pressure or by inflammation everything in its way, collected under and around the lower portion of the brain, and destroyed life as we have said.

This case, with the results of the post-mortem, goes to prove several points in the study of diseases of the ear.

First, and most important of all is it to teach us to bear in mind the necessity of care in cleansing and treating all discharges from the ear.

Second, the very great amount of destructive inflammation which apparently insidiously may be going on within the ear, working the destruction of the brain without any particular constitutional disturbance, etc.

There are certain appearances and symptoms which can be observed in these various forms of mastoid disease, which will assist us in arriving at a correct diagnosis. In simple inflammation of the lining membrane of the bone, or periostitis, we have swelling, heat, redness, and pain not deeply seated, with great tenderness on pressure. If this condition is not attended with middle ear trouble, and only the external auditory canal is inflamed, we may be sure that the fibrous covering of the bone is involved.

In simple congestion of the mucous membrane, we may expect to find tenderness on pressure, deep-seated pain, and swelling of the integuments.

Chronic subacute inflammation is not characterized by any definite trains of symptoms. Its existence can only be proven by direct physical examination. Where there is sclerosis it is often recognized by the glistening appearance and the hyperostoses by the gradual enlargement of the bony cells, and they become filled up with solid material. The subacute form with congestion and the filling up with bloody matter, we have already illustrated by the cases reported. Brain symptoms, however, do not always indicate uniform pathological conditions, and, as in the case reported, they may be absent even when there is extensive caries of the parts with local meningitis. Facial paralysis may occasionally occur, and this indicates that the bony walls of the tympanum, through which the nerve takes its course, have become involved. There are cases in every-day practice in which local medication temporarily produces this result, or it may arise from simple pressure of pus or bone. Sudden diminution of the purulent discharge with pain is almost the first indication of acute mastoid inflammation. In some rare cases the discharge of pus takes place through the Eustachian tube, and the membrana tympani may be found entire, or the obstruction may be from granulations, which latter must always

be carefully examined with a bent probe, to try to discover any opening leading to the mastoid cells. Swelling of the (occlusion) superior or inferior wall of the external auditory canal has been noticed in a few cases. In most of them it seemed to be associated with caries of the bony meatus or neighboring temporal bone. The following case will illustrate this class of cases :

Mrs. Wm. H., aged 36, applied for treatment March 12, 1877. Mother and father healthy. The general health of the patient not good; has been married for a number of years; had one child, which died at the age of three months. The ear affected was the left. The duration of the disease in this ear was three years. Has been under the care of two physicians during that time.

Symptoms.-A boring pain in the head which has been almost constant during all these years.

Examination. Meatus very irritable and so narrow as not to admit the smallest speculum with prolapse of its walls. When a view was ultimately obtained of the membrana tympani it was found ulcerated with a large irregular perforation. Eustachian tube closed, middle ear filled up with pus and mucus, which could not be expelled by the patient. A loud ticking watch was not heard on contact. Tuning fork was heard. The throat and nose were irritable; touching the perforation of the membrana tympani would cause coughing, and a disagreeable sensation in the tongue.

Treatment.-Washing out the meatus through a long delicate silver speculum, introduced to keep the walls apart. Touching the orifice of the Eustachian tube with a 40-grain solution of nitrate of silver, by means of my Eustachian forceps, in the teeth of which was placed a small piece of fine sponge. The pharyngeal surface was washed with a solution of common salt and carbolic acid spray through the nose. Various means were tried to dilate the narrow meatus by means of compressed lint, sponge, and laminarium, but without an operation. Yet they all proved unsuccessful. Resorted to cutting down to the bone, with a spring knife, under the influence of ether. This was performed three times, and in the opening, pressure was afterwards kept up by carbolized lint. This course of treatment was kept up with the use of a wash of sulphate of copper, at home, which she was able to use through a long narrow speculum.

She commenced to improve, and continued to do so from March 31st to May 3d, when she had a return of her old pain, which was not relieved by large doses of bromide of potassium and chloral, so I visited her at her home, and again, for the fourth time, cut the contracted tissue. There was also a disposition to alarming chills, which accompanied the pain, and for these she took for some time a mixture of oil of turpentine and sulphate of quinia. Was free again until the 21st of May, when she had a feeling of fulness and swelling, but this yielded to careful washing out of the ear and opening of the Eustachian tube by means of chloroform vapor. By testing her hearing after the opening of the tube, it had increased to 1 inches.

On May 27th the patient again informed me that she was suffering pain in front, and behind the ear, also inside of the meatus with aural vertigo, and when asleep would wake up with a feeling as if the bed was moving and was falling. Removed again a collection of altered and retained secretions, also directed six leeches behind the ear, with hot foot bath, and increased the quantity of bromide of potassium. Had no return of these distressing symptoms during July or August, which she spent at Atlantic City, where I visited her twice a week, and later in the season she went to the mountains by my directions, and returned to the city in September, when she visited my office, for treatment, once or twice a week. Under this mode of treatment and careful attention to the state of her health, she is now, April 17th, so well that she only visits me once a month, is free from all pain or distress in her head, has no discharge to annoy her, and the meatus is so opened as to admit a good sized speculum, while the membrana tympani is healed; opens the Eustachian tube freely by her own efforts, and her hearing has increased to nearly one foot. Ordinary conversation can be heard without much trouble in that ear.

