object looked at may be seen, or the object may be doubled: the hearing in one or both ears may be diminished, or impressions may be produced not depending on external sounds: the taste or the smell may be rendered obtuse or vitiated, or some particular portion of the body may lose its common sensibility: convulsive actions may take place in some small portion of the body, or decided epilepsy may be induced: and though the cause of all these symptoms is fixed and increasing, yet the symptoms are generally transient, and in a remarkable degree capable of variation and interruption. As these chronic diseases increase, the mind gradually suffers, the memory becomes defective, the power of fixing the attention lost, and a state approaching to imbecility may in extreme cases be observed.

The most common exciting causes of chronic changes and tumours within the brain are blows and falls, which, more particularly where the tubercular diathesis prevails, often lay the foundation for that chronic action on which the development of tubercular growth depends; and if such tendency does not exist, still the violence may be so great as materially to injure or lacerate the brain, and thus prove a commencement of important structural change.

Treatment of Chronic Changes in the Brain.—When changes of this nature are suspected, we should endeavour by every means in our power to diminish the local action without injuring the powers of the system, which it will be more particularly desirable to maintain in that condition of the body which favours tubercular or scrophulous deposits. We have a double object in view: first, to retard the progress of the presumed morbid change or growth, and secondly, to prevent the attack and progress of that inflammatory action in the surrounding parts which is constantly to be feared. With regard to the first of these objects, it will be necessary carefully to avoid excitement, not

only such as under circumstances of health would be considered excessive, but even the excitement which arises from the ordinary avocations of life. All exciting conversation, all mixed society, all places of public amusement, and all social entertainment should be sedulously avoided, and everything which through the operation either of the body or the mind can induce over action or turgescence of the vessels of the brain: besides which, when the supposed disorganization is of a strumous character, all those measures are to be adopted which serve to strengthen the system, through the united influence of fresh and wholesome air, moderate exercise, and a mild generous diet.

When inflammation has begun to show itself, or there is any evidence of action being set up in or about the chronic disease, this must be met by leeches and cupping, or even if acute by general bleeding. Brisk purging, and blisters to the nape of the neck and temples, with other means of counter-irritation both near the head and in distant parts, and frequently repeated dry cupping will be of service. Cold should be assiduously applied to the head, and all the precautions adopted which serve to prevent cerebral excitement.

OTITIS.

OTITIS is an inflammation of the organ of hearing in any of its parts. The symptoms are pyrexia, and intense pain in the ear, extending over the head and face, with redness and swelling, observable in the meatus, but also invading the internal organ. This inflammation sometimes ends in resolution, but often goes on to suppuration, and not unfrequently passes into a chronic state, attended by discharge, which continues at intervals during many years. The acute form of this disease is marked by the most intense and agonizing pain, owing probably to the unyield

ing nature of the parts in which the inflamed tissues are imbedded: this pain often continues for some days, suffering aggravation and diminution according to the state of the circulation, and frequently becoming worse as the evening approaches: during this period of the disease the meatus is almost closed, and the sense of hearing is nearly lost. If resolution take place the alleviation of the pain is gradual, but if the disease goes on to suppuration, the discharge of a few drops of pus is followed by instantaneous relief; and although fresh formations of pus not unfrequently occur, yet the disease soon subsides: in other cases, however, more particularly when the inflammation has been the result of some weakening disease, as scarlatina, other structures in the meatus besides the cellular tissue appear to be affected, and the glands become so much deranged that their secretion is rendered acrid and altered in such a degree as to keep up a constant irritation in the part, which continues for years. This discharge either at length subsides, or by its constant irritation affects the deeper structures, often goes on to ulceration, and destroys the membrana tympani, or communicates with the cavities of the petrous portion of the temporal bone; and under the influence of some aggravating circumstances produces inflammation of the membranes and suppuration of the brain itself.

Morbid appearance.-While the disease is confined to the external parts, there are few opportunities of examining the state of the lining membrane of the meatus, which is thickened and inflamed, with no doubt effusion into the scanty cellular membrane beneath it, and this effusion becoming purulent. As there is no possibility of this effusion dilating the bony canal in which it is contained, the lining membrane necessarily advances upon itself so as nearly to close the meatus.

When the disease has assumed the chronic form, we find the lining membrane thickened, granular, or ulcerated; the membrana tympani frequently ulcerated through, and the internal cavity of the ear filled with an unhealthy puriform matter, sometimes of the thickness of curd, in which occasionally, although the tympanum has been destroyed, we find the bones of the ear still imbedded. All the cavities and canals of the ear are often filled with the same unhealthy secretion, which likewise pervades the cancellated structure of the surrounding bone. A small perforation is probably next found in the internal plate of the bone, from which, as from a centre, inflammation has attacked the dura mater, which is affected over a greater or less extent: sometimes a layer of pus separates a portion of the membrane from the bone; sometimes the membrane is in a state approaching to gangrene: perhaps only a small spot on the external surface of the brain and of the arachnoid shows marks of disease; but on cutting into the brain at that spot, which is generally in the middle lobe, a suppurating portion, sometimes of very large extent, is found. These appearances, however, which bespeak the destruction of a portion of the brain, vary much according to circumstances.

The predisposing causes are such as induce an inflammatory condition of the system; neglect of the bowels; and unwholesome modes of living, especially in persons of a strumous habit.

Exciting causes.-The most frequent exciting cause is exposure to cold, from currents of air striking on the ear, particularly when the body is heated by previous exercise; it is likewise occasionally the result of Cynanche, the inflammation extending itself along the Eustachian tube, and thus involving the internal structure of the ear. It also follows the excitement of some debilitating diseases, more particularly Scarlatina and Rubeola, in which the mucous and fol

licular apparatus are strikingly involved; and not unfrequently it is a sequel of continued fever; in all which cases it often attacks both ears either together or in succession.

Prognosis. In the acute form of the disease, arising under ordinary states of the body, and when no particular cerebral derangement exists, very little danger is to be apprehended; but when the disease has assumed the chronic form, attended with otorrhoea, there is considerable ground for apprehension that sooner or later its extension inwards. will involve the brain and its membranes in fatal mischief.

Treatment. The indications of cure are to reduce inflammation, to allay pain, and to restore the natural tone and action to the parts which have been left weakened or deranged by the disease.

In the early part of the disease, therefore, while it is acute, the strictest antiphlogistic treatment is to be adopted. It is not very often necessary to have recourse to general bleeding, but in some cases this may be employed, although in general ten or fifteen leeches behind the ear may be substituted with advantage. Brisk purging is always desirable, first with a dose of calomel or blue pill, quickly followed by a senna mixture, and afterwards with the saline purgatives. The acuteness of the pain, defying all rest or sleep, often demands the aid of an opiate, in which case it should be combined with some diaphoretic, as for instance, eight, ten, twelve, or twenty minims, or more, of the liquor opii, or of the tinctura opii, according to the age and circumstances of the patient, with two or three drachms of liquor ammon. acet., and a scruple or half a drachm of the liquor antimon. potas. tart., taking care to obviate the constipating effect of the opiate by a purgative. While these remedies are being administered, warm local applications are to be assiduously employed, of which the poppy fomentation or a soft poultice are amongst the best.