In noting these cases, in some instances the objective, and in others the subjective symptoms, have been first recorded; but the accounts which even educated people give of the history of their deafness are frequently most incongruous, and often puzzling; and the apathy and indifference with which persons in all ranks of life have allowed the insidious approaches of aural disease to creep upon them are really marvellous. Mr. Saunders, with whose valuable essay upon the ear I wish the profession were better acquainted than they are, remarked upon this subject, in his own peculiar lucid manner of expressing himself, nearly half a century ago:-"A clear and distinct recital of symptoms is rarely obtained from the deaf. They are conscious of their infirmity, but very few are impressed with a notion that hearing may be impaired by a variety of causes. The approach of deafness is insidious, and often unaccompanied with pain. Few strong impressions are made on the mind of the patient, and he loses his faculty of hearing so imperceptibly, that in general his friends sooner discover his misfortune than himself."

With respect to the mode of conducting the inquiry in the Hospital cases, I may remark, that where a patient presented with a totally Incurable disease, a second note has rarely been recorded; indeed, the patient has always been discouraged attending the Institution. It is less likely to bring discredit upon the art when people are honestly told that, owing to their own neglect, or to their improper treatment, the time has passed by for affording them relief, than to allow them to continue for weeks or months in attendance, and often at a great expense of time. This observation holds good in private practice even more than in the management of institutions, or in treating the poor.

As in all diseases, so especially in aural affections, the first grand point is accuracy of diagnosis, without which all treatment must be empirical, and to arrive at which it is indispensably necessary that we should be thoroughly acquainted with the best mode of conducting an examination. For that reason, and because it is in it I find both the practitioner and student most frequently at fault, I have in the following pages dwelt at greater length and entered more minutely into that part of the subject, than is usual in works of this description.

Passing for the present the subjective symptoms, which will best appear in the words of the patient, let us inquire into the best method of forming a diagnosis from the physical signs presented. The patient being placed opposite strong, direct sun-light,with the head inclined at such an angle that the sun's rays may fall directly through a tubular speculum upon the membrana tympani,-we first carefully observe the condition of the concha, external meatus, mastoid process, infrazygomatic region, and the space immediately below the lobe of the ear. The auricle, its various folds, its colour, its temperature in particular, its thickness as learned by feeling its hem or helix between the fingers, and the angle which it forms posteriorly with the cranium,—together with the position, size, shape, and colour of the external meatus, as seen without altering the relation of the parts,-should be specially noticed. The upper rim of the helix should then be grasped between the finger and thumb of one hand, and drawn upwards, backwards, and outwards, while the thumb of the other hand, placed in front of the tragus, by drawing it and the integuments forward upon the zygoma, exposes the outer third or more of the auditory canal to view. This little gorget-like instrument will also be found useful in examining the external aperture. The finger should

then be pressed deeply and firmly upon the moveable root of the tragus, and backwards into the depression between it and the articulation of the jaw. While the finger is retained in this position the patient should be desired to open and shut the mouth, and the amount of pain or inconvenience experienced by pressure in those two different positions of the jaw accurately noted. The middle and fore-fingers should likewise be inserted deeply behind the ramus of the jaw towards the styloid process, and notice taken of the sensations there experienced.

Where we have reason to believe inflammatory action exists, the mastoid process in an especial manner claims our attention. Its colour, size, shape, and temperature, may be learned by even a

cursory examination; but, besides this, it should be most carefully pressed upon with a couple of fingers, with a much greater degree of force and firmness than is usual in making examinations of the like nature elsewhere; and this examination should not only be applied to the mastoid region, but to the whole posterior and lateral portion of the head, if we have reason to suspect any inflammation, or its effects. The insertion of the sterno-mastoid, as well as the upper third of that muscle, should also be carefully examined in the same way, as there is a small gland, in shape and size like a horsebean, situated immediately behind the auricle, over the middle of the mastoid process, which frequently becomes enlarged during the progress of aural inflammations, and is also the seat of violent neuralgic pain in some instances. If the integuments and soft parts are swollen or oedematous, as is frequently the case in certain inflammatory affections of the car, as also where they have be come thickened from long-continued disease, it will require a considerable degree of force to make a perfectly satisfactory examination. The amount of pitting made by the finger during this examination, and its degree of permanency, are also circumstances of value in the formation of a diagnosis. Percussion of the mastoid process, immediately behind the attachment of the auricle, occasionally affords some information, as will be shown in some of the cases hereafter detailed.

