desire is to lay before the reader, if I can, the general aspect of disease when it affects the ear; to mention the best established results of examination and methods of treatment, but, above all, to suggest the many problems, some of them of the highest interest, which they open out. By this means, I may at least avoid the temptation to make a little knowledge, or a partial experience, spread itself over a large space, which ought rather to be recognized as still empty; and I shall have failed indeed, if it does not plainly appear that, so far from disease of the ear being a barren or unattractive field, it is one full of promise.

For to this conclusion, more than all, my own little study in this domain has led me; that if there have been in the minds of medical men anything of indifference in respect to diseases of the ear, or doubt of their power to relieve more than a few of its simpler forms, that idea is destined soon to give place to the feeling that very few fields of practice afford subjects of greater interest to study, or give a larger reward to the exercise of skill. Alike for the success which attends simple and easy modes of treatment, and for the pathological and physiological interest of those cases for which no yet known treatment avails, it cannot but

be that aural medicine will ere long cease to be a neglected, and become a favourite branch of practice; not in the hands of specialists merely, but in those of the profession at large.

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Scarcely anything is needed to make it so beyond the little trouble that would suffice to render the surgeon conversant with the appearances of the membrane; an end to which I trust the illustrations I have endeavoured to give of the morbid conditions of that organ, in the recently published Atlas of the Membrana Tympani," may in some degree contribute. I have felt it the less necessary to go into every detail of the subject, because of the recent publication of other works, of which such details must be a repetition; as for example the translation I have had the pleasure of making of Dr. Von Tröltsch "On the Surgical Affections of the Ear," and of Prof. Helmholz's "Treatise on the Mechanism of the Ossicula," for the Sydenham Society; and Mr. Dalby's "Lectures on Diseases of the Ear," which give an excellent outline of the subject. I may refer also to a very complete work, easily accessible in this country, Dr. St. John Roosa's Treatise on Diseases of the Ear." *

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Also not to repeat what is better told elsewhere,

* New York. Wood and Co., 1873.

I have, with few exceptions, omitted the anatomy of the organ. Nor do I profess to give accurately the credit of their discoveries to each author, nor even to mention the source of every statement made. Nothing is claimed as original. The chief part of our recent knowledge comes from Germany, with liberal contributions from America. But unhappily in the former country personal disputation runs so high, especially on the point of priority, that a foreigner may beg to be excused an inevitably unsuccessful endeavour to do justice. The names, among living men, of Bonnafont, Gruber Jacobi, Löwenberg, Lucae, Magnus, Moos, Politzer, Rüdinger, Schwartze, Triquet, Voltolini, Von Tröltsch, Weber, Wendt, Wreden, are held in honour by all whom the study of the ear has attracted, and a multitude of other names compete for our regard and thanks.

In the "Atlas" drawings are given of the membrane in many of the cases mentioned in this volume: a reference is made to them in each instance. The two books are, however, quite distinct. JAMES HINTON.

London, 1st March, 1874.

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THE QUESTIONS OF AURAL SURGERY.

CHAPTER I.

GENERAL OBSERVATIONS.

THE chief peculiarities of aural disease are determined by simple facts of structure: as, that sound is conveyed to the nerve of hearing by means of a cavity containing air, supplied from the throat by a somewhat long and narrow channel; that this cavity is deeply seated, is bounded both externally and internally by a thin vascular membrane, and is crossed by a delicately-jointed chain of bones. There are also some negative circumstances which are important; namely, that the nervous apparatus is inaccessible to direct observation, and is divided into structures of some of which the functions are at present a matter of doubt. Finally the nerve of hearing is, in its origin, intimately connected with the nuclei of the great nerves of the digestive and respiratory apparatus, and appears to have peculiarly close relations with the parts of the brain concerned in the emotions.

But it is to the part played by air contained within the

B

tympanum, in the conduction of sound, that the most practically important characters of aural disease are due. Generally speaking, the main object of the surgeon will be to see that this air-containing cavity with the passages leading to it are subject to no obstruction, either occluding their calibre, or impairing the delicacy of oscillation of the structures pertaining to them. As the conducting portion of the eye is a camera with lenses, so that of the ear is a pneumatic apparatus, and the surgical methods appropriate are corresponding in their character. Our business here is with the air-that the channels it should permeate be free; that the organs it bathes, and essentially supports by its pressure, encounter no hindrance in their reception and transmission of impulses.

Bearing these things in mind, aural surgery is simply surgical common sense, and needs comparatively little insistence on special points, beyond that which a trained surgical instinct would suggest. Owing to the structure of the ear, however that the tympanum lies so deeply, and is itself so irregular a cavity with its only outlet placed not at its most dependent portion, while, when diseased, its lining membrane pours out viscid secretion in extreme abundance-one duty lies on the surgeon, in treating the ear, with somewhat peculiar exigence that of ensuring a perfect cleansing. In every case connected with discharge his sheet anchor is cleanliness.

Another requisite is patience. In so far as the feeling,