external ear for which the assistance of the surgeon is sought, are, first, malformations, and, secondly, various kinds of inflammation; to these may be added cases of cysts and tumors, which are, however, comparatively rare.

I. Malformations of the external ear generally coexist with partial or entire absence of the external meatus; but as the state of the outer ear usually attracts attention first, I shall consider the two conditions together in this place. Sometimes the tragus is pressed backwards and inwards so as to close the meatus; in such a case, the patient must wear habitually a small silver tube, or have a portion of the tragus excised. A much more serious malformation, and unfortunately one that is not uncommon, consists in the absence of the cartilage of the external ear, together with the external meatus; the only representative of these parts being one or more soft and shapeless duplications of the integuments: sometimes, indeed, there is no vestige of either meatus or auricle.

The attention of the surgeon is called to cases of malformation of the external ear, in order that he may give an opinion, in the case of infants newly born, as to the amount of hearing they are likely to possess; or when children with this affection grow up with a certain degree of hearing, to decide whether an operation will probably be of any benefit; and, lastly, to do all in his power to diminish the deformity arising from the partial absence of the external ear.

A case is cited by Mr. S. Cooper (loc. cit. p. 470) of a child he saw, when it was exhibited in London as a curiosity, which was wholly destitute of external ears, and in whom no meatus auditorii were visible. The child, nevertheless, "could hear a great deal, although the sense was certainly dull and imperfect." No careful investigation seems to have been made of this case, nor is it stated whether the presence of any meatus auditorii could be detected through the integuments. Judging from somewhat analogous cases. which will be cited, it is most probable that the meatus was entirely absent.

Fritelli and Overteuffer are also quoted by Cooper, as having seen cases in which the outer ear was entirely absent. The former says that the physiognomy of the child resembled that of an ape, and the latter states that his patient heard very well. In some instances the auricle is deformed without any abnormal condition of the meatus or tympanum; but, as a general rule, malformation of

the external ear is accompanied by a defective development of the meatus and tympanic cavity.

This subject has been examined with care by Professor Allen Thomson, who published a notice of several cases of malformation of the external ear, and of experiments on the state of hearing in such persons, in the Edinburgh Journal of Medical Science, for April, 1847, to which is appended an account of the dissection of a similar case of malformation by myself. It appears that there are upon record only three dissections similar to those now under consideration of these, one is described by Professor Jaeger of Erlangen, one is in the museum of the University of Edinburgh, and the third is one made by myself, at the request of the Pathological Society of London, before whom it was brought by Dr. Lloyd. In the first two instances, one ear only was affected. "In both (quoting Dr. Thomson), the labyrinth appears to be quite naturally formed; the cavity of the tympanum and the bony Eustachian tube exist, but are much smaller than usual. The chain of ossicles differs materially from the natural structure, being united, in one of the examples, into one straight and simple piece, and, consequently assuming very much the form and appearance of the columella of birds or reptiles. The most striking departure from the normal form of the bone consists in the entire obliteration of the meatus externus, which seems to be connected with the absence of that portion of the temporal bone which forms the tympanic ring and lower side of the bony canal of the meatus, and the extension backwards of the articular or true glenoid portion of the temporal bone to twice its natural breadth. There is a total deficiency, therefore, of what may be termed the tympanic bone, or of that which forms the posterior nonarticular part of the glenoid cavity of the temporal bone, intervening between the fissure of Glasser and the vaginal ridge of the spinous process. Were this part of the bone merely deficient, the cavity of the tympanum would be left freely open below; but in the two bones now described, it seems to be closed by the unusual extension of the glenoid or articular portion of the bone backwards." In reviewing the cases recorded by him, and comparing them with the results of dissection, Dr. Thomson arrives at the conclusion that the following are the most prominent points of deviation from the natural form and structure:-1st. An incomplete development of the integumental part of the apparatus, viz., the external auricle and outer part of the meatus. 2d. The absence of the membrana tympani

ring and bony part of the meatus, in consequence of the incomplete development of the tympanic bone, or a part of the structure which, in the lower animals, bears that name. 3d. The defective state of the cavity of the tympanum and chain of small bones. 4th. Occasional irregularity or deficiency in the development of the malar, palatal, and maxillary portions of the face." My own dissection was laid before the Pathological Society in 1847; both ears were equally affected. The external ear consists of a fold of integument of much the same shape and size as the natural lobe, but directed forwards, so that the concave surface which usually looks outwards is directly applied to the surface of the head, and conceals the tra

gus, which is rather smaller than natural. There are two orifices on the upper part of the interior surface of the appendage, and one at its posterior part: these are the openings of mucous follicles. The meatus externus is entirely absent, and a slight depression in the integuments is the only indication of its usual position. Upon removal of the integuments, no meatus or membrana tympani was discovered; but in their place is a flat surface of bone, which presents two fissures, one very narrow, with a direction forwards, and a second, three or four lines in length, and from half to three-quarters of a line in breadth, commencing at the anterior and inferior part of the other fissure, with a direction downwards and slightly backwards. This fissure is covered by a membrane. The whole of the tympanic ring is absent, so that the mastoid and squamous portions of the temporal bone are only parted by these fissures, the lower of which seems to represent the Glasserian fissure and the external meatus united into one.

The membrane which covers the fissure appears to be the analogue of the membrana tympani. The zygomatic process of the temporal

bone is represented by a small osseous layer developed in the middle of a ligament, which extends from the external part of the squamous portion to the orbit: the malar bone is absent, the external

part of the orbital circle being formed by a ligament connecting the superior maxillary and frontal bones.

Upon removing the membrane just described, a cavity was observed lined with mucous membrane; this is evidently the cavity of the tympanum, but so very much smaller than natural, as itself to resemble somewhat a fissure in the substance of the bone. It measures two lines in its vertical diameter, two and a half from before backwards, and about half a line from without inwards. This cavity contains two bones which are the analogues of the malleus and the stapes. The former consists of a narrow process directed upwards, and a globular body below, from which another process is directed inwards; but it has no connection with the stapes to which it is superior. The stapes, instead of its two crura, has a process flattened above and below, and about three-fourths of a line in length; to the inner extremity is attached the base, firmly fixed in the fenestra ovalis, while the outer extremity is slightly attenuated and presents no articulating surface. Over the stapes, and having a direction from above downwards and backwards, the portio dura nerve is seen unsurrounded by bone, but in contact with the mucous

membrane of the tympanum. The tensor tympani muscle is in a natural state, as is also the Eustachian tube, which opens into the anterior part of the tympanic cavity. The stapedius muscle is absent; the auditory nerve, cochlea, vestibule, and semicircular canals appear in all respects healthy.

The Tympanic Cavity, with the Eustachian tube, opening into its anterior and inferior part. The two ossicles, detached from each other, are to the right.

The healthy state of the labyrinth would lead the surgeon to expect that sufferers from this deformity might hear some sounds; but considering the absence of an external meatus and membrana tympani, and the imperfect state of the tympanic cavity, the comparatively large amount of hearing enjoyed must be a source of surprise. In the following case there is every reason to suppose that the condition of the ears was similar to that just detailed; yet the power of hearing was much more acute than in many instances in which the ear is perfectly developed, but in which there exists some thickening of that part of the apparatus essential to hearing.

Case. Congenital malformation of both ears, and absence of the meatus auditorii.-Miss A. J., aged 22, consulted me in 1851, on the recommendation of Dr. Theophilus Thompson. On examination, a very small fold of integument, in which was a delicate portion of cartilage, represented each external ear. The only vestige of the meatus auditorii was a very slight depression on each side, at the floor of which firm bone was felt. She heard the voice perfectly when spoken to loudly within a foot of the head, and best when the voice was directed towards the vertex of the head. She has a slight impediment in her speech, and her face is short and square-shaped; the zygomatic process appears to be undeveloped. When she attempts a forcible expiration with close nostrils, she feels a sensation of pressure in both ears. Does not hear so well during a cold. Three months previously a surgeon had made a crucial incision over