the desired object was not, fortunately for the sufferers, obtained. Even Kramer speaks of pushing a catgut bougie, introduced through the Eustachian tube, " between the handle of the malleus and the incus"! People are, however, beginning to find that this attempt for I know in many cases it is only an attempt-to force solid or fluid substances into the cavity of the drum, is as ineffectual to remove deafness as the almost indiscriminate excision of the tonsils since preserved in pickle-pots-recommended for a like purpose a few years ago, has proved to be. I have heard of cases in which the middle ear has been said to be explored by such mechanical means, even in this country, and I have been shown steel sounds manufactured for the purpose. Such instruments are, however, with the exception of the tearing and inflammation which they may cause in the nasal extremity of the tube, harmless, for they could not by any possibility, even in the dead subject, be passed through the upper end of the Eustachian tube. We should bear this rule ever in remembrance before exploring the middle ear; it is one which Sir A. Cooper observed to me many years ago, and I have ever since acted upon it:Whenever the patient is himself able to inflate the tympanum, never use any artificial means to do so; it is unnecessary and may be injurious. Let me to this aphorism add another, to which I have already alluded, and which surgeons would do well to remember. Where there is reason to believe that the cavity of the drum is inflamed, carefully abstain from all poking with catheters, or any attempt to introduce foreign substances into that delicately-organized portion of the animal machine. As good general surgery teaches us to avoid the introduction of instruments through an inflamed urethra, or into an irritable bladder, so ought judicious aural surgery teach us to abstain from meddling in the cases to which I have alluded. The only solid instrument with which I now ever venture to explore the Eustachian passage, and that for only a short distance, is an ivory bougie, rendered flexible by having the earthy matter removed by immersion in an acid, and the point of which for an inch at least had been previously softened in water so as to resemble a piece of gelatine. A large-sized catheter should be first introduced, and the bougie passed up

through it; but stricture of the Eustachian tube is so exceedingly rare, and so difficult to recognise during life, that the surgeon is very seldom called on to practise such an operation.

In connexion with Eustachian catheterism should be mentioned, the mode of injecting fluids for the purpose of washing out the tube and the middle ear, in case of impaction of the former, or mucous accumulation in the latter; and of introducing gases, etherous vapours, resinous and other volatile substances, for the purpose of altering the condition of the mucous membrane, or stimulating the nervous expansion on its surface. A simple elastic bag, with the nozzle adapted to the end of the catheter, will, for those who may be inclined to practise it, effect all that is required or that can be attained by syringing out the tympanum: in general I believe the fluid seldom reaches that point, while it causes great irritation by regurgitating into the throat; but in order that it may have a fair chance of going into the middle ear, the catheter ought to be fixed by the frontlet as already described. Supposing we may with safety explore the Eustachian tube, and endeavour by artificial means to press a column of air or a jet of fluid into the middle ear, and thereby free it of its extraneous contents, and restore to its natural position the vibrating portion of the tympanal membrane, it will be of little avail to effect these objects,-as it would be merely to press out the contents of the lachrymal sac in a case of mucocele, or chronic inflammation of the mucous membrane of that cavity,unless we at the same time make use of such means, both topically and constitutionally, as shall restore the healthy character of the lining membrane, which evidently participates in the diseased action, and of which manifest traces are observable upon the external aspect of the membrana tympani.

For vaporizing the tympanum a variety of ingenious contrivances have been invented, especially by the continental aurists, consisting of air-tight jars containing gas, connected with the catheter by elastic tubes, or vessels shaped like retorts, in which the substances to be vaporized are placed, fixed upon the ordinary chemical stands over spirit-lamps. These shall be more particu

larly considered in the section relating to "nervous deafness," the disease for which such fumigations are said to be applicable.