We next proceed to inquire into the condition of the auditory canal, and external surface of the membrana tympani. To effect this, and to explore every portion of the surface of these parts, it is necessary to resort to the mechanical assistance of the speculum; first taking care to remove any impaction of wax, accumulated discharge, or other mechanical impediment which may exist and obstruct our vision. If this obstruction is complete, and that we have reason to suppose that it is the chief cause of deafness, the employment of a syringe and some plain warm water is the best mode of removing it; but if the obstruction merely co-exists with other, and particularly with some of the inflammatory affections of the meatus or tympanal membrane, or if it be only partial, and consists of portions of detached cuticle, hairs, or scales of hardened, inspissated cerumen, it is better to remove these gently with a

pair of fine forceps, because the very act of syringing, even with warm water, causes in a healthy ear an increased vascularity, which will mask the actual amount of disease present. The same observation applies also with respect to slight otorrhoea, but if there be much discharge present, we must have recourse to the syringe. Having found that the handles of the instruments introduced through the tubular speculum and the fingers of the operator interfere to a certain degree with the direct sun-rays, I have latterly had instruments constructed with an angle in the shaft, as shown in the accompanying view of a pair of ear forceps, the utility of which is at once manifest.

Up to a very recent period we possessed no better means of examining the external meatus and the membrana tympani than that afforded by the usual ear speculum, made somewhat in the form of a crane-bill forceps, and derived, with various modifications, from the time of Fabricius Hildanus. Itard, Deleau, Verret, Robbi, Kramer, and others have improved upon this speculum, which was that in general use in this country until I introduced the tubular form in my Essay on Otorrhoea. Another description, with three arms, and opening by a screw in the form of a vagina speculum, was manufactured by Mr. Weiss, on the supposition that the external auditory passage could be increased in caliber by mechanical means, and Hoffman has published an account of a somewhat similar instrument in "Casper's Wochenschrift" for 1841. In making examinations of the meatus and membrana tympani with any of these instruments, the chief requisite is a strong direct light, transmitted without interruption to the tympanal membrane, or that portion of the passage which we wish to examine. This is best effected by means of the sun's rays, but as the ordinary speculum can only dilate or straighten the external cartilaginous portion of the passage, a person accustomed to aural examinations can

frequently, especially where the meatus is of a large size, observe the tympanal membrane, or at least a portion of it, without, as well as with, such an instrument, by merely lifting up the auricle with one hand and pressing the tragus forward with the thumb of the other. The light must, however, be strong, and made to fall directly upon the passage. In all such examinations the patient should be seated beneath the examiner, with the head slightly bent, opposite a window through which the sun is shining at the moment, and, if possible, between the hours of eleven and three.

Artificial light has been recommended, but it is not so requisite in this as in other countries. In Vienna, for instance, during the winter months, there are many days on which there is not sufficient sunlight for accurate aural examinations. Cleland used a convex glass, which was held before a wax candle in order to concentrate the rays of light into the meatus. To this apparatus Bozzini added a concave mirror, but without much effect; Deleau further modified it by placing a lighted taper between two concave mirrors. The invention of the instrument of this description which possesses greatest power is undoubtedly due to our countryman, Buchanan, the principle of whose lamp exhibits an evident acquaintance with the laws of light, and the mechanism of optical instruments. This was subsequently improved upon, and its effects increased by Kramer, who substituted an argand lamp for the comparatively feeble waxlight of the original inventor. This instrument, which in form, construction, and effect, very nearly resembles a common magic lantern, consists of a tin box, having its interior blackened, and being provided with a strong lamp and powerful reflector, opposite which there is a tube containing two convex lenses, each two inches and a half in diameter. In using this apparatus, a disc of strong light, about the size of a halfpenny, is thrown upon the opening of the meatus, a portion of which light is, by means of any of the ordinary specula straightening the cartilaginous portion of the tube, transmitted to the membrane of the drum. Now, independent of the inconvenience of this lamp, I may remark that, although it undoubtedly illuminates the passage and membrane very powerfully, yet the peculiar lurid glare which it throws upon