the long curved scissors (figured on the preceding page) half an inch of the points of which alone are cutting, and the whole of which measures five inches; or by the small double-edged knife; or the curved one represented at page 296; all of which, as well as the toothed forceps, can, when the growth is of small size and fully exposed, be used with freedom and effect through the tu bular speculum. These instruments are figured a third less than the natural size.

The best instrument for the removal of aural polypus from any portion of the meatus is the small snare-like apparatus here represented, consisting of a fine steel stem, five inches long, and

bent in the centre, for the reasons explained at page 57; with a moveable bar sliding on the square portion near the handle, which latter part fits over the thumb, as shown in the cut. The upper extremity is perforated with holes running parallel with the stem; and loops at the angle serve the same purpose. A fine wire, fastened to the cross bar, passes through these loops and holes; it should be of such a length that, when the cross bar is drawn up tight to handle, the ligature is fully on the stretch. Having tried wires of different materials,-silver and platina, and of various degrees of strength and flexibility, I have found that fine steel wire of No. 24 grist, with the temper taken out of it by heat, is far the toughest, most flexible, and least apt to cut. In making this instrument, the loops at the side and the holes at the top should be very smooth, and their edges bevilled off, so that the wire will not scrape or cut in running through them. The thumb piece and

For the history of this instrument, see the author's Essay upon the Causes and Treatment of Otorrhoea, page 52; and also that upon the Inflammatory Affections of the Membrana Tympani and Middle Ear, page 10,-both referred to at page 51 of this work. This snare removes gelatinous polypi from the nose with much greater facility, and with very much less pain and injury to the parts, than the ordinary forceps used for that purpose.

may

cross bar be formed of German silver. In using it the cross bar is pushed forward, and a noose made of the wire at the small extremity, of sufficient size to include the morbid growth, which it is then made to surround, and towards the root of which it is pressed by means of the stem; the cross bar is then drawn up smartly to the handle, while the point of the stem is pressed downwards; and it never fails of either cutting across or of drawing with it whatever was included in the noose. Bleeding generally follows, upon the subsidence of which we should syringe the canal with tepid water, and again examine the ear, and if possible discover what portion of the polypus may remain, which, whether it be the mere point of attachment, or a portion inaccessible to instruments, should be touched with the armed porte-caustic, and the same application applied from day to day until all traces of the morbid growth have vanished. Unless this latter point of practice be strictly and perseveringly adhered to, it is in vain. that we can expect a total eradication of the disease; no more however, of the auditory apparatus should be submitted to the action of the caustic than the actual granulating or fungous surface. I have frequently seen the whole canal in a state of ulceration, and an erysipelatous inflammation extending over the entire auricle, from a stick of lunar caustic having been inserted into and rolled round in the meatus to remove a polypus or fungous growth, the eradication of which had already been frequently attempted by instruments; a practice as cruel as it was ineffectual.

Some practitioners prefer the potassa fusa and various other caustics for the removal of these growths; but, with respect to these and all other remedies of a like character, I can only say, that after a very extensive trial during many years of the snare and the solid nitrate of silver, I have never found them to fail in eradicating polypi, no matter of what description.

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Dr. Evory Kennedy, in his paper upon uterine diseases,* commends the use of the nitrate of mercury in the treatment of polypoid growths and ulcerations of the os uteri; but my experience of all such applications to the ear is, that they are too deliquescent,

* See Dublin Quarterly Journal of Medical Science for February, 1847.

and their action cannot always be limited. Astringent lotions will not cure aural polypi.

CARIES.

The third and most frequent complication and consequence of otorrhoea is caries. Necrosis of the bony case of the ear is not an unfrequent, and is always a dangerous, attendant upon, or a source of, aural discharge, but here a doubt arises as to what the original disease was, whether it proceeded from otitis, spreading to the periosteum, and thence to the bone,-or from inflammation of the mucous membrane extending from the drum into the mastoid cells. This latter mode is what I believe frequently takes place in those cases when, after the continuance of otorrhoea, the mastoid process comes away; and there are several pathological specimens which tend to confirm this view.

