tained within the cells, and give rise to urgent symptoms without any change in the external tissues. It is of the utmost importance not to delay too long; and since the ether spray will generally suffice to deaden the pain, incision over the mastoid process should be had recourse to promptly in every, even doubtful, case. I may repeat that I have never regretted making the incision, and scarcely ever decided against making it without regretting that I did not. 1 When threatening symptoms first arise, of course vigorous preventive treatment would be adopted: perfect rest, fomentations, mild aperients, sedatives at night, and the free application of leeches. By means of this kind, especially long-continued rest, cases of the gravest aspect have perfectly recovered. Mr. Prescott Hewitt reports the case of a young woman, in whom, after protracted symptoms of pyæmia thro' the lateral sinus, entire restoration was secured by good support.* * And the numerous cases in which large masses of dead bone, often including almost the entire labyrinth, have come away, with no permanent damage to the health, prove how strong are the recuperative powers, provided only free exit for discharge is secured and the strength sustained. Dr. Ogle mentions the case of a soldier, who suffered from aberration and noises in the ears. After two years a fetid discharge came on, and he became deaf. The discharge * "Pathol. Soc.," May 17, 1864. and deafness both ceased after a time, but he shortly died of phthisis and softening of the brain, and each tympanum was found diseased, the membranes being destroyed. It is probable that the starting-point of the disease here was in the ear. The patient had been often punished for malingering. CHAPTER XIII. PROLIFEROUS INFLAMMATION OF THE TYMPANUM; AFFECTIONS OF THE MUSCLES OF THE EUSTACHIAN TUBE. ELECTRICITY. THE class of affections which have recently been included under the name of proliferous inflammation of the mucous membrane of the tympanum (Toynbee's thickening and rigidity), constitutes a subject that needs a careful reconsideration. The symptoms which have been supposed to characterize it are similar, only less in degree, to those which indicate anchylosis of the stapes; and are mainly negative. The hearing becomes gradually impaired, tinnitus generally marking the onset and continuing, but as the rulé pain has not been present. In uncomplicated cases, or cases which have not advanced to secondary impairment of the nervous function, the tuning-fork is well heard on the teeth, and loudest on the worst side; closure of the meatus does not affect its sound. The Eustachian tube is open, and air enters on inflation with a dry harsh sound, seldom improving the hearing even for a time. Suction of air from the meatus may or may not diminish, momentarily, the tinnitus. The hearing is generally better in a noise. The membrane is whitish and shining, sometimes of normal curvature, sometimes seeming flat; it moves but slightly on inflation (unless thro' abuse of that practice it has been relaxed and bulges in excess). There is no history of colds, and the throat is not inflamed, but not unfrequently temporary relief has been given by the removal of cerumen. Dr. J. Gruber has given the most detailed account of this form of disease as it has been supposed to exist, and the following description is quoted from him.* "Occasioned by some injurious influence, there arises in some portion or the whole of the mucous membrane of the middle ear a great hyperæmia, with swelling, and, in fact, also a new formation of vessels, and increase of the intercellular fluid. The corpuscles of the connective tissue multiply by division, and perhaps through other processes also. These results now increase in the substance of the mucous membrane, the epithelium of which is swollen. It is generally less moist than in the other form, and the free exudation, which is formed in part from the protoplasma of the epithelium, is much less profuse; in many cases it is not discoverable. Sometimes the inflammation leads to increased formation of epithelium, which then undergoes farther metamorphoses, and may lay a basis for choleastomatous formations. "As the process advances, the newly-formed elements (which are either uniformly distributed or found in groups) receive partly or altogether a higher organization. By outgrowth and division of their processes, meeting with those of others, there is formed a complex, intimately-interlaced, soft connective substance, either distributed uniformly, or constituting single or manifold granular excrescences, or even running on to polypi. It should be expressly mentioned, that in the continued development of connective tissue and corpuscles, it often happens that they are not confined to their place of origin, but that they * 66 Ohrenheilkunde," Wien, 1872, p. 514. R extend to quite other surfaces, either by means of the epithelium of the part, or by their freer growth if that be already exfoliated. This occurs in the formation of polypi, but is shown still more strikingly in this affection by the connective threads and membranes which extend in every direction from one part of the tympanum or mastoid cells to another. "Thus far we have described the development of the newly-pro- . duced elements; but it must be observed also that many of these elements undergo a retrograde metamorphosis. They are molecularly disintegrated, become fatty, and are absorbed, or, as sometimes happens in very chronic cases, become chalky. "Even the newly formed, as well as the simply distended, bloodvessels ulcerate in the course of the process, whereby they are either reduced to simple fibres, or grow fatty or chalky, together with their contents, and gradually become absorbed." (Pp. 514-516.) SECTION OF THE MUCOUS MEMBRANE OF THE TYMPANUM FROM A CASE OF HYPERTROPHIC INFLAMMATION: it was thickened Dr. Gruber's treatment is as follows: "We must endeavour to prevent the farther development of the new formed elements, or even to destroy them. For this purpose we possess various methods, according to the portion of the tympanum affected by the inflammation, and the condition of the ear in other |