their mode of administration or application, will be explained when speaking of the diseases to which they are applicable.

97

CHAPTER III.

STATISTICS AND NOSOLOGY OF EAR DISEASES.

Statistics of St. Mark's Hospital.-Analogy between Diseases of the Eye and Ear; Amaurosis and Nervous Deafness.-The Author's Table of 2385 Cases: their Diseases, Ages, and Sexes.-Kramer's Statistics, their Value and Peculiarities.-Tscharner's Statistics.-Toynbee's Pathological Investigations.-The Author's Abstract of 200 Cases.-Proofs of Inflammatory Action in Ear Diseases.-Nosological Arrangements of Galen, Buchanan, Harvey, Deleau, Kramer, Pilcher, Lincke, &c.- The Anatomical and Pathological Bases.-The Author's Classification.

THE

HE subject of vital statistics has of late years engaged the attention of the scientific world more than at any former period, and within the last few years the statistics of ear diseases have been noticed by a few Continental writers. As, however, some time must elapse before an exact knowledge of aural diseases is arrived at, and until their nomenclature is fixed, such variety must exist in the accounts of different authors as to lead to apparent discrepancy, if not to a semblance of ignorance. It is not as in general medicine or surgery, where there is but little danger among educated practitioners of mistakes in registering cases of fever, pneumonia, peritonitis, or calculus ;-in diseases of the ear, what one practitioner would call nervous deafness, another might believe to be the result of some organic lesion consequent upon inflammation, &c.; and so the proportion which the different diseases bear to one another or the whole would vary according to the mode of registering, and the amount of knowledge and peculiar opinions of the registrar. As therefore statistics involve nomenclature, so does the latter subject lead us to the consideration of nosological arrangement.

The earliest and most complete statistics of ear diseases published in these Kingdoms were, I believe, those appended to the Report of St. Mark's Hospital for the year 1844-45. Since that period as accurate a registry has been kept of all the cases which presented as the means and appliances at any public

H

institution can afford, and the results thereof have appeared from time to time either in the Annual Reports or in the public journals. I do not think it possible to keep a sufficiently accurate account of all private patients, and therefore none such are included in these returns. From the 1st of March, 1844, to the 1st October, 1852, as shown by the accompanying Table at page 102, the number of ear patients whose diseases were registered amounted to 2385;-besides very many others of whose disease no note was taken at the time.

When I first commenced the study of aural diseases, I believed that in most cases where I had no positive evidence of disease in the meatus or membrana tympani, the deafness and tinnitus were caused by some defect in the nerve of hearing, or what is termed "nervous deafness." As, however, my field of observation extended, and as my knowledge of the healthy and morbid appearances of the membrane improved, I gradually began to find that the instances of deafness with perfectly healthy tympanal membranes which fell under my observation were comparatively few: while I daily became familiarized with a variety of pathological appearances in these structures, which I was soon convinced were the result of different forms of inflammation of an acute or chronic nature, arising from some idiopathic or specific cause. These appearances naturally led me to pay particular attention to those diseases in their early stages, the only period at which, in most of them, art can be of any avail.

As the acquisition of knowledge is progressive, so my means of forming an accurate diagnosis improved with my experience, and therefore the value to be attached to the early years included in this Table is not so great as that for a later period. I have consequently divided the results into two portions: the first including three, the second four and a half, years. In the first portion of the Table, out of 706 recorded cases, 85 were set down to "nervous deafness," which I am inclined to think was an exaggeration, as by a more carefully conducted examination, and with increased experience, I found but 18 cases out of 1679 in the second period; having observed since the former period that many of the cases attributed, for want of a better name, to "nervous deafness,"