Remarks. When irritation or inflammation of the brain originates with a chronic affection of the ear, the cause of its extension to that important organ may be traced to the want of a free egress for the discharge of pus, blood, or serum. In the case above related the prolapsed external meatus with its tumefied walls created a barrier to the free outlet for the irritating secretion.

EXPERIMENTS AND OBSERVATIONS ON THE PHYSIOLOGICAL

PROPERTIES OF HYDROBROMIC ETHER.

BY LAURENCE TURNBULL, M.D., PH.G.,

AURAL SURGEON, JEFFERSON COLLEGE HOSPITAL, ETC.

IN the author's work,' published in March, 1878, there will be found four pages devoted to the bromide of ethyl or hydrobromic ether, describing its mode of preparation, physical and chemical action, also its influence upon man and upon animal life, and proving it to be a most valuable anæsthetic agent. It was first made for me by Prof. Joseph P. Remington, of Philadelphia, in July, 1877. It was the first preparation of hydrobromic ether made, and the first to be used on man in this country. Two men were anesthetized and were fully under its influence, for although M. Rabuteau' called the attention of medical men to it as a new and valuable anesthetic, he reported no experiments on man, but only on animals. This month, with the assistance of a medical friend, I have made a more extended series of experiments to determine more accurately its true physiological and therapeutic value.

The appearance of hydrobromic ether is like chloroform, but it is much more volatile and acts more rapidly when inhaled, producing less distress of the head and heart.

The odor of hydrobromic ether is much more agreeable than that of ordinary ether. A recent specimen prepared by Mr. Remington had a slight alliaceous odor, owing perhaps to a minute quantity of phosphorus which is employed in its preparation. The taste of this ether is not as sweet as that of chloroform, but sweeter and more pleasant than that of sulphuric ether. Hydrobromic ether is heavier than water; specific gravity, 1.40 (Löwig) vapor density,

The Advantages and Accidents of Artificial Anæsthesia. Being a Manual of Anæsthetic Agents and their Modes of Adminstration. By Laurence Turnbull, M.D., Ph.G., pp. 208. Lindsay & Blakiston, Phila., 1878. 2 Comptes Rendus, vol. lxxxiii. p. 1294.

3 Proceedings of the American Pharmaceutical Association, 1877, vol. xxv. p. 450.

3.754 (R. Marchand); boiling-point, 40.7 C., when the barometer stands at 757 mm. (Pièrre) sparingly soluble in water, but mixes in all proportions with alcohol and ether. Recovery from the effects of this ether is much more rapid than either chloroform or sulphuric ether; it is more like nitrous oxide.

It has the soothing effects of the bromides on the brain, and the same effects in relieving headache, ringing in the ears or tinnitus aurium when there is no permanent organic change. The dose is mx ter die. It has all the properties of sulphuric ether in reliev ing coloic flatulence and hysteria, also asthma and spasmodic cough. I have employed the hydrobromic ether by inhalation, and as injected vapor in a number of cases of tinnitus aurium, where in most of the cases the noises were of a nervous character and the result of functional disturbance, with success; but as the great majority of these cases of tinnitus arise and are kept up by an altered condition of the middle ear, the result of excessive secretion of serum, blood, mucus, or pus, these latter conditions must be relieved by local and general treatment in conjunction with the hydrobromic ether, etc. I prefer the hydrobromic ether to nitrite of amyl or hydrobromic acid, there being less risk than with the first, and it having yielded better results than the acid in my hands. The following case will serve to illustrate its advantages over chloroform as an anæsthetic, and for the relief of tinnitus before referred to.

CASE 1.-March 15, 1878, Juniata W., aged 18, residence Pennsylvania. Father living. Mother died of congestion of the brain. General health good, both ears affected. Ear most affected was the left. Duration three years. Presumed cause cold; lived near a damp mill; has also suffered from scarlet fever and measles. Has no pain in the ears, but has a rustling and pumping noise in her head. The only treatment which she has had prior to visiting me was washing out by syringing the ears. The meatus of both sides were free from even the normal secretion of cerumen; membrana tympani of both ears opaque, dull, sunken, and without any light spot. Eustachian tubes narrowed; pharyngeal orifices swollen, and the swollen mucous membrane on edges disposed to close the faucial opening. Nostril of left side swollen and collapsed. Hearing distance of right ear four feet with a watch of thirty feet. Hearing distance of left ear seven inches with the same watch. Stopping the ears produces dizziness. Is subject to vertigo from slight causes. Has chronic pharyngitis.

Diagnosis. Chronic catarrh of middle ear and tubes, with congestion of labyrinth and semicircular canals, etc.

Treatment.-Careful use of Eustachian catheter to inflate middle ear to remove the mucus. Attention to throat by means of spray

Tinnitus Aurium; Causes and Treatment. By L. Turnbull; 2d edition. J. B. Lippincott & Co., 1876.