In the previous description of the method of examining the external and middle ear it has been presumed that the external auditory conduit is free; it may, however, and it often does, happen, that we are unable to explore the passage, or obtain a view of the membrana tympani, owing to obstruction of the former with cerumen, collections of hair, or thickened and detached epithelium, the muco-purulent secretion consequent upon otorrhoea, or foreign bodies of any description; and therefore it is sometimes necessary to have recourse to the operation of syringing merely to assist our diagnosis. Simple as this operation may appear, and frequently as it is resorted to by uneducated persons, it is one which requires some degree of tact, caution, and dexterity, in its performance.

To avoid slopping in syringing the ears, I have found the form of vessel represented below very useful: it is metallic, six inches long, four broad, and two deep; its concave part fits accurately the curve beneath the lobe of the ear, and the perforated septum strains the clean water from the dirty. If held by the patient in the proper position, closely applied to the cheek, no water can get down by its side.

The top of the auricle should be grasped with the left hand, and drawn slightly upwards, outwards, and forwards, so as to assist in straightening the auditory canal; and then we can inject

a steady stream of water, the thumb raising and depressing the piston by means of a brass syringe, capable of holding three or four ounces of fluid, but so constructed, as shown in the accompanying cut, with a pair of loops attached to its upper extremity, through which the fore and middle fingers are passed, that it may be worked with facility by the right hand.

This instrument is, however, only suited to the hands of a surgeon. The small pewter, bone, and glass syringes are really of little or no use. The gum-elastic bag is the safest for general use; but I do not think it possible for any one effectually to syringe his own ear.

In some persons, syringing, or the mere introduction of a speculum, induces violent paroxysms of coughing; in others, the simple act of injecting tepid water will produce syncope, although such patients tell us that it is not from the pain they feel. The removal of a granulation, or a small polypus from the external auditory passage, will at times produce sickness of stomach, weakness, and even fainting.

There is a circumstance connected with this part of the aural examination worthy of attention. We often observe that, during the removal of wax, in syringing or in any way interfering with the meatus, the patient is seized with a fit of spasmodic coughing, apparently caused by some irritation in the larynx, and we can reproduce the phenomenon simply by the introduction of a probe, and touching ever so gently a particular spot upon the surface of the meatus. This is not a very unusual phenomenon, although it cannot be produced in all cases. I never witnessed it in children or very young persons; it is most common in males of about middle life, and is in no wise connected with any previous disease existing in the respiratory apparatus. In some persons the

slightest touch of the floor of the external auditory passage, about midway between its external outlet and the inferior attachment of the membrana tympani, will bring on violent irritation and spasmodic action in the larynx. In this case also the patient will generally tell us, upon inquiry, that he does not experience pain; but that the moment we touch this very sensitive spot he feels a tickling sensation in his throat, which immediately increases to the feeling one has when "a bit is gone astray." What the nervous connexion may be which induces this has not been fully determined, but the fact is worthy of note. The different degrees of sensibility of the several parts of the external ear are worthy of remark. For further particulars on this point, and also as reregards syringing, see the section on Cerumen in Chapter IV.

The effort of coughing, sneezing, blowing the nose, and deglutition, in causing or increasing pain, is also to be particularly attended to, if we suspect inflammation in the drum or the Eustachian tube.

There are two methods of examining the ear, on which, from their frequency in this country, I am induced to make some remarks, in the hope of putting a stop to practices not only useless, but in some cases positively injurious. I allude to the common. habit of syringing indiscriminately, and also of probing the ears, without proper inspection of the parts. The former is of daily occurrence; thus a patient labouring under deafness, or, what perhaps is worse, violent pain in the ear, is examined either without the assistance of a speculum, or by means of some of the old divaricating instruments, most probably in a badly-lighted apartment,—at all events, without the membrana tympani being brought into view, a dark cavity being all that the explorer is able to perceive;-it is deemed advisable to try what might come out by squirting hot water into this dark passage for a quarter of an hour or longer; but, nothing satisfactory following this operation, the diagnosis that there is no wax in the ear is accordingly made. Now, there may be a collection of cerumen, which may not be got rid of by this operation; while, if the cause of the pain or deafness is owing to an inflammatory condition of the auditory canal and its membranous extremity, a decided in