few days ago, when the deafness slowly returned, and he is now nearly as deaf as on the 14th. The orifice in each membrana tympani had closed. As he was unable to wait until the remedies for opening the tube could be tried, I made a triangular flap, about two lines long, and a line broad below, in each membrane, by means of a scalpel, the blade of which was about two lines in breadth: the apex of the flap was above, and it was turned down. The result was as instantaneously favorable as in the previous operation: and as it was considered probable that the aperture would close, active treatment for the purpose of opening the tube was at once carried out. The consequence was, that in a fortnight, although the orifice. in each membrana tympani had closed, the air passed freely through the Eustachian tube, and the patient heard well.

Closure of the tympanic orifice of the Eustachian tube by the effusion of fibrine will be spoken of when describing cases of the effusion of fibrine into the tympanic cavity.

(d.) OBSTRUCTION OF THE MIDDLE PART OF THE EUSTACHIAN TUBE;

BY A COLLECTION OF MUCUS, BY A STRICTURE OF ITS CARTILAGINOUS OR OSSEOUS PORTIONS, OR BY BANDS OF ADHESION CONNECTING THE WALLS.

In the tabular view giving the result of 1523 dissections, it will have been observed that in thirteen instances the Eustachian tube contained mucus. In my opinion, however, a collection of mucus rarely offers insuperable resistance to the action of the muscles of the tube, to the pressure of the air in the fauces during the act of deglutition, or to an attempt at a forcible respiration, with closed nostrils, &c. It is nevertheless possible that in some of the cases where the tympanic orifice of the tube is closed by thick mucous membrane, there may be also an accumulation of mucus: but as its presence would not require any alteration in the treatment, it is unnecessary to dilate upon the subject.

Stricture of the osseous portion of the Eustachian tube is very rare. Only one case has fallen under my observation; but as I had the opportunity of seeing the patient during life, and afterwards of making a dissection of the ear, it is of sufficient interest to be detailed at length.

Case I. Stricture of the osseous portion of the Eustachian tube;

dissection.-C. J., aged 45, was visited by me in the month of November, 1849. He was dying from tubercular disease, so that I was precluded from making so minute an examination as would have been desirable. The history of the origin and progress of the deafness, as far as could be ascertained, was as follows:-About twenty years ago, the patient suffered from a violent inflammation in the right ear, followed by a discharge from the external meatus, which had continued almost without intermission up to the time he was seen by me. For a considerable period this ear had been unable to distinguish sounds, and the left ear had been gradually growing less and less sensitive to sonorous vibrations during the preceding six or seven years. No pain had been felt in it, however, and there had been no discharge from the external meatus.

Upon inspection by means of a speculum and lamp, the membrana tympani of the right ear was observed to be absent, while the mucous membrane lining the tympanic cavity was very thick, and covered by a large quantity of purulent matter. In the left ear, the lining membrane of the external ear was slightly reddened, and the membrana tympani was as white as writing paper; while the handle of the malleus, usually so distinctly seen, could not be distinguished from the surrounding membrane. Towards its centre, the surface of the membrana tympani had lost the natural shining appearance; but a small portion of its surface, on each side of the handle of the malleus, although perfectly white, was so smooth as to reflect the light of the lamp. As the patient was in a state of great debility, the otoscope was not applied to either ear to test the condition of the Eustachian tube. The patient died a few days after the examination.

Post-mortem inspection. Right ear.-The mucous membrane lining the tympanic cavity was thick and in parts ulcerated; while the bone forming the upper wall of the cavity, with which the ulcerated membrane was in contact, was carious. The Eustachian tube was healthy.

Left ear. The central portion of the membrana tympani was found to be white and thick; but those parts of it which lie anteriorly and posteriorly to the handle of the malleus, were soft and attenuated, and the white appearance was due to the presence of mucus in the tympanic cavity, in immediate contact with the inner surface of the membrana tympani. So softened was this portion of that membrane, that on applying the slightest pressure, the fibres

composing it gave way, and three small orifices were produced. The cavity of the tympanum and the mastoid cells were filled with thick, white mucus, and no air was discoverable. The mucous membrane lining the cavity was also thicker than natural.

