838 nose, and thicken his speech. Before examining him it occurred to me, from his opening remark, that he had possibly a movable naso-pharyngeal polypus. He refers the sensation accurately to the situation of the tympanum, and states that it keeps constantly recurring for days, and then disappears for weeks without any apparent cause. His own words are, " It will suddenly fall and alter the whole tenor of my feelings at once, producing great mental depression." He is in the habit of removing

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... e sensation by closing his nose and mouth, and making a strong inspiratory effort. He states that if he is reading aloud or speaking, and the flapping occurs, his voice at once becomes thick and blurred, as the voice of a drunken man. I imagined that this was only an altered perception of the sound of his own voice, but he asserts that his wife and friends notice the change immediately it happens. He suffers, in consequence, greatly from depression, which is much aggravated at the periods of the aural movements, and which is distinctly relieved by strong tea or alcohol. At such times he has a craving for stimulants, and, in fear of yielding to this temptation, he has wisely given up all spirits, &c. He has perpetually a feeling of weight at the vertex, and a general 11 sleepy sensation " in the head. On examination the hearing distance in both ears was for my watch, which should be heard at ninety inches, half an inch, most distinct in the left; he also heard the tuning fork at about the same distance. The left membrane had evidently been the seat of repeated inflammations, and was thick and fleshy-looking, the malleus being undistinguishable. The right membrane was far more transparent, and on telling him to expire forcibly by Valsalva's method, the membrane was clearly seen to bulge out in two sections above and below the malleus, and he at once exclaimed that that was the sensation, though not precisely like that felt when it occurred spontaneously; on inspiring, the membrane fell back, apparently moving quite an appreciable distance. The impression given to the eye was like inflating and then exhausting a paper bag. No movements were visible, nor have they ever been felt in the left membrane. I am aware that such movements in a membrane weakened and thinned by repeated inflammations are by no means rare, as I have frequently noticed it before, though, as a rule, patients are not conscious of any unpleasant sensation. The membrane also frequently looks so thin and brittle, and the movement is so forcible, that I have been astonished that rupture has not taken place. I ordered an inhalation of aldehyde to be forced into the tympana by Valsalva's method, and chloral and aconite drops to be placed in the meatus; and on a second visit at the end of a week I was pleased, and to a certain extent surprised, to hear my patient tell me that the hearing was better, that the tinnitus was less, and that the feeling of cerebral oppression was considerably removed. The movements in the membrane were again very marked, though the sensations had not occurred spontaneously during the week : the treatment by inhalation, with the internal administration of bromide of potassium on subsequent visits, proved so successful that I did not consider it necessary to perforate, as I had contemplated doing; the movements, however, never entirely disappeared. The cerebral symptoms in this case are remarkable and probably depend upon some alteration in labyrinthine pressure, though it is difficult to determine in what way it is produced ; it is reasonable to suppose that symptoms may be produced either by increased or diminished pressure. It should be noted that the unpleasant feeling is diminished by drawing the membrane inwards; the hearing might be expected to be improved by this process, as pressure on a relaxed membrane does improve the hearing power in some cases. Meniere relates a case of a judge who habitually pressed a pin against the drumhead to enable him to hear : in this case pressure with a probe, and with an artificial membrane, produced no appreciable results. The rare condition of permanent patency of the Eustachian tube has some features slightly resembling those described here, and is also temporarily relieved by the inspiratory manceuvre. Sudden sensa. tions of movement in the ear are often mentioned by patients, and are sometimes described as improving, and sometimes as impairing the hearing power; in many old-standing cases, especially of perforation, the patient knows some little trick by which he can temporarily improve his hearing; these examples vary, however, so remarkably, that it is extremely difficult to obtain from them really trustworthy insights into the physiology of the internal ear. In the somewhat rare instances of collection of serum in the tympanum, the movement of the fluid is sometimes felt by the patient, and can be seen by the surgeon; in such a case paracentesis should be performed. The foregoing is not a typical case of " auditory nerve vertigo," which is usually accompanied by a sensation of falling, or an actual fall, generally to the side opposite the ear affected. I have known persons in whom sneezing, or violently blowing the nose, produced giddiness, and even severe falls. This is owing to the sudden rush of air into the tympanum exerting undue pressure on the fenestra ovalis and thence on the labyrinth. The subject of ear disease in relation to cerebral symptoms is one of great interest to the physician as well as the aurist, as probably many cases of vertigo, so-called bilious attacks, confusion in the head, hypochondriasis, and even insanity, might be traced to some quite unsuspected ear affection. Dr. Gowers has recently published some papers on the diagnosis of auditory vertigo, with cases, the causes of which might well have passed undiscovered had not the physician been on the alert to discover obscure aural symptoms. Dr. Rhys Williams has also lately published in THE LANCET a most interesting case of actual mania dependent on aural disease, the cause of which was only discovered after some months' stay in the asylum, and which was imme. diately cured by an incision. Other instances could be cited in which deafness and tinnitus suddenly arose without any apparent cause, and within a few weeks the patients became maniacal. Dr. Hughlings Jackson considers that almost any kind of ear disease may cause paroxysms of vertigo and reeling, with faintness and vomiting.