death from bronchitis, from heart disease, from hooping cough, from croup. And in cases of tuberculosis of the brain, I found more than once collections of apparently tubercular matter within the tympanum and mastoid cells.

But the most remarkable fact that has been ascertained respecting inflammatory conditions of the ear in childhood, is one of which every one who has dissected the ears of infants has had proof, but to which Von Tröltsch and Wreden have paid most attention: namely, that in much more than half of all children dying of affections of the lungs or brain, the tympanum, generally on each side, contained pus, and its lining membrane was inflamed and swollen.* Dr. Von Tröltsch found the ear normal but in thirteen cases out of forty-six, and Wreden out of eighty found but fourteen healthy. But the membrane was never perforated in Von Tröltsch's cases, and only once in Wreden's. The oldest of the children was 14 months.

It should be observed that these results were found among the poorest classes of the community, chiefly in the inmates of foundling hospitals. But Von Tröltsch states that whenever the ear was healthy there was no other pathological appearance; and Wreden's opinion is that in more than half his cases the pus that was present in the tympanum had given rise to consecutive affections which were often the direct cause of death. The signifi

* "Diseases of the Ear:" by Dr. Anton Von Tröltsch; translated by Dr. St. John Roosa. Pp. 392, 408.

cance of these facts cannot yet be estimated; and especially the relation in which the aural affection standswhether as cause or mere concomitant-to the other morbid conditions and the death of the child, remains for future determination. I would venture to suggest, merely as a hypothesis, that the condition is less one of inflammation than of mere breaking down; or, rather, is identical in character with the purulent condition which so often arises in the tympanum in the last stage of phthisis; that it is, therefore, probably almost unaccompanied by pain, and is rather a symptom of dissolution than a primary constituent of disease. At the same time it

may be true that from it there start, in the weakened condition of the child, the most serious secondary results; but not local treatment but general support, or rather such maintenance as should save the patient from ever sinking into the already almost moribund condition in which the aural affection has its root, would be the true remedy. A cause for the tympanum being specially subject to this degenerative process may perhaps be found. in the active "developmental" changes which take place in it during the first period of independent life. Von Tröltsch showed that before birth the tympanum is completely occupied by a cushion of cellular tissue, and Wreden found that its absorption is normally completed within twenty-four hours after birth. Possibly this process, when the vital power breaks down, may be prone to lapse into a purulent degeneration. One slight circum

stance may tend to confirm this supposition, namely, that the internal surface of the membrana tympani, which has less part in forming the pre-natal "cushion," participates very little in the morbid change.

That a frequent cause of deaf-mutism is to be found in the occurrence of these conditions of the tympanum, hardly admits of doubt. And there is another class of cases that strongly claims the attention of all under whose care infantile diseases come, those, namely, in which a child becomes deaf after "convulsions." Frequently, in such cases, when the hearing is totally destroyed, marks of inflammation within the tympanum are betrayed by the appearance of the membrane; nor can any form of eccentric irritation be well imagined more likely to express itself in convulsive seizures.

There is yet another peculiar affection of the ear occurring in children, the true significance of which is yet undetermined. Voltolini first drew especial attention to it, and described it as being an inflammation confined to the labyrinth, but involving both sides. The symptoms are those of acute fever with implication of the brain-of meningitis in a word-but after a few days they all disappear, and no result whatever remains except total abolition of the hearing. The tympanum shows no sign of disease. The question is whether the affection is one involving the brain or membranes-whether, for example, it is to be regarded as a sporadic cerebro-spinal meningitis or whether the labyrinth alone is its seat. The

chief argument in favour of the latter view is, that an affection of the central organs severe enough to produce the acute initial symptoms, and to entirely abolish the power of hearing, could not pass away so rapidly and leave no other effects. On the other hand, an extreme degree of deafness, for which no reasonable treatment suggests itself, remains sometimes after an attack of cerebro-spinal meningitis: some such cases I saw after the late epidemic in Ireland; and Dr. Down* has lately reported a case in which during an attack of this disease a paralysed condition of several of the motor and sensitive nerves was present, and among the other symptoms was deafness on the right side. On recovery the deafness alone persisted. Unfortunately, the state of the tympanum appears not to have been examined; but supposing it healthy, as is most probable, to what cause should the non-recovery of the hearing alone be ascribed?

* "Brit. Med. Journ.," Feb. 7, 1874.

CHAPTER XII.

AFFECTIONS OF THE BRAIN, OR PYÆMIA, RESULTING FROM

DISEASE OF THE EAR.

THE frequency with which fatal effects follow inflammatory affections of the ear has long attracted attention, Mr. Toynbee having especially thrown light upon their nature and pathology; so that it is no longer necessary to dwell upon the importance of the subject. The fatal result is the consequence either of caries, affecting the brain or vessels by continuity, or of poisoning thro' the veins of the diploe; or abscess may form in the brain in the neighbourhood of an inflamed tympanum without caries or any apparent means of propagation of the morbid action. In addition to these results, fatal hæmorrhage has taken place from ulceration alike of the carotid artery and of the lateral sinus. When caries of the roof of the tympanum exists, it is often covered with a thick layer of lymph, the value of which as a preservative against the spread of the disease has been pointed out by Mr. Prescott Hewitt; and I have observed, in dissecting petrous bones in which the tympanum had been long diseased, that a new deposit of bone had been formed beneath the dura