The Eustachian tube.-The internal portion for the length of half an inch was healthy; but at about that distance from the cavity of the tympanum, there was a sudden constriction, and for the length of about a line and a half the tube was so contracted, that, even when its superior wall was removed, it was with difficulty that an ordinary sized bristle could be introduced into the opening.

This stricture resulted from the external and internal walls of the tube pressing against each other; the small space still permeable being at the upper part. The more remote cause of the stricture would appear, however, to have been an enlargement of portions of the bone constituting the external and internal osseous walls of the tube: the former being at this part twice its natural thickness, and somewhat rough, while the latter was forced outwards by the dilatation of the carotid canal, which, pressing thus upon the cartilaginous portion of the Eustachian tube with which it was in contact, produced a flattening of the natural concavity of the internal wall. The mucous membrane lining the Eustachian tube was in a natural

state.

Although three dissections are recorded of adhesion between the walls of the tube by means of membranous bands, I have not hitherto met with a case during life. In such an instance the treatment would consist in puncturing the membrana tympani, and establishing an orifice in it.

MUCOUS MEMBRANE-a, CONGESTION. b, ACUTE INFLAMMATION-AFFECTING THE PORTIA DURA NERVE-EXTENDING TO THE BRAIN-SCROFULOUS MATTER IN THE TYMPANIC CAVITY. C, CHRONIC INFLAMMATION. d, CHRONIC CATARRHAL INFLAMMATION. 6, CHRONIC CATARRHAL INFLAMMATION EXTENDING TO THE BONE, DURA MATER, OR BRAIN. f, ULCERATION OF THE MUCOUS MEMBRANE.

Anatomical Observations.-The tympanic cavity is lined throughout by a fine membrane, which forms the internal layer of the membrana tympani, and from which it can sometimes be detached without difficulty. Internally it covers the surface of the promontory and the membrana propria of the fenestra rotunda; it is reflected from the promontory at the circumference of the fenestra ovalis upon the surface of the stapes, and it envelopes the incus and malleus, by means of which it is continuous with the inner layer of the membrana tympani; above and below that membrane it covers the osseous walls of the tympanum, and is prolonged posteriorly into the mastoid cells, while anteriorly it is continuous with the lining membrane of the Eustachian tube. The mucous membrane of the tympanic cavity, in a healthy ear, is so extremely thin as to be quite transparent; and its presence upon the surface of the osseous walls and ossicles of the tympanum, can often only be detected by the use of a magnifying-glass and by the touch. In a natural state the nervous filaments upon the surface of the promontory are very distinctly seen, the margin of the fenestra rotunda is defined and regular, and the membrane which occupies, it is thin and transparent. The crura of the stapes, as well as their point of connection with the base, are clearly seen, and a distinct fissure is observable between the inferior surface of the crura and the promontory. The quantity of mucus covering

this membrane in a healthy ear is so small as to be scarcely perceptible. The membrane itself is composed of extremely fine and delicate fibres, and it has a strong analogy with the serous membranes: first, in respect to its extreme tenuity and great smoothness; second, in the frequency with which membranous bands connect together various parts of the tympanic cavity. Over its surface extends a layer of very minute epithelial cells, some of which are ciliated. The supply of blood vessels is abundant, though they are so minute as not to be discernible, except when distended with blood: this happens in disease, and then they are often very much dilated and surcharged. In young persons the membrane is highly vascular, and, when successfully injected, is found to be pervaded by plexiform ramifications. Beneath the mucous membrane lie the branches of the tympanic nerve from the glosso-pharyngeal.

The upper wall of the tympanum is formed by a layer of bone which separates the tympanic cavity from that of the cerebrum, and which deserves special attention, inasmuch as the diseases of the tympanum, which affect the brain, usually advances through that bone. Its form is an elongated oval, and it measures about

three-quarters of an inch long and from a quarter to half an inch in breadth. Its direction is obliquely inwards and forwards, like that of the petrous bone. Externally it is attached to the lower part of the squamous, and internally to the outer part of the petrous, bone: anteriorly it is continuous with the roof of the