CHAP, vii.] CERVICAL AURICLES. 177 



(hyo-branchial). Besides they point out that the evidence in the few 

 cases in which the course of the duct has been traced, shewed that it 

 passed between the external and internal carotids. In their judgment, 

 therefore, cervical fistula? are all to be referred to the second (hyo-bran- 

 chial) cleft. 



Next it is to be remembered that according to many observers 

 (especially His) there is at no period a complete connexion between the 

 outer gill-clefts and the evagination from the pharynx or branchial 

 sacs, but the membrane separating these chambers is stated by tin-in 

 never to be broken down. If this account is accepted, it is, as 

 Kostanecki and jMielecki have said, necessary to suppose that in the 

 case of any complete cervical fistula a communication between the 

 exterior and the pharynx has arisen by some abnormal occurrence. 

 This is illustrated by reference to the normal condition of the first or 

 hyo-mandibular cleft. Here the auditory meatus represents an external 

 incomplete fistula, and the Eustacbian tube an internal incomplete 

 fistula, the two being separated by the tympanic membrane. In a 

 single case given by VIRCIIOAV' a complete passage existed congenitally 

 in this position, together with great abnormality in position and form 

 of the external ear. 



From the evidence it may thus on the whole be concluded that 

 incomplete external fistula? result from imperfect closure of the sinus 

 cervicalis, and that incomplete internal fistula? may arise by persistence 

 of one of the branchial sacs, but it is doubtful whether many cases of 

 the latter properly belong to the category of branchial fistula? at all. 



Supernumerary A uricles. 



144. Abnormal appendages attached to the neck have been described by 

 several observers, and by those who have discussed the subject of 

 cervical fistula? some account of these appendages is generally given. 

 In the neighbourhood of the external ears, especially near the anti- 

 tragus, such structures having the form of small warts or flaps of skin 

 are not very uncommon. Their presence is generally associated with 

 deformity of the external ear, and often with what are known as 

 "aural fistula? 2 ." In the region of the neck, supernumerary auricles 



1 VIECHOW, Arch, ptitli. Aunt. it. Pliys.. 1865, xxxn. 



2 Aural fistulas are spoken of by many writers as being of the same nature as 

 cervical or branchial fistula?. They are blind ducts or pits, opening on some part 

 of the external ear and are nearly always associated with other abnormalities either 

 in the form of the ear or defective hearing, &c. (Scmriiz, De fist, colli coni/en., 

 Inaug. Diss., Halle, 1873 [not seen, W. B.]; URBANTSCHITSCH, Moiiatxch. f. Ohrfiih., 

 1877, transl. Edin. Med. Jour., xxm. 1878, p. 690.) They may be either unilateral, 

 or on both sides of the body. SIR JAMES PAGET (Trans. Med. Cliir. Soc.. LXI., p. 41) 

 described the occurrence of such fistulae in the ears of several members of a family, 

 many of whom were affected with deafness. The supposed connexion of these 

 fistulas with cervical fistulas was in this case suggested by the fact that several cases 

 of actual cervical fistulas occurred in the same family, several of its members having 

 both cervical and aural fistulas. From the evidence of the not infrequent association 

 of the two kinds of malformation most writers (PAGET, URBANTSCHITSCH, &c.) con- 

 sider that the aural fistulas must be biauchial in origin and may be taken to 

 represent the first (hyo-mandibular) cleft. 



KOSTANECKI and MIELECKI (I. c.), following His, point out that since in 

 no case has an aural fistula ever been known to communicate with the auditory 

 rneatus or tympanic cavity, this belief is unsupported; and in addition, that from 

 the mode of development of the external ear from a number of tubercles, it is 



B. 12 