Instances of the loss of the whole or a portion of the mastoid process are by no means uncommon; the preparation represented

in the accompanying wood-cut, and which forms the entire bulk of the mastoid process, a large piece of the petrous portion of the temporal bone, including the posterior wall of the middle ear, and one of the semicircular canals, was removed in my presence from a child three years of age, by Mr. Cusack, in the Dispensary of Steevens' Hospital, in the year 1833. Having had charge of that case for a considerable time subsequently, my attention was then first called in an especial manner to aural affections. Cases of this description, however, the result of extension of disease from the meatus and middle ear, are not to be confounded with inflammation of the periosteum of the mastoid process, occurring idiosynchronously, nor of abscess taking place underneath it, nor between the dura mater and the bone, upon a corresponding portion of the internal surface of the cranium.

The splendid pathological collection of the Richmond Hospital, in this city, contains five most interesting and valuable preparations of disease of the temporal bone, and one of these is in exact accordance with the view which I have expressed above. The

subject of this affection, aged 16, was idiotic, and nearly deaf and dumb. For some months previous to her death she had pain in and semi-purulent discharge from both ears, and was also frequently attacked with fits of epilepsy. Death took place suddenly. Professor Smith, who laid the case before the Pathological Society, stated, that on the right side, the membrana tympani, the malleus, stapes, and incus were all destroyed, and the mastoid cells contained purulent matter. "The left side presented a very remarkable specimen of disease of the mastoid and petrous portions of the temporal bone. Above the meatus the temporal bone was perforated by a large opening, which communicated on one side with the cavity of the tympanum, and on the other with the mastoid cells. All the partitions of the mastoid cells were destroyed, and the whole cavity thus formed was filled with fetid pus, mixed with particles of carious bone. The purulent matter had also penetrated into the vestibule, the cochlea, and the aqueduct of Fallopius. The foramen rotundum, and fenestra ovalis, were thrown into one large opening. On tracing the nerves, it was found that the portio dura, where it passes through the aqueduct of Fallopius, was covered with lymph and purulent matter of a greenish hue. The dura mater covering the anterior surface of the petrous portion of the temporal bone, was slightly discoloured, but there was no pus in the vicinity. The great lateral sinus upon the same side presented the appearance of commencing inflammation; the lining membrane was of a dark-green colour, and the blood in the sinus was coagulated. There was in this case no paralysis or distortion of the face."

Had injections been used in this case, or had art interfered with it in any way, and had no examination been made after death, it would, among the disciples of Itard, have been set down as one manifesting the deleterious effects of stimulating applications; or, had even milk been injected, it would, as well as the linseed oil already referred to, have been forthwith expunged the aurist's pharmacopoeia.

Instances of caries of the temporal bones producing death, as the effects of otorrhoea, might be multiplied without end. The preparations in the Richmond Museum exhibit the process of the

inflammation, death, and separation of the bone in its various stages, all sooner or later affecting the head. In these, and I am led to believe in the great majority of other instances also, the destructive process had proceeded from without inwards, and what was originally an otorrhoea from an inflamed mucous and periosteal membrane spread from thence to the bone itself.

A very remarkable case of otorrhoea and death caused by caries of the petrous portion of the temporal bone, has been recorded by the late Dr. Graves. The subject of it was a scrofulous boy, ten years of age, who was admitted into hospital for dropsy and diarrhoea, of which he was relieved-" when it was observed that there was paralysis of the right side of the face, but obvious only when the muscles of the face were in action. Thus the attempt to close the eye failed on the affected side. There was a discharge from the ear of the same side, which originated seven years previously. The opinion formed of the case was, that there was disease of the petrous portion of the temporal bone, and that with this was connected the affection of the portia dura of the seventh pair, from which the paralysis might be considered to result. There was pain in the head to the right side, which after some time changed its place, and moved to the back of the head, and from this time the discharge from the ear ceased. The pain then moved down the spine. A few days before death there were tetanic convulsions, and an extreme sensibility of the entire surface of the body. Three years before there had been similar convulsions. The power of locomotion and the intellect continued to the last unimpaired. During the few days which intervened between the first appearance of the convulsions, and his death, they had recurred five or six times. The body was examined after death. Within the skull a perforation was observed in the dura mater, immediately opposite to the aqueduct of the vestibule, in the petrous portion of the temporal bone, which was

It is with heartfelt sorrow I have now to speak and write of Dr. Graves in the past tense. Since my previous notice of this distinguished physician, the science of medicine at large, and the Irish nation in particular, have experienced a loss which is not likely to be replaced in the lifetime of the present generation; and the author has been deprived by death of one of his earliest, firmest, and best of friends.