blood vessels and the rapidity of flow of the circulating fluid; in the smaller blood-vessels such as are found in the immediate vicinity of the perceptive portion of the human ear the flow of the blood is continuous and not rhythmic in response to the impulse from the heart as is the case in the larger arteries; the sound resulting from the circulation in the smaller blood vessels of the ear is a high pitched singing ranging from a tone of about 15000 v.s. to one of 45000 v.s. while the sounds produced by the larger vessels are very much lower in pitch; these sounds are present in normal conditions, but are not noticed because the adjustment of the sound-transmitting portion of the human ear, the drum head, the chain of small bones and the adjacent parts is such that sounds of this class, within certain limits of intensity, may be transmitted directly outward and pass unnoticed; in the event, however, of structural changes which interfere with the mobility of this sound-transmitting apparatus, the circulation sounds are retained within the ear and become appreciable. This does not occur however in chronic progressive cases such as was Beethoven's until the disease, insidious in its onset, is already well advanced, so that while the first mention of the impairment of hearing and of the subjective noises is made in 1798, it is more than probable that the disease had been at that time several years in progress. Taking these facts in connection with the other symptoms already mentioned, difficulty of distinguishing words and the dread of sudden loud noises, a definite clinical picture is presented which taken in its entirety permits the diagnosis of a chronic progressive thickening of the mucous membrane lining the cavity of the middle ear and of the passages leading therefrom to the throat.