Abstracts of the Gulstonian Lectures on the Nature of Fever

own responsibility contain mineral astringents in considerable quantities, as they sometimes cause great pain, aud excite inflammation as soon as they reach the perforation. If it is thought that the expulsion of the discharge from the tympanum through the perforation tends to keep open the perforation, let it be remembered-(and it is a matter of common knowledge) that if a membrane is inclined to heal, nothing of this kind prevents it; of this fact we have ample evidence in the case of perforations made for remedial purposes in cases of chronic proliferous catarrh; and it surely is desirable in the instance of perforation caused by disease that at the time when this happens as little as possible of the products of inflammation should be left within the tympanic cavity. And now in regard to the tolerance or intolerance respectively which perforations of long standing exhibit to well recognised and useful applications. Take for example the case of alcohol. Many perforations with unhealthy edges, discharging in large quantities from the tympanum, at once become more bealthy under the use of alcohol in various dilutions ; but to some, alcohol, even extremely diluted, is most painful and irritating. This is especially noticeable if the perforation is of small size. How can it safely be said in a general way that alcohol is a good treatment for perforations ? The same may be said of iodoforrn or boracic acid. What satisfactory results either of these applications often produce in old perforations with bone granulations and a fcetid discharge ! But the fact that they occasionally set up irritation is enough to prevent me, and probably many others, fromn recommending them when the patient is subject to pains in the head, especially if these pains are chiefly on the same side as the perforation. The tolerance and intolerance of all forms of artificial membrane or support which perforations show is so well recognised that it is hardly deserving of mention; and the excellent hearing and improved local condition of the perforation is perhaps better known than occasional intolerance which some perforations show to its employment; but the following case will perhaps illustrate so well what I might term the behaviour of a perforation under treatment that I relate it. About fifteen years ago, a gentleman had perforations of both membranes after scarlet fever. On the right side all hearing was lost and the psrforation healed. It was then found that on the left side (he being extremely deaf with this ear), he could obtain excellent hearing by the use of a cotton wool pad, which he learned to apply to the perforation. This he habitually used during fourteen years spent in active work which necessitated good hearing. Finding one day that the pad did not give the usual result, he tried various applications without avail. Having noticed that the pad was very dry when it was removed, he proceeded, on his own account, to irritate the ear in several ways in order to produce a discharge. Amongst other plans which he tried, onie was by dipping the pad into turpentine. This was soon followed (strangely enough, without any pain) by a discharge, and on again adjusting the pid, he heard well for several days Finally, nothing succeeded; the ear became dry and he was deaf. When I saw Min, I found, as he told me was the case, that the perforation ha(l healed. The size of the old perforation was markedly shown and filled up with new tissue. After I had made an incision into the membrana, and after a great deal of trouble, the new tissue disappeared, leaving the old perforation as before, and he could again use the pad with efficiency, and without the tendency to heal being shown. Could anything illustrate better than this little history the behaviour of perforations ? One might almost say that it is necessary to make use of our experience to anticipate their moods, and even then we shall be often wrong in our surmises. What is needed, however, to treat satisfactorily perforations of the membrana tympani, anid many other forms of chronic disease, is the intelligent co-operation of the patient, and whoever is the subject of them must patiently learn to manage himself. When it is remembered that by careful management the hearing may fre. quently be made and kept good enough for the ordinary purposes of life, and, more important still, the patient may be often kept free from the dangers which have a fatal ending, it is not trouble ill-spent. Of all the many forms of perforation, some of the most troublesome are perforations of Shrapnell's membrane, and the most difficult to treat are those in which there is evidence of caries. The easiest to treat are perhaps those in which the perforation has arrived at a dry state without any discharge, a state which it may retain for many years if not interfered with ; then a masterly inactivity, as shown by leaving it alone (it may be permitted to say for this perforation, if for none other) is the best of all treatments. ABSTRACTS OF