Edinburgh has not contributed much towards aural surgery. I know of but one special work on diseases of the ear which has issued from the Press of that ancient and celebrated School of Medicine since the time of Degravers, viz. "Treatise on the Accessary Organs of Hearing, comprising the Special Pathology and Treatment of their Diseases, by James Mercer, M.D.," which was written, I understand, as a probationary essay for the Fellowship of the College of Surgeons in 1840. In the Monthly Journal for March, 1848, will be found a very useful paper on the pathological sequences of acute inflammation of the fibro-mucous structure of the cavity of the tympanum, by the same author.

In the Monthly Journal of Medical Science for 1845 and 1846, Dr. A. Warden, "Aurist in Ordinary to the Queen," published papers on the Inspection of the Meatus Auditorius Externus. This gentleman fixed to the ordinary tubular speculum a prism for the purpose of polarizing light, -a totally useless addition. In 1847 he promised a work on the subject, of which the following is the advertisement, as it appeared in one of the Scotch newspapers:" In the Press, and shortly will be published, the Nature and Treatment of Diseases of the Ear, as more fully revealed by the Prismatic Auriscope; with fifty coloured Delineations of Natural and Diseased Conditions. With the Prism in our hand we may now go forward as with a torch powerful enough to dispel all obscurity, and to enable and entitle us to plant the union-jack of the profession on the whole domain in the usual form of maps and delineations of disease.'-Preface." Neither work nor preface ever appeared, and criticism of the dead would now be ungenerous.

While these pages are passing through the press, Mr. Harvey, of London, whose writings have been already alluded to at p. 35, has issued another work, entitled, "Rheumatism, Gout, and Neuralgia, as affecting the Head and Ear; with Remarks on some forms of Headach in connexion with Deafness." In it the author appears to be under the impression that he is entitled to originality for his views, my answer to that will be found at pp. 225 and 267. The literature relating to deaf-dumbness will be considered in the section bearing on that subject.

E

What is the legitimate aural practitioner in the present day, and how far does his art extend over disease? A practitioner in aural surgery, or, if it pleases the public to call him, an Aurist, in our day must, or at least he ought to be, a well-educated surgeon or physician, who applies the recognised principles of medicine and surgery to diseases of the organs of hearing, in the same manner as the modern ophthalmic surgeon does to diseases of the eye. We daily hear and read, and it has been reiterated from mouth to mouth, and copied from work to work, that the treatment of such affections is an opprobrium to the healing art, "in surditate quidnam est male," and that deafness is without the pale of human knowledge. Now notwithstanding the injudicious treatment by quacks and nostrum-mongers, the neglect of patients, and-as in many instances we know it is-the total abandonment of all treatment by the general practitioner, still, were the statistics of all diseases carefully collected, it would be found that there were among them as many curable cases of affections of the ear as there are among the severer maladies of the eye, or among diseases of the chest, the brain, the liver, or any other organ. Up to a very recent period, from well educated medical men in this country either considering it beneath their station or acquirements to treat so insignificant an organ specially, or not finding in the direct cultivation of aural surgery a sufficient remuneration for their time and talents, this branch of the healing art remained in the state in which ophthalmic surgery was half a century ago. All this added to the smaller share of sympathy afforded to the deaf than the blind; to impairment of hearing interfering less with man's means of subsistence, and also to the great difficulty of either minutely examining during life, or of investigating after death, the morbid changes which occur in the middle and internal car-serves to account for aural surgery and pathology not having kept pace with the other rapid improvements in medical science. Yet the well-instructed aurist of our time possesses a knowledge and a power which is not general among the profession-of making an accurate diagnosis, which, when given with honesty, will frequently save the patient much anxiety, unnecessary suffering, and loss of time and money.

Plan of the Work.-Records of Cases.-Means of forming a Diagnosis, and mode of Examination.-Physical Signs.-Instruments and Remedies.-The Auditory Canal and Membrana Tympani.-Lamps, the various forms of. The Speculum.-Eustachian Catheterism.-The Stethoscope.-Syringing.-The Hearing Distance.-The Throat. The Voice.-Tinnitus.-Subjective Symptoms.-Depletion.-Leeches.Counter-Irritation.-Galvanism and Electricity.-Mercury, &c.

HAVING in the preceding chapter offered some remarks upon the subject of Aural Surgery generally, and given a short outline of the history of the art, I will now explain the plan which I have adopted in the following chapters. At the commencement of each I have given a brief anatomical description of the parts concerned in the affections under consideration, and a concise account of their most remarkable malformations and congenital diseases; afterwards, the etiology and treatment of those diseases with which I am myself most familiar are described. I have followed that division into the diseases of the external, middle, and internal ear, because it seems to facilitate description, as well as to make the most lasting impression on the mind of the student. The work concludes with a section on deaf-dumbness, which contains the result of the inquiry set on foot under the Irish Census Commission for 1851, and which I have compressed from the official Report upon that subject.*

From 1843 to the present time I have published several essays and monographs on diseases of the ear in the Dublin Journal of Medical Science, the Dublin Quarterly Journal, and the London Medical Times.† The substance of these essays, modified by sub

See also the Author's paper on the Statistics of Deaf-dumbness, communicated to the British Association at Belfast, September, 1852, and published in the Journal of the Statistical Society of London, for March, 1853.

The earliest of these essays-Upon the Causes and Treatment of Otorrhoea,—that by which the tubular speculum was first introduced in this country,-appeared in the First

sequent knowledge, and amplified by whatever improvements had been made in the art since their publication, I have reprinted in this work. Those diseases of the ear with which I am not myself acquainted I have briefly enumerated and described, and given the references for their authenticity.

In an art but just emerging from the mists of quackery, which have until recently enveloped the pathology and treatment of diseases of the ear, it is of great importance to accumulate facts, and openly, fairly, and fearlessly to state the truth, even at the expense of what is termed popular reputation. Observing in the periodicals, from time to time, records of "cures" of deafness, and aural affections, which evidently prove their authors to be unacquainted with the ordinary pathological appearances of such diseases; and moreover, seeing daily "causes of deafness" put forward in books and papers, which, according to my experience, rarely, if ever, exist; and furthermore, hearing, and having continually brought under my notice (although, curious to relate, generally by persons who are themselves incurably deaf), accounts of success in the treatment of deafness in other parts of the United Kingdom, which I do not and cannot credit;—I determined to make an accurate note of every case of disease of the ear among the patients who applied at the Hospital for twelve months in succession. I believe it to be of the greatest importance, in the present state of our knowledge, to accumulate facts, and to make the profession at large acquainted with the appearances which any deviation from the normal or healthy state presents in the ear; and I have also thought it useful to familiarize the

Series of the Dublin Medical Journal, for January, 1844, vol. xxiv. p. 318, as Part 1. of "Contributions to Aural Surgery." This Essay, which met with a very favourable reception on the Continent, was translated into German, and published separately by Dr. Von Haselberg, of Stralsund, in 1846, and afterwards large portions of it were translated by Dr. Schmalz, of Dresden, in 1848. Part 1.-Upon the Early History of Aural Surgery, with a Nosological Chart of Diseases of the Ear, already referred to at page 47-was published in the same periodical for May, 1844. Part III.—On the Inflammatory Affections of the Membrana Tympani and Middle Ear-was printed in the Dublin Quarterly Journal of Medical Science, No. vIII., for November, 1847, and No. XI., for February, 1848. The Practical Observations on Diseases of the Ear, with the records of cases alluded to in the text, were commenced in the Medical Times for March 29th, 1851, and have been continued until the present time.

pupils attending the Institution over which I am placed with those methods of examination which will best enable them to form an accurate diagnosis and prognosis.

Each case, as it presented, was accurately investigated in the presence of a class of advanced students and young medical men; the most prominent symptoms were noticed, the pathological condition of the parts demonstrated, and a few remarks made upon the cause of the disease, its prognosis, and treatment. Occasionally the students, under my direction, conducted the examination. A short-hand writer, familiar with medical terms, who was always in attendance, recorded with accuracy what passed. These notes, when reduced to writing, I myself corrected, and frequently compared with the appearances presented upon the patient's next attendance. By this means a vast amount of time and labour was saved, and the diseases being thus noted by myself, without the usual intervention of a "case-taker," I believe them to be more accurate than those usually related in medical writings. By this means a vast amount of information was collected. In most of these clinical cases a running comment is, as might be expected, mixed up with the description,—a more colloquial, but perhaps not less useful, form of instruction than that commonly met with in medical books and periodicals.

As far as progress and the effects of treatment are concerned, many of these cases are very defective, because, in a large public Institution, as every one knows who is extensively engaged in treating the poor, it is not possible to follow out their history. Several of the persons applying for relief, having little hope held out of ultimate restoration to perfect hearing, do not return a second time; others are kept away by their respective avocations; and many of them, having changed their residence, have found it inconvenient to attend. Unsatisfactory as these drawbacks are, and must always be under the like circumstances, I think the publication of an abstract of these cases will be so far useful, by enabling the profession to judge from what causes deafness most usually arises, and what morbid appearances most commonly present. Some of these cases, exhibiting types of disease, have already appeared in the "Medical